Frailty and disability on the rise in the US, but where is the response?
The US health care system is facing new challenges of caring for a rapidly aging population with complex health care needs. According to the Administration on Aging, the US population age 65 and older increased to 40 million in 2010 (a 15% increase in one decade), and will grow to 55 million, a 57% increase, in the next 10 years. By 2030, driven by the Baby Boom Generation, the number of Americans over age 65 will have more than doubled in a 30-year period.(1) Americans are also reaching increasingly advanced ages; the segment of the population of individuals aged 90 and older is not only the fastest growing in the US, but is expected to quadruple in size from 2010 to 2050 and will comprise a greater proportion of the US total population than ever before.(2) With this demographic shift, millions of older Americans are now vulnerable to frailty and functional decline that often accompany advanced age, along with chronic conditions that can further limit mobility and physical function, including cardiovascular and pulmonary diseases, diabetes and obesity.
Already, 133 million Americans (or 45% of the total population) have at least one chronic disease, and the burden of physical difficulties rise with age: almost 85 percent of people aged 90 and older have at least one physical limitation in their daily life and nearly 70 percent of people in this group had mobility limitations related to walking or climbing stairs.(2) Additionally, nearly half of the elderly American population suffers from sarcopenia, age-related muscle losses that leave millions of older adults vulnerable to falls and fractures; chronic conditions like diabetes, cardiovascular disease and obesity; hospitalization; loss of mobility; frailty; institutionalization; and death.(3) In 2000, 1.5 million people were institutionalized, and 33% of these people were admitted to long‐term health care facilities because of their inability to perform activities of daily living due to reduced mobility, at a cost of billions of dollars in health care costs.(3),(4) These numbers will surely rise as the age boom reaches its apex.
Though these statistics paint a very startling picture, little has been done on the regulatory front to allow for greater ease in confronting the growing and costly challenge of functional decline in the elderly, most especially in the development of clinical trials that might improve physical performance and independence among the elderly. Current treatments are limited to targeting one specific disease and clinical trials often eliminate patients with comorbid conditions (5), a strategy that ignores the fact that many of the older patients who need those treatments the most are living with more than one chronic condition or limited physical activity.
One aspect of improving health of older patients is clear: regardless of variance of health status in individual patients, functional capacity in the older population is a very telling, predictive measure of mortality and other outcomes including disability onset, loss of independence and admission to a nursing home (5), and therefore is a measure that merits further consideration in treating older patients. Because decreased functional capacity and frailty are commonly the consequence of many different chronic conditions (5), and frailty ironically eliminates older patients from clinical trials for treatments of these very conditions, targeting improved physical function should be considered a priority by regulators and healthcare providers.
A growing body of research demonstrates the effectiveness of assessments like the Short Physical Performance Battery (SPPB) or usual gait speed in predicting patient outcomes and presenting a clear picture of an older patient’s health status to identify those individuals in need of intervention, and points to numerous opportunities for the development of treatments and interventions to improve functional capacity, strength and independence of our nation’s growing aging population. It is crucial to open dialogue between regulators and other stakeholders to increase understanding around the importance of functional status in older patients, and to rethink practices in clinical trial and treatment development. The nation’s older population has changed, and it’s time for our health care to follow suit.
(1) Administration on Aging. A Profile of Older Americans 2010. http://www.aoa.gov/aoaroot/aging_statistics/Profile/2010/16.aspx 7 May 2012.
(2) Wan He and Mark N. Muenchrath, US Census Bureau, American Community Survey Reports, ACS-17, 90+ in the United States: 2006-2008, US Government Printing Office, Washington, DC, 2011. http://www.census.gov/prod/2011pubs/acs-17.pdf 7 May 2012.
(3) Janssen I, Shepard DS, Katzmarzyk PT, Roubenoff R. The Healthcare Costs of Sarcopenia in the United States. Journal of the American Geriatric Society 52:80–85, 2004.
(4) Thompson, D.D. (2007). Aging and sarcopenia. Journal of Musculoskeletal & Neuronal Interactions, 7, 344-345.
(5) Evans, William; Reynolds, Donald W. Functional Outcomes for Clinical Trials in Frail Older Persons: Time To Be Moving. Journal of Gerontology: Series A, Volume 63, Issue 2, Pp. 160-164. http://biomedgerontology.oxfordjournals.org/content/63/2/160.full.pdf+html, 7 May 2012.