Given the rapid growth of our elderly population, it is no surprise that we are anesthetizing more geriatric patients daily. It is hard to believe that there was a time not so long ago when an older patient might have been denied a surgery solely due to his or her advanced age. This is rarely not the situation now, and in addition to an increase in the volume of cases on our oldest patients, the complexity of the surgeries can be daunting as well. Clinic data suggest that this trend will continue steadily: 25 percent of ambulatory visits to orthopedic surgeons and 36 percent of all visits to general surgeons were from patients over 65 in 2001, up from prior years. Just as we cannot afford to ignore the demographic changes challenging our clinical practices in the operating room, we also must ensure that our graduates receive adequate education on issues specific to the elderly patient.

Graduate medical education in the United States is regulated by the Accreditation Council for Graduate Medical Education (ACGME). Each accredited specialty appoints members to an ACGME residency review committee (RRC) that is responsible for establishing and monitoring education requirements. The Anesthesiology RRC includes a requirement for instruction in geriatric care. Each program must provide “appropriate didactic instruction and sufficient clinical experience in managing problems of the geriatric population.”¹ The published joint ASA/American Board of Anesthesiology content outline for in-training examinations also includes a section on “Geriatric Anesthesia/Aging: The Pharmacological Implications, MAC Changes and the Physiological Implications on Major Organ Systems.” These mandates make geriatric education a requirement for any program in anesthesiology. Surprisingly this is not the rule in all graduate medical education programs. A recent survey by the Association of Directors of Geriatric Academic Programs² reviewed ACGME policies required by 100 nonpediatric RRCs. They found that only 27 of these programs had specific requirements for geriatric training; anesthesiology and pain management were two of these.

Although we have established a requirement to teach geriatrics, the real challenge lies in creating meaningful programs in geriatric education. The organizational structure of any geriatric curriculum may vary tremendously depending on the given department or institution. Options include an integrated curriculum that addresses the needs of a geriatric patient during each subspecialty rotation or a more purist approach that uses a dedicated block to systematically review geriatric anesthesiology. Whatever the actual organization, there is good evidence from the adult education literature that teaching venues such as Problem-Based Learning Discussions (PBLDs), case presentations and small-group discussions are best for the adult learner.

A new twist on residency education to be considered when setting up a curriculum in 2004 is the ACGME competencies. ACGME now requires mandatory evidence of training in the six competencies, which include patient care, medical knowledge, practice-based learning, interpersonal and communication skills, professionalism and systems-based practice. Incorporating some of these into a geriatric curriculum may provide an innovative and efficient way to evaluate some of the competencies while teaching geriatric principles. For instance interpersonal and communication skills can be taught and evaluated during the preoperative assessment of the confused patient and their burned-out caregiver. An example of systems-based practice may involve a dialogue on how to handle a do-not-resuscitate order during the perioperative period. Practice-based learning may involve a discussion on risk reduction with beta blockade in elderly vascular patients undergoing high-risk surgery. The competencies have created huge challenges for education programs, and integrating the competencies into a geriatric curriculum may be a real asset to a residency.

The future of geriatric anesthesiology ultimately lies in the research and development of new programs that improve care of the elderly and develop committed faculty. What can we do to excite our trainees and reward our faculty and entice them into the field of aging? It is important to present geriatrics competitively, challenge the evidence in the literature for recommended anesthetic techniques, and use DVDs, patient video clips and other educational tools that enhance learning and engage the learner. Certain areas are particularly relevant in geriatrics. For instance preanesthetic assessment in the complex elderly patient can be very challenging but also presents an opportunity to discuss evidence for streamlining the assessment, judicious laboratory testing and cardiac risk assessment. Postoperative cognitive dysfunction also is an important topic. Some evidence-based questions to discuss in this area include what anesthetic choices might be better to prevent postoperative confusion and the merits of regional versus general anesthesia. What should we tell family members about their elderly relative’s risks of cognitive dysfunction after surgery? These are just a few issues that are relevant to education on the elderly; there are obviously many more examples.

Over the past 10 years, there has been substantial progress in the development of geriatric anesthesiology and postgraduate education. An example of the recognition of geriatrics was the selection of Terri G. Monk, M.D., President-Elect of the Society for Advancement of Geriatric Anesthesia (SAGA) to present the 2003 ASA Emery A. Rovenstine Memorial Lecture. Her talk was titled “Postoperative Cognitive Dysfunction: The Next Challenge in Geriatric Anesthesia.” Geriatric panels have been presented at ASA in past years and at many subspecialty meetings this year. In addition there are several Refresher Course Lectures and PBLDs on geriatric topics each year at the ASA Annual Meeting that provide opportunities for education and faculty development in geriatrics.

Geriatric anesthesiology has benefited tremendously through the “Geriatrics for Specialists” initiative led by the American Geriatrics Society (AGS) and funded by the John A. Hartford Foundation. This program has provided several opportunities for nongeriatric specialists to develop careers in geriatrics. Two examples are the Geriatrics Education for Specialty Residents program that has been awarded to anesthesiology and geriatric departments to create geriatric education programs in subspecialty residencies. A second example is the Dennis W. Jahnigen Career Development Scholars Award that is given to subspecialty faculty pursuing research in age-related issues. Anesthesiologists have been successful in obtaining grants through this program as well, and we should continue to take advantage of these unique opportunities. The Paul B. Beeson Career Development Award in Aging is another prestigious award providing substantial support for career development through the American Federation of Aging Research. Those interested in geriatrics should check out the AGS Web site at <www.americangeriatrics.org>. This is a tremendous resource, and there are a surprising number of grant opportunities for anesthesiologists interested in age-related research or support for curriculum development.

The ASA Committee on Geriatric Anesthesia has been instrumental in promoting geriatric education in anesthesiology. This year the committee has organized a unique conference following the AGS Annual Meeting on Friday, May 21, at the Venetian Hotel, room 507, from 7:45 a.m. to 12:45 p.m. in Las Vegas, Nevada, on the “Consolidation of Teaching Geriatrics to Anesthesia Residents.” This is the first conference to dedicate time and energy to develop an improved syllabus in geriatric anesthesiology, and anyone interested in education in geriatric anesthesia is invited to attend. SAGA is a young society dedicated to the elderly patient. The SAGA Web site <www.sagahq.org> provides information on education in geriatric anesthesiology as well as potential speakers.

There are quality education resources available for those who teach and develop curriculum on geriatric anesthesiology. The ASA Committee on Geriatric Anesthesia has created a syllabus that is available on the ASA Web site, which includes more than 30 chapters on relevant geriatric issues <www.ASAhq.org/clinical/geriatrics/syllabus.htm>. In addition there exist several excellent texts, including Geriatric Anesthesiology, edited by Charles H. McLeskey, M.D.³ (a second edition will be available later in the year), and Geroanesthesiology by Stanley Muravchick, M.D.⁴ AGS and the John A. Hartford Foundation also have published a “Geriatrics Syllabus for Specialists”⁵ that was created for nongeriatricians; information on obtaining this text is available on the AGS Web site at <www.americangeriatrics.org/products/gss2.shtml>.

In summary there has been substantial progress in the development of education initiatives for the elderly patient undergoing anesthesia. Anesthesiology as a field has shown a significant commitment to education and research in aging, and we have benefited tremendously from collaborations with AGS. There are great opportunities and a wealth of resources for education research and career development in the field of geriatric anesthesiology.

Ten years ago, most of my education in geriatric anesthesiology could be summarized in just a few words: “start low, go slow.” We have certainly come a long way, although “start low, go slow” is still sage advice!


References:

1. Accreditation Council for Graduate Medical Education <www.acgme.org>.

2. Association of Directors of Geriatric Academic Programs (ADGAP) Longitudinal Study of Training and Practice in Geriatric Medicine: Training & Practice Update. Medical Student Training in Geriatrics at the Beginning of the 21st Century. <www.americangeriatrics.org/news/october_2003.pdf>.

3. McLeskey CH, ed. Geriatric Anesthesiology. Baltimore: Lippincott, Williams & Wilkins; 1997.

4. Muravchick S. Geroanesthesia. St Louis: Mosby; 1997.

5. Katz PR, Grossberg GT, Potter JF, et al. Geriatrics Syllabus for Specialists, 2002.

Sheila R. Barnett, M.D., is Assistant Professor of Anesthesiology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts.