Care of the Elderly Is the New Frontier of Anesthetic Practice

he number of patients over the age of 65 years who undergo noncardiac surgery will increase from 7 million to 14 million over the next few decades, becoming a very large part of our practice. Anesthesiology, like all medical specialties, is under pressure to achieve new levels of performance and utilize costly resources more efficiently. Thus we had better become masters in managing elderly surgical patients.

One of the best opportunities for interacting with a small but growing group of clinician scientists interested in the care of the elderly is the Society for the Advancement of Geriatric Anesthesia (SAGA). This year SAGA will hold its Annual Meeting on Sunday, October 23, 2005, from 4:30 p.m. to 7 p.m. in the Magnolia room at the Hilton New Orleans Riverside. This year’s meeting will feature a discussion of several potential multicenter, geriatric clinical research projects and the logistics of starting a multicenter research group. Information about the Annual Meeting, SAGA programs and membership can be located at <www.sagahq.org>. Take the extra effort to become an expert in the care of the geriatric patient and join our organization, which is dedicated to the best care of all elderly surgical patients.

Among the issues receiving the most attention in postoperative geriatric care are the roles of anesthetic medications and genetic makeup in the development of postoperative central nervous system dysfunction. While all of this research is in the early stage, it is unclear, to a large extent, whether either “postoperative” delirium or cognitive dysfunction are unique to the postoperative environment or represent a more generalized reaction to illness. Choice of regional versus general anesthesia does not seem to make a big difference. Recent articles by Deborah J. Culley, M.D.,¹ and Roderic G. Eckenhoff, Ph.D.,² present the interesting suggestion that anesthetic agents themselves are potentially damaging, at least to rat brains and isolated cells and tissues. If this turns out to be true, an extensive search for a new nontoxic anesthetic may occupy the next generation of anesthetic researchers. In addition, as if the toxicity of the drug itself were not sufficient, there is developing evidence — most of which comes from the Neurologic Outcome Research Group, or NORG, directed by Mark F. Newman, M.D., at Duke University Medical Center — that suggests that our genetic makeup plays an important role in our susceptibility to perioperative injury of all sorts. The realm of personalized medicine may well enter geriatric anesthetic practice sooner than anyone might have imagined. A relatively controversial article by Terri G. Monk, M.D.,3 adds further support to the suggestion that anesthetic exposure may have a longer impact on postoperative outcomes than anesthesiologists want to believe. One can only encourage clinicians to keep up with evolving data in these areas as both patients and oversight agencies are likely to maintain an active interest in these developments.

Those among you who have an idea about how geriatric patients might be better understood or cared for have multiple grant opportunities. These are significant research support mechanisms that budding investigators should explore. The Dennis W. Jahnigen Career Development Scholars Awards program offers two-year career development awards to support young faculty in the specialties, including anesthesiology. Each grant will provide two-year salary support of $75,000 per year for salary and fringe benefits, plus $25,000 per year to support costs of doing research. This is an extraordinary opportunity for young faculty with an interest in geriatric anesthesiology. Information relative to the Jahnigen award can be found at <www.americangeriatrics.org/hartford/scholars_award.shtml>.

The Paul B. Beeson Career Development Awards in Aging Research Program (formerly the Beeson Physician Faculty Scholars Program) has supported 91 Beeson Scholars from 36 of the nation’s top medical schools and research institutions. This year Leanne Groban, M.D., from Wake Forest University, has been awarded a Beeson Award for her project “Growth Hormone, Angiotensin II, Cardiac Aging,” in which preliminary data suggest that angiotensin II promotes remodeling in the aging heart. More information on the Beeson Award can be found at <www.beeson.org>.

The Foundation for Anesthesia Education and Research also remains an important resource for investigators interested in geriatric research <http://faer.org/grants.php>.

Although certainly not the only other opportunity, educators interested in geriatrics (which should be all of you) should consider the “Geriatrics Education for Specialty Residents (GESR)” grants to anesthesiologists. The American Geriatrics Society (AGS) — through a program funded by The John A. Hartford Foundation titled Increasing Geriatrics Expertise in Surgical and Related Medical Specialties — funds proposals for specialty-specific initiatives from academic training centers to develop, initiate and evaluate programs designed to increase education for residents in the geriatric aspect of their disciplines.

Whether you like it or not, hospital-based anesthesiologists will encounter greater numbers of sicker old people in the coming years. If you develop your interest now, the knowledge will pay off in the near future.

References:

1. Culley DJ, Baxter MG, Crosby CA, Yukhananov R, Crosby G. Impaired acquisition of spatial memory 2 weeks after isoflurane and isoflurane-nitrous oxide anesthesia in aged rats. Anesth Analg. 2004; 99(5):1393-1397.

2. Eckenhoff RG. Inhaled anesthetic enhancement of amyloid-beta oligomerization and cytotoxicity. Anesthesiology. 2004; 101(3):703-709.

3. Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg. 2005; 100(1):4-10.

Terri G. Monk, M.D., is Professor of Anesthesiology, Duke University Medical Center, Durham, North Carolina.

Jeffrey H. Silverstein, M.D., is Associate Dean, Vice-Chair for Research and Associate Professor of Anesthesiology, Surgery, Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, New York.