Christopher J. Jankowski, M.D., Board Member
Society for the Advancement of Geriatric Anesthesia

t is difficult to open a newspaper or magazine these days without seeing articles relating to the “Graying of America.” By now the statistics may be familiar, but they are no less sobering: In 2000, there were 35 million U.S. residents over 65 years old, comprising 12 percent of the population but accounting for more than 16 million surgical procedures that year — about one-third of the total. By 2050, those older than 65 will make up 21 percent of the population and number 85 million.¹

Increasing numbers of older patients have an impact on our practices outside, as well as inside, the operating room. For example the elderly often require more extensive preoperative evaluations and postoperative care than younger patients undergoing equivalent procedures, and they are more likely to require intensive care. Finally, they are frequent users of pain clinics. Clearly the aging of the population has profound implications for our specialty.

Although Paul H. Lorhan, M.D., published the first monograph on geriatric anesthesiology² in 1955, it was not until 2000 that a subspecialty society came into being. The Society for the Advancement of Geriatric Anesthesia (SAGA) was formed to improve the care of older surgical patients by encouraging the development of expertise in the unique challenges they pose. This group is still small but very enthusiastic. The SAGA Web site <www.sagahq.org> contains information on membership as well as a number of resources for patient care and geriatric anesthesiology education.

Increasing Awareness
Fortunately awareness of the importance of geriatric issues in perioperative medicine is increasing. For example, at the ASA 2005 Annual Meeting in Atlanta, Georgia, there were five Refresher Courses, four Problem-Based Learning Discussions, two panels, a clinical forum and a scientific paper session devoted to geriatric issues.

In addition SAGA has sponsored sessions devoted to the perioperative care of the elderly at the annual meetings of the Society of Cardiovascular Anesthesiologists (SCA), the Society for Ambulatory Anesthesia and at the Postgraduate Assembly of the New York State Society of Anesthesiologists. In May 2006, SAGA will again sponsor a session at the SCA Annual Meeting in San Diego, California.

Going Global
Growing appreciation of geriatric anesthesiology extends outside the United States as well. In March 2006, the 1st International Master Class on Anesthesia and Perioperative Care in the Older Patient will be held in Rotterdam, The Netherlands. The course has excellent faculty and will expose attendees to state-of-the-art approaches to the care of elderly surgical patients. Registration information can be obtained at <www.apcop2006.org>.

Importantly, leaders within the specialty have recognized the significance of this emerging field. In 2003, Terri G. Monk, M.D., current SAGA President, was selected to deliver the Emery A. Rovenstine Memorial Lecture at the ASA Annual Meeting. Her presentation discussed postoperative cognitive dysfunction (POCD), a significant issue facing elderly surgical patients.

In the NEWS
The May 2004 issue of the ASA NEWSLETTER focused on geriatric anesthesiology. Jeffery H. Silverstein, M.D., SAGA Past President, provided an update on frailty, highlighting the need for more research into the basic mechanisms of aging and on the clinical impact of age-related physiological changes. Dr. Monk contributed an article reviewing issues related to postoperative delirium and POCD. Sheila R. Barnett, M.D., SAGA President-Elect, reviewed the state of geriatric anesthesiology education, including the Accreditation Council for Graduate Medical Education Residency Review Committee for Anesthesiology and the joint ASA/American Board of Anesthesiology mandates that require geriatric instruction in anesthesiology training programs. Finally, Michelle Adams of the Portal of Geriatric Online Education (POGOe) introduced the POGOe Web site <www.pogoe.org>, a gateway to a variety of educational tools. She also emphasized the necessity of a multidisciplinary approach to the care of geriatric patients.

A FAER Amount of Research
Research will underpin future advances in the care of the elderly and improvements in resident education in geriatric anesthesiology. Already geriatric anesthesiology has been the focus of a number of projects that have received competitive funding through the National Institutes of Health and other agencies. Much work remains, however.

To that end, the Foundation for Anesthesia Education and Research (FAER) recently convened a Geriatrics Research Council. Led by Arnold J. Berry, M.D., the group is addressing several key issues, including 1) the need for research funding for topics related to geriatric anesthesiology, 2) the need to encourage and support anesthesiologists interested in research careers focusing on the perioperative care of the elderly and 3) the need for improved geriatric education in anesthesiology training. The council has issued a Request for Applications to all FAER grant programs for proposals pertaining to perioperative outcomes in the elderly. Details can be found on the FAER Web site <www.FAER.org>.

Emblematic of the cross-specialty collaboration required in the care of geriatric surgical patients, the John A. Hartford Foundation and the American Geriatrics Society joined forces to publish New Frontiers in Geriatrics Research: An Agenda for Surgical and Related Medical Specialties.³ This work reviews existing perioperative geriatric literature and identifies research questions in 10 specialties, including anesthesiology. Its mission is to “develop the area of clinical science that would lead to improved outcomes for older patients receiving specialty care.” The text highlights the need for systematic study of the perioperative care of the aged. It provides an excellent framework for developing a research program in anesthesiology by identifying areas that are not only of clinical interest but also those in which research efforts are likely to be fruitful. The first edition was published in early 2004. David J. Cook, M.D., was the anesthesiology content expert, and Alec Rooke, M.D., Ph.D., was the senior author. An updated version is currently being prepared.

Older patients will make up an ever-increasing portion of our practice in the coming years and require us to develop special expertise in the care of this vulnerable group. Research and education will be the basis of improved outcomes. Fortunately efforts are under way to realize this goal.

References:
1. U.S. Interim Projections by Age, Sex, Race and Hispanic Origin, U.S. Census Bureau. 2004 <www.census.gov/ipc/www/usinterimproj/natprojtab02a.pdf>. Accessed on January 9, 2006.

2. Lorhan PH. Geriatric Anesthesia. Springfield, IL: Charles C. Thomas; 1955.

3. Cook DJ. New Frontiers in Geriatrics Research: An Agenda for Surgical and Related Medical Specialties. New York: American Geriatrics Society; 2004.

Christopher J. Jankowski, M.D., is Assistant Professor of Anesthesiology, Mayo Clinic College of Medicine, and Consultant in Anesthesiology, Mayo Clinic and Foundation, Rochester, Minnesota.