This is the second in an occasional series on the subspecialties of anesthesiology. FAER will publish pieces on other subspecialties in the coming months.

n 2000, the Society for the Advancement of Geriatric Anesthesia (SAGA) was established. The over-reaching and ambitious mission of this fledgling Society is to improve the care of elderly surgical patients through enhanced communication and collaboration in clinical practice, research and education. This year, SAGA held its Seventh Annual Meeting at the ASA Annual Meeting last October in San Francisco. The meeting provided an opportunity to review last year’s work and to brainstorm with like-minded “geriatric” anesthesiologists about the future of geriatric anesthesia and the role of SAGA.

What Is SAGA All About?
SAGA exists to improve the care of the older patient having anesthesia and surgery. Successful outcomes in the elderly can only be achieved through care that encompasses all aspects of the surgical experience. SAGA’s mission is to:

• Enhance and improve the outcomes of geriatric patients undergoing surgery.

• Encourage high ethical and professional standards by fostering scientific progress in the perioperative care of the elderly patient.

• Participate in the development of guidelines for geriatric anesthesia education.

• Support research contributing to relevant age-related fields.

Information about membership and events can be found on the Web site www.sagahq.org.

Challenges
Barriers to providing excellent care of our elderly patients are numerous, and many are similar to those battled by geriatric medicine during its early days. Negative generalizations about geriatrics permeate our operating rooms and culture. A common myth encountered is the perception that old patients are all the same and that the cases, although difficult, are unexciting and unglamorous. In addition, the seeming futility and hopelessness when dealing with the very old and sick can be frustrating. These and other similar misperceptions can make it difficult to engage our colleagues, residents and students in the excitement surrounding the field of aging. These barriers cannot be eliminated overnight, but positive changes are occurring already because of the persistence of leaders in SAGA and geriatric anesthesia and the critically needed support of FAER, ASA, the American Geriatric Society (AGA) and our members. Over the last few years, there has been an increase in education and research on age-related topics, witnessed by the number of presentations at prestigious meetings such as through ASA, the Society for Ambulatory Anesthesia and the Society of Cardiovascular Anesthesiologists.

Education and Research
As our knowledge about aging physiology and associated diseases grows, it will be imperative that all anesthesiologists have expertise in common aging issues. The ASA Committee on Geriatric Anesthesia and SAGA have together updated a geriatric curriculum for all members. This curriculum will be available in upcoming months. Through generous support of AGS and the John A. Hartford Foundation, many SAGA members have received funding in past years to create dedicated geriatric curricula through the Geriatric Expertise in Surgical and Related Medical Specialties Initiative.

Other initiatives — for instance, to found a fellowship in geriatric anesthesiology — are still in their infancy. Critical questions as to whether our specialty is ready for a geriatric fellowship and what it should look like continue to be explored. Any fellowship will require a significant research element as well as dedicated clinical time to develop an understanding of the subtleties recognized by our colleagues in geriatric medicine. This fellowship may provide the ultimate perioperative opportunity. Similarly, there will need to be programs to assist faculty in developing and maintaining expertise in geriatric issues, and the ASA Committee on Geriatric Anesthesia, FAER and the SAGA leadership are working together to develop educational venues that could be used to satisfy future American Board of Anesthesiology Maintenance of Certification in Anesthesiology (MOCA) requirements. A starting point will be the development of guidelines for elderly patients that can be applied clinically and against which individual practice performance can be measured.

Fortunately, even as we struggle to create new opportunities, there is significant evidence of increasing awareness in geriatrics as an emerging field. At this year’s ASA Annual Meeting, there were several refresher courses dedicated to geriatrics, numerous Problem-Based Learning Discussions and, for the first time, two dedicated poster sessions. In addition, very successful panel presentations addressing functional outcomes in the elderly and anesthesia at extremes of age were led by SAGA officers.

Research in geriatric areas is clearly an expanding field. Cognitive dysfunction is a particularly rich area that continues to mystify. Cardiac aging is another area with evidence of active and exciting research. But there are still many areas that have yet to be fully explored and are still in the early stages. For instance, what are the true functional outcomes after regional and general anesthesia? What about the impact of newer anesthetic agents in the older patient and the impact of less invasive procedures?

By 2050, 13 to 20 percent of the population (78 million) will be over 65 years, and the number aged 85 and older will also increase exponentially. Considering it is estimated that one-third of all surgeries occur in patients over 65 years, the numbers of elderly patients who can be expected in operating rooms is staggering. Clearly there is a great need to develop strategies to help our oldest patients through surgery, and it is time to start establishing best practices and clear recommendations for our oldest patients. In SAGA, we have only scratched the surface of geriatrics — raising perhaps more questions than can be answered. But one answer is incontrovertible: There is a tremendous and growing need for research and education in geriatric anesthesiology. Please consider joining our increasing ranks in SAGA.

Sheila R. Barnett, M.D., is Assistant Professor of Anesthesiology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts. She is Chair of the ASA Committee on Geriatrics.

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