Peter Pompei, M.D.
Associate Professor of Medicine
Stanford University School of Medicine
pompei@leland.stanford.edu

Anesthesiologists and geriatricians share the role of managing medical illness among elderly surgical patients. During the immediate perioperative period, anesthesiologists provide the principle care and generally function in an acute illness model of practice. Problems that arise, such as hypertension, hypoxemia or hyperglycemia are judged correctable and an appropriate intervention is initiated to correct them. In contrast, geriatricians, as primary care physicians for older persons over the last years of their lives, more often operate in a chronic disease model. Activity of chronic illness is quite variable over time, and a long-term treatment plan is the most effective approach to managing problems that will most likely not be cured. When an older person with stable osteoarthritis, heart disease, hypertension and diabetes falls and breaks a hip, physicians caring for this patient must address both the acute illness and its potential effects on various organ systems and the longer term management of chronic illnesses to reestablish homeostasis and optimize function. The best outcomes can be expected from comprehensive, coordinated, and attentive management of both the acute and chronic disease states of older surgical patients.

Beyond appropriate management of accumulated chronic illnesses, anesthesiologists and geriatricians can contribute to improved outcomes by comprehensive risk assessment and management. There is a long history of this tradition in anesthesiology as evidenced by the remarkable value of the ASA Physical Status scoring system that has been used to successfully risk stratify operative patients for over fifty years.¹ Additional methods have been developed to predict specific complications, e.g. the Goldman criteria for cardiac complications of non-cardiac surgery,² and the timed-walk test to predict pulmonary complications.³ More recently, the American Heart Association and the American College of Cardiology have developed a practice guideline for cardiovascular evaluation for noncardiac surgery.⁴ A significant advantage of this guideline is its explicit recommendations for specific clinical situations. Clinicians are prompted to consider comorbid conditions, functional abilities, and the risk of the surgical procedure in a step-wise approach to determine what measures should be taken before the patient arrives in the operating room. From the perspective of the geriatrician, two aspects of this guideline are especially notable. First, "advanced age" is included among the minor clinical predictors, acknowledging that chronological age is a much less important risk factor than the extent of concomitant medical problems. Second, physical functional status, a central concern in geriatric medicine, is featured prominently in the guideline. As this guideline becomes implemented, we hope to see reports of improved patient outcomes.

A particularly worrisome outcome of surgical interventions among older persons is cognitive decline. Considerable attention has been directed at the acute, reversible postoperative cognitive changes recognized as delirium.⁵ More recently, attention has been directed at more persistent cognitive decline. A multinational study of over twelve hundred patients 60 years of age and older who underwent major noncardiac surgery reported a 25.8% incidence of cognitive decline at 1 week and a 9.9% incidence at 3 months.⁶ Risk factors for the short term decline included age, duration of anesthesia, little education, a second operation, postoperative infection and respiratory complications. The only risk factor for the longer term decline that achieved statistical significance was age. The investigators carefully monitored patients for arterial hypotension and hypoxemia and found that these were not significant risk factors for short or long term cognitive decline. No attempt was made in this first study to examine the contribution of various anesthetic techniques. There is still considerable work to be done to first identify mutable risk factors and them develop strategies to optimally manage patients at risk so that cognitive decline is minimized as a complication of operative therapy among older persons.

Important studies have been done to examine the role of intra-operative anesthetic management of selected patient outcomes.^7,8 While regional and general anesthesia have been compared with respect to mortality, thromboembolism, blood loss, and pulmonary function among other outcomes, no widespread consensus has emerged regarding the application of these approaches. Combined approaches are also being investigated, but more studies need to be done on older persons facing a variety of different operations. Postoperative pain management strategies have also been compared, with limited attention to outcomes other than analgesia.^9,10 Working together, anesthesiologists and geriatricians could design studies that will address acute illness and chronic disease outcomes that are important to the overall health status and quality of life of older persons.

References:

1. New classification of physical status. Anesthesiology 1963;24:111
2. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977;297:845-850
3. Williams-Russo P, Charlson ME, MacKenzie CR, et al. Predicting postoperative pulmonary complications: Is it a real problem? Arch Intern Med 1992;152:1209-1213
4. ACC/AHA guidelines for perioperative cardiovascular evaluation for noncardiac surgery. Circulation. 1996;93:1278-1317
5. Marcantonio ER, Goldman L, Mangione CM, et al. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA 1994;271:134-139
6. Moller JT, Rasmussen LS, Houx P. et al. Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study. Lancet 1998;351:857-861
7. Brinker MR, Reuben JD, Mull JR, et al. Comparison of general and epidural anesthesia in patients undergoing primary unilateral THR. Orthopedics 1997;20(2):109-115
8. Ballantyne JC, Carr DB, deFerranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: Cumulative meta-analyses of randomized, controlled trials. Anesth Analg 1998;86:598-612
9. de Leon-Casasola OA, Karabella D, Lema MJ. Bowel function recovery after radical hysterectomies: Thoracic epidural bupivacaine-morphine versus intravenous patient-controlled analgesia with morphine: a pilot study. J Clin Anesth 1996;8:87-92
10. Thorn SE, Wattwil M, Naslund I. Postoperative epidural morphine, but not epidural bupivacaine, delays gastric emptying on the first day after cholecystectomy. Reg Anesth 1992; 17:91-94

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