What’s New With the Old?

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June 1, 2013 Volume 77, Number 6
What’s New With the Old? Ruben J. Azocar, M.D. Chair Committee on Geriatric Anesthesia

The term “Grey Tsunami” was coined several years ago, likely as an analogy to the South Pacific natural disaster of 2004. The term forecasted a “catastrophic wave” of older adults who would “hit” society in the future. Today, this is not a prediction any longer. In 2011, the baby boomer generation started to cross the 65-year-old threshold at a rate of 7-10,000 people every day. That means the wave has reached us and its impact will be felt at all levels. This includes health care. Together, the “grey tsunami” and the coming health care reform changes will create the “perfect storm.”

The percentage of Americans 65 and older will grow from 13 percent to more than 20 percent of the total population by 2030; the fastest growing segment of this group, adults 85 years of age and older, will triple in number over the next four decades.1-2 Living longer also means requiring more resources, particularly health care services. For example, in 1970, individuals 65 and older represented 10 percent of the population, and they accounted for 20 percent of hospital discharges and 33 percent of the days of care.1-2 By 2007, the percentage of persons 65 and older grew to 13 percent, yet their hospital use increased drastically to 37 percent of hospital discharges and 43 percent of all hospital days used. 1,3,4

Additionally, in 2006, elderly patients underwent 35.3 percent of inpatient procedures and 32.1 percent of outpatient procedures.1,5

The Patient Protection and Affordable Care Act of 2010 will fundamentally alter the nature of health care delivery and reimbursement in the United States. Besides the reforms to the health delivery systems, including accountable care organizations and the patient-centered medical home, there is an emphasis on improving the value of health services in the U.S.; in other words, improving health outcomes relative to costs.

Our Society has been responsive to these upcoming challenges. On October 5, 2012, the ASA presented the Perioperative Surgical Home model of care to a special White House Roundtable on Health Care Delivery, highlighting the potentially significant role that hospital-based physicians, such as anesthesiologists, play in improving quality of care as well as in reducing cost.6

In this context, the members of the Committee on Geriatric Anesthesia strongly believe that improving the state of knowledge and practice within the specialty related to the care of older adults represents a key opportunity in allowing anesthesiologists to contribute to the provision of high-value health care in the U.S. This will allow us to take steps toward achieving the Surgical Home’s goal of improving quality of care and outcomes while ensuring patient safety and achieving cost savings across a wide range of surgical interventions.

Who are we and what have we done so far?
A small but growing number of ASA members have developed a keen interest in geriatric anesthesiology. Many have started their academic careers supported with grants by the American Geriatric Society (AGS) or the National Institute on Aging’s Grants for Early Medical/Surgical Subspecialists’ Transition to Aging Research (GEMSSTAR). In addition, a geriatric anesthesia curriculum7, two textbooks and a manual in the perioperative care of the older adult have been published.

The committee also maintains close collaboration with the Society for the Advancement of Geriatric Anesthesiology (SAGA) and the AGS, particularly with its Section for Enhancing Geriatric Understanding and Expertise Among Surgical and Medical Specialists (SEGUE). Two members of the geriatric committee are members of SEGUE.

This year, the committee decided to take a leap forward and created a white paper with recommendations for education, research and quality initiatives in the perioperative care of the elderly. The white paper was submitted to and approved by the ASA’s Administrative Council. This initiative will help our committee and ASA move to the forefront of perioperative care of the geriatric patient.

Briefly, our recommendations included:

  • Enhancing the educational opportunities in geriatric anesthesiology for ASA members.
  • Support from ASA to partner with other committees to create initiatives that will enhance the perioperative care of the older adult.
  • Continue to support the Foundation for Anesthesia Education and Research (FAER) to encourage research in the area of geriatric perioperative care, including of FAER’s involvement in the support of the National Institute on Aging’s GEMSSTAR.
  • Continue collaboration with other professional and academic organizations that focus on the care of the older adult and explore opportunities for collaboration in education, research and evidence synthesis related to the perioperative care of older adults.
  • One last task was having more presence in the NEWSLETTER. In this issue of the NEWSLETTER, Sheila Barnett, M.D. and Jeff Silverstein, M.D. (page 14) will further discuss the impact of the aging population and review important quality measures related to the older adult. Shamsuddin Akhtar, M.B., B.S. will touch on the topic “Perioperative Care of the Elderly: Extrapolation of Guidelines or Real Evidence?” on page 18. Deborah Culley, M.D. and Christopher Jankowski, M.D. will provide us with an update on postoperative central nervous system dysfunction – one of the most critical issues surrounding the outcome of the elderly patient undergoing anesthesia and surgery (page 22).

    The key to preventing a natural phenomenon from becoming a disaster is prevention. Since 2004, the Pacific Tsunami Warning Center has expanded the areas it monitors as well as its monitoring capabilities.8 We should do the same and enhance our resources, knowledge and skills to provide the excellent clinical and value-based care our older adults deserve and expect.

    Ruben J. Azocar, M.D. is Vice-Chair for Education and Simulation and Residency Program Director, Department of Anesthesiology, Boston Medical Center, and Associate Professor of Anesthesiology, Boston University School of Medicine.

    1. Chow WB, Rosenthal RA Merkow RP, et at. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012; 215(4): 453-466.
    2. Vincent GK, Velkoff VA; U.S. Census Bureau. The next four decades, the older population in the United States: 2010 to 2050, population estimates and projections. Current Population Reports [P25-1138]. http://purl.access.gpo.gov/GPO/LPS126596. Published May, 2010. Accessed March 25, 2013.
    3. DeFrances CJ, Lucas CA, Buie VC, Golosinskiy A. 2006 National Hospital Discharge Survey. Natl Health Stat Report. 2008;(5): 1–20.
    4. Hall MJ, DeFrances CJ, Williams SN, Golosinskiy A, Schwartzman A. National Hospital Discharge Survey: 2007 summary. Natl Health Stat Report. 2010;(29):1–20, 24.
    5. Cullen KA,Hall MJ,Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Report. 2009;(11):1–25.
    6. ASA presents the Perioperative Surgical Home™ model of care to special white house roundtable on health care delivery. American Society of Anesthesiologists website. http://www.asahq.org/For-Members/Advocacy/Washington-Alerts/ASA-Presents-Surgical-Home-to-White-House-Roundtable.aspx. Published October 11, 2012. Accessed March 25, 2013.
    7. Geriatric anesthesiology curriculum. American Society of Anesthesiology website. http://www.asahq.org/For-Members/Clinical-Information/Geriatric-Curriculum.aspx. Accessed March 25, 2013.
    8. PTWC History. Pacific Tsunami Warning Center website. http://ptwc.weather.gov/ptwc/history.php. Accessed March 25, 2013.