GERIATRICS AND ANESTHESIA

How do geriatric patients represent a new opportunity in anesthesia? As more people live longer and technology continues to advance, older patients are becoming an increasing part of the overall surgical population. Today more than 33 million people, about 13% of the United States population, are age 65 or older. By the year 2040, over 68 million people, 23% of the population, will be in this age group. As the millenium arrives, 100,000 individuals will be 100 years old or older. The group over 84 years of age is the fastest growing segment of the population. Yet, for the first third of the twentieth century, it was generally believed that elective surgery for patients over age 50 was improper. Today, chronologic age is not a limitation for undergoing anesthesia or surgery. In fact, over 5.5 million patients aged 65 and older had major procedures in 1994. 18 Even centenarians undergo major elective surgeries. Significantly, more surgical procedures are being performed upon an increasingly larger and older population—this is the new opportunity in anesthesia. The academic disciplines of gerontology and geriatric medicine have grown dramatically over the last 20 to 30 years. Specific issues pertinent to the care of the elderly have shown sufficient intellectual rigor and practical usefulness to generate specialty training, academic societies, and an institute in the National Institutes of Health. Surgical (and medical) specialties have developed increasing interest in aging in recent years. Within anesthesiology, a series of textbooks devoted exclusively to geriatric anesthesia document a substantial body of knowledge. 36,40,52 These works explore the aging process and how anesthesiologists should approach aging patients. They capitalize upon years of basic gerontologic work to make anesthetizing elderly patients safer. The accomplishments of gerontology are not simply an increase in the number of older people who spend increasing years mired in increasing disability. In fact, disability rates among the elderly are declining. Eighty-nine percent of individuals between the ages of 65 and 75 report no disability and more than 40% of individuals over 85 years of age are fully functional. 45 Indeed, gerontology is not simply the study of age-related diseases and chronic conditions such as Alzheimer's disease. There is increasing interest and knowledge concerning healthy aging. Rowe and Kahn, for example, distinguish usual (nonpathologic but high-risk) from successful (low-risk and high function) aging. 46 Successful aging is defined as including: "low probability of disease and disease-related disability, high cognitive and physical functional capacity, and active engagement with life." 47 Many older individuals with systolic hypertension, increased blood glucose, and excess abdominal fat used to be considered normal but are now seen as experiencing usual aging, since these changes convey an increased risk of disease or dysfunction. An important corollary is that many of the alterations associated with usual aging are susceptible to alteration by changes in lifestyle or through specific treatment. Basic science has also begun to use the concept of successful aging to advance our understanding of senescence from molecular, cellular, and physiologic perspectives. 15,27,39 Multidisciplinary efforts have identified lifestyle, psychosocial, and nutritional factors that have an impact on the maintenance of high physical and mental function. This information has been compiled in several popular presentations that have found great interest among baby boomers and their parents.* *Rowe JW and Kahn R: Successful Aging, Academic Press, 1998 and The RealAge Program at www.realage.com Almost all anesthesiologists care for elderly patients every day. However, the level of interest in geriatric physiology is historically less than for obstetric or pediatric physiology. A recent informal survey of United States residency programs discovered that an average of less than 3 hours of formal teaching time during residency training was dedicated to geriatric issues. Hence, we describe new opportunities, or opportunities for improvement, in four realms of anesthetic practice. First, we will discuss some examples of aging physiology that impact on anesthetic care. Second, we will discuss some of the means by which a practice can be optimized to care for elderly patients, focusing on balancing patient satisfaction and efficiency. We will then suggest that research into anesthetic care of the geriatric patient is the principal research opportunity in clinical anesthesia at the onset of the twenty-first century. Finally, we will briefly address the subject of palliative care, a newly recognized area in geriatric medicine ripe for collaboration with anesthesiology.