Developing the concept of Geriatric anesthesia Fritz Sieber, M'D'

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Developing the concept of Geriatric
anesthesiaFritz Sieber, M.D.

• Objectives
• To present an overview of how the curriculum in
  Geriatric Anesthesia was developed
• To discuss why Geriatric anesthesia is still
  suffering from an identity crisis in the US
• To present possible solutions to successfully
  developing the specialty area of Geriatric
  anesthesia

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Geriatric anesthesia curriculum

• Residency level
• Textbook
• American Society of Anesthesiologists

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American Geriatrics Society Geriatrics Education
for Specialty Residents (GSR) grants

• Program has supported surgical and related
  specialty residencies to pilot methods for
  integration of geriatrics within residency
  programs
• Encourage development of curricular content

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Stipulations of the American Geriatrics Society
grants

• Collaboration with the Geriatrics program in the
  participating institution
• Setting a structured curriculum
• Use of technology

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How were grant recipients supposed to design a
geriatric anesthesia curriculum?

• Geriatric input was provided by the AGS and
  included two books
• Geriatric Syllabus for Specialists (primarily for
  surgeons)
• Geriatrics at your fingertips (http//www.geriatri
  csatyourfingertips.org/)

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Geriatrics at your fingertips

• Not a textbook
• Quick guide for referral including many
  assessment instruments
• Covers a myriad of problems which beset the
  elderly
• Relevance of this information to the practicing
  anesthesiologist is unclear

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Problemmuch of the suggested curriculum was not
specific to anesthesia

• Geriatrician on grant proposal (Colleen
  Christmas) for advice
• Looked at Geriatric topics covered on the
  Anesthesia written board examination
• Selectively utilized the AGS resources

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important themes in geriatric anesthesia
incorporated into resident curriculum

• Pharmacology
• Organ specific aging
• Elderly specific complications (particularly CNS)
• Focus on board exam topics limited the overall
  content

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difficulties with writing a textbook on Geriatric
Anesthesia

• Deciding what other topics were relevant for a
  book on Geriatric Anesthesia
• Lack of information specific to the elderly
• Editing book becomes labor intensive as many
  authors had difficulty maintaining focus on
  anesthesia issues specific to the Geriatric
  patient

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important themes in geriatric anesthesia
incorporated into textbook

• Used the previous geriatric curriculum put
  together by Alec Rooke on the ASA website
  (http//www.asahq.org/clinical/geriatrics/syllabus
  .htm) for suggestions
• Pharmacology
• Organ specific aging
• Elderly specific complications (particularly CNS)
• Social/societal issues
• Elderly specific management issues (ICU, pain)
• LIMITED BODY OF GERIATRIC FOCUSED INFORMATION

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Examples of inability to maintain focus on issues
specific to geriatricscardiovascular chapter

• Topics covered included MI CHF A Fib AICD
  preoperative cardiac evaluation
• ? What is new and specific to geriatrics
• When AGS materials and other textbooks are
  examined, the content is similar to what
  anesthesia authors thought was important

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Reasons for inability to maintain focus on issues
specific to geriatrics lack of data

• In chapter on consciousness monitoring the author
  states-there is a paucity of data specifically
  pertaining to consciousness monitoring in the
  elderly
• In chapter on acute pain management few studies
  quoted which examined the elderly population

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ASA committee on geriatric anesthesia put
together a syllabus

• Nuts and bolts of curriculum topics agreed on by
  committee of recognized experts
• contained on ASA websitehttp//www.asahq.org/clin
  ical/GeriatricAnesthesiologyCurriculum_123007.pdf
• Intent is to provide residency programs an
  outline for teaching content

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Efforts in continuing medical education

• ASA annual meeting contains refresher courses and
  learning tracks with Geriatric content
• Emerging role of practice review
• SAGA

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Why is there still an identity crisis for
Geriatric Anesthesia?
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The issue is lack of specificity

• The information may not be unique to the elderly
  population
• Only a few areas are specifically relevant to
  geriatrics
• Need make our case for geriatric anesthesia by
  doing a better job of cataloging geriatric
  specific information/insights
• Lack of evidence based information- especially in
  terms of patient management

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US Population
www.census.gov
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Possible means of developing approaches and an
information base which is specific to geriatrics

• Changes with aging and their implications for
  pharmacokinetics and pharmacodynamics
• Build on the multidisciplinary care model
• Geriatric specific evaluation
• Research
• Evidence based knowledge compilation for
  Geriatric anesthesia

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Best practice in managing geriatric patients
involves a multidisciplinary care approach
N Engl J Med 311(26)1664, 1984

• These types of models have been shown to be
  effective in trauma, intensive care, and pain
  management
• We need to better define the roles and
  interactions between the specialties
• Nursing is a particularly underutilized resource
• How does Anesthesia fit into streamlined surgical
  care of the elderly

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Example of multidisciplinary care
approach-structured clinical protocols for
delirium prevention

• Specialist delirium units may represent best
  practice model
• Structured clinical protocols assess for delirium
  risk factors
• Targeted risk factor modification

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Some examples of risk factors targeted for
intervention
NEJM 340669, 1999

• Cognitive impairment-what is the best anesthetic?
• Sleep deprivation-best anesthetic or means of
  pain management?
• Immobility-how to provide rapid mobility through
  pain management techniques
• Dehydration-newer studies looking at various
  means of intraoperative fluid management

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Should we incorporate the Geriatricians approach
into preoperative evaluation-i.e. use the
comprehensive geriatric assessment

• Demonstrates that the elderly patient is a
  different animal
• Utilizes information and approaches which are
  specific to geriatrics
• Incorporates many of the principles of geriatrics
  into the anesthesia mindset

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Outcomes reassessment

• Traditional outcomes include morbidity and
  mortality
• In older population may need to redefine more
  robustly using quality of life, therapeutic
  tolerance, symptom control and function

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Functional assessment

• Activities of Daily Living (ADL) are required for
  maintenance of basic, independent living and
  include bathing, toileting, dressing and
  feeding. 
• Deficits in ADLs are predictive of
  post-hospitalization and 2-year overall
  mortality  
• Instrumental Activities of Daily Living (IADL)
  include shopping and cooking, house and money
  management, transportation and ability to take
  medication.   IADLs reflect ones ability to
  function within society
• Deficits in IADL are predictive of poor
  therapeutic tolerance, and often are harbingers
  of ADL deficits

We need to know what this means for anesthesia!
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polypharmacy

• common among community-dwelling elders
• The average patient takes gt 4 prescribed
  medications (not including OTC or CAM)
• increased risk for side effects and drug
  interactions (competition, binding, pH
  modification)

What are the pertinent anesthesia issues?
Analogous statements could be made for
nutritional factors
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Some research priorities have already been set by
Research Agenda-Setting Project (RASP) of AGS

• What preoperative assessments are useful in
  developing patient management plans for surgeries
  common in the elderly?
• Can postoperative analgesic techniques reduce
  postoperative morbidity or improve functional
  status at discharge?
• How can postoperative pulmonary complications in
  the elderly be reduced?

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Two approaches to building a library of geriatric
specific information on patient management which
is evidence based

• Use the Cochrane database approach
• Try to collate what others have already analyzed

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Caveat we are able to agree on several issues
regarding the elderly

• We have to agree on a definition of the elderly
• Elderly population is more robust and healthier
  than ever before
• The nature of surgery has changed dramatically
• Anesthetic and medical care has changed
  dramatically

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Age of the Oldest 6 of the U.S. Population
Average increase of 0.13 years per year!
www.census.gov
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Cochrane reviewsSome areas where the results are
specific to geriatrics

• Epidural pain relief vs opioid-based pain relief
  for abdominal aortic surgery
• Interventions for protecting renal function
  during the perioperative period
• Peribulbar vs retrobulbar anaesthesia for
  cataract surgery
• Perioperative fluid volume optimization following
  proximal femoral fracture

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Other examples of EBM with focus on geriatrics

• National guideline clearinghouse
  (www.guideline.gov)
• E.g.-acute pain management in older adults
• Studies, results and evidence levels already
  outlined for the reader

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Proposal to AAA

• Collate available evidence based summaries in one
  place which are specific to Geriatric
  anesthesia-easiest
• Develop needs assessment and fill in the gaps
  with new research or a Cochrane based literature
  review-much more work
• The approach for each summary in this EBM
  database could be loosely based on an ask the
  expert format
• Develop an open access journal based on evidence
  based summaries or submit to open access
  journals-allows work to receive academic credit
• divide and conquer-Geriatric anesthesia
  organizations coordinate their topics and work
  together to accomplish this goal