As Dr. Barnett et al. have so aptly described in Springer’s 2013 release entitled Manual of Geriatric Anesthesia, the elderly and aged population globally is growing at a rate never before seen. As practicing anesthesiologists, we shall be taking older often sicker patients to the operating room much more frequently and must find ways to manage them. I will certainly never forget the oldest patient I have anesthetized to this point in my career; I was a first-year attending, on-call in the middle of the night when a frail 104-yr-old woman required emergency surgery. Fortunately, my patient did fine, but not without testing my mettle.
Manual of Geriatric Anesthesia is comprised of 25 chapters divided into five parts and contains color charts, diagrams, and photos. The authors describe quite beautifully the greater impact of the aging population on the future of anesthesia practice while touching on public health concerns, finance, and sociology. The rapidly increasing elderly population is a worldwide phenomenon and the statistics provided are staggering. The World Health Organization predicts that the 600 million people aged 60 yr and older in 2000 will grow to an estimated 1.2 billion in the year 2025 and 2 billion by the year 2050. Although historically, elective procedures in patients older than 50 yr of age were uncommon, it has become commonplace to see octogenarians and older patients on our daily operating room schedules. Quite clearly, as Barnett et al. elaborate, this patient population often requires unique considerations due to various contributing factors, such as multiple comorbidities, polypharmacy with an ever-present potential for drug interactions, and side effects compounded by the relative decline in major organ systems, to name just a few.
The manual is far from an anesthetic prescription. Rather, the authors do a wonderful job of discussing in detail the pertinent facts surrounding procedures commonly performed in the elderly population, such as cataracts, hip fractures, and cardiac surgery. For example, chapter 22, entitled “Management of the Hip Fracture Patient,” is devoted to the epidemiology, anatomy, repair, and system-wide implications of this all-too common ailment. Per the text, it is estimated that there were 340,000 hip fractures in the United States costing the healthcare system approximated $8.5 billion dollars in 1995. One can only guess what the social and financial impact secondary to hip fractures will be when the elderly population has doubled.
The overall tone of the text is current and informative, well-written, and relevant. Common ailments and surgical procedures in the elderly are discussed individually in detail. What stood out to me was the effort put forth by the authors to demonstrate that an all-encompassing care plan composed of geriatricians, anesthesiologists, surgeons, and other support services is not only possible but also necessary and beneficial. The occasionally forgotten and sometimes easily ignored social and psychological aspects associated with the elderly population and surgery are described vividly as the authors state, “it has been clear since early in the history of modern anesthesia, … that patients have cognitive and behavioral changes following surgery.” Pulitzer Prize–winning author Larry McMurtry, who wrote Terms of Endearment, described his own struggles with postoperative cognitive dysfunction by saying he felt that he went “From being a living person with a distinct personality … to more or less like an outline of that person—and then even the outline began to fade.”
It is not uncommon for anesthesiologists to say one of the reasons he or she chose the field was to avoid a long-term relationship with their patients or rather the appreciation of immediate gratification. We often have very brief introductions quickly followed by premedications, then we are off to the operating suite. This text does a wonderful job of discussing the process of performing an anesthesia on an elderly person in its entirety. It is not simply the “hip” in operating room 8, but a person with a family, a patient with multiple factors that need to be considered throughout the entire perioperative process, not just in the postanesthesia recovery unit.
One would be hard pressed to find a more relevant topic in the field of anesthesiology than geriatric anesthesia now and for the foreseeable future. I believe this text is a worthwhile read and I highly recommend it for all practicing anesthesiologists as we will undoubtedly be caring for more elderly patients in the time to come.