James C. Eisenach, M.D., Editor.
Geriatric Anesthesiology. Edited by Charles H. McLeskey. Baltimore, Williams & Wilkins, 1997. Pages: 703. Price:$85.00.
Anyone who provides anesthesia for adults is aware that the future is old. The elderly population receives a disproportionate amount of surgery, and their numbers are steadily increasing. Our specialty has long been aware that the treatment of an elderly patient requires a more gentle touch than the care of a robust 20-yr-old. Interest in the mechanisms behind these differences and how best to modify anesthetic techniques for the elderly population increases steadily, judging from the content of the educational programs at national anesthesia meetings. In a sense, this interest has now culminated in the publication of the first comprehensive textbook of anesthesia for the elderly population.
With an average length of only 12 pages, exclusive of references, most of the 48 chapters in this multi-authored textbook are short enough to absorb in a single sitting. This strength of the text is much appreciated by the reader because most chapters contain vast quantities of facts that need to be there for the sake of completeness but can make for soporific reading. It also appears that each chapter was designed to be a self-contained unit. This, too, is helpful because it is impossible to read all related chapters in a single sitting. The disadvantage to this approach is that many chapters provide a review of the basic physiologic changes of aging to present a logical basis for the proposed modifications in anesthetic management. In addition to qualifying for the Department of Redundancy, these mini-reviews are rarely as good as the chapter devoted to the topic in the first place, and sometimes the information is contradictory. Sometimes topics become too fragmented. For example, different aspects of anesthetic risk comprise major portions of at least three separate chapters.
The first two sections of the textbook cover demographics and the basic physiology of aging. The latter chapters frequently include a discussion of disease processes that are common in the elderly population. This additional material is particularly useful because one is less likely to encounter a healthy elderly patient than one with some level of chronic disease. The disease summaries are tailored to that which is clinically pertinent to anesthesiologists and, whenever possible, describes the interaction of disease and aging as it relates to physiologic reserve and the stress of anesthesia and surgery. What is lacking from many of these chapters is a discussion of how anesthetic management needs to altered by either disease or aging. Nevertheless, some of the chapters are so good (e.g., respiratory, pharmacology) that they are worth reading even if one is not interested in aging.
The next section, 26 chapters, comprises the bulk of the textbook and describes a variety of issues in the anesthetic treatment of the elderly population. Topics include preoperative evaluation and preparation, details on the use of most every anesthetic drug, temperature regulation, regional versus general anesthesia, monitoring, ICU care, pain management, trauma, cognitive changes with surgery, cardiopulmonary resuscitation, drug interactions, and positioning. The final 12 chapters deal with surgical procedures common to the elderly patient plus a chapter on the mechanisms of aging. The diversity of topics includes material that is applicable to more than just the elderly population. Although this material can be found in other textbooks, its inclusion works surprisingly well because it is presented with the perspective of the elderly patient and allows the reader to gain new insights on seemingly mundane information.
Overall, the chapters are well written and comprehensive. Figure shave been appropriately selected and effectively illustrate important points. Unfortunately, some chapters are already out of date with few or no references more recent than 1990. In consequence, a number of key references are lacking. One “criticism” that is not the fault of the textbook is incomplete knowledge of the response by the elderly population to a variety of anesthetic techniques. When it is not known why elderly patients respond differently or how an anesthetic technique should be modified for the elderly, the author can offer little more than to state that one should be more “careful” with the elderly population. The frequent appearance of such platitudes speaks to the need for further research.
In summary, the text represents a strong beginning toward a compilation of all that is known about anesthesia for elderly patients. It is a good reference textbook, suitable for residents and experienced practitioners. Geriatric Anesthesiology is well worth its modest price of $85.00.
G. Alec Rooke, M.D., Ph.D.
Department of Anesthesiology; University of Washington; Seattle, Washington 98195