To the Editor:—

Dr. Rooke et al . provide much food for thought in their recent editorial. 1They neatly describe the predicament that we as anesthesiologists face, namely, the challenge of caring for an increasingly aging population. Anesthesiology as a specialty has experienced a significant expansion in the direction of laboratory-based research in the past decade, perhaps sacrificing a more holistic view of the delivery of perioperative care. The older patient is particularly in need of such a multidisciplinary approach. A pertinent example is that of the older patient undergoing ambulatory surgery. Preoperative assessment should include evaluation of social circumstances, not just who is at home, but how many stairs the patient will have to go down to the bathroom.

Cognitive assessment before surgery is vitally important to the issue of valid consent. A Mini Mental State Examination 2(MMSE) score of 19 infers that the patient is incapable of making safe decisions and transfer of power of attorney may be necessary before proceeding with surgical intervention.

A patient with a MMSE score of 26 may be managing just fine in her own environment, but will become agitated in the alien atmosphere of the hospital facility. This agitation may earn her the administration of further sedation! Further cognitive decline can be anticipated for up to 1 week after surgery and anesthesia. 3This means we need to know who is going to manage the medications during that important first week. Prescribing optimal analgesia will be futile if our patient does not remember where she left those pills and what time she should take them. Other simple issues, usually beyond our remit, include nutrition and mobility. If the perioperative period encompasses the safe and effective recovery of our patients, then who gets the shopping and cooks the meals is something we should be aware of. So when was the last time we asked any of these questions? Anesthesiology for the older patient is nothing new per se , we have been managing elderly patients in the operating room, postanaesthesia care unit, and intensive care throughout the development of our specialty. What is a challenge is the holistic approach to clinical practice. Whether this means a new subspecialty interest or departmental leaders in the field remains to be seen.

Rooke GA, Reves J, Rosow C: Anesthesiology and geriatric medicine. A nesthesiology 2002; 96: 2–4
Folstein MF, Folstein SE, McHugh PR: A Practical method of grading the cognitive state of patients for the clinician. J Psych Res 1975; 12: 189–98
Moller JT, Cluitmans P, Rasmussen LS, Houx P, Rasmussen H, Canet J, Rabbitt P, Jolles J, Larsen K, Hanning CD, Langeron O, Johnson T, Lauven PM, Kristensen PA, Biedler A, Van Been H, Fraidakis O, Silverstein JH, Beneken JEW, Gravenstein JS, for the ISPOCD investigators: Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study. Lancet 1998; 351: 857–61
for the ISPOCD investigators