SOCIETY FOR THE
ADVANCEMENT
OF
GERIATRIC
Anesthesia
NEWSLETTER
Volume 1, Number 1 January 2011
Author: Zhongcong Xie
SAGA MEMBERS IN THE WORLD
Invited by the Society of Chinese Anesthesiology (CSA), SAGA member Drs. Sheila Barnett and
Zhongcong Xie attended the annual meeting of CSA in Beijing on September 24 – 26. Dr. Barnett‟s lecture
title was “Geriatric Anesthesia”, Dr. Xie talked about the anesthesia neurotoxicity. The following pictures
were taken in the meeting and in the Great Wall of China.
Please e-mail Dr. Zhongcong Xie (zxie@partners.org) your stories, we will publish them in the Newsletter.
Author: Chris Jankowski, M.D.
GERIATRIC ANESTHESIA: CLINICAL OVERVIEW
Geriatric patients present a host of challenges to the clinical anesthesiologist. Some of these are seemingly
mundane but can have a significant impact on outcome. An example is taking care to avoid positioning-
related injuries in patients who are frail or have significant arthritis. Others, such as maintaining appropriate
intravascular volume in patients who, because of an aging cardiovascular system, are prone to hypotension
and congestive heart failure in the face of hypo- and hypervolemia, respectively, require vigilance, but are
well-understood clinical issues. However, there is another category of challenges: those of concern to
patients, but for which we have few answers. Postoperative central nervous system dysfunction (PCNSD)
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falls into this category, and may be the defining syndrome of geriatric anesthesia.
Because of media attention to the issue, many patients are aware of PCNSD. Recently, I saw a patient in the
preoperative clinic who was preparing to have a knee replacement. He in his 70s and had a number of
chronic conditions that were under moderate control. He had had his other knee replaced several years ago,
and both the patient and his son said that he had had noticeable cognitive difficulties since then.
Specifically, he found it more difficult to manage his finances. His primary concern about the upcoming
operation was whether he was likely to experience further decline.
Despite being first described over fifty years ago and being among the most common complications in
elderly surgical patients, there was little systematic investigation of PCNSD until more recently. There are
two primary forms of PCNSD: delirium and postoperative cognitive dysfunction. Delirium is a disturbance
of consciousness associated with perceptual disturbances that tends to fluctuate over the course of the day
and cannot be explained by a dementia. Delirium in the postoperative period further divided into emergence
delirium – that which occurs immediately upon awakening from general anesthesia – and postoperative
delirium (POD), which typically presents on postoperative days one to three.
Postoperative cognitive dysfunction (POCD) is the other main form of PCNDS. POCD is not a formal
diagnosis. Rather, it is a research construct whose definition varies from study to study. However, POCD
may be broadly defined as cognitive decline temporally related to anesthesia and surgery. A series of
landmark studies beginning in the late 1990s by the International Study of Postoperative Cognitive
Dysfunction Group and others increased awareness amongst both the medical and lay communities.
Although its mechanisms are poorly understood, age is a major risk factor for all forms of PCNSD.
Laboratory studies have investigated the hypothesis that volatile anesthetics contribute to PSCND (see
accompanying article in this issue). Volatile anesthetics impair learning and performance of previously
learned tasks in aged rats. And in cell culture models, they cause increases in the production and
oligerimization of beta-amyloid and apoptosis. These events are consistent with the pathological changes of
Alzheimer‟s disease.
Normal aging is associated with diminished cognitive reserve. However, few clinical studies have
examined whether anesthesia and surgery contribute to pathological long-term cognitive decline. A recent
article by Avidan, et al. addressed this question. In this retrospective cohort study, participants in the
Washington University (St. Louis, MO) Alzheimer‟s Disease Research Center database were followed.
They underwent an annual clinical examination that included extensive psychometric testing. The 575
participants were divided into three groups: (1) those who had not undergone surgery and had no history of
major illness, (2) those who had undergone surgery, and (3) those who had a history of major illness
requiring hospitalization, but who had not had surgery. 361 participants had mild or very mild dementia at
enrollment and 214 were not demented. Severity of dementia was determined using the University of
Washington Clinical Dementia Rating Scale (CDR) in which scores of 0, 0.5, 1, 2, or 3 indicate, no, very
mild, mild, moderate, or severe dementia, respectively. The authors followed the trajectory of participants‟
cognitive decline. As might be expected, cognitive status in participants with higher CDR scores at entry
declined more markedly than those without dementia. But cognitive trajectories did not differ between
participants who had surgery, major illness or neither. Surgery and major illness were not major predictors
cognitive decline or transition to dementia.
Though the study is not without limitations. For example, participants had a wide variety of surgeries and
medical illnesses. It may be that specific operations or medical illness are more likely to be associated with
long-term cognitive decline. In addition, cognitive testing was performed at annual intervals, so the authors
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were not able to determine whether patients had short- or medium-term PCNSD. Thus, the study does not
address whether PCNSD is associated with long-term declines. However, it suggests that surgery in the
elderly should proceed based on its necessity and the patient‟s ability to tolerate the surgical episode from a
medical standpoint, rather than concerns about adverse long-term cognitive outcomes.
Clearly, our understanding of the cognitive sequelae of anesthesia and surgery in older patients is
incomplete and much work remains to be done. However, a number of ongoing laboratory and clinical
projects – many of them headed by members of SAGA – will provide better understanding of this issue in
coming years.
Author: Sheila Barnett, M.D.
GERIATRIC ANESTHESIA: EDUCATION ASPECT
The importance of education on geriatric issues has long been recognized as an important
requirement for health care professionals; however the development of educational programs in aging in
most specialties has been slow, especially in the surgical specialties. As we consider the challenges of
training the next generation of anesthesiologists in this turbulent time in healthcare, it is important to not
forget the unique needs of the elderly and their growing numbers in our practices.
Many of the advances in education in geriatric anesthesiology in recent years have been possible because of
the support of the American Geriatric Society „Geriatric for Specialists Initiative‟ (GSI). Originally
established in 1994 and supported though grants from John A. Hartford Foundation and other private
contributors, the GSI has provided funding and leadership to advance geriatrics in the surgical specialties in
many arenas including research and education. In addition to individual grants, the GSI was instrumental in
creating the White Paper on retooling the American health force produces by the IOM and released in April
of 2008. (http://www.iom.edu/Reports/2008/Retooling-for-an-Aging-America-Building-the-Health-Care-
Workforce.aspx) This document outlines the „short fall‟ of our health care system and emphasizes the need
to prepare our entire healthcare force for the change demographics of our society. The workforce was
chaired by Dr. Jack Rowe, one the early pioneers in Geriatric Medicine. It is a valuable read for those
interested in a diverse look at healthcare as a whole and offers a new perspective on the vast numbers of
professionals it will take to care for the elders in our future.
The GSI is now in its 5th phase of funding and the Surgical Specialty group has metamorphosed into the
Council for the Section for enhancing Geriatric Understanding and Expertise among Surgical and Medical
Specialists (SEGUE). This council brings together expertise form many surgical specialties such as
orthopedic surgery, ophthalmology , emergency medicine and urology and others. Dr Jeffrey Silverstein,
former SAGA President and founder, has chaired the council for the last year and with Dr John Burton of
the AGS and others has successfully navigated this council through some difficult financial times. The
SEGUE has been instrumental in preserving the valuable Jahnigen fellowships (see the section on research
for more information) and has worked closely this year with many important agencies within the surgical
specialties including anesthesiology. A major product of the GSI and SEGUE has been the geriatric
education grants dedicated to enhancing geriatric principles into the curriculum for specialty residents
(GSR). These are educational grants that have been awarded to subspecialties to partner with geriatrician
and develop curricula for their residencies. From 2001 – 2011 the GSR has funded 90 of these grants, and 8
of these have been in anesthesiology; several have been awarded to SAGA members. For further
information please visit the website: re detailed information on SEGUE and the AGS:
http://specialists.americangeriatrics.org/
Educational progress has not been limited to the contributions of the AGS. In 2007 the AAMC published
core competencies in geriatric medicine – these are now required for all medical students prior to
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graduation. (http://www.aamc.org/newsroom/presskits/competencies.pdf) The establishment of these
competencies helps to identify the challenges facing healthcare, but these alone will do little to impact
geriatric expertise in specialties such as anesthesia.
One of the most promising initiatives that being undertaken to ensure basic geriatric competence for
our future graduates is the work being by the American Board of Anesthesiology (ABA) and ACGME.
These two entities are working together to include geriatric issues within the recommended ACGME
curriculum. This is a work in progress, and we look forward to an „ageist‟ outcome, fortunately Dr Deborah
Culley, a long time SAGA member and founder has been appointed to the RRC, and we will be hope she
will be able assist in to keeping geriatrics „on the table‟ at the ACGME.
Along with supporting education efforts in geriatrics for our residents, the ASA has also included the
information for seniors on their website. These geriatric modules can be viewed at:
http://www.lifelinetomodernmedicine.com/.
In conclusion, education efforts in Geriatric Anesthesiology continue to grow and there are many
opportunities to improve and expand our efforts. However our success so far has to be balanced against the
enormity of the issues –millions of our patients will be elderly in years to come and we need to ensure that
our future anesthesiologists are ready – definitely „a work in progress‟.
Author: Zhongcong Xie, M.D., Ph.D.
GERIATRIC ANESTHESIA: RESEARCH AND FUNDING OPPORTUNITY
Anesthesiologists who are interested in geriatric anesthesia research can apply for both federal and
non-federal grants to support the research. Part of these grants will be described in the followings.
1. Foundation for Anesthesia Education and Research (FAER):
This grant opportunity is for junior anesthesiologists who want to have training in clinical, basic
science and translational anesthesiology research. There are mentored research training grant (basic science
or clinical and translational research), research fellowship grant and research in education grant. In addition
to general FAER grant, there is specific grant application to support studies related to geriatric anesthesia,
e.g., postoperative cognitive dysfunction. The deadline for the application is February 15 each year. More
information can be found from FAER website (http://www.faer.org).
2. The Dennis W. Jahnigen Career Development Awards Program:
The Dennis W. Jahnigen Career Development Awards Program is sponsored by American Geriatric
Society. This grant opportunity is also for junior anesthesiologists who want to have training in anesthesia
research under the supervision of mentor(s). The grant will support anesthesiologists to do geriatric
anesthesia-related research for two years. For details, please check the website
(http://www.americangeriatrics.org/hartford/jahnigen.shtml).
3. Paul B. Beeson Career Development Awards in Aging Research Program:
The Beeson award is funded by the National Institute on Aging, the John A. Hartford Foundation,
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the Atlantic Philanthropies,
the Starr Foundation, and is administered by the National Institute on Aging
and the American Federation for Aging Research. The award will support research related to aging and
aging-related disorders, including geriatric anesthesia studies. The Beeson website
(http://www.afar.org/beeson.html) can provide more information.
4. K12:
The K12 [National Institute of Health (NIH) Institutional Research and Academic Career
Development Award] is awarded to a senior researcher in university or hospital. The junior anesthesiologist
can apply for this grant from the senior researcher. The K12 grant can provide about $ 60,000 for salary and
$ 20,000 for research supply for two or three year. National Institute on Aging and National (NIA) and
National Institute of General Medical Sciences (NIGMS) are among the institutes of NIH to fund the K12
award.
5. K08 or K23:
The NIH K08 (Mentored Clinical Scientist Research Career Development Award) or K23 (Mentored
Patient-Oriented Research Career Development Award) will support junior anesthesiologists up to five
years to perform research. The award includes support for salary and research supply. The K08 or K23 grant
application includes both science part and the equally important career development section. It is generally
suggested that the junior anesthesiologists who want to apply for K08 or K23 should talk to the
anesthesiologists who obtained the K08 or K23 before to learn the lessens and experiences.
6. R21 and R01:
Both R21 and R01 are the NIH independent research grants, which support the applicant for two and
four or five years, respectively. Recently, there are several changes in the R21 and R01 application,
including the page limitation and new review criteria. The junior anesthesiologists are encouraged to read
the NIH website for the full description of R21 and R01, as well as to attend grant writing classes offered by
universities or hospitals.
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