Perioperative Education in Geriatrics
Angela G. Catic, MD Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, Texas
Sheila Barnett, MD Beth Israel Deaconess Medical Center, Boston, Massachussets
Secondary to declining fertility and increasing life expectancy, the median age of the world’s population is increasing. In the United States, the population of people aged 65 years or older is expected to double in the next 20 years.1 With the aging of America, the number of individuals aged 65 years and older will increase from 35 million in 2000 to 71 million in 2030. The number of oldest old, aged 80 years and older, will catapult from 9.3 to 19.5 million during the same timeframe. The percentage of the population living into late life is also projected to increase from 13% in 2000 to over 20% by 2030.2 This aging trend is also occurring on a worldwide basis. The number of individuals aged 60 years and older is growing by 2%/y, and those aged 80 years and older are growing by 3.8%/y. By 2050, the percentage of people aged 60 years and older worldwide is expected to be 21% and will exceed the number of younger individuals for the first time in history. The number of older patients undergoing surgical procedures is also increasing. Currently, 30% to 40% of all surgeries are performed on elderly patients. Although advancements in preoperative screening, perioperative care, and new surgical techniques have contributed to making surgery safer for elders, there is risk involved. Population-based evidence from Washington state found that 90-day mortality increased sharply with age from 2.5% in individuals aged 65 to 69 years to 16.7% among those aged 90 years and older.3 In addition to advancing age, increasing numbers of medical comorbidities are also associated with worse surgical outcomes. Nursing home residents, often considered the frailest elders, experience significantly higher rates of postoperative complications and mortality compared with noninstitutionalized Medicare enrollees.4
REPRINTS: ANGELA G. CATIC, MD, BAYLOR COLLEGE OF MEDICINE AND MICHAEL E. DEBAKEY VA MEDICAL CENTER, HOUSTON, TEXAS. E-MAIL: [email protected] INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 52, Number 4, 1–13 r 2014, Lippincott Williams & Wilkins
www.anesthesiaclinics.com | 1
2
’
Catic and Barnett
Despite the high numbers of elders undergoing surgical procedures and the increased risk of adverse outcomes, there is a significant lack of formalized training regarding the unique issues encountered in elderly surgical patients. Although it has been recognized that incorporating geriatrics throughout medical education is critical to a successful integrated aging program, there are no widely disseminated geriatric curricula within most anesthesia programs.5–8 This is especially of concern given the shortage of geriatricians and the growing need for anesthesiologists and other surgical specialists to have a strong geriatric knowledge base to enable optimal care of their elderly patients. Never has this been more important than now as anesthesiologists seek to expand their roles as perioperative physicians. There are multiple challenges to creating a robust, sustainable geriatrics curriculum for anesthesiologists and surgical subspecialists. The increasing demand to cover an ever growing body of medical knowledge is not unique to anesthesiology and presents a challenge for medical educators in all specialties. However, many physicians do not recognize the need for specialized geriatric education as they care for many elders in the course of their practice and believe that this qualifies them to care for geriatric patients. The current recognition of the need for geriatric education, combined with the lack of a dedicated aging curriculum for most specialists, make this the ideal time to develop and implement integrated geriatric curricula for anesthesiologists and surgical specialists.
’
Postgraduate Education
The American Council for Graduate Medical Education (ACGME) and specialty boards have increased the oversight and regulation of postgraduate medical training over the last several years. Working with the ACGME, the American Board of Anesthesiology has established required competencies and a set anesthesiology curriculum. All residents must demonstrate proficiency within competency categories: essential attributes, patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, systems-based practice, clinical skills, and overall clinical competence. The ACGME and American Board of Anesthesiology both require basic knowledge in aging physiology, pharmacology, and evidence of management of elderly patients. However, formal requirements regarding education in geriatric anesthesia are limited to the general directive that trainees should receive appropriate didactic instruction and clinical experience caring for elderly patients. Despite an overall dearth of formalized geriatric education for anesthesiologists, there are a number of geriatric anesthesiology www.anesthesiaclinics.com
Perioperative Education in Geriatrics
’
3
resources available. The Society for the Advancement of Geriatric Anesthesia, an US-based society that provides education on geriatric anesthesia and valuable networking opportunities for those with a special interest in caring for elders, was established in 2000. The American Geriatrics Society, the Reynolds Foundation, and the John A. Hartford foundation also encourage geriatric education among the surgical specialties, including anesthesiology, through educational grants. Unfortunately, most institutions have experienced difficulty in sustaining the curricular interventions beyond the funding period. Online and print resources are available to assist in building an anesthesiology and surgical specialty geriatric curriculum. The Portal of Geriatric Online Education is a public Web site with a robust collection of geriatric educational materials that can be used free of charge http:// www.pogoe.org. The educational offerings are updated on a regular basis and include downloadable problem based learning discussions, didactics, and virtual patients. The Portal of Geriatric Online Education is also an excellent forum for anesthesiologists and surgical specialists to submit their educational materials, thus building their educational portfolios and allowing others to benefit. The American Society of Anesthesiologists has several geriatric anesthesia resources available, including a curriculum and booklet of frequently encountered clinical questions related to the care of geriatric patients http://www.asahq.org. Geriatric anesthesia and surgical specialty textbooks are also available.9,10
’
Geriatric Anesthesia Curriculum Development
To develop a meaningful geriatric anesthesia curriculum, educators must focus on areas that are common or have significant morbidity among elders in which there is sufficient geriatric research and knowledge to support the educational program. In addition, the curriculum must be tailored for the culture of the learners. Whereas geriatrics is traditionally an intellectual specialty where in-depth discussions about a single patient are prized as an educational method, anesthesia is a highly technical field often requiring quick decisionmaking capability and the ability to manage multiple patients simultaneously. As such, a curriculum that includes learning experiences tailored to this type of environment is required. The integration of simulation into anesthesia curricula has been popular and successful. This is an excellent tool to use to include geriatrics in a way that is both relevant and exciting to anesthesiologists. For example, a simulation session involving a delirious postoperative elder in the post-anesthesia care unit can be used to teach about the physiology of aging, intraoperative issues, pain management, and delirium. Other effective educational modalities include case discussions, team training, games www.anesthesiaclinics.com
4
’
Catic and Barnett
(Jeopardy, etc.), online modules, and multidisciplinary sessions with anesthesiologists, geriatricians, and surgeons to review challenging cases, present varying treatment strategies for common geriatric issues, and discuss how to further collaborate in the care of elders. Determining who will present curricular content is also an important consideration. Many learners will respond best to an anesthesiologist who is well versed in geriatric issues, as this individual will have more working knowledge of anesthesiology and be familiar with that culture. However, it can be very beneficial to engage a geriatrician for a portion of the teaching. Geriatricians are often particularly effective in teaching about goals of care, polypharmacy, physiology of aging, and cognitive issues. It is important for the anesthesiologist directing the curriculum to work with geriatricians to ensure that all presentations are relevant to the learners. ’
Development of a Curriculum
The core age-related areas that should be covered in a geriatric anesthesia curriculum are described below.11,12 As in all areas of medical education, it is important to continually edit curricular content as medical knowledge and learner needs evolve over time. Physiology of Aging
Education regarding age-related physiological changes provides an important foundation for understanding the normal aging process including why elders often have atypical presentations of disease and how to appropriately adjust medication dosages. Normal aging is associated with a loss of homeostasis and, secondary to a decrease in physiological reserve, elders often present early in the course of disease and often face increased surgical complications and a prolonged recovery period compared with younger individuals. Although all systems undergo age-related changes, a clear understanding of the alterations in the central nervous, cardiopulmonary, and renal systems are particularly key in caring for older surgical patients. It is important to differentiate between the changes in normal aging and pathology (Table 1). This information is often best presented in case-based discussions, so that learners can appreciate how the physiological changes of aging impact clinical outcomes. Age-related Pathology
Age-related physiological changes contribute to the decreased ability of the body to maintain homeostasis. Dysregulation of homeostasis, in conjunction with greater time for the development of pathology, results www.anesthesiaclinics.com
Perioperative Education in Geriatrics
Table 1.
5
Organ System Changes of Normal Aging Versus Age-related Pathology
Body System
Age-related Changes
k neurons k axon/dendrite branches k action potential speed Cardiovascular m left ventricular wall thickness m stiffness heart and vessels Pulmonary k elastin fibers k elastic recoil of lung k vital capacity and forced expiratory volume k collagen crosslinks k residual volume Gastrointestinal m dysphagia m achlorhydria m mucosal cell atrophy Musculoskeletal m adipose deposits k fast twitch fibers k bone density Sensory m thickening of lenses and tympanic membrane k cochlear neurons k elasticity and efficiency of ossicular articulation Endocrine k growth hormone, testosterone, estrogen m parathyroid hormone, baseline cortisol, erythropoietin Renal k kidney size k number of functional glomeruli k renal blood flow Nervous
’
Consequences of Normal Aging
Age-related Pathology
Dementias, k fine motor cerebrovascular control accidents k muscle innervation k sensation k response under Hypertension, congestive stress heart failure, myocardial infarction k exercise tolerance k pulmonary reserve
Pneumonia, emphysema, pulmonary embolism, sleep apnea
k absorption iron Gastritis, hiatal hernia, diverticulitis, and many esophageal strictures, vitamins constipation m transit time k tone, strength, Sarcopenia, osteoporosis and elasticity k accommodation Cataracts, glaucoma, macular degeneration, and dark presbycusis, tinnitus, adaption vertigo m conductive deafness and sensorineural hearing loss k stress response
Diabetes, thyroid disorders
k concentrating ability
Chronic kidney disease
Up arrow signifies increased and the down arrow signifies decreased.
www.anesthesiaclinics.com
6
’
Catic and Barnett
in increased incidence of certain pathologies or disease among elderly individuals (Table 1). A geriatric anesthesia curriculum should devote time to understanding the most common age-related pathologies and how they may have an impact on the perioperative course. Cognitive Dysfunction
With the aging of the population, the prevalence of cognitive dysfunction is increasing. Currently, 1 of 5 adults aged 80 years and older have dementia and this is expected to skyrocket to 13 million individuals by 2050. In addition, postoperative cognitive dysfunction, commonly defined as a significant and persistent change in mental status as assessed by poorer than expected performance on postoperative neurocognitive testing, is of great concern to patients and health care providers.13,14 A geriatric anesthesia curriculum should include information regarding what is currently understood about postoperative cognitive dysfunction, the most common etiologies of dementia, appropriate cognitive assessment methods, and a basic overview of available treatments. It is particularly important for learners to understand how to administer some basic cognitive screening tools that can be carried out before surgery to determine the patient’s preoperative cognitive baseline. The Mini-Cog and Montreal Cognitive Assessment are ideal choices for preoperative screening, as they are relatively short, easy to administer, and sensitive.15,16 If these screenings are abnormal, further in-depth cognitive assessment by a geriatrician, neurologist, or other specialist should be considered before surgery to inform decision making regarding postoperative recovery potential. Delirium
Delirium, an acute disorder of attention and cognition, is a common and morbid condition affecting up to 53% of postoperative elders. This is a very important topic to cover in some detail within any geriatric anesthesia curriculum. Learners should be familiar with tools to help them predict which patients are at highest risk for developing delirium during hospitalization.17–19 They should also understand the evidence regarding pharmacologic and nonpharmacologic prevention measures.20–24 Learners should know how to diagnose delirium, preferably using the Confusion Assessment Method, the gold standard.25 Special attention should be paid to the pharmacologic treatment options including geriatric appropriate dosing, possible risks, and how to council the patient’s decision maker regarding the use of these medications.26,27 Simulation sessions can be especially effective in teaching about the diagnosis and treatment of delirium, as learners can visualize the impact of their interventions. www.anesthesiaclinics.com
Perioperative Education in Geriatrics
’
7
Preanesthesia Assessment
It has become widely recognized that preanesthesia assessment should be individualized, and that fewer “standard” tests are required than were traditionally obtained. The geriatric population provides an ideal opportunity to teach targeted preanesthesia assessment. In addition to considering cardiac and pulmonary risk factors, it is often helpful to perform functional and cognitive assessments, review goals of care, and discuss the options for rehabilitation after surgery. If possible, it is beneficial to involve a geriatrician in teaching this component of the curriculum so that they can highlight how geriatric experts think about elderly surgical patients. In addition, this enables learners to appreciate the advantages of a multidisciplinary approach in addressing the complex needs of the geriatric patient population. Pain Management
Pain is common among elderly patients with up to 64% of all hospitalized elders reporting pain.28 Successful pain management among elders undergoing surgery is particularly challenging, as these patients typically anticipate less pain and are less willing to express their pain.29,30 In addition, accurate pain assessment can be challenging in elders with cognitive impairment. A geriatric anesthesiology curriculum should include teaching on which tools are the most effective in assessing pain in the elderly and a review of analgesic options including appropriate dosing and side effect management. Given the reluctance among many providers to administer opioids to elders because of their concern of precipitating delirium, it is worth highlighting that undertreated pain is statistically associated with delirium.31 Case discussions are often effective vehicles for teaching about pain management in the elderly. Involving pain and regional anesthesia specialists in teaching this portion of the curriculum can be an effective method in increasing geriatric content within the curriculum. Pharmacology
A clear understanding of the pathophysiological and pharmacokinetic changes of aging is vital for appropriate selection and administration of medications in geriatric patients. In addition, a geriatric anesthesiology curriculum should include a discussion of the components of polypharmacy including adverse drug events, drug-drug interactions, and drug-disease interactions. Learners should be familiar with factors associated with inappropriate prescribing and adverse drug events in elders (Table 2). Case reviews can be helpful to practice using prescribing guidelines such as the Beers Criteria, Screening Tool of Older Persons’ potentially inappropriate www.anesthesiaclinics.com
8
’
Catic and Barnett
Table 2. Factors Associated With Inappropriate Prescribing and Adverse Drug Events in Elders Advanced age Female sex Lower educational level Multiple health problems Request for multiple medications Use of multiple medications Use of multiple pharmacies
Age >85 y Low body weight or body mass index Z3 chronic diseases Creatinine clearance
Angela G. Catic, MD Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, Texas
Sheila Barnett, MD Beth Israel Deaconess Medical Center, Boston, Massachussets
Secondary to declining fertility and increasing life expectancy, the median age of the world’s population is increasing. In the United States, the population of people aged 65 years or older is expected to double in the next 20 years.1 With the aging of America, the number of individuals aged 65 years and older will increase from 35 million in 2000 to 71 million in 2030. The number of oldest old, aged 80 years and older, will catapult from 9.3 to 19.5 million during the same timeframe. The percentage of the population living into late life is also projected to increase from 13% in 2000 to over 20% by 2030.2 This aging trend is also occurring on a worldwide basis. The number of individuals aged 60 years and older is growing by 2%/y, and those aged 80 years and older are growing by 3.8%/y. By 2050, the percentage of people aged 60 years and older worldwide is expected to be 21% and will exceed the number of younger individuals for the first time in history. The number of older patients undergoing surgical procedures is also increasing. Currently, 30% to 40% of all surgeries are performed on elderly patients. Although advancements in preoperative screening, perioperative care, and new surgical techniques have contributed to making surgery safer for elders, there is risk involved. Population-based evidence from Washington state found that 90-day mortality increased sharply with age from 2.5% in individuals aged 65 to 69 years to 16.7% among those aged 90 years and older.3 In addition to advancing age, increasing numbers of medical comorbidities are also associated with worse surgical outcomes. Nursing home residents, often considered the frailest elders, experience significantly higher rates of postoperative complications and mortality compared with noninstitutionalized Medicare enrollees.4
REPRINTS: ANGELA G. CATIC, MD, BAYLOR COLLEGE OF MEDICINE AND MICHAEL E. DEBAKEY VA MEDICAL CENTER, HOUSTON, TEXAS. E-MAIL: [email protected] INTERNATIONAL ANESTHESIOLOGY CLINICS Volume 52, Number 4, 1–13 r 2014, Lippincott Williams & Wilkins
www.anesthesiaclinics.com | 1
2
’
Catic and Barnett
Despite the high numbers of elders undergoing surgical procedures and the increased risk of adverse outcomes, there is a significant lack of formalized training regarding the unique issues encountered in elderly surgical patients. Although it has been recognized that incorporating geriatrics throughout medical education is critical to a successful integrated aging program, there are no widely disseminated geriatric curricula within most anesthesia programs.5–8 This is especially of concern given the shortage of geriatricians and the growing need for anesthesiologists and other surgical specialists to have a strong geriatric knowledge base to enable optimal care of their elderly patients. Never has this been more important than now as anesthesiologists seek to expand their roles as perioperative physicians. There are multiple challenges to creating a robust, sustainable geriatrics curriculum for anesthesiologists and surgical subspecialists. The increasing demand to cover an ever growing body of medical knowledge is not unique to anesthesiology and presents a challenge for medical educators in all specialties. However, many physicians do not recognize the need for specialized geriatric education as they care for many elders in the course of their practice and believe that this qualifies them to care for geriatric patients. The current recognition of the need for geriatric education, combined with the lack of a dedicated aging curriculum for most specialists, make this the ideal time to develop and implement integrated geriatric curricula for anesthesiologists and surgical specialists.
’
Postgraduate Education
The American Council for Graduate Medical Education (ACGME) and specialty boards have increased the oversight and regulation of postgraduate medical training over the last several years. Working with the ACGME, the American Board of Anesthesiology has established required competencies and a set anesthesiology curriculum. All residents must demonstrate proficiency within competency categories: essential attributes, patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, systems-based practice, clinical skills, and overall clinical competence. The ACGME and American Board of Anesthesiology both require basic knowledge in aging physiology, pharmacology, and evidence of management of elderly patients. However, formal requirements regarding education in geriatric anesthesia are limited to the general directive that trainees should receive appropriate didactic instruction and clinical experience caring for elderly patients. Despite an overall dearth of formalized geriatric education for anesthesiologists, there are a number of geriatric anesthesiology www.anesthesiaclinics.com
Perioperative Education in Geriatrics
’
3
resources available. The Society for the Advancement of Geriatric Anesthesia, an US-based society that provides education on geriatric anesthesia and valuable networking opportunities for those with a special interest in caring for elders, was established in 2000. The American Geriatrics Society, the Reynolds Foundation, and the John A. Hartford foundation also encourage geriatric education among the surgical specialties, including anesthesiology, through educational grants. Unfortunately, most institutions have experienced difficulty in sustaining the curricular interventions beyond the funding period. Online and print resources are available to assist in building an anesthesiology and surgical specialty geriatric curriculum. The Portal of Geriatric Online Education is a public Web site with a robust collection of geriatric educational materials that can be used free of charge http:// www.pogoe.org. The educational offerings are updated on a regular basis and include downloadable problem based learning discussions, didactics, and virtual patients. The Portal of Geriatric Online Education is also an excellent forum for anesthesiologists and surgical specialists to submit their educational materials, thus building their educational portfolios and allowing others to benefit. The American Society of Anesthesiologists has several geriatric anesthesia resources available, including a curriculum and booklet of frequently encountered clinical questions related to the care of geriatric patients http://www.asahq.org. Geriatric anesthesia and surgical specialty textbooks are also available.9,10
’
Geriatric Anesthesia Curriculum Development
To develop a meaningful geriatric anesthesia curriculum, educators must focus on areas that are common or have significant morbidity among elders in which there is sufficient geriatric research and knowledge to support the educational program. In addition, the curriculum must be tailored for the culture of the learners. Whereas geriatrics is traditionally an intellectual specialty where in-depth discussions about a single patient are prized as an educational method, anesthesia is a highly technical field often requiring quick decisionmaking capability and the ability to manage multiple patients simultaneously. As such, a curriculum that includes learning experiences tailored to this type of environment is required. The integration of simulation into anesthesia curricula has been popular and successful. This is an excellent tool to use to include geriatrics in a way that is both relevant and exciting to anesthesiologists. For example, a simulation session involving a delirious postoperative elder in the post-anesthesia care unit can be used to teach about the physiology of aging, intraoperative issues, pain management, and delirium. Other effective educational modalities include case discussions, team training, games www.anesthesiaclinics.com
4
’
Catic and Barnett
(Jeopardy, etc.), online modules, and multidisciplinary sessions with anesthesiologists, geriatricians, and surgeons to review challenging cases, present varying treatment strategies for common geriatric issues, and discuss how to further collaborate in the care of elders. Determining who will present curricular content is also an important consideration. Many learners will respond best to an anesthesiologist who is well versed in geriatric issues, as this individual will have more working knowledge of anesthesiology and be familiar with that culture. However, it can be very beneficial to engage a geriatrician for a portion of the teaching. Geriatricians are often particularly effective in teaching about goals of care, polypharmacy, physiology of aging, and cognitive issues. It is important for the anesthesiologist directing the curriculum to work with geriatricians to ensure that all presentations are relevant to the learners. ’
Development of a Curriculum
The core age-related areas that should be covered in a geriatric anesthesia curriculum are described below.11,12 As in all areas of medical education, it is important to continually edit curricular content as medical knowledge and learner needs evolve over time. Physiology of Aging
Education regarding age-related physiological changes provides an important foundation for understanding the normal aging process including why elders often have atypical presentations of disease and how to appropriately adjust medication dosages. Normal aging is associated with a loss of homeostasis and, secondary to a decrease in physiological reserve, elders often present early in the course of disease and often face increased surgical complications and a prolonged recovery period compared with younger individuals. Although all systems undergo age-related changes, a clear understanding of the alterations in the central nervous, cardiopulmonary, and renal systems are particularly key in caring for older surgical patients. It is important to differentiate between the changes in normal aging and pathology (Table 1). This information is often best presented in case-based discussions, so that learners can appreciate how the physiological changes of aging impact clinical outcomes. Age-related Pathology
Age-related physiological changes contribute to the decreased ability of the body to maintain homeostasis. Dysregulation of homeostasis, in conjunction with greater time for the development of pathology, results www.anesthesiaclinics.com
Perioperative Education in Geriatrics
Table 1.
5
Organ System Changes of Normal Aging Versus Age-related Pathology
Body System
Age-related Changes
k neurons k axon/dendrite branches k action potential speed Cardiovascular m left ventricular wall thickness m stiffness heart and vessels Pulmonary k elastin fibers k elastic recoil of lung k vital capacity and forced expiratory volume k collagen crosslinks k residual volume Gastrointestinal m dysphagia m achlorhydria m mucosal cell atrophy Musculoskeletal m adipose deposits k fast twitch fibers k bone density Sensory m thickening of lenses and tympanic membrane k cochlear neurons k elasticity and efficiency of ossicular articulation Endocrine k growth hormone, testosterone, estrogen m parathyroid hormone, baseline cortisol, erythropoietin Renal k kidney size k number of functional glomeruli k renal blood flow Nervous
’
Consequences of Normal Aging
Age-related Pathology
Dementias, k fine motor cerebrovascular control accidents k muscle innervation k sensation k response under Hypertension, congestive stress heart failure, myocardial infarction k exercise tolerance k pulmonary reserve
Pneumonia, emphysema, pulmonary embolism, sleep apnea
k absorption iron Gastritis, hiatal hernia, diverticulitis, and many esophageal strictures, vitamins constipation m transit time k tone, strength, Sarcopenia, osteoporosis and elasticity k accommodation Cataracts, glaucoma, macular degeneration, and dark presbycusis, tinnitus, adaption vertigo m conductive deafness and sensorineural hearing loss k stress response
Diabetes, thyroid disorders
k concentrating ability
Chronic kidney disease
Up arrow signifies increased and the down arrow signifies decreased.
www.anesthesiaclinics.com
6
’
Catic and Barnett
in increased incidence of certain pathologies or disease among elderly individuals (Table 1). A geriatric anesthesia curriculum should devote time to understanding the most common age-related pathologies and how they may have an impact on the perioperative course. Cognitive Dysfunction
With the aging of the population, the prevalence of cognitive dysfunction is increasing. Currently, 1 of 5 adults aged 80 years and older have dementia and this is expected to skyrocket to 13 million individuals by 2050. In addition, postoperative cognitive dysfunction, commonly defined as a significant and persistent change in mental status as assessed by poorer than expected performance on postoperative neurocognitive testing, is of great concern to patients and health care providers.13,14 A geriatric anesthesia curriculum should include information regarding what is currently understood about postoperative cognitive dysfunction, the most common etiologies of dementia, appropriate cognitive assessment methods, and a basic overview of available treatments. It is particularly important for learners to understand how to administer some basic cognitive screening tools that can be carried out before surgery to determine the patient’s preoperative cognitive baseline. The Mini-Cog and Montreal Cognitive Assessment are ideal choices for preoperative screening, as they are relatively short, easy to administer, and sensitive.15,16 If these screenings are abnormal, further in-depth cognitive assessment by a geriatrician, neurologist, or other specialist should be considered before surgery to inform decision making regarding postoperative recovery potential. Delirium
Delirium, an acute disorder of attention and cognition, is a common and morbid condition affecting up to 53% of postoperative elders. This is a very important topic to cover in some detail within any geriatric anesthesia curriculum. Learners should be familiar with tools to help them predict which patients are at highest risk for developing delirium during hospitalization.17–19 They should also understand the evidence regarding pharmacologic and nonpharmacologic prevention measures.20–24 Learners should know how to diagnose delirium, preferably using the Confusion Assessment Method, the gold standard.25 Special attention should be paid to the pharmacologic treatment options including geriatric appropriate dosing, possible risks, and how to council the patient’s decision maker regarding the use of these medications.26,27 Simulation sessions can be especially effective in teaching about the diagnosis and treatment of delirium, as learners can visualize the impact of their interventions. www.anesthesiaclinics.com
Perioperative Education in Geriatrics
’
7
Preanesthesia Assessment
It has become widely recognized that preanesthesia assessment should be individualized, and that fewer “standard” tests are required than were traditionally obtained. The geriatric population provides an ideal opportunity to teach targeted preanesthesia assessment. In addition to considering cardiac and pulmonary risk factors, it is often helpful to perform functional and cognitive assessments, review goals of care, and discuss the options for rehabilitation after surgery. If possible, it is beneficial to involve a geriatrician in teaching this component of the curriculum so that they can highlight how geriatric experts think about elderly surgical patients. In addition, this enables learners to appreciate the advantages of a multidisciplinary approach in addressing the complex needs of the geriatric patient population. Pain Management
Pain is common among elderly patients with up to 64% of all hospitalized elders reporting pain.28 Successful pain management among elders undergoing surgery is particularly challenging, as these patients typically anticipate less pain and are less willing to express their pain.29,30 In addition, accurate pain assessment can be challenging in elders with cognitive impairment. A geriatric anesthesiology curriculum should include teaching on which tools are the most effective in assessing pain in the elderly and a review of analgesic options including appropriate dosing and side effect management. Given the reluctance among many providers to administer opioids to elders because of their concern of precipitating delirium, it is worth highlighting that undertreated pain is statistically associated with delirium.31 Case discussions are often effective vehicles for teaching about pain management in the elderly. Involving pain and regional anesthesia specialists in teaching this portion of the curriculum can be an effective method in increasing geriatric content within the curriculum. Pharmacology
A clear understanding of the pathophysiological and pharmacokinetic changes of aging is vital for appropriate selection and administration of medications in geriatric patients. In addition, a geriatric anesthesiology curriculum should include a discussion of the components of polypharmacy including adverse drug events, drug-drug interactions, and drug-disease interactions. Learners should be familiar with factors associated with inappropriate prescribing and adverse drug events in elders (Table 2). Case reviews can be helpful to practice using prescribing guidelines such as the Beers Criteria, Screening Tool of Older Persons’ potentially inappropriate www.anesthesiaclinics.com
8
’
Catic and Barnett
Table 2. Factors Associated With Inappropriate Prescribing and Adverse Drug Events in Elders Advanced age Female sex Lower educational level Multiple health problems Request for multiple medications Use of multiple medications Use of multiple pharmacies
Age >85 y Low body weight or body mass index Z3 chronic diseases Creatinine clearance
