Volume 37, number 3 of the quarterly published series Anesthesiology Clinics by Elsevier focuses on Geriatric Anesthesia, a topic that forces itself on every anesthesiologist and critical care physician in daily life. Editors Elizabeth A. Whitlock, MD, MSc, and Robert A. Whittington, MD, 2 proven experts on the clinical and basic science aspects of perioperative care for older adults, gathered 36 exclusively North American contributors for a collection of 14 review articles. Dr Whittington has notably been the first and so far only executive editor for the Geriatric Anesthesia section in Anesthesia & Analgesia (A&A), launched in 2017. With numerous manuscripts handled for A&A and as active members of the Society for the Advancement of Geriatric Anesthesia, the editors are ideally positioned to assemble this collection.
In 192 pages, the book explores the challenges of relevant comorbidities, frailty, and functional and cognitive decline, which health care providers are facing in the growing population of older patients, the so-called silver tsunami. The crucial role of the anesthesiologist in selecting the best management approach for this vulnerable group of patients is emphasized. Because some articles are coauthored by surgeons, neurologists, and geriatricians, the reader is equipped with an armamentarium to not only understand specific aspects of physiology and pharmacology in the aging individual but also to become active in advanced care planning and shared decision making.
The first article in this series presents demographic data and names considerable anesthetic risks. The anesthesia provider is asked to take a leading part in facilitating shared decision making between patients, their families, and caregivers. The next 2 articles highlight the preoperative assessment and the postoperative period and showcase an interdisciplinary model of establishing goals of care that take into account how the patient’s cognitive and functional status may be altered in the long term. Discussing the risks and benefits of surgery with individual patients is important. In a stepwise approach, the anesthesiologist is guided through a systematic preoperative assessment focusing on polypharmacy, malnutrition, frailty, and cognition. Article 4 introduces the rather new concept of multimodal prehabilitation programs. Physical exercise protocols to improve cardiovascular fitness, as well as nutritional support and cognitive training, are designed to enhance readiness for surgery. Frailty syndrome as a predictor of perioperative morbidity and mortality is discussed in the next article. Age-related structural and functional organ system changes and their anesthetic implications are listed in tabular form, at hand for clinical routine. The following article gives the reader an understanding of pharmacokinetic and pharmacodynamic changes in the elderly. It covers the most common drug classes and provides useful hints for daily practice. An article on emergency surgery—certainly a must for any book on geriatric anesthesia—contains a short discussion about acute intraoperative optimization strategies. The book then continues with 2 chapters on pain. The article on acute pain introduces commonly used drugs and recommends adaptations to dosing, as well as a multimodal approach including regional anesthesia techniques. The next article on postoperative delirium and cognitive dysfunction describes the science behind perioperative neurocognitive disorders and provides instructions on the management of high-risk patients. Geriatric critical care is the subject of yet another article, because intensive care unit (ICU) admissions are common in the elderly. General aspects of care in critically ill older adults are highlighted. In addition, the article reminds us to respect the autonomy of patients who may well have their focus on other outcomes than survival. A separate article discusses the process of informed consent and the ethical principles involved in medical decisions. Guidelines for the care of patients with advance directives are included. Steps toward shared decision making as a cornerstone of patient-centered care are made in the following article. The book closes with a chapter on the future of geriatric anesthesiology, and once more emphasizes the need for interdisciplinary collaboration in the perioperative setting. Geriatric anesthesia is designated as a new subspecialty.
It is ambitious to sum up the state-of-the-art of geriatric anesthesia in such a small book. We compliment Drs Whitlock and Whittington for mastering this challenge. As in every Clinics Review Articles series by Elsevier, single articles in this collection are PubMed-indexed and PDF versions are available online ($30.00 USD). While this succession of review articles currently sells for $129.00 (USD) in hardcover form, it is possible to handpick papers of special interest on the Internet. For the reader looking for a concise overview, it may be worthwhile to purchase the whole book.
Franziska Wellner, MD
Nicolai Goettel, MD, DESA, EDIC
Department of Anesthesia
Prehospital Emergency Medicine and Pain Therapy
University Hospital Basel
University of Basel