PRESIDENT’S CORNER
Marek Brzezinski, MD PhD, Department of Anesthesia and Perioperative Care, UCSF
Aging is a prevalent topic these days, largely due to our collective anxiety about it. Our culture’s obsession with eternal youth is omnipresent: stop the clock, stay forever young, and look perpetually in your twenties. Recently, with masks no longer a necessity, I was struck by how noticeably people’s faces have aged in just two years—though, naturally, mine seems to have escaped the ravages of time. But here’s the twist: aging is actually something to be thankful for when you consider the alternatives our ancestors faced. For most of human history, life expectancy was under 40 years. In the 18th century, people in England lived to about 35, and in Massachusetts, it was even lower—just 28 years. The concept of aging as we understand it is relatively modern. Evolutionarily speaking, some even question whether aging is part of our genetic blueprint at all. For much of history, the goal was to live long enough to raise offspring and then fade away while still relatively young. Essentially, aging wasn’t a central concern—early death was.
Today, life expectancy has soared, shifting our priorities from mere survival to thriving over a longer lifespan. This shift has driven significant progress in geriatrics, with the origins of geriatric anesthesia tracing back to Emery Rovenstine’s groundbreaking 1955 review in Geriatrics. However, it wasn’t until the creation of the Committee on Geriatric Anesthesia by the American Society of Anesthesiologists (ASA-CoCA) in 1994 and the establishment of the Society for the Advancement of Geriatric Anesthesia (SAGA) in 2001 that the field gained substantial traction.
As the “silver tsunami” of elderly patients increasingly enters operating rooms, geriatric anesthesia has become more critical than ever. Already, 35% of all surgical procedures involve elderly patients, who face growing medical complexities and heightened expectations for their anesthesia care. Many patients and their families, aware of the unique challenges, are specifically requesting care from specialists in geriatric anesthesia, as shown by numerous inquiries SAGA receives. The field of geriatric anesthesia is advancing rapidly, with frequent updates to guidelines and recommendations. Staying informed is essential to addressing the needs of this growing patient population and ensuring optimal care during their surgical procedures.
To support you, SAGA, in collaboration with ASA-CoCA, aims to act as a “living clearinghouse” for information related to geriatric anesthesia. We are committed to simplifying your work by providing timely updates, resources, and opportunities for engagement within the society (https://sagahq.org). Please help us in this endeavor by sharing your needs and challenges with us at sagahq.org@gmail.com so we can better tailor our support. We also encourage you to get involved with SAGA to benefit from and contribute to our collective expertise. Your feedback and participation are crucial for advancing geriatric anesthesia and enhancing patient care.
GERIATRIC ANESTHESIA RESEARCH
My Anesthesia Choice-Hip Fracture: Bringing Shared Decision-Making to Geriatric Anesthesia.
Mark D. Neuman, MD, MSc, University of Pennsylvania
This year, SAGA partnered with investigators at the University of Pennsylvania and Washington University in St. Louis to support a new PCORI-funded study, entitled My Anesthesia Choice-Hip Fracture (MAC-HF). Led by Mary Politi, PhD (WUSTL) and me, MAC-HF builds on the results of the REGAIN randomized trial (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) through an innovative approach to increase shared decision-making and patient engagement in choices about anesthesia for hip fracture care.
Now enrolling patients at 6 US hospitals (Penn Presbyterian Medical Center, Henry Ford Hospital, Dartmouth Hitchcock Medical Center, University of Florida Health, Atrium Health Wake Forest Baptist, and Cleveland Clinic Fairview), MAC-HF focuses on implementing a plain-language, 1-page decision support tool designed to facilitate discussions between anesthesiologists, patients, and families about anesthesia for hip fracture surgery. The MAC-HF conversation guide incorporates current evidence on outcomes for spinal anesthesia and general anesthesia for older adults with hip fractures and builds on decades of research on effective tools for facilitating communication between patients and clinicians; the guide is freely available, along with other information about the study at www.myanesthesiachoice.org. The MAC-HF study will evaluate sites’ experiences in implementing this conversation guide and study the impact of implementation on measures of shared decision-making, patients’ choices about anesthesia, and overall patient experience with anesthesia care for hip fracture. More details on the study can be found at the PCORI website and here.
Along with ASA, ASRA, AAOS, the Orthopedic Trauma Association, and Blue Cross Blue Shield of Michigan, SAGA is a key stakeholder organization to the MAC-HF project. SAGA representatives will participate in regular meetings with the study team to provide input on overall study approaches and key decisions related to study implementation, results interpretation, and dissemination of findings to key audiences within and beyond the anesthesia community. To this end, the MAC-HF team looks forward to participating in this year’s annual SAGA meeting, where we will give a brief presentation about the study and have a chance to get feedback on the project directly from SAGA members.
On behalf of the MAC-HF team, I wish to express our gratitude to SAGA for supporting this project and for the opportunity to speak to this group in Philadelphia this October. We our excited to work together with SAGA and its members to advance our shared goal of improving care for older adults with hip fracture.
PERSPECTIVE
A Perspective from an Aging Anesthesiologist
Daniel Masluk MD, Anesthesia and Analgesia Medical Group, Napa, CA
Well, “experienced” is just another word for old. Been there, done that, bought the t-shirt. I’m the one they now refer to as the “aging anesthesiologist”. In response, let me paraphrase Pearl Buck: the one who finds joy in work has discovered the fountain of youth. I continue to violate all the “work hours restrictions” my younger colleagues often discuss—and I wouldn’t have it any other way!
My journey likely reflects that of many in our anesthesia community. My career has been a rewarding mix of challenges and achievements, providing a balance that has kept me engaged without the need for additional fellowship training. Coming from an immigrant family, I feel incredibly fortunate to have completed my education and medical training and to have dedicated the past 35 years to anesthesia at a community hospital in Northern California. I’m truly grateful and humbled by this experience.
Learning has been a guiding North Star throughout my career. I’ve had the privilege of working with skilled and compassionate colleagues and caring for countless patients, each teaching me something new. While formal education provided the foundation, the real depth of my expertise has come from years of hands-on experience. Administering nearly 40,000 anesthetics has given me a profound understanding of the “art of anesthesia” that goes beyond textbooks and theories. It’s this direct patient experience that has truly shaped my practice.
Financially, my career hasn’t made me rich, but it has allowed me to support my six children through college and save a bit for retirement. The true wealth for me, however, is found in moments like running into former patients at the local market who remember me and express their gratitude. When I’m not on call, I sleep well and wake up eager for the day ahead. My hands remain steady, my mind clear, and I continue to engage meaningfully with patients and collaborate closely with my surgical colleagues.
Still, I can’t help but wonder how long I’ll be able to keep this up. Aging comes with its own set of challenges, and there might come a day when I’m advised to hang up my stethoscope. The thought of leaving a job I love feels as likely as becoming a professional skateboarder at my age! For now, I’m determined to keep the same passion and dedication that have defined my career. I plan to keep making a difference for as long as I can, balancing my love for the job with the realities of getting older. So, stay tuned for an update in 10 years—assuming I’m not too busy mastering the skateboard park!
PROGRAM SPOTLIGHT
Advancing Geriatric Anesthesia at Henry Ford Health, Detroit, MI
Neeju Ravikant, MS, MD, Department of Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Health, Detroit
Functional quality of life is critical for our geriatric patients. As anesthesiologists, we are uniquely poised to advance that goal. The Henry Ford Health Department of Anesthesiology is committed to this work in 3 areas of innovation.
Preoperative: we created an innovative risk tool that triages health acuity of elderly patients scheduled for elective surgery. Those that score high risk are seen in our newly expanded presurgical optimization clinic. We address quality metrics that impact perioperative outcomes (anemia, diabetic control, renal insufficiency, anticoagulant management for VTE risk, frailty, cognition, Jehova’s Witness management, cardiopulmonary decompensation, etc). We coordinate all consultants (internal or external to Henry Ford), arrange treatments, provide uniform patient instructions for all medications per guidelines and adjust existing guidelines as clinical consensus evolves. We recently received funding for a clinic expansion in recognition of the depth and breadth of our service. We now see significantly more patients across all surgical specialties. We anticipate formal programs in prehabilitation, presurgical nutrition and integration of the ASA Brain Health Initiative under our clinic soon.
Intraoperative: we are a participating site in the multicenter THRIVE trial (Trajectories of Recovery after Intravenous Propofol vs Inhaled Volatile Anesthesia) funded by PCORI (Patient Centered Outcomes Research Institute). Anesthesiology care teams adjust anesthetics for patients with cognitive deficits in variable ways. We seek opportunities to adjust our care with more consistent and informed approaches to TIVA and inhaled agents.
Point of delivery: certain cases are frequent and impactful in the geriatric population. Cataract surgery improves safety through vision. Cystoscopies and prostate biopsies reduce risks of UTI/sepsis and cancer. Joint replacement improve mobility. At our institution, surgeons for these high volume cases run most of their practice at our freestanding ambulatory surgery centers. Deferring medically complex patients to hospital settings delays geriatric care due to OR availability. We expanded access for the complex elderly at these centers by revising our eligibility criteria in a novel way. Instead of the conventional way of asking surgeons to follow a list of medical conditions eligible for boarding, we asked them to observe absolute exclusions only. This allows us to evaluate all remaining patients on an individual basis and proactively look for ways to care for them at these centers. We also created a new integrated PATO platform (PreAnesthesia Testing RNs + Optimization anesthesiologists/APPs). This is an efficient workflow to review complex geriatric patients and safely meet their rapidly increasing surgical needs.
SAGA AND ASA’S COMMITTEE ON GERIATRIC ANESTHESIA
Thank you, Dr McSwain Chair Committee on Geriatric Anesthesia (CoGA).
Itay Bentov, MD PhD, Department of Anesthesiology and Pain Medicine, University of Washington
SAGA would like to thank Julie McSwain MD, MPH, FASA professor of Anesthesia & Perioperative Medicine at MUSC for her service as chair of the ASA’s Committee on Geriatric Anesthesia (CoGA), as she transitions to other leadership positions. Dr McSwain has been instrumental in her leadership and support in improving the care of older adults, we are grateful for her dedication to our community.
CoGA and its Subcommittee on Perioperative Brain Health Initiative (PBHI) are working on several ongoing projects that contribute to the education and empowerment of ASA members who work with older adults.
The Committee on Geriatric Anesthesia and the Subcommittee on Perioperative Brain Health were selected as recipients of a $100,000 CMSS Diagnostic Excellence grant. The grant is funded by the John A. Hartford Foundation and the Gordon and Betty Moore Foundation. The goal is to develop free educational virtual learning products with CME awarded to train physician anesthesiologists on the use of important diagnostic tools needed to improve the care of older adults. In addition to the CME credit, after all components are completed of the course a learner can apply for American Board of Anesthesiology MOCA – Part 4 Quality Improvement Credit.
You can find the program at https://www.asahq.org/shop-asa/e023g00w00 it is free and available to all.
Webinar 1: “Practical Tips for Preoperative Cognitive Screening” –Presenter Jeanna D. Blitz, MD, FASA. 0.5 CME associated with webinar completion.
Webinar 2: “Frailty Assessments by Anesthesiologists: Why & How” – Presenter: Itay Bentov, MD, PhD. 0.5 CME associated with webinar completion.
Webinar 3: “Post Anesthesia Care Unit Delirium” – Presenters Susana Vacas, MD, PhD, 0.5 CME
Live town hall: Perioperative Communication with the Older Adult – Presenters Baretto Chang, MD, PhD, Cecilia Canales, MD, MPH, Mark Neuman, MD, MSc, Carrie Nieman, MD, MPH and Mary Politi, PhD, 1.0 CME associated with recording of this townhall upon completion.
Recently the Webinar “Strategies to Improve Perioperative Brain Health in the Older Adult” launched on May 31st 2024. The aim of the webinar is to familiarize clinicians with the risks associated with frailty and cognition, as well as practical steps that anesthesiologists can take to help improve brain health for example Age-related changes in abbreviated frontal EEG during general anesthesia and how to better manage symptoms and improve the brain health of older surgical patients.
INVITED INSIGHTS
Engage with the ASA Professional Issues Educational Track.
Vilma Joseph, MD,MPH,FASA, Chair, ASA Educational Track Subcommittee on Professional Issues
Department of Anesthesiology, Albert Einstein College of Medicine
The American Society of Anesthesiologists (ASA) has an annual meeting which is an international educational event that has over 10,000 attendees including physician anesthesiologists, residents and medical students. The next meeting is in Philadelphia, Pennsylvania from October 18-22, 2024. The field of geriatric anesthesia is well-represented at the ANESTHESIOLOGY® Annual Meeting. There are several Educational Tracks available at the meeting such as Professional Issues, Cardiac, and Geriatric Anesthesia. At the upcoming meeting, the Professional Issues Track has a session called “Perioperative Management of the Aging Patient – A Practical Guide to Fragility, Cognitive and Shared Decision Making”. This will encompass some of the many issues affecting geriatric patients.
For those interested in highlighting your work in geriatrics at next year’s ANESTHESIOLOGY® Annual Meeting, there are many opportunities to participate. You can utilize an array of learning platforms including panels, refresher course lectures, snap-talks, clinical forums, and workshops. As chair of the Educational Track Subcommittee on Professional Issues, we welcome submissions on geriatric anesthesia. Submissions are accepted via the website at https://www.asahq.org/annualmeeting/education/submissions from August 27, 2024 until November 25, 2024. Participants must be ASA members, but exceptions can be made.
The ANESTHESIOLOGY® Annual Meeting is a great time to collaborate with your colleagues and provide mentorship/sponsorship. This is a wonderful opportunity to promote your subspeciality. See you at the ASA.
