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MAIMONIDES MEDICAL CENTER DEPARTMENT of ANESTHESIOLOGY 4802 Tenth Avenue, Brooklyn, New York 11219 Steven N

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MAIMONIDES MEDICAL CENTER DEPARTMENT of ANESTHESIOLOGY 4802 Tenth Avenue, Brooklyn, New York 11219 Steven N GERIATRICC CURRICULUM (Geriatric Education Research Initiative and Anesthesia Training of Residents in Core Curriculum) MAIMONIDES MEDICAL CENTER DEPARTMENT OF ANESTHESIOLOGY 4802 Tenth Avenue, Brooklyn, New York 11219 Steven N. Konstadt, M.D., Chairman Kalpana Tyagaraj, M.D. Dennis E. Feierman, PhD, M.D. Suhaila Alam, M.D. Piyush M. Gupta., M.D Mohamad S. Hashim, M.D. Samy Lasheen, M.D. Emil Malamud, M.D. Giuseppe Trunfio, M.D. Jennifer Breznay, M.D. M.P.H. Darlene Saberito, RN INTRODUCTION The geriatric patient group is the fastest growing demographic group as life expectancies increase. Who is old, and how do we classify them? The government classifies old (geriatric) as anybody over the age of 65. We have further divided the elderly population into young old 65-75 years, middle old >75-85 years, very old >85-100 years and the ultra old >100 years. As the baby boomers age, currently, it is estimated that number of Americans aged 65 and older will more than double, from 35 million (13%) today to more than 78 million (24%) in 2050. Each year the elderly undergo almost 40% (approximately 8 million) of all surgical procedures, including elective and emergency surgery. Furthermore, emergency department and rehabilitation units are disproportionately used by the elderly. To appropriately care for these patients it is necessary to understand the natural physiological changes of aging, the co-morbidities found in the elderly, and the effects these co-morbidities have on the aging process. They are also more likely to suffer a wide range of postoperative complications. To deal with this age group, the provision of high quality, “gerosensitive” care will become even more of a critical issue in the surgical and related specialties. Despite the higher number of elderly patients having surgery, mortality and morbidity rates have been declining thanks to advances in medical sciences (prevention, early diagnosis, treatment). The old age appears to have less influence on the perioperative morbidity and mortality. Aging is a progressive phenomena characterized by degeneration in both structural and functional reserves of organs and tissues. The brain undergoes some physical changes with advancing age. It's likely that these physical changes account for at least some of the noticeable cognitive changes. But discovering the exact links has so far proved elusive. Nonetheless, given the evidence accumulated thus far, some 09/26/2011 1 theories have been proposed, and more research is being conducted. To date, only a few studies have attempted to make a direct correlation between the physiologic changes of the brain and cognitive decline and other age-related effects. The perioperative management of patients undergoing vascular surgery is one of the most challenging and controversial areas in the field of anesthesiology. Much progress has been made in management of vascular patients in three decades. In the 1970s it was recognized that vascular surgery has the greatest risk for perioperative cardiac morbidity. In the 1980s an effort was made to identify patients who were at greatest risk for morbid outcomes. In the 1990s numerous clinical trials were done to study the best anesthetic techniques, sympatholytic drugs, hemodynamic control and analgesia regime to prevent perioperative cardiac and other morbidities. In 2000, endovascular surgery has provided less invasive approaches and alternatives to conventional vascular reconstruction. Cardiac surgery is now offered to septuagenarians and octogenarians with good results. In fact the elderly may become the majority of cardiac patients in the near future. Independently of diseases, the aging cardiovascular system is characterized by alterations of cardiovascular performance that may have little relevance at rest, but become of paramount importance under perioperative stress. Pain management in the elderly is to alleviate the pain and its consequences on the activities of daily living and improve patient functional status and mood behaviors. In the case of acute postoperative pain management it is essential for speeding up recovery and healing, to decrease morbidity and mortality and to minimize the length of hospital stay. We need to not only understand the medical and social issues related to these patients, but also understand the normal physiological changes in different organs and tissues associated with aging. To respond to this need for better geriatric training, the American Geriatric Society (AGS) established the Geriatrics for Specialist Project in 1994. Anesthesiology is one of the 10 surgical and related specialties participating in this project. The Department of Anesthesiology at Maimonides Medical center is proud to be selected by the Geriatric Education for Specialty Residents (GESR) program. To achieve the requirements of the GESR program, our Department of Anesthesia has initiated a Geriatric Expansion Project entitled “Geriatrics Education Research Initiative and Anesthesia Training of Residents In Core Curriculum,” (GERIATRICC) which will enable our residents to learn the various aspects of Geriatric anesthesia care. There is a growing population of elderly patients that require different operations requiring different sub-specialties of anesthesia. For example, at Maimonides Medical Center, the Orthopedic and Vascular Surgery services have a significant number of geriatric patients. These groups of patients usually present with significant concerns for anesthesia because of: • Physiological changes of aging • Pre-existing multiple, chronic co-morbid diseases • Multiple drug therapy • Type of surgery and the urgency of the same. 09/26/2011 2 All residents are trained how to be safe, competent, and clinically excellent anesthesia consultants. Additionally, our residents are exposed to an array of geriatric patients during all three years of the residency program. Furthermore, there will be a specific rotation and a series of core lectures throughout the training that will address specific issues that pertain to geriatric patients. GOALS & OBJECTIVES: As with all subspecialty rotations, we expect a continuum in the development of the resident’s professionalism, knowledge base, clinical skills, and interpersonal skills and to integrate his/her practice into the overall health system. Residents are evaluated in each of the six ACGME defined core competencies: 1. Professionalism 2. Medical Knowledge 3. Patient Care 4. Practice Base Learning And Improvement 5. Interpersonal And Communication Skills 6. System-Based Practice Although the ‘goals and objectives’ for professionalism, practice base learning and improvement, interpersonal and communication skills, and system-based practice are nearly identical for all the subspecialty rotations, we urge you to read through them for each rotation, as certain rotations have additional goals and objectives in these areas. I. PROFESSIONALISM • Demonstrate a commitment to carrying out professional responsibilities with respect, compassion, and integrity. • Arrive for clinical and learning responsibilities in a timely and punctual fashion. • Answer pages in a timely fashion. • Respond to questions, requests for information, follow-up, and other communication in a timely fashion. • Demonstrate truthful and ethical standards in professional conduct. o Adhere to departmental and university policies and procedures. o Exhibit honesty in record keeping and medical records. o Present information, concerns and suggestions without bias or for personal gain. o Report concerns, errors or potential problems to the PACU attending or appropriate authority that are available 24 hours/day-7 days/week. • Demonstrate sensitivity and responsiveness to patient’s culture, age, gender, religion and disabilities. • Demonstrate ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices. • Value patients’ leadership role in their own care. • Recognize patient vulnerability. • Cope with diversions and minimize distractions while maintaining vigilance. 09/26/2011 3 II. MEDICAL KNOWLEDGE • Residents should be able to discuss the various pathophysiological changes in all organ systems due to aging: • List and have knowledge about age related concomitant diseases • Discuss fluid and electrolyte management in the anesthetized Geriatric patient • List the reason for using special precautions while positioning the Geriatric patient • Discuss the various techniques to reduce blood loss • Describe different techniques to maintain an appropriate level of anesthesia Organ System Changes A) Central Nervous System Age-related changes in the brain include: Brain shrinkage Lost connections Plasticity Pathological changes Brain shrinkage Throughout adulthood, there is a gradual reduction in the weight and volume of the brain. This decline is about 2% per decade. Contrary to previously held beliefs, the decline does not accelerate after the age of 50, but continues at about the same pace from early adulthood on. The accumulative effects of this are generally not noticed until older age. Scientists used to think that the reason for brain shrinkage is the loss of neurons. Some past studies estimated that adults lose as many as 100,000 neurons a day. However, improved testing techniques have revealed that the actual loss of neurons is far less significant than previously thought, and may not be occurring at all. The reduction in brain volume is more a function of the neurons themselves and
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