Dr. Crowe correctly identifies the importance of a holistic approach to the perioperative care of older patients. Less clear, however, is the appropriate role of anesthesiologists in the management of patients with poor cognitive function, difficult social issues, or any other nontraditional anesthetic issue. If all we do is discover such issues just before surgery, management will be no more optimal than in the days when a patient presented to the operating room with unstable angina. The solution to the patient with cardiac disease was to improve the timing and quality of the preoperative assessment, and to involve nonanesthesia care providers well in advance of surgery. There is no reason the same approach cannot apply to psychosocial issues. Some institutions, including the Mayo Clinic, screen patients to assure that the care necessary after surgery is available at home, and if not, involve social services to provide the care. Perhaps our role is to ensure that the necessary protocols are in place.
The last issue raised by Dr. Crowe was whether anesthesiology needs a new subspecialty, or if simply having leaders in geriatric anesthesia will suffice. Subspecialty status raises the specter of who should be permitted to provide care for older patients. Personally, I believe creation of a new subspecialty would be a bad idea. I do not need to be a specialist in regional anesthesia to perform blocks, and neither should anesthesiologists have to be specialists in geriatric anesthesiology to provide anesthetic care to older patients. Nevertheless, I appreciate the existence of my colleagues who do have special skills in regional anesthesia and consult with them regularly. My vision is one where all anesthesiologists would have access to colleagues who have special expertise in geriatric anesthesia. The Society for the Advancement of Geriatric Anesthesia was formed to promote the development of such anesthesiologists and to serve as a forum for those individuals to share knowledge and ideas. The purpose of the original editorial 1was to make interested individuals aware of what is going on in geriatric anesthesia at the national level. With this reply I encourage someone in every department or group practice to acquire additional knowledge of geriatric anesthesia and become a resource to the members of their group or community.