All diseases run into one, old age
— Ralph Waldo Emerson
The demography of the world population is changing. Not only are there more people on the planet, but thanks to improvements in agriculture, public wealth and health, and relative political stability, a greater number of people are surviving to old age, and are remaining fitter as they do so. This is undoubtedly cause for celebration, but the rapidity with which this change has occurred brings with it new challenges for humankind. These are already being felt in more developed countries: who will look after the elderly and who will pay for their care? What should be done about employment and housing? What are the limits of medicine in keeping people alive and healthy? Proportional increases in the incidence of older people presenting for surgery continue to exceed those of the UK population in general. We are anaesthetising many more elderly patients now compared with a decade ago, and this trend is likely to continue into the foreseeable future. However, in many ways, we have failed to make any real improvements in the peri-operative care of this vulnerable patient group over the same time period [1, 2], or add to the evidence base that drives the necessary quality improvement.
In recognition of this, we would like to welcome you to the 2014 Anaesthesia for the Elderly supplement. Whilst the format is similar to previous years, with world-renowned experts critically reviewing evidence in controversial subject areas and directing the reader to further literature, this year's supplement also introduces the Association of Anaesthetists of Great Britain and Ireland's updated guideline Perioperative Care of the Elderly. The idea is that clinical anaesthetists who care for elderly patients (i.e. pretty much all of us) will be able to read the guideline and refer – in the same issue – to some of the evidence on which it is based.
Despite concerns about the demographic ‘time bomb’, Keays suggests, in his editorial,  that these assume a worst-case scenario that may fail to materialise if countered by other demographic changes, or be offset by improvements in the organisation of healthcare services and in attitudes towards the elderly. Peri-operative care, for example, will need to be redesigned as a seamless continuity of the multidisciplinary care older people receive in the community. Comprehensive geriatric pre-assessment is part of this process , allowing geriatricians and anaesthetists to plan peri-operative care of the elderly patient towards optimising postoperative recovery, rehabilitation and discharge back into the community.
Pre-operative assessment also allows for the identification of those elderly patients at the highest risk of poor peri-operative outcome, whichever ‘outcomes’ are most appropriate in this age group , and directing care accordingly. These include frail patients, who, as Hubbard and Story note, are easy to spot, but less easy to define and optimise .
Perhaps the greatest improvements in peri-operative outcome directly attributable to anaesthesia may be achieved through the postoperative avoidance of pain and delirium, both of which delay rehabilitation and hospital discharge [7, 8]. Pain and delirium are interlinked: pain and analgesia can worsen delirium, in turn, making pain management more difficult. Both conditions can be hard to assess and both require multimodal intervention strategies for prevention and treatment, in which the conduct of anaesthesia plays a major role. This is particularly the case in cognitively impaired patients and after emergency surgery, and contributes to the excess morbidity and higher mortality seen in these patient groups .
Indeed, pre-existing and postoperative cognitive impairment is increasingly prevalent with age, and renders patients vulnerable to receiving the poor care highlighted in recent national reports. Persistently negative attitudes within healthcare need to be challenged by positive ‘exceptionalism’, where the elderly, as the largest patient group with the greatest needs, are provided with healthcare preferentially . An alternative is to provide their care more effectively, efficiently and with greater dignity. This might be coordinated in anaesthetic practice, for example, by the appointment of a Lead for Geriatric Anaesthesia in each department responsible for continuous quality improvement, and institutional involvement in multicentre trial and observational research .
The 2014 guideline emphasises these and a number of other points: dignified peri-operative care for older people requires senior multidisciplinary input adapted for each individual patient, contributed to by timely surgery, peri-operative care protocols and sympathetic anaesthesia that encourages re-enablement .
We can do better, we have to do better: we will rely on these improvements ourselves one day.