The pangs that drive geriatric research…growing stronger by the day!

Ageing is an inevitable phenomenon. Except for the Gods in mythology, such as Hercules, Zeus, Chiranjeevi, and some others, no living being on earth has escaped the phenomenon of ageing. The silent and gradual process of ageing is accompanied by a decline in the function of all organs. Almost every facet of the body's physiology is affected, including emotions, sleep, and mood. The rhythm, ensemble, intonation, and vibrancy of the human endocrine orchestra are affected as the function of the thyroid, the pancreas, the gonads, and the adrenals declines steadily. The fall in the level of gonadal hormones affects the vascular health and brain health, especially cognition.^[1] All this can result in multiple comorbidities, and we anaesthesiologists can often encounter these in the aged patient posted for surgery. The aged patient is, in fact, an endocrine enigma waiting to be explored. The authors of a review article in this issue rightly stress the importance of anaesthesiologists being well versed in the management of endocrine-related comorbidities in the perioperative patient.^[2]

Brain oxidative stress that occurs with ageing is known to lead to Alzheimer’s disease.^[3] Oestrogen lack, which occurs with ageing, increases the risk of dementia and also affects the vascular endothelium and processes involved in inflammation, atherosclerosis, thrombosis, thrombolysis, and fibrinolysis.^[4] It has been found that neurodegenerative insults will be more effective in those with a lack of oestrogen.^[5] Whether the same holds true for perioperative insults and stress needs to be researched. Further, the subtle biochemical and cellular changes that occur deep inside the body in old age, especially at the mitochondrial and nucleic acid level and molecular pathways, are yet to be completely unravelled and have elicited many a researcher’s curiosity. Studies have explored various aspects of ageing, including the ageing mechanism, methods to reduce the ageing process, elimination of senescent cells, senolytic therapy, and the genetic architectures underlying organ-specific ageing.^[6,7]

Sarcopenia and frailty are an accompaniment of ageing. Nevertheless, sarcopenia leads to frailty. Sarcopenia and frailty are known to produce negative perioperative outcomes, including delayed postoperative recovery, increased risk of surgical infections, higher risk of postoperative delirium, functional decline, prolonged hospital stay, and poor quality of life.^[8,9] The preoperative assessment of frailty can enable the anaesthesiologist as a perioperative physician to predict the perioperative risk of morbidity and mortality and tailor clinical care, including making decisions about stressful perioperative techniques.^[10] In fact, frailty assessment during the preanaesthetic assessment is now a well-established practice as it can help in the adoption of suitable perioperative risk reduction strategies, appropriate anaesthesia techniques, and postoperative management strategies.^[11,12]

Nonetheless, sarcopenia, frailty, and their relation to poor perioperative outcomes are being explored. The impact of frailty and old age on weaning from invasive ventilation has been studied.^[13] In a recent study, the authors propose ‘risk-equivalent’ age as an operationally defined metric that reflects an individual’s position on a continuum of clinically meaningful risk.^[14] A recent cohort study concludes that frailty and sarcopenia act independently and have an additive effect on patient morbidity. The postoperative morbidity risk was found to be twice as high for the elderly patients who had both sarcopenia and frailty as for those who had neither.^[9] Several studies on the contribution of inflammation, oxidative stress, and metabolic dysregulation to skeletal muscle function and ageing are also going on.^[15]A recent systematic review explores the motor unit and neuromuscular junction dysfunction in ageing and sarcopenia. Though several studies on sarcopenia are underway,^[16] quality research studies on perioperative sarcopenia, including its recognition and optimisation to promote faster and better postoperative recovery, are warranted.

The current era has seen a surge in ultrasound-guided regional anaesthesia and enhanced recovery after surgery (ERAS). Regional nerve blocks and fascial plane blocks can aid faster postoperative recovery in the aged patient. Most of the published studies show that ERAS is possible and safe in elderly patients, especially for colorectal, gynaecological, urological, and orthopaedic surgeries. In addition to reducing the stress response, ERAS in older patients offers other benefits such as the reduction of postoperative delirium, early mobilisation, and early oral intake. Prehabilitation, the use of minimally invasive surgical techniques, and the application of patient-centred multi-disciplinary models, including collaboration with geriatric medicine, are important aspects of ERAS in the elderly.^[17] Two studies published in this issue of the journal are centred on fascial plane blocks, including external oblique intercostal plane block versus subcostal transversus abdominis plane block for upper abdominal laparoscopic surgeries, and ultrasound-guided erector spinae plane block versus ilioinguinal-iliohypogastric nerve block in patients undergoing unilateral inguinal hernia meshplasty. The authors of these studies have conducted the research on patients aged 18-70 years. ^[18,19] However, it is pertinent to note that the elderly are often subjected to upper abdominal laparoscopic surgeries and inguinal hernia surgery, and similar studies on the elderly population would bring in more insights. Nonetheless, it is often observed that most studies in anaesthesia research including dissertations are conducted in the younger age group and those in the geriatric population are few, may be because of issues such as the presence of multiple comorbidities in the elderly, poor data on drug safety in them and lack of patient cooperation and in some instances moral and ethical considerations inhibit the conduct of research in this population. All this has led to the continued existence of several knowledge gaps in geriatric medicine. These gaps have to be explored, and the lacunae have to be filled.

The road of geriatric research is long beyond doubt, and the potholes are many. There are many miles to go, and the haul is long, but the journey is needed and has to be embarked on and completed.