On being 60

Nancy Redfern

Consultant Anaesthetist

Honorary Membership Secretary AAGBI nancyredfern@hotmail.co.uk

The Ageing Anaesthetist

Baby Boom (1945-1962)

• Optimistic, ambitious permissive, rebellious

• Value - youth, personal success, wealth

• Workaholics work is part of your identity

and as patients?

Richard Marks Learn@AAGBI WSM 2014

Generation Y (1982 – 2002)

• Co-operation, communication, conformity, perfection

• Don’t stay long in bad jobs

• Want to get job done & have fun

• Relationship with employers – expect to be trained, have positive bosses and encouragement

• Like a consensus view

• Want good working atmosphere & family friendly

• Sense of civic responsibility

• Location of job important

• Independent, resourceful entrepreneurial

• Alienated & misunderstood

• Don’t have same levels of allegiance

• Will go abroad, change jobs

Richard Marks Learn@AAGBI WSM 2014

Generation X (1963-1981)

Attitude to Work

Cognitive function declines

• processing speed slower (dealing with incoming information quickly and efficiently)

• working memory less agile (short-term memory and maintenance of new information)

• episodic memory encoding declines (formation of new memories of specific events or episodes)

Tiredness makes this worse

Vigilance becomes more variable

Premature diagnostic closure

Age related physical illnesses

– Normal declining function e.g. eyesight & hearing

– Impact of common health problems e.g. musculoskeletal, DM, hypertension, surgery

Redfern 2014

Age-related changes in performance

Ageing & Sight

• accommodation (focusing power), contrast sensitivity, and visual acuity all decline with age

• Drug labels and monitor displays are easier to read if they are high contrast and if they have larger print.

• legibility of different font styles - sans serif fonts, (Arial, Calibri) easier to read than Serif fonts, (Times New Roman)

Redfern 2014

If older people continue to work

• Increased number of workers with a chronic disease

• Will need effective interventions to improve participation of people with a chronic disease

• Wholescale change in the way society views health and work

• Workplaces that promote health and wellbeing

• Ensure that everybody with the potential to work has the support they need to do so

To enable people to work longer needs

Evidence from clinical practice

• Canadian study: rate of successful claims against anaesthetists aged > 65 yrs 1.5 times anaesthetists < 51 yrs, led to more severe injuries, despite the older anaesthetists’ being involved in fewer complex cases

Tessler et al Anesthesiology 2012; 116: 674-9

• Increased risk of permanent complications from thyroidectomy performed by less experienced surgeons & by those in practice for > 20 yrs. Suggested surgeons aged 35-50 provided the safest care

Dudos et al BMJ 2011: 343 :d8041

• Similar evidence for carotid artery surgery, cardiac surgery, parathyroidectomy, laparoscopic hernia

Redfern 2014

Age (yr) Practice activities

60-64

• no further on-call duties (to avoid interrupted sleep, stress of

higher case acuity, limited help available to deal with crises)

• recommend annual simulation CPD to practice and assess

crisis management

65-69 • no further high-intensity/high-acuity cases (defined for the

individual, with no exceptions unless in a life-or-limb crisis)

> 70

• retirement from operating room clinical practice

• if desired, replace with non-operating room activities such as

pre-assessment clinic, admin, research, mentoring, education

Structured pre-retirement “winding down” of clinical activities - example

Baxter AD , Boet S, Reid D and Skidmore G The aging anesthesiologist: a narrative review and suggested strategiesCan JAnesth. 2014

On being 60

Nancy Redfern

Consultant Anaesthetist

Honorary Membership Secretary AAGBI nancyredfern@hotmail.co.uk

Cognitive function declines with age

• semantic memory (knowledge) & routinised behaviours show little change - just as quick to respond and draw on previous experience when not tired

Over 60 -

• processing speed slower (dealing with incoming information quickly and efficiently)

• working memory less agile (short-term memory and maintenance of new information)

• episodic memory encoding declines (formation of new memories of specific events or episodes)

Redfern & Gallagher Anaesthesia 2014

Expert performance

4 types of process

• Reading the situation

• Making decisions

• Overt activity

• Metacognition

3 modes of cognition

• intuitative

• analytic

• deliberative

Automatic routines punctuated by rapid intuitative decisions based on tacit understanding of the situation Involves

Eraut

Using deliberative thinking

‘A mixture of analysis, intuition and reflection’

Used by skilled professionals when

• outcomes are particularly critical

• uncertain about outcomes/need to incorporate differing interests/ need to consult other people

• managing messy, fuzzy, unique and context related problems

• a new situation - no previous experience

• feel uneasy with initial choice of action

• misinterpret a situation and events do not develop as expected

• guidance from theory is only partially helpful

Eraut

Decision-making using deliberative thinking

Making a good decision using deliberative thinking

depends on • the correct analysis of the problem

• considering the full range of potential actions

• assessing their risks and benefits

• finding the best fit between the situation and the options (including getting more information before reaching a decision)

• relies on self-awareness and open honest enquiry • processing speed slower, working memory &

episodic memory less agile

Eraut

Cognitive function declines with age

Over 60 –

slower at recognising & managing new situations

more variable & declining vigilance

• problem if the older anaesthetist

– does not notice situation is changing,

– misinterprets events,

– has no previous experience upon which to draw

Redfern & Gallagher Anaesthesia 2014

Ageing anaesthetists - tiredness • tiredness affects older doctors’ performance & mood

• quality of sleep worsens with age; sleep becomes shorter

• reduced capacity to adapt to shift work with increasing age

• cognitive performance of older shift workers more impaired during night work but may be less aware of their degree of impairment than younger shift workers

Normal pension age - 66 by 2020 - 68 by 2046

Redfern & Gallagher Anaesthesia 2014

Age related physical health problems

• chronic conditions

musculoskeletal problems, diabetes, hypertension

• Hearing - beeps, alarms, conversation

• acute illess e.g. ischaemic heart disease / cancer

• Return to work after illness/surgery very tiring at any age

• Many people feel less confident

Redfern 2014

Ageing & Sight

• accommodation (focusing power), contrast sensitivity, and visual acuity all decline with age

• Cataracts, glaucoma, Age Related Macular Degeneration more common

• Drug labels and monitor displays are easier to read if they are high contrast and if they have larger print.

• legibility of different font styles - sans serif fonts, (Arial, Calibri) easier to read than Serif fonts, (Times

New Roman)

Redfern & Gallagher Anaesthesia 2014

Age related physical health problems

• chronic conditions

musculoskeletal problems, diabetes, hypertension

• Hearing - beeps, alarms, conversation

• acute illess e.g. ischaemic heart disease / cancer

• Return to work after illness/surgery very tiring at any age

• Many people feel less confident

Redfern 2014

Age related changes in organ function

• Hearing - beeps, alarms, conversation

• Vision

• Stamina is less

• Physiological reserve is less

• circadian rhythm disruption & inability to adapt to changes in the sleep-wake cycle

• chronic conditions

musculoskeletal problems, diabetes, hypertension

• Self perception of poor health is the main reason for leaving work

Redfern 2014

Age related physical health problems

• Return to work after illness/surgery is tiring

• Many people feel less confident Departments more likely to retain staff if they offer sensibly paced return to work plan good support from colleagues gradual increase in responsibilities realistic future job planning regular review so anaesthetist can reassess capability and stamina appreciate effect on performance of chronic condition /long term treatment on performance

Redfern & Gallagher Anaesthesia 2014

How might this affect departments?

• Older anaesthetists

– less good at night work

– need colleagues on hand in case of difficulties

– Good at pattern recognition

– ? Education, Standing up to external pressure

• Younger anaesthetists also tired – young families

• Good job planning & good access to a consultant Occupational Physician with an interest in doctors’ health

• 7 day service

• Recruitment

• 24 hour consultant presence

• Peri-operative physicians

Redfern 2014