Should ASA physical status classification consider geriatric age?

In 2020, the American Society of Anesthesiologists (ASA) developed and approved pediatric and obstetric examples for determining physical status (PS) classification.[1] However, ASA has been missing out on developing and approving geriatric-age examples.[2-4] Although adult examples can be considered to include the geriatric population, it is interesting to note that ASA must have deemed it necessary to delineate pediatric and obstetric examples from adult examples. The primary question is whether extreme geriatric age should be considered to increase the ASA PS classification. There are already ASA-approved examples where premature infants and full-term infants of <6 weeks of age were upgraded to ASA PS class III based solely on the extremes of their age. If the significantly altered physiology during “normal” pregnancy were considered ASA II, then the case for geriatric patients of >70 years of age should also be proposed as ASA III in its next amended statement. Moreover, there must be a reason why the age of >70 years has been routinely qualified for additional reimbursements from payers.[5] Normal aging evolves with significantly altered physiology as well, considering that major adverse cardiac events may be related to the patient’s age itself, acting as an independent perioperative risk factor.[6-8] If a patient’s age were considered “just a number,” then the same argument should also be made against body mass index when deeming an obese patient as class II or III.[9] Interestingly, due to the evolving humanitarian lifestyle, the question of whether the age of 70 years old could or would always remain an appropriate cutoff is becoming clinically significant to suggestively increase the perioperative risks. Although there is an increasing incidence of known coexisting conditions in the geriatric population, it may not be uncommon to encounter healthily aging geriatric patients who have no known comorbidities. Therefore, the dilemma persists whether healthily aging geriatric patients can be suitably deemed ASA I even if they are centenarians with no known comorbidities.[10] Interestingly, it is a common practice for anesthesiologists in lower- and middle-income countries to upgrade their perioperative patients based solely on their patients’ geriatric age by presuming a high prevalence of underdiagnosed and thus unknown co-morbidities among developing nations’ patient populations. This condition is contradictory to those in developed nations having the preoperative privilege of presumable high prevalence of known comorbidities. Essentially, inspired by the success of its adult examples, ASA should standardize geriatric age-specifying examples among adult examples if the patient’s chronological age itself is known to have any perioperative significance. In the interim, anesthesiologists could and would upgrade the ASA PS classification for geriatric patients based on their assessment by giving weightage only to their geriatric patients’ known co-morbidities. Financial support and sponsorship Nil. Conflicts of interest The authors are siblings.