Perioperative management of malnutrition in the elderly^†

In addition to dental and oral problems, taste changes can also include food choices. The elderly have reduced saliva secretion and proneness to oral infection increase the identification threshold of a variety of taste stimuli, especially the feeling of mixed taste, which can affect appetite and increase the risk of malnutrition.

The gastrointestinal function of the elderly is weakened with advancement of age. If the diet is not correct, it will cause malabsorption of proteins, vitamins, and minerals. Furthermore, the elderly have a need for more protein and they are more likely to experience malnutrition than younger people when in trauma or during illnesses. Elderly patients with recovering wounds require significantly more protein at 1.5 g/kg/d, than younger patients.

Gout affects the food choice of patients, which leads to malnutrition. The elderly with joint diseases who go to stores to buy food and prepare food are significantly affected. Gout is also a risk factor for malnutrition. The elderly mostly suffer from chronic diseases. Many old people use 2–5 drugs every day. It is easy to mutually offset between more than two different drugs or drugs and nutrients, leading to drug-induced malnutrition. For example, sympathomimetic drugs, anti-parkinsonian drugs, antidepressants, and hypoglycemic drugs can cause nausea, vomiting, taste and smell decline or dry mouth and affect the appetite. Aspirin effects on the digestive tract will hinder the normal process of food digestion and absorption. Long-term use of indomethacin and reserpine can stimulate the gastrointestinal epithelial cell walls, resulting in impaired gastrointestinal function, directly or indirectly hindering the absorption of nutrients.³

Sudden major changes, such as the loss of a spouse or accidents, can have a huge impact on the psychology of the elderly, affecting their normal digestive function, which can lead to malnutrition. In addition, long-term lack of family care and long-term loneliness also make them unable to pay attention to their nutritional status and lead to nutritional imbalance.⁴

The income level also affects the habits of the elderly. Those with a high income at their disposal suffer less from malnutrition than those having a lower income. The elderly with financial constraints will inevitably try to consume less food in order to save money, and hence cause nutritional imbalance.

Urban living, institutional pension, high education level, married, and living with partners are the protective factors of malnutrition among the elderly. The surrounding environment having pollution, including chemical pollution, noise pollution, and so on, will affect the nutritional status of the elderly.⁵

Elderly surgical patients can be evaluated using the Fried Frailty syndrome criteria, Frailty index, and FRAIL scale The Fried Frailty syndrome standard is applicable to hospitals or pension institutions, the Frailty Index assessment is applicable to professionals, while the FRAIL scale proposed by the International Society of Geriatric Nutrition is more suitable for rapid clinical evaluation. The Frail score comprises five parts: (1) fatigue; (2) resistance: difficulty on the upper staircase; (3) free movement: unable to walk one block; (4) multiple diseases coexist (>5 diseases); and (5) weight loss (weight loss >5.0% in 1 year).⁶ In addition, body mass index can be calculated by weight, height, BMI, arm circumference (AC), triceps skinfold thickness (TST), calf circumference (CC), upper arm muscle circumference (AMC), upper arm muscle area (AMA), and upper arm fat area (AFA).⁷

Some findings suggest that preoperative assessment includes not only the physical condition and surgical risks of elderly patients, but also their mental and cognitive status.⁸ Elderly patients have cognitive dysfunction such as increased risk of postoperative delusion. Postoperative long-term cognitive impairment may be further aggravated, which will lead to prolonged hospitalization, cognitive function and physical function decline, and even increased risk of death. Before surgery, we can evaluate the patient’s condition and combine it with the relevant scale in advance. The commonly used assessment scale includes the simple cognitive assessment scale (Mini-Cog).⁹

Preoperative communication includes communication with patients and with their family members. Family members play an important role in the patient care team, with support and education, helping to improve treatment outcomes.

The preoperative communication includes past medical history and medication status; auxiliary information about cognitive and functional defects; how family members assist patients to participate in and cooperate with disease treatment; family care; and psychological counseling. Besides, during the preoperative anesthesia assessment, we can also communicate with the patient and the family members, according to the preoperative ASA anesthesia assessment level, to further understand whether the patient has organ dysfunction, whether they affect the anesthesia and surgical operation, and need special support and monitoring.¹⁵

In addition, communication to understand the patient’s disease status, such as chronic diseases and inflammation, can also assess whether the patient is at risk of malnutrition. Early detection and treatment of malnutrition is crucial to improve patient outcomes.¹⁶ Therefore, understanding preoperative nutritional status through family members is important to improve surgical outcomes, reduce the occurrence of complications, and shorten the length of hospital stay.¹⁷

According to their nutritional status and surgery, appropriate nutritional support, including enteral nutrition (EN) and parenteral nutrition should be taken care of. Of all the factors that affect postoperative morbidity and mortality, nutritional status is the most important.¹⁹ Malnutrition significantly increases the morbidity and mortality of postoperative complications, leading to prolonged hospital stay and altered quality of life.²⁰ According to the evaluation results, appropriate nutritional support was provided to patients with nutritional risk, such as EN and parenteral nutrition.²¹

As part of the joint management of multidisciplinary intervention, caregivers should work together to provide personalized nutrition information, education, and nutritional counseling services to the malnourished or at risk, to raise awareness of nutritional problems and promote adequate dietary intake.² After finding elderly patients with malnutrition risk by using nutrition screening tools, the diagnosis and grading of malnutrition should be clarified according to the GLIM criteria. For example, esophagectomy is one of the most invasive procedures for patients with esophageal cancer; besides tumor resection, the procedure requires extensive surgical fields and lymph node dissection and resection. Because the function of the esophagus affects the metabolism, and the neuroendocrine and immune systems, the postoperative nutritional status will be significantly worsened due to high metabolism and digestive and absorption disorders.²² Furthermore, the oral food intake was significantly reduced after surgery due to mechanical and functional changes in the gastrointestinal tract leading to swallowing disorders, and early saturated postprandial dumping syndrome.²³ Therefore, some patients with esophageal cancer need EN and parenteral nutrition to meet the perioperative nutritional needs.

Different surgical sections use different ways of nutrition intake post-operation. For non-abdominal surgery, such as subarachnoid anesthesia and epidural anesthesia, EN support can be provided for 3–6 h after surgery. In general anesthesia, after nausea and vomiting has disappeared, EN can be performed. Gastrointestinal surgery generally needs fasting for 24–48 h; after the recovery of intestinal peristalsis, EN support can be gradually increased. If adequate energy cannot be obtained by EN, supplementary parenteral nutrition (SPN) support should be given to meet the demand, to improve the nutritional status and clinical outcomes.²⁴

Depending on the patient, it is expected that without oral intake for >3 d or dietary intake <50% of energy needs for up to 1 week, EN should be provided to meet nutritional needs and maintain or improve nutritional status. If the expected EN time is <4 weeks, use the nasal feeding tube; if the expected EN time is 4 weeks or intolerant, select percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ), and the first 3 d of EN treatment should be closely monitored to prevent complications. According to the situation of the individual, when there is a severe disorder of gastrointestinal function, and EN cannot be used or EN cannot meet 60% of the target requirements, PN should be initiated to meet the individualized needs. It should be closely monitored during treatment to avoid complications. According to the results of comprehensive nutrition assessment, individualized calorie target value, protein target value, trace element target value, and fluid target value are formulated for patients. It is recommended that the elderly with malnutrition or nutritional risk have dietary reinforcement between meals and attention should be paid to providing improved fortified food for those with difficulties in swallowing and chewing, to ensure adequate energy intake.

Some postoperative elderly patients can also take oral nutrition agents. The benefits of oral nutrition are explained by the cephalic thermogenic response (CPR). CPR is to prepare food digestion and absorption for the gastrointestinal tract by promoting physiological changes before food intake.²⁵ CPR stimulates the vagus nerve, resulting in the release of bioactive substances (saliva, gastric fluid, and exocrine pancreatic fluid) and hormones (insulin and glucagon). Furthermore, CPR leads to increased gastric motility, changes in heart function, increased blood pressure, increased respiratory entropy, and increased postprandial thermogenesis metabolic rate. A randomized controlled trial and an animal experiment with colorectal surgery showed that oral and sham feeding (using chewing gum) enhanced the autonomic nervous system and reduced inflammatory complications and hospital stay more than the enteral and parenteral pathways.²⁶ Furthermore, oral feeding reduces complications and hospital stay more than the enteral route in upper gastrointestinal surgery.²⁷

The elderly have difficulty in pain assessment due to disease, decreased metabolism, and cognitive dysfunction, which increases the difficulty of postoperative analgesia. Poor postoperative analgesia can induce or aggravate postoperative delusion, and excessive analgesia may also lead to cognitive dysfunction, delusion, and so on. Providing individualized patient and family centered education should be included in the entire surgical procedure, rehabilitation program, extent and pattern of postoperative pain, pain management methods, and pain management objectives.

Elderly patients with malnutrition need to develop an individualized and multimodal analgesic regimen according to their past medical history and drug use.²⁸ Acetaminophen and non-steroidal anti-inflammatory analgesics can be used as the first-line pain treatment for multimodal analgesia in the elderly; intravenous-controlled analgesia (patient controlled analgesia [PCA]) enables dynamic management and improves the analgesic effect; local infiltration analgesia (LIA) during the incision is for injection or infiltration of a long-acting local anesthetic. Less systemic response means good local analgesic effect. Surgical site-specific peripheral nerve block techniques can be used for analgesia after geriatric orthopedic surgery. Low risk and definite analgesic efficacy, less systemic impact, and Rhabis abdominis plane (transversus abdominis plane [TAP]) block is a method of regional block. Perioperative analgesia for abdominal surgery in the elderly is done by conduction of blocked spinal nerves.²⁹

Elderly malnourished patients are encouraged to perform appropriate postoperative activities to promote patient appetite and recovery of blood circulation.

According to the condition of the patient’s body and surgery, appropriate activity guidance, including exercise type, intensity, and frequency are given. In clinical practice, based on the comprehensive assessment of nutrition, the multidisciplinary team should develop individualized multicomponent exercise programs and rehabilitation exercise programs to maintain or improve muscle quality and function for the undernourished or at risk of undernutrition, while ensuring adequate caloric and protein intake.²

Researchers have explored numerous activity interventions in elderly patients, such as diet and nutrition guidance interventions, psychosocial support, cognitive training, physical training, and physical therapy programs. Exercise interventions in the elderly, such as resistance training, individual progressive dual-task training, multicomponent exercise, and traditional Chinese medicine exercise (Baduanjin, Taijiquan), have also been explored. However, there is great heterogeneity among the different studies in terms of the timing, frequency, outcome measures, and effect evaluation of the exercise intervention. This study found that moderate-to-high-intensity exercise reduced fatigue and depression symptoms in elderly patients. These improvements were accompanied by metabolic changes. Moderate to high intensity exercise should be implemented in the standard care.³⁰ In addition, to maintain beneficial effects, one needs to maintain exercise. Aerobic and resistance exercise improve physical fitness in aerobic capacity, endurance, and strength in elderly patients.³¹ Patients are followed up during their postoperative exercise to understand their recovery and give necessary guidance. In the future of patient recovery, legal care services may decrease, rather than increase, suggesting that the burden of care will again fall on the spouse (possibly elderly), other family members, or the private sector (nursing home). This, coupled with the findings that many elderly people with severe mental and physical disabilities can live for a long time, fully demonstrates the importance of providing public and voluntary services.³²