Original Article: Preoperative Assessment in Older Adults: A Comprehensive Approach
Issue Date: August 15, 2018
See additional reader comments at:https://www.aafp.org/afp/2018/0815/p214.html
To the Editor: This article is deserving of praise for its thoroughness and recognition of an important issue. I wish to reiterate the significance of nutrition and offer practical recommendations for nutritional optimization.
More than 50% of older surgical patients are thought to have malnutrition.1 Poor nutrition is associated with increased postoperative complications, prolonged length of hospitalization, and increased health care costs.2 In terms of modifiable preoperative risk factors, malnutrition is one of the few that is associated with poor surgical outcomes, including mortality.3,4 Although referral to a dietitian may be ideal for certain patients, there can be multiple barriers to implementation. Only one out of five patients receives any nutritional intervention in the preoperative and postoperative periods.5
Herein lies an opportunity for the family physician to make two recommendations. The first is supplementation with arginine and fish oil, and the second is high-protein supplements taken two to three times daily (minimum of 18 g of protein per serving).5 Both may be obtained at local pharmacies or ordered online. Supplementation for a minimum of five days for low-risk patients and seven days for those at higher risk has been recommended.5 A patient at higher risk would have an albumin level of less than 3.0 g per dL (30 g per L) or would meet any of the following criteria: body mass index of less than 20 kg per m2 if older than 65 years, unplanned weight loss of more than 10% of total body weight in the past six months, or eating less than 50% of a person's normal diet in the past week. In addition, one could communicate that total protein content is more important than total caloric intake.5
In Reply: Thank you for your comments on nutrition in older adults. Given the breadth of material we wanted to cover on the perioperative visit, we focused our nutritional assessment and intervention recommendations on areas with the strongest supporting data. The study by Williams and Wischmeyer quoted by Dr. Orlovich in his letter looked primarily at colorectal and gastrointestinal surgical oncology programs; although they comprise a large number of surgeries that older adults undergo, they are not inclusive of all the types of surgeries in older adults.
Malnutrition increases length of hospital stay and related costs and is associated with an increased risk of adverse postoperative events. Assessment should include history of unintentional weight loss and documentation of baseline weight, height, and albumin level. If available, and if time permits, patients identified to have poor nutrition may benefit from referral to a dietitian for a comprehensive plan to optimize nutritional status. Nutrition recommendations may include modifications to diet, food consistency changes, and nutritional supplements. Compared with no intervention, dietary advice and/or nutritional supplements improve body weight, muscle bulk, and strength, although there is inconclusive evidence of improved survival. Patients with dentures should be reminded to bring them to the hospital to facilitate appropriate caloric intake postoperatively.1
Current studies are too heterogeneous and lack conclusive evidence that preoperative oral nutritional support with dietary supplements improves outcomes for patients undergoing surgery.2
Other barriers include adding supplements in patients who may already take a number of medications and our limited understanding of how these natural supplements may or may not interact with a patient's current medications, especially given concerns around the lack of U.S. Food and Drug Administration monitoring for nutritional supplements. Cost is also a major factor for older adults.
We agree that a focus on nutritional support and supplementation is an important area of further research, although it remains unclear whether it improves surgical outcomes or mortality for older adults when started before surgery.