Role of Nutrition in the Elderly Surgical Patient – Review of the Literature and Current Recommendations

Poor nutritional status is common among inpatients, and particularly so among surgical patients. The problem is even more pronounced among elderly surgical patients, with age itself being an independent risk factor for malnutrition. With older adults representing a large proportion of patients undergoing emergency operations, and with malnutrition contributing to worse surgical outcomes, peri-operative nutritional optimization has garnered significant interest in the surgical literature. We sought to review the literature, specifically over the last five years, regarding the approach to nutritional evaluation and optimization in the pre- and post-operative settings in the elderly surgical patient. Recent research has focused on the pathophysiologic mechanisms that drive cachexia, including inflammatory and endocrine pathways and their interplay in patients subjected to the stress of surgery, as well as on the important differences between cachexia and sarcopenia. Emphasis has been placed on approaching nutritional status in a systematic fashion and on using context-specific validated screening tools in addition to biochemical and anthropometric parameters. In the elective setting, Enhanced Recovery After Surgery (ERAS) pathways have become the norm. With this, the concept of multimodal prehabilitation has been extensively studied and societal recommendations have been made. Elderly surgical patients constitute a particularly vulnerable population who is at risk of poor post-operative outcomes by virtue of both advanced age and poor nutritional status. Serum albumin, BMI, and history of recent involuntary weight loss or poor intake should be supplemented with screening tools such as the Nutritional Risk Screening (NRS-2002) to evaluate each patient’s nutritional risk. Nutritional and physical activity interventions lead to better outcomes, and should be implemented well before surgery and continued in the post-operative setting. It will be interesting and useful in the future to evaluate how these strategies translate to patients undergoing emergency surgery and who therefore do not usually have the benefit of pre-operative optimization.