Surgery is increasingly common among older adults, with 33% of U.S. inpatient surgical procedures performed on adults ages 65 or older. The quality of hospital care has become a key Medicare focus area, and its hospital quality reporting program includes several measures addressing readmission rates, infection, complications and higher cost of care relevant to the surgical population.
Many older adults also have chronic conditions—such as hypertension/coronary artery disease—and reduced/declining function, thus special consideration should be given to helping older adults best prepare for and recover from surgical procedures.
Good nutrition is essential for effective surgery preparation and recovery. The American College of Surgeons has identified that when older adults are malnourished prior to surgery, they have a greater risk of complications after the procedure and are less likely to return home. In addition, nutrition is an important part of Enhanced Recovery After Surgery (ERAS) protocols and there is new evidence underscoring this.
What Is ERAS?
Surgical teams and healthcare providers follow ERAS protocols to help elective surgery patients better prepare for surgery, recover more quickly, and get back to their everyday activities as soon as possible. ERAS began 25 years ago as a surgical quality improvement initiative focused on perioperative care of patients undergoing colorectal surgery. The initiative sought to improve patient outcomes through active patient involvement and the collaboration of multidisciplinary healthcare professionals. Practice recommendations were based on multimodal, evidence-based interventions, and outcomes were monitored by systematic audits. Acceptance and adoption of ERAS protocols has grown and there are now protocol recommendations for more than 20 surgeries.
Nutrition in ERAS
Nutrition plays a significant role in evidence-based ERAS protocols, including avoiding or minimizing the preoperative fasting period, enabling preoperative carbohydrate loading with clear liquids up to two hours before anesthesia, supporting immunonutrition before and after surgery, and re-establishing oral feeding as soon as possible after surgery. Previous research has shown the value of nutrition in reducing hospital length of stay and readmission rates in surgery patients. New research on ERAS protocols that include nutrition components have demonstrated the value of ERAS in improving patient outcomes.
An ERAS protocol for colectomy surgery patients at a large U.S. teaching hospital included pre-operative carbohydrate loading, multimodal approaches to pain management, mobilizing patients soon after surgery, and immunonutrition supplements before and after surgery. A study of this program found that patients who had surgery after implementation of the ERAS protocol had lower rates of post-operative nausea and vomiting and reduced use of opioids.
In a separate study, the impact of ERAS protocols that closely followed established guidelines implemented in Whipple procedures, distal pancreatectomies and surgeries for head and neck cancer at an ERAS Academic Center of Excellence was examined. Patients who had surgery after the ERAS protocol was implemented had shorter hospital stays without increases in unplanned readmissions. Also, patients who resumed early nutrition post-operatively had shorter hospital stays.
Nutrition is an important but often overlooked part of surgical preparation and recovery, particularly for older adults. Effective nutrition care, combined with other best practices, can speed patient recovery and reduce hospital stays. Older adults who may be having elective surgery should consult their physician or a registered dietitian nutritionist to help optimize their nutrition prior to surgery and benefit their recovery.
Kirk W. Kerr, PhD, is senior manager of global health economics and outcomes research for the Abbott Nutrition Division of Abbott in Columbus, Ohio.
