Surgery in the elderly: the role of nutritional support

Clinical Nutrition (2001) 20(2): 103–116 & 2001 Harcourt Publishers Ltd doi:10.1054/clnu.2001.0400, available online at http://www.idealibrary.com on

REVIEW ARTICLE

Surgery in the elderly: the role of nutritional support F. BOZZETTI Italian Society for parenteral and enteral nutrition (Correspondence to: FB, Residenza Le Querce, Milano Due, 20090 Segrate, Milan, Italy)

Key words: elderly; nutritional support; nutritional status; surgical risk

Anthropometrics and body composition Body weight in women increases until approximately the fifth decade of life, and remains steady throughout the seventh, when it begins to decline. The pattern is similar for men, except for the fact that their weight gain usually ceases around the fourth decade of life. Studies have demonstrated that body weight peaks between ages 55 and 65 in women and between ages 34 and 54 in men, only to decrease thereafter (3). Men are estimated to lose up to 6.6 kg between ages 70 and 81 as compared to 5.7 kg in women over the age of the same period (4). Loss of weight occurs at the expense of body water and lean body mass, whereas fat loss is usually negligible (5). In 1960, Master et al. (6) published a table providing average weight-for-height for the age-range 65 to 94: ideal body weight usually included 2.2 kg and 1.3 kg for clothes in men and women, respectively. More recently, Andres has developed a weight range for the age of 65 (7), and Frisancho has produced weight-per-height percentiles for the ages from 55 to 74 (8). By using these age-specific tables, a more valid ideal weight can be assigned to patients. Height has been found to decrease with age, with an estimated decline of 1 cm for each decade after the age of 20, namely due to narrowing of intervertebral disk spaces. However, from ages 60 to 80 the loss of height is about 0.5 cm every year (9). If actual height is unable to be measured for some reason (e.g. in patients with severe spinal curvature, or bedridden patients), stature may be calculated approximately by measuring length from the bottom of the foot to the anterior knee (with ankle and knee positioned in a 90-degree angle) and using the following formula (in cm):

Introduction The technical life-span of human beings is 112 years in Italy, with a peak of 122 years—the highest in Europe— in France (1). As a general rule, subjects who are 65 years old or older (a value a little higher than the median value of the longest expected survival) represent the population of elderly patients as referred to in a medical context, even if individuals over 80 years old are often defined as being very old. However, it is clear that such a statement is arbitrary, since functional and biological deterioration is a progressive process that initiates after the first three decades of life (Figure 1). With regards to length of life, on one hand, the age at which 50% of the population is still alive appears to have increased dramatically over time; on the other hand, maximum life-span potential seems essentially to be constant (Figure 2). For example, the United States population has grown by 39% in the past 30 years, but the segments older than 65 and 85 grew by 89% and 232%, respectively (2). As a consequence, everyday clinical practice confronts surgeons with a legion of ever older patients who are therefore frailer than normal and have a low tolerance of any injury, whether traumatic, infectious, or surgical. The recent trend for carrying out surgical procedures in increasingly older patients is illustrated in Table 1.

Nutritional assessment stature for men ¼ 64:19 ÿ ð0:04
ageÞ Nutritional assessment in the elderly requires special consideration. Because of the physiological changes incurred by the ageing process, interpretation of standard nutritional assessment parameters should be adjusted for the geriatric population. This is especially valid for anthropometric and biochemical indices.

þ ð2:02
knee heightÞ; stature for women ¼ 84:88 ÿ ð0:24
ageÞ þ ð1:83
knee heightÞ: Recently a regression equation has been designed for estimating stature and weight in the Italian elderly using 103

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other anthropometric measures (10). statureðcmÞ ¼ 94:87 þ ð1:58
knee heightÞ ÿ ð0:23
ageÞ þ ð4:8
sexÞ weightðfor menÞðkgÞ ¼ 36:2 log arm circumference þ 42:47
log calf circumference þ 6:91
log sub-scapular skin-fold þ 0:8
ðknee height ÿ 25:37Þ weightðfor womenÞðkgÞ

and 45 per cent, respectively). By age 70, adults have lost approx 40% of their peak adult muscle mass (13) and from 70 to 90 years of age, muscle strength decreases by 26–52% in healthy elderly subjects (23). Females start to lose muscle mass at a later age than males and at a slower rate. Percentiles for sub-scapular skin-fold, triceps skinfold, and mid-arm circumference have been developed for the age range 55–74 using combined National Health and Nutrition Examination Survey data (8) (Table 2). Others are found in the American literature (24–27).

¼ 1:41
arm circumference þ 1:11
calf circumference þ 0:47
ðsub-scapular skin-fold þ 1Þ
ðknee height ÿ 67:37Þ Fat stores are redistributed throughout life. An increase of body fat has been documented at 0.5 to 1.5 per cent per year, beginning at approximately the age of 30 (11), whereas lean body mass declines by 6.3 per cent every 10 years (12). However, in older individuals (470 years) total fat mass tends to decline (13, 14). Adipose tissue thickness decreases on the arm and leg with age (9, 15, 16) whereas the thickness of subcutaneous and internal adipose tissue increases on the trunk (17, 18). Therefore, skinfolds and circumference measurements from the limbs decrease with age, whereas abdominal circumferences increase (16, 19). Generally speaking, a mid-arm muscle circumference or mid-arm muscle area a triceps skin-fold below the 10th percentile indicate poor nutritional status (20, 21, 22). Skeletal mass decrease is 20 per cent less in adults aged 70 or over than in younger patients (27 per cent

Fig. 1 Data compiled by Shock and colleagues clearly document the loss of organ functional capacity that occurs with advancing age. From Shock N W. Physiologic aspects of ageing. J. Am Diet Assoc, 1970; 56: 492 (254).

Fig. 2 Human survivorship curve at different periods in history. From Cutler R G. Evolutionary perspective of human longevity. In: Hazzard W R, Andres R, Bierman E L et al. (eds). Principles of Geriatric Medicine and Gerontology, ed. 2. New York, McGraw-Hill, 1985, p. 16 (255). *only for males

CLINICAL NUTRITION

Table 1 Surgical procedures: trends from 1972 to 1981 (in 1000s) Type of operation

Coronary artery bypass surgery Rectal cancer resection Endarterectomy Cholecystectomy Mastectomy Vascular surgery Peptic ulcer

1972

1981

65–74 Years of age

475 Years of age

65–75 Years of age

2.5

8

46

6.8

5.2

4.7

11.8

7.8

7.3 63.2 17.5 8.2 31.2

8.4 29.7 12.8 3.2 16.9

49.1 84.9 24.2 8.2 23.8

29.1 52.8 17.9 6.1 21.8

475 Years of age

Modified from Valvona J, Sloan F. Datawatch: rising rates of surgery among the elderly. Health Affairs 1985; 4: 108–119, (249).

Table 2 Mid-arm circumference (MAC) and sub-scapular skin-fold (SSSF) thickness (cm) in subjects 74 years old Age (yrs)

Median values MAC (cm)

SSSF (cm)

Males 45–54 55–64 65–74

32.2 31.7 30.7

1.2 1.1 1.1

Females 45–54 55–64 65–74

29.9 30.3 29.9

2.5 2.5 2.4

According to the American Committee on Diet and Health Report, the desirable Body Mass Index (BMI) value should range between 24 kg/m2 and ¼ 29 kg/m2 for people over 65 years of age (28, 29). With age there is an overall decline in body cell mass. The reduction in whole body potassium is disproportionately greater than that of protein, due to the fact that skeletal muscle, which contains the highest concentration of potassium, is reduced to a greater extent than other protein-containing tissues. Body fat, particularly that distributed centrally, increases in middle life but, frequently with increasing anorexia, over the age of 75, fat mass tends to decline. Total body water declines with age (11% and 17% in men and women, respectively) from the third to the eighth decade, primarily due to a decrease in intracellular water, and in proportion to the whole body potassium. The ratio of whole body potassium in intracellular water remains constant, whereas the ratio of intracellular to extracellular water declines. Biochemical indices The most commonly used parameter, serum albumin, has been reported to be somewhat modified in the elderly, though these studies have been controversial (30–34), Bistrian describes it as only a minimal alteration (33), while Roe describes it as a moderate decrease (34). Nevertheless centenarains appear to have signifi-

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cantly lower serum albumin levels than do younger people (35). Recent studies on large patient populations (36, 37) have identified age as an important predictor of hypoalbuminemia (535 g/L). According to some studies on geriatric populations, (38, 39) serum albumin concentration did not correlate with the clinical evaluation of nutritional status. Transferrin too, which is more sensitive to nutritional repletion, has been found to decrease with age, and reaches the lowest levels in centenarians (35). This may be due to the increase of iron stores (ferritin) with age, and the subsequent drop in transferrin. Transferrin as a marker of malnutrition has not been found to be useful, and does not correlate with anthropometric measurements (40). Prealbumin and retinol-binding protein are well maintained in the geriatric population but a decrease in prealbumin levels may occur in very old men (490 years) (35). The plasma concentration of insulin growth factor-1 IGF-1 decreases by 35% to 60% between the fourth and ninth decades (41–44) and also growth hormone secretion (44) and testosterone decrease. There is however an increase in leptin which is reversible by testosterone administration. Serum creatinine and urinary creatinine excretion reflect muscle mass and therefore decline with age; a creatinine height index of 8 and 7.2 in subjects aged 65– 74 and 75–84, respectively, as opposed to values of 9–10 in younger people, has been reported. With regards to total lymphocyte count, some studies have reported a decrease (45–48) and others, no change (49–55). A defective delayed cutaneous hypersensitivity skin testing has been related to increasing age (55–57) as well as a decline in polimorphonuclear function (58, 59). Chandra (60) found that 25% of free-living elderly were anergic. There is evidence of age-related T-cell dysfunction, in that the production of T-cell derived interleukin-2 is reduced in the elderly (61). B-cell dysfunction is evidenced by the impaired responses to delayed hypersensitivity testing, and to vaccination and skin antigen testing. Changes in vitamin and mineral status in the aged population and desirable values are reported in Tables 3 and 4. Metabolic abnormalities Ageing is associated with a deterioration in glucose tolerance (62–64), impaired levels of IGF-1 (65) and of somatomedine (65, 66), increased renal threshold for glucose (65, 66) and increased cortisol level following injury (64). The capacity to metabolise lipid also decreases throughout adult life (67). All these abnormalities seem to be related to receptor and enzyme alterations at the cellular level. Many studies (68–70) indicate that there is a decrease in whole-body protein turnover with advancing age. However, when whole-body amino acid flux rates are

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Table 3

Effect of ageing on vitamin and mineral status in the elderly

Increased

Unchanged

Decreased

Serum copper Liver iron (females) Serum ferritin

Liver iron (males) Liver folate Serum vitamin A Serum carotene Serum riboflavin

Serum and hair zinc Serum calcium Skin and aorta silicon Platelet tocopherol Serum 1,25-dehydroxy vitamin D Serum iron Serum thiamine Tissue chromium Serum selenium Plasma and leukocyte vitamin C Tissue vitamin C Serum vitamin B6 Serum vitamin B12

Serum biotin Serum pantothenate Leukocyte zinc Blood vessel copper

Adapted from Morley J E. Nutritional status of the elderly. Am J Med 1986; 81: 680 (250).

Table 4 Biochemical assessment of nutritional status in the elderly

Plasma retinol (mg/100 mL) Serum folate (ng/mL) Red cell folate (ng/mL) Serum vitamin B12 (pg/mL) Serum vitamin B6 (ng/mL) Red cell vitamin B6 (ng/mL) Serum ascorbic acid (mg/100 mL) Leukocyte ascorbic acid (mg/100 mL)

Acceptable

Low

Deficient

420.0 46.0 4150 4200 44.0 414.0 40.30 415

10–20.0 3–6.0 100–150 100–200 3–4.0 12–14.0 0.20–0.29 8–15

510.0 53.0 5100 5100 53.0 512.0 50.20 58

Adapted from Roe D A: Nutritional assessment of the elderly. World Rev Nutr Diet 1986; 48: 107 (34).

adjusted for fat-free mass, the effect of ageing disappears in most studies. In fact, skeletal muscle is the largest single protein pool, and it accounts for 80% of cell mass and 30% of whole-body turnover in lean young adults, whereas at the age of 75 muscle represents only 40% of fat-free mass and contributes to the whole-body protein synthesis for less than 20% (71). As regards muscle protein synthesis, it should be considered that muscle comprises various proteins with different fractional synthesis rates. In general, the mixed muscle protein synthesis declines with ageing (71–73) but within this subcellular pool of several proteins the synthesis of myofibrillar proteins was reduced in healthy older people (72–76), as was the synthesis of both mitochondrial proteins (77, 78) and the contractile myosin heavy chain, whereas the synthesis rate of the sarcoplasmatic pool was unchanged (71, 77). When expressed relative of mixed muscle protein synthesis rate, sarcoplasmic protein synthesis actually increased in older subjects compared with younger ones. Little data exists on the effects of ageing on non-muscle proteins. Fu and Nair (79) report that both the plasma concentration and fractional synthesis rate of albumin remain unchanged between the ages of 20 and 80, whereas the circulating fibrinogen concentration increase despite a concomitant decrease in the synthesis rate. Finally, there is a tendency for the elderly to become dehydrated. This is due to a decrease in free water

volume that leads to an increase in free-fatty mass density. It has been shown in fact that when elderly individuals suffer a major injury or sepsis they exhibit a delayed resolution of body water expansion (80, 81), which is usually associated with long periods of ventilatory support, intensive care, and hospitalization. Elderly persons are at increased risk for zinc deficiency, primarily related to low intakes of both zinc and energy and consequent adverse effects on wound healing (82). Prevalence of malnutrition Undernutrition is quite common in the institutionalized elderly (83–91). A national survey carried out in Great Britain documented a malnutrition frequency of 6% in men and 5% in women between the ages of 70 and 80 and of 12% in men and 8% in women over the age of 80 (92). Malnutrition was not only limited to protein/ calorie deficiency, but also to low intake of iron, ascorbic acid, thiamine, and vitamin D. Approximately 20% of the healthy elderly have reduced vitamin C levels (50.5 mg/dL), and 10% have reduced serum levels of vitamin A (50.33 mg/dL). In the United States, surveys in nursing homes revealed malnutrition frequencies as high as 52% and 85% (93–95), and hypo-albuminemia in 37% of the subjects (96). An Italian survey of 334 hospitalized patients (465 years old) revealed low serum folate or low iron levels in 60% of them, and low plasma zinc in 16.8% (97). Calcium intake decreased by 18% between 60 and 70 years of age (98). It is well-known that older patients are more likely than younger ones to lose their appetites in response to a physiologic stress (99). Hospital starvation has been reported to occur in 30% to 60% of patients (100), while several authors have stated that 42% to 56% of elderly patients maintain nutrient intakes under their basal metabolic rate, while hospitalized (101–104) and that there is a significant correlation between change in body weight and energy intake among patients hospitalized for more than two weeks (105). Hospital starvation together with drug-nutrient interference (Table 5) may account for the iatrogenic component of undernutrition. In conclusion, there is ample evidence from previous literature (94, 104, 106) and from recent studies (100) that hospitalized patients often receive less than optimal levels of nutritional care. Old age as a determinant of surgical risk It is well-known that the process of ageing is characterized by the progressive loss of individual organ functions, which is highly variable in extent depending

CLINICAL NUTRITION

on the specific organ system and the individual in question. This decreased reserve may initially be manifested at a time of physical and metabolic stress following major trauma. Several reports in the surgical literature indicate that age is not per se a contraindication to major surgery, which can also be performed safely in older patients. In keeping with this impression, a study focusing on the

Table 5 Drug therapy and nutritional support in the elderly Drugs interfering with nutrient assimilation/metabolism Al and MgOH Vit B1, folate, phosphorus H2 antagonists Vit B12 Cholesterol binding Fat-soluble vitamins, folate Phenytoin Vit D and K, folate, Vit B6 Isoniazide, penicillamine Vit B6 Antiepilectic Folate, Vit D Biguanides Glucose, amino acid, Vit B12 Colchicine Vit B12 Ethanol Vit A, Vit B1, Vit B2, Vit B6, Vit B12, glucose, amino acid, folate Methotrexate Xylose, folate Neomycine Vit B12, fatty acids P. aminosalycilic Vit B12, folate, Vit C Sulfasalazine Folate Tetracycline Iron, Ca, Vit K Cholestiramine Vit A, Vit K Coumadin Vit K Digitalis Zn Diuretics Zn, Vit B6 L-DOPA Vit B6 Sulphamidics Vit B1, Vit B6 Vit C Vit B12 Cathartics Vit A, D, K, E, B2, B12 Drugs interfering with nutrient delivery Sucralfate Clogs feeding tube Digoxin, phenytoin theophylline, Diarrhea due to hyperosmolality potassium chloride Nutrients affecting drug therapy Calcium Vitamin K

Phenytoin absorption Anticoagulants

107

interaction of functional status and age concluded that there was no difference in mortality between the youngest and the oldest groups, when considering patients without functional limitations (107). The majority of these investigations suffer from methodological flaws insofar as they usually refer to a favourably selected population of patients. In fact, if one refers to collective series of several thousand patients (108), there is clear evidence that morbidity and mortality increase progressively with advancing age. Surgeons certainly prefer to operate on a perfectly healthy old subject rather than a very ill middle-aged patient. The question is, however, what percentage of old patients is in such a good condition to tolerate well a surgical injury, and, the clinical status being equal whether old age represents a risk factor. It should be recalled that ageing per se adversely affects the function of body organs (Table 6) and this cannot be without consequence on the frequency of complication or their severity. Furthermore, comorbid illness is associated constantly with poor outcome and comorbid disease is reported to be 17% in the fourth decade, 44% in the sixth decade, and 65% by the age of 75 years (109). Accordingly, it is acknowledged that there is a relationship at univariate analysis between age and hospital mortality in patients who have received intensive care after elective and emergency surgery, trauma and sepsis (107, 110–117). Perhaps the most significant data are those of the mortality rates from acute trauma at different ages, since there is no selection at all, as opposed to elective surgery, which could affect the risk of an adverse outcome in these patients (Table 7). Data clearly show that elderly trauma patients die more frequently of injuries than members of any other age group and, within the elderly group, the mortality rate increases with age (118–121). Oneskowitch et al.

Table 6 Effects of ageing on body composition and major organ systems Organ system

Anatomic changes

Functional changes

Body composition

Increased lipid fraction Loss of skeletal mass

Nervous system

Attrition of neurons Decreased neurotransmitter activity

Cardiovascular system

Decreased arterial elasticity Ventricular hypertrophy Reduced adrenergic responsiveness Loss of lung elastin Increased thoracic stiffness Reduced alveolar surface area

Increased half-life for lipid-soluble drugs Decreased O2 consumption, heat production, and cardiac output Deafferentation, neurogenic atrophy, and decreased anesthetic requirement Impaired autonomic Homeostasis Increased impedance to ejection, widened pulse pressure Decreased maximal cardiac Output Increased residual volume Loss of vital capacity Impaired efficiency of gas Exchange Increased work of breathing Decreased plasma flow, glomerular filtration rate, drug clearance, and ability to handle salt and water loads Reduced hepatic blood flow and drug clearance

Pulmonary system

Renal system

Reduced vascularity Tissue atrophy

Hepatic system

Reduced tissue mass

Adapted from Muravchick S. Anaesthesia for the elderly. In: Miller R D (ed.). Anesthesia, ed 3. New York, Churchill Livingstone, 1990, p. 1970 (251).

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Table 7 Mortality from trauma by age groups Age (years)

Fatalities (percent)

14–24 25–34 35–44 45–54 55–64 65–74 75–84 85þ

8.9 9.8 9.8 10.6 14.4 15.6 20.1 16.9

Adapted from Finelli F C, Jonsson J, Champion H R et al. A case control study for major trauma in geriatric patients. J Trauma 1989; (29: 541, 118).

(122) have estimated that the mortality rate in elderly trauma victims is six times greater than in younger victims when controlling for degree of injury. This negative impact of ageing is more evident in men than in women (123). Moreover, in the elderly recovery from surgery is slower than in younger people (124), and recovery from malnourished status also appears slower (125), since they are unable to regain weight lost after surgery (126) or after underfeeding (127). Finally, the costs of medical care are greater for those older than 65 years of age (128) since a large proportion of several injured patients require intensive care (129, 130) or extended ICU length of stay (131) due to comorbid conditions.

Malnutrition as a component of surgical risk Undernutrition has been associated with increased incidence of infections and antibiotic use, decreased wound healing, increased length of hospital stay and mortality and it is considered to be a marker of endstage chronic illness (38, 132–143). Quite recently, it has been shown (137) that throughout their hospitalization many elderly patients receive a nutrient intake far lower than their estimated maintenance energy requirements— which finally results in low serum total cholesterol, low albumin and prealbumin and may contribute to increase the risk of mortality. Among hospitalized older patients, hypoalbuminemia too has been recognized as a marker of risk for in-hospital complications, longer hospital stay, more frequent readmission, increased in-hospital mortality and higher mortality 90 days and 1 year after hospital discharge (38, 144–156). For every 2.5 g/L decrease in serum albumin concentration, there is a 24% to 56% increase in the likelihood of dying (155, 157, 158). In an investigation on 4728 persons aged 57–74 (36), older age was recently demonstrated to be an independent predictor of hypoalbuminemia. Among nursing home residents who were hospitalized, severe hypoprealbuminemia predicted extended hospitalization but not mortality (159). Furthermore, the Thyroxin-binding prealbumin level admission also might accurately predict hospital mor-

tality (146). Insulin Growth Factor-1 is a strong predictor of life-threatening complications and may be a useful marker for protein-energy undernutrition among metabolically stable hospitalized elderly patients (160, 161). IGF-1 levels were found to correlate with BMI, triceps skinfold thickness and albumin, arm and muscle arm circumferences and transtyretin (162) low levels of serum cholesterol correlate with a substantial increase in mortality (163). Finally, the suppression of cellular immunity and delayed hypersensitivity reaction has a strong value as a prediction of mortality in the elderly (60). Some authors (164) think that serum acute phase proteins have no more clinical utility than the erythocyte sedimentation rate to predict death in the elderly population, while others (165) have reported a more complex score, the Prognostic Inflammatory and Nutritional Index (PINI), to be an indicator of mortality. PINI ¼  ÿ acid glycoprotein
mg
LC reactive protein
mg
L albumin
g
Lprealbumin
mg
L Recently, Naber et al. (166) have demonstrated the specificity of the Nutrition Risk Index (7.489
albumin
g
Lþ41.7
present weight
usual weight) also in older people, whereas the Maastricht Index should be limited to subjects under 70 years of age. In Sweden (167) the Subjective Global Assessment was tested in terms of validity and interpreter variability in the assessment of elderly outpatients 70 years of age or older, with positive results. The regression analysis, however, showed that weight index was the main significant objective factor influencing the subjective assessment. A recent paper by Duerksen et al. (38) confirmed the reproducibility and validity of the subjective global assessment in the elderly. A weight loss of 5% (168) or 10% (169, 170) is usually associated with adverse health outcome (171) morbidity (172–175) mortality (176, 178), longer hospital stay and increased cost (179). A low BMI appears to be related to hampered functional capabilities (4, 180, 181). Poor nutritional status, as measured by arm muscle area or BMI, has been associated with decreased survival in the hospital population (132, 182, 183). The BMI associated with minimum in-hospital mortality increases with each decade and after 50 years of age, subjects at or below a BMI of 27 kg/m2 (183, 184) or below 24 kg/m2 (28, 184) experience a higher in-hospital mortality than their heavier weight peer. Recently, Flodin et al. (185) found that BMI is an independent predictor of 1-year mortality at the logistic regression analysis, perfectly in keeping with the results of other authors (186, 187). A plot of predicted mortality versus body weight or BMI resulted in the generation of a U-shaped curve (183). A weight-height index ratio lower than the 90th percentile has been linked to an increased incidence of

CLINICAL NUTRITION

infection in hospitalized patients older than 65 years (188), as have a weight loss 410% and a decrease in albumin and total lymphocyte count (189, 190). As regards anthropometry, Friedman et al. (132, 182, 191) have suggested that severe muscle wasting diagnosed by the corrected mid-arm muscle area (MAMA) might be a better indicator of mortality than weight-loss in elderly men. Recently, Vellas et al. (192) have designated and validated a composite test, the Mini Nutritional Assessment (MNA), that includes anthropometric measurements, a global and a subjective assessment, and dietary questionnaire. This scale notably distinguishes between elderly patients with adequate nutritional status and different degrees of malnutrition, but was also found to be predictive of mortality and hospital cost. It is noteworthy that MNA test showed a 92% accuracy when compared with a clinical status evaluation carried out by two physicians expert in nutrition and a 98% accuracy when compared with a comprehensive nutrition assessment that included anthropometrics, food records, and biochemical indices (193). Furthermore, there was no added benefit from including biochemical indices in the MNA test (194). The normal age-related depletion of skeletal muscle which occurs in the elderly, the so-called sarcopenia, may well represent the link between age and poor tolerance of the injury. It has been shown (195) that from the middle 20s onwards there is a reduction in total muscle fibre numbers that on the average produces, between the ages of 20–80, a 40% reduction in muscle cross-sectional area. This is explained by a progressive motoneurone loss and involves not only the skeletal muscle but also the respiratory and cardiac muscles. It is now well established that sarcoplasmic protein synthesis is not affected by ageing (71) and that myosin heavy-chain (71) and mitochondrial protein synthesis rates (196) are substantially reduced. If we accept that a persistent trauma or sepsis status can induce a daily lean body mass loss of approximately 1% (2% of the skeletal muscle) (197), this may cause in about 40 days that 40% critical loss which is crucial for survival (198). Dealing with people 60 years old or older, we expect a skeletal muscle mass already reduced by 20% in comparison with that of young adults. This is equivalent to the loss of 10 or more days of ‘protein reserve’ and thus it shortens the projected survival time to 30 days or less.

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5.23 kcal/day/yr (%21.97 kj) or, more simply, that the energy requirement for kilogram of ideal body weight decreases by 3–5% per decade of age after 46 years (199). This is due to a decrease in the body cell mass (200, 201) and in the lean body mass (11), whereas the body weight may increase because of the growth in the subcutaneous and visceral fat. Muscle accounts for about 20–25% of resting energy expenditure and this contribution may increase during physical activities. As a result, decline in muscle mass contributes to the overall age-associated decline in energy expenditure. In fact, when the basal metabolic rate is expressed in terms of units of body cell mass, it is not affected by age (201). However, the most relevant determinant of energy requirement is physical activity. It has been shown by the Baltimore Longitudinal Ageing Study (199) that there is a decrease in the mean calorie intake form 2700 kcal/day (%11340 kj) at 20–30 years to about 2100 kcal/day(%8820 kj) at 75–79 years, which is accounted for by a reduction in the basal metabolic rate for one-third, and by a decreased physical activity as regards the remaining 400 kcal (%1680 kj). The average hospital in-patient requires a total energy intake of about 1.3 times the estimated basal metabolic rate to maintain weight and 1.5–1.7 times the basal metabolic rate if weight gain has been achieved. In conclusion, an intake of 30–35 kcal/kg/day is desirable in most elderly patients. When planning the nutritional support, it has been suggested that fats should account for 35 to 50% of total calorie intake. Higher doses may be provided during acute illness but for long-term treatment fat should be limited to about 30% of the total energy requirement. Amino acid requirements The rate of protein turnover and synthesis is modestly reduced on a weight basis (202), but protein synthesis and degradation increase when expressed on units of body cell mass (75, 203–205). The recommended dose of amino acid to be administered in normal condition should be at least 1–1.2 g/kg/ day (206, 207) and up to 1.5 g/kg/day in the sick elderly. Protein intake should account for 12–15% of total energy consumed. Malnourished or ill elderly subjects have even higher protein turnover value per kilogram of body weight than do healthy elderly persons as a result of a hypercatabolic state (208, 209).

Nutritional requirements and nutritional support Water and micro-nutrients requirements The nutritional support of the elderly is slightly different from that in younger subjects. Energy requirements It is well acknowledged that ageing is associated with a decrease in the basal metabolic rate of approximately

The baseline administration of fluid should be 25–30 mL/kg/day (210, 211). When hypernatremia develops, it should be compensated for with water in an amount equal to 4% of body weight for each 10 mEq/L increase in serum Na above normal. The requirements for vitamins, minerals and trace elements are not

110

SURGERY OF THE ELDERLY

substantially different from those of other adult patients (212) (Table 8), but older nursing-home subjects require a higher intake of ascorbic acid to achieve normal concentrations of these vitamins in their white blood cells (213).

Response to nutritional support In the elderly, the nutritional response to an intravenous or enteral support is usually more sluggish than that observed in younger adult patients. This has been clearly showed by Shizgal (214) who reported that a 15-day course of TPN was able to improve the body cell mass only in patients less than 65 years old. The calorie requirement to restore body cell mass in malnourished patients increases with age probably because of the reduced capacity to metabolise glucose and lipid. This decrease may be related to both receptor and enzyme alterations at the cellular level. It has been shown that increasing the amino acid availability (orally or intravenously), muscle protein synthesis and net muscle anabolism improve in the elderly as in young adults. A recent study by Bos et al. (215) has shown that a short-term oral supplementation (1.67 MJ/d and 30 g protein/d610 days) was associated with an increase in fat-free mass and a stimulation of nitrogen kinetics in elderly malnourished patients. A weight gain has been achieved with oral seep feed for periods ranging from 6 days (216) to 2 months (217). On the contrary, the addition of glucose to an amino acid mixture does not increase muscle protein synthesis, but rather it decreases protein breakdown and thus improves the net balance. Therefore, it has been suggested not to use amino acid glucose supplements (218) but Table 8 Recommended daily dietary allowances for adults aged over 51 years Male Vitamin A (mg RE)* Vitamin D (IU) Vitamin E (mg) Vitamin C (mg) Thiamine (mg) Riboflavin (mg) Niacin (mg) Vitamin B6 (mg) Folacin (mg) Vitamin B12 (mg) Calcium (mg) Phosphorus (mg) Magnesium (mg) Iron (mg) Zinc (mg) Chromium (mg) Selenium (mg) Iodine (mg) Fluoride (mg)

1000 400 10 60 1.2 1.4 16 2.2 400 3.0 1200 700 420 10 15 50–200 50–200 150 4

Female 800 400 8 62 1.0 1.2 13 2.0 400 3.0 1200 700 320 10 15 50–200 50–200 150 3

*Retinol equivalent; 1 RE ¼ 3.33 IU vitamin A activity from Retinol or 10 IU vitamin A activity from beta-carotene. Adapted from Food and Nutrition Board, Committee on Dietary Allowances: Recommended Dietary Allowances, ed 9 (revised). Washington, DC, National Academy of Sciences, 1980 (252).

those containing only amino acid or protein. Consistent with these findings, the study of Beaumont et al. (209) showed that refeeding did not result in a significant increase in protein kinetics or in net protein balance, although a trend toward that was observed. In fact, the excess requirements for 1 kg of weight gain in young females has been reported to be 7500 kcal/kg (%31 500 kj/kg) (219) vs 8856–22626 kcal/kg (%37 195– 90 504 kj/kg) in malnourished home patients (220). Similarly, He´buterne et al. (221) showed that body weight, serum, transferrin, prealbumin, 24-hour urinary creatinine better improved in the middle-aged than in elderly patients receiving enteral nutrition at 1.5 REE. The compensation for the fat-free mass and body cell mass was especially difficult. The effect of arginine supplementation (17 g/day for 4 weeks) is controversial: Kirk et al. (222) reported an increase in lymphocyte response to mitogenic and allogenic stimulation and in hydroxyproline accumulation in wound, while others (223) did not observe any enhancement in the proliferative response. Protein repletion through supplements has been reported to be associated with increased levels of IGF-1 (224). Unfortunately, there is little information about the clinical efficacy of nutritional support in the elderly. This is due to the fact that it is rather more usual for the clinical researchers to focus on a certain disease than on a category of subjects defined only by age. Furthermore, there is a paucity of reports on shortterm nutritional support in surgical patients whereas more data are available on long-term oral supplementation of institutionalized elderly subjects. As regards the supplementary enteral tube feeding, Bastow et al. (225, 226) showed the clinical value of this approach in elderly malnourished women with fractured neck of femur. Patients receiving an overnight nasogastric postoperative feeding in addition to normal ward diet had an improvement in anthropometric and plasma protein measurements, in rehabilitation time and length of hospital stay when compared to patients not receiving any overnight supplementation. In such patients, a consistent clinical benefit (quicker recovery, shorter hospital stay, lower complications and mortality) was reported from using oral supplements and sip feeds (227, 228). Provision of supplements led to clinical and functional decrease in mortality in the most poorly nourished group (229). However, results from randomized and non randomized studies (232, 237–241) usually apply to long-term provision of oral supplements and focus on the nutrition status. Only three studies (230, 234, 235) report the effects of at least one-month supplementation—a period of time which could also apply to surgical patients. A benefit was observed as regards energy and protein intake (236), body weight (230, 235), skin-fold thickness (230), anthropometric indices (235), immune response (230) and independence in daily activity (234, 235).

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111

In this context, the beneficial role of the muscular exercise cannot be overlooked. Recently, Fiatarone et al. (231) have shown that nutrient supplements without concomitant exercise does not reduce physical frailty and Bermon et al. (242) have demonstrated that a 3-week aerobic training program associated with enteral nutrition better improves the global nutritional deficiency index, serum albumin and prealbumin. Resistance exercise training results in increased muscle strength and size, increased muscle protein accumulation and, consequently, reduced urinary nitrogen loss and overall increased nitrogen retention (243).

Table 9 Life expectancy

Conclusions

higher in old patients than in young ones because they are more easily sedated and less able to expectorate or to tolerate inhalation in the lungs. The surgical indications in old patients usually stem, as in other strata of patient population, from a balance between the expected benefit and the risk from the surgical procedure of an adverse outcome associated to no surgical therapy. In this context, surgeons have to consider the expected survival of old subjects should their disease be surgically treated (Table 9). Clinicians should realize that a nutritional success is difficult to achieve with a short-term nutritional support and, especially in the postoperative period, it may be compromised without additional procedures such as techniques to attenuate the stress, to relieve the pain in a dynamic way, to avoid immobilization through active and passive exercises, to control nausea, vomiting and ileus and finally to start early with enteral nutrition.

Malnutrition frequently occurs in the elderly. Malignancy accounts for approximately one third of severely weight-losing old people and poor dietary habits, chronic illness and socio-economic factors are responsible in the remaining cases. According to the Consensus Conference of the Nutrition Screening Initiative (244) the main indicators of poor nutritional status of the elderly are the following: 1) significant weight change over time 2) significant (greater than 20%) low or high weight for height 3) significant reduction in serum albumin (lower than 3.5 g/dL) 4) significant change in functional status 5) significant and sustained inappropriate food intake 6) presence of other nutrition-related disorders (biochemical signs).

Age

Years expected

65 70 75 80 85 90 95 100 105 110

16.6 13.4 10.6 8.4 6.7 4.4 3.3 2.7 2.4 2.2

Modified from Adkins R B Jr. History and philosophy. In:Adkins R B Jr, Scott H W (eds.). Surgical Care for the Elderly. Baltimore, Williams & Wilkins, 1988 (253).

References The enteral route for nutritional support is the route of choice for all patients unless contraindicated. In general, the ageing of the gastrointestinal tract organs is evinced by a decrease in motility secretion and absorptive capacity (245–247). However, the reserve capacity of such organs is so great that this functional failure does not result in actual function impairment or undernutrition. The enteral route, besides being more physiological, seems to be more appropriate for old persons. Slow administration of a diet including complex sugars, which are progressively absorbed by the gut, is better tolerated than the intravenous infusion of simple sugars to patients with decreased glucose tolerance. Also, the risk of fluid overload is lower when nutrition is enteral rather than parenteral. It is noteworthy, however, that at calorie intakes below 1200–1400 kcal (%5040–5800 kj) —which usually corresponds to a liquid diet of 1200– 1400 mL/day—it is difficult to meet the RDAs for vitamins and minerals and therefore in such cases vitamins and minerals supplements are advised (248). Obviously, the risk of gastro-oesophageal reflux is also

1. McWhirter N. Guinness Book of World Records. 1998 Annual Edition. New York: Bantam Books Inc., 1981: p. 85 2. Bureau of the Census: Current Population Reports. Special Studies: Sixty-five plus in America. Government Printing Office, Washington DC 3. Rossman I. Anatomic and body composition changes with ageing. In: Finch C E, Hayflick L (eds). Handbook of the biology of ageing. New York: Van Nostrand Reinhold, 1997: p. 66 4. Steen B, Lundgren B K, Isaksson B. Body composition at age 70, 75, 79, and 81 years: a longitudinal population study. In: Chandra R K (ed.). Nutrition, immunity and illness in the elderly. New York: Pergamon Press, 1985: p. 144 5. Klieber M. The fire of life. Huntington, NY: Robert E. Krieger Publishing, 1985 6. Master A M, Lasser R P, Beckman G. Tables of average weight and height of Americans aged 65 to 94 years. JAMA 1960; 172: 658–662 7. Andres R, Elahi D, Tobin J D, Muller D C, Brant L. Impact of age on weight goals. Ann Intern Med 1985; 103 (6 (Pt.2)): 1030–1033 8. Frisancho A R. New standards of weight and body composition by frame size and height for assessment of nutritional status of adults and the elderly. Am J Clin Nutr 1984; 40: 808–819 9. Chumlea W C, Garry P J, Hunt W C et al. Serial changes in stature and weight in the healthy elderly population. Hum Biol 1988; 60: 918 10. Donini L M, De Felice M R, De Bernardini L, Ferrari G, Rosano A, Medici M, Cannella C. Equazioni di predizione della statura

112

11.

12. 13. 14. 15. 16.

17. 18. 19. 20. 21. 22. 23. 24.

25.

26.

27.

28. 29.

30. 31. 32. 33.

34.

SURGERY OF THE ELDERLY

e del peso per la popolazione italiana in eta` geriatrica. Riv Ital Nutr Par Ent 2000; 18: 26–32 Lang C. Nutrition assessment of the elderly. Geriatric Nutrition: Issues and Intervention. Postgraduate Course #5. Silver Spring, MD, American Society of Parenteral and Enteral Nutrition, 1989: p. 13 Forbes G B, Reina J C. Adult lean body mass declines with age: some longitudinal observations. Metabolism 1970; 19: 653–663 Steen B. Body composition and ageing. Nutr Rev 1988; 46: 45 Silver A J, Guillen C P, Kahl M J et al. Effect of ageing on body fat. J Am Geriatr Soc 1993; 41: 211 Steen B, Isaksson B, Svanborg A. Body composition at 70 and 75 years of age: a longitudinal population study. J Clin Exp Gerontol 1979; 1: 185 Noppa H, Andersson M, Gengtsson C et al. Longitudinal studies of anthropometric data and body composition: the population of women in Goteborg, Sweden. Am J Clin Nutr 1980; 33: 155 Borkan G A, Hults D E, Gerzof S G et al. Comparison of body composition in middle-aged and elderly men using computed tomography. Am J Phys Anthropol 1985; 66: 289 Baumgartner R N, Heymsfield S B, Roche A F et al. Quantification of abdominal composition by computed tomography. Am J Clin Nutr 1989; 50: 221 Friedlander J S, Costa P T, Bosse R et al. Longitudinal physique changes among healthy white veterans at Boston. Hum Biol 1977; 49: 541 Campbell A J, Spears G F S, Brown J S et al. Anthropometric measurements as predictors of mortality in a community population aged 70 years and over. Age Ageing 1990; 19: 131 Lansey S, Waslien C, Mulvihill M et al. The role of anthropometry in the assessment of malnutrition in the hospitalized frail elderly. Gerontology 1993; 39: 346 Frisancho A R. New norms of upper limb fat and muscle areas for assessment of nutritional status. Am J Clin Nutr 1981; 34: 2540 Saltzman E, Mason J B. Enteral nutrition in the elderly. In: Rombeau J L, Rolandelli R H (eds). Clinical nutrition: enteral and tube feeding. Philadelphia: Saunders, 1997: 385 Abraham S, Johnson C L, Najjar M F. Weight and height of adults 18–74 years of age. Vital and health statistics series 11. DHEW Publication (PHS) 79–1659. Rockville, MD: National Center for Health Statistics, 1979 Stoudt H W, Damon A, McFarland R et al. Weight, height, and selected body dimensions of adults. Vital and health statistics series 11. DHEW Publication (PHS) 8. Rockville, MD: National Center for Health Statistics, 1969 Stoudt H W, Damon A, McFarland R et al. Skinfold, body girths, biacromial diameter and selected anthropometric indices of adults. Vital and health statistics series 11. DHEW Publication (PHS) 35. Rockville, MD: National Center for Health Statistics, 1970 Najjar M F, Rowland M. Anthropometric reference data and prevalence of overweight. Vital and health statistics series 11. DHEW Publication (PHS) 87–1688. Rockville, MD: National Center for Health Statistics, 1987 Ham R J. Indicators of poor nutritional status in older Americans. Am Fam Physician 1992; 45: 219–228 Beck AM, Ovesen L. At which body mass index and degree of weight loss should hospitalized elderly patients be considered at nutritional risk? Clin Nutr 1998; 17(5): 195–198 Campion E W, de Labry L O, Glynn R J. The effect of age on serum albumin in healthy males: report from the normative ageing study. J Gerontol 1988; 43: 18–20 Cooper J K, Gardner C. Effect of ageing on serum albumin. J Am Geriatr Soc 1989; 37: 1039–1042 Phillips A, Shaper A G, Whincup P H. Association between serum albumin and mortality from cardiovascular disease, cancer, and other causes. Lancet 1989; 2: 1434–1436 Bistrian B R. Nutritional Assessment of the Elderly. Monograph from the Nutritional Support for the Long Term Care Patient Symposium. Minneapolis, MN: Sandoz Nutrition Crop., 1989; 2: 3 Roe D A. Nutritional assessment of the elderly. World Rev Nutr Diet 1986; 48: 107

35. Tietz N, Shuey D, Wekstein R. Laboratory values in fit ageing individuals—sexagenarians through centenarians. Clin Chem 1992; 38: 1167 36. Reuben D B, Moore A A, Damesyn M, Keeler E, Harrison G G, Greendale G A. Correlates of hypoalbuminemia in communitydwelling older persons. Am J Clin Nutr 1997; 66: 38–45 37. Salive M E, Cornoni-Huntley J, Phillips C L, Guralnik J M, Cohen H J, Ostfeld A M, Wallace R B. Serum albumin in older persons: relationship with age and health status. J Clin Epidemiol 1992; 45(3): 213–221 38. Duerksen D R, Yeo T A, Simens J L, O’Connor M P. The validity and reproducibility of clinical assessment of nutritional status in the elderly. Nutrition 2000; 16: 740–744 39. Friedman P J, Campbell A J, Caradoc-Davies T H. Hypoalbuminemia in the elderly is due to disease not malnutrition. J Clin Exp Gerontol 1985; 7: 1991 40. Finucane P, Rudra T, Hsu R et al. Markers of the nutritional status in acutely ill elderly patients. Gerontology 1988; 33: 304 41. O’Connor K G, Stevens T E, Blackman M R. Growth hormone and ageing. In: Juul A, Jorgensen J O L (eds). Growth hormone in adults; physiological and clinical aspects. Cambridge, UK: Cambridge University Press 1996; 323–366 42. Donahue L R, Hunter S J, Sherblom A P et al. Age-related changes in serum insulin-like growth factor-binding proteins in women. J Clin Endocrinol Metab 1990; 71: 575 43. Yamamoto H, Sohmiya M, Oka N et al. Effects of ageing and sex on plasma insulin-like factor I (IGF-I) in normal adults. Acta Endocrinol 1991; 124: 497 44. Rudman D, Kutner M H, Rogers C M et al. Impaired growth hormone secretion in the adult population: relation to age and adiposity. J Clin Invest 1981; 67: 1361–1369 45. Augener W, Cohnen G, Reuter A et al. Decrease of T lymphocytes during ageing (letter). Lancet; 1974; I: 1164 46. Diaz-Jouanen E, Strickland R G, Williams R C. Studies of human lymphocytes in the newborn and the aged. Am J Med 1975; 58: 620 47. Jamil N A K, Millard R E. Studies of T, B and ‘‘null’‘ blood lymphocytes in normal persons of different age groups Gerontology 1981; 27: 79 48. Alexopoulos C, Babitis P. Age dependence of T lymphocytes. Lancet 1976; I: 426 49. Teasdale C, Thatcher J, Whitehead R H et al. Age dependence of T-lymphocytes. Lancet 1976; I: 1410 50. Davey F R, Huntington S. Age-related variation in lymphocyte subpopulations. Gerontology 1977; 23: 381 51. Hallgren H M, Kersey, Dubey D P et al. Lymphocyte subsets and integrated immune function in ageing humans. Clin Immunol Immunopathol 1978; 10: 65 52. Reddy M M, Goh K. B and T lymphocytes in man. IV. Circulating B, tT and ‘‘null’’ lymphocytes in ageing population. J Gerontol 1979; 34: 5 53. Cobleigh M A, Braun D P, Harris J E. Age-dependent changes in human peripheral blood B cells and T cell subsets: correlation with mitogen responsiveness. Clin Immunol Immunopathol 1980; 15: 162 54. My’sliwsky J, Witkowski J, My’sliwska A. Proportion of early E rosettes formed by peripheral blood lymphocytes from young and aged subjects. Gerontology 1981; 27: 140 55. Mascart-Lemone F, Delespesse G, Servais G et al. Characterization of immunoregulatory T lymphocytes during ageing by monoclonal antibodies. Clin Ep Immunol 1982; 48: 148 56. Weksler M E. Senescence of the immune system. Med Clin North Am 1983; 67: 263–272 57. Lipschitz D A, Mitchell C O. The correctability of the nutritional, immune, and hematopoietic manifestations of protein calorie malnutrition in the elderly. J Am Coll Nutr 1982; 1: 17–25 58. Rea I M. Age and sex changes in neutrophil function. Immunol Infect Dis 1988; 1: 121–130 59. Corberand J, Ngyen F, Laharrague P, Fontanilles A M, Gleyzes B, Gyrard E, Senegas C. Polymorphonuclear functions and ageing in humans. J. Am Geriatr Soc 1981; 29: 391–397 60. Chandra R K. Nutritional regulation of immunity and risk of infection in old age. Immunology 1989; 67: 141 61. Nagel J E, Chopra R K, Chrest F J et al. Decreased proliferation, interleukin-2 synthesis, and interleukin-2 receptor expression is

CLINICAL NUTRITION

62. 63. 64. 65. 66. 67. 68. 69. 70. 71.

72.

73. 74. 75. 76. 77. 78. 79. 80.

81. 82.

83. 84. 85. 86.

accompanied by decreased mRNA expression in phytohemagglutinin-simulated cells from elderly donors. J Clin Invest 1988; 81: 1096 Reiser S, Hallfrisch J. Carbohydrate nutrition and ageing. In:Hse J M, Davis R L (eds). Handbook of geriatric nutrition. Park Ridge, New Jersey: Noyes Publications, 1981 Silverstone F A, Brandfonbrener M, Shock N W, Yiengst M J. Age differences in the intravenous glucose tolerance tests and the response to insulin. J Clin Invest 1957; 36: 504–514 Desai D, March R, Watters J M. Hyperglycemia after trauma increases with age. J Trauma 1989; 29: 719 Jeevanandam M, Holaday N J, Shamos R F, Petersen R S. Acute IGF-1 deficiency in multiple trauma victims. Clin Nutr 1992; 11: 352–357 Jeevanandam M, Ramias L, Shamos R F, Schiller W R. Decreased growth hormone levels in the catabolic phase of severe injury. Surgery 1992; 111: 495–502 Kritchevsky D. Diet, lipid metabolism and ageing. Fed Proc 1979; 38: 2001–2006 Millward D J, Fereday A, Gibson N, Pacy P J. Ageing, protein requirements, and protein turnover. Am J Clin Nutr 1997; 66: 774–786 Nair K S. Muscle protein turnover: methodological issues and the effect of ageing. J Gerontol 1995; 50A: 107–112 Morais J A, Gougeon R, Pencharz P B, Jones P J H, Ross R, Marliss E B. Whole-body protein turnover in the healthy elderly. Am J Clin Nutr 1997; 66: 880–889 Balagopal P, Rooyackers O E, Adey D B, Ades P A, Nair K S. Effects of ageing on in vivo synthesis of skeletal muscle myosin heavy-chain and sarcoplasmic protein in humans. Am J Physiol 1997; 273: E790–E800 Yarasheski K E, Zachwieja J J, Campbell J A, Bier D M. Effect of growth hormone and resistance exercise on muscle growth and strength in older men. Am J Physiol 1995; 9: 159–174 Yarasheski K E, Zachwieja J J, Bier D M. Acute effects of resistance on muscle protein synthesis rate in young and elderly men and women. Am J Physiol 1993; 265: E210–E214 Welle S, Thornton C, Jozefowicz R, Statt M. Myofibrillar protein synthesis in young and old men. Am J Physiol 1993; 264: E693–E698 Welle S, Thornton C, Statt M, McHenry B. Postprandial myofibrillar and whole body protein synthesis in young and old human subjects. Am J Physiol 1994; 267: E599–E604 Welle S, Thornton C, Statt M. Myofibrillar protein synthesis in young and old human subjects after three months of resistance training. Am J Physiol 1995; 268: E422–E427 Rooyackers O E, Adey D B, Ades P A, Nair K S. Effect of age on in vivo rates of mitochondrial protein synthesis in human skeletal muscle. Proc Ntal Acad Sci USA 1996; 93: 15 364–15 369 Sahort K R, Barazzoni R, Nair K S. Age effect on mitrochondrial protein synthesis rate in rat skeletal muscle, liver, and heart. FASEB J 1999; 13: A909 (abstract) Fu A, Nair K S. Age effect on fibrinogen and albumin synthesis in humans. Am J Physiol 1998; 275: E1023–E1030 Clark M A, Plank L D, Connolly A B, Streat S J, Hill A A, Gupta R, Monk D N, Shenkin A, Hill G L. Effect of a chimeric antibody to tumor necrosis factor-a on cytokine and physiologic responses in patients with severe sepsis: a randomized clinical trial. Crit Care Med 1998; 26: 1650 Cheng A T H, Plank L D, Hill G L. Prolonged overexpansion of extracellular water in elderly septic patients. Arch Surg 1998; 133: 745 Sandstead H H, Henrisken L K, Greger J L, Prasad A S, Good R A. Zinc nutrition in the elderly in relation to taste acuity, immune response and wound healing. Am J Clin Nutr 1982; 36: 1046– 1059 Barch D H, Fox C C, Mobarhan S A. Effects of chronic disease on nutrition. Nutr Int 1987; 65: 876–882 Cederholm T, Ja¨gren C, Hellstro¨m K. Nutritional status and performance capacity in internal medical patients. Clin Nutr 1993; 12: 8–14 McWhirter J, Pennington C. Incidence and recognition of malnutrition in hospital. Br Med J 1994; 308: 945–948 Bienia R, Ratcliff S, Barbour G S, Kummer M. Malnutrition in hospitalized geriatric patients. J Am Geriatric Soc 1982; 30: 436–443

113

87. Rapin C H, Lagier R. Age-related blood changes in hip osteoarthritis patients: a possible indicator of bone quality. Ann Rheum Dis 1982; 41: 215–216 88. Rapin C H, Lagier R, Boivin G, Jung A, MacGee W. Biochemical findings in blood of aged patients with femoral neck fractures: a contribution to the detection of occult osteomalacia. Calcif Tissue Int 1982; 34: 465–469 89. Stephens N D, Messner R L, Neitch S M. Incidence of malnutrition in a rural nursing home. Nutr Supp Serv 1988; 8:5–11 90. Henderson C T. Nutrition and malnutrition in the elderly nursing home patient. Clin Geriatr Med 1988; 4: 527–547 91. Thomas D R, Verdery R D, Gardner L, Kant A, Lindsay J. A prospective study of outcome from protein-energy malnutrition in nursing home residents. JPEN 1991; 15: 400–404 92. Department of Health and Social Security: A nutrition survey of the elderly. Rep Health Soc Subj (Lond) 1979; 16: 1–209 93. Pinchcofsky-Devin G D, Kaminski M V. Incidence of protein calorie malnutrition in the nursing home population. J Am Coll Nutr 1987; 6: 109–112 94. Pinchcofsky G D, Kaminski M V Jr. Increasing malnutrition during hospitalization. J Am Coll Nutr 1985; 4: 471–479 95. Shaver H J, Loper J A, Lutes R A. Nutritional status of nursing home patients. JPEN 1980; 4: 367–370 96. Rudman D, Feller A G, Nagraj H S, Javkson D L, Rudman I W, Mattson D E. Relation of serum albumin concentration to death rate in nursing home men. JPEN 1987; 11(4): 360–363 97. Zanon D. La carenza di acido folico nel siero di pazienti anziani ospedalizzati. Tesi di laurea, Universita` di Padova, relatori Prof. Crepaldi G e Prof. Zangaglia O. Anno academico 1980–81. In: Enzi G. La nutrizione nell’anziano. Aggiornamento del Medico 1986; 9(1): 36 98. Exton-Smith A N. Nutritional status: diagnosis and prevention of malnutrition. In: Exton-Smith A N, Caird F I (eds). Metabolic and Nutritional disorders in the elderly. J Wright Publ., Bristol, 1980, p. 66 99. Morley J E. Anorexia of ageing: physiologic and pathologic. Am J Clin Nutr 1997; 66: 760–773 100. Sullivan D H, Sun S, Walls R C. Protein-energy undernutrition among elderly hospitalized patients. A prospective study. JAMA 1999; 281(21): 2013–2019 101. Klipstein-Grobusch K, Reilly J J, Potter J, Edwards C A, Roberts M A. Energy intake and expenditure in elderly patients admitted to hospital with acute illness. Br J Nutr 1995; 73: 323–334 102. Rammohan M, Juan D, Jung D. Hypophagia among hospitalized elderly. J Am Diet Assoc 1989; 89: 1774–1779 103. Todd E A, Hunt P, Crowe P J, Royle G T. What do patients eat in hospital? Hum Nutr Appl Nutr 1984; 38: 294–297 104. Hessov I. Energy and protein intake in elderly patients in an orthopedic surgical ward. Acta Chir Scand 1997; 143: 145–149 105. Sandstrom B, Alhaug J, Einarsdottir K, Simpura E M, Isaksson B. Nutritional status, energy and protein intake in general medical patients in three Nordic hospitals. Hum Nutr Appl Nutr 1985; 39A: 87–94 106. Kamath S K, Lawler M, Smith A E, Kalat T, Olson R. Hospital malnutrition. J Am Diet Assoc 1986; 86: 203–206 107. Mayer-Oakes S A, Oye R K, Leake B. Predictors of mortality in older patients following medical intensive care – the importance of functional status. J Am Geriatr Soc 1991; 39: 862–868 108. Colorectal Cancer Collaborative Group. Survey for colorectal cancer in elderly patients: a systematic review. Lancet 2000; 356: 968–974 109. Milzman D P, Boulanger B R, Rodriguez A et al. Pre-existing disease in trauma patients: a predictor of fate independent of age and ISS. J Trauma 1992; 32: 236 110. Gee M H, Gottlieb J E, Albertine K H, Kubis J M, Peters S P, Fish J E. Physiology of ageing related to outcome in the adult respiratory distress syndrome. J Appl Physiol 1990; 69(3): 822–829 111. Heuser M D, Case L D, Ettinger W H. Mortality in intensive care patients with respiratory disease – is age important? Arch Intern Med 1992; 152: 1683–1688 112. McClish D K, Powell Sh, Montenegro H, Nochomovitz M. The impact of age on the utilization of intensive care resources. J Am Geriatr Soc 1987; 35: 983–988

114

SURGERY OF THE ELDERLY

113. Nicolas F, Le Gall J R, Alperovitch A, Loirat P, Villers D. Influence of patients’ age on survival, level of therapy and length of stay in intensive care units. Intensive Care Med 1987; 13(1): 9–13 114. Ridley S, Jackson R, Findlay J, Wallace P. Long term survival after intensive care. Br Med J 1990; 301: 1127–1130 115. Watters J M, McClaran J C. The elderly surgical patient. In: Wilmore D W, Brennan M F, Harken A H (eds). Care of the surgical patient. New York, Scientific American/American College of Surgeons, 1990 116. Wynne H A, Cope L H, Mutch E, Rawlins M D, Woodhouse K W, James O F. The effect of age upon liver volume and apparent liver blood flow in healthy men. Hepatology 1989; 9: 297–301 117. Alves A, Panis Y, Pocard M, Regimbeau J M, Valleur P. Management of anastomotic leakage after nondiverted large bowel resection. J Am Coll Surg 1999; 189: 554–559 118. Finelli F C, Jonsson J, Champion H R, Morelli S, Fouty W J. A case control study for major trauma in geriatric patients. J Trauma 1989; 29: 541–548 119. Champion H R, Copes W S, Buyer D, Flanagan M E, Bain L, Sacco W J. Major trauma in geriatric patients. Am J Public Health 1989; 79: 1278–1282 120. Baker S P, O’Neill B, Haddon E et al. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974; 14: 187 121. Goins W A, Reynolds H N, Nyanjom D et al. Outcome following prolonged intensive care unit stay in multiple trauma patients. Crit Care Med 1991; 19: 339–345 122. Oreskovitch M R, Howard J D, Copass M K et al. Geriatric trauma: injury patterns and outcome. J Trauma 1984; 24: 565 123. Morris J A, MacKenzie E J, Damiano A M et al. Mortality in trauma patients: the interaction between host factors and severity. J Trauma 1990; 30: 1476 124. Rosenthal R A, Anderson D K. Surgery in the elderly. In: Andres R, Bierman E L, Hazzard W R (eds). Principles in geriatric medicine. New York: McGraw-Hill, 1985; 909–932 125. Hardy C, Wallace C, Khansur T, Vance R B, Thigpen J T, Balducci L. Nutrition, cancer and ageing: an annotated review: II. Cancer cachexia and ageing. J Am Geriatr Soc 1986; 34: 219–228 126. Vellas B J, Albarede J-L, Garry P J. Diseases ageing: patterns of morbidity with age; relationship between ageing and ageassociated diseases. Am J Clin Nutr 1992; 55: 1225S–1230S 127. Roberts S B, Fuss P, Heyman M B, Evans W J, Tsay R, Rasmussen H, Fiatarone M, Cortiella J, Dallal G E, Young V R. Control of food intake in older men. JAMA 1994; 272: 1601– 1606 128. Cassel C K. Philosophical and ethical issues in geriatrics. In: Kelley W N (ed.): Textbook of Internal Medicine, ed. 3. Philadelphia, Lippincott-Raven, 1997, pp 2563–2567 129. Scalea T M, Simon H M, Duncan A O et al. Geriatric blunt multiple trauma: improved survival with early invasive monitoring. J Trauma 1990; 30: 129 130. Shapiro M B, Dechert R E, Colwell C et al. Geriatric trauma: aggressive intensive care unit management is justified. Am Surg 1994; 60: 695 131. MacKenzie E J, Morris J A, Edelstein S. Effect of pre-existing disease on length of hospital stay in trauma patients. J Trauma 1989; 29: 6 132. Friedman P J, Campbell A J, Caradoc-Davies T H. Prospective trial of a new diagnostic criterion for severe wasting malnutrition in the elderly. Age Ageing 1985; 14: 149–154 133. Morley J E. Anorexia in older patients: its meaning and management. Geriatrics 1990; 45: 59–66 134. Rudman D, Mattson D E, Hoskote S, Nagray H S, Caindec N, Rudman I W, Jackson D L. Antecedents of death in the men of a Veterans Administration nursing home. J Am Geriatr Soc 1987; 35(6): 496–502 135. Butterworth C E, Blackburn G L. Hospital malnutrition. Nutr Today 1975; Mar/Apr: 8–18 136. Wood B, Lo L, Cleary J, Bontoft J, Kelleher D, Burns E, Thien C. Nutritional status in hospital inpatients: implications for nutritional support services. Aust N Z Med 1985; 15(4): 435–441 137. Sullivan D H, Patch G A, Walls R C, Lipschitz D A. Impact of nutrition status on morbidity and mortality in a selected population of geriatric rehabilitation patients. Am J Clin Nutr 1990; 51(5): 749–758

138. Young M E. Malnutrition and wound healing. Heat Lung 1988; 17: 60–67 139. Verdery R B. ‘‘Wasting away’’ of the old. Can it – and should it – be treated? Geriatrics 1990; 45: 26–31 140. Sandman P O, Adolfsson R, Nygren C, Hallmans G, Winblad B. Nutritional status and dietary intake in institutionalized patients with Alzheimer’s disease and multiinfarct dementia. J Am Geriatr Soc 1987; 35(1): 31–38 141. Vellas B, Conceicao J, Lafont C, Fontan B, Garry P J, Adoue D, Albarede J L. Malnutrition and falls [Letter]. Lancet 1990; 336(8728): 1447 142. Marton K I, Sox H C, Krupp J R. Involuntary weight loss: diagnostic and prognostic significance. Ann Intern Med 1981; 95: 568–574 143. Fischer J, Johnson M A. Low body weight and weight loss in the aged. J Am Diet Assoc 1990; 90: 1697–1706 144. Herrmann F R, Safran C, Levkoff S E, Minaker K L. Serum albumin level on admission as a predictor of death, length of stay and readmission. Arch Intern Med 1992; 152: 125–130 145. Patterson B M, Cornell C N, Carbone B, Levine B, Chapman D. Protein depletion and metabolic stress in elderly patients who have a fracture of the hip. J Bone Joint Surg 1992; 74–A: 251–260 146. Fu¨lo¨p T Jr, Herrmann F, Rapin C -H. Prognostic role of serum albumin and prealbumin level in elderly patients at admission to a geriatric hospital. Arch Gerontol Geriatr 1991; 12: 31–39 147. Ferguson R P, O’Connor P, Crabtree B, Batchelor A, Mitchell J, Coppola D. Serum albumin and prealbumin as predictors of clinical outcomes of hospitalized elderly nursing home residents. J Am Geriatr Soc 1993; 41: 545–549 148. Dreblow D M, Anderson C F, Moxness K. Nutritional assessment of orthopedic patients. Mayo Clin Proc 1981; 56: 51–54 149. Agarwal N, Acevedo F, Leighton L S, Cayten C G, Pitchumoni C S. Predictive ability of various nutritional variables for mortality in elderly people. Am J Clin Nutr 1988; 48: 1173–1178 150. Anderson C F, Moxness K, Meister J, Burrit M F. The sensitivity and specificity of nutrition-related variables in relationship to the duration of hospital stay and rate of complications. Mayo Clin Proc 1984; 59: 477–483 151. Anderson C F, Wochos D N. The utility of serum albumin values in the nutritional assessment of hospitalized patients. Mayo Clin Proc 1982; 57: 181–184 152. Bruyere A, Rapin C H, Dirren H. Blood nutritional parameters in patients with femural neck fracture. In: Chandra R I C (ed). Nutrition, Immunity and Illness in the Elderly. Chandra R I C. New York: Pergamon Press, 1984: p. 242 153. Harvey K B, Moldawer L L, Bistrian B R, Blackburn G L. Biological measures for the formulation of a hospital prognostic index. Am J Clin Nutr 1981; 34: 2013–2022 154. Corti M C, Guralnik J M, Slaive M E, Sorkin J D. Serum albumin level and physical disability 155. Goldwasser P, Feldman J. Association of serum albumin and mortality risk. J Clin Epidemiol 1997; 50: 693 156. Sahyoun N R, Jacques P F, Dallal G, Russell R M. Use of albumin as a predictor of mortality in community dwelling and institutionalized elderly. J Clin Epidemiol 1996; 49: 981 157. Lowrie E, Lew N. Death risk in hemodialysis patients: the predictive value of commonly measured variables and an evaluation of death rate differences between facilities. Am J Kidney Dis 1990; 15: 458 158. Guijarro C, Massy Z A, Widerkehr M R et al. Serum albumin and mortality after renal transplantation. Am J Kidney Dis 1996; 27: 117 159. Ferguson R P, O’Connor P, Crabtree B et al. Serum albumin and prealbumin as predictors of clinical outcomes of hospitalized elderly nursing home residents. J Am Geriatr Soc 1993; 41: 545 160. Sullivan D H, Carter W J. Insulin-like growth factor 1 as an indicator of protein-energy undernutrition among metabolically stable hospitalized elderly. J Am Coll Nutr 1994; 13: 184–191 161. Ponzer S, Tidermak J, Brismar K, Soderqvist A, Cederholm T. Nutritional status, insulin-like growth factor-1 and quality of life in elderly women with hip fractures. Clin Nutrition 1999; 18(4): 241–246 162. Campillo B, Paillaud E, Bories P N, Noel M, Porquet D, LeParco J C. Serum levels of insulin-like growth factor-1 in the three months following surgery for a hip fracture in elderly:

CLINICAL NUTRITION

163. 164.

165. 166.

167. 168.

169.

170.

171. 172. 173. 174. 175. 176. 177. 178. 179.

180. 181. 182. 183. 184.

185. 186. 187.

relationship with nutritional status and inflammatory reaction. Clinical Nutrition 2000; 19(5): 349–354 Rudman D, Mattson D E, Nagraj H S et al. Prognostic significance of serum cholesterol in nursing home men. JPEN 1988; 12: 155 Katz P R, Karusa J, Gutman S I, Bartholomew W, Richman G. A comparison between erythrocyte sedimentation rate (ESR) and selected acute-phase proteins in the elderly. Am J Clin Pathol 1990; 94: 637–640 Constans T, Bruyere A, Grab B, Rapin C-H. Pini as a mortality index in the hospitalized elderly patient. Internat J Vit Nutr Res 1992; 62: 191–192 Naber T H J, de Bree A, Schermer T R J, Bakkeren J, Ba¨r B, de Wild G, Katan M B. Specificity of indexes of malnutrition when applied to apparently healthy people: the effect of age. Am J Clin Nutr 1997; 65: 1721–1725 Ek A C, Unosson M. Larsson J et al. Interrater variability and validity in subjective nutritional assessment of elderly patients. Scand J Caring Sci 1996; 10: 163 Wallace J I, Schwartz R S, LaCroix A Z, Uhlmann R F, Pearlman R A. Involuntary weight loss in older outpatients: incidence and clinical significance. J Am Geriatr Soc 1995; 43: 329–337 Cornoni-Huntley J C, Harris T B, Everett D F, Albanes D, Micozzi M S, Miles T P, Feldman J J. An overview of body weight of older persons, including the impact on mortality. J Clin Epidemiol 1991; 44(8): 743–753 Rajala S A, Kanto A J, Haavisto M V, Kaarela R H, Koivunen M J, Hekinheimo R J. Body weight and the three-year prognosis in very old people. International Journal of Obesity 1990; 14: 997–1003 Andres R. Mortality and obesity. In: Andres R, Bierman E L, Hazzard W R (eds). Principles of geriatric medicine. New York: McGraw-Hill, 1985: p. 99 Silver A J, Morley, J E, Storme L S et al. Nutritional status in an academic nursing home. J Am Geriatr Soc 1988; 36: 487 Pinchcofsky-Devin G D, Kaminski M V. Correlation of pressure sores and nutritional status. J Am Geriatr Soc 1986; 34: 435 Anderson K E, Kvorning S A. Medical aspects of the decubitus ulcer. Int J Dermatol 1982; 21: 265 Allman R M, Laprade C A, Noel L B et al. Pressure sores among hospitalized patients. Ann Intern Med 1986; 105: 337 Dwyer J T, Coleman K A, Krall E et al. Changes in relative weight among institutionalized elderly adults. J Gerontol 1987; 42: 246 Harris T, Cook E F, Garrison R et al. Body mass index and mortality among nonsmoking older persons. The Framingham Heart Study. JAMA 1988; 259: 1520 Barrocas A, Belcher D, Champagne C et al. Nutrition assessment practical approaches. Clin Geriatr Med 1995; 11: 675 Epstein A M, Read J L, Hoefer M. The relation of body weight to length of stay and charges for hospital services for patients undergoing elective surgery: a study of two procedures. Am J Public Health 1987; 77: 993 Lew E A, Garfinkel L. Variations in mortality by weight among 750,000 men and women. J Chron Dis 1979; 32: 563 Burr M L, Lennings C I, Milbank J E. The prognostic significance of weight and of vitamin C status in the elderly. Age Ageing 1982; 11: 249 Friedman P J. A prospective comparison of methods to identify lethal wasting malnutrition. Nutr Res 1986; 6: 139 Potter J F, Schafer D F, Bohi R L. In-hospital mortality as a function of BMI: an age dependent variable. Journal of Gerontology 1988; 43: 59–63 Dorn J, Schisterman E F, Winkelstein W, Trevisan M. Body mass index and mortality in a general population sample of men and women. The Buffalo Health Study. Am J Epid 1997; 146: 919–931 Flodin L, Svensson S, Cederholm T. Body mass index as a predictor of 1 year mortality in geriatric patients. Clin Nutr 2000; 19(2): 121–125 Galanos A N, Pieper C F, Kussin P S. Relationship of body mass index to subsequent mortality among seriously ill hospitalized patients. Crit Care Med 1997; 25: 1962–1968 Seersholm N. Body mass index and mortality in patients with severe alpha 1-antitrypsin deficiency. Respir Med 1997; 91: 77–82

115

188. Bienia R, Ratcliff S, Barbour G et al. Malnutrition in the hospitalized geriatric patient. J Am Geriatr Soc 1982; 20: 433 189. Thompson J S, Robbins J, Cooper J K. Nutrition and immune function in the geriatric population. Clin Geriatr Med 1987; 3: 309 190. Chandra R K. Nutrition-immunity-infection interactions in old age. In: Chandra R K (ed.). Nutrition, immunity and illness in the elderly. New York: Pergamon Press,1985: 173 191. Friedman P J. Is wasting itself lethal? A case-control prospective study. Nutr Res 1987; 7: 707 192. Vellas B, Guigoz Y, Garry P J, Nourhashemi F, Bennahum D, Lauque S, Albarede J-L. The Mini Nutritional Assessment (MNA) and its use in grading the nutritional state of elderly patients. Nutrition 1999; 15: 116–122 193. Guigoz Y, Vellas B, Garry P J. Mini Nutritional Assessment: a practical assessment tool for grading the nutritional status of elderly patients. Facts Res Gerontol 1994; 4 (suppl 2): 15 194. Katz S, Ford A B, Moskowitz R W et al. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA 1963; 185: 914 195. Lexell J, Taylor C C, Sjostrom M. What is the cause of the ageing atrophy? Total number, size and proportion of different fiber types studied in whole vastus lateralis muscle from 15- to 83-yearold men. J Neurol Sci 1988; 84: 275–294 196. Rooyackers O E, Adey D B, Ades P A, Nair K S. Effect of age on in vivo rates of mitochondrial protein synthesis in human skeletal muscle. Proc Natl Acad Sci USA 1993; 93: 15 364–15 369 197. Finn P J, Plank L D, Clark M A, Connolly A B, Hill G L. Progressive cellular dehydration and proteolysis in critically ill patients. Lancet 1996; 347(9002): 654–656 198. Winick M (ed.) Hunger disease: Studies by the Jewish physicians in the Warsaw ghetto. New York: John Wiley, 1979 199. McGandy R B, Barrows C H, Spanias A, Meredith A, Stone J L, Norris A H. Nutrient intakes and energy expenditure in men of different ages. J Gerontol 1966; 21: 581–587 200. Heber D, Bray G A. Energy requirements. In: Exton-Smith A N, Caird F I (eds). Metabolic and nutritional disorders in the elderly. Chicago: A John Wright and Sons Ltd., 1980: 1–12 201. Roza A M, Shizgal H M. The Harris-Benedict equation reevaluated: resting energy requirements and the body cell mass. Am J Clin Nutr 1984; 40: 168–182 202. Kao K T, Lakshmanan E L. Protein nutrition and ageing. In: Hsu J M, Davis R L (eds). Handbook of Geriatric Nutrition. Park Ridge, New Jersey: Noyes Publications, 1981 203. Winterer J C, Steffee W P, Davy W et al. Whole body protein turnover in ageing man. Exp Gerontol 1976; 11: 79–87 204. Gersowitz M, Bier D, Mathews D, Udall J, Munro H N, Young V R. Dynamic aspects of whole body glycine metabolism: influence of protein intake in young adult and elderly males. Metabolism 1980; 29: 1087–1094 205. Benedek C, Berclaz P Y, Jecquier E, Schutz Y. Resting metabolic rate and protein turnover in apparently healthy elderly men. Am J Physiol 1995; 268: E1083–E1088 206. Heimburger D C, Young V R, Bistrian B R, Ettinger W H, Lipshitz D A, Dudman D. The role of protein in nutrition with particular reference to the composition and use of enteral feeding formulas. A consensus report. JPEN 1986; 10: 425–430 207. Gersovitz M, Motil K, Munro H N, Scrimshaw N S, Young V R. Human protein requirements: Assessment of the adequacy of the current Recommended Dietary Allowance for dietary protein in elderly men and women. Am J Clin Nutr 1982; 35(1): 6–14 208. Phillips P. Protein turnover in the elderly: a comparison between ill patients and normal controls. Hum Nutr Clin Nutr 1983; 37C: 339–344 209. Beaumont D, Lehmann A B, James O F W. Protein turnover in malnourished elderly subjects: the effects of refeeding. Age Ageing 1989; 18: 235–240 210. Randall H T. Fluid, electrolyte, and fluid base balance. Surg Clin North Am 1976; 56: 1019–1058 211. Nelson R C, Franzi L R. Nutrition and ageing. Medical Clinics of North America 1989; 73(6): 1531–1550 212. Food and Nutrition Board, National Research Control, National Academy of Sciences: Recommended Dietary Allowances, Ed. 10. Washington, DC: National Academy Press, 1989 213. Andrews J, Letcher M, Brook M. Vitamin C supplementation in the elderly: a 17-month trial in an old person’s home. Br Med J 1969; 2: 416–418

116

SURGERY OF THE ELDERLY

214. Shizgal H M, Martin M F, Gimmon Z. The effect of age on the caloric requirement of malnourished individuals. Am J Clin Nutr 1992; 55: 783–789 215. Bos C, Benamouzig R, Bruhat A, Roux C, Mahe´ S, Valensi P, Gaudichon C, Ferrie`re F, Rautureau J, Tome´ D. Short-term protein and energy supplementation activate nitrogen kinetics and accretion in poorly nourished elderly subjects. Am J Clin Nutr 2000; 71: 1129–1137 216. Ganzoni A, Heilig P, Schonenberger K, Hugli O, Filling J W, Brandli O. High calorie nutrition in chronic obstructive airways disease. Schweiz Rundsch Med Prax 1994; 83: 13 217. Hankey C R, Summerbell J, Wynne H A. The effect of dietary supplementation in continuing care of elderly people: nutritional, anthropometric and biochemical parameters. J Hum Nutr Diet 1993; 6: 317–322 218. Volpi E, Rasmussen B B. Nutrition and muscle protein in the elderly. Diab Nutr Metab 2000; 13: 99–107 219. Walker J, Roberts S L, Halmi K A, Goldberg S C. Caloric requirements for weight gain in anorexia nervosa. Am J Clin Nutr 1979; 32: 1396–1400 220. Abbasi A A, Basu S N, Rudman D. Observations concerning the tube-feeding of nursing home residents. In: Watson R R (ed.). Handbook of nutrition in the aged. 2nd ed. Boca Raton: CRC Press Inc. 1994: 135–144 221. He´buterne X, Schneider S, Peroux J -L, Rampal P. Effects of refeeding by cyclic enteral nutrition on body composition: comparative study of elderly and younger patients. Clin Nutr 1997; 16: 283–289 222. Kirk S J, Hurson M, Regan M C et al. Arginine stimulates wound healing and immune function in elderly human beings. Surgery 1993; 114: 155–159 223. Langkamp-Henken B, Herrlinger-Garcia KKA, Stechmiller J K, Nickerson-Troy J A, Lewis B, Moffatt L. Arginine supplementation is well tolerated but does not enhance mitogen-induced lymphocyte proliferation in elderly nursing home residents with pressure ulcers. JPEN 2000; 24: 280–287 224. Schu¨rch M A, Rizzoli R, Slosman D, Vadas L, Vergnaud P, Bonjour P. Protein supplements increase serum Insulin-like Growth Factor-1 levels and attenuate proximal femur bone loss in patients with recent hip fracture. Ann Intern Med 1998; 128: 801–809 225. Bastow M D, Rawlings J, Allison S P. Benefits of supplementary tube feeding after fractured neck of femur: a randomized controlled trial. BMJ 1983; 297: 1589–1592 226. Bastow M D, Rawlings J, Allison S P. Overnight nasogastric tube feeding. Clin Nutr 1985; 4: 7–11 227. Brown K M, Seabrook N A. Nutritional influences on recovery and length of hospital stay in elderly women following femoral fracture. Proc Nutr Soc 1992; 51: 132A 228. Delmi M, Rapin C -H, Bengoa J -M, Delmas P D, Vasey H, Bonjour J -P. Dietary supplementation in elderly patients with fractured neck of the femur. Lancet 1990; 335: 1013–1016 229. Potter J M, Roberts M A, Reilly J J, McColl J H. An evaluation of protein energy supplementation in medically ill admissions to a geriatric unit. Proc Nutr Soc 1998; 17: 88A 230. Chandra R K, Puri S. Nutritional support improves antibody response to influenza virus vaccine in the elderly. BMJ 1985; 291: 705–706 231. Fiatarone M A, O’Neill E F, Ryan N D, Clements K M, Solares G R, Nelson M E, Roberts S B, Kehayias J J, Lipsitz L A, Evans W J. Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med 1994; 330: 1769–1775 232. Gray-Donald K, Payette H, Boutier V. Randomized clinical trial of nutritional supplementation shows little effect on functional status among free-living elderly. J Nutr 1995; 125: 2965–2971 233. Meredith C N, Frontera W R, O’Reilly K P, Evans W J. Body composition in elderly men: effect of dietary modification during strength training. J Am Geriatr Soc 1992; 40: 155–162 Submission date: 30 June 2000 Accepted: 18 October 2000

234. Volkert D, Hubsch S, Oster P, Schlierf G. Nutritional support and functional status in undernourished geriatric patients during hospitalization and 6-month follow-up. Ageing Clin Exp Res 1996; 8: 386–395 235. Woo J, Ho S C, Mak Y T, Law L K, Cheung A. Nutritional status of elderly patients during recovery from chest infection and the role of nutritional supplementation assessed by a prospective randomized single-blind trial. Age Ageing 1994; 23: 40–48 236. Bourdel-Marchasson I, Barateau M, Rondeau V, DequaeMerchadou L, Salles-Montaudon N, Emeriau J -P, Manciet G, Dartigues J -F, for the GAGE Group. A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. Nutrition 2000; 16: 1–5 237. Bunker V W, Stansfield M F, Deacon-Smith R, Marzil R A, Hounslow A, Clayton B E. Dietary supplementation and immuno-competence in housebound elderly subjects. Br J Biomed Sci 1994; 51: 128–135 238. Cederholm T E, Hellstrom K H. Reversibility of protein-energy malnutrition in a group of chronically-ill elderly outpatients. Clin Nutr 1995; 14: 81–87 239. Lipschitz D A, Mitchell C O, Steele R W, Milton K Y. Nutritional evaluation and supplementation of elderly subjects participating in a ‘‘Meals on Wheels’’ program. JPEN 1985; 9: 343–347 240. Welch P K, Dowson M, Endres J M. The effect of nutrient supplements on high risk long term care residents receiving pureed diets. J Nutr Elderly 1991; 10: 49–62 241. Larsson J, Unosson M, Ek A -C, Nilsson L, Thorslund S, Bjurulf P. Effects of dietary supplementation on nutritional status and clinical outcome in 501 geriatric patients – a randomized study. Clin Nutr 1990; 9: 179–184 242. Bermon S, He´buterne X, Peroux J -L, Marconnet P, Rampal P. Correction of protein-energy malnutrition in older adults: effects of a short-term aerobic training program. Clin Nutr 1997; 16: 291–298 243. Evans W J, Campbell W W. Exercise, ageing and protein metabolism. Diabet Nutr Met 2000; 13: 108–112 244. Report of nutrition Screening 1: Toward a common view: Nutrition Screening Initiative. Washington, DC, Green, Margolis, Mitchell, Burns and Associates, 1991 245. Khalil T, Poston G J, Thompson J C. Effects of ageing on gastrointestinal hormones. In: Prinsley D M, Sanstead H H (eds). Progress in Clinical and Biological Research, Nutrition and Ageing, vol. 326. New York: Alan R. Liss, 1990: 39–71 246. Koruda M J, Sheldon G F. Surgery in the aged. Adv Surg 1991; 24: 293–331 247. Shamburek R D, Scott R B, Farrar J T. Gastrointestinal and liver changes in the elderly. In: Katlic M R (ed.): Geriatric surgery. Baltimore, Urban & Schwarzenberg, 1990: pp 97–113 248. Sutnick M R. Dietary guidance for the elderly. Clin Geriatr Med 1988; 4: 193–202 249. Valvona J, Sloan F. Data watch: rising rates of surgery among the elderly. Health Affairs 1985; 4: 108–119 250. Morley J E. Nutritional status of the elderly. Am J Med 1986; 81: 680 251. Muravchick S. Anaesthesia for the elderly. In: Miller R D (ed.). Anesthesia. 3rd ed. New York: Churchill Livingstone, 1990: p. 1970 252. Food and Nutrition Board, Committee on Dietary Allowances: Recommended Dietary Allowances 9th ed. (revised). Washington, DC, National Academy of Sciences, 1980 253. Adkins R B Jr. History and philosophy. In: Adkins R B Jr, Scott H W (eds). Surgical Care for the Elderly. Baltimore: Williams & Wilkins, 1988 254. Shock, N W. Physiologic aspects of ageing. J Am Diet Assoc, 1970; 56: 492 255. Cutler R G. Evolutionary perspective of human longevity. In: Hazzard WR, Andres R, Bierman E L (eds). Principles of Geriatric Medicine and Gerontology. 2nd ed. New York: McGraw-Hill, 1985: 16