Skip to main content
NCBI home page
Annals of Surgery logoLink to Annals of Surgery
. 1993 Sep;218(3):380–393. doi: 10.1097/00000658-199309000-00017

Impaired recovery of strength in older patients after major abdominal surgery.

J M Watters 1, S M Clancey 1, S B Moulton 1, K M Briere 1, J M Zhu 1
PMCID: PMC1242984  PMID: 8373279

Abstract

OBJECTIVE: This study compared changes in muscle strength after major elective abdominal surgery in young and old patients, and related these changes to body composition and nitrogen balance. SUMMARY BACKGROUND DATA: The breakdown of muscle protein, erosion of lean tissue, and negative nitrogen balance are characteristic metabolic responses to surgical illness. With a substantial loss of muscle mass typical of advancing age, the authors postulated that older patients would be weaker during acute surgical illness and less able to maintain muscle function and meet metabolic demands. METHODS: Active, community-dwelling individuals undergoing major abdominal procedures who were 70 years of age or older or 50 years of age or younger were studied. Total body water (TBW) was determined preoperatively by deuterium oxide dilution. Maximal voluntary handgrip, respiratory muscle strength, and visual analog pain scores were measured preoperatively and on postoperative days 2, 4, and 6. All urine was collected postoperatively for 7 days for determination of total nitrogen, creatinine, and cortisol. RESULTS: The young (age, 36 +/- 9 years [mean +/- standard deviation]; n = 20) and old groups (age, 77 +/- 5 years; n = 20) were similar regarding weight, sex distribution, nutritional status, surgical procedures and anesthesia, and postoperative urine cortisol values. Age group, time after operation, and interaction effects were significant for each strength variable (all p < 0.005 by analysis of variance). Older patients had lower preoperative strength (29% to 41%) and mean 24-hour urine creatinine (27%). Postoperative strength was decreased most markedly on postoperative day 2, with similar proportional changes in the two age groups but lower absolute levels in the older patients. The rate of recovery of strength was substantially less rapid and complete in older patients. Older patients had less postoperative pain and received much less parenteral narcotic than younger patients. Postoperative urine nitrogen was similar in each group. Recovery of strength was not related to malignancy, preoperative strength, muscle mass (urine creatinine), lean body mass (TBW), sex, malignancy, pain, or narcotic administration. CONCLUSIONS: Older patients are weaker preoperatively than younger patients; their strength falls to lower levels after surgery and their postoperative recovery of strength is impaired. The lesser preoperative strength of older patients is due in large part but not totally to diminished muscle mass. Their impaired postoperative recovery appears to be related to more acute factors, such as muscle energetics or substrate availability.

Full text

PDF
380

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Ali J., Weisel R. D., Layug A. B., Kripke B. J., Hechtman H. B. Consequences of postoperative alterations in respiratory mechanics. Am J Surg. 1974 Sep;128(3):376–382. doi: 10.1016/0002-9610(74)90176-7. [DOI] [PubMed] [Google Scholar]
  2. Bastow M. D., Rawlings J., Allison S. P. Benefits of supplementary tube feeding after fractured neck of femur: a randomised controlled trial. Br Med J (Clin Res Ed) 1983 Nov 26;287(6405):1589–1592. [PMC free article] [PubMed] [Google Scholar]
  3. Bellville J. W., Forrest W. H., Jr, Miller E., Brown B. W., Jr Influence of age on pain relief from analgesics. A study of postoperative patients. JAMA. 1971 Sep 27;217(13):1835–1841. [PubMed] [Google Scholar]
  4. Black L. F., Hyatt R. E. Maximal respiratory pressures: normal values and relationship to age and sex. Am Rev Respir Dis. 1969 May;99(5):696–702. doi: 10.1164/arrd.1969.99.5.696. [DOI] [PubMed] [Google Scholar]
  5. Chan S. T., McLaughlin S. J., Ponting G. A., Biglin J., Dudley H. A. Muscle power after glucose-potassium loading in undernourished patients. Br Med J (Clin Res Ed) 1986 Oct 25;293(6554):1055–1056. doi: 10.1136/bmj.293.6554.1055. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Christie P. M., Hill G. L. Effect of intravenous nutrition on nutrition and function in acute attacks of inflammatory bowel disease. Gastroenterology. 1990 Sep;99(3):730–736. doi: 10.1016/0016-5085(90)90962-z. [DOI] [PubMed] [Google Scholar]
  7. Cohn S. H., Vartsky D., Yasumura S., Sawitsky A., Zanzi I., Vaswani A., Ellis K. J. Compartmental body composition based on total-body nitrogen, potassium, and calcium. Am J Physiol. 1980 Dec;239(6):E524–E530. doi: 10.1152/ajpendo.1980.239.6.E524. [DOI] [PubMed] [Google Scholar]
  8. Craig D. B. Postoperative recovery of pulmonary function. Anesth Analg. 1981 Jan;60(1):46–52. [PubMed] [Google Scholar]
  9. Craig D. B., Wahba W. M., Don H. F., Couture J. G., Becklake M. R. "Closing volume" and its relationship to gas exchange in seated and supine positions. J Appl Physiol. 1971 Nov;31(5):717–721. doi: 10.1152/jappl.1971.31.5.717. [DOI] [PubMed] [Google Scholar]
  10. Davies C. W., Jones D. M., Shearer J. R. Hand grip--a simple test for morbidity after fracture of the neck of femur. J R Soc Med. 1984 Oct;77(10):833–836. doi: 10.1177/014107688407701006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. 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 Apr 28;335(8696):1013–1016. doi: 10.1016/0140-6736(90)91073-j. [DOI] [PubMed] [Google Scholar]
  12. Detsky A. S., McLaughlin J. R., Baker J. P., Johnston N., Whittaker S., Mendelson R. A., Jeejeebhoy K. N. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987 Jan-Feb;11(1):8–13. doi: 10.1177/014860718701100108. [DOI] [PubMed] [Google Scholar]
  13. Ferrell B. A. Pain management in elderly people. J Am Geriatr Soc. 1991 Jan;39(1):64–73. doi: 10.1111/j.1532-5415.1991.tb05908.x. [DOI] [PubMed] [Google Scholar]
  14. Forbes G. B., Reina J. C. Adult lean body mass declines with age: some longitudinal observations. Metabolism. 1970 Sep;19(9):653–663. doi: 10.1016/0026-0495(70)90062-4. [DOI] [PubMed] [Google Scholar]
  15. Griffith C. D., Whyman M., Bassey E. J., Hopkinson B. R., Makin G. S. Delayed recovery of hand grip strength predicts postoperative morbidity following major vascular surgery. Br J Surg. 1989 Jul;76(7):704–705. doi: 10.1002/bjs.1800760717. [DOI] [PubMed] [Google Scholar]
  16. Grimby G. Physical activity and muscle training in the elderly. Acta Med Scand Suppl. 1986;711:233–237. doi: 10.1111/j.0954-6820.1986.tb08956.x. [DOI] [PubMed] [Google Scholar]
  17. Harper C. M., Lyles Y. M. Physiology and complications of bed rest. J Am Geriatr Soc. 1988 Nov;36(11):1047–1054. doi: 10.1111/j.1532-5415.1988.tb04375.x. [DOI] [PubMed] [Google Scholar]
  18. Hunt D. R., Rowlands B. J., Johnston D. Hand grip strength--a simple prognostic indicator in surgical patients. JPEN J Parenter Enteral Nutr. 1985 Nov-Dec;9(6):701–704. doi: 10.1177/0148607185009006701. [DOI] [PubMed] [Google Scholar]
  19. Jiang Z. M., He G. Z., Zhang S. Y., Wang X. R., Yang N. F., Zhu Y., Wilmore D. W. Low-dose growth hormone and hypocaloric nutrition attenuate the protein-catabolic response after major operation. Ann Surg. 1989 Oct;210(4):513–525. doi: 10.1097/00000658-198910000-00012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Kalfarentzos F., Spiliotis J., Velimezis G., Dougenis D., Androulakis J. Comparison of forearm muscle dynamometry with nutritional prognostic index, as a preoperative indicator in cancer patients. JPEN J Parenter Enteral Nutr. 1989 Jan-Feb;13(1):34–36. doi: 10.1177/014860718901300134. [DOI] [PubMed] [Google Scholar]
  21. Kallman D. A., Plato C. C., Tobin J. D. The role of muscle loss in the age-related decline of grip strength: cross-sectional and longitudinal perspectives. J Gerontol. 1990 May;45(3):M82–M88. doi: 10.1093/geronj/45.3.m82. [DOI] [PubMed] [Google Scholar]
  22. Khaled M. A., Lukaski H. C., Watkins C. L. Determination of total body water by deuterium NMR. Am J Clin Nutr. 1987 Jan;45(1):1–6. doi: 10.1093/ajcn/45.1.1. [DOI] [PubMed] [Google Scholar]
  23. Klidjian A. M., Foster K. J., Kammerling R. M., Cooper A., Karran S. J. Relation of anthropometric and dynamometric variables to serious postoperative complications. Br Med J. 1980 Oct 4;281(6245):899–901. doi: 10.1136/bmj.281.6245.899. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Klitgaard H., Mantoni M., Schiaffino S., Ausoni S., Gorza L., Laurent-Winter C., Schnohr P., Saltin B. Function, morphology and protein expression of ageing skeletal muscle: a cross-sectional study of elderly men with different training backgrounds. Acta Physiol Scand. 1990 Sep;140(1):41–54. doi: 10.1111/j.1748-1716.1990.tb08974.x. [DOI] [PubMed] [Google Scholar]
  25. Larsson L., Grimby G., Karlsson J. Muscle strength and speed of movement in relation to age and muscle morphology. J Appl Physiol Respir Environ Exerc Physiol. 1979 Mar;46(3):451–456. doi: 10.1152/jappl.1979.46.3.451. [DOI] [PubMed] [Google Scholar]
  26. Latimer R. G., Dickman M., Day W. C., Gunn M. L., Schmidt C. D. Ventilatory patterns and pulmonary complications after upper abdominal surgery determined by preoperative and postoperative computerized spirometry and blood gas analysis. Am J Surg. 1971 Nov;122(5):622–632. doi: 10.1016/0002-9610(71)90290-x. [DOI] [PubMed] [Google Scholar]
  27. Lexell J., Taylor C. C. Variability in muscle fibre areas in whole human quadriceps muscle: effects of increasing age. J Anat. 1991 Feb;174:239–249. [PMC free article] [PubMed] [Google Scholar]
  28. Maxwell A. Muscle power after surgery. Lancet. 1980 Feb 23;1(8165):420–421. doi: 10.1016/s0140-6736(80)90966-6. [DOI] [PubMed] [Google Scholar]
  29. McCue J., Newham D. Postoperative muscle strength. Ann R Coll Surg Engl. 1990 Sep;72(5):291–295. [PMC free article] [PubMed] [Google Scholar]
  30. McCully K. K., Forciea M. A., Hack L. M., Donlon E., Wheatley R. W., Oatis C. A., Goldberg T., Chance B. Muscle metabolism in older subjects using 31P magnetic resonance spectroscopy. Can J Physiol Pharmacol. 1991 May;69(5):576–580. doi: 10.1139/y91-084. [DOI] [PubMed] [Google Scholar]
  31. Montoye H. J., Lamphiear D. E. Grip and arm strength in males and females, age 10 to 69. Res Q. 1977 Mar;48(1):109–120. doi: 10.1080/10671315.1977.10762158. [DOI] [PubMed] [Google Scholar]
  32. Owen J. A., Sitar D. S., Berger L., Brownell L., Duke P. C., Mitenko P. A. Age-related morphine kinetics. Clin Pharmacol Ther. 1983 Sep;34(3):364–368. doi: 10.1038/clpt.1983.180. [DOI] [PubMed] [Google Scholar]
  33. Phillips S. K., Bruce S. A., Newton D., Woledge R. C. The weakness of old age is not due to failure of muscle activation. J Gerontol. 1992 Mar;47(2):M45–M49. doi: 10.1093/geronj/47.2.m45. [DOI] [PubMed] [Google Scholar]
  34. Rizzato G., Marazzini L. Thoracoabdominal mechanics in elderly men. J Appl Physiol. 1970 Apr;28(4):457–460. doi: 10.1152/jappl.1970.28.4.457. [DOI] [PubMed] [Google Scholar]
  35. Road J. D., Burgess K. R., Whitelaw W. A., Ford G. T. Diaphragm function and respiratory response after upper abdominal surgery in dogs. J Appl Physiol Respir Environ Exerc Physiol. 1984 Aug;57(2):576–582. doi: 10.1152/jappl.1984.57.2.576. [DOI] [PubMed] [Google Scholar]
  36. Rowe J. W., Kahn R. L. Human aging: usual and successful. Science. 1987 Jul 10;237(4811):143–149. doi: 10.1126/science.3299702. [DOI] [PubMed] [Google Scholar]
  37. Russell D. M., Prendergast P. J., Darby P. L., Garfinkel P. E., Whitwell J., Jeejeebhoy K. N. A comparison between muscle function and body composition in anorexia nervosa: the effect of refeeding. Am J Clin Nutr. 1983 Aug;38(2):229–237. doi: 10.1093/ajcn/38.2.229. [DOI] [PubMed] [Google Scholar]
  38. SCHLOERB P. R., FRIIS-HANSEN B. J., EDELMAN I. S., SOLOMON A. K., MOORE F. D. The measurement of total body water in the human subject by deuterium oxide dilution; with a consideration of the dynamics of deuterium distribution. J Clin Invest. 1950 Oct;29(10):1296–1310. doi: 10.1172/JCI102366. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Schoeller D. A., van Santen E., Peterson D. W., Dietz W., Jaspan J., Klein P. D. Total body water measurement in humans with 18O and 2H labeled water. Am J Clin Nutr. 1980 Dec;33(12):2686–2693. doi: 10.1093/ajcn/33.12.2686. [DOI] [PubMed] [Google Scholar]
  40. Scott J., Huskisson E. C. Graphic representation of pain. Pain. 1976 Jun;2(2):175–184. [PubMed] [Google Scholar]
  41. Shizgal H. M., Vasilevsky C. A., Gardiner P. F., Wang W. Z., Tuitt D. A., Brabant G. V. Nutritional assessment and skeletal muscle function. Am J Clin Nutr. 1986 Dec;44(6):761–771. doi: 10.1093/ajcn/44.6.761. [DOI] [PubMed] [Google Scholar]
  42. Threlfall C. J., Stoner H. B., Galasko C. S. Patterns in the excretion of muscle markers after trauma and orthopedic surgery. J Trauma. 1981 Feb;21(2):140–147. doi: 10.1097/00005373-198102000-00008. [DOI] [PubMed] [Google Scholar]
  43. Tkatch L., Rapin C. H., Rizzoli R., Slosman D., Nydegger V., Vasey H., Bonjour J. P. Benefits of oral protein supplementation in elderly patients with fracture of the proximal femur. J Am Coll Nutr. 1992 Oct;11(5):519–525. doi: 10.1080/07315724.1992.10718256. [DOI] [PubMed] [Google Scholar]
  44. Vaughan R. W., Wise L. Postoperative arterial blood gas measurement in obese patients: effect of position on gas exchange. Ann Surg. 1975 Dec;182(6):705–709. doi: 10.1097/00000658-197512000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Wahba W. M. Influence of aging on lung function--clinical significance of changes from age twenty. Anesth Analg. 1983 Aug;62(8):764–776. [PubMed] [Google Scholar]
  46. Webb A. R., Newman L. A., Taylor M., Keogh J. B. Hand grip dynamometry as a predictor of postoperative complications reappraisal using age standardized grip strengths. JPEN J Parenter Enteral Nutr. 1989 Jan-Feb;13(1):30–33. doi: 10.1177/014860718901300130. [DOI] [PubMed] [Google Scholar]
  47. Windsor J. A., Hill G. L. Risk factors for postoperative pneumonia. The importance of protein depletion. Ann Surg. 1988 Aug;208(2):209–214. doi: 10.1097/00000658-198808000-00013. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES