Unintentional Weight Loss

Aka: Unintentional Weight Loss, Unintentional Weight Loss in Older Adults, Failure to Thrive in the Elderly, Geriatric Failure to Thrive, Cachexia, Cachexia Syndrome, Wasting Syndrome, Malnutrition, Anorexia, Abnormal Weight Loss, Involuntary Weight Loss, Unexplained Weight Loss

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II. Epidemiology: Incidence

  1. Community older adults: >5%
  2. Hospitalized older adults: >50%
  3. Nursing Home residents: 25-40%
    1. Silver (1988) J Am Geriatr Soc 36:487-91 [PubMed]
  4. Overall over age 64 years: 13%
    1. Murden (1994) J Gen Intern Med 9:648-50 [PubMed]

III. Definitions

  1. Malnutrition
    1. Deficiency, excess or imbalance in individual intake of energy and nutrients
  2. Unintentional Weight Loss in age >65 years old
    1. Unintentional Weight Loss of >5% of body weight within 6-12 months
  3. Cachexia Syndrome (Wasting Syndrome)
    1. Unintentional Weight Loss of >5% of body weight within 12 months attributed to known chronic disease
    2. Examples
      1. Cachexia in Cancer
      2. Severe COPD
      3. Wasting in HIV
      4. End Stage Renal Disease

IV. Causes

  1. See Unintentional Weight Loss Causes
  2. See Unintentional Weight Loss due to Medications
  3. Contributing Factors
    1. Physical function decline (Generalized Weakness, Falls, ADL decline)
    2. Malnutrition (Weight loss, Anorexia, decreased Immunity)
    3. Major Depression
    4. Cognitive Impairment (Delirium, Dementia)

V. Precautions

  1. Substantial weight loss should not be attributed to aging alone
    1. See Body Composition Changes with Aging
    2. Total body weight typically peaks at age 60 years and does not change substantially after

VI. History

  1. How much weight loss over how much time?
    1. Patients down play weight changes
    2. Clothing or belt size changes
    3. Impressions of friends and family on weight change
  2. Associated Gastrointestinal Symptoms
    1. Nausea or Vomiting
    2. Dysphagia
      1. See Dysphagia
      2. Poorly fitting dentures
      3. Poor Dentition (e.g. Dental Caries)
      4. Esophageal Stricture
    3. Chronic Diarrhea
      1. Infectious Diarrhea
      2. Inflammatory Bowel Disease
      3. Malabsorption (e.g. Celiac Sprue)
    4. Abdominal Pain
      1. Peptic Ulcer Disease
      2. Biliary Colic, Cholecystitis or Cholelithiasis
      3. Mesenteric Ischemia
      4. Small Bowel Obstruction
      5. Inflammatory Bowel Disease
  3. Associated Symptoms
    1. Fever, Fatigue or weakness
      1. Malignancy
      2. Infection
      3. Autoimmune disorder
      4. Diabetes Mellitus
      5. Hyperthyroidism
      6. Underlying neuromuscular condition
      7. Alcohol or Drug Abuse
    2. Dyspnea or exertional Fatigue
      1. Congestive Heart Failure
      2. Lung infection
      3. Chronic Obstructive Lung Disease
      4. Anemia
    3. Preoccupation with thinness
      1. Anorexia Nervosa
  4. Dietary history
    1. See Nutritional Health Checklist
    2. Are meals skipped?
    3. Does the patient need help preparing meals?
    4. Are meals well balanced (Food Pyramid)?
    5. Are any Nutritional Supplements used?
    6. Is patient following any dietary restrictions?
  5. Secondary cause history
    1. Medication and substance use
      1. See Unintentional Weight Loss due to Medications
      2. See Polypharmacy
      3. Over-the-counter medications or herbal supplement use?
      4. Is there concurrent Drug Abuse or Alcohol use?
        1. See Substance Abuse Screening
    2. Food is not appealing
      1. Malignancy
      2. Medication adverse effects
      3. Major Depression
    3. Altered Taste Sensation (Dysgeusia)
      1. Medication adverse effects
      2. Acute Hepatitis or Chronic Liver Disease
      3. Sinusitis
      4. Vitamin B Deficiency
      5. Zinc Deficiency
      6. Mental health concerns
    4. Mechanical problems (affects chewing and Swallowing)
      1. See Dysphagia
      2. See Dyspnea
      3. Poorly fitting Dentures
      4. Painful Oral Lesions (e.g. Candidiasis, Gingivitis)
    5. Weight loss despite increased appetite
      1. Hyperthyroidism
      2. Diabetes Mellitus
      3. Celiac Sprue
      4. Pancreatic Insufficiency
    6. Significant comorbidity
      1. See Unintentional Weight Loss Causes
      2. See Dementia Related Malnutrition
      3. See Malnutrition Following ICU Admission
      4. See Cachexia in Cancer
      5. HIV Infection or AIDS

VII. Exam

  1. See Comprehensive Geriatric Assessment
  2. Record accurate weights on same scale at every visit (without shoes)
    1. Unexplained Weight Loss >5% should be investigated
    2. Anticipated time for 15% weight loss
      1. Complete starvation: 15% of weight lost in 3 weeks
      2. Half of normal food intake: 3 months
      3. Half food intake and comorbid conditions: 3 weeks
  3. Vital Sign clues
    1. Fever
    2. Tachycardia
  4. Body Mass Index (BMI) predicts mortality in elderly
    1. Women: BMI <22 kg/m2 predicts increased mortality
    2. Men: BMI <23.5 kg/m2 predicts increased mortality
    3. Calle (1999) N Engl J Med 341:1097-105 [PubMed]
  5. Head and neck changes
    1. Dentition, Periodontal Disease or poorly fitting dentures
    2. Glossitis
    3. Thyromegaly
  6. Cardiopulmonary Changes
    1. Congestive Heart Failure
    2. COPD-related Findings
  7. Other examination focus areas
    1. Loss of Soft Tissue Mass in face and extremities
    2. Abdominal masses
    3. Lymphadenopathy
    4. Peripheral Neuropathy
    5. Chest Masses

VIII. Labs: Approach

  1. Start with basic lab evaluation
    1. Complete Blood Count
    2. Comprehensive Metabolic Panel
    3. Urinalysis
    4. Thyroid Stimulating Hormone (TSH)
    5. Fecal Occult Blood Testing
    6. Serum Lactate Dehydrogenase (LDH)
    7. Erythrocyte Sedimentation Rate (ESR)
    8. C-Reactive Protein (CRP)
    9. Serum Ferritin
  2. Lab testing should be directed by history and physical
    1. See below for potentially indicated labs

IX. Labs: As directed by history and physical

  1. Stool studies
    1. Fecal Occult Blood (3 samples)
    2. Stool for Ova and Parasites
  2. Complete Blood Count
    1. White Blood Cell Count with differential
    2. Hemoglobin
  3. Acute phase reactants
    1. Erythrocyte Sedimentation Rate
    2. C-Reactive Protein
  4. Endocrine tests
    1. Thyroid Stimulating Hormone (TSH)
    2. Serum Testosterone in men
    3. Serum Cortisol (8 am)
  5. Comprehensive Metabolic Panel
    1. Serum Glucose
    2. Electrolytes
    3. Renal Function tests
    4. Liver Function Tests
    5. Serum Lactate Dehydrogenase
  6. Infectious disease
    1. Blood Culture (if febrile)
    2. Tuberculin Skin Test (PPD)
    3. HIV Test
    4. Urinalysis
    5. Rapid Plasma Reagin (RPR)
  7. Malnutrition Assessment
    1. See Lab Markers of Malnutrition
    2. Serum Albumin
    3. Total Cholesterol
  8. Malabsorption
    1. Fecal fat (sudan stain)
    2. Serum carotene
    3. Serum Folic Acid
    4. Celiac Sprue serologies (IgA Tissue Transglutaminase or TTG)
  9. Malignancy Evaluation
    1. Serum Protein Electrophoresis (SPEP)
    2. Urine Protein electrophoresis (UPEP)
    3. Common Non-Specific Marker Abnormalities in Underlying Malignancy
      1. Serum Albumin decreased
      2. Leukocytosis
      3. Thrombocytosis
      4. Hypercalcemia
      5. Increased acute phase reactants (e.g. CRP, ESR)
      6. Nicholson (2020) BMJ 370:m2651 +PMID: 32816714 [PubMed]

X. Imaging

  1. Chest XRay

XI. Diagnostics: Testing to consider

  1. Anatomic screening with CT Scan
    1. Not routinely recommended as first-line (low yield)
    2. Consider CT Chest AbdomenPelvis if other associated B-Symptoms, or examination findings
    3. Consider Lung Cancer Screening CT Chest if indicated
  2. Upper Endoscopy (or Upper gastrointestinal series)
  3. Mammogram
  4. Abdominal Ultrasound
  5. Colonoscopy
  6. Echocardiogram
  7. Pulmonary Function Tests

XII. Diagnosis: Cachexia Syndrome Criteria

  1. Unintentional Weight Loss of >5% of body weight within 12 months AND
  2. Known causative chronic disease AND
  3. Minor criteria (3 of the following required)
    1. Fatigue
    2. Anorexia
    3. Low fat-free mass-index (Muscle mass to height)
    4. Decreased Muscle Strength
    5. Abnormal lab values
      1. Lab Markers of Malnutrition (e.g. decreased Serum Albumin)
      2. Anemia
      3. Acute phase reactant abnormalities (increased ESR, CRP)

XIII. Evaluation

  1. Cognition
    1. Saint Louis University Mental Status (SLUMS)
    2. Mini-Cognitive Assessment Instrument (Mini-Cog)
    3. Mini-Mental State Exam (MMSE)
  2. Function: Activities of Daily Living
    1. Katz ADL Scale
    2. Lawton IADL Scale
    3. Six-Minute Walk Test
  3. Geriatric Depression
    1. Geriatric Depression Scale
    2. Patient Health Questionaire 2 (PHQ-2)
    3. Patient Health Questionaire 9 (PHQ-9)
  4. Malnutrition
    1. See Subjective Global Assessment of Nutritional Status
    2. See Lab Markers of Malnutrition
    3. See Nutritional Health Checklist
    4. Mini-Nutritional Assessment (Nestle Nutrition)
      1. http://www.mna-elderly.com/clinical-practice.htm
    5. Malnutrition Universal Screening Tool
      1. https://www.bapen.org.uk/screening-and-must/must-calculator

XIV. Management: Empiric

  1. Identify underlying cause
    1. Evaluation for secondary cause may stop after initial tests if no obvious etiologies are identified
    2. Empiric management with reevaluation at 3-6 month intervals is recommended approach
      1. At serial evaluations, additional testing should be directed by interval history
    3. Treat acute illness (e.g. infections)
      1. See Infections in Older Adults
    4. Optimize chronic disease management
    5. See Depression in the Elderly
  2. Referrals
    1. Dietician
    2. Speech Therapy (Swallowing evaluation)
    3. Social services
    4. Address Advanced Directives
  3. General Measures
    1. Increase meal frequency with manageable servings
    2. Consider flavor enhancers (indicated in Hyposmia)
      1. Example: Ham, bacon or roast beef flavors sprinkled on food
    3. Eliminate or reduce dietary restrictions
    4. Consider Meals on Wheels or senior dining facility
    5. Choose foods with high calorie density
    6. Correct ill fitting dentures and impaired chewing
    7. Encourage Physical Activity
      1. Avoid bed rest
      2. Up in chair for all meals
      3. Walk twice daily in hallway if able
      4. Consider Physical Therapy
      5. Avoid restraints including Foley Catheter
      6. Bathroom use (up with assistance)
    8. Consider liquid oral dietary supplements (e.g. Ensure, Boost)
      1. Give 2 hours before a scheduled meal
        1. Split one can supplement into four doses
        2. Take interspersed as snacks
        3. Take with medications
        4. Make more palatable by mixing with ice cream
      2. Should be an adjunct to meals and snacks (not a meal replacement)
      3. Routine high calorie supplements are not recommended by American Geriatrics Society
        1. Lack of evidence on impact to quality of life or long term survival
      4. However Cochrane has found mortality benefit in undernourished patients
        1. Milne (2009) Cochrane Database Syst Rev (2):CD003288 [PubMed]
  4. Medications
    1. Focus first on Deprescribing
      1. See Deprescribing
      2. See Polypharmacy
      3. See Medication Use in the Elderly
      4. What medications can be stopped?
      5. Are medications dosed correctly?
        1. Interpret doses in light of Renal Function
      6. Are medication side effects resulting in failure?
        1. See Unintentional Weight Loss due to Medications
      7. Consider Drug Interactions
        1. See Drug-Drug Interactions in the Elderly
    2. Appetite Stimulants are not recommended by American Geriatrics Society
      1. Lack of evidence on impact to quality of life or long term survival, and potential adverse effects
    3. Treat Major Depression: SSRI
      1. Mirtazapine (Remeron)
        1. Risk of Dizziness, Orthostatic Hypotension and Fall Risk
        2. May be preferred SSRI in Failure to Thrive
        3. Raji (2001) Ann Pharmacother 35:1024-7 [PubMed]
      2. Fluoxetine (Prozac)
      3. Sertraline (Zoloft)
    4. Cannabinoid: Dronabinol (Marinol)
      1. Adverse effects: sedation and confusion
  5. Medications that are no longer recommended due to risks outweighing efficacy
    1. Growth Hormone
      1. Increased mortality risk
    2. Megestrol (Megace)
      1. Typical dose: 320 mg to 800 mg PO qd
      2. Adverse effects: edema, Constipation and Delirium; thrombosis risk
      3. Low efficacy in appetite stimulation outside of Cachexia in AIDS and cancer

XV. Complications: Weight loss more than 10-20% below normal weight

  1. Weight loss >10-20% is associated with increased mortality (approaches 16%)
    1. Sullivan (1991) Am J Clin Nutr 53:599-605 [PubMed]
  2. Weight loss >10-20% is associated with overall increase in morbidity
    1. Weakness or Fatigue
    2. Muscle wasting
    3. Immunosuppression
    4. Skin breakdown
    5. Mood changes (Apathy, Irritability)
    6. Recurrent Falls
    7. Hip Fracture (women)

XVI. References

  1. Heizer in Dornbrand (1992) Ambulatory Care, p. 15-18
  2. Karsh in Friedman (1991) Medical Diagnosis, p. 13-16
  3. Alibhai (2005) CMAJ 172(6): 773-80 [PubMed]
  4. Dwyer (1993) Am Fam Physician 47(3):613-20 [PubMed]
  5. Gaddey (2021) Am Fam Physician 104(1):34-40 [PubMed]
  6. Gaddey (2014) Am Fam Physician 89(9):718-22 [PubMed]
  7. Grazewood (1998) J Fam Pract 47(1): 19-25 [PubMed]
  8. Huffman (2002) Am Fam Physician 65(4):640-50 [PubMed]
  9. McMinn (2011) BMJ 342:d1732 +PMID: 21447571 [PubMed]
  10. Morley (1995) Ann Intern Med 123:850-9 [PubMed]
  11. Robertson (2004) Am Fam Physician 70:343-50 [PubMed]
  12. Stajkovic (2011) CMAJ 183(4): 443-9 [PubMed]
  13. White (1991) Am Fam Physician 44(6): 2087-97 [PubMed]
  14. Zawada (1996) Postgrad Med 100(1):207-25 [PubMed]

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