Geri

Unintentional Weight Loss

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Unintentional Weight Loss, Geriatric Failure to Thrive, Cachexia, Wasting Syndrome, Malnutrition, Anorexia

  • Definition
  1. Unintentional Weight Loss of >5% of body weight within 6-12 months
  • Precautions
  1. Substantial weight loss should not be attributed to aging alone
    1. See Body Composition Changes with Aging
  • 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 or Alcohol use?
    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
  • Exam
  1. Record accurate weights on same scale at every visit
    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
  2. Vital Sign clues
    1. Fever
    2. Tachycardia
  3. 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]
  4. Head and neck changes
    1. Dentition
    2. Glossitis
    3. Thyromegaly
  5. Other examination focus areas
    1. Loss of soft tissue mass in face and extremities
    2. Abdominal masses
    3. Lymphadenopathy
    4. Peripheral Neuropathy
  • 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)
  2. Lab testing should be directed by history and physical
    1. See below for potentially indicated labs
  • 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
  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
  8. Malabsorption
    1. Fecal fat (sudan stain)
    2. Serum carotene
    3. Serum Folic Acid
    4. Celiac Sprue serologies (IgA Tissue Transglutaminase or TTG)
  • Imaging
  1. Chest XRay
  2. Abdominal Ultrasound
  3. Mammogram
  4. Screening with CT Scan not recommended (low yield)
  • Diagnostics
  • Testing to consider
  1. Upper gastrointestinal series or Upper Endoscopy
  2. Flexible Sigmoidoscopy or Colonoscopy
  • 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
  2. Referrals
    1. Dietician
    2. Speech Therapy (swallowing evaluation)
    3. Social services
  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. Consider liquid oral dietary supplements (e.g. Ensure)
      1. Give 2 hours before a scheduled meal
      2. Should be an adjunct to meals (not a meal replacement)
    7. Correct ill fitting dentures
    8. Encourage Physical Activity
  4. Medications
    1. 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)
    2. 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
  • Complications
  • Weight loss more than 10-20% below normal weight
  1. Increased mortality approaches 16%
    1. Sullivan (1991) Am J Clin Nutr 53:599-605 [PubMed]
  2. Overall increase in morbidity
    1. Weakness or Fatigue
    2. Muscle wasting
    3. Immunosuppression
    4. Skin breakdown
    5. Mood changes (Apathy, Irritability)
    6. Hip Fracture (women)