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unintentional weight loss

Etiology: 1) weight loss over a period of a few days indicates loss of body fluids 2) mechanisms a) decreased caloric intake* b) malabsorption* c) increased metabolism 3) progressive sustained weight loss over a period of months a) gastrointestinal disease - malaborption syndromes - gastrointestinal obstruction b) endocrine disorders - diabetes mellitus type 1 - hyperthyroidism - pheochromocytoma - hyperparathyroidism - adrenal insufficiency - panhypopituitarism c) chronic infection (esp. HIV, tuberculosis, endocarditis) d) malignancy, especially gastrointestinal cancer - upper gastrointestinal cancer most common (RR=3.1-7.4) [22] - gastrointestinal cancer, liver cancer, pancreatic cancer, biliary cancers - colon cancer does not usually cause weight loss or cachexia unless intestinal obstruction or extensive metastases [23] - leukemia (RR=4.1) - lower risk for colorectal cancer & lung cancer (RR=1.5) - breast cancer, prostate cancer, gynecologic cancer not associated with weight loss [22] - most common cause in younger adults [2] - risk > 3% with [17] - abdominal mass; abdominal pain; appetite loss; chest signs; iron deficiency anemia; jaundice; lymphadenopathy - low serum albumin; leukocytosis, thrombocytosis, hypercalcemia, & elevated inflammatory markers - men > 60 & male smokers 50 years - also specific to men - dysphagia, hemoptysis, noncardiac chest pain - specific to women - back pain, change in bowel habits, dyspepsia, & venous thromboembolism e) heart failure f) renal failure g) pulmonary disease h) depression i) anorexia nervosa j) Alzheimer's disease or other dementia [4,6] k) medications - may cause anorexia or interfere with taste & smell - potassium-sparing diuretics - may cause xerostomia, constipation - may interfere with specific nutrients (i.e. metformin & vit B12) - anticonvulsants - thyroid medications - cholinesterase inhibitors (SOE=A) [6,19] * when diarrhea from malabsorption leads to diminished calorie intake, diminished calorie intake is the said cause of weight loss [6] Epidemiology: - 13% of elderly, 25-50% of hospitalized elderly Pathology: 1) involuntary weight loss of > 5% over 6 months or 10% over 1 year is associated with increased mortality & functional deterioration 2) weight loss in patients with cancer may result from release of: - tumor necrosis factor (TNF), adipsin, interleukin-1 & interleukin-6 3) cachectin may produce anorexia History: - inadequate food intake is 25-50% below recommended [18] Physical examination: - body weights: BMI < 17 kg/m2 is consistent with undernutrition [18] Clinical manifestations: 1) significant weight loss is [5] 1-2% of body weight in 1 week > 5% in 1 month, > 7% in 3 months, > 10% in 6 months 1) anorexia generally occurs with weight loss due to cancer 2) temporal muscle wasting 3) intercostal muscle wasting 4) palpable mass or enlarged liver may be present Laboratory: 1) serum thyroid-stimulating hormone (TSH) [2] 2) HIV testing [2] 3) appropriate cancer screening [2] a) fecal occult blood testing b) Pap Smear in women c) prostate-specific antigen (PSA) in men > 50 years 4) as indicated [2] a) complete blood count (CBC) b) erythrocyte sedimentation rate (ESR) c) urinalysis d) comprehensive metabolic panel e) serum vitamin B12 f) serum 25-OH vitamin D [18] Special laboratory: - flexible sigmoidoscopy vs colonoscopy as indicated Radiology: 1) chest X-ray 2) GI radiography as indicated 3) mammogram in women > 40 years of age 4) computed tomography (CT) is NOT routinely indicated - CT scan of the chest, abdomen & pelvis if malignancy suspected Management: 1) determine goals of management in elderly 2) when no cause is apparent, the etiology generally becomes apparent within 6 months 3) behavioral strategies 4) eliminate non-essential medications, especially those with adverse GI effects [6] 5) see cachexia-anorexia syndrome for cachexia at end-of-life 6) 1st-line strategies in elderly patients diet modification to address patient preferences & swallowing & chewing issues [2,21] 7) nutrition - Mediterranean diet - vit D 1000 IU daily [18] - calcium 1000 mg daily [18] - high-calorie supplements increase weight in elderly, but do not benefit quality of life, functional status, or mortality [18] - evidence-based option to promote weight gain in patients with dementia & difficulty eating [20] - adequate protein [6] - socialize meal time [18] - feeding assistance as needed [18] - hand feeding of frail elderly [6] - small meals of foods preferred by patient near end-of-life [6] - several small feedings throughout the day not indicated (MKSAP19) [2] - see specific disorders associated nutritional deficiency - see pressure ulcer 8) pharmaceutical agents: a) megestrol* 320-800 mg PO QD [9] b) mirtazapine appears to be effective for appetite stimulation & weight gain in context of depression [9] c) dronabinol* 2.5 mg PO BID-TID d) cyproheptadine* e) enteral feeding [11,12] r) total parenteral nutrition * avoid as low benefit/risk ratio

Related

weight gain weight reduction; intentional weight loss; excess weight reduction

Specific

cachexia

General

weight loss

References

  1. Guide to Physical Examination & History Taking, 4th edition, Bates B, JB Lippincott, Philadelphia, 1987
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 17, 19 American College of Physicians, Philadelphia 1998, 2015, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 245
  4. Journal Watch 25(5):41, 2005 Stewart R, Masaki K, Xue QL, Peila R, Petrovitch H, White LR, Launer LJ. A 32-year prospective study of change in body weight and incident dementia: the Honolulu-Asia Aging Study. Arch Neurol. 2005 Jan;62(1):55-60. PMID: 15642850
  5. Phebe Chin, MS, RN, Clinical Dietician, VA Medical Center West Los Angeles, CA April 11, 2005
  6. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  7. Chapman IM. Weight loss in older persons. Med Clin North Am. 2011 May;95(3):579-93 PMID: 21549879
  8. Simmons SF, Keeler E, Zhuo X et al Prevention of unintentional weight loss in nursing home residents: a controlled trial of feeding assistance. J Am Geriatr Soc. 2008 Aug;56(8):1466-73. PMID: 18637983
  9. Fox CB, Treadway AK, Blaszczyk AT, Sleeper RB Megestrol acetate and mirtazapine for the treatment of unplanned weight loss in the elderly. Pharmacotherapy. 2009 Apr;29(4):383-97 PMID: 19323618
  10. Palecek EJ, Teno JM, Casarett DJ et al Comfort feeding only: a proposal to bring clarity to decision- making regarding difficulty with eating for persons with advanced dementia. J Am Geriatr Soc. 2010 Mar;58(3):580-4 PMID: 20398123
  11. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD007209. Review. PMID: 19370678
  12. Shega JW. Informed decision-making surrounding the use of chronic enteral nutrition: let's talk the talk. South Med J. 2010 Feb;103(2):109-10. PMID: 20065907
  13. Chapman IM. Weight loss in older persons. Med Clin North Am. 2011 May;95(3):579-93, PMID: 1549879
  14. McMinn J, Steel C, Bowman A Investigation and management of unintentional weight loss in older adults. BMJ. 2011 Mar 29;342:d1732 PMID: 21447571
  15. Stajkovic S, Aitken EM, Holroyd-Leduc J. Unintentional weight loss in older adults. CMAJ. 2011 Mar 8;183(4):443-9. Review. PMID: 21324857 Free PMC Article
  16. Gaddey HL, Holder K. Unintentional weight loss in older adults. Am Fam Physician. 2014 May 1;89(9):718-22. Review. PMID: 24784334 Free Article
  17. Nicholson BD et al. Prioritising primary care patients with unexpected weight loss for cancer investigation: Diagnostic accuracy study. BMJ 2020 Aug 13; 370:m2651 PMID: 31548272 https://www.bmj.com/content/370/bmj.m2651
  18. Talebraza S et al Geriatrics Evaluation & Management Tools American Geriatrics Society. 2021 https://geriatricscareonline.org/ProductAbstract/geriatrics-evaluation-management-tools/B007/
  19. Soysal P, Isik AT, Stubbs B et al. Acetylcholinesterase inhibitors are associated with weight loss in older people with dementia: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2016 Dec;87(12):1368-1374 PMID: 27261502 https://jnnp.bmj.com/content/87/12/1368
  20. Hanson LC, Ersek M, Lin FC, Carey TS. Outcomes of feeding problems in advanced dementia in a nursing home population. J Am Geriatr Soc 2013;61(10):1692-1697 PMID: 24083403 PMCID: PMC4385385 Free PMC article
  21. Perera LAM, Chopra A, Shaw AL. Approach to patients with unintentional weight loss. Med Clin North Am. 2021;105:175-186. PMID: 33246517
  22. Wang Q-L et al. Cancer diagnoses after recent weight loss. JAMA 2024 Jan 23/30; 331:318. PMID: 38261044 https://jamanetwork.com/journals/jama/fullarticle/2814132
  23. Unintentional Weight Loss in Older Adults. Gaddey HL, Holder KK. Am Fam Physician. 2021 Jul 1;104(1):34-40. PMID: 34264616 Free article. Review.