Transcript Slide 1

Weight loss in the Elderly
• Objectives:
1. Describe the significance of unintentional weight loss in
the older patient.
2. Identify the factors and conditions associated with
weight loss in the elderly.
3. Develop an appropriate approach to investigate and manage
weight loss in the older patient.
4. Describe the components of inter-disciplinary approach in the
management of unintentional weight loss in the older patient.
Definition of Weight loss in the elderly
• No uniformly accepted definition of weight loss in the older patient
• Definition varies with patient population setting . These include:
1. Community dwellers
2. Hospitalized patients
3. Nursing home residents
• The Minimal data set : use for nursing home patients,
defines weight loss at 5 % or more in 1month or 10% or more in past
6 months.
Epidemiology of Unintentional weight loss :
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Prevalence:
13% to 27% in frail older community patients
50% to 65% of nursing home residents
Pathophysiology of weight loss
• Decreased caloric intake
• Altered gastrointestinal absorption
• Impaired utilization
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Etiology of weight loss in the elderly
• The nine D of weight loss in the older patients:
1. Dentition
6. Depression
2. Dysgeusia
7. Dementia
3. Dysphagia
8. Dysfunction
4. Diarrhea
9. Drugs
5. Disease(chronic)
10. “Dollars”(econonic factors)
Common Causes of unintentional weight loss:
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Malignant disease :
Psychiatry disorder :
Gastrointestinal disease :
Endocrine disorder: :
Cardiovascular disease:
Nutritional disorders:
Respiratory disease:
Neurological disease:
Chronic infection:
Renal Disease
Connective tissue disease
Drug-induced
Unknown
(16%-36%)
(9% 24%)
(6-19%)
(4%-11%)
(2%-9%)
(4%-8%)
(6%)
(2%-7%)
(2%-5%)
(5%)
(2%-4%)
(2 %)
(10%-36%)
Evaluation: History
• Take a good History :
1. Document weight loss; up to 50% of wt loss is undocumented
2. Detailed medical, psychosocial and dietary history: ie.
Dental: Inability to chew or swallow
Functional: Is is due to Dementia or depression
Medication: Are there Side effects due to medication
Food preference: Food access and ability to secure food
3. Weight loss with normal intake: Red Flag for Physiologic cause
Evaluation: Physician Exam
• Use information from H&P
1.Comprehensive: Emphasize on oral cavity , respiratory an
GI exam
2.Calculate: Body mass index(BMI) = wt(kg)/ht(m2):
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3. Cognition: mood and affect
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Evaluation
• Assessment Tools:
1. DETERMINE checklist:
Use to Identify patients at risk and raise awareness.
2. The Short form Mini-nutritional Assessment):
(MNA-SF) use as the first step for nutritional screening
3. SNAQ (Simplified nutritional Appetite questionnaire) training
tool can predict weight loss in the older patients.
Lab tests:
• Test should be based on clues from history physical
exam
• In general, Initial test are:
1. Complete blood count
2. Electrolytes, BUN/Cr , albumin
3. TSH
4. Urinalysis
5. Stool guiac
Other diagnostic studies:
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Other diagnostic test based on History and physical:
Chest X-ray: Smokers
Skeletal X-ray: Focal bone pain
Renal USN/Cysto: Hematuria
Endo/Colonoscopy: Heme+, Reflux symptoms, dysphagia
CT/MRI: To further asses exam findings if other
evaluations are negative.
Management of weight loss:
• Identify and treat the under-lying cause.
• Addressed important associated factors
• Involve a dietician and social worker early
• Nonpharmacologic and pharmacologic approach to
treatment
Management:
• Non pharmacological :
1. less restricted diet: diabetics, CHF, hypercholesterol
2. Oral nutritional supplements
3. Enhance protein and energy intake: between meals
4. Optimized diet texture in consult with speech therapy
5. Encourage oral intake: greater than 75% of meal
6. Use flavor enhancers: patients with hyposmia
7. Exercise: To stimulate appetite.
Interventions:
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Pharmacologic management:
Evidence for use in geriatric weight loss is limited
• Appetite stimulant:
Mirtazapine: doses: 3.75-45mg; increase appetite and promote
while treating depression.
Cyproheptadine: 2-4mg with meals (CNS); no weight data.
Megestrol: 400-800mg orally has been use to treat cachexia in AIDS
and cancer patients. Shows some weight gain in LTC pts.
Dronabinol: 2.5mg in older patients; side effects includes confusion,
dizziness and somnolence. Benefit from antimemetic
and analgesic effect.
Summary:
• Unintentional weight loss in the elderly is increasing
unrecognized.
• It is important to do nutritional screen periodically.
• Identify patients at risk and intervene early
• Treat underlying cause
• No identifiable cause of weight loss may be found in
some patients. Keep close follow-up.
Future research:
• Future: Cytokines such as interleukins, interferon, TNF
alpha, hypothalamic monoaminergic neurotransmission
play roles in cachexia.
• Interference with these factors may be effective
therapeutic strategy in patients with anorexia along with
CCK antagonist.
• There is Research on Feeding associated gene products
which will enhance understanding of the mechanisms of
anorexia.