Archief Roodbont

Question

An 86-year old patient in a senior living center has lost 34 pounds in the past 6 months. She claims her appetite is good, and no medical problems are apparent. How should I approach the evaluation of weight loss in this elderly patient?

Response from Barbara Resnick, PhD Professor, University of Maryland; Nurse Practitioner, a Continuing Care Retirement Community, Baltimore, Maryland

Unexplained weight loss or losing weight without trying is often, but not always, associated with an underlying medical disorder. Loss of a few pounds is rarely a cause for concern in an older individual. A provider should be concerned, however, about unexplained weight loss over a 6-month period of 10 pounds (4.5 kg), weight loss of more than 5% of the patient's body weight, or weight loss that is persistent despite interventions.

The first thing to check when evaluating weight loss is whether the patient is eating a sufficient number of calories to maintain body weight. A dietician can be of value if help is needed in making such a determination. If intake is inadequate, it is helpful to look for psychosocial factors or normal changes of aging that might be contributing to reduced dietary intake. Changes in smell and taste, nausea, constipation, poor oral health, functional changes that make shopping and cooking challenging, eating alone, and being unable to afford food are all factors associated with reduced intake. If the underlying problem is found to be poor intake, interventions should focus on increasing oral intake and calories. High calorie snacks and small frequent meals are reasonable options. Nutritional supplements (eg, Ensure®), if accessible and affordable, are another option. Dietary restrictions (eg, low sodium diets) should be eliminated.

When dietary intake seems to be adequate, the weight loss is more likely to be a consequence of disease. Numerous medical problems can cause or contribute to unexplained weight loss (Table).

Table. Diseases Associated With Weight Loss

Addison disease

Cancer

Celiac disease

Chronic obstructive pulmonary disease

Crohn disease

Dementia

Depression

Diabetes

Heart failure

HIV/AIDS

Hypercalcemia

Thyroid disease

Parkinson disease

Peptic ulcer

Tuberculosis

Ulcerative colitis

Irritable bowel disease

Clostridium difficile

Causes include undiagnosed celiac disease, thyroid disorders, malignancies, dementia, depression, and diabetes. A comprehensive history and physical will guide the search for an underlying cause of the weight loss. History taking should particularly explore possible signs and symptoms that may indicate an underlying clinical problem such as cough, nausea, constipation, or pain. The physical exam should look for lymphadenopathy, breast changes, or thyroid changes. Laboratory tests should be ordered to evaluate for infection, anemia, electrolyte imbalances, and renal disease.

Treatment involves addressing the underlying cause for the unintentional weight loss (improving management of blood glucose in diabetes, treating depression, etc) and work to increase oral intake. If no improvement in weight occurs, then the patient should be re-evaluated with respect to the level of energy that is being expended (eg, is in the patient acutely ill or wandering excessively?) If no additional cause can be identified, consideration of pharmacologic management with appropriate medications to increase weight can be considered.