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Key Features

Essentials of Diagnosis

  • Inquire about

    • Age; caloric intake; secondary confirmation (eg, changes in clothing size)

    • Fever; change in bowel habits

    • Substance abuse

    • Age-appropriate cancer screening history

General Considerations

  • Body weight is determined by person's

    • Caloric intake

    • Absorptive capacity

    • Metabolic rate

    • Energy losses

  • Involuntary weight loss is clinically significant when it exceeds 5% or more of usual body weight over a 6- to 12-month period

  • Often indicates serious physical or psychological illness

  • Most common causes

    • Cancer (~30% of cases)

    • Gastrointestinal disorders (~15%)

    • Dementia or depression (~15%)

  • In approximately 15–25% of cases, no cause for the weight loss can be found

  • In postmenopausal women, unintentional weight loss was associated with increased rates of hip and vertebral fractures

Clinical Findings

Symptoms and Signs

  • History should include medication profile and 24-h diet recall

  • Cancer

    • Night sweats

    • Cough

    • Breast mass

    • Constipation

    • Hematochezia

    • Bone pain

  • Gastrointestinal disease

    • Nausea

    • Vomiting

    • Diarrhea

    • Abdominal pain

  • Depression

    • Anhedonia

    • Sleep disorder

    • Suicidal ideation

    • Recent psychosocial stressors

  • Dementia

    • Memory loss

    • Wandering

    • Isolation

  • Physical examination for evidence of cancer

Differential Diagnosis

MEDICAL

  • Malignancy

  • Gastrointestinal disorders, eg, malabsorption, pancreatic insufficiency, peptic ulcer

  • Hyperthyroidism

  • Chronic heart, lung, or renal disease

  • Uncontrolled diabetes mellitus

  • Mesenteric ischemia (ischemic bowel)

  • Dysphagia

  • Anorexia due to azotemia

  • Hypercalcemia

  • Tuberculosis

  • Subacute bacterial endocarditis

  • Frailty syndrome

PSYCHOSOCIAL

  • Depression

  • Dementia

  • Alcoholism

  • Anorexia nervosa

  • Loss of teeth, poor denture fit

  • Social isolation

  • Poverty

  • Inability to shop or prepare food

DRUG-RELATED

  • Nonsteroidal anti-inflammatory drugs

  • Antiepileptics

  • Digoxin

  • Selective serotonin reuptake inhibitors

Diagnosis

  • The history and physical examination should guide the evaluation looking for symptoms and signs that could point to a potential cause (eg, abdominal pain—peptic ulcer disease, tachycardia—hyperthyroidism)

  • When the history, physical examination, and basic laboratory studies do not suggest a possible diagnosis, additional evaluation (eg, total body CT scan) is usually low yield

  • When no other cause is identified, the frailty syndrome should be considered

Treatment

Medications

  • Appetite stimulants

    • Mild to moderate effectiveness in promoting weight gain

    • But no evidence of any decrease in mortality

    • May cause significant side effects

    • Agents used include

      • Corticosteroids

      • Progestational agents

      • Dronabinol

      • Serotonin antagonists

  • Anabolic agents

    • Growth hormone

    • Testosterone derivatives

  • Anticatabolic agents

    • Omega-3 fatty acids

    • Pentoxifylline

    • Hydrazine sulfate

    • Thalidomide

Therapeutic Procedures

  • Treatment of the underlying disorder

  • Consultation with dietician

  • Caloric supplementation to achieve intake of 30–40 kcal/kg/day

  • Oral feeding is preferred, but temporary nasojejunal tube, or permanent cutaneous gastric or jejunal tube may be necessary

Outcome

Prognosis

  • Rapid unintentional weight loss is predictive of morbidity and mortality

  • Mortality rates at 2-year follow-up

    • 8% for unexplained involuntary weight ...

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