Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 4-04: Management of Common Geriatric Problems + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ Prognosis ++ Rapid unintentional weight loss is predictive of morbidity and mortality Mortality rates at 2-year follow-up 8% for unexplained involuntary weight loss 19% for weight loss due to nonmalignant disease 79% for weight loss due to malignant disease +++ When to Refer ++ Weight loss caused by malabsorption Persistent nutritional deficiencies despite adequate supplementation Weight loss as a result of anorexia or bulimia +++ When to Admit ++ Severe protein-energy malnutrition, including the syndromes of kwashiorkor and marasmus Vitamin deficiency syndromes Cachexia with anticipated progressive weight loss secondary to unmanageable psychiatric disease Careful electrolyte and fluid replacement in protein-energy malnutrition and avoidance of "re-feeding syndrome" + Reference Download Section PDF Listen +++ + +Abu RA et al. PEG insertion in patients with dementia does not improve nutritional status and has worse outcomes as compared with PEG insertion for other indications. J Clin Gastroenterol. 2017 May/Jun;51(5):417–20. [PubMed: 27505401]