Introduction

• Body weight is determined by the interplay of calorie intake, activity level, and the metabolic rate. Significant alterations involving any of these factors may result in weight loss.
• Unintentional weight loss, defined as the loss of 10 lb (4.5kg) or a decrease of more than 5% of usual body weight during a 6 to 12 month period, is an important predictor of morbidity and mortality.
• However, weight loss is a non-specific finding with multiple possible etiologies that include organic, psychosocial, and idiopathic etiologies.
• The clinical evaluation should include a careful history and physical examination. If these do not provide clues to the weight loss, simple diagnostic tests are indicated.
• The first steps in managing elderly with weight loss are to identify and treat any specific causative or contributing conditions and to provide nutritional support when indicated.

Sign and Symptoms

Evaluation: The cause of involuntary or unintentional weight loss is rarely occult. Careful history and physical examination, in association with directed diagnostic testing, will identify the cause of weight loss in 75% of patients.

In the history taking,

It is important to determine whether the following symptoms are present :

• fever, pain, shortness of breath or cough, palpitation
• weakness, change in the ability to taste or smell
• abdominal pain, decreased appetite, nausea, vomiting, diarrhoea, constipation, difficult to swallow
• changes in pattern of urination
• problems with dentition
• changes in activities of daily living (ADL),
• changes in mental or functional status.
• risk factor for HIV infection
• psychiatric problems
• previous abdominal surgeries
• financial issues (affect food intake)
• History of tobacco, alcohol use and medications.

On physical examination,

• Anthropometric measurements, specifically the patient’s height and weight, are of prime importance and should be compared with minimum and maximum adult weights. The patient’s body mass index (BMI) can be calculated by dividing the weight in kilograms by the square of the height in meters.
• vital signs
• appearance and skin; for pallor, jaundice, scars of previous surgeries, skin turgor
• oral cavity; for thrush and dental disease
• thyroid; for enlarged thyroid gland
• lymphatic system; for enlarged lymph nodes
• heart and lung; for signs of cardiac or pulmonary disease
• abdomen; for organomegaly
• breast; for lump
• rectal/pelvic examination
• neurological evaluation,including Mini-Mental State Examination.

Complications

Some of the consequences of unintentional weight loss include :

• anemia
• decreased cognition
• oedema
• falls, hip fractures
• immune dysfunction
• infection
• muscle loss
• osteoporosis
• pressure sores

Treatment

The differential diagnosis of unintended weight loss in the elderly can be extensive. The most commonly identified causes are summarized with the mnemonic “Meals on Wheels”

Medications (eg, digoxin, theophylline, antipsychotic agents)
Emotional problems (depression)
Anorexia tardive (nervosa) or alcoholism
Late-life paranoia
Swallowing disorders (dysphagia)

Oral problems (eg, poorly fitting dentures)
Nosocomial infections (tuberculosis, Helicobacter pylori); no money

Wandering and other dementia-related behaviours
Hyperthyroidism, hypercalcemia, hypoadrenalism
Enteric problems (eg, malabsorption)
Eating problems (eg, difficulty in self –feeding)
Low-salt, low-cholesterol diet
Stones (cholelithiasis)

Diagnostic testing should first be directed at clues or areas of concern found on history and physical examination. If no clues are discovered during history and physical exam, initial following tests are indicated:

• Complete blood count with differential
• ESR
• Electrolytes, calcium, glucose
• Renal and liver function test
• Urinalysis
• TSH
• Chest x-ray
• Stool occult blood(OB)
• HIV test for persons at risk

Routine screening test for cancer is indicated such as:

• Flexible sigmoidscopy
• (if fecal occult blood negative and age > 50)
• Cervical Pap Smear in women
• Mammography in women aged > 40years
• Prostate-specific antigen in men aged > 50yrs.

Mini nutritional assessment :

• Dietary history, patient’s psychosocial situation
• Nutritional therapy if indicated.

To observe the elderly person with weight loss while he or she is eating. This part of the evaluation is important such as: how the patient is positioned at the table, if self-fed, any difficulties with managing eating utensils, time spent eating, how much of the food offered is eaten, any chewing problems, any difficulties swallowing, any visual difficulties that interfere with feeding oneself and qualities of food offered that make it appetizing and appealing to the patient.

Pharmacological Treatment:

• Various agents have been used to stimulate appetite and promote weight gain but none have been specifically indicated to treat weight loss in elderly patients.
• Although medications may help to promote appetite and weight gain in older patients with unintentional weight loss, drugs should not be considered as the first-line treatment.
• Even if drugs are successful in inducing weight gain, their long–term effects on quality of life are unknown. They also have a large range of severe side effects.

Lists of drugs associated with weight gain:

1. Tricylic Antidepressants: e.g Amitriptylline, Despramine
2. Appetite Stimulants: e.g Dronabinol, Megestrol acetate
3. Anabolic Steroids : eg Oxandrolone
4. Glucocorticoids: e.g Dexamethasone, Prednisolone
5. Antipsychotic Agents; e.g Haloperidol, Olanzapine
6. Miscellaneous; e.g Lithium, Omeprazole

Final comment:

The evaluation of unexplained weight loss in the elderly sometimes yields no cause other than “unexplained”. If a physical cause for the weight loss exist, it usually becomes evident within six months. Consequently, continued weight loss should be monitored, even when the initial evaluation does not supply a diagnosis.