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 : 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.

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: Malignant disease : (16%-36%) Psychiatry disorder : (9% 24%) Gastrointestinal disease : (6-19%) Endocrine disorder: : (4%-11%) Cardiovascular disease: (2%-9%) Nutritional disorders: (4%-8%) Respiratory disease: (6%) Neurological disease: (2%-7%) Chronic infection: (2%-5%) Renal Disease (5%) Connective tissue disease (2%-4%) Drug-induced (2 %) Unknown (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):. 3. Cognition: mood and affect.

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: 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: Pharmacologic management: Evidence for use in geriatric weight loss is limited Appetite stimulant: Mirtazapine: doses: mg; increase appetite and promote while treating depression. Cyproheptadine: 2-4mg with meals (CNS); no weight data. Megestrol: mg 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.