1. Unintentional Weight Loss AIMGP Seminar MSH/UHN January 2008 Yash Patel

2. Seminar Objectives  Develop an approach to unintentional weight loss  Define unintentional weight loss  Review the incidence and prevalence of weight loss  Review the common causes of weight loss  Cover treatment strategies

3. Selected References  An approach to the management of unintentional weight loss in elderly people. Alibhai S. et al; CMAJ: Mar 15, 2005  Rational approach to patients with unintentional weight loss. Bouras E. et al; Mayo Clin Proc: Sept 2001  Evaluating and treating unintentional weight loss in the elderly. Huffman G.; Am Fam Physician: Feb 15, 2002

4. Case  You are referred a 69 F for evaluation of unintentional weight loss.  She has lost 5 kg in the past 12 months, her current weight is 60 kg. Is her weight loss clinically important? How common is weight loss in the elderly?

5. Is her weight loss clinically important?  Definition Clinically important weight loss can be defined as loss of 5 kg or more than 5% of usual weight over 6-12 months  Why it’s important! Unintentional weight loss may reflect disease severity of a chronic illness or a yet undiagnosed illness. Even after adjusting for co-morbidities weight loss of 5% or more of body weight is associated with increased mortality (approx increase in RR 1.6)

6. How common is weight loss in the elderly?  Prevalence estimates of weight loss are quite variable 15-20% elderly patients experience weight loss (defined as loss of 5 kg or 5% body wt over 5-10 years) The prevalence can be as high as 27% in high-risk populations such as the frail elderly  The incidence of unintentional weight loss in clinical studies of adults seeking health care is also quite variable Depending on the setting and definition it varies from 1.3 to 8%

7. Case  HPI: She confirms that her weight was 65 kg 1 year ago when it was measured at the family doctors office Her appetite is “normal” and she reports no other constitutional symptoms The clinical review is negative for cardiac, respiratory, gastrointestinal, and neurologic symptoms

8. Case  PMHx: Hypertension (on ACEI and HCTZ) Dyslipidemia (on statin) OA of both kness (on prn acetominophen)  Social Hx: Widowed 3 years ago Lives in apartment, independent in ADLs and iADLs X-smoker (quit 10 years ago), occasional ETOH use

9. Case  Physical Exam: VS: BP-118/74, HR-74 regular, T-37.3 C H+N: normal thyroid and no lymph nodes CV/RS: normal heart sounds, clear lungs GI: negative Castell’s sign, and normal liver span NE: normal muscle bulk, strength, and tone

10. Case  Now What? What are the common causes of unintentional weight loss?

11.  Causes of unintentional weight loss can classified into 3 broad groups Organic Psychosocial Idiopathic (up to 10-36% of cases)

12. What are the common causes of unintentional weight loss?  Organic Causes - top three Malignancy (16-36%)  Usually it’s clear from the history, physical, or routine lab data that malignancy is a potential cause Gastrointestinal (most common non-malignant organic cause, 6-19%)  PUD, IBD, dysmotility, hepatobiliary/pancreatic disease, or oral problems Endocrine (4-11%)  DM, thyroid disease, and adrenal insufficiency

13. What are the common causes of unintentional weight loss?  Organic causes (less common) Cardiovascular disease (2-9%) Respiratory disease (~6%) Chronic infections (2-5%) Renal disease (~4%) Drugs/Medication Side effects (~2%) Neurologic disorder (2-7%)

14. What are the common causes of unintentional weight loss?  Psychosocial Causes Psychiatric disorder (9-42%)  Depression Dementia (2-5%) Poor nutritional intake  Due to poverty or inadequate access to meals

15. What are the common causes of unintentional weight loss?  Psychosocial Causes Depression and dementia are poorly recognized in clinical practice All elderly patients with weight loss should undergo screening for  dementia with the MMSE  depression with the Geriatric Depression Scale Screen for malnutrition with one of these validated tools (ENS or SCREEN) at www.dietitians.ca/seniors/index.asp

16. What are the common causes of unintentional weight loss?  Several key concepts emerge from etiologic studies of unintentional weight loss Among organic causes cancer is most common Etiology of weight loss is evident without extensive evaluation in most patients Psychiatric illness and nondiagnostic evaluations are common

17. Case  So far her history and physical is unremarkable  You explore other issues… You ask her about medication side effects - she reports none. You do a MMSE and she scores 30/30! Access to food and meals is not an issue for her.  What further assessment or investigations are now indicated?

18. What further assessment or investigations are now indicated?  The diagnostic utility of the medical history and physical examination in identifying the cause of weight loss has not been evaluated  The same can be said about screening investigations  Despite the lack of systematic evaluation, a complete history, physical examination and selected “routine” investigations are recommended

19. What further assessment or investigations are now indicated?  Routine Investigations CBC Biochemistry (lytes, glucose, Ca, PO4) TSH Liver enzymes Urinalysis CXR

20. What further assessment or investigations are now indicated?  Additional tests are ordered as clinically indicated HIV test SPEP PSA, mammogram GI investigations (if there are symptoms, microcytic anemia, or abnormal liver enzymes)  OGD or colonoscopy plus biopsies  Stool analysis  Celiac serology  Abdominal imaging

21. Case  She is send for the “routine investigations” and returns for follow- up All the investigations are normal or negative  She is relieved, but still wants to know why she has lost 5 kg?  Now What?

22. Case  You pursue the assessment further and ask about symptoms of depression She does occasionally feel lonely since her husband passed away but…the Geriatric Depression Scale is negative  You reassure her that she does not have an organic or pyschosocial cause for her weight loss Her diagnosis is idiopathic unintentional weight loss  How should weight loss be treated?  What follow up does she need?

23. How should weight loss be treated?  Treat the underlying organic cause  When pyschosocial issues are involved then a multi-disciplined approach is required to address the key issues including social work, dietician, community services and psychiatrist  For idiopathic weight loss seek advice from a dietician for strategies to increase caloric intake

24. What follow up does she need?  Reassess her weight in 3 months If it remains stable or goes up then further assessment is not necessary If she is continuing to lose weight then repeat the evaluation process, with emphasis on searching for an organic or psychosocial cause

25. Case  She returns after 3 months and her weight has remained stable She is following the advice of the dietician to increase her caloric intake  You feel confident that she has idiopathic weight loss  At this point you discharge her from clinic and ask her family doctor to monitor her weights every 3-6 months.

26. Summary  Unintentional weight loss is a common concern especially in the elderly  Common causes can be grouped into one of 3 categories: organic, psychosocial, or idiopathic  Psychosocial causes are under appreciated by clinicians  Extensive investigations are usually not necessary

27. Appendix  The following are some figures and tables from Shabir Alibhai’s review article from the CMAJ  And my approach to weight loss summarized in a figure

28. Copyright ©2005 CMA Media Inc. or its licensors Alibhai, S. M.H. et al. CMAJ 2005;172:773-780

29. Copyright ©2005 CMA Media Inc. or its licensors Alibhai, S. M.H. et al. CMAJ 2005;172:773-780

30. Copyright ©2005 CMA Media Inc. or its licensors Alibhai, S. M.H. et al. CMAJ 2005;172:773-780 Fig. 1: Strategies for treating weight loss in elderly patients

31. Copyright ©2005 CMA Media Inc. or its licensors Alibhai, S. M.H. et al. CMAJ 2005;172:773-780 Table 3.

32. Approach to Weight Loss Weight Loss (>5% body wt) Voluntary… dieting, anorexia/bulimia Involuntary Increased Appetite… DM, malabsorption, hyperthyroidism Decreased Appetite Idiopathic (25%) Psychiatric… depression, dementia (15%) Organic Cancer (20%) Noncancer (40%) GI Endocrine Infectious Medications CV Neurologic Pulmonary Renal CTD