Weight loss resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Javaria Anwer M.D.[2]
Synonyms and Keywords: weight loss management guide, unintentional weight loss management guide, loss of weight resident survival guide, pathologic weight loss resident survival guide.

Weight loss resident survival guide microchapters
Overview
Causes
Diagnosis and Management
Do's
Don'ts

Overview

A loss of >5% of the usual body weight within 6 - 12 months represents pathologic weight loss. Weight loss may be intentional or unintentional. Unintentional weight loss is more common among the elderly. Common causes of weight loss among patients aged >65 years include malignancies (specifically digestive and non-hematologic), dementia, stroke, parkinson's disease, and polymyalgia rheumatica. In comparison, Endocrine disorders, infections, and psychiatric disorders make up the majority of the causes of weight loss among individuals aged <65 years. A thorough history from the patient or a caregiver provides useful insights to the cause. It is important to assess the availability of food and nutritional status first. A detailed physical exam and observing an elder patient have a meal in front of the physician may provide clues to neurocognitive dysfunctions. CBC, CMP provides a general picture of patient condition. Follow-up is necessary to completely treat the known and identify unknown causes of weight loss. A multidisciplinary approach ensures the optimum management option. Nutritional supplements may be warranted in selected cases but should act as an adjunct to normal meals.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. The life-threatening causes of weight loss include:

Common Causes

Age >65 years[2]

Age <65 years[2]

Common causes classified

  • The chart below demonstrates the cause of unintentional weight loss in adult population. The incidence describes the full range of occurrence described in five studies in older individuals.[3][4][5][6][2][7][8][9][10][11]
 
 
 
 
 
 
 
Causes of weight loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Intentional weight loss
 
 
 
 
 
 
 
Unintentional weight loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-Malignant (~60%)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infectious (2 - 8%)

❑ Chronic diarrhea
Tuberculosis (TB)
HIV
infective endocarditis

❑ Infective colitis and gastroenteritis.
 
 
Psychologic/ Psychiatric (9 - 42%)

Depression
Bipolar disorder
Somatoform disorder
Schizophrenia
OCD
Anxiety
Dementia
❑ Social exclusion or rejection
❑ Neglect

Disability
 
Organ system based
 
Drug-induced (6 - 8%)

Narcotic analgesics (such as opioids) interfere with cognition and ability to eat
Sedatives also interfere with cognition
Psychedelic drugs
Cocaine
Alcohol (4 - 8%)
SSRIs
Psychotropic drug dose reduction

❑ Other drugs that cause vomiting, anorexia, dysphagia, and dysgeusia
 
Unexplained / Unknown (6 - 36%)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  • To read about other causes of unintentional weight loss click here.

Diagnosis and Management

Abbreviations: GI: Gastrointestinal system; GERD: Gastroesophageal reflux disease; BMI: Body Mass Index; HEENT: Head, Eyes, Ears. Nose, and Throat exam; IM: Infectious Mononucleosis; CBC: Complete blood count; ESR: Erythrocyte sedimentation rate; LDH: Lactate dehydrogenase; CMP: Comprehensive metabolic panel; CRP:C-reactive protein; TSH: Thyroid stimulating hormone; PTH: Parathyroid hormine; COPD: Chronic Obstructive Pulmonary Disease

Shown below is an algorithm summarizing the diagnosis of weight loss.[9][12][13][14][15][16][5][3][17][18]

 
 
 
 
 
 
 
 
 
Patient presents with weight loss/ incidental finding
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Loss of >5% of the usual body weight within 6 - 12 months
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History

Source of history:
Patient or well-informed caregiver (elderly may be unaware or deny weight loss).
Patient age:
Helps determine age-specific causes, such as malignancy among the elderly.
Duration of symptoms:
(weeks in acute/severe versus years in chronic conditions).
Associated symptoms:
Assess if the patient is nauseated or vomiting/ anorexia/ dysphagia/ odynophagia/ social reasons hindering food supply.
Systemic review:
Cardiovascular, respiratory, renal, hepatic, rheumatologic, and GI exam.

GI: Indigestion, early satiety, altered stool pattern, abdominal pain may demonstrate GERD, peptic ulcer,cholecystitis, and GI malignancy

Past medical history:
Helps assess the nutritional status. May suggest of immunodeficiency (recurrent infections), diagnosed malignancy, malabsorption (chronic diarrhea), HF, dyspepsia.
Past surgical history:
Helps assess nutritional status.
Medication history: Assess the use of medications known to cause weight loss. Polypharmacy may cause anorexia or altered taste.
Family history:
Certain malignant disorders (breast cancer, ovarian cancer, colon cancer, or stomach cancer))
Social history:
Tobacco, alcohol use, opioid, cocaine use
Sexual history:
Suggestive of HIV AIDS

Exposure:
Communicable infectious diseases/ travel to high-risk areas.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nutritional status

Dietary history: Food availability, diet adequacy in the quantity (daily caloric intake), and quality (balance of nutrition), and nutritional supplements.
Weight record: Weight measurement records or best estimate of weight loss accessed by clothing size.
Mini Nutritional Assessment: To assess the nutritional risk among the elderly.
Functional status: Assess the mental and functional status of the patient.

Psychological status: Psychiatric illness screening: Geriatric Depression Scale may be utilized to assess for depression among elderly.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weight loss history

Is BMI<20.5?
Q1: Lost weight within last 3 months?
Q2: Reduced dietary intake in the last week?

Q3: Severe illness?
 
No
 
Reaccess in weekly
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Characterise the severity of the condition
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical exam

❑ Appearance of the patient:
Cachexia is observed among patients with malignancy. Surgical scar marks demonstrating previous surgery for intentional weight loss or malignancy treatment
Vital signs

Temperature: Low-grade/ high-grade fever with fatigue may demonstrate infection, autoimmune disorders, thyroid disease, malignancy, diabetes
Heart rate: Tachycardia with regular pulse may demonstrate infection.
Respiratory rate: Tachypnea (infection\ metastasis), dyspnea (heart failure, COPD, and lung infection
Blood pressure: Chronic hypertension or hypotension is common among elders.
Oxygen saturation: Low saturation may demonstrate respiratory system involvement or hematologic malignancies, such as multiple myeloma.

BMI assessment or simply weight among immobile or bed-ridden patients.
❑ HEENT
Cardiovascular examination
Respiratory examination
Gastrointestinal system exam includes oral examination, abdominal examination, and digital rectal exam.

Organomegaly) may demonstrate metastases or primary lesions such as hepatosplenomegaly in IM, Hodgkin's lymphoma. hepatomegaly is more common in non-Hodgkin's lymphoma.

❑ Observing the patient having a meal may demonstrate

❑ Distractions by external stimuli may demonstrate dementia.
❑ Inadequate movements of the patient to feed him/herself may demonstrate neuromuscular disorders or functional limitations.
❑ Mini mental state examination to assess the cognitive function, and mood assessment.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Intentional weight loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assessment
❑ Assess for self-induced vomiting/ anorexigenic drugs/ diuretic/ laxative use
❑ Monitor BMI
❑ Serum electrolytes
 
 
 
 
 
 
 
 
 
 
 
 
Unintentional weight loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment

❑ Multidisciplinary approach
Anorexia nervosa medical therapy
Counseling
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nutritional status/ caloric intake
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Adequate
 
 
 
 
 
Inadequate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspect malabsorption
 
 
 
 
Suspect altered metabolism
 
 
 
Access to food
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspect cognitive dysfunction/ consider social factors
 
 
Consider oral or dental issues/ dysphagia/ dysgeusia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order initial screening labs and
Nutritional supplements

CBC with differential and peripheral smear
ESR, CRP, LDH
HbA1c
CMP
Lipid profile
TSH, free T4
Urinalysis
FOBT
Chest X-ray
❑ Abdominal ultrasound
Echocardiography
Rheumatoid factor
PTH levels

  • Labs may vary on case by case basis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Provisional diagnosis established
 
Progressive oropharyngeal or esophageal dysphagia/ oral/ dental issues
 
Peptic ulcer
celiac disease, whipple disease
 
Potential depression
Cognitive dysfunction
 
Suspected malignancy
 
Suspected nutritional deficiency
 
Suspected infection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Specific tests

Nephrotic syndrome: 24-hour urine collection (urine protein >3.5 g/day).
Nephritic syndrome: Assess complement levels, HBV, HCV, HIV serologies, c-ANCA and p-ANCA, and anti-dsDNA antibodies.
COPD or interstitial lung disease: PFTs
Pneumonia: Sputum microscopy, culture and sensitivity
Stroke: CT or MRI head.
Hyperparathyroidism: Serum calcium, phosphate levels to identify the type.

❑ Drug-induced
 
Specific tests
❑ Videofluoroscopy
Dysphagia barium swallow
❑ Visual exam
❑ Dental issues: Refer to the dentist.
 
Specific tests
❑ Upper or lower GI endoscopy with biopsy
Stool fat, anti-transglutaminase antibodies, elastase, lactoferrin
❑ Upper GI and small bowl series
 
Specific scales

Geriatric Depression Scale
Clinical depression diagnostic criteria is to be met to diagnose clinical depression

MoCA
 
Specific tests
 
Specific tests

❑ Serum ferritin
❑ Vitamins: Beta carotene, vitamin D, tocopherol, vitamin B12, and folic acid

❑ Minerals: Serum copper and zinc, manganese, and magnesium
 
Specific tests

❑ Chronic diarrhea: Stool osmotic gap, culture, ova and parasite, electrolytes, leukocytes, lactoferrin, and C. difficile test.
For a detailed information on differentials click here
Tuberculosis: AFB and sputum culture sputum
HIV:ELISA or Latex Agglutination Test for screening and viral RNA (P24) for confirmation
Endocarditis: Modified Duke Criteria and at least two blood cultures

Gastroenteritis and colitis: Stool exam as in chronic diarrhea.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment

Nephrotic syndrome
COPD
Pneumonia
Stroke treatment depends upon the cause
❑ Discontinuing or replacing the suspected drug
Hyperthyroidism
medical therapy|Hepatitis
Chronic cholecystitis

Hyperparathyroidism
 
Treatment
❑ Food as puree or thickened liquids
❑ Speech therapy for oropharyngeal issues
❑ Dentist referral for dental issues
Esophageal cancer treatment
 
 
Treatment

❑ Referral to a specialist (psychotherapist and/or a psychiatrist)
Psychotherapy
Clinical depression medications

Mirtazapine is also appetite stimulant
 
Treatment
Surgical resection
Chemotherapy

Radiotherapy
TNM staging
❑ Appetite stimulants for wasting syndrome and cachexia : ❑ Oxandrolone or ornithine (not tested among elderly)

Megestrol 320 mg/day (lower dosages for elderly)
 
Treatment
❑ Decreased dietary restrictions
❑ Increase oral intake with frequent small servings
❑ Nutritional supplements with regular meals
❑ Community support services if required
❑ Multidisciplinary approach
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow-up in 1 or 3 months depending upon the cause.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weight gain
 
 
 
 
No weight gain/ continued weight loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monitor until the desired weight is achieved
 
 
 
 
Reevaluate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cause identified
 
 
Cause unidentified
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider medications
❑ Metoclopramide for nausea (side effects include parkinsonism)
Cyproheptadine appetite stimulant
 
6 months after presentation cause still unidentified
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No weight gain
 
Unexplained unintentional weight loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider feeding tube
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Monitor
 

Do's

  • Perform a thorough physical exam to evaluate for cause of weight loss.
  • Assess the nutritional status of the patient and screen for possible depression.
  • Assess serum electrolytes to assess for life-threatening electrolyte abnormalities.
  • Prevent further weight loss by advising proper meals, supplements, and consulting a nutritionist.
  • Treat the underlying cause.
  • Medications for weight gain must be looked for side effects and recommendations for the elderly.
  • Prefer liquid supplements to solids and serve separate from solid everyday meals.
  • Encourage exercise and physical therapy.

Don'ts

References

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