Unintentional Weight Loss in Older Adults



FREE PREVIEW Log in or buy this issue to read the full article. AAFP members and paid subscribers get free access to all articles. Subscribe now.


FREE PREVIEW Subscribe or buy this issue. AAFP members and paid subscribers get free access to all articles.

Am Fam Physician. 2014 May 1;89(9):718-722.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

  Patient information: See handout on unintentional weight loss in older adults, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Unintentional weight loss in persons older than 65 years is associated with increased morbidity and mortality. The most common etiologies are malignancy, nonmalignant gastrointestinal disease, and psychiatric conditions. Overall, nonmalignant diseases are more common causes of unintentional weight loss in this population than malignancy. Medication use and polypharmacy can interfere with taste or cause nausea and should not be overlooked. Social factors may contribute to unintentional weight loss. A readily identifiable cause is not found in 16% to 28% of cases. Recommended tests include a complete blood count, basic metabolic panel, liver function tests, thyroid function tests, C-reactive protein levels, erythrocyte sedimentation rate, glucose measurement, lactate dehydrogenase measurement, and urinalysis. Chest radiography and fecal occult blood testing should be performed. Abdominal ultrasonography may also be considered. When baseline evaluation is unremarkable, a three- to six-month observation period is justified. Treatment focuses on the underlying cause. Nutritional supplements and flavor enhancers, and dietary modification that takes into account patient preferences and chewing or swallowing disabilities may be considered. Appetite stimulants may increase weight but have serious adverse effects and no evidence of decreased mortality.

Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality.1 In this population, unintentional weight loss can lead to functional decline in activities of daily living,2 increased in-hospital morbidity,3 increased risk of hip fracture in women,4 and increased overall mortality.57 Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments.1

Because unintentional weight loss is a nonspecific condition and no published guidelines exist for evaluation and management, the appropriate workup, if any, is difficult to determine. This article focuses on the evaluation, diagnosis, and potential treatments of unintentional weight loss in patients older than 65 years.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Unintentional weight loss of more than 5% within six to 12 months is associated with increased morbidity and mortality in older adults and should prompt evaluation.

C

57, 11, 13

Consistent findings from multiple prospective cohort studies with good follow-up

A baseline evaluation for unexplained, unintentional weight loss in older adults includes history, physical examination, laboratory tests, chest radiography, fecal occult blood testing, and possibly abdominal ultrasonography.

C

1116

Findings from three retrospective and three prospective studies

If baseline test results are negative, close observation for three to six months is justified.

C

11, 12

Consistent findings from two prospective trials

Although appetite stimulants can be used to increase weight in older adults, none have been shown to reduce mortality in those with unintentional weight loss.

C

17, 27

Few randomized controlled trials have been conducted


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Unintentional weight loss of more than 5% within six to 12 months is associated with increased morbidity and mortality in older adults and should prompt evaluation.

C

57, 11, 13

Consistent findings from multiple prospective cohort studies with good follow-up

A baseline evaluation for unexplained, unintentional weight loss in older adults includes history, physical examination, laboratory tests, chest radiography, fecal occult blood testing, and possibly abdominal ultrasonography.

C

1116

Findings from three retrospective and three prospective studies

If baseline test results are negative, close observation for three to six months is justified.

C

11, 12

Consistent findings from two prospective trials

Although appetite stimulants can be used to increase weight in older adults, none have been shown to reduce mortality in those with unintentional weight loss.

C

17, 27

Few randomized controlled trials have been conducted


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion,

The Authors

HEIDI L. GADDEY, MD, is associate program director at the Ehrling Bergquist Family Medicine Residency Program, Offutt Air Force Base, Neb. At the time this article was written she was associate program director at the David Grant Medical Center Family Medicine Residency Program, Travis Air Force Base, Calif.

KATHRYN HOLDER, MD, is a faculty member with the David Grant Medical Center Family Medicine Residency Program.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force Medical Department or the U.S. Air Force at large.

Address correspondence to Heidi L. Gaddey, MD, Ehrling Bergquist Medical Clinic, 2501 Capehart Rd., Offutt AFB, NE 68113 (e-mail: heidi.gaddey@us.af.mil). Reprints are not available from the authors.

REFERENCES

1. McMinn J, Steel C, Bowman A. Investigation and management of unintentional weight loss in older adults. BMJ. 2011;342:d1732.

2. Ritchie CS, Locher JL, Roth DL, et al. Unintentional weight loss predicts decline in activities of daily living function and life space mobility over 4 years among community-dwelling older adults. J Gerontol A Biol Sci Med Sci. 2008;63(1):67–75.

3. Chapman KM, Nelson RA. Loss of appetite: managing unwanted weight loss in the older patient. Geriatrics. 1994;49(3):54–59.

4. Ensrud KE, Ewing SK, Stone KL, et al. Intentional and unintentional weight loss increase bone loss and hip fracture risk in older women. J Am Geriatr Soc. 2003;51(12):1740–1747.

5. Wallace JI, Schwartz RS, LaCroix AZ, et al. Involuntary weight loss in older outpatients: incidence and clinical significance. J Am Geriatr Soc. 1995;43(4):329–337.

6. Locher JL, Roth DL, Ritchie CS, et al. Body mass index, weight loss, and mortality in community-dwelling older adults. J Gerontol A Biol Sci Med Sci. 2007;62(12):1389–1392.

7. Newman AB, Yanez D, Harris T, et al. Weight change in old age and its association with mortality. J Am Geriatr Soc. 2001;49(10):1309–1318.

8. Atalayer D, Astbury NM. Anorexia of aging and gut hormones. Aging Dis. 2013;4(5):264–275.

9. Ruscin JM, Page RL II, Yeager BF, et al. Tumor necrosis factor-alpha and involuntary weight loss in elderly, community-dwelling adults. Pharmacotherapy. 2005;25(3):313–319.

10. Wallace JI, Schwartz RS. Epidemiology of weight loss in humans with special reference to wasting in the elderly. Int J Cardiol. 2002;85(1):15–21.

11. Lankisch PG, Gerzmann M, Gerzmann JF, et al. Unintentional weight loss: diagnosis and prognosis. J Intern Med. 2001;249(1):41–46.

12. Metalidis C, Knockaert DC, Bobbaers H, et al. Involuntary weight loss. Does a negative baseline evaluation provide adequate reassurance? Eur J Intern Med. 2008;19(5):345–349.

13. Marton KI, Sox HC Jr, Krupp JR. Involuntary weight loss: diagnostic and prognostic significance. Ann Intern Med. 1981;95(5):568–574.

14. Rabinovitz M, Pitlik SD, Leifer M, et al. Unintentional weight loss. A retrospective analysis of 154 cases. Arch Intern Med. 1986;146(1):186–187.

15. Wallace JI, et al. Involuntary weight loss in elderly outpatients: recognition, etiologies, and treatment. Clin Geriatr Med. 1999;13(4):717–735.

16. Hernández JL, Riancho JA, Matorras P, et al. Clinical evaluation for cancer in patients with involuntary weight loss without specific symptoms. Am J Med. 2003;114(8):613–617.

17. Alibhai SM, et al. An approach to the management of unintentional weight loss in elderly people. CMAJ. 2005;172(6):773–780.

18. Stajkovic S, Aitken EM, Holroyd-Leduc J. Unintentional weight loss in older adults [published correction appears in CMAJ. 2011;183(8):935]. CMAJ. 2011;183(4):443–449.

19. Huffman GB. Evaluating and treating unintentional weight loss in the elderly. Am Fam Physician. 2002;65(4):640–650.

20. Morley JE, Silver AJ. Nutritional issues in nursing home care. Ann Intern Med. 1995;123(11):850–859.

21. Robbins LJ. Evaluation of weight loss in the elderly. Geriatrics. 1989;44(4):31–34, 37.

22. Guigoz Y, Vellas B, Garry PJ. Assessing the nutritional status of the elderly. Nutr Rev. 1996;54(1 pt 2):S59–S65.

23. The clinical and cost-effectiveness of medical nutrition therapies: evidence and estimates of potential medical savings from the use of selected nutritional intervention. June 1996. Summary report prepared for the Nutrition Screening Initiative.

24. Arroll B, Goodyear-Smith F, Crengle S, et al. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med. 2010;8(4):348–353.

25. Yesavage JA, et al. Development and validation of a geriatric depression screening scale. J Psychiatr Res. 1982–1983;17(1):37–49.

26. Ebell MH. Brief screening instruments for dementia in primary care. Am Fam Physician. 2009;79(6):497–498, 500.

27. Padala KP, Keller BK, Potter JF. Weight loss treatment in long-term care. J Nutr Elder. 2007;26(3–4):1–20.

28. Boffelli S, Rozzini R, Trabucchi M. Nutritional intervention in special care units for dementia. J Am Geriatr Soc. 2004;52(7):1216–1217.

29. Simmons SF, Patel AV. Nursing home staff delivery of oral liquid nutritional supplements to residents at risk for unintentional weight loss. J Am Geriatr Soc. 2006;54(9):1372–1376.

30. Porter C, Schell ES, Kayser-Jones J, et al. Dynamics of nutrition care among nursing home residents who are eating poorly. J Am Diet Assoc. 1999;99(11):1444–1446.

31. Ruigrok J, Sheridan L. Life enrichment programme. Int J Health Care Qual Assur Inc Leadersh Health Serv. 2006;19(4–5):420–429.

32. Schiffman SS, Graham BG. Taste and smell perception affect appetite and immunity in the elderly. Eur J Clin Nutr. 2000;54(suppl 3):S54–S63.

33. Mathey MF, Siebelink E, de Graaf C, et al. Flavor enhancement of food improves dietary intake and nutritional status of elderly nursing home residents. J Gerontol A Biol Sci Med Sci. 2001;56(4):M200–M205.

34. Essed NH, van Staveren WA, Kok FJ, et al. No effect of 16 weeks flavor enhancement on dietary intake and nutritional status of nursing home elderly. Appetite. 2007;48(1):29–36.

35. Ruiz Garcia V, López-Briz E, Carbonell Sanchis R, et al. Megestrol acetate for treatment of anorexia-cachexia syndrome. Cochrane Database Syst Rev. 2013;(3):CD004310.

36. Fox CB, Treadway AK, Blaszczyk AT, et al. Megestrol acetate and mirtazapine for the treatment of unplanned weight loss in the elderly. Pharmacotherapy. 2009;29(4):383–397.

37. Lacy C; American Pharmacists Association. Drug Information Handbook. 17th ed. Hudson, Ohio: Lexi-Comp; 2008.

38. Kardinal CG, Loprinzi CL, Schaid DJ, et al. A controlled trial of cyproheptadine in cancer patients with anorexia and/or cachexia. Cancer. 1990;65(12):2657–2662.


Copyright © 2014 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

Article Tools

  • Download PDF
  • Print page
  • Share this page
  • AFP CME Quiz

More in Pubmed

Navigate this Article