Weight loss resident survival guide: Difference between revisions

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{{WikiDoc CMG}}; {{AE}} {{JA}}<br>
{{WikiDoc CMG}}; {{AE}} {{JA}}<br>
{{SK}} [[weight loss management guide]], [[unintentional weight loss management guide]], [[loss of weight resident survival guide]], [[pathologic weight loss resident survival guide]].
{{SK}} [[weight loss management guide]], [[unintentional weight loss management guide]], [[loss of weight resident survival guide]], [[pathologic weight loss resident survival guide]].
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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Lymphadenopathy resident survival guide microchapters}}
! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align="center" |{{fontcolor|#2B3B44|Weight loss resident survival guide microchapters}}
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Weight loss resident survival guide#Overview|Overview]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Weight loss resident survival guide#Overview|Overview]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Weight loss resident survival guide#Causes|Causes]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Weight loss resident survival guide#Causes|Causes]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Weight loss resident survival guide#Management|Management]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Weight loss resident survival guide#Diagnosis and Management|Diagnosis and Management]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Weight loss resident survival guide#Do's|Do's]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Weight loss resident survival guide#Do's|Do's]]
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Weight loss resident survival guide#Don'ts|Don'ts]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align="left" |[[Weight loss resident survival guide#Don'ts|Don'ts]]
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==Overview==
==Overview==
Weight loss may be intentional or unintentional.  
A loss of >5% of the usual body weight within 6 - 12 months represents [[pathology|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 [[Malignancy|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]], [[Comprehensive metabolic panel|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==
==Causes==
===Life Threatening Causes===
===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
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:
* [[Life threatening cause 1]]
 
* [[Life threatening cause 2]]
*[[Electrolyte]] disturbances as a result of [[malnutrition]] may lead to [[arrhythmias]] and be life-threatening if not corrected in time.<ref name="pmid25192814">{{cite journal |vauthors=Abed J, Judeh H, Abed E, Kim M, Arabelo H, Gurunathan R |title="Fixing a heart": the game of electrolytes in anorexia nervosa |journal=Nutr J |volume=13 |issue= |pages=90 |date=September 2014 |pmid=25192814 |pmc=4168120 |doi=10.1186/1475-2891-13-90 |url=}}</ref>
* [[Life threatening cause 3]]


===Common Causes===
===Common Causes===
* [[Common cause 1]]
====Age >65 years<ref name="pmid28388637">{{cite journal |vauthors=Bosch X, Monclús E, Escoda O, Guerra-García M, Moreno P, Guasch N, López-Soto A |title=Unintentional weight loss: Clinical characteristics and outcomes in a prospective cohort of 2677 patients |journal=PLoS ONE |volume=12 |issue=4 |pages=e0175125 |date=2017 |pmid=28388637 |pmc=5384681 |doi=10.1371/journal.pone.0175125 |url=}}</ref>====
* [[Common cause 2]]
 
*[[Malignancy|Malignancies]] (specifically digestive and non-hematologic)
*[[Dementia]]
*[[Stroke]]
*[[Parkinson's disease]]
*[[Polymyalgia rheumatica]]
*[[Oral]] disorders.


====Age <65 years<ref name="pmid28388637">{{cite journal |vauthors=Bosch X, Monclús E, Escoda O, Guerra-García M, Moreno P, Guasch N, López-Soto A |title=Unintentional weight loss: Clinical characteristics and outcomes in a prospective cohort of 2677 patients |journal=PLoS ONE |volume=12 |issue=4 |pages=e0175125 |date=2017 |pmid=28388637 |pmc=5384681 |doi=10.1371/journal.pone.0175125 |url=}}</ref>====
*[[Endocrine]] disorders
*[[Infections]] such as [[TB]] and [[HIV]]
*[[Psychiatric disorders]] such as [[depression]], [[anxiety]], and [[OCD]]
*[[Malignancy|Malignancies]] such as [[hematology|hematologic]]
====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.<ref name="Alibhai2005">{{cite journal|last1=Alibhai|first1=S. M.H.|title=An approach to the management of unintentional weight loss in elderly people|journal=Canadian Medical Association Journal|volume=172|issue=6|year=2005|pages=773–780|issn=0820-3946|doi=10.1503/cmaj.1031527}}</ref><ref name="WuBosch2017">{{cite journal|last1=Wu|first1=Wen-Chih Hank|last2=Bosch|first2=Xavier|last3=Monclús|first3=Esther|last4=Escoda|first4=Ona|last5=Guerra-García|first5=Mar|last6=Moreno|first6=Pedro|last7=Guasch|first7=Neus|last8=López-Soto|first8=Alfons|title=Unintentional weight loss: Clinical characteristics and outcomes in a prospective cohort of 2677 patients|journal=PLOS ONE|volume=12|issue=4|year=2017|pages=e0175125|issn=1932-6203|doi=10.1371/journal.pone.0175125}}</ref><ref name="pmid24784334">{{cite journal |vauthors=Gaddey HL, Holder K |title=Unintentional weight loss in older adults |journal=Am Fam Physician |volume=89 |issue=9 |pages=718–22 |date=May 2014 |pmid=24784334 |doi= |url=}}</ref><ref name="pmid11168783">{{cite journal |vauthors=Lankisch P, Gerzmann M, Gerzmann JF, Lehnick D |title=Unintentional weight loss: diagnosis and prognosis. The first prospective follow-up study from a secondary referral centre |journal=J. Intern. Med. |volume=249 |issue=1 |pages=41–6 |date=January 2001 |pmid=11168783 |doi=10.1046/j.1365-2796.2001.00771.x |url=}}</ref><ref name="pmid28388637">{{cite journal |vauthors=Bosch X, Monclús E, Escoda O, Guerra-García M, Moreno P, Guasch N, López-Soto A |title=Unintentional weight loss: Clinical characteristics and outcomes in a prospective cohort of 2677 patients |journal=PLoS ONE |volume=12 |issue=4 |pages=e0175125 |date=2017 |pmid=28388637 |pmc=5384681 |doi=10.1371/journal.pone.0175125 |url=}}</ref><ref name="pmid23633816">{{cite journal |vauthors=Sarkar SB, Sarkar S, Ghosh S, Bandyopadhyay S |title=Addison's disease |journal=Contemp Clin Dent |volume=3 |issue=4 |pages=484–6 |date=October 2012 |pmid=23633816 |pmc=3636818 |doi=10.4103/0976-237X.107450 |url=}}</ref><ref name="pmid1512386">{{cite journal |vauthors=Brymer C, Winograd CH |title=Fluoxetine in elderly patients: is there cause for concern? |journal=J Am Geriatr Soc |volume=40 |issue=9 |pages=902–5 |date=September 1992 |pmid=1512386 |doi=10.1111/j.1532-5415.1992.tb01987.x |url=}}</ref><ref name="pmid8919685">{{cite journal |vauthors=Guigoz Y, Vellas B, Garry PJ |title=Assessing the nutritional status of the elderly: The Mini Nutritional Assessment as part of the geriatric evaluation |journal=Nutr. Rev. |volume=54 |issue=1 Pt 2 |pages=S59–65 |date=January 1996 |pmid=8919685 |doi=10.1111/j.1753-4887.1996.tb03793.x |url=}}</ref><ref name="pmid8201141">{{cite journal |vauthors=Morley JE, Kraenzle D |title=Causes of weight loss in a community nursing home |journal=J Am Geriatr Soc |volume=42 |issue=6 |pages=583–5 |date=June 1994 |pmid=8201141 |doi=10.1111/j.1532-5415.1994.tb06853.x |url=}}</ref><ref name="pmid2022802">{{cite journal |vauthors=Thompson MP, Morris LK |title=Unexplained weight loss in the ambulatory elderly |journal=J Am Geriatr Soc |volume=39 |issue=5 |pages=497–500 |date=May 1991 |pmid=2022802 |doi=10.1111/j.1532-5415.1991.tb02496.x |url=}}</ref>
{{familytree/start |summary=Weight loss causes Algorithm.}}
{{familytree/start |summary=Weight loss causes Algorithm.}}
{{familytree | | | | | | | | A01 |A01=Causes of weight loss }}  
{{familytree | | | | | | | | A01 |A01=Causes of weight loss }}  
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{{familytree | | | | | | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | | | | | | |!| | | | |}}
{{familytree | | | | | | | | |,|-|-|-|-|^|-|-|-|-|-|.| }}
{{familytree | | | | | | | | |,|-|-|-|-|^|-|-|-|-|-|.| }}
{{familytree | | | | | | | | D01 | | | | | | | | | | D02 | | |D01=Non-Malignant<br>|D02= Malignant<br>}}
{{familytree | | | | | | | | D01 | | | | | | | | | | D02 | | |D01='''Non-Malignant''' (~60%)<br>|D02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Malignant (19 - 39%)'''<div class="mw-collapsible mw-collapsed">
❑ '''Gastrointestinal''' (53%) based on one study :<br> [[Oesophageal cancer]], [[stomach cancer]], [[colon cancer]], and [[rectal cancer]].<br>
❑ '''Renal''':<br> [[Renal cancer]] and [[Transitional cell carcinoma|renal pelvis cancer]].<br>
❑ '''Pulmonary''':<br> [[Bronchial cancer]] and [[lung cancer]]<br>
❑ '''Hepato-pancreatic''':<br> [[HCC]], [[pancreatic cancer]], [[cholangiocarcinoma|intra-hepatic bile duct cancer]].<br>
❑ '''Genitourinary''':<br>  [[Ovarian cancer]], [[cervical cancer]], [[endometrial cancer]], [[prostate cancer]], [[ureter cancer]], [[bladder cancer]]<br>
❑ '''Hematologic''':<br> [[Hodgkin's lymphoma]] and [[Non-Hodgkin's lymphoma]]<br>
❑  [[Breast cancer]]<br>
❑  [[Malignant neoplasm]]s}}
{{familytree | | | | | | | | |!| | | | | | | | | | }}
{{familytree | | | | | | | | |!| | | | | | | | | | }}
{{familytree | | | | | | | | |!| | | | | | | | | | }}
{{familytree | | | | | | | | |!| | | | | | | | | | }}
{{familytree | |,|-|-|-|v|-|-|+|-|-|-|v|-|-|-|v|-|-|-|.|}}
{{familytree | |,|-|-|-|v|-|-|+|-|-|-|v|-|-|-|v|-|-|-|.|}}
{{familytree | E01 | | E02 | | E03 | | E04| | E05 | | E06 | | |E01='''Infectious''' |E02=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Autoimmune'''<div class="mw-collapsible mw-collapsed">
{{familytree | E01 | | E02 | | E03 | | E04| | E05 | | E06 | | |E01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Infectious''' (2 - 8%)<div class="mw-collapsible mw-collapsed">
❑ Chronic [[diarrhea]]<br>
❑ [[Tuberculosis]] (TB)<br>
❑ [[HIV]]<br>
❑  [[infective endocarditis]]<br>
❑ Infective [[colitis]] and [[gastroenteritis]]. |E02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Autoimmune''' (2 - 7%)<div class="mw-collapsible mw-collapsed">
❑ [[SLE]]<br>
❑ [[SLE]]<br>
❑ [[Rheumatoid arthritis]]<br>
❑ [[Rheumatoid arthritis]]<br>
❑ [[Polyarteritis nodosa]]<br>
❑ [[Polyarteritis nodosa]]<br>
❑ [[Polymyalgia rheumatica]]<br>
❑ [[Polymyalgia rheumatica]]<br>
❑ [[Giant cell arteritis]] with [[polymyalgia rheumatica]] |E03=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Psychological'''<div class="mw-collapsible mw-collapsed">
❑ [[Giant cell arteritis]] with [[polymyalgia rheumatica]] |E03=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Psychologic'''/ '''Psychiatric '''(9 - 42%)<div class="mw-collapsible mw-collapsed">
❑ [[Depression]]<br>  
❑ [[Depression]]<br>  
❑ [[Bipolar disorder]]<br>  
❑ [[Bipolar disorder]]<br>  
Line 57: Line 86:
❑ Social exclusion or rejection<br>
❑ Social exclusion or rejection<br>
❑ Neglect<br>
❑ Neglect<br>
❑ [[Disability]] |E04=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Organ system based'''<div class="mw-collapsible mw-collapsed">
❑ [[Disability]] |E04=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Organ system based'''<div class="mw-collapsible mw-collapsed">
❑ '''Gastrointestinal''': [[Gastric ulcers|Gastric]] and [[Duodenal ulcer|duodenal]] [[ulcer]]s, [[IBD]], [[celiac disease]], [[malabsorption]], [[steatorrhea]], [[vascular]] disorders affecting [[intestine]]s, non-infective [[gastroenteritis]] and [[colitis]], [[swallowing]] pathologies, and [[dental]] issues <br>
❑ '''Gastrointestinal''' (6 - 30%): [[Cholecystitis]], [[Gastric ulcers|Gastric]] and [[Duodenal ulcer|duodenal]] [[ulcer]]s, [[IBD]], [[celiac disease]], [[malabsorption]], [[steatorrhea]], [[vascular]] disorders affecting [[intestine]]s, non-infective [[gastroenteritis]] and [[colitis]], [[swallowing]] pathologies, and [[dental]] issues. <br>
❑ '''Renal''': [[Pyelonephritis]], [[nephritic syndrome]], [[nephrotic syndrome]]<br>
❑ '''Renal''' (4%):<br>
❑ '''Pulmonary''': [[Lung abscess]] (without [[pneumonia]]), [[interstitial lung disease]] ([[Idiopathic pulmonary fibrosis|fibrotic]] or [[idiopathic]]), [[pleural effusion]], and [[pyothorax]] (without [[fistula]])<br>
[[Pyelonephritis]], [[nephritic syndrome]], and [[nephrotic syndrome]]<br>
❑ '''Neurologic''': [[Stroke]], [[parkinson's disease]], and [[motor neuron disease]]<br>
❑ '''Cardiopulmonary''' (2-10%):<br>
❑ '''Endocrine''': [[Type I diabetes]], [[type 2 diabetes]], [[hyperthyroidism]], [[primary hyperparathyroidism]], and [[subacute thyroiditis]].
[[Heart failure]], [[COPD]], [[lung abscess]] (without [[pneumonia]]), [[interstitial lung disease]] ([[Idiopathic pulmonary fibrosis|fibrotic]] or [[idiopathic]]), [[pleural effusion]], and [[pyothorax]] (without [[fistula]]). <br>
|E05='''Drug-induced'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 20em; padding:1em;">
❑ '''Neurologic''' (2 - 7%):<br>[[Stroke]], [[parkinson's disease]], and [[motor neuron disease]].<br>
❑ '''Endocrine''' (4 - 11%):<br>[[Type I diabetes]], [[type 2 diabetes]], [[hyperthyroidism]], [[primary hyperparathyroidism]], [[Addison's disease]], and [[subacute thyroiditis]].
|E05=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Drug-induced''' (6 - 8%)<div class="mw-collapsible mw-collapsed">
❑ [[Narcotic analgesic]]s (such as [[opioids]]) interfere with [[cognition]] and ability to eat<br>
❑ [[Sedatives]] also interfere with [[cognition]]<br>
❑ [[Psychedelic drug]]s<br>
❑ [[Cocaine]]<br>
❑ [[Cocaine]]<br>
❑ [[Opioids]]<br>
❑ [[Alcohol]] (4 - 8%)<br>
❑ [[Alcohol]]<br>
❑ [[SSRI]]s<br>
❑ [[Psychedelic drug]]s, |E06='''Unexplained '''}}
❑ [[Psychotropic drug]] dose reduction <br>
❑ Other drugs that cause [[vomiting]], [[anorexia]], [[dysphagia]], and [[dysgeusia]]|E06='''Unexplained '''/ '''Unknown''' (6 - 36%)}}
{{familytree | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | }}
{{familytree/end}}
{{familytree/end}}


==Diagnosis==
*To read about other causes of unintentional weight loss [[Weight loss#Causes|click here]].
Shown below is an algorithm summarizing the diagnosis of <nowiki>[[disease name]]</nowiki> according the the [...] guidelines.
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | A01 | | | A01= }}
{{familytree | | | | |!| | | | }}
{{familytree | | | | B01 | | | B01= }}
{{familytree | | |,|-|^|-|.| | }}
{{familytree | | C01 | | C02 | C01= | C02= }}


==Diagnosis and Management==
<span style="font-size:85%">'''Abbreviations:''' '''GI:''' [[Gastrointestinal system]]; '''GERD:''' [[GERD|Gastroesophageal reflux disease]]; '''BMI:''' [[BMI|Body Mass Index]]; '''HEENT:''' [[Head, Eyes, Ears. Nose, and Throat exam]]; '''IM:'''  [[Infectious Mononucleosis]]; '''CBC:''' [[CBC|Complete blood count]]; '''ESR:''' [[ESR|Erythrocyte sedimentation rate]]; '''LDH:''' [[LDH|Lactate dehydrogenase]]; '''CMP:''' [[Comprehensive metabolic panel]]; '''CRP:'''[[C-reactive protein]]; '''TSH:''' [[TSH|Thyroid stimulating hormone]];  '''PTH:''' [[PTH|Parathyroid hormine]]; '''COPD:''' [[COPD|Chronic Obstructive Pulmonary Disease]]</span><br><br>
Shown below is an algorithm summarizing the diagnosis of [[weight loss]].<ref name="pmid8919685">{{cite journal |vauthors=Guigoz Y, Vellas B, Garry PJ |title=Assessing the nutritional status of the elderly: The Mini Nutritional Assessment as part of the geriatric evaluation |journal=Nutr. Rev. |volume=54 |issue=1 Pt 2 |pages=S59–65 |date=January 1996 |pmid=8919685 |doi=10.1111/j.1753-4887.1996.tb03793.x |url=}}</ref><ref name="pmid31330781">{{cite journal |vauthors=Reber E, Gomes F, Vasiloglou MF, Schuetz P, Stanga Z |title=Nutritional Risk Screening and Assessment |journal=J Clin Med |volume=8 |issue=7 |pages= |date=July 2019 |pmid=31330781 |pmc=6679209 |doi=10.3390/jcm8071065 |url=}}</ref><ref name="pmid12880610">{{cite journal |vauthors=Kondrup J, Allison SP, Elia M, Vellas B, Plauth M |title=ESPEN guidelines for nutrition screening 2002 |journal=Clin Nutr |volume=22 |issue=4 |pages=415–21 |date=August 2003 |pmid=12880610 |doi=10.1016/s0261-5614(03)00098-0 |url=}}</ref><ref name="pmid9673603">{{cite journal |vauthors=Gazewood JD, Mehr DR |title=Diagnosis and management of weight loss in the elderly |journal=J Fam Pract |volume=47 |issue=1 |pages=19–25 |date=July 1998 |pmid=9673603 |doi= |url=}}</ref><ref name="pmid23115205">{{cite journal |vauthors=Hu J, Van Valckenborgh E, Menu E, De Bruyne E, Vanderkerken K |title=Understanding the hypoxic niche of multiple myeloma: therapeutic implications and contributions of mouse models |journal=Dis Model Mech |volume=5 |issue=6 |pages=763–71 |date=November 2012 |pmid=23115205 |pmc=3484859 |doi=10.1242/dmm.008961 |url=}}</ref><ref name="pmid6380395">{{cite journal |vauthors=Biemer JJ |title=Hepatic manifestations of lymphomas |journal=Ann. Clin. Lab. Sci. |volume=14 |issue=4 |pages=252–60 |date=1984 |pmid=6380395 |doi= |url=}}</ref><ref name="pmid24784334">{{cite journal |vauthors=Gaddey HL, Holder K |title=Unintentional weight loss in older adults |journal=Am Fam Physician |volume=89 |issue=9 |pages=718–22 |date=May 2014 |pmid=24784334 |doi= |url=}}</ref><ref name="Alibhai2005">{{cite journal|last1=Alibhai|first1=S. M.H.|title=An approach to the management of unintentional weight loss in elderly people|journal=Canadian Medical Association Journal|volume=172|issue=6|year=2005|pages=773–780|issn=0820-3946|doi=10.1503/cmaj.1031527}}</ref><ref name="pmid11871682">{{cite journal |vauthors=Huffman GB |title=Evaluating and treating unintentional weight loss in the elderly |journal=Am Fam Physician |volume=65 |issue=4 |pages=640–50 |date=February 2002 |pmid=11871682 |doi= |url=}}</ref><ref name="Kondrup2003">{{cite journal|last1=Kondrup|first1=J|title=ESPEN Guidelines for Nutrition Screening 2002|journal=Clinical Nutrition|volume=22|issue=4|year=2003|pages=415–421|issn=02615614|doi=10.1016/S0261-5614(03)00098-0}}</ref>
{{familytree/start |summary=Weight loss Diagnostic Algorithm.}}
{{familytree | | | | | | | | | | A01 | | | | | | |A01=[[Patient]] presents with [[weight loss]]/ incidental finding }}
{{familytree | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | B01 | | | | | |B01=Loss of >5% of the usual body weight within 6 - 12 months}}
{{familytree | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | Z01 | | | | | | | |Z01='''History'''<div style="float: left; text-align: left; width: 20em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>
❑ '''Source of history''':<br>  [[Patient]] or well-informed caregiver ([[elderly]] may be unaware or deny weight loss).<br>
❑ '''[[Patient]] [[age]]''':<br>  Helps determine age-specific causes, such as [[malignancy]] among the elderly.<br>
❑ '''Duration of [[symptoms]]''':<br>  (weeks in [[acute]]/severe versus years in [[chronic]] conditions).<br>
❑ '''Associated [[symptoms]]''':<br> Assess if the [[patient]] is [[Nausea|nauseated]] or [[vomiting]]/ [[anorexia]]/ [[dysphagia]]/ [[odynophagia]]/ social reasons hindering food supply.<br>
❑ '''Systemic review''':<br> [[Cardiovascular system|Cardiovascular]], [[respiratory system|respiratory]], [[renal system|renal]], [[liver|hepatic]], [[Rheumatology|rheumatologic]], and [[Gastrointestinal system|GI]] exam.
:❑ [[Gastrointestinal system|GI]]: Indigestion, [[early satiety]], altered stool pattern, [[abdominal pain]] may demonstrate [[GERD]], [[peptic ulcer]],[[cholecystitis]], and [[gastrointestinal system|GI]] [[malignancy]]<br>
❑ '''Past medical history''':<br>  Helps assess the nutritional status. May suggest of [[immunodeficiency]] (recurrent [[infections]]), diagnosed [[malignancy]], [[malabsorption]] (chronic [[diarrhea]]), [[HF]], [[dyspepsia]]. <br>
❑ '''Past surgical history''':<br> Helps assess nutritional status.<br>
❑ '''Medication history''': Assess the use of medications known to cause [[weight loss]]. [[Polypharmacy]] may cause [[anorexia]] or altered taste.<br>
❑ '''Family history''':<br> Certain malignant disorders ([[breast cancer]], [[ovarian cancer]], [[colon cancer]], or [[stomach cancer]]))<br>
❑ '''Social history''':<br> [[Tobacco]], alcohol use, [[opioid]], [[cocaine]] use<br>
❑ '''Sexual history''':<br> Suggestive of [[HIV AIDS history and symptoms|HIV AIDS]]<br>
❑ '''Exposure''':<br> Communicable [[infectious disease]]s/ travel to high-risk areas.}}
{{familytree | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | S01 | | | | | | |S01='''Nutritional status''' <div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed">
❑ '''Dietary history''': Food availability, diet adequacy in the quantity (daily caloric intake), and quality (balance of nutrition), and nutritional supplements.<br>
❑ '''Weight record''': Weight measurement records or best estimate of weight loss accessed by clothing size. <br>
❑ '''Mini Nutritional Assessment''': To assess the nutritional risk among the elderly.<br>
❑ '''Functional status''': Assess the mental and functional status of the [[patient]].<br>
❑ '''Psychological status''': Psychiatric illness screening: Geriatric Depression Scale may be utilized to assess for [[depression]] among elderly.<br>}}
{{familytree | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | K01 |-| K02 |-| K03 | | K01='''Weight loss history'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed">
Is [[BMI]]<20.5?<br>
Q1: Lost weight within last 3 months?<br>
Q2: Reduced dietary intake in the last week?<br>
Q3: Severe illness?|K02=No|K03=Reaccess in weekly}}
{{familytree | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | Y01 | | | | | | |Y01=Yes }}
{{familytree | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | T01 | | | | | | |T01=Characterise the severity of the condition}}
{{familytree | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | M01 | | | | | | | M01='''Physical exam'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>
❑ Appearance of the [[patient]]:<br>[[Cachexia]] is observed among [[patients]] with [[malignancy]]. Surgical scar marks demonstrating previous surgery for intentional weight loss or [[malignancy]] treatment<br>
❑ [[Vital signs]]<br>
:❑ [[Temperature]]: Low-grade/ high-grade fever with [[fatigue]] may demonstrate [[infection]], [[autoimmune]] disorders, [[thyroid]] disease, [[malignancy]], [[diabetes]] <br>
:❑ [[Heart rate]]: [[Tachycardia]] with regular pulse may demonstrate [[infection]]. <br>
:❑ [[Respiratory rate]]: [[Tachypnea]] ([[infection]]\ [[metastasis]]), [[dyspnea]] ([[heart failure]], [[COPD]], and lung [[infection]]<br>
:❑ [[Blood pressure]]: [[Chronic hypertension]] or [[hypotension]] is common among elders.<br>
:❑ [[Oxygen saturation]]: Low saturation may demonstrate [[respiratory system]] involvement or hematologic [[malignancies]], such as [[multiple myeloma]].<br>
❑ [[BMI]] assessment or simply [[weight]] among immobile or bed-ridden [[patients]].<br>
❑ HEENT<br>
❑ [[Cardiovascular examination]]<br>
❑ [[Respiratory examination]]<br>
❑ [[Gastrointestinal system]] exam includes [[oral examination]], [[abdominal examination]], and [[digital rectal exam]]. <br>
:❑ [[Organomegaly]]) may demonstrate [[mtastasis|metastases]] or primary lesions such as [[hepatosplenomegaly]] in [[infectious mononucleosis|IM]], [[Hodgkin's lymphoma]]. [[hepatomegaly]] is more common in [[non-Hodgkin's lymphoma]].<br>
❑ Observing the [[patient]] having a meal may demonstrate<br>
:❑  Distractions by external stimuli may demonstrate [[dementia]]. <br>
:❑  Inadequate movements of the [[patient]] to feed him/herself may demonstrate [[neuromuscular]] disorders or functional limitations. <br>
❑ Mini mental state examination to assess the [[cognitive function]], and [[mood]] assessment.}}
{{familytree | | | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | | | |)|-|-|-|-|.| | }}
{{familytree | | | | | | | | | | |!| | | | K01 | | | | |K01=Intentional weight loss }}
{{familytree | | | | | | | | | | |!| | | | |!| | | | }}
{{familytree | | | | | | | | | | |!| | | | L01 | | | |L01=Assessment<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 15em; padding:1em;">❑ Assess for self-induced [[vomiting]]/ [[anorexigenic drugs]]/ [[diuretic]]/ [[laxative]] use<br>❑ Monitor [[BMI]]<br>❑ Serum [[electrolytes]] }}
{{familytree | | | | | | | | | | F01 | | | |!| | |F01=Unintentional weight loss }}
{{familytree | | | | | | | | | | |!| | | |H01 | |H01='''Treatment'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>❑ Multidisciplinary approach<br>❑ [[Anorexia nervosa medical therapy]]<br>❑ [[Counseling]] }}
{{familytree | | | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | | | K01 | | | | | | |K01=Nutritional status/ [[calorie|caloric]] intake }}
{{familytree | | | | | | | |,|-|-|^|-|-|-|.| | | }}
{{familytree | | | | | | | J01 | | | | | | J02 | | | | |J01=Adequate|J02=Inadequate}}
{{familytree | | | |,|-|-|-|^|-|.| | | | | |!| | | | | | | }}
{{familytree | | I01 | | | | | I02 | | | | I03 | | | | |I01=Suspect [[malabsorption]]|I02=Suspect altered [[metabolism]]|I03=Access to food}}
{{familytree | | |!| | | | | | |!| | | | | |!| | || }}
{{familytree | | |!| | | | | | |!| | | |,|-|^|-|.| | | | | }}
{{familytree | | |!| | | | | | |!| | | G01 | | | G02 | | | | | G01=No|G02=Yes}}
{{familytree | | |!| | | | | | |!| | | |!| | | | |!| | | | }}
{{familytree | | |!| | | | | | |!| | | F01 | | | F02 | | | | |F01=Suspect [[cognitive]] dysfunction/ consider social factors|F02=Consider [[oral]] or [[dental]] issues/ [[dysphagia]]/ [[dysgeusia]]}}
{{familytree | | |!| | | | | | |!| | | |!| | | | |!| | |}}
{{familytree | | |!| | | | | | |!| | | |!| | | | |!| | }}
{{familytree | | |!| | | | | | |!| | | |!| | | | |!| | }}
{{familytree | | |`|-|-|-|-|-|-|^|-|-|-|+|-|-|-|-|'| }}
{{familytree | | | | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | | | | U01 | | | | | | | U01='''Order initial screening labs''' and<br> '''Nutritional supplements'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 15em; padding:1em;">
❑ [[CBC]] with differential and [[peripheral smear]]<br>
❑ [[ESR]], [[CRP]], [[LDH]]<br>
❑ [[HbA1c]]<br>
❑ [[Comprehensive metabolic panel|CMP]]<br>
❑ [[Lipid profile]]<br>
❑ [[TSH]], free [[T4]]<br>
❑ [[Urinalysis]]<br>
❑ [[FOBT]]<br>
❑ [[Chest X-ray]]<br>
❑ Abdominal [[ultrasound]]<br>
❑ [[Echocardiography]]<br>
❑ [[Rheumatoid factor]]<br>
❑ [[PTH]] levels
*''Labs may vary on case by case basis''}}
{{familytree | | | | | | | | | | | | | |!| | | | | | |}}
{{familytree | |,|-|-|-|v|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|v|-|-|-|.|}}
{{familytree | B07 | | B01 | | B02 | | B03 | | B04 | | B05 | | B06 | |B07= Provisional diagnosis established| B01=Progressive [[oropharyngeal]] or [[esophageal]] [[dysphagia]]/ oral/ dental issues|B02=[[Peptic ulcer]]<br> [[celiac disease]], [[whipple disease]]|B03=Potential [[depression]]<br> Cognitive dysfunction|B04=Suspected [[malignancy]]|B05=Suspected nutritional deficiency|B06=<div style="float: left; text-align: center; width: 15em;">Suspected [[infection]]}}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!|}}
{{familytree |C07| | C01 | | C02 | | C03 | | C04 | | C05 | | C06 | |C07=<div style="float: left; text-align: left; width: 15em;">Specific tests<div class="mw-collapsible mw-collapsed">
❑ [[Nephrotic syndrome]]: [[24-hour urine collection]] ([[urine]] protein >3.5 g/day). <br>
❑ [[Nephritic syndrome]]: Assess [[complement levels]], [[HBV]], [[HCV]], [[HIV]] serologies, [[c-ANCA]] and [[p-ANCA]], and [[anti-dsDNA antibodies]].<br>
❑  [[COPD]] or [[interstitial lung disease]]: [[PFTs]]<br>
❑  [[Pneumonia]]: [[Sputum]] [[microscopy]], [[culture]] and sensitivity<br>
❑ [[Stroke]]: [[CT]] or [[MRI]] head.<br>
❑ [[Hyperparathyroidism]]: Serum [[calcium]], [[phosphate]] levels to identify the type.<br>
❑  Drug-induced|C01=<div style="float: left; text-align: left; width: 15em;">Specific tests<div class="mw-collapsible mw-collapsed">❑ Video[[fluoroscopy]]<br>❑ [[Dysphagia barium swallow]]<br>❑ Visual exam<br>❑ Dental issues: Refer to the [[dentist]].|C02=<div style="float: left; text-align: left; width: 15em;">Specific tests<div class="mw-collapsible mw-collapsed">❑ Upper or lower [[gastrointestinal system|GI]] [[endoscopy]] with [[biopsy]]<br>
❑ [[Fecal fat|Stool fat]], [[anti-transglutaminase antibodies]], [[elastase]], [[lactoferrin]]<br>❑ Upper GI and small bowl series|C03=<div style="float: left; text-align: left; width: 15em;">Specific scales<div class="mw-collapsible mw-collapsed">
❑ [[Geriatric Depression Scale]]<br>
❑ [[Clinical depression diagnostic criteria]] is to be met to diagnose ''clinical depression''<br>
❑ [[MoCA]]|C04=<div style="float: left; text-align: left; width: 15em;">Specific tests<div class="mw-collapsible mw-collapsed">❑ [[CT]] ([[chest]], [[abdomen]], [[pelvis]], [[head]], etc)<br>
❑[[PET scan]]<br>
❑ [[Colonoscopy]]<br>
❑ [[Mammogram]]<br>
❑ [[Protein electrophoresis]]|C05=<div style="float: left; text-align: left; width: 15em;">Specific tests<div class="mw-collapsible mw-collapsed">
❑ Serum [[ferritin]]<br>
❑ Vitamins: [[Beta carotene]], [[vitamin D]], [[tocopherol]], [[vitamin B12]], and [[folic acid]]<br>
❑  Minerals: Serum [[copper]] and [[zinc]], [[manganese]], and [[magnesium]]|C06=<div style="float: left; text-align: left; width: 15em;">Specific tests<div class="mw-collapsible mw-collapsed">
❑ Chronic [[diarrhea]]: Stool osmotic gap, [[Stool culture|culture]], [[ova]] and parasite, [[electrolytes]], [[leukocytes]], [[lactoferrin]], and [[C. difficile]] test.<br>
For a detailed information on differentials [[Chronic diarrhea differential diagnosis|click here]]<br>
❑ [[Tuberculosis]]: [[acid-fast-bacilli|AFB]] and [[sputum culture]] [[sputum]]<br>
❑ [[HIV]]:[[ELISA]] or [[Latex fixation test|Latex Agglutination Test]] for screening and viral [[RNA]] (P24) for confirmation <br>
❑ [[Endocarditis]]: [[Modified Duke Criteria]] and at least two [[blood culture]]s
❑ [[Gastroenteritis]] and [[colitis]]: Stool exam as in chronic [[diarrhea]].}}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!|}}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!|}}
{{familytree | D07 | | D01 | | D02 | | D03 | | D04 | | D05 | | D06 | | | |D07=<div style="float: left; text-align: left; width: 15em;"> '''Treatment'''<div class="mw-collapsible mw-collapsed">
❑ [[Nephrotic syndrome medical therapy|Nephrotic syndrome]]<br>
❑ [[Chronic obstructive pulmonary disease medical therapy|COPD]]<br>
❑ [[Pneumonia medical therapy|Pneumonia]]<br>
❑ [[Stroke]] treatment depends upon the cause<br>
❑ Discontinuing or replacing the suspected drug<br>
❑ [[Hyperthyroidism medical therapy|Hyperthyroidism]]<br>
❑ [[Hepatitis| medical therapy|Hepatitis]]<br>
❑ [[Chronic cholecystitis medical therapy|Chronic cholecystitis]]<br>
❑ [[Hyperparathyroidism medical therapy|Hyperparathyroidism]]|D01=<div style="float: left; text-align: left; width: 15em;">'''Treatment'''<div class="mw-collapsible mw-collapsed">❑ Food as puree or thickened liquids<br>❑ Speech therapy for oropharyngeal issues<br>❑ Dentist referral for dental issues<br>❑ [[Esophageal cancer medical therapy|Esophageal cancer treatment]]|D02=<div style="float: left; text-align: left; width: 15em;">'''Treatment'''<div class="mw-collapsible mw-collapsed">❑ [[Peptic ulcer medical therapy|Peptic ulcer]]<br>
❑ [[Celiac disease medical therapy|Celiac disease]]<br>
❑ [[Whipple's disease medical therapy|Whipple's disease]]|D03=<div style="float: left; text-align: left; width: 15em;"> '''Treatment'''<div class="mw-collapsible mw-collapsed">
❑ Referral to a specialist ([[psychotherapist]] and/or a [[psychiatrist]])<br>
❑ [[Psychotherapy]]<br>
❑ [[Clinical depression medical therapy|Clinical depression medications]]<br>
:❑  [[Mirtazapine]] is also appetite stimulant|D04=<div style="float: left; text-align: left; width: 15em;">'''Treatment'''<div class="mw-collapsible mw-collapsed"> ❑  [[Surgical resection]]<br> ❑ [[Chemotherapy]]<br>
❑ [[Radiotherapy]]<br>
❑ [[TNM]] staging<br>
❑ Appetite stimulants for wasting syndrome and [[cachexia]] :
❑ [[Oxandrolone]] or [[ornithine]] (not tested among elderly)
❑ [[Megestrol]] 320 mg/day (lower dosages for elderly) |D05=<div style="float: left; text-align: left; width: 15em;">'''Treatment'''<div class="mw-collapsible mw-collapsed">❑ Decreased dietary restrictions<br>❑ Increase oral intake with frequent small servings<br>❑ Nutritional supplements with regular meals<br>❑ Community support services if required<br>❑ Multidisciplinary approach|D06=<div style="float: left; text-align: left; width: 15em;"> '''Treatment'''<div class="mw-collapsible mw-collapsed">
❑ [[Chronic diarrhea medical therapy|Chronic diarrhea treatment]]<br>
❑ [[Tuberculosis medical therapy|Tb treatment]]<br>
❑ [[HIV AIDS medical therapy|HIV treatment]]<br>
:❑ [[Dronabinol]] appetite stimulant.
❑ [[Endocarditis medical therapy|Infective endocarditis treatment]]
❑ [[Gastroenteritis medical therapy|Gastroenteritis treatment]] and [[Colitis medical therapy|colitis treatment]]}}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!|}}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!|}}
{{familytree | |`|-|-|-|^|-|-|-|^|-|-|-|+|-|-|-|^|-|-|-|^|-|-|-|'| | |}}
{{familytree | | | | | | | | | | | | | |!| | | |}}
{{familytree | | | | | | | | | | | | | |!| | | | | | }}
{{familytree | | | | | | | | | | | | | E01 | | | | | | |E01=<div style="float: left; text-align: left; width: 20em;"> Follow-up in 1 or 3 months depending upon the cause.<br> }}
{{familytree | | | | | | | | | | |,|-|-|^|-|.| |}}
{{familytree | | | | | | | | | W01 | | | | | W02 | | |W01=Weight gain|W02=No weight gain/ continued weight loss }}
{{familytree | | | | | | | | | |!| | | | | | |!| | | }}
{{familytree | | | | | | | | | X02 | | | | | X01 | | |X02=Monitor until the desired weight is achieved|X01=Reevaluate}}
{{familytree | | | | | | | | | | | | | | |,|-|^|-|.| }}
{{familytree | | | | | | | | | | | | | | Y02 | | | Y01 | | |Y02=Cause identified|Y01=Cause unidentified}}
{{familytree | | | | | | | | | | | | | | |!| | | |,|^|-|.| }}
{{familytree | | | | | | | | | | | | | | |`|-|-| P02 | | P01 | | |P02='''Consider medications'''<div style="float: left; text-align: left; width: 15em;"><div class="mw-collapsible mw-collapsed">
:❑ Metoclopramide for [[nausea]] (side effects include [[parkinsonism]])<br>
:❑ [[Cyproheptadine]] appetite stimulant |P01=<div style="float: left; text-align: left; width: 15em;"> 6 months after presentation cause still unidentified}}
{{familytree | | | | | | | | | | | | | | | | | | |!| | | |!| | |}}
{{familytree | | | | | | | | | | | | | | | | | | O01 | | O02 | | | | O01=No weight gain|O02=Unexplained unintentional weight loss}}
{{familytree | | | | | | | | | | | | | | | | | | |!| }}
{{familytree | | | | | | | | | | | | | | | | | | W01 | W01=Consider [[feeding tube]]}}
{{familytree | | | | | | | | | | | | | | | | | | |!| }}
{{familytree | | | | | | | | | | | | | | | | | | F01 | |F01=Monitor}}
{{familytree/end}}
{{familytree/end}}


==Treatment==
==Do's==
Shown below is an algorithm summarizing the treatment of <nowiki>[[disease name]]</nowiki> according the the [...] guidelines.
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | A01 |A01= }}
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | B01 | | | | | | | | B02 | | |B01= |B02= }}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | C01 | | | | | | | | |!| |C01= }}
{{familytree | |,|-|^|.| | | | | | | | |!| }}
{{familytree | D01 | | D02 | | | | | | D03 |D01= |D02= |D03= }}
{{familytree | |!| | | | | | | | | |,|-|^|.| }}
{{familytree | E01 | | | | | | | E02 | | | E03 |E01= |E02= |E03= }}
{{familytree | | | | | | | | | | |!| | | | |!| }}
{{familytree | | | | | | | | | | F01 | | | F02 |F01= |F02= }}
{{familytree/end}}


==Do's==
*Perform a thorough [[physical exam]] to evaluate for cause of [[weight loss]].
* Perform a thorough [[physical exam]] to evaluate for cause of [[weight loss]].
*Assess the [[nutrition|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==
==Don'ts==
* The content in this section is in bullet points.
 
*Do not miss the oral exam especially among the elderly.
*Do not rely on the [[patient]] history among [[patient]]s with [[cognitioncognitive]] dysfunctions.


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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[[Category:Resident survival guide]]
[[Category:Resident survival guide]]
[[Category:Templates]]
[[Category:Primary care]]
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[[Category:Oncology]]
[[Category:Medicine]]
[[Category:Medicine]]
 
[[Category:Up-To-Date]]
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Latest revision as of 15:51, 23 October 2020


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

  1. Abed J, Judeh H, Abed E, Kim M, Arabelo H, Gurunathan R (September 2014). ""Fixing a heart": the game of electrolytes in anorexia nervosa". Nutr J. 13: 90. doi:10.1186/1475-2891-13-90. PMC 4168120. PMID 25192814.
  2. 2.0 2.1 2.2 Bosch X, Monclús E, Escoda O, Guerra-García M, Moreno P, Guasch N, López-Soto A (2017). "Unintentional weight loss: Clinical characteristics and outcomes in a prospective cohort of 2677 patients". PLoS ONE. 12 (4): e0175125. doi:10.1371/journal.pone.0175125. PMC 5384681. PMID 28388637.
  3. 3.0 3.1 Alibhai, S. M.H. (2005). "An approach to the management of unintentional weight loss in elderly people". Canadian Medical Association Journal. 172 (6): 773–780. doi:10.1503/cmaj.1031527. ISSN 0820-3946.
  4. Wu, Wen-Chih Hank; Bosch, Xavier; Monclús, Esther; Escoda, Ona; Guerra-García, Mar; Moreno, Pedro; Guasch, Neus; López-Soto, Alfons (2017). "Unintentional weight loss: Clinical characteristics and outcomes in a prospective cohort of 2677 patients". PLOS ONE. 12 (4): e0175125. doi:10.1371/journal.pone.0175125. ISSN 1932-6203.
  5. 5.0 5.1 Gaddey HL, Holder K (May 2014). "Unintentional weight loss in older adults". Am Fam Physician. 89 (9): 718–22. PMID 24784334.
  6. Lankisch P, Gerzmann M, Gerzmann JF, Lehnick D (January 2001). "Unintentional weight loss: diagnosis and prognosis. The first prospective follow-up study from a secondary referral centre". J. Intern. Med. 249 (1): 41–6. doi:10.1046/j.1365-2796.2001.00771.x. PMID 11168783.
  7. Sarkar SB, Sarkar S, Ghosh S, Bandyopadhyay S (October 2012). "Addison's disease". Contemp Clin Dent. 3 (4): 484–6. doi:10.4103/0976-237X.107450. PMC 3636818. PMID 23633816.
  8. Brymer C, Winograd CH (September 1992). "Fluoxetine in elderly patients: is there cause for concern?". J Am Geriatr Soc. 40 (9): 902–5. doi:10.1111/j.1532-5415.1992.tb01987.x. PMID 1512386.
  9. 9.0 9.1 Guigoz Y, Vellas B, Garry PJ (January 1996). "Assessing the nutritional status of the elderly: The Mini Nutritional Assessment as part of the geriatric evaluation". Nutr. Rev. 54 (1 Pt 2): S59–65. doi:10.1111/j.1753-4887.1996.tb03793.x. PMID 8919685.
  10. Morley JE, Kraenzle D (June 1994). "Causes of weight loss in a community nursing home". J Am Geriatr Soc. 42 (6): 583–5. doi:10.1111/j.1532-5415.1994.tb06853.x. PMID 8201141.
  11. Thompson MP, Morris LK (May 1991). "Unexplained weight loss in the ambulatory elderly". J Am Geriatr Soc. 39 (5): 497–500. doi:10.1111/j.1532-5415.1991.tb02496.x. PMID 2022802.
  12. Reber E, Gomes F, Vasiloglou MF, Schuetz P, Stanga Z (July 2019). "Nutritional Risk Screening and Assessment". J Clin Med. 8 (7). doi:10.3390/jcm8071065. PMC 6679209 Check |pmc= value (help). PMID 31330781.
  13. Kondrup J, Allison SP, Elia M, Vellas B, Plauth M (August 2003). "ESPEN guidelines for nutrition screening 2002". Clin Nutr. 22 (4): 415–21. doi:10.1016/s0261-5614(03)00098-0. PMID 12880610.
  14. Gazewood JD, Mehr DR (July 1998). "Diagnosis and management of weight loss in the elderly". J Fam Pract. 47 (1): 19–25. PMID 9673603.
  15. Hu J, Van Valckenborgh E, Menu E, De Bruyne E, Vanderkerken K (November 2012). "Understanding the hypoxic niche of multiple myeloma: therapeutic implications and contributions of mouse models". Dis Model Mech. 5 (6): 763–71. doi:10.1242/dmm.008961. PMC 3484859. PMID 23115205.
  16. Biemer JJ (1984). "Hepatic manifestations of lymphomas". Ann. Clin. Lab. Sci. 14 (4): 252–60. PMID 6380395.
  17. Huffman GB (February 2002). "Evaluating and treating unintentional weight loss in the elderly". Am Fam Physician. 65 (4): 640–50. PMID 11871682.
  18. Kondrup, J (2003). "ESPEN Guidelines for Nutrition Screening 2002". Clinical Nutrition. 22 (4): 415–421. doi:10.1016/S0261-5614(03)00098-0. ISSN 0261-5614.