Weight loss resident survival guide

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:

• Electrolyte disturbances as a result of malnutrition may lead to arrhythmias and be life-threatening if not corrected in time.

Common Causes

Age >65 years

• Malignancies (specifically digestive and non-hematologic)
• Dementia
• Stroke
• Parkinson's disease
• Polymyalgia rheumatica
• Oral disorders.

Age <65 years

• Endocrine disorders
• Infections such as TB and HIV
• Psychiatric disorders such as depression, anxiety, and OCD
• Malignancies such as 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.

Causes of weight loss

Intentional weight loss

Unintentional weight loss

Non-Malignant (~60%)

Malignant (19 - 39%) ❑ Gastrointestinal (53%) based on one study : Oesophageal cancer, stomach cancer, colon cancer, and rectal cancer. ❑ Renal: Renal cancer and renal pelvis cancer. ❑ Pulmonary: Bronchial cancer and lung cancer ❑ Hepato-pancreatic: HCC, pancreatic cancer, intra-hepatic bile duct cancer. ❑ Genitourinary: Ovarian cancer, cervical cancer, endometrial cancer, prostate cancer, ureter cancer, bladder cancer ❑ Hematologic: Hodgkin's lymphoma and Non-Hodgkin's lymphoma ❑ Breast cancer ❑ Malignant neoplasms

Infectious (2 - 8%) ❑ Chronic diarrhea ❑ Tuberculosis (TB) ❑ HIV ❑ infective endocarditis ❑ Infective colitis and gastroenteritis.

Autoimmune (2 - 7%) ❑ SLE ❑ Rheumatoid arthritis ❑ Polyarteritis nodosa ❑ Polymyalgia rheumatica ❑ Giant cell arteritis with polymyalgia rheumatica

Psychologic/ Psychiatric (9 - 42%) ❑ Depression ❑ Bipolar disorder ❑ Somatoform disorder ❑ Schizophrenia ❑ OCD ❑ Anxiety ❑ Dementia ❑ Social exclusion or rejection ❑ Neglect ❑ Disability

Organ system based ❑ Gastrointestinal (6 - 30%): Cholecystitis, Gastric and duodenal ulcers, IBD, celiac disease, malabsorption, steatorrhea, vascular disorders affecting intestines, non-infective gastroenteritis and colitis, swallowing pathologies, and dental issues. ❑ Renal (4%): Pyelonephritis, nephritic syndrome, and nephrotic syndrome ❑ Cardiopulmonary (2-10%): Heart failure, COPD, lung abscess (without pneumonia), interstitial lung disease (fibrotic or idiopathic), pleural effusion, and pyothorax (without fistula). ❑ Neurologic (2 - 7%): Stroke, parkinson's disease, and motor neuron disease. ❑ Endocrine (4 - 11%): Type I diabetes, type 2 diabetes, hyperthyroidism, primary hyperparathyroidism, Addison's disease, and subacute thyroiditis.

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.

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 ❑ CT (chest, abdomen, pelvis, head, etc) ❑PET scan ❑ Colonoscopy ❑ Mammogram ❑ Protein electrophoresis

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 ❑ Peptic ulcer ❑ Celiac disease ❑ Whipple's disease

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

Treatment ❑ Chronic diarrhea treatment ❑ Tb treatment ❑ HIV treatment ❑ Dronabinol appetite stimulant. ❑ Infective endocarditis treatment ❑ Gastroenteritis treatment and colitis treatment

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

• Do not miss the oral exam especially among the elderly.
• Do not rely on the patient history among patients with cognitioncognitive dysfunctions.