Weight loss resident survival guide: Difference between revisions
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{{familytree | | | | | | | | | | | | | |!| | | | |}} | {{familytree | | | | | | | | | | | | | |!| | | | |}} | ||
{{familytree | | | | | | | | |,|-|-|-|-|^|-|-|-|-|-|.| }} | {{familytree | | | | | | | | |,|-|-|-|-|^|-|-|-|-|-|.| }} | ||
{{familytree | | | | | | | | D01 | | | | | | | | | | D02 | | |D01='''Non-Malignant''' (~60%)<br>|D02=<div style="float: left; text-align: left; width: | {{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> | ❑ '''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> | ❑ '''Renal''':<br> [[Renal cancer]] and [[Transitional cell carcinoma|renal pelvis cancer]].<br> | ||
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{{familytree | |,|-|-|-|v|-|-|+|-|-|-|v|-|-|-|v|-|-|-|.|}} | {{familytree | |,|-|-|-|v|-|-|+|-|-|-|v|-|-|-|v|-|-|-|.|}} | ||
{{familytree | E01 | | E02 | | E03 | | E04| | E05 | | E06 | | |E01=<div style="float: left; text-align: left; width: | {{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> | ❑ Chronic [[diarrhea]]<br> | ||
❑ [[Tuberculosis]] (TB)<br> | ❑ [[Tuberculosis]] (TB)<br> | ||
❑ [[HIV]]<br> | ❑ [[HIV]]<br> | ||
❑ [[infective endocarditis]]<br> | ❑ [[infective endocarditis]]<br> | ||
❑ Infective [[colitis]] and [[gastroenteritis]]. |E02=<div style="float: left; text-align: left; width: | ❑ 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: | ❑ [[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> | ||
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❑ Social exclusion or rejection<br> | ❑ Social exclusion or rejection<br> | ||
❑ Neglect<br> | ❑ Neglect<br> | ||
❑ [[Disability]] |E04=<div style="float: left; text-align: left; width: | ❑ [[Disability]] |E04=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Organ system based'''<div class="mw-collapsible mw-collapsed"> | ||
❑ '''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> | ❑ '''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''' (4%):<br> | ❑ '''Renal''' (4%):<br> | ||
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❑ '''Neurologic''' (2 - 7%):<br>[[Stroke]], [[parkinson's disease]], and [[motor neuron disease]].<br> | ❑ '''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]]. | ❑ '''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: | |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> | ❑ [[Narcotic analgesic]]s (such as [[opioids]]) interfere with [[cognition]] and ability to eat<br> | ||
❑ [[Sedatives]] also interfere with [[cognition]]<br> | ❑ [[Sedatives]] also interfere with [[cognition]]<br> |
Revision as of 20:25, 7 September 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.
Lymphadenopathy resident survival guide microchapters |
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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 a common complaint 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. Endocrine disorders, infections, and psychiatric disorders make up the most part for 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, 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 provide a general picture of patient condition. Follow-up is necessary to completely treat the known and identify unknown causes of weight loss.
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 of not corrected in time.[1]
Common Causes
Age >65 years[2]
- Malignancies (specifically digestive and non-hematologic)
- Dementia
- Stroke
- Parkinson's disease
- Polymyalgia rheumatica
- Oral disorders.
Age <65 years[2]
- 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.[3][4][5][6][2][7][8][9][10][11]
- To read about other causes of unintentional weight loss click here.
Diagnosis and Management
Shown below is an algorithm summarizing the diagnosis of weight loss.[9][12][13][14][15][16][5]
Patient presents with weight loss/ incidental finding | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Loss of >5% of the usual body weight within 6 - 12 months | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
History ❑ Source of history:
❑ Systemic review: Communicable infectious diseases/ travel to high-risk areas. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Physical exam ❑ Appearance of the patient:
❑ BMI assessment or simply weight among immobile or bed-ridden patients.
❑ Observing the patient having a meal may demonstrate
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Intentional weight loss | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Unintentional weight loss | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Nutritional status/ caloric intake | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Adequate | Inadequate | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Suspect malabsorption | Suspect altered metabolism | Access to food | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Suspect cognitive dysfunction/ consider social factors | Consider oral or dental issues/ dysphagia/ dysgeusia | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Initial screening labs ❑ CBC with differential and peripheral smear
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Provisional diagnosis established | Progressive oropharyngeal or esophageal dysphagia | Peptic ulcer celiac disease, whipple disease | Potential depression Cognitive dysfunction | Suspected malignancy | Suspected nutritional deficiency | Suspected infection | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Specific tests ❑ Dental issues: Refer to the dentist. ❑ Nephrotic syndrome: 24-hour urine collection (urine protein >3.5 g/day). | Specific tests | 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 | Specific tests ❑ CT (chest, abdomen, pelvis, head, etc) ❑PET scan | Specific tests ❑ Serum ferritin | Specific tests ❑ Chronic diarrhea: Stool osmotic gap, culture, ova and parasite, electrolytes, leukocytes, lactoferrin, and C. difficile test. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
Treatment ❑ Nephrotic syndrome | Esophageal cancer treatment | Treatment | Treatment ❑ Referral to a specialist (psychotherapist and/or a psychiatrist) | Treatment | |||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Multidisciplinary approach ❑ Nutritional supplements with regular meals | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Follow-up in 1 or 3 months depending upon the cause. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Weight gain | No weight gain/ continued weight loss | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Reevaluate | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Cause unidentified after 6 months of presentation | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Unexplained unintentional weight loss | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Do's
- Perform a thorough physical exam to evaluate for cause of weight loss.
- Assess the nutritional status of the patient.
- Assess the patient for possible depression.
- Assess serum electrolytes to assess for life-threatening electrolyte abnormalities.
Don'ts
- Do not miss the oral exam especially among the elderly.
- Do not rely on the patient history among patients with cognitioncognitive dysfunctions.
References
- ↑ 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.
- ↑ 2.0 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.
- ↑ 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.
- ↑ 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.
- ↑ 5.0 5.1 Gaddey HL, Holder K (May 2014). "Unintentional weight loss in older adults". Am Fam Physician. 89 (9): 718–22. PMID 24784334.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 9.0 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.
- ↑ 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.
- ↑ 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.
- ↑ 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. - ↑ 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.
- ↑ Gazewood JD, Mehr DR (July 1998). "Diagnosis and management of weight loss in the elderly". J Fam Pract. 47 (1): 19–25. PMID 9673603.
- ↑ 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.
- ↑ Biemer JJ (1984). "Hepatic manifestations of lymphomas". Ann. Clin. Lab. Sci. 14 (4): 252–60. PMID 6380395.