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Rational Approach to Patients With Unintentional Weight Loss

      Unintentional weight loss is a problem encountered frequently in clinical practice. Weight loss and low body weight have potentially serious clinical implications. Although a nonspecific observation, weight loss is often of concern to both patients and physicians. There are multiple potential etiologies and special factors to consider in selected groups, such as older adults. A rational approach to these patients is based on an understanding of the relevant biologic, psychological, and social factors identified during a thorough history and physical examination. The goal of this article is to discuss the clinical importance, review potential pathophysiology, and discuss specific etiologies of unintentional weight loss that will enable the clinician to formulate a practical stepwise approach to patient evaluation and management.

      Abbreviations:

      AIDS (acquired immunodeficiency syndrome), BMI (body mass index)
      Body weight is determined by a complex interaction of caloric intake, absorption, and utilization. Multiple factors (age, health status, medications, etc) influence this interaction. Among healthy people, total body weight tends to peak in the fifth to sixth decade of life.
      • Williamson DF
      Descriptive epidemiology of body weight and weight change in U.S. adults.
      • Friedlaender JS
      • Costa Jr, PT
      • Bosse R
      • Ellis E
      • Rhoads JG
      • Stoudt HW
      Longitudinal physique changes among healthy white veterans at Boston.
      • Chumlea WC
      • Garry PJ
      • Hunt WC
      • Rhyne RL
      Distributions of serial changes in stature and weight in a healthy elderly population.
      Once weight has peaked, there is relative stability, with longitudinal studies of physique changes demonstrating a decrease of only 1 to 2 kg per decade thereafter.
      • Friedlaender JS
      • Costa Jr, PT
      • Bosse R
      • Ellis E
      • Rhoads JG
      • Stoudt HW
      Longitudinal physique changes among healthy white veterans at Boston.
      • Chumlea WC
      • Garry PJ
      • Hunt WC
      • Rhyne RL
      Distributions of serial changes in stature and weight in a healthy elderly population.
      Clinically important weight loss can be defined as the loss of 10 lb (4.5 kg) or more than 5% of the usual body weight over a period of 6 to 12 months, especially when progressive. Weight loss greater than 10% is considered to represent protein-energy malnutrition, which is associated with impaired physiologic function such as impaired cell-mediated and humoral immunity.
      • Reife CM
      Involuntary weight loss.
      Weight loss in excess of 20% implies severe protein-energy malnutrition and is associated with pronounced organ dysfunction.
      • Bistrian BR
      Nutritional assessment.
      Weight loss may also be characterized by the decrease in lean body mass relative to body fat. Excessive loss of lean body mass results in skeletal and cardiac muscle wasting and loss of visceral protein.
      • Keys A
      • Broz?ek J
      • Henschel A
      • Mickelsen O
      • Taylor HL
      Accompanying nutrient deficiencies also have clinical implications.
      As a cumulative effect, low body weight and weight loss are powerful predictors of morbidity (eg, wound healing, infectious complications, pressure sores, performance status), response to medical therapy, and mortality.
      • Keys A
      • Broz?ek J
      • Henschel A
      • Mickelsen O
      • Taylor HL
      • Fischer J
      • Johnson MA
      Low body weight and weight loss in the aged.
      • Tayback M
      • Kumanyika S
      • Chee E
      Body weight as a risk factor in the elderly.
      • Stevens J
      • Cai J
      • Pamuk ER
      • Williamson DF
      • Thun MJ
      • Wood JL
      The effect of age on the association between body-mass index and mortality.
      • Payette H
      • Coulombe C
      • Boutier V
      • Gray-Donald K
      Weight loss and mortality among free-living frail elders: a prospective study.
      • Tully CL
      • Snowdon DA
      Weight change and physical function in older women: findings from the Nun Study.
      Weight loss is usually a concern for both patients and physicians; however, weight loss is a nonspecific finding with broad diagnostic possibilities. Indeed, the etiology can be multi-factorial or idiopathic. Unintentional weight loss is encountered frequently in clinical practice, identified in up to 13% of elderly outpatients
      • Wallace JI
      • Schwartz RS
      • LaCroix AZ
      • Uhlmann RF
      • Pearlman RA
      Involuntary weight loss in older outpatients: incidence and clinical significance.
      and 50% to 65% of nursing home residents.
      • Chang JI
      • Katz PR
      • Ambrose P
      Weight loss in nursing home patients: prognostic implications.
      • Morley JE
      • Kraenzle D
      Causes of weight loss in a community nursing home.
      Some patients may be undisturbed by their weight loss, may welcome it, and may mistakenly attribute it to their attempts to lose weight. Therefore, routine determination of weight is an important strategy in any primary care practice.
      Given the prevalence of unintentional weight loss, particularly among older adults, and the associated clinical importance of weight loss and low body weight, the clinician must address several important questions. Does the patient have an underlying malignancy or other serious illness? What are the immediate clinical implications of the weight loss (eg, operative morbidity) for this patient? What is the best way to proceed with an evaluation? How should this patient be treated?

      PATHOPHYSIOLOGY OF WEIGHT LOSS

      The precise mechanism of weight loss is unknown in many patients. Caloric intake, absorption, utilization, and loss are key components that determine an individual's weight. Alteration in the balance of these components affects a patient's ability to maintain weight. For example, caloric intake may be modified by altered smell or taste, anorexia, nausea, abnormal satiation, etc. Absorption may be modified by altered gastrointestinal motility, exocrine pancreatic function, mucosal absorptive capacity, luminal bacteria, and medications, among other factors. Utilization is primarily affected by the metabolic rate, which is affected by the systemic inflammatory response of various medical conditions. In addition to primary gut disease, excessive loss of calories can be secondary to diseases of the skin and kidneys. Mediators of anorexia and weight loss include cytokines such as cachectin (tumor necrosis factor) and interleukins, humoral substances (eg, bombesin-like substances, hypersensitivity to cholecystokinin), and proposed anorectic agents such as corticotropin-releasing factor.
      • Morley JE
      Neuropeptide regulation of appetite and weight.
      • Morley JE
      • Silver AJ
      Anorexia in the elderly.

      ETIOLOGIES OF WEIGHT LOSS

      Whereas dieting and eating disorders (ie, anorexia nervosa and bulimia nervosa) explain most cases of intentional weight loss, unintentional weight loss can be divided into organic, psychosocial, and idiopathic etiologies. Additionally, selected groups (eg, older adults) often have multiple etiologies to explain their weight loss. Three studies that have evaluated the etiologies of unintentional weight loss, defined as more than 5% of usual body weight, are summarized in Table 1.
      • Marton KI
      • Sox Jr, HC
      • Krupp JR
      Involuntary weight loss: diagnostic and prognostic significance.
      • Rabinovitz M
      • Pitlik SD
      • Leifer M
      • Garty M
      • Rosenfeld JB
      Unintentional weight loss: a retrospective analysis of 154 cases.
      • Thompson MP
      • Morris LK
      Unexplained weight loss in the ambulatory elderly.
      Although each study can be challenged for methodological bias, several key concepts emerge: (1) among organic etiologies, cancer is most common; (2) the etiology of weight loss is evident without an extensive evaluation in most patients; and (3) psychiatric illness and nondiagnostic evaluations are common.
      Table 1Published Studies of Unintentional Weight Loss
      StudyMarton et al
      • Marton KI
      • Sox Jr, HC
      • Krupp JR
      Involuntary weight loss: diagnostic and prognostic significance.
      Rabinovitz et al
      • Rabinovitz M
      • Pitlik SD
      • Leifer M
      • Garty M
      • Rosenfeld JB
      Unintentional weight loss: a retrospective analysis of 154 cases.
      Thompson & Morris
      • Thompson MP
      • Morris LK
      Unexplained weight loss in the ambulatory elderly.
      DesignProspectiveRetrospectiveRetrospective
      Population70% InpatientInpatientOutpatient
      Study size (No. of patients)9115445
      Mean age (y)596472
      Male:female ratio90:11.2:11:2
      Weight loss (time)>5% (6 mo)>5% (unspecified)>7.5% (6 mo)
      Mortality (follow-up)25% (18 mo)38% (30 mo)9% (24 mo)
      Diagnosis (%)
       Cancer193616
       Organic (not cancer)503040
       Psychiatric91020
       Idiopathic262324
      Similar studies from France
      • Leduc D
      • Rouge PE
      • Rousset H
      • Maitre A
      • Champay-Hirsch AS
      • Massot C
      Clinical study of 105 cases of isolated weight loss in internal medicine [in French].
      and Mexico
      • Huerta G
      • Viniegra L
      Involuntary weight loss as a clinical problem [in Spanish].
      have reported a higher prevalence of psychiatric etiologies (primarily depression and stress), prompting the authors to encourage a thorough search for psychiatric disorders. Of note, although patients with involuntary weight loss have higher mortality rates than those without weight loss, the prognosis appears to be better for those in whom no organic cause of weight loss is identified.

      Organic Etiologies of Unintentional Weight Loss

      The organic etiologies most commonly identified in patients presenting with unintentional weight loss are listed in order of decreasing frequency.
      • Reife CM
      Involuntary weight loss.
      • Marton KI
      • Sox Jr, HC
      • Krupp JR
      Involuntary weight loss: diagnostic and prognostic significance.
      • Rabinovitz M
      • Pitlik SD
      • Leifer M
      • Garty M
      • Rosenfeld JB
      Unintentional weight loss: a retrospective analysis of 154 cases.
      • Thompson MP
      • Morris LK
      Unexplained weight loss in the ambulatory elderly.
      • Leduc D
      • Rouge PE
      • Rousset H
      • Maitre A
      • Champay-Hirsch AS
      • Massot C
      Clinical study of 105 cases of isolated weight loss in internal medicine [in French].
      • Huerta G
      • Viniegra L
      Involuntary weight loss as a clinical problem [in Spanish].
      Cancer.-Malignancies account for approximately one third of all patients presenting with unintentional weight loss. Signs and symptoms suggesting malignancy may be nonspecific or subtle but are often identified by history and physical examination. Metabolic derangements, often coupled with the production of anorectic agents, have been implicated as pathophysiologic mechanisms. Malignancies to consider include gastrointestinal, hepatobiliary, hematologic, lung, breast, genitourinary, ovarian, and prostate.
      Gastroenterological Disorders.-Gastroenterological disorders are the most common nonmalignant organic etiologies identified in patients with unintentional weight loss, accounting for about 15% of cases in published series. Peptic ulcer disease, inflammatory bowel disease, dysmotility syndromes (eg, gastroparesis and pseudo-obstruction), chronic pancreatitis, celiac disease, constipation, atrophic gastritis, and oral problems (eg, poor dentition, periodontal disease, and xerostomia) are some of the potential etiologies that can precipitate weight loss. A thorough history and physical examination will usually reveal signs or symptoms suggestive of a primary gastrointestinal etiology.
      Endocrine Diseases.-Diabetes mellitus, hyperthyroidism, and hypothyroidism are the most common endocrinopathies that cause unintentional weight loss. Less common diagnoses include pheochromocytoma, panhypopituitarism, adrenal insufficiency, and hyperparathyroidism.
      Infection.-Tuberculosis, fungal disease, parasites, subacute bacterial endocarditis, human immunodeficiency virus, and other hidden infections can occasionally cause unintentional weight loss. Asking about risk factors, including travel, occupation, living arrangements, lifestyle, and history of exposure, is essential. Patients with the acquired immunodeficiency syndrome (AIDS) may develop AIDS wasting syndrome, one of the most common AIDS-defining illnesses.
      Medications.-Frequently overlooked, medications are an important potential etiology of unintentional weight loss, particularly in elderly patients. Adverse effects, including anorexia, nausea, diarrhea, and dysgeusia, can alter the intake, absorption, and utilization of nutrients.
      Cardiovascular Diseases.-Cardiovascular diseases can lead to unintentional weight loss via multiple mechanisms, but the primary mechanisms are increased metabolic demand and decreased appetite and caloric intake. Cachexia is a frequent complication of severe congestive heart failure (ie, cardiac cachexia). Routine dietary restrictions for patients with cardiac disease may further accentuate weight loss. Mesenteric ischemia is relatively uncommon but should be considered. Affected patients present with sitophobia (fear of eating). Inadequate blood flow to the gut postprandially precipitates abdominal discomfort, termed intestinal angina, that improves following revascularization.
      Neurologic Illness.-Nervous system injury or degeneration (eg, stroke, quadriplegia, multiple sclerosis, and dementia) can contribute to visceral dysfunction (ie, dysphagia, constipation) and other functional limitations that impair caloric intake. One such example is Parkinson disease, which has been associated with intestinal dysmotility, defecatory dysfunction, and increased caloric demands. In addition, prescribed medications often cause xerostomia, anorexia, and early satiety, which further compromise nutrient intake. Cognitive dysfunction, such as dementia, frequently diminishes interest in nutritional intake, which can lead to unintentional weight loss.
      Pulmonary Diseases.-As with cardiac diseases, unintentional weight loss may be a secondary manifestation of pulmonary diseases. Severe chronic obstructive pulmonary disease can lead to an increase in metabolic demands secondary to the increased use of accessory muscles of respiration. Dyspnea, aerophagia, and adverse effects of medication often produce anorexia, early satiety, bloating, and dyspepsia-all factors that may contribute to reduced nutrient intake.
      Renal Disease.-Uremia often produces anorexia, nausea, and vomiting. Protein loss in the urine, as seen in patients with nephrotic syndrome, often leads to a negative caloric balance. Hemodialysis is accompanied by swings in metabolic balance that have been associated with losses in lean body mass over time.
      Connective Tissue Diseases.-Acute and chronic inflammatory diseases increase metabolic demand, and associated anorexia may also disrupt nutritional balance. In addition, connective tissue diseases that affect the gut (eg, scleroderma) may produce various motility disturbances, including dysphagia, delayed gastric emptying, pseudo-obstruction, and constipation. Resultant bacterial overgrowth may exacerbate nutrient malabsorption. All these sequelae can compromise the intake, absorption, and utilization of nutrients.

      Psychosocial Etiologies of Unintentional Weight Loss

      Blazer and Williams
      • Blazer D
      • Williams CD
      Epidemiology of dysphoria and depression in an elderly population.
      reported that 15% of elderly people have depressive symptoms, with approximately 4% meeting criteria for major depression. In addition, 2% to 3% of patients aged 65 to 79 years have dementia; this increases to 20% in those older than 80 years.
      • Morley JE
      • Silver AJ
      Anorexia in the elderly.
      Depression and dementia, which are poorly recognized in clinical practice, may lead to apathy, an inability to care for oneself, and a decreased recognition for the need to eat, all of which lead to weight loss. In fact, weight loss may not just be a late manifestation of dementia but may be one of the most apparent presenting symptoms.
      • Barrett-Connor E
      • Edelstein SL
      • Corey-Bloom J
      • Wiederholt WC
      Weight loss precedes dementia in community-dwelling older adults.
      In a longitudinal study of patients with Alzheimer disease, White et al
      • White H
      • Pieper C
      • Schmader K
      • Fillenbaum G
      Weight change in Alzheimer's disease.
      found that nearly twice as many patients experienced a weight loss of 5% or greater compared with controls. This finding of weight loss was confirmed in a review of 8 international studies on nutrition in patients with Alzheimer disease.
      • Wolf-Klein GP
      • Silverstone FA
      Weight loss in Alzheimer's disease: an international review of the literature.
      The presence of altered affect or cognition should also prompt an evaluation for associated medical conditions (eg, thiamin, folate, or vitamin B12 deficiency) that may present with symptoms similar to depression or dementia.
      • Fischer J
      • Johnson MA
      Low body weight and weight loss in the aged.
      • Hutto BR
      Folate and cobalamin in psychiatric illness.
      • Martin DC
      B12 and folate deficiency dementia.
      • Cole MG
      • Prchal JF
      Low serum vitamin B12 in Alzheimer-type dementia.
      • Iber FL
      • Blass JP
      • Brin M
      • Leevy CM
      Thiamin in the elderly-relation to alcoholism and to neurological degenerative disease.
      Anxiety has been associated with several functional gastrointestinal disorders, including rumination syndrome and nonulcer dyspepsia. Weight loss may accompany these disorders.
      • Malcolm A
      • Thumshirn MB
      • Camilleri M
      • Williams DE
      Rumination syndrome.
      • Tack J
      • Piessevaux H
      • Coulie B
      • Caenepeel P
      • Janssens J
      Role of impaired gastric accommodation to a meal in functional dyspepsia.
      Treatment directed at the psychological cause is often helpful. Other psychosocial issues include alcoholism, physical isolation, poverty, and other barriers to obtaining adequate nutrition. These functional limitations are frequently underappreciated by physicians and family members.
      Older adults represent a select group of patients in whom multiple medical, pharmacological, and psychosocial issues can lead to weight loss. Since lean body mass declines with age, weight loss in the elderly population may be of greater clinical importance. Several excellent reviews have outlined special considerations in the evaluation and management of weight loss in older adults.
      • Fischer J
      • Johnson MA
      Low body weight and weight loss in the aged.
      • Olsen-Noll CG
      • Bosworth MF
      Anorexia and weight loss in the elderly: causes range from loose dentures to debilitating illness.
      • Robbins LJ
      Evaluation of weight loss in the elderly.
      • Wallace JI
      • Schwartz RS
      Involuntary weight loss in elderly outpatients: recognition, etiologies, and treatment.
      • Gazewood JD
      • Mehr DR
      Diagnosis and management of weight loss in the elderly.
      Identification of weight loss in the elderly population should prompt a thorough evaluation that includes an assessment of specific age-related factors (impaired smell and taste, dementia, social isolation, etc) and common organic etiologies. Robbins
      • Robbins LJ
      Evaluation of weight loss in the elderly.
      nicely summarized many of these considerations in his “nine D's” of weight loss in the elderly population (Table 2).
      Table 2The Nine D's of Weight Loss in the Elderly
      • Dentition
      • Dysgeusia
      • Dysphagia
      • Diarrhea
      • Disease (chronic)
      • Depression
      • Dementia
      • Dysfunction
      • Drugs
      Reprinted with permission from Robbins.
      • Robbins LJ
      Evaluation of weight loss in the elderly.

      EVALUATION OF UNINTENTIONAL WEIGHT LOSS

      In most patients, the etiology of unintentional weight loss is identified through a detailed history and physical examination. Key concepts of the evaluation include: (1) document weight loss-in up to 50% of patients, weight loss cannot be documented
      • Chang JI
      • Katz PR
      • Ambrose P
      Weight loss in nursing home patients: prognostic implications.
      ; (2) perform a detailed history-medical, psychosocial, and dietary-and physical examination; (3) perform tests based on history and physical findings in conjunction with limited standard tests; and (4) establish appropriate follow-up to assess response to management.
      A rational stepwise approach to the patient presenting with unintentional weight loss is outlined in Figure 1. If targeted investigations fail to reveal a diagnosis, completion of a limited standard testing panel, to include age-dependent cancer screening, is indicated. Given the high prevalence of gastroenterological disease, evaluation of the upper and lower gut should be considered, particularly in patients with gastrointestinal symptoms. Several factors, including age, patient tolerance, and presence or absence of anemia or diarrhea, will help the clinician in determining the diagnostic yield of endoscopy vs radiographic studies.
      Figure thumbnail gr1
      Figure 1Stepwise approach to patients with unintentional weight loss. Alk Phos = alkaline phosphatase; ALT = alanine aminotransferase; AST = aspartate aminotransferase; BUN = blood urea nitrogen; CBC = complete blood cell count; CRP = C-reactive protein; diff = white blood cell count differential; ESR = erythrocyte sedimentation rate; HIV = human immunodeficiency virus; MCV = mean corpuscular volume; MMSE = Mini-Mental State Examination
      • Folstein MF
      • Folstein SE
      • McHugh PR
      “Mini-mental state:” a practical method for grading the cognitive state of patients for the clinician.
      ; Pap = Papanicolaou; PSA = prostate-specific antigen; UA = urinalysis. *Depression inventories may be useful.
      • Derogatis LR
      • Lazarus L
      SCL-90-R, brief symptom inventory, and matching clinical rating scales.
      • Beck AT
      • Ward CH
      • Mendelson M
      • Mock J
      • Erbaugh J
      An inventory for measuring depression.
      • Yesavage JA
      • Brink TL
      • Rose TL
      • et al.
      Development and validation of a geriatric depression screening scale: a preliminary report.
      Assessment of study results and reevaluation of the patient should be followed by a definitive plan. Patients with a negative evaluation are unlikely to have a serious organic explanation for weight loss. The clinician should be cognizant of relevant psychosocial issues that may have a role in the patient's presentation. Additional studies should be performed for specific concerns or to follow up abnormalities identified on initial testing (Table 3). If a satisfactory evaluation is negative (in about 25% of patients), one should establish a management plan that includes a predetermined follow-up in 3 to 6 months because some causes of weight loss can be subtle and may be revealed with time and continued vigilance. Additionally, many patients' nutritional status should be monitored even if a specific etiology of weight loss cannot be determined.
      Table 3Specialized Testing to Consider in Patients With Unintentional Weight Loss
      Based on clinical concerns or preliminary findings. CT = computed tomography; LDH = lactate dyhydrogenase; PPD = purified protein derivative; RPR = rapid plasma reagin.
      Structural investigationsSmall bowel x-ray film (inflammatory bowel disease, diarrhea, malabsorption, obstruction)
      Body CT scan (malignancy, abscess, chronic pancreatitis, intestinal complications, etc)
      Mesenteric Doppler ultrasonography vs angiography (intestinal ischemia)
      Functional investigationsScintigraphic assessment of gastrointestinal/colonic transit (dysmotility)
      Laboratory studiesRPR, PPD, LDH, growth hormone, testosterone
      HistopathologySmall bowel (malabsorptive process), colon (diarrhea), amyloid staining, etc
      Psychosocial issuesFormal testing, psychology or psychiatry consultation
      * Based on clinical concerns or preliminary findings. CT = computed tomography; LDH = lactate dyhydrogenase; PPD = purified protein derivative; RPR = rapid plasma reagin.

      MANAGEMENT PRINCIPLES

      Early intervention based on the findings of the diagnostic evaluation provides the greatest opportunity for success. The severity of weight loss should be determined by a nutritional assessment, including a biochemical analysis combined with a thorough dietary history, evaluation of the patient's psychosocial situation, and consideration of anthropometric or other qualitative evaluations. A simple and common anthropometric evaluation is the body mass index (BMI). The BMI is defined as body weight (kilograms)/height (meters2). A BMI lower than 17 is consistent with undernutrition.
      The specific etiologies of weight loss should be treated accordingly, with medications, structural or functional modifications (eg, gut revascularization, dentistry), nutritional supplementation, psychosocial modulation, or multi-modal therapy. These treatments are also beneficial for patients with no specific diagnosis because low body weight and weight loss are risk factors for morbidity and mortality regardless of the underlying etiology.
      • Keller HH
      Weight gain impacts morbidity and mortality in institutionalized older persons.

      Nutritional Therapy

      Nutritional therapy, including dietary education and/or use of dietary supplements supervised by a dietitian, is beneficial for most patients. One should consider reducing dietary restrictions instituted for an underlying disease if they are further aggravating nutritional balance. The goal of nutrient intake in patients with low body weight and pronounced weight loss should be 30 to 35 kcal/kg per day with 20% or greater protein content. For malnourished elderly patients and those with mild to moderate illness, a goal of 40 kcal/kg per day should be used.
      • Gazewood JD
      • Mehr DR
      Diagnosis and management of weight loss in the elderly.
      High caloric snacks and nutritionally complete supplements are useful; however, one should be mindful of the timing of supplement delivery (snacks between rather than with meals) and the type of supplement prescribed (composition, patient tolerance, etc).
      • Wallace JI
      • Schwartz RS
      Involuntary weight loss in elderly outpatients: recognition, etiologies, and treatment.
      Nutritional supplementation should be enteral, with the oral route preferred. For patients who are unable to ingest adequate calories, tube feeding, either with a temporary nasojejunal tube or more permanent access with a percutaneous gastric or jejunal tube, should be considered.
      • Howard L
      A global perspective of home parenteral and enteral nutrition.
      • Nicholson FB
      • Korman MG
      • Richardson MA
      Percutaneous endoscopic gastrostomy: a review of indications, complications and outcome.
      • DeWitt RC
      • Kudsk KA
      Enteral nutrition.
      • Cattan S
      • Cosnes J
      Enteral feeding techniques.
      • Loser C
      Clinical aspects of long-term enteral nutrition via percutaneous endoscopic gastrostomy (PEG).
      • Campos AC
      • Marchesini JB
      Recent advances in the placement of tubes for enteral nutrition.
      The addition of a daily multivitamin will help restore deficient micronutrients. Parenteral nutrition should be reserved for highly selected patients.

      Pharmacological Therapy

      Various agents
      • Reife CM
      Involuntary weight loss.
      • Ottery FD
      • Walsh D
      • Strawford A
      Pharmacologic management of anorexia/cachexia.
      that have been used to stimulate appetite and promote weight gain are listed in Table 4. Although some studies involving selected patients (eg, those with AIDS and cancer) suggest efficacy manifested as improved appetite and weight, studies demonstrating improvement in long-term survival are not available. Some of these drugs have serious potential adverse effects and should be used with caution. Any therapeutic trials with these agents necessitate close supervision.
      Table 4Agents Used to Stimulate Appetite and Promote Weight Gain
      CategoryExamples
      Orexigenic agents
       CorticosteroidsDexamethasone, methylprednisolone
       Progestational agentsMegestrol acetate, medroxyprogesterone acetate
       DronabinolMarinol
       Serotonin antagonistCryoheptadine
      Anabolic agents
       Growth hormonesGrowth hormone, insulin-like growth factor
       Androgen therapyTestosterone, dihydrotestosterone, testosterone analogues
      Anticatabolic agents
       Dietary anticytokineω-3 Fatty acids
       Methylxanthine derivativePentoxyifylline
       Inhibitor of gluconeogenesisHydrazine sulfate
       Proposed anticytokine activityThalidomide, melatonin

      Additional Considerations for Older Adults

      As mentioned previously, psychosocial issues are prevalent in older adults. In addition to the aforementioned standard management, clinicians should discuss the following factors
      • Chapman KM
      • Nelson RA
      Loss of appetite: managing unwanted weight loss in the older patient.
      with their elderly patients when appropriate: maintain companionship during meal preparation and intake; optimize meal preparation (eg, receive meals from meals-on-wheels); maximize caloric intake during the favorite meal of the day; take medication with meals to limit adverse effects such as anorexia, nausea, and early satiety; avoid gas-forming foods and beverages; manage bowel movements to avoid constipation and diarrhea; increase physical activity to stimulate appetite and improve sense of well-being; and promote oral health.

      SUMMARY

      Body weight, as determined by several key components, remains relatively stable over time. Unintentional weight loss, defined as a decrease of more than 5% of usual body weight during a 6- to 12-month period, is an important predictor of morbidity and mortality. However, weight loss is a nonspecific finding with multiple possible etiologies, including organic, psychosocial, and idiopathic. A rational stepwise approach based on relevant data extracted from the history and physical examination, with special attention to psychological and social issues, is highly effective in establishing a diagnosis and determining effective management. Treatment should be based on the results of the tests and each patient's clinical situation.

      REFERENCES

        • Williamson DF
        Descriptive epidemiology of body weight and weight change in U.S. adults.
        Ann Intern Med. 1993; 119: 646-649
        • Friedlaender JS
        • Costa Jr, PT
        • Bosse R
        • Ellis E
        • Rhoads JG
        • Stoudt HW
        Longitudinal physique changes among healthy white veterans at Boston.
        Hum Biol. 1977; 49: 541-558
        • Chumlea WC
        • Garry PJ
        • Hunt WC
        • Rhyne RL
        Distributions of serial changes in stature and weight in a healthy elderly population.
        Hum Biol. 1988; 60: 917-925
        • Reife CM
        Involuntary weight loss.
        Med Clin North Am. 1995; 79: 299-313
        • Bistrian BR
        Nutritional assessment.
        in: Goldman L Bennett JC Cecil Textbook of Medicine. 21st ed. WB Saunders Co, Philadelphia, Pa2000: 1145-1148
        • Keys A
        • Broz?ek J
        • Henschel A
        • Mickelsen O
        • Taylor HL
        The Biology of Human Starvation. University of Minnesota Press, Minneapolis, Minn1950
        • Fischer J
        • Johnson MA
        Low body weight and weight loss in the aged.
        J Am Diet Assoc. 1990; 90: 1697-1706
        • Tayback M
        • Kumanyika S
        • Chee E
        Body weight as a risk factor in the elderly.
        Arch Intern Med. 1990; 150: 1065-1072
        • Stevens J
        • Cai J
        • Pamuk ER
        • Williamson DF
        • Thun MJ
        • Wood JL
        The effect of age on the association between body-mass index and mortality.
        N Engl J Med. 1998; 338: 1-7
        • Payette H
        • Coulombe C
        • Boutier V
        • Gray-Donald K
        Weight loss and mortality among free-living frail elders: a prospective study.
        J Gerontol A Biol Sci Med Sci. 1999; 54: M440-M445
        • Tully CL
        • Snowdon DA
        Weight change and physical function in older women: findings from the Nun Study.
        J Am Geriatr Soc. 1995; 43: 1394-1397
        • Wallace JI
        • Schwartz RS
        • LaCroix AZ
        • Uhlmann RF
        • Pearlman RA
        Involuntary weight loss in older outpatients: incidence and clinical significance.
        J Am Geriatr Soc. 1995; 43: 329-337
        • Chang JI
        • Katz PR
        • Ambrose P
        Weight loss in nursing home patients: prognostic implications.
        J Fam Pract. 1990; 30: 671-674
        • Morley JE
        • Kraenzle D
        Causes of weight loss in a community nursing home.
        J Am Geriatr Soc. 1994; 42: 583-585
        • Morley JE
        Neuropeptide regulation of appetite and weight.
        Endocr Rev. 1987; 8: 256-287
        • Morley JE
        • Silver AJ
        Anorexia in the elderly.
        Neurobiol Aging. 1988; 9: 9-16
        • Marton KI
        • Sox Jr, HC
        • Krupp JR
        Involuntary weight loss: diagnostic and prognostic significance.
        Ann Intern Med. 1981; 95: 568-574
        • Rabinovitz M
        • Pitlik SD
        • Leifer M
        • Garty M
        • Rosenfeld JB
        Unintentional weight loss: a retrospective analysis of 154 cases.
        Arch Intern Med. 1986; 146: 186-187
        • Thompson MP
        • Morris LK
        Unexplained weight loss in the ambulatory elderly.
        J Am Geriatr Soc. 1991; 39: 497-500
        • Leduc D
        • Rouge PE
        • Rousset H
        • Maitre A
        • Champay-Hirsch AS
        • Massot C
        Clinical study of 105 cases of isolated weight loss in internal medicine [in French].
        Rev Med Interne. 1988; 9: 480-486
        • Huerta G
        • Viniegra L
        Involuntary weight loss as a clinical problem [in Spanish].
        Rev Invest Clin. 1989; 41: 5-9
        • Blazer D
        • Williams CD
        Epidemiology of dysphoria and depression in an elderly population.
        Am J Psychiatry. 1980; 137: 439-444
        • Barrett-Connor E
        • Edelstein SL
        • Corey-Bloom J
        • Wiederholt WC
        Weight loss precedes dementia in community-dwelling older adults.
        J Am Geriatr Soc. 1996; 44: 1147-1152
        • White H
        • Pieper C
        • Schmader K
        • Fillenbaum G
        Weight change in Alzheimer's disease.
        J Am Geriatr Soc. 1996; 44: 265-272
        • Wolf-Klein GP
        • Silverstone FA
        Weight loss in Alzheimer's disease: an international review of the literature.
        Int Psychogeriatr. 1994; 6: 135-142
        • Hutto BR
        Folate and cobalamin in psychiatric illness.
        Compr Psychiatry. 1997; 38: 305-314
        • Martin DC
        B12 and folate deficiency dementia.
        Clin Geriatr Med. 1988; 4: 841-852
        • Cole MG
        • Prchal JF
        Low serum vitamin B12 in Alzheimer-type dementia.
        Age Ageing. 1984; 13: 101-105
        • Iber FL
        • Blass JP
        • Brin M
        • Leevy CM
        Thiamin in the elderly-relation to alcoholism and to neurological degenerative disease.
        Am J Clin Nutr. 1982; 36: 1067-1082
        • Malcolm A
        • Thumshirn MB
        • Camilleri M
        • Williams DE
        Rumination syndrome.
        Mayo Clin Proc. 1997; 72: 646-652
        • Tack J
        • Piessevaux H
        • Coulie B
        • Caenepeel P
        • Janssens J
        Role of impaired gastric accommodation to a meal in functional dyspepsia.
        Gastroenterology. 1998; 115: 1346-1352
        • Olsen-Noll CG
        • Bosworth MF
        Anorexia and weight loss in the elderly: causes range from loose dentures to debilitating illness.
        Postgrad Med. February 1989; 85: 140-144
        • Robbins LJ
        Evaluation of weight loss in the elderly.
        Geriatrics. 1989; 44 (37.): 31-34
        • Wallace JI
        • Schwartz RS
        Involuntary weight loss in elderly outpatients: recognition, etiologies, and treatment.
        Clin Geriatr Med. 1997; 13: 717-735
        • Gazewood JD
        • Mehr DR
        Diagnosis and management of weight loss in the elderly.
        J Fam Pract. 1998; 47: 19-25
        • Folstein MF
        • Folstein SE
        • McHugh PR
        “Mini-mental state:” a practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • Derogatis LR
        • Lazarus L
        SCL-90-R, brief symptom inventory, and matching clinical rating scales.
        in: Maruish ME The Use of Psychological Testing for Treatment Planning and Outcome Assessment. Lawrence Erlbaum Associates, Hillsdale, NJ1994: 217-248
        • Beck AT
        • Ward CH
        • Mendelson M
        • Mock J
        • Erbaugh J
        An inventory for measuring depression.
        Arch Gen Psychiatry. 1961; 4: 561-571
        • Yesavage JA
        • Brink TL
        • Rose TL
        • et al.
        Development and validation of a geriatric depression screening scale: a preliminary report.
        J Psychiatr Res. 1982–83; 17: 37-49
        • Keller HH
        Weight gain impacts morbidity and mortality in institutionalized older persons.
        J Am Geriatr Soc. 1995; 43: 165-169
        • Howard L
        A global perspective of home parenteral and enteral nutrition.
        Nutrition. 2000; 16: 625-628
        • Nicholson FB
        • Korman MG
        • Richardson MA
        Percutaneous endoscopic gastrostomy: a review of indications, complications and outcome.
        J Gastroenterol Hepatol. 2000; 15: 21-25
        • DeWitt RC
        • Kudsk KA
        Enteral nutrition.
        Gastroenterol Clin North Am. 1998; 27: 371-386
        • Cattan S
        • Cosnes J
        Enteral feeding techniques.
        Curr Opin Clin Nutr Metab Care. 1998; 1: 287-290
        • Loser C
        Clinical aspects of long-term enteral nutrition via percutaneous endoscopic gastrostomy (PEG).
        J Nutr Health Aging. 2000; 4: 47-50
        • Campos AC
        • Marchesini JB
        Recent advances in the placement of tubes for enteral nutrition.
        Curr Opin Clin Nutr Metab Care. 1999; 2: 265-269
        • Ottery FD
        • Walsh D
        • Strawford A
        Pharmacologic management of anorexia/cachexia.
        Semin Oncol. 1998; 25: 35-44
        • Chapman KM
        • Nelson RA
        Loss of appetite: managing unwanted weight loss in the older patient.
        Geriatrics. 1994; 49: 54-59