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#Diagnosis and Management|Diagnosis and 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==
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]]. [[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]], [[Comprehensive metabolic panel|CMP]] provide 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 act as an adjunct to normal meals.
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 that may result in death or permanent [[disability]] within 24 hours if left untreated. The life-threatening causes of [[weight loss]] include:
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.<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>
 
*[[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>
 
===Common Causes===
===Common Causes===
====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>====
====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>====
*[[Malignancy|Malignancies]] (specifically digestive and non-hematologic)
*[[Malignancy|Malignancies]] (specifically digestive and non-hematologic)
* [[Dementia]]
*[[Dementia]]
* [[Stroke]]
*[[Stroke]]
* [[Parkinson's disease]]
*[[Parkinson's disease]]
*[[Polymyalgia rheumatica]]
*[[Polymyalgia rheumatica]]
* [[Oral]] disorders.
*[[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>====
====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
*[[Endocrine]] disorders
* [[Infections]] such as [[TB]] and [[HIV]]
*[[Infections]] such as [[TB]] and [[HIV]]
* [[Psychiatric disorders]] such as [[depression]], [[anxiety]], and [[OCD]]
*[[Psychiatric disorders]] such as [[depression]], [[anxiety]], and [[OCD]]
* [[Malignancy|Malignancies]] such as [[hematology|hematologic]]
*[[Malignancy|Malignancies]] such as [[hematology|hematologic]]
 
====Common causes classified====
====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>
*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.}}
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{{familytree | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | }}
{{familytree/end}}
{{familytree/end}}
*To read about other causes of unintentional weight loss [[Weight loss#Causes|click here]].
*To read about other causes of unintentional weight loss [[Weight loss#Causes|click here]].


==Diagnosis and Management==
==Diagnosis and Management==
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>
<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/start |summary=Weight loss Diagnostic Algorithm.}}
{{familytree | | | | | | | | | | A01 | | | | | | |A01=[[Patient]] presents with [[weight loss]]/ incidental finding }}
{{familytree | | | | | | | | | | A01 | | | | | | |A01=[[Patient]] presents with [[weight loss]]/ incidental finding }}
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❑ '''Duration of [[symptoms]]''':<br>  (weeks in [[acute]]/severe versus years in [[chronic]] conditions).<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>
❑ '''Associated [[symptoms]]''':<br> Assess if the [[patient]] is [[Nausea|nauseated]] or [[vomiting]]/ [[anorexia]]/ [[dysphagia]]/ [[odynophagia]]/ social reasons hindering food supply.<br>
❑ '''Nutritional status''':<br>
:❑ Dietary history: Food availability, diet adequacy in the quantity (daily caloric intake), and quality (balance of nutrition), and nutritional supplements.<br>
:❑ 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>
:❑ Assess the mental and functional status of the [[patient]].<br>
:❑ Psychiatric illness screening. Geriatric Depression Scale may be utilized to assess for [[depression]] among elderly.<br>
❑ '''Systemic review''':<br> [[Cardiovascular system|Cardiovascular]], [[respiratory system|respiratory]], [[renal system|renal]], [[liver|hepatic]], [[Rheumatology|rheumatologic]], and [[Gastrointestinal system|GI]] exam.
❑ '''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>
:❑ [[Gastrointestinal system|GI]]: Indigestion, [[early satiety]], altered stool pattern, [[abdominal pain]] may demonstrate [[GERD]], [[peptic ulcer]],[[cholecystitis]], and [[gastrointestinal system|GI]] [[malignancy]]<br>
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❑ '''Sexual history''':<br> Suggestive of [[HIV AIDS history and symptoms|HIV AIDS]]<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.}}
❑ '''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 | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | M01 | | | | | | | M01='''Physical exam'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>
{{familytree | | | | | | | | | | M01 | | | | | | | M01='''Physical exam'''<div style="float: left; text-align: left; width: 15em; padding:1em;"><div class="mw-collapsible mw-collapsed"><br>
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{{familytree | | | | | | | | | | |!| | | | |!| | | | }}
{{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 | | | | | | | | | | |!| | | | 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 | | | | | | | | | | F01 | | | |!| | |F01=Unintentional weight loss }}
{{familytree | | | | | | | | | | |!| | | | | | | }}
{{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 | | | | | | | | | | K01 | | | | | | |K01=Nutritional status/ [[calorie|caloric]] intake }}
{{familytree | | | | | | | |,|-|-|^|-|-|-|.| | | }}
{{familytree | | | | | | | |,|-|-|^|-|-|-|.| | | }}
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{{familytree | | | | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | | | | |!| | | | | | | }}
{{familytree | | | | | | | | | | | | | U01 | | | | | | | U01='''Initial screening labs'''<div class="mw-collapsible mw-collapsed"><div style="float: left; text-align: left; width: 15em; padding:1em;">
{{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>
❑ [[CBC]] with differential and [[peripheral smear]]<br>
❑ [[ESR]], [[CRP]], [[LDH]]<br>
❑ [[ESR]], [[CRP]], [[LDH]]<br>
Line 183: Line 205:
❑ [[Rheumatoid factor]]<br>
❑ [[Rheumatoid factor]]<br>
❑ [[PTH]] levels
❑ [[PTH]] levels
*''Labs may vary on case by case basis'' }}
*''Labs may vary on case by case basis''}}
{{familytree | | | | | | | | | | | | | |!| | | | | | |}}
{{familytree | | | | | | | | | | | | | |!| | | | | | |}}
{{familytree | |,|-|-|-|v|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|v|-|-|-|.|}}
{{familytree | |,|-|-|-|v|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|v|-|-|-|.|}}
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❑ [[Hepatitis| medical therapy|Hepatitis]]<br>
❑ [[Hepatitis| medical therapy|Hepatitis]]<br>
❑ [[Chronic cholecystitis medical therapy|Chronic cholecystitis]]<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">❑ 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>
❑ [[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>
❑ [[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">
❑ [[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>
❑ Referral to a specialist ([[psychotherapist]] and/or a [[psychiatrist]])<br>
❑ [[Psychotherapy]]<br>
❑ [[Psychotherapy]]<br>
❑ [[Clinical depression medical therapy|Clinical depression medications]]|D04=<div style="float: left; text-align: left; width: 15em;">'''Treatment'''<div class="mw-collapsible mw-collapsed"> ❑  [[Surgical resection]]<br> ❑ [[Chemotherapy]]<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>
❑ [[Radiotherapy]]<br>
❑ [[TNM]] staging|D05=<div style="float: left; text-align: left; width: 15em;">'''Treatment'''<div class="mw-collapsible mw-collapsed">❑ Decreased dietary restrictions<br>❑ Increase oral intake<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">  
❑ [[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>
❑ [[Chronic diarrhea medical therapy|Chronic diarrhea treatment]]<br>
❑ [[Tuberculosis medical therapy|Tb treatment]]<br>
❑ [[Tuberculosis medical therapy|Tb treatment]]<br>
❑ [[HIV AIDS medical therapy|HIV treatment]]<br>
❑ [[HIV AIDS medical therapy|HIV treatment]]<br>
:❑ [[Dronabinol]] appetite stimulant.
❑ [[Endocarditis medical therapy|Infective endocarditis treatment]]
❑ [[Endocarditis medical therapy|Infective endocarditis treatment]]
❑ [[Gastroenteritis medical therapy|Gastroenteritis treatment]] and [[Colitis medical therapy|colitis treatment]]}}  
❑ [[Gastroenteritis medical therapy|Gastroenteritis treatment]] and [[Colitis medical therapy|colitis treatment]]}}  
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{{familytree | | | | | | | | | W01 | | | | | W02 | | |W01=Weight gain|W02=No weight gain/ continued weight loss }}
{{familytree | | | | | | | | | W01 | | | | | W02 | | |W01=Weight gain|W02=No weight gain/ continued weight loss }}
{{familytree | | | | | | | | | |!| | | | | | |!| | | }}
{{familytree | | | | | | | | | |!| | | | | | |!| | | }}
{{familytree | | | | | | | | | X02 | | | | | X01 | | |X02=Continue monitoring|X01=Reevaluate}}
{{familytree | | | | | | | | | X02 | | | | | X01 | | |X02=Monitor until the desired weight is achieved|X01=Reevaluate}}
{{familytree | | | | | | | | | | | | | | |,|-|^|-|.| }}
{{familytree | | | | | | | | | | | | | | |,|-|^|-|.| }}
{{familytree | | | | | | | | | | | | | | Y02 | | | Y01 | | |Y02=Cause identified|Y01=Cause unidentified}}
{{familytree | | | | | | | | | | | | | | Y02 | | | Y01 | | |Y02=Cause identified|Y01=Cause unidentified}}
{{familytree | | | | | | | | | | | | | | |!| | | |,|^|-|.| }}
{{familytree | | | | | | | | | | | | | | |!| | | |,|^|-|.| }}
{{familytree | | | | | | | | | | | | | | |!| | | |!| | P01 | | |P01=<div style="float: left; text-align: left; width: 15em;">6 months of presentation cause unidentified<br>❑ Labelled unexplained unintentional weight loss }}
{{familytree | | | | | | | | | | | | | | |`|-|-| P02 | | P01 | | |P02='''Consider medications'''<div style="float: left; text-align: left; width: 15em;"><div class="mw-collapsible mw-collapsed">
{{familytree | | | | | | | | | | | | | | |`|-|v|-|'| | | | }}
:❑ Metoclopramide for [[nausea]] (side effects include [[parkinsonism]])<br>
{{familytree | | | | | | | | | | | | | | | | O01 | | | | | O01=Consider medications for weight gain}}
:❑ [[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}}


==Do's==
==Do's==
* Perform a thorough [[physical exam]] to evaluate for cause of [[weight loss]].
 
* Assess the [[nutrition|nutritional status]] of the [[patient]].
*Perform a thorough [[physical exam]] to evaluate for cause of [[weight loss]].
* Assess the [[patient]] for possible [[depression]].
*Assess the [[nutrition|nutritional status]] of the [[patient]] and screen for possible [[depression]].
* Assess [[serum electrolytes]] to assess for life-threatening [[electrolyte]] abnormalities.
*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==
* Do not miss the oral exam especially among the elderly.
 
* Do not rely on the [[patient]] history among [[patient]]s with [[cognitioncognitive]] dysfunctions.
*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}}
[[Category:Help]]
[[Category:Projects]]
[[Category:Resident survival guide]]
[[Category:Resident survival guide]]
[[Category:Templates]]
[[Category:Primary care]]
[[Category:Oncology]]
[[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

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