Family medicine
Approach to patient with Unintentional Weight Loss
Dr. Mayasah A. Sadiq FICMS-FM Monday 19-3-2018
Objectives
- Develop an approach to unintentional weight loss
- Define unintentional weight loss
- Review the incidence and prevalence of weight loss
- Review the common causes of weight loss
- Cover treatment strategies
Case
You are referred a 69 F for evaluation of unintentional weight loss.
She has lost 5 kg in the past 12 months, her current weight is 60 kg.
Is her weight loss clinically important?
How common is weight loss in the elderly?
Definition
Clinically important weight loss can be defined as loss of 5 kg or more than 5% of usual weight over 6-12 months
Why it’s important!
Unintentional weight loss may reflect disease severity of a chronic illness or a yet undiagnosed illness.
Even after adjusting for co-morbidities weight loss of 5% or more of body weight is associated with increased mortality (approx increase in RR 1.6)
How common is weight loss in the elderly?
- Prevalence estimates of weight loss are quite variable
15-20% elderly patients experience weight loss (defined as loss of 5 kg or 5% body wt over 5-10 years)
- The prevalence can be as high as 27% in high-risk populations such as the frail elderly
- The incidence of unintentional weight loss in clinical studies of adults seeking health care is also quite variable
Depending on the setting and definition it varies from 1.3 to 8%
Back to our Case
HPI:
She confirms that her weight was 65 kg 1 year ago when it was measured at the doctors office
Her appetite is “normal” and she reports no other constitutional symptoms
The clinical review is negative for cardiac, respiratory, gastrointestinal, and neurologic symptoms
PMHx:
Hypertension (on ACEI and HCTZ)
Dyslipidemia (on statin)
OA of both kness (on prn acetominophen)
Social Hx:
Widowed 3 years ago
Lives alone.
X-smoker (quit 10 years ago).
Physical Exam:
VS: BP-118/74, HR-74 regular, T-37.3 C
H+N: normal thyroid and no lymph nodes
CV/RS: normal heart sounds, clear lungs
GI: negative Castell’s sign, and normal liver span
NE: normal muscle bulk, strength, and tone
Common causes of unintentional weight loss:
Causes of unintentional weight loss can classified into 3 broad groups:
- Organic
- Psychosocial
- Idiopathic (up to 10-36% of cases)
- Organic Causes - top three
- Malignancy (16-36%)
Usually it’s clear from the history, physical, or routine lab data that malignancy is a potential cause
- Gastrointestinal (most common non-malignant organic cause, 6-19%)
PUD, IBD, dysmotility, hepatobiliary/pancreatic disease, or oral problems
- Endocrine (4-11%)
DM, thyroid disease, and adrenal insufficiency
Organic causes (less common)
- Cardiovascular disease (2-9%)
- Respiratory disease (~6%)
- Chronic infections (2-5%)
- Renal disease (~4%)
- Drugs/Medication Side effects (~2%)
- Neurologic disorder (2-7%)
- Psychosocial Causes
- Psychiatric disorder (9-42%)
Depression
- Dementia (2-5%)
- Poor nutritional intake
Due to poverty or inadequate access to meals
Psychosocial Causes
Depression and dementia are poorly recognized in clinical practice
All elderly patients with weight loss should undergo screening for
dementia with the MMSE
depression with the Geriatric Depression Scale
Screen for malnutrition with one of these validated tools (ENS or SCREEN) .
Several key concepts emerge from etiologic studies of unintentional weight loss
- Among organic causes cancer is most common
- Etiology of weight loss is evident without extensive evaluation in most patients
- Psychiatric illness and non diagnostic evaluations are common
Back to our Case
So far her history and physical is unremarkable
You explore other issues…
You ask her about medication side effects - she reports none.
You do a MMSE and she scores 30/30!
Access to food and meals is not an issue for her.
What further assessment or investigations are now indicated?
The diagnostic utility of the medical history and physical examination in identifying the cause of weight loss has not been evaluated
The same can be said about screening investigations
Despite the lack of systematic evaluation, a complete history, physical examination and selected “routine” investigations are recommended
So??
Routine Investigations
- CBC
- Biochemistry (lytes, glucose, Ca, PO4)
- TSH
- Liver enzymes
- Urinalysis
- CXR
Additional tests are ordered as clinically indicated
- HIV test
- SPEP (Serum Protein Electrophoresis)
- PSA, mammogram
- GI investigations (if there are symptoms, microcytic anemia, or abnormal liver enzymes)
OGD or colonoscopy plus biopsies
Stool analysis
Celiac serology
Abdominal imaging
Back to our Case
She is send for the “routine investigations” and returns for follow-up
All the investigations are normal or negative
She is relieved, but still wants to know why she has lost 5 kg?
Now What?
You pursue the assessment further and ask about symptoms of depression
She does occasionally feel lonely since her husband passed away but…the Geriatric Depression Scale is negative
You reassure her that she does not have an organic or pyschosocial cause for her weight lossHer diagnosis is idiopathic unintentional weight loss
How should weight loss be treated?
What follow up does she need?
Treatment of weight loss regardless the cause:
Treat the underlying organic cause
When pyschosocial issues are involved then a multi-disciplined approach is required to address the key issues
including social work, dietician, community services and psychiatrist
For idiopathic weight loss seek advice from a dietician for strategies to increase caloric intake
What follow up does our case need?
Reassess her weight in 3 months
If it remains stable or goes up then further assessment is not necessary
If she is continuing to lose weight then repeat the evaluation process, with emphasis on searching for an organic or psychosocial cause
She returns after 3 months and her weight has remained stable
She is following the advice of the dietician to increase her caloric intake
You feel confident that she has idiopathic weight loss
At this point you monitor her weights every 3-6 months.
Summary
Unintentional weight loss is a common concern especially in the elderly
Common causes can be grouped into one of 3 categories: organic, psychosocial, or idiopathic
Psychosocial causes are under appreciated by clinicians
Extensive investigations are usually not necessary
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