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:

  1. Organic
  2. Psychosocial
  3. Idiopathic (up to 10-36% of cases)
  1. 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%)
  1. 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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