Weight loss in older patients

Clinical question

How can I assess and address weight loss in older patients?

Bottom line

Weight loss is common and can be challenging to manage. Quandaries include identifying the problem, determining the appropriate workup, balancing fear of missing a diagnosis with invasive investigation, and effective treatment.¹

Weight loss is a reduction of more than 5% of body weight over 1 month or 10% over 6 months.² Useful screening questions include asking older patients if their clothing has loosened or if they have had to wear a smaller size. Screening for unintentional weight loss is important given its association with mortality, functional decline, and clinical frailty. The approach to weight loss in older patients might be more complex than in younger patients owing to the higher risk of serious underlying illness such as cancer, but also owing to psychosocial factors such as cognitive impairment, limited financial or social supports, functional decline related to frailty, and oral health issues.^3–6 As a result, your patient’s social circumstances must be assessed. Investigations should be guided by the patient’s history and findings of a physical examination, focusing on confirming diagnoses. The contribution of medications is also important to consider.

Evidence

• Exercise might be as helpful as nutritional supplements, which if used should be provided between meals to avoid decreasing appetite further.^7,8

• There is limited evidence for pharmacologic treatments, and Choosing Wisely recommends against routine use.⁹

• Up to 40% of people with dementia have weight loss.¹⁰

• Many common medications are associated with weight loss.

Approach

• Serial weight measurements and routine screening such as asking about decreased intake and change in clothing fit can identify people meeting or close to meeting the criteria for weight loss and help to focus interventions.

• Box 1 provides a mnemonic to help identify possible causes.

• A detailed history, oral and abdominal examinations, a neurologic assessment, and a mental status review are important for diagnosing any underlying disease.

• It is important to review prescribed and over-the-counter medications (refer to Box 2 in Holroyd-Leduc).¹

• The presence and severity of frailty,¹¹ along with patient care goals, can guide how aggressively to investigate weight loss. Eliminating restrictive diets might be appropriate for those with limited life expectancy or moderate to severe frailty.

Implementation

Remediable factors should be optimized first,¹² especially for patients with dementia or frailty. A critical medication review should use a deprescribing lens.¹³ The benefit of nutritional supplements is unclear. There is limited evidence for appetite stimulants; social factors and exercise might be more helpful.

Nutrition resources related to weight loss are available for health care providers (www.nutritioncareincanada.ca) and for older Canadians (https://www.dietitians.ca/Your-Health/Nutrition-A-Z/Seniors.aspx).