Unintentional weight loss, particularly in older adults, can be a concerning sign of underlying health issues. It's crucial to identify the cause to provide appropriate treatment and support.
Introduction
Unintentional weight loss in adults older than 65 years is generally defined as a 5% or greater loss of body weight in a six- to 12-month period and is associated with increased morbidity and mortality. It is a diagnostic challenge, and once identified, it should be evaluated. Weight loss can be assessed by numerical documentation or, if no baseline weight is available, corroboration with a change in clothing size or from a relative may be used.
Defining Unintentional Weight Loss
Weight loss is typically considered clinically important if it exceeds 5% of body weight or 5 kg over 6 months. Unintentional weight loss occurs in 15%-20% of adults aged above 65 years. Weight loss of more than 5% of usual body weight over 6-12 months is considered significant. It is important to clarify with patients whether the weight loss is unintentional or intentional. Intentional weight loss can be due to a controlled diet, increase in physical activity, and medications such as diuretic therapy in patients with heart failure or diabetes oral therapy.
Causes of Unintentional Weight Loss
The pathophysiology of unintentional weight loss is not well understood. Body composition and lean body mass decrease with age. Lean body mass can decrease up to 0.7 lb (0.3 kg) per year between 20 and 30 years of age. Fat mass continues to increase until 65 to 70 years of age. Therefore, total body weight usually peaks at 60 years of age with only small decreases after that.
Many diseases cause involuntary weight loss, including almost any chronic illness of sufficient severity. However, many of these are clinically obvious and have typically been diagnosed by the time weight loss occurs. Other disorders are more likely to manifest as involuntary weight loss.
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In community-dwelling older adults, unintentional weight loss causes are most often classified as organic or psychosocial. Prospective and retrospective studies in inpatient and outpatient settings have demonstrated that overall non-malignant diseases are more common causes of unintentional weight loss than malignant causes. However, malignancy accounts for up to one-third of cases of unintentional weight loss. A readily identifiable cause is not found for 6% to 28% of cases.
Malignant Causes
Malignancy accounts for up to one-third of cases of unintentional weight loss. Adults with unexplained weight loss are at least 12 times more likely to have cancer than people who aren’t experiencing weight loss. Weight loss is often the first symptom of cancer - approximately 40% of cancer diagnoses begin this way. While many people believe that cancer-related weight loss signals advanced cancer, it can also occur in the early stage of some cancers. Researchers report that people with early-stage colorectal, pancreatic and lung cancer have reported weight loss.
Non-Malignant Causes
Non-malignant diseases are more common causes of unintentional weight loss than malignant causes. Causes for nonmalignant weight loss include endocrinological disorders, rheumatological diseases and chronic heart disease or chronic kidney disease.
Digestive Diseases and Conditions
Gastrointestinal (GI) issues account for 10% to 20% of unexpected weight loss cases. Digestive diseases can cause inflammation and malabsorption, which may affect your metabolism and hinder the body’s ability to take in calories and macronutrients. GI conditions that commonly lead to sudden weight loss include:
- Celiac disease
- Chronic diarrhea
- Inflammatory bowel diseases
- Overuse of laxatives, often suggesting an eating disorder
Mental Health Issues
Mental health disorders are responsible for unintentional weight loss approximately 10% to 23% of the time. Your appetite may be affected by:
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- Anxiety
- Depression
- Eating disorders
- Obsessive-compulsive disorder (OCD)
- Stress
Other Possible Causes
While cancer and GI issues and mental health cause most unintentional weight loss, there are many other reasons you might suddenly lose weight, including:
- Dementia, due to changes in mealtime habits
- Endocrine issues, including thyroid disorders and diabetes
- Medication side effects, which can cause dry mouth, vomiting, nausea or altered senses that interfere with eating
- Oral disorders, including gum disease, dysphagia (trouble swallowing) or any condition that makes it uncomfortable to eat
- Social factors, such as alcoholism, financial limitations or difficulty getting food
Medication use and polypharmacy can interfere with the sense of taste or induce nausea and should not be overlooked as causative factors. Social factors such as isolation and financial constraints may contribute to unintentional weight loss.
Normal age-related changes that can contribute to weight loss include the following: Decreased sensitivity to certain appetite-stimulating mediators (eg, orexins, ghrelin, neuropeptide Y) and increased sensitivity to certain inhibitory mediators (eg, cholecystokinin, serotonin, corticotropin-releasing factor) A decreased rate of gastric-emptying (prolonging satiety) Decreased sensitivities of taste and smell Loss of muscle mass (sarcopenia) In older adults, multiple chronic disorders often contribute to weight loss. Dental problems (eg, periodontitis) become more common with aging and can compromise nutrient intake and digestion. Social isolation tends to decrease food intake. Particularly in nursing home patients, depression is a very common contributing factor.
Evaluation of Unintentional Weight Loss
A baseline evaluation for unintentional weight loss includes a complete history and physical examination focusing on symptoms that could indicate the cause of weight loss. An article on the comprehensive in-office geriatric assessment published in American Family Physician reviewed tools to assess cognitive impairment, depression, and functional status, all of which can lead to weight loss. Medication and supplement use should be reviewed. Physical examinations should assess any concerning findings from the history and include assessment of the oral cavity and dentition and examination for heart, lung, gastrointestinal, or neurologic abnormalities. Shared decision-making and goals of care should guide diagnostic evaluation. Evaluation focuses on detection of otherwise occult causes. Because these are numerous, evaluation must be comprehensive.
History
History-taking should start with the duration and amount of weight loss. It may be useful to have a corroborative history from a family member or caregiver, especially if the patient is unable to independently provide a history. Previous health records, if available, can be used to determine if there has been objective weight loss. A dietary history and systematic review should be done to identify any systemic disorders. This can help guide a targeted clinical examination and relevant investigations. A social history should be obtained to exclude any psychosocial cause of unintentional weight loss. A thorough family history may give a clue to certain diseases that a patient may be predisposed to.
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History of present illness includes questions about the amount and time course of weight loss. A report of weight loss may be inaccurate; thus, corroborating evidence should be sought, such as weight measurement in old medical records, changes in size of clothes, or confirmation by family members. Appetite, food intake, swallowing, and bowel patterns should be described. For repeat evaluations, patients should keep a food diary because recollections of food intake are often inaccurate. Nonspecific symptoms of potential causes are noted, such as fatigue, malaise, fevers, and night sweats.
Review of systems must be complete, seeking symptoms in all major organ systems. Past medical history and social history may reveal a disease capable of causing weight loss. Also addressed should be use of prescription medications, over-the-counter medications, recreational drugs, and herbal products. Social history may reveal changes in living situations that could explain why food intake is decreased (eg, loss of loved one, loss of independence or ability to prepare meals, financial circumstances, loss of communal eating routine).
Physical Examination
A comprehensive clinical examination, including examination of the cardiovascular, respiratory, gastrointestinal and neurological systems, should be done. Often forgotten are the thyroid, breast, oral (e.g.
Vital signs may reveal fever, tachycardia, tachypnea, and hypotension. Weight and height are measured and body mass index (BMI) is calculated; the addition of a waist circumference measurement allows calculation of the body roundness index (BRI). Triceps skinfold thickness and mid upper arm circumference can be measured to estimate lean body mass.
General examination should be particularly comprehensive, including examination of the heart, lungs, abdomen, head and neck, breasts, neurologic system, rectum (including prostate examination and testing for occult blood), genitals, liver, spleen, lymph nodes, joints, skin, mood, and affect.
Red Flags
- Fever, night sweats, generalized lymphadenopathy
- Bone pain
- Dyspnea, cough, hemoptysis
- Inappropriate fear of weight gain in an adolescent or young adult
- Polydipsia and polyuria
- Headache, jaw claudication, and/or visual disturbances in an older adult
- Roth spots, Janeway lesions, Osler nodes, splinter hemorrhages, retinal artery emboli
Diagnostic Investigations
Initial workup for most patients should include laboratory studies and imaging. Diagnostic investigations include simple blood tests and radiological imaging such as a chest X-ray.
Laboratory Tests
Laboratory tests include complete blood count, basic metabolic panel, liver function tests, thyroid function tests, C-reactive protein level, erythrocyte sedimentation rate, glucose measurement, lactate dehydrogenase measurement, protein electrophoresis, ferritin, urinalysis, and fecal occult blood testing. Low albumin and elevated total white blood cell count, platelets, calcium, or inflammatory markers are most associated with cancer.
Recommended tests include age-appropriate cancer screenings, complete blood count, basic metabolic panel, liver function tests, thyroid function tests, C-reactive protein level, erythrocyte sedimentation rate, lactate dehydrogenase measurement, ferritin, protein electrophoresis, and urinalysis.
- Complete Blood Count (CBC): Your blood can show signs of certain health conditions like diabetes, celiac disease and infections.
- Basic Metabolic Panel: Serum chemistries (serum electrolytes, calcium, hepatic and renal function tests)
- Liver Function Tests:
- Thyroid Function Tests: It can also give your provider information about how your metabolism, thyroid and adrenal glands are working.
- C-Reactive Protein (CRP) Level:
- Erythrocyte Sedimentation Rate (ESR):
- Lactate Dehydrogenase (LDH) Measurement:
- Ferritin:
- Protein Electrophoresis:
- Urinalysis: A urinalysis can provide information about your kidneys and bladder, including certain health conditions and infections.
- Fecal Occult Blood Testing:
Imaging
Chest radiography and fecal occult blood testing should be performed. Further imaging and invasive testing may be considered based on initial evaluation. Tests like an MRI (magnetic resonance imaging) or CT scan (computed tomography scan) can provide detailed images of your organs, like your brain, heart, lungs and abdominal organs. You may need one of these tests if your provider wants to rule out tumors or diseases that may be visible on these scans.
Cancer Screening Tests
If your provider wants to rule out cancer, you may need screening or imaging tests. For example, a colonoscopy can detect colorectal cancer. Age-appropriate cancer screening (eg, colonoscopy, mammography) is indicated if not previously performed.
Follow-Up
Appropriate follow-up of patients with unexplained, unintentional weight loss is needed if the initial evaluation is unclear. Studies suggested that if the initial evaluation was normal and screening tests were negative, no further workup is needed, and a three- to six-month observation period is warranted. However, a more recent study with more extensive follow-up (up to 66 months) in 2,677 patients indicated that extended follow-up would result in identifiable causes of weight loss (most often undetected malignancy) and, typically, a diagnosis was found within six to 28 months of the initial evaluation. Autopsies were required to establish the diagnosis in 14 patients. The length and frequency of follow-up should be specific to the clinician and patient.
When the initial evaluation is unremarkable, a three- to six-month observation period is recommended with follow-up based on clinician and patient preferences.
Treatment of Unintentional Weight Loss
Treatment should focus on the underlying cause and often involves a multidisciplinary team, including dentists; dietitians; speech, occupational, or physical therapists; and social service workers. Once a thorough history and clinical examination are performed, any reversible and treatable conditions confirmed through diagnostic studies should be managed accordingly. Dietitian and social worker reviews should be considered. If no cause is found or if the weight loss is less than 5% of the usual body weight, close follow-up, depending on clinical suspicion, is recommended. If initial investigations are unrevealing or if there are symptoms suggestive of an underlying pathology, a referral to the appropriate specialist may be warranted.
Dietary Modifications
Decreased saliva production, ill-fitting dentures, periodontal disease, and weakened mastication muscles can lead to poor dentition and impaired chewing. A cross-sectional, self-administered study distributed to more than 100,000 community-dwelling older adults in Japan found a significant correlation between having fewer teeth and lower weight in both sexes. Dietary modifications that consider patient preferences and chewing or swallowing disabilities should be considered.
Appetite Stimulants and Supplements
According to the Choosing Wisely campaign by the American Geriatrics Society, appetite stimulants and high-calorie supplements should be avoided secondary to lack of evidence on long-term survival and quality of life. Treatment should instead focus on feeding assistance, addressing contributing medications, providing appealing foods, and social support as indicated. Supplementation, if given, should provide extra calories but not replace scheduled meals and snacks. A Cochrane review of mostly poor-quality studies (N = 10,187) noted that supplementation provides a small but consistent weight gain in older patients; however, there was no statistically significant change in mortality overall. When limited to undernourished patients (n = 2,461), supplementation had a statistically significant mortality benefit (relative risk = 0.79; 95% CI, 0.64 to 0.97). Despite the lack of evidence of benefits and potential harms, appetite stimulants such as megestrol (Megace) and mirtazapine (Remeron) are prescribed. Adverse effects of megestrol include gastrointestinal upset, insomnia, impotence, hypertension, thromboembolic events, and adrenal insufficiency. Mirtazapine, a serotonin antagonist used to treat depression, has weight gain as a known adverse effect in up to 12% of patients. However, no literature exists solely looking at mirtazapine use for unintentional weight loss.