The main topic in this BMJ is investigation of weight loss in elderly people.
What counts as significant weight loss?
Generally, anything over 5% of body weight over 6 – 12 months, although smaller losses may be important in frail people.
What should I remember to ask in the history?
Appetite and intake, obviously. Are they actually eating less, and, if so, why? Bear psychological and social factors strongly in mind – are they depressed, is money an issue, are there practical problems with shopping for or cooking food? What about confusion? What about chewing the food – do they have problems with their teeth?
As with anything else, cherchez la medicament. (OK, I just invented that phrase, and I probably didn’t even get the French right, but you get the idea.) In weight loss, as in just about any other symptom under the sun, drugs can potentially be a culprit. There are a number of potential mechanisms – nausea, dry mouth, dysphagia, altered sense of taste or smell, or just plain loss of appetite.
And, of course, full review of symptoms to look for a physical cause.
There are a couple of potentially useful mnemonics worth noting down – the 9 Ds and MEALS ON WHEELS. 9 Ds – Dementia, Depression, Disease (acute or chronic), Dysphagia, Dysgeusia (OK, hands up anyone else who had no idea what that meant? It’s a term for altered sense of taste, apparently), Diarrhoea, Drugs, Dentition, and Dysfunction (functional disability). MEALS ON WHEELS: Medication, Emotional problems (e.g. depression), Alcoholism/Anorexia, Late life paranoia, Swallowing problems, Oral factors (such as teeth), No money, Wandering (that one is meant to refer to dementia-related behaviours, which is something of a stretch, but, hey, all’s fair in love, war, and coming up with decent mnemonics), Hyper/hypothyroidism or Hyperparathyroidism (or Hypoadrenalism, if you want to look at the real zebras), Enteric problems, Eating problems (such as inability to feed self), Low salt/cholesterol diet, and Social problems or Stones. Phew. Anyone think they have any chance of remembering that lot? My memory isn’t what it used to be, I’ll tell you that.
What should I remember to look for on examination?
Everything, basically. Lymphadenopathy, mouth, a full cardiovascular/respiratory/abdominal examination, and breast examination in a woman.
What investigations should be done?
The basics: FBC, U&Es, LFTs, TFTs, CRP/PV, glucose, and LDH (not sure exactly what the latter’s meant to show except that it does have a high positive predictive value for malignant causes and thus is a red flag to investigate further). Also CXR, consider FOB, and the article suggests urinalysis although they admitted that there wasn’t any clear evidence that it was any use here, so frankly I think I’d skip it.
And then what?
Let’s say you’ve done all of the above, no obvious cause for the weight loss has been picked up, and all tests are normal. What then? Well, this is actually a pretty common outcome – even after more intensive investigations than those, a sizeable minority of elderly people with weight loss (between 16 and 28%) don’t have an identifiable cause. Fortunately, their prognosis appears to be pretty good. It’s thought that the weight loss in those cases may be due to a mish-mash of causes from the above list, each contributing to a small enough extent that it’s not obvious in itself but still adds its straw to the camel’s back. So, if that list of history, examination and investigations hasn’t turned up anything, leaving it and assessing the situation in a few months is more reasonable than proceeding straight to more invasive investigations. (The authors admitted to not having the answer to the obvious next question of what to do if things are no better at that point and there’s still no apparent cause; from my point of view, what I’d do would be to refer to a geriatrician who could have the joy of making that decision.)
One thing that is worth doing, however – for all elderly patients with weight loss, both those in whom a cause is identified and those in whom it isn’t – is referral to a dietician. Whatever else is going on, it’s quite plausible that malnutrition in some form is playing at least some role.