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Weight loss in the elderly: what’s normal and what’s not

Weight Loss in the Elderly:
What’s Normal and What’s Not
Michael Lewko, MD, Ayham Chamseddin, MD, Maged Zaky, MD, and Richard B. Birrer, MD, MPH
INTRODUCTION
metabolic rate as well as with changes in the senses of taste Involuntary weight loss (IWL) is commonly observed in the older population, affecting 13% of ambulatory patients and Overly restricted diets, such as those that are low in fat and 50% to 60% of nursing-home residents.1 It is an important salt, may cause decreased intake8; therefore, a special or indicator of significant decline in health and function, resulting restricted diet (low in cholesterol, salt, or concentrated sweets) in a higher risk for infection, depression, and death.
often reduces food intake without significantly improving the Although it is important to recognize that periods of sub- stantially positive or negative energy balance and body weight The role of inflammatory cytokines, including tumor necro- fluctuation occur as a normal part of life, a weight loss greater sis factor (TNF, formerly cachectin), interleukin-1 (IL-1), and than 5% over six months should be investigated.
interleukin-6, has also been postulated.9 Physiological changes We can divide the major causes of weight loss in the elderly in the regulation of food intake take place, even in the presence of the increased body fat and the increased rates of obesity thatoccur with age, some of which can be explained by altered Generally speaking, individuals aged 65 years and older experience a mild loss of weight, a near doubling of adiposity,and a significant non-fat mass loss of 5% to 15%.11 The clinical evaluation should include a careful history and Sarcopenia, the loss of skeletal muscle mass—and thus physical examination. If these do not provide clues to the leading to a loss of protein—may play an important role in IWL.
weight loss, simple diagnostic tests are indicated. A period of Muscle loss can be the result of negative nitrogen balance that watchful waiting is preferable to blind pursuit of additional occurs with normal aging and with inadequate protein intake, diagnostic testing that may yield few useful data if the results which is commonly obser ved among the elderly.12,13 Age- of these initial tests are normal. The first steps in managing related changes in anabolic hormones may contribute to non- patients with weight loss are to identify and treat any specific fat mass loss. Low testosterone levels in men correlate with the causative or contributing conditions and to provide nutritional loss of lean body mass, and loss of estrogen during menopause support when indicated. Orexigenic (appetite-stimulating) is associated with non-fat mass loss in women.14,15 drugs have found an established place in the management of Growth hormone appears to play an important role in body composition; growth hormone levels may decrease by 14%per decade.16 It has been found that replacement of growth PATHOPHYSIOLOGY
hormone in older people results in increased lean body mass Regulation of food intake changes with increasing age, lead- ing to what has been called a “physiological anorexia of aging.” The amount of circulating cholecystokinin, a satiating hor-mone, increases in the circulation.2 Other substances are also The interplay between the brain and the gut is gaining increasing attention as a mechanism of anorexia and sub- sequent weight loss. A highly complex process involving taste sensation, neural and humoral signals from the gastro- intestinal tract, and neurotransmitters and peptides in the hypothalamus or other brain regions regulates food intake and, consequently, energy homeostasis.5 Psychosocial and spiritual distress can also influence the sensation of hunger, Loss of lean body mass is common in older people.7 HISTORY AND EVALUATION
Advancing age is also associated with a decrease in the basal Clinicians should seek common treatable causes of weight loss in elderly patients. One approach is to distinguish amongfour basic causes of weight loss: anorexia, dysphagia, socio- Dr. Lewko is Chief of Geriatrics, Dr. Chamseddin and Dr. Zaky are economic factors, and weight loss despite normal intake.18 internal medicine residents, and Dr. Birrer is President and Chief Often, these causes are interrelated. Whichever approach is Executive Officer, all at St. Joseph’s Medical Center in Paterson, New used, the initial evaluation can yield a reason for weight loss 734 P&T® • November 2003 • Vol. 28 No. 11
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The medical evaluation should begin with a comprehensive nition and the ability to eat.25 A reduction in the dosage of history and physical examination, with emphasis on relevant psychotropic medications may also cause weight loss, possi- medical, pharmacological, psychological, and functional fac- bly by unmasking an underlying disorder such as anxiety or tors. It is important to determine whether the patient is taking in an adequate number of calories; questioning the caregiveris essential.
PHYSICAL EXAMINATION
The activities of daily living (ADL) and the instrumental The physical examination of elderly patients with uninten- activities of daily living (IADL) are important measures of tional weight loss is directed by the information gathered patient function. A higher level of functioning is required to per- during the history-taking process. It is particularly important form IADL. A variety of medical conditions can impair these to evaluate the oral cavity and the respiratory and gastro- activities. In addition, cognition, memory, vision, and hearing Anthropometric measurements, specifically the patient’s A change in living habits may also indicate cognitive decline; height and weight, are of prime importance and should be com- clinicians should assess for cognitive dysfunction caused by pared with minimum and maximum adult weights. The patient’s body mass index (BMI) can be calculated by dividing Depression not only is an indicator of poor function but also the weight in kilograms by the square of the height in meters.
is an independent factor associated with weight loss.20 It has In one study,27 a BMI of less than 22 kg/m2 in women and less been found that weight loss precedes the development of than 23.5 kg/m2 in men was associated with increased mor- Alzheimer’s disease in 50% of patients and may be secondary tality. In another study,28 the optimal BMI in older adults was 24 to 29 kg/m2. Because of the difficulty in determining height Using the “Get Up and Go” test to screen for physical in some elderly patients (e.g., those who are confined to beds function, functional reach, and handgrip may elaborate diffi- or wheelchairs), the BMI is less commonly used than weight.
culty with the strength and mobility that patients need to Stevens et al. found that after age 75, mor tality rates maneuver in the grocery store or kitchen. A thorough review increased with a BMI below 25.29 Reynolds et al.30 and Landi of medications may reveal that patients are experiencing et al.31 demonstrated that a low BMI among community- polypharmacy, which is known to interfere with taste and to dwelling elderly adults was associated with increased mortality independently of any pre-existing diseases.
Many individual medications have been associated with unintentional weight loss (Table 1).23 These include some DIFFERENTIAL DIAGNOSIS
selective serotonin reuptake inhibitors (SSRIs), such as flu- The differential diagnosis of unintended weight loss in the oxetine (Prozac®, Eli Lilly).24 Other SSRIs may have a lesser elderly can be extensive. The most commonly identified causes anorectic effect, but patients taking those drugs should still be are summarized with the mnemonic “Meals on Wheels”:32 Sedatives and narcotic analgesics may interfere with cog- Medications (e.g., digoxin, theophylline, antipsychotic
Emotional problems (depression)
Drugs Associated with Weight Loss
Anorexia tardive (nervosa) or alcoholism
Late-life paranoia
SSRI Antidepressants
Swallowing disorders (dysphagia)
• Citalopram hydrobromide (Celexa®, Forest) Oral problems (e.g., poorly fitting dentures)
• Fluoxetine (Prozac®, Eli Lilly)• Paroxetine (Paxil®, GlaxoSmithKline)* Nosocomial infections (tuberculosis, Helicobacter pylori,
Cardiac Agents
Wandering and other dementia-related behaviors
Hyperthyroidism, hypercalcemia, hypoadrenalism
Enteric problems (e.g., malabsorption)
Stimulants and Appetite Suppressants
Eating problems (e.g., difficulty in self-feeding)
• Amphetamine/dextroamphetamine (Adderall®, Shire) Low-salt, low-cholesterol diet
• Dextroamphetamine sulfate (Dexedrine®, GlaxoSmithKline) Stones (cholelithiasis)
• Methylphenidate (Ritalin®, Novartis; Concerta®, Alza)• Pemoline (Cylert®, Abbott) Causes of weight loss in residents of long-term-care facilities • Phentermine (e.g., Ionamin®, Celltech)• Sibutramine HCl monohydrate (Meridia®, Abbott) may differ from those in ambulatory patients. In one study, Benzodiazepines
depression was present in 36% of nursing-home residents with unintentional weight loss.10 Overall, psychiatric disorders, including depression, account for 58% of the cases of involun- Miscellaneous
tary weight loss in nursing-home patients.26 • Metformin (Glucophage®, Bristol-Myers Squibb) * Can also cause increased appetite.
DIAGNOSTIC STUDIES
From Drug Facts and Comparisons, 2002. Micromedex Health Care Series Although unexplained weight loss in the elderly can have (2002); and Drug Information Handbook (1999–2000), 7th ed, LexiComp.
myriad causes, an undirected (“shotgun”) approach to labora- Vol. 28 No. 11 • November 2003 • P&T® 735
Weight Loss in the Elderly
tory tests and other diagnostic studies is rarely fruitful. Initial high-cholesterol foods. Patients with diabetes mellitus may also targeted studies can determine the cause in many patients.9,19 be given a less restrictive diet; in some instances, weight loss The findings of the history and physical examination guide in these patients may reflect overzealous blood glucose con- the initial diagnostic assessment. A reasonable initial panel of trol. However, blood sugar and glycosylated hemoglobin levels tests in the elderly patient with unintentional weight loss should continue to be monitored in patients with diabetes Adding flavor enhancers that amplify the intensity of food • a fecal occult blood test to screen for cancer.
odors may be useful in patients with hyposmia.23 Patients with • a complete blood count to assess for infection, iron dysphagia may require puréed foods and thickened liquids.
deficiency anemia, or lymphoproliferative disorder.
Patients may benefit from simply being offered frequent, • a chemistry profile to check for evidence of diabetes small servings of foods that they like. Large portions may be mellitus, renal dysfunction, or dehydration.
overwhelming and may actually discourage intake.
• a thyroid-stimulating hormone test to check for When possible, physical exercise and even physical therapy should be encouraged, because increased activity has been • a urinalysis to check for evidence of infection, renal shown to promote appetite and food intake. One study found that caloric intake was greater in patients who received both (radiography or endoscopy) may bewarranted in patients with GI-related Medication reviewDirected laboratory testing occur in 6% to 43% of nursing-home res-idents. Hypoalbuminemia is commonlyconsidered a sign of malnutrition. How- No cause identified or condition not treatable ever, low serum albumin may be a betterindication of inflammation than mal- nutrition caused by cytokine excess.
This excess inhibits albumin synthesis in Provide frequent, small meals.
Allow unlimited intake of favorite foods.
the liver and causes albumin leakage into a poor marker of nutritional status.
MANAGEMENT
weight loss is directed at identifying the evaluation is proceeding or if a cause isnot well defined, the goal is to preventfurther weight loss. Initiating nutritional support early may help to avoid some ofthe complications related to weight Weight gain
orexigenic agents, or tube feedings.
* Weight loss of concern is generally defined in several ways: (1) loss of 5% to 10% of body weight in care facilities, the food service manager the previous one to 12 months or (2) loss of 2.25 kg (5 lb) in the previous three months. Nursing-home guidelines require evaluation if there is a 10% loss in the previous six months, a 5% loss in the previousmonth or a 2% loss in the previous week. ualized suggestions for facilitating foodintake.
Figure 1 Management of weight loss in elderly adults. (From Huffman GB.
Evaluating and treating unintentional weight loss in the elderly. Am Acad Fam Physi- cians 2002;65:640–650. Copyright 2002, American Academy of Family Physicians.
736 P&T® • November 2003 • Vol. 28 No. 11
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nutritional supplements and exercise than in patients who lowing hospitalization.39 No studies have been conducted in long-term-care institutions. It would be reasonable to study the When liquid-calorie supplements are used, they should not effects in malnourished men with low testosterone levels; be given with meals because total caloric intake does not testosterone supplementation might be more useful in sarco- improve with this method of administration.34,35 Liquid sup- plements are preferable to solids.35 With liquids, the gastricemptying time is quicker, and total caloric intake is more likely Oxandrolone
to be maximized. Wilson et al.36 found that the liquid-calorie Another anabolic steroid, oxandrolone (Oxandrin®, supplement, when given before meals, increased total caloric Savient), decreased weight loss, nitrogen loss, and the length intake. Therefore, patients should take caloric supplements of hospitalization in elderly burn patients.40 In patients with between meals, not with meals.
chronic obstructive pulmonary disease (COPD), 10 mg ofoxandrolone twice daily produced weight gain.41 Although the PHARMACOLOGICAL TREATMENT
U.S. Food and Drug Administration (FDA) has approved The pharmacological treatment of primary anorexia and oxandrolone for the treatment of IWL, this agent has not yet severe weight loss attempts to alter metabolic, neuroendocrine, and anabolic activities in order to provide symptomaticimprovement.37,38 Although several drugs have been used to Megestrol Acetate
promote weight gain (Table 2), none have been specifically Megestrol acetate (MA) (Megace®, Bristol-Myers Squibb On- indicated to treat weight loss in elderly patients and few have cology) 400–800 mg has been used successfully to treat cachexia in patients with AIDS or cancer.42 Yeh et al. noted significant Although medications may help to promote appetite and weight gain by three months after administration of MA.43 weight gain in older patients with unintentional weight loss, There have been several studies of MA in geriatric patients.
drugs should not be considered the first-line treatment. Even Castle et al. reported weight gain in two of four patients if drugs are successful in inducing weight gain, their long-term receiving MA. Patients were to receive 400 mg of MA for six effects on quality of life are unknown.
weeks.44 In a randomized, double-blind study, 74% of 27 long-term care patients taking 800 mg of MA over 24 weeks showed Testosterone
a significant increase in weight, with the weight gain being Bakhshi et al. indicated that the administration of testos- terone improved functioning in men during rehabilitation fol- In a small number of nursing-home residents receiving MA, Karcic et al. reported an increase in food intake, BMI, albumin, Drugs Associated with Weight Gain
pre-albumin, hemoglobin, and lymphocyte count.46 Yeh et al.
showed that taking MA decreased IL-6, TNF p75 receptor, Tricyclic Antidepressants
and soluble IL-2 receptor levels.47 In addition, Lambert et al.
• Amitriptyline (Elavil®, AstraZeneca) showed that MA reduced IL-6 levels, suggesting that MA • Despramine (Norpramin®, Aventis)• Impramine (Tofranil®, Mallinckrodt)• Nortriptyline (Aventyl®, Eli Lilly; Pamelor®, Mallinckrodt) Established Pharmacological Treat-
Appetite Stimulants
ments of Involuntary Weight Loss
• Dronabinol (Marinol®, Roxane)• Megestrol acetate (Megace®, Bristol-Myers Cortico-
steroids* Progestins† Prokinetics‡
Anabolic Steroids
• Oxandrolone (Oxandrin®, Biotechnology General Glucocorticoids
• Dexamethasone (e.g., Decadron®, Merck) • Methylprednisone (e.g., Medrol®, Pharmacia) • Prednisolone: (e.g., Prelone® Syrup, Muro) Antipsychotic Agents
• Haloperidol (e.g., Haldol®, Ortho-MacNeil) and others * Short-term application of prednisolone equivalent 20 to 50 mg for one Miscellaneous
† Intermediate- to high-dose megestrol acetate or medroxyprogesterone ‡ Metoclopramide 10 to 15 mg is administered 30 minutes before meals • Lithium (Eskalith®, GlaxoSmithKline; Lithobid®, Solvay) Key: – = no effect reported; + = mild effect; ++ = established effect; ? = controversial effect; (+) = possible effect.
* Zyprexa® is also associated with weight loss.
Adapted from Strasser F, Bruera ED. Update on anorexia and cachexia.
From Drug Facts and Comparisons, 2002. Micromedex Health Care Series Hematol Oncol Clin North Am 2002;16(3):589–617. Copyright 2002, with (2002); and Drug Information Handbook (1999–2000), 7th ed, LexiComp.
Vol. 28 No. 11 • November 2003 • P&T® 737
Weight Loss in the Elderly
might be useful in cytokine excess states, as measured by and antiserotoninergic medication that causes a mild increase in appetite. In one study,62 patients with a median age of 65 One drawback of MA is its tendency to increase fat mass; years who received cyproheptadine experienced a decrease in with an exercise program, however, non-fat mass may increase.
their rate of weight loss but no weight gain. Drowsiness and The exact duration and optimal dose of MA in geriatric patients dizziness are side effects that may make the use of this are not known. One retrospective study suggested that MA at medication particularly problematic in elderly patients.
dosages ranging from 80 mg to 400 mg effectively reversedIWL in nursing-home patients after three months of use.49 Metoclopramide
It is known that MA can cause edema, constipation, delirium, Metoclopramide (Reglan®, Schwarz Pharma), a prokinetic hypogonadism, hyperglycemia, adrenal insufficiency, and pos- agent, may relieve nausea-induced anorexia,63 but it can cause sibly deep vein thrombosis. These side effects may limit its use- severe dystonia and may precipitate parkinsonian symptoms Table 3 shows a comparison between the effects and the pro- kinetics of corticosteroids and those of progestins.50 Involuntary weight loss is associated with increased mor- Mirtazapine
bidity and mortality in older adults. Identifying the multi- The treatment of depression itself may cause weight gain.
factorial causes of this condition in these patients poses a Mir tazapine (Remeron®, Organon) has been shown to challenge to clinicians, and a comprehensive geriatric assess- increase appetite and promote weight gain while it also treats ment aids in reviewing the multitude of potential causes.
the underlying depression.51 Depressed patients should Patients with depression should receive an antidepressant receive treatment without dietary restriction with orexigenic that has orexigenic properties. Orexigenic drugs should be used when no obvious treatable cause of IWL is present andwhen nonpharmacological interventions are ineffective. Close Dronabinol
monitoring for potential side effects is necessary in elderly The cannabinoid dronabinol (Marinol®, Roxane) is indi- patients. More studies are needed to define the role of these cated for the treatment of anorexia accompanied by weight medications in end-of-life and palliative care.
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