พญ. อักษรา ขจรกิจเจริญ

16 กย. 53

Weight Loss in Elderly

Intentional weight loss

Unintentional weight loss

Effect on the ability to function & quality of life

Increase in mortality 9-38% over a 1-2.5years period after

wt. loss

No identifiable cause in up to ¼ of patients

Prevalence: 27% of ≥ 65 year olds

Weight loss is strongly associated with 76% increase in mortality risk among home-bound older adults.

Involuntary weight loss greater than 4% of BW is an independent predictor of increased mortality

Men ≥ 65 year-old + BMI <22 kg/m2

VS

Men ≥ 75 year-old + BMI < 20.5 kg/m2

Women ≥ 65 year-old + BMI <22 kg/m2

VS Women ≥ 75 year-old +BMI < 18.5 kg/m2

Increase to 20% higher

Increase to 40% higher

Weight loss is also associated with

Decline in activities of daily living / functional status

Twofold increase risk of disability

Increase risk for in-hospital mortality & life threatening complication

Higher rates of admission to an institution

poorer quality of life

When is weight loss clinically important?

All weight loss of 5% over 6 months should be investigated.

High risk populations Increasing age

disability

coexisting medical illnesses

previous admission to hospital

low education level

presence of cognitive impairment

Smoking

loss of a spouse

low baseline body weight

Wasting = involuntary loss of weight

mainly due to poor dietary food intake

Cachexia = involuntary loss of fat-free mass (muscle, organ, tissue, skin and bone) or body cell mass

Associated with a systemic inflammatory response, increased cytokine concentrations and impaired immunity

Negative nitrogen balance

Associated with chronic disease

Sarcopenia = decline in skeletal muscle mass

major age-related physiological change in elderly

Organic

• Neoplastic

• Nonneoplastic

• Age-related

Psychological

• depression

• Dementia

• anxiety

Non-medical

• social

• economy

Etiology

Etiology of Weight Loss in the Elderly

DM

The 9 Ds of weight loss in the elderly

Dementia

Depression

Disease (acute and chronic)

Dysphagia

Dentition

Dysgeusia

Diarrhea

Drugs

Dysfunction (functional disability)

total body weight tends to peak in the 5th to 6th decade, remaining stable until age 65 to 70

After the 7th decade the elderly subject tends to develop very small decrements in weight at a rate of 0.1-0.2 kg/year

Loss of up to 3 kg of lean body mass per decade after the age of 50

↑Body fat

reduced physical activity

Reduced growth hormone secretion

diminished sex hormones

decreased resting metabolic rate

fat free mass ( skeletal m.)

Age-related weight loss

Biological changes of the digestive system

Dysphagia

gastrointestinal reflux (GERD)

Constipation

Reduced esophageal motility

Delay gastric emptying time

Reduced gastric acid secretions ( PPI are frequently used for prolonged periods in older people leading to suppressed acid secretions)-- predisposes the gut to small bowel bacterial overgrowth

reduced pancreatic secretion

Physiological changes of digestive system and aging

↑Leptin, ↑cholecystokinin, neuropeptide Y

Drugs may cause anorexia in older people

Dysgeusia = distortion of the sense of taste (eg. metallic taste)

Age-related chemosensory losses play a substantial role in the anorexia

Reversible causes of dysgeusia

Medications: antihistamines, captopril, carbamazepine, allopurinol, levodopa, clofibrate, lithium, baclofen, any chemotherapy

Common causes of dysgeusia include chemotheraphy, drugs, and less commonly zinc deficiency.

Managing dysgeusia

Non-phamacologic Non-metallic silverware

Avoiding metallic or bitter tasting foods

Consumption of foods high in protein

Serving foods cold in order to reduce any unpleasant taste or odor

Phamacologic artificial saliva or oral pilocarpine (Xerotomia)

Zn supplementation

ถั่วลิสง

Herb, spice, dark leafy green

Psychiatric

Dementia

Depression

Bereavement

Anorexia nervosa or tardive

Alcoholism

Manipulation

Cholesterol phobia

Choking phobia

Psychiatric disorder (especially depression) 9%–42%

Malignant disease 16%–36%

Unknown 10%–36%

Gastrointestinal disease ( Gallstones, smell & taste) 6%–19%

Endocrine disorder (especially hyperthyroidism) 4%–11%

Cardiovascular disease 2%–9%

Nutritional disorders or alcoholism 4%–8%

Respiratory disease ~6%

Neurologic disorder 2%–7%

Chronic infection 2%–5%

Renal disease ~4%

Connective tissue disease 2%–4%

Drug-induced weight loss (medication side effects) ~2%

Common causes of unintentional weight loss in elderly patients

Careful taking medical history from elderly person & family members

Specific features on physical examination ( such as cachexia, lymphadenopathy or palpable masses, alopecia, edema, glossitis, skin desquamation)

Screening for dementia and depression by using instruments such as the Mini-Mental Status Examination (MMSE) and the Geriatric Depression Scale (GDS)

The first priority in managing weight loss is identify and treat the underlying causes

Optimal clinical approach to weight loss

common treatable causes of unintentional weight loss in the elderly

M Medication effects

E Emotional problems, especially depression

A Anorexia tardive (nervosa), alcoholism

L Late-life paranoia

S Swallowing disorders

O Oral factors (e.g., poorly fitting dentures, cavities)

N No money

W Wandering and other dementia-related behaviours

H Hyperthyroidism, hypothyroidism, hyperparathyroidism, hypoadrenalism

E Enteric problems (e.g., malabsorption)

E Eating problems (e.g., inability to feed self)

L Low-salt, low-cholesterol diets

S Social problems (e.g., isolation, inability to obtain preferred foods) gallstones

Initial diagnostic work-up for involuntary weight loss in elderly subjects

All Patients

CBC, ESR

Urinalysis

Renal function tests

Levels of liver enzymes, Albumin

Calcium and phosphorus

Electrolytes

Fasting blood sugar

Thyroid function test

Chest X-ray

HIV testing, if risk factors are present

absence of localized symptoms

Fecal occult blood testing

Flexible sigmoidoscopy

Cervical Papanicolaou smear

Mammography

Prostate-specific antigen

Nonpharmacologic interventions

Minimize dietary restrictions

Optimize energy intake by:

maximizing intake with high-energy foods at the best meal of the day

eating smaller meals more often

eating favourite foods and snacks

providing finger foods

Optimize and vary dietary texture

Avoid gas-producing foods

Ensure adequate oral health

Gas-Producing foods

Vegetables

หอมใหญ่, แครอท, แตงกวา, กะหล ่าปลี, ผักชีฝรั ง, หัวไชเท้า

Beans & Peas

Fruit

ลูกเกด, กล้วย, ลูกพรุน, ผลไม้อบแห้ง

Carbohydrate

Caffeine

Beer

Hot spicy foods

Nonpharmacologic interventions

Take high-energy and nutritionally dense supplements or add fats or oils to usual foods

Take supplements between meals

Eat in company or with assistance

Use flavour enhancers

Participate in regular exercise

Take a multiple vitamin supplement daily

Pharmacologic interventions

Orexigenic drugs Cyproheptadine

Growth hormone

Megestrol

Ornithine oxoglutarate

Tetrahydrocannabinol

Metoclopramide

Cisapride

Meclobemide

Testosterone (males only)

Oxandrolone