Managing Involuntary Weight Loss in Older

Adults

Jeannine Lawrence, PhD, RD, LDDivision of Human Nutrition

Learning Objectives

• Identify potential causes of involuntary weight loss in older adults (OAs)

• Explore the potential impact of involuntary weight loss on physical function and health outcomes in this population

• Describe the goals of weight management in OAs during illness

• Discuss effective, multidisciplinary strategies for ameliorating involuntary weight loss in OAs

Definitions & Prevalence

• Unintentional weight loss - loss of body mass that can occur due to illness or disease, stress, psychological conditions, and/or unknown causes

• Weight loss = >3% of body weight or 2 kg• Clinically relevant – >5% body weight in 6 months• “Problematic” weight loss – ≥5% in 1 month– ≥10% in 6 months or longer

US Omnibus Budget Reconciliation Act of 1987

Definitions & Prevalence (cont.)

• Undernutrition - common in older adults (Clinics in Geriatric Med. 2002)

– 5-12% of community-residing older adults– 11% of medical outpatients– 20% of higher-risk, community-residing– 32-50% of hospitalized

• Involuntary weight loss– Affects 15-20% of older adults– Contraindicated in the OA• Including the obese OA

Factors Associated with Unintentional Weight Loss

M – Medication effectsE – Emotional problems, esp. depressionA – Anorexia nervosa, alcoholism, abuseL – Late-life paranoiaS – Swallowing disorders

O – Oral factors (e.g. taste, teeth, poorly fitting dentures, caries)N – No money (poverty)

W – Wandering and other dementia-related behaviorsH – Hyper- and hypothyroidism, hyperparathyroidism,

hypoadrenalismE – Enteric problemsE – Eating problems (e.g. difficulty/inability to feed self)L – Low-salt, low-cholesterol dietsS – Shopping or social issues (e.g. inability to obtain preferred foods,

isolation, etc) Morley 1995

Comparison of Causes of Unintentional Weight Loss in OA

No iden

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Psychiat

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Cancer

Benign

GI diso

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Medica

tion effect

Neuro

logic diso

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Other (hyp

othyroidism

, poor in

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TB, fo

od avoidan

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tc)0

10

20

30

40

50

60

70

OP (n=45)LTC (n=185)IP (n=154)OP + IP (n=91)

Huffman 2002

Functional & Health Outcomes

• Physical function– loss of skeletal muscle mass→ frailty →

decreased mobility

• Health Outcomes– exacerbate disease –↓ immune function– ↑ morbidity and mortality

Nutrition Screening Tools• DETERMINE and MNA – extensively validated,

identify at-risk OAs• Nutrition Screening Initiative (NSI) – 25 national

health and aging organizations– Developed the Determine Your Nutritional Health

Checklist to highlight warning signs of malnutrition– Level I – BMI, weight change, eating habits, living

environment, and functional status questions – Level II – anthropometrics, lab data, clinical exam,

cognitive/mental status evaluation Lipschitz 1992

Nutrition Screening Tools (cont.)•Mini Nutritional Assessment (MNA) – short and long forms

Step 1 - Assessment

• Anthropometrics (ht, wt, wt change)– BMI

• height may be inaccurate 2° osteoporosis • may not be an accurate estimate of lean mass• 24.0-29.0 may be optimal Beck 1998

• Medical hx, labs• Medications and supplement use• Physical function, physical activity (↓

associated with poorer appetite)• Psycho/Social – cognition, depression, social

support and interaction

Dietary Intake Assessment in OAs

• Methods– Diet records– 24-hr dietary recall– FFQ– Diet history

• Validity of multiple methods are comparable to younger adults

Special Considerations for Dietary Intake Assessment in OA

• Memory impaired– Must assess cognitive abilities– Avoid - Recall, FFQ– Add – memory strategies (multiple pass, product

recognition), prior notification of interview, combining methods

– Caregiver interview beneficial• Physical limitations – arthritis, eyesight, etc– Avoid – self-administered tools

Special Considerations for Dietary Intake Assessment in OA (cont.)

• Altered dentition – Probe for specialized food prep

• Chronic illness & specialized diets– May introduce bias (both + & -)

• Supplement use

Step 2 - Weight Management

• Identify and treat the underlying cause, then -

• Dietary goal1. Stop the weight loss2. Plan for weight regain (when

appropriate)• What is reasonable?• +250-500 kcal/day or up to 35 kcal/kg

• Provide favored foods– If sweets, choose more nutrient-dense options:

pudding > cookies > hard candies

• Increase snacking, but monitor effect on meals• Get creative in masking nutrients to ↑ nutrient

density without ↑ing volume– Adding protein powders (whey), fiber

supplements, fats/oils to foods and beverages– Cookbooks available for hiding vegetables in

meals (targeted to parents)

• Diet liberalization – often warranted

Interventions to Improve Intake:Problem- Decreased Volume

• Keep nonperishable, ready-to-eat foods available

• Batch cook and freeze complete meals that can be microwaved (avoid stove reheating if fatigue or cognition is an issue)

• Consider enrollment in a community meal provider service (like Meals on Wheels)

Problem: Decreasing Ability to Prepare Foods

• Provide visual cues– Place foods and beverages in areas

where OA will see them– Attach notes with reminders to eat in

high-traffic areas

• Offer foods regularly• Have OA eat with others (in a

controlled setting)

Problem: Forgetting to Eat or Drink

• Due to ↓ taste and smell acuity or medication side effects– ↑ spices to enhance flavor– Serve foods warm to increase aroma– Cook other foods that smell delicious at mealtimes

• Cookies, bread

• Due to reduction in PA– ↑ PA

• Due to fatigue– Maximize on best meal –typically breakfast– Offer small snacks periodically– Make every food/beverage count

Problem: Loss of appetite

• Eat with others• Easily distracted– Eat with others so all are performing the

same task– Serve meals in a quiet, pleasant,

controlled environment– Use plain plates and tablecloths

Problem: Isolation, Depression, or MCI

• Dental eval• Swallowing evaluation – may require

medical intervention– Texture-modified foods– Thickened liquids

• Dehydration risk

• Supplements – an option, offer >1hour apart from meals– consider whole milk with CIB

• Supplemental enteral feeding, or full enteral feeding

Problem: Dental, Chewing, or Swallowing Issues

Additional Methods to Ameliorate Weight Loss

• Engage social and family support• Increase physical activity• Address fatigue, sleeping issues

Management During Illness

• Be proactive and aggressive–Weight loss is a downward spiral

• Consider it a comorbidity (to primary diagnosis) when developing tx plan

Medications and Supplements that May Increase Appetite*

Comments

Megace Do not use – contraindicated for use in OAs

RemeronTrazodoneDexamethasoneMarinol Anti-anxiety, anti-nauseaMetoclopromide Avoid unless for gastroparesis Ornithine oxoglutarate (OGO)

* All except Megace are non-FDA approved for this usage in this population

Summary

• Involuntary weight loss -15-20% of older adults– Contraindicated in the OA, including the

obese• Interventions require a

multidisciplinary approach– Begin with identifying the cause– Assess the patient from medical,

pharmacological, nutrition, and sociological perspectives

– Address weight management plan from multiple avenues

Case StudyA 73-year-old woman presents to

your clinic complaining of unintentional weight loss. She reports having lost 15 lbs (6.8 kg) over the past year. She reports that she is eating three meals per day as usual.

The patient’s past medical history is notable for:

• Osteoporosis• Left hip fracture three years• Osteoarthritis with osteoarthritic

changes in the knees• Hypothyroidism• Hypercholesterolemia. • Radiograph of the chest, CBC,

electrolytes, creatinine, TSH, and albumin are WNL.

Medications• levothyroxine • a statin • a bisphosphonate • vitamin D and calcium • nonsteroidal anti-inflammatory

medications (NSAIDs; prn for knee pain)

She is an ex-smoker and does not drink alcohol.

Weight -120 lbs (54.5 kg) Usual weight - 135 lbs (61.3 kg)89% of UBWBody mass index (BMI) - 22.0.

Adapted from Alibhai CMAJ 2005

Case Study (cont.)

On further questioning, the patient admits that:• Even though she had been eating three meals per

day, she eats less at each meal than previously. • Her husband of 50 years died suddenly 10 months ago.

– She reports her mood is fine but that she still has not gotten over his death. She feels lonely and is finding it difficult to motivate herself to prepare adequate meals for only one person.

• She also reports experiencing nausea and some difficulty chewing over the past month.

• You take a closer look in her mouth and notice that her dentures are loose and that there are a few small ulcers on her hard palate.

Plan• In an attempt to address her risk factors, you advise her to

have her dentures adjusted. Suspecting that the NSAIDS may be contributing to her nausea, you advise her to use acetaminophen for her knee pains instead. At your encouragement, she starts attending grief counseling and becomes involved in social activities, including a supper club, at her local seniors centre.

• Over the next two months, her appetite improves and she gains 4#.

• Her weight loss appears to have been the result of multiple factors, including social isolation, bereavement, chewing issues, decreased oral intake and possibly the use of NSAIDs.

• Risk factor modification appears to have been successful so you do not consider further nutritional or pharmacologic interventions at this time.