weight loss in older adults - siriraj hospital club_grand round... · common treatable causes of...
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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