#467 Unintentional Weight Loss with Dr. Eva Szymanski

January 20, 2025 | By Leah Witt

Audio

Video

Transcript available via YouTube

Become a mini geriatrician in our new Geriatrics series!

Geriatricize your knowledge of caring for older adults with unintentional weight loss! You’ll round out your history taking and weight gain plan by harnessing the age-friendly “5Ms”. We’re joined by Dr. Eva Szymanski (@eva_szy), expert geriatrician at Penn Medicine.

Claim CME for this episode at curbsiders.vcuhealth.org!

Patreon | Episodes | Subscribe | Spotify | YouTube | Newsletter | Contact | Swag! | CME

Show Segments

• Intro
• Rapid fire questions
• Case
• Defining Unintentional Weight Loss
• Applying the Geriatric 5Ms Framework
• Diagnostic Work-Up
• Addressing Ageism in Medical Decisions
• Defining Geriatric Syndromes
• Weight Loss Treatments
• Outro

Unintentional Weight Loss Pearls

1. Use the Geriatrics 5Ms to manage unintentional weight loss (and other chronic diseases/geriatric syndromes).
2. The Geriatrics 5Ms are Multicomplexity, Mind, Mobility, Medications, and what Matters Most.
3. Dealing with uncertainty and complexity in geriatric syndromes is challenging– know that you are not alone and this is important work!

Unintentional Weight Loss – Notes

Definitions

Unintentional Weight Loss

>5% weight loss (unintentionally) in 6-12 months (in normal aging people might lose 0.2-0.4 lbs per year).

Cachexia

Loss of skeletal muscle due to chronic underlying disease (eg COPD, cancer).

Sarcopenia

Loss of muscle mass and strength.

Failure to Thrive/Frailty

Global syndrome of decline in which physical frailty is present (sarcopenia and unintentional weight loss are often present), and there is impairment in ADLs and/or neuropsychiatric function (eg dementia or depression).

Geriatric Syndromes

Multifactorial clinical conditions that are common in older adults– these can’t be explained by an impairment in just one organ system.  Other examples: recurrent falls, delirium, urinary incontinence.  Apply the 5Ms to eval and treat (see below)!

The Geriatric 5Ms

The Geriatric 5Ms are a great way to approach any condition in older adults (Health in Aging Tip Sheet, Holliday et al 2022)! (Note: don’t get confused, some sources like the IHI/John A. Hartford Foundation call this the “4Ms” which doesn’t include multicomplexity).  Check out how Leah Witt, MD and Amber Lanae Martirosov, PharmD  applied them to the care of COPD (#408 COPD in Older Adults).

Multimorbidity/Multicomplexity

Consider comorbidities and organic causes of weight loss. For example, do they have advancing or severe COPD or heart failure? Do they have an undiagnosed new disease like cancer or a malabsorptive condition?

Make sure to review neglected symptoms that can affect eating such as visual deficits, smell or taste impairment, and dental issues.

Mind/mentation

Focus on mood symptoms/depression and cognitive impairment/dementia.  Depression may reduce interest in eating.  Dementia can cause dysphagia, behavioral issues with eating like food pocketing, wandering (increasing energy expenditure), and impaired ability to purchase or prepare food.  Mild/moderate cognitive impairment can also contribute to weight loss, particularly if they have a neuropsychiatric symptom like apathy or paranoia (eg the person worries the food is poisoned).

Mobility

Consider activities of daily living (ADLs) and instrumental activities of daily living (IADLs). ADLs: are they able to feed themselves? IADLs: are they able to shop and/or prepare food (or arrange for shopping and food preparation independently)? If there are deficits, do they have adequate caregiving or social support?  What is their physical function and activity level– are they more sedentary and losing muscle mass?

Medications

Go through the medications (including over the counter meds) with a fine-toothed comb! Medications can cause impairments in taste, appetite, dry mouth, nausea, etc– all of which can contribute to weight loss (Gaddey and Holder 2021). Examples of meds to look out for include antibiotics, propranolol and allopurinol (which can cause altered taste or smell), anticholinergics and antihistamines (which can cause dry mouth), and metformin, anticonvulsants, and SSRIs (which can cause anorexia). Also explore substance use that could affect appetite (eg alcohol or tobacco).

What Matters

Learn about the patient’s day to day life– what brings them joy and value in their life? Are they socially isolated? Are there financial or physical barriers to purchasing food?

Unintentional Work Loss Work-up

Guide your work-up by the 5Ms, history, and physical exam.

Labs

Start with the basics: CBC (looking for anemia that might signal an occult GI malignancy or bone marrow issue), complete metabolic panel (with particular attention to liver and renal function as well as glucose), TSH (to assess thyroid function) and vitamin B12. If they haven’t been screened for HIV or HCV this should be done.  Consider if A1c, ferritin, or ESR/CRP would help you, but do not order in every situation. Beware of the hail mary prostate specific antigen PSA– this is not very useful in this context.

Imaging

Some sources suggest starting with a chest x-ray or abdominal ultrasound depending on symptoms (Gaddey and Holder 2021).  Dr. Szymanski suggests doing a chart review to see if they have had recent imaging that helps to rule out conditions/need for additional imaging, but she typically pursues cross-sectional imaging (eg CT chest and/or abd/pelvis) if she decides imaging is needed (expert opinion). Whole body CT scanning for unintentional weight loss has been shown to have a diagnostic yield of 33.5% for organic etiologies (Goh et al. 2018).

Cancer evaluation?

Making sure a patient is  “up to date” with cancer screenings isn’t totally appropriate in an unintentional weight loss work-up, because at this point the tests are diagnostic, not for screening (since the patient is symptomatic).  Carefully chart review historic data which may uncover colonic polyps or lung nodules that were never followed up on and could guide next steps.

Beware of ageism!

Ageism can impact the health of older adults, and is compounded by structural racism (Sun et al 2023). This can contribute to disease underdiagnosis (eg being dismissive because someone is a certain age) AND overdiagnosis (eg being overly aggressive in diagnostics in a person who is frail and chronically ill, and does not wish for aggressive interventions). Age is just a number– it is important to assess physiologic age and fitness and use that information in concert with a patient’s goals and values to drive evaluation and treatment. 

Treating Unintentional Weight Loss

Counseling the patient and caregiver

When unintentional weight loss is present, patients and caregivers are often worried about malignancy. They can be reassured that a negative initial workup is usually reassuring against malignancy (and non-malignant organic causes). Watchful waiting is appropriate in this situation (with an agile response/change in management if things get worse) (Bosch et al. 2017). Explain the multifactorial nature of unintentional weight loss, the intended evaluation (guided by “What Matters”) and what the future might hold.

Patient/caregiver resources are so valuable– the Alzheimer’s Association has advice for people with cognitive impairment/dementia as does the Family Caregiver Alliance.

 Medications

Treat underlying causes such as depression, with appropriate medications. Mirtazipine can help stimulate appetite and cause weight gain in those who have depression, but there is little evidence that it should be prescribed outside of depression management.

What about appetite stimulants (eg megestrol acetate and dronabinol)?  It is an American Geriatrics Society Choosing Wisely recommendation to avoid using these in older adults, because of rampant side effects (Choosing Wisely, Health in Aging resource, Garcia et al 2013).

High-calorie supplements and dietary recommendations 

The American Geriatrics Society also recommends against high-calorie supplements (Choosing Wisely, Health in Aging resource), but Dr. Szymanski suggests that these may have a role in select patients (expert opinion). They have been shown to help people to gain weight but it isn’t clear if this translates to real outcomes like mortality.  It is important to stress to patients that eating “real food” is best, and if supplements are suppressing appetite at mealtime, that is counter productive. Use supplements in between meals. Supplements can also be very expensive– note Carnation Instant Breakfast is cheaper than Boost or Ensure (courtesy of Dr. Josh Uy’s dot phrase!) (Milne et al 2009).

Liberalize the diet completely– add oil, butter, peanut butter, etc to add extra calories where they can.  Undo the messages they have received their whole lives to “watch their diet”– she suggests telling them “if you feel like ice cream, eat the ice cream”.

You can also encourage patients to play around with food texture, spice/taste, temperature and smell.

Social recommendations

Social connection and social eating is an important recommendation. Explore if the patient needs help with feeding, affording food, physically obtaining groceries and/or making meals, and recommend appropriate social programs/caregiving resources.

What about a feeding tube?

Anxiety and worry over weight loss is often an emotionally charged discussion that includes uncertainty, grieving, etc.  Enteral feeds in advanced-staged dementia is not recommended and can cause harms (eg hospitalizations, bed sores) and does not improve mortality.  It is important to provide alternatives to a feeding tube instead of saying there is nothing we can do (eg we are going to do careful 1:1 hand-feeding) (Choosing Wisely, Health in Aging resource, Finucane et al 1999, Palecek et al 2010).

Steal a dot phrase!

Courtesy of Dr. Josh Uy, import this into your EMR for your patient instructions:

To stimulate your appetite try changing the variety in your food.  Specifically change the 

1.  Taste-Salty, sweet, bitter, sour, spicy

2.  Temperature-Hot or cold

3.  Texture-Crunchy, soft, chewy, liquid

4.  Smell (for taste issues)

Make sure your mouth is clean to improve taste

Make sure your mouth is moist

Eat with others

Puree the foods to make chewing easier

To increase calories

1.  No restriction on diet:  No limits on salt, sugar, fat, or carb restriction.  Eat anything you want:  Bacon, sausage, bread, ice cream, candy, cookies, cheese etc.

2.  Increase the calories in your food by adding:  Heavy cream, cheese, sugar, oil, avocado, full fat yogurt

3.  Buy Carnation Instant Breakfast instead of Boost or Ensure because it is cheaper.  Drink them between meals, not with meals.  

Links

1. Geriatric 5Ms pocket card
2. GeriKit app – a resource for comprehensive geriatric assessments which is related to 5Ms
3. Alzheimer’s Association Food & Eating
4. American Geriatrics Society work at the intersection of structural racism & ageism

Goal

Listeners will develop a framework to evaluate and treat unintentional weight loss in older adults.

Learning objectives

After listening to this episode listeners will…  

1. Define unintentional weight loss as a geriatric syndrome, and differentiate it from related concepts of anorexia, sarcopenia, cachexia, and failure to thrive.
2. Use the Geriatric 5Ms framework as a tool to develop an unintentional weight loss differential diagnosis list and create individualized management plans.
3. Review the evaluation of unintentional weight loss including history, examination, and laboratory testing.
4. Develop multi-modal treatment strategies that address the multifactorial processes driving unintentional weight loss as a geriatric syndrome.

Disclosures

Dr. Szymanski reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

The production of this episode was supported by the Penn Geriatrics AGE-SMART Geriatric Workforce Enhancement Grant. This podcast content is solely the responsibility of the authors and does not necessarily represent the official views of the Health Resources and Services Administration or the U.S. Department of Health and Human Services.

Citation

Witt LJ, Miller R, Szymanski E, Williams PN, Watto MF. “#467 Unintentional Weight Loss”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date Jan 20, 2025.