Addressing involuntary weight loss

Scenario

An 86-year-old woman with more than two years' history of progressive Alzheimer's dementia came to your office with her home health aide for a routine appointment. You noticed the woman had experienced significant weight loss. She was well dressed but smelled of urine. You were not able to get a good history since the patient could not recall any recent events. The aide was new and not very familiar with the patient's routine. But, since she started working there two days earlier, the patient had not complained of any pain or discomfort.

The patient's medical history includes hypertension and osteoporosis. She had a hip fracture a year ago, and her ambulation is very limited. Her medications include amlodipine, Fosamax, Aricept, Namenda and calcium with vitamin D. She lives in her apartment with a private aide. This aide is there every day, around the clock. Her daughter, who lives out of town, calls daily.

Your physical exam showed a woman looking her age, alert and disoriented. Her weight was down 15 lbs. since her last visit three months ago. Head and neck, cardiovascular, and lung exam were normal. She was mildly tender over epigastrium with deep palpation. Her skin was very dry. The patient became very agitated when the nurse tried to draw blood.

Discussion

Elderly patients with unintentional weight loss, like the woman described here, are at higher risk for infections, depression and even death. According to the literature, a loss of 5% to 10% of body weight over the course of one to 12 months is a red flag. It is a problem frequently seen by physicians who treat older patients. Some studies estimate prevalence as high as 27% among high-risk populations, such as frail elderly people who live in the community. And, although people tend to experience some degree of lean body mass loss as they age, this degree of weight loss should not be considered a normal part of the aging process. Nonetheless, addressing it can be tricky. Some of the most common causes are depression, dementia, cancer, cardiac disorders and benign gastrointestinal diseases. Some medications known to impair taste, or cause nausea or excessive sedation can be a factor, as can polypharmacy. But in about a quarter of these patients, no specific cause is identified.

In this particular case, loss of appetite related to the patient's advanced dementia is likely to be the primary trigger for her weight loss. Patients with Alzheimer's or other dementias may have marked loss of taste and smell, abnormal eating behaviors or anorexia. However, treatable conditions, among them urinary tract infections, chronic constipation, cancer and thyroid disease, are part of the differential diagnosis and need to be investigated.

A conversation with family members about the demands of this process is critical. Remember, for this woman, a simple blood draw was a difficult procedure and led her to become agitated. Invasive tests such as a colonoscopy, or others such as CT scans or MRIs, promise to be even more traumatic, as would any resulting downstream surgeries or treatments. Her family needs to be informed and consulted before such diagnostic steps are taken.

Social issues also may contribute to the decline in food intake. Loneliness and social isolation have been linked to poor nutrition. In this case, questions need to be answered about the availability and presentation of prepared food, about dietary restrictions that result in tasteless meals, or about physical disabilities that prevent the patient from using a spoon.

Neglect also can be an issue. The need to feed a patient who can no longer feed himself or herself can be time-consuming and frustrating. It has been shown that the quality of the relationship between the person being fed and the feeder is an important predictor of food intake.

Swallowing, too, may be a difficulty. Dysphagia is very common in patients with advanced dementia. The caregiver should be asked about coughing and choking during meals -- common signs of food aspiration. A swallowing evaluation by a speech therapist is usually helpful in the diagnosis of swallowing dysfunction and the evaluation of its severity.

An examination of the patient's oral cavity to ensure she can chew and swallow is necessary. Ill-fitting dentures, deficient mouth hygiene, dry mouth (a risk for patients taking anticholinergic medications) or thrush (often seen in diabetics or patients taking antibiotics or steroids) can cause discomfort and result in refusal to eat.

Multiple interventions could be recommended to the family or caregivers to improve food intake. It is important to make sure that food is available not only at meal times. Many patients need reminders or simple cues to feed themselves. Maximizing food's taste and smell, and taking into consideration the patient's food preferences can help. Research supports the use of oral liquid nutritional supplements. They should be given between meals to increase calorie consumption. A consultation with a nutritionist or dietician can aid in developing a more healthy and calorie-rich diet

Finally, appetite stimulants are often considered. To date, no medications are Food and Drug Administration-approved to promote weight gain in older adults. The few agents (megestrol acetate, dronabinol) that have been shown to improve intake in some patient populations (such as those with cancer or HIV) have not been well studied in the elderly and have the potential of causing significant side effects.