What is the appropriate workup for an elderly woman presenting with unintentional weight loss?

Workup for Unintentional Weight Loss in Elderly Women

The appropriate workup for an elderly woman with unintentional weight loss should begin with comprehensive screening for malignancy, medication effects, social factors, and common organic diseases, as these represent the most frequent causes of involuntary weight loss in this population. 1, 2

Initial Assessment

History and Targeted Physical Examination

• Weight loss quantification: Document amount (>5% in 6 months or >10% beyond 6 months is significant) 1
• Medication review: Focus on drugs that may cause:
  • Nausea/vomiting
  • Altered taste (dysgeusia)
  • Anorexia
  • Dysphagia 2
• Nutritional assessment:
  • Dietary intake patterns
  • Chewing/swallowing difficulties
  • Appetite changes 2
• Social factors evaluation:
  • Isolation
  • Financial constraints
  • Food accessibility
  • Depression screening 2

First-Line Laboratory Tests

• Complete blood count
• Basic metabolic panel
• Liver function tests
• Thyroid function tests (ultrasensitive TSH)
• C-reactive protein and erythrocyte sedimentation rate
• Lactate dehydrogenase
• Ferritin
• Protein electrophoresis
• Urinalysis 2

Initial Imaging and Screening

• Age-appropriate cancer screenings
• Chest radiography
• Fecal occult blood testing 2

Second-Line Investigations

Targeted Testing Based on Initial Findings

• Gastrointestinal evaluation:
  • Upper endoscopy (particularly valuable in selected patients)
  • Colonoscopy (for patients with GI symptoms or positive fecal occult blood) 2, 3
• Advanced imaging:
  • CT scan (particularly for suspected malignancy)
  • Consider tumor markers (CEA, PSA, CA 19-9) though their utility is debated 3

Specialty Consultations

• Geriatric assessment for comprehensive evaluation
• Psychiatric evaluation if depression or other mental health conditions suspected
• Dietitian consultation for nutritional assessment 1

Common Causes to Consider

1. Non-malignant diseases (most common):

   • Gastrointestinal disorders
   • Cardiac conditions
   • Depression (especially in long-term care residents) 2

2. Malignancy (accounts for up to one-third of cases):

   • Lung cancer
   • Gastrointestinal malignancies 2, 4

3. Medication effects and polypharmacy 2

4. Neuropsychiatric disorders (23.5% of cases) 3

5. Unknown cause (6-28% of cases) 2, 3

Management Approach

• Focus treatment on underlying cause when identified
• For cases without clear etiology, implement a 3-6 month observation period with regular follow-up 2
• Address contributing medications
• Provide dietary modifications considering patient preferences and eating abilities
• Ensure adequate protein intake (at least 1g/kg body weight/day) 1
• Consider vitamin D supplementation (15 μg/600 IU daily) 1
• Implement weekly weight monitoring and monthly reassessment of nutritional interventions 1

Important Caveats

• Appetite stimulants and high-calorie supplements alone are not recommended by current guidelines 2
• Malignancy accounts for only about 17% of cases in elderly patients, despite common physician concern 3
• Avoid focusing solely on caloric intake without addressing protein needs 1
• In patients with obesity-related health problems, intentional weight loss should be carefully managed with protein preservation and exercise to prevent sarcopenia 1
• Consider that multiple factors often contribute simultaneously to weight loss in elderly patients 5

Remember that early identification and intervention for unintentional weight loss is critical, as it is associated with increased morbidity and mortality in elderly patients 2, 4.