From the Guidelines
The standard workup for weight loss in an older adult should begin with a comprehensive history and physical examination, focusing on potential causes including medical conditions, medication side effects, and psychosocial factors. This approach is supported by the ESPEN guideline on clinical nutrition and hydration in geriatrics 1, which emphasizes the importance of individualized dietary counseling for geriatric patients with weight loss and function.
Key components of the initial evaluation include:
- Complete blood count, comprehensive metabolic panel, thyroid function tests, urinalysis, and inflammatory markers like erythrocyte sedimentation rate or C-reactive protein
- Targeted testing such as hemoglobin A1c for diabetes screening, HIV testing if risk factors are present, and a fecal occult blood test to screen for gastrointestinal bleeding
- Nutritional assessment to evaluate protein status with albumin and prealbumin levels, and check for vitamin deficiencies (B12, folate, vitamin D)
- Depression screening using tools like the Geriatric Depression Scale, as depression commonly contributes to weight loss in older adults
- Cognitive assessment using tools such as the Mini-Mental State Examination to identify dementia or other cognitive issues that may affect eating behaviors
Further testing may be necessary based on the initial evaluation, such as:
- Chest X-ray, abdominal imaging, upper endoscopy, colonoscopy, or CT scans to evaluate for malignancy
- Screening for malnutrition, as recommended by the ESPEN guidelines on nutrition in dementia 1
- Assessment of eating problems and behavioral symptoms, using tools such as the Aversive Feeding Behavior Inventory (AFBI) or the Edinburgh Feeding Evaluation in Dementia Questionnaire (EdFED-Q)
The ESPEN guideline on nutrition in dementia 1 also recommends close monitoring and documentation of body weight in every person with dementia, and suggests repeated weighing at least every 3 months.
In addition, the American Diabetes Association recommends that obese older adults with diabetes may benefit from modest energy restriction and an increase in physical activity, and that a daily multivitamin supplement may be appropriate, especially for those older adults with reduced energy intake 1.
Overall, a comprehensive and systematic approach is necessary to identify the underlying cause of weight loss in older adults, which is crucial for reducing morbidity and mortality.
From the Research
Standard Workup for Weight Loss in Older Adults
The standard workup for weight loss in older adults involves a thorough history, targeted physical examination, and simple laboratory evaluation to identify the underlying cause of weight loss.
- A 4% body weight loss over 1 year should trigger a search for causes, which commonly include depression, cancers, benign gastrointestinal conditions, and medication toxicity 2.
- The workup should start with a detailed history and physical examination, followed by full bloodwork, urinalysis, chest x-ray, and a faecal occult blood test 3.
- In certain cases, ultrasound and upper endoscopy may be further recommended 3.
- The evaluation should also consider medication, social, psychological, logopaedic, and neurocognitive aspects 3.
- Whole body CT scanning may be a useful investigation for the noninvasive workup of patients with unexplained weight loss, with a diagnostic yield of 33.5% and good sensitivity, specificity, positive and negative predictive values for organic etiologies 4.
Key Considerations
- Unintentional weight loss is a common clinical problem with a broad differential diagnosis that is clinically important because of the associated risks of morbidity and mortality 5.
- Community-dwelling adults are often diagnosed with malignancy, nonmalignant gastrointestinal disorders, and psychiatric disorders as the cause of unintentional weight loss, whereas institutionalized older adults are diagnosed most often with psychiatric disorders 5.
- Up to a quarter of patients do not have a diagnosis after comprehensive workup, and close follow-up is warranted 5.
- Treatment involves management of underlying causes 5.