It is important to establish up front the presence of weight loss. A significant proportion of elderly people with documented weight loss may not complain about losing weight or, less commonly, may mistakenly attribute weight loss to successful diet or lifestyle modifications.1,24
Furthermore, disturbed eating behaviours and body image (e.g., anorexia tardive)32
among some elderly people may lead them to regard weight loss as desirable and therefore nonreportable. Conversely, up to half of people who claim to have lost weight have no documented evidence of weight loss.1
If it is not possible to measure weight directly, a change in clothing size, corroboration of weight loss by a relative or friend, or a numerical estimate of weight loss provided by the patient are suggestive enough of true weight loss.1,3,29
A careful history may elicit localizing symptoms (e.g., changes in defecation frequently imply involvement of the gastrointestinal tract) that may guide further investigations in almost half of patients.4,29
All elderly patients with weight loss should undergo screening for dementia and depression30
by using instruments such as the Mini-Mental Status Examination49
and the Geriatric Depression Scale50
respectively. Specific features on physical examination, such as cachexia, lymphadenopathy or palpable masses, may suggest a physical cause of weight loss (e.g., malignant disease).1,4
However, the diagnostic utility of the medical history and physical examination in identifying the cause of weight loss have not been adequately evaluated.
Although few studies have systematically evaluated the utility of screening investigations for weight loss, the most useful noninvasive procedures appear to include a complete blood count, tests of liver enzyme levels (including alkaline phosphatase and bilirubin), measurement of lactate dehydrogenase level, and chest radiography.1,4,25,29
Patients with iron-deficiency anemia or symptoms likely to originate in the gastrointestinal tract, and patients with elevated liver enzyme levels on initial screening, should undergo investigation of their gastrointestinal tract (either endoscopy or upper gastrointestinal series) or an abdominal ultrasound, respectively.1,4,24,29
Three scoring systems have been developed to help clinicians identify which patient with weight loss is likely to have a physical1,4
cause as opposed to a psychological or unknown cause. None of these scoring systems has been validated in independent populations presenting with weight loss.1,4,51
When weight loss is apparent in the elderly patient with no evidence of an organic disorder, primary malnutrition (i.e., resulting from inadequate food intake) must be considered as a contributor.
In general, elderly people are at increased risk of malnutrition because of insufficient food intake (quantity) rather than inappropriate selection of food (quality). Two screening tools, ENS52,53
) and SCREEN54,55
), have been developed and validated in Canada to identify community-dwelling elderly people who are at risk of malnutrition. Two other assessment tools, the Mini Nutritional Assessment (www.mna-elderly.com
) and the Nutrition Screening Initiative (www.aafp.org/x16081.xml
), which was created by the American Academy of Family Physicians with the American Dietetic Association, are also freely available to be used for nutritional assessment of elderly patients.