Vol 65: OCTOBER | OCTOBRE 2019 | Canadian Family Physician | Le Médecin de famille canadien 723 É D I T O R I A L G E R I A T R I C G E M S
Geriatric Gems are produced in association with the Canadian Geriatrics Society Journal of CME, a free peer-reviewed journal published by the Canadian Geriatrics Society (www.geriatricsjournal.ca). The articles summarize evidence from review articles published in the Canadian Geriatrics Society Journal of CME and offer practical approaches for family physicians caring for elderly patients.
Weight loss in older patients
Chris Frank MD CCFP(COE) FCFP Frank Molnar MSc MD CM FRCPC Jayna Holroyd-Leduc MD FRCPC
Clinical question
How can I assess and address weight loss in older patients?
Bottom line
Weight loss is common and can be challenging to manage.
Quandaries include identifying the problem, determining the appropriate workup, balancing fear of missing a diagnosis with invasive investigation, and effective treatment.
1Weight loss is a reduction of more than 5% of body weight over 1 month or 10% over 6 months.
2Useful screening ques- tions include asking older patients if their clothing has loos- ened or if they have had to wear a smaller size. Screening for unintentional weight loss is important given its asso- ciation with mortality, functional decline, and clinical frailty.
The approach to weight loss in older patients might be more complex than in younger patients owing to the higher risk of serious underlying illness such as cancer, but also owing to psychosocial factors such as cognitive impairment, lim- ited financial or social supports, functional decline related to frailty, and oral health issues.
3-6As a result, your patient’s social circumstances must be assessed. Investigations should be guided by the patient’s history and findings of a physical examination, focusing on confirming diagnoses. The contri- bution of medications is also important to consider.
Evidence
• Exercise might be as helpful as nutritional supplements, which if used should be provided between meals to avoid decreasing appetite further.
7,8• There is limited evidence for pharmacologic treatments, and Choosing Wisely recommends against routine use.
9• Up to 40% of people with dementia have weight loss.
10• Many common medications are associated with weight loss.
Approach
• Serial weight measurements and routine screening such as asking about decreased intake and change in clothing fit can identify people meeting or close to meeting the cri- teria for weight loss and help to focus interventions.
• Box 1 provides a mnemonic to help identify possible causes.
• A detailed history, oral and abdominal examinations, a neurologic assessment, and a mental status review are important for diagnosing any underlying disease.
• It is important to review prescribed and over-the-counter medications (refer to Box 2 in Holroyd-Leduc).
1• The presence and severity of frailty,
11along with patient care goals, can guide how aggressively to investigate weight loss.
Eliminating restrictive diets might be appropriate for those with limited life expectancy or moderate to severe frailty.
Implementation
Remediable factors should be optimized first,
12especially for patients with dementia or frailty. A critical medication review should use a deprescribing lens.
13The benefit of nutritional
supplements is unclear. There is limited evidence for appetite stimulants; social factors and exercise might be more helpful.
Nutrition resources related to weight loss are available for health care providers (www.nutritioncareincanada.ca) and for older Canadians (https://www.dietitians.ca/Your- Health/Nutrition-A-Z/Seniors.aspx).
Dr Frank is a family physician practising in Kingston, Ont. Dr Molnar is a specialist in geriatric medi- cine practising in Ottawa, Ont. Dr Holroyd-Leduc is Head of and Professor in the Section of Geriatric Medicine at the University of Calgary in Alberta.
Competing interests None declared References
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9. Ten things clinicians and patients should question. Philadelphia, PA: Choosing Wisely; 2015.
10. Franx BAA, Arnoldussen IAC, Kiliaan AJ, Gustafson DR. Weight loss in patients with dementia: considering the potential impact of pharmacotherapy. Drugs Aging 2017;34(6):425-36.
11. Geriatric Medicine Research. Clinical Frailty Scale. Halifax, NS: Dalhousie University; 2007.
12. Alibhai SM, Greenwood C, Payette H. An approach to the management of unintentional weight loss in elderly people. CMAJ 2005;172(6):773-80.
13. Molnar FJ, Haddad T, Dyks D, Farrell B. Problem-based deprescribing: a practical patient-centred approach to promoting the use of existing deprescribing resources in frontline care. Can Geriatr Soc J CME 2018;8(2).
This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to www.cfp.ca and click on the Mainpro link.
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro d’octobre 2019 à la page e429.
