An 88-year-old woman is evaluated for progressive decrease in appetite and weight loss of 4.5 kg (10 lb) over the past 3 months. She has had no nausea, vomiting, abdominal pain, or diarrhea. Medical history is significant for a long history of hypertension and slowly declining kidney function. Her medications have not been changed or adjusted over the past 6 months. The patient does not use tobacco or alcohol. Temperature is 37.1 C (98.8 F), blood pressure is 140/90 mm Hg, and pulse is 78/min. BMI is 18 kg/m2. She appears thin and frail. Examination shows 1+ bilateral lower extremity edema. Mental status examination shows a normal affect. Cognition is intact. Laboratory studies are as follows:
| Complete blood count | ||
| Hemoglobin | 10.3 g/dL | |
| Mean corpuscular volume | 90 µm3 | |
| Platelets | 240,000/mm3 | |
| Leukocytes | 7,500/mm3 | |
| Serum chemistry | ||
| Sodium | 140 mEq/L | |
| Potassium | 4.6 mEq/L | |
| Bicarbonate | 22 mEq/L | |
| Blood urea nitrogen | 40 mg/dL | |
| Creatinine | 3.2 mg/dL | |
| Calcium | 8 mg/dL | |
| Glucose | 100 mg/dL | |
| eGFR | 11 mL/min/1.73 m2 | |
Serum TSH and liver function studies are normal. Fecal occult blood testing is negative. What is the most appropriate next step in the management of weight loss in this patient?
Unintentional weight loss in elderly patients | |
Definition |
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Causes |
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CKD = chronic kidney disease; COPD = chronic obstructive pulmonary disease. | |
Unintentional weight loss is generally defined as a >5% involuntary weight loss over 6-12 months. There are many causes of unintentional weight loss in elderly patients (eg, age >75), including malignancy, depression, social isolation, dysphagia, diminished sense of taste and smell, and advanced end-organ disease.
Advanced end-organ disease contributes to weight loss via components of both anorexia (ie, loss of appetite) and cachexia (ie, inflammatory loss of muscle mass). Chronic heart failure, chronic kidney disease (CKD), and chronic obstructive pulmonary disease are among the most notable conditions associated with this phenomenon. This patient's initial workup, including history, physical examination, and basic laboratory testing (including TSH, fecal occult blood testing), is unremarkable other than findings of advanced CKD (ie, mild normocytic anemia, estimated glomerular filtration rate <15 mL/min/1.73 m2).
In such patients without findings to suggest malignancy (eg, blood in the stool, hypercalcemia, unexplained anemia), watchful waiting is typically most appropriate. This is especially true for elderly patients with limited life expectancy (such as this frail, 88-year-old patient) and other explanations for weight loss (eg, CKD) because watchful waiting avoids diagnostic testing that is unlikely to improve quality of life or life expectancy. Furthermore, unnecessary diagnostic testing may increase patient anxiety, physical discomfort, and financial stress. In addition, such patients with evidence of malnutrition (eg, BMI <18.5 kg/m2) often benefit from nutritional supplementation (eg, high-calorie supplement drinks), which can help reverse cachexia progression (protein-energy wasting).
(Choice B) Selective serotonin reuptake inhibitors (eg, sertraline) are used to treat major depressive disorder (MDD), a common cause of anorexia and unintentional weight loss. In elderly patients, MDD may also present with cognitive difficulties. However, this patient's normal affect and cognition make MDD unlikely.
(Choices C and D) Upper and lower gastrointestinal endoscopy and upper gastrointestinal series with small bowel follow-through are used to evaluate for malignancy (eg, gastric cancer, colon cancer) and other causes of unintentional weight loss (eg, peptic ulcer disease). However, these tests are not indicated at this time because this frail, elderly patient has no signs or symptoms to suggest an underlying gastrointestinal disorder (eg, abdominal pain, blood in the stool), and her weight loss and normocytic anemia are likely explained by advanced CKD.
(Choice E) Whole-body CT scan is more likely to reveal incidental findings than an occult malignancy in this patient without localizing signs or symptoms and is not indicated.
Educational objective:
Advanced end-organ disease (eg, chronic kidney disease) is a common cause of unintentional weight loss in elderly patients. In the absence of signs, symptoms, or unexplained laboratory findings to suggest malignancy, watchful waiting and nutritional supplementation are appropriate in such patients.