Rational approach to patients with unintentional weight loss

Exploring the interplay of frailty, physical function, physical activity, nutritional status, and their association with quality of life and depressive symptoms in older adults with the frailty phenotype

OBJECTIVE

This study aimed to explore the interplay between frailty, physical function, physical activity, nutritional status, and their impact on the quality of life and depressive status in older adults with frailty.

METHODS

A cross-sectional study involving 235 pre-frail/frail older adults residing in Spanish communities was conducted. Frailty was assessed using Fried's criteria, physical function was evaluated using the Short Physical Performance Battery, and physical activity levels were measured via wrist-worn accelerometers. Nutritional status was determined using the Mini-Nutritional Assessment alongside anthropometric measurements. Quality of life was gauged using the EuroQoL 5-Dimension 5-Level, while depressive status was assessed using the Yesavage 15-item Geriatric Depression Scale. Multivariate linear regression and logistic regression analyses were employed to elucidate the associations of these factors with quality of life and depression.

RESULTS

Our findings revealed significant correlations between various factors and quality of life. Notably, reported fatigue (β = -0.276, p = 0.002), performance in the 4-m gait test (β = -0.242, p = 0.001), the score on the short version of the Mini-Nutritional Assessment (β = 0.312, p = 0.002), and engagement in light physical activity (β = 0.180, p = 0.023) were all found to be associated with quality of life. In terms of depressive symptoms, the Mini-Nutritional Assessment score emerged as a protective factor (Odds ratio, OR: 0.812, p < 0.001), as did participation in moderate physical activity (OR: 0.988, p = 0.028). Conversely, fatigue (OR: 3.277, p = 0.003) and a slow gait speed (OR: 1.136, p = 0.045) were identified as risk factors for depressive symptoms.

CONCLUSIONS

This study underscores the detrimental association of fatigue and slow gait speed on both quality of life and depressive status among older adults with frailty. In contrast, engaging in physical activity and addressing malnutrition risk emerge as critical protective factors for enhancing quality of life and ameliorating depressive symptoms in this population.

CLINICAL TRIAL REGISTRATION

This is a study that uses cross-sectional data from a trial registered at ClinicalTrials.gov (Identifier: NCT05610605).

The impact of an oral nutritional supplement on body weight gain in older adults with malnutrition: an open-label randomized controlled trial

BACKGROUND

The global aging population is expanding rapidly and many individuals have a particularly higher risk of malnutrition. Malnutrition can lead to impaired body function, morbidity, and mortality. Meeting nutritional requirements is a key strategy to minimize multiple debilitating adverse outcomes associated with malnutrition in the elderly. Oral nutritional supplements (ONS) have been widely used as a dietary intervention for malnutrition in older adults. These supplements provide additional nutrients and calories to support nutritional requirements and have been shown to improve nutritional status, physical function, and quality of life in malnourished older adults.

METHODS

This is an open-label, randomized controlled, parallel-group study including 50 institutionalized older adults (aged > 60 years) with malnutrition or at risk of malnutrition, living in a selected elderly care institution in Colombo, Sri Lanka. The aim is to assess improvement in healthy body weight gain and body composition in older adults with malnutrition at risk of malnutrition by using an ONS. Older adults will be screened for malnutrition using the Mini Nutrition Assessment (MNA) tool and eligible participants randomized using the simple random sampling technique to intervention and control groups (1:1 allocation ratio). The intervention group will consume 200 mL of ONS before bed continuously for 12 weeks. The primary outcome is the percentage who achieved at least 5% weight gain in the intervention group compared to the control group. Nutritional status (anthropometric, biochemical, clinical, and dietary), body composition (dual-energy X-ray absorptiometry), frailty, functional capacity (hand grip strength, knee extension, and Barthel index) cognitive status (Montreal Cognitive Assessment), and physical activity will be assessed as secondary outcomes at baseline and at the end of the 12-week intervention. Some measurements (anthropometry, dietary, and functional assessments) will also be performed at the end of the 4th week. Data will be analyzed using SPSS V-23.

DISCUSSION

This study will determine whether the use of an ONS is effective in promoting healthy weight gain in older adults with malnutrition or at risk of malnutrition. In addition, investigating the impact of an ONS on multiple outcomes via clinical, nutritional, functional, and cognitive function will provide a more comprehensive understanding of the potential benefits of these supplements.

TRIAL REGISTRATION

Sri Lanka Clinical Trail Registry SLCTR/2022/021. Oct. 6, 2022.

Recognition, diagnostic practices, and cancer outcomes among patients with unintentional weight loss (UWL) in primary care

OBJECTIVES

Identify the incidence, rate of physician recognition, diagnostic practices and cancer outcomes for unintentional weight loss (UWL).

METHODS

We completed a secondary analysis of structured and unstructured EHR data collected from adult patients between January 1, 2020 and December 31, 2021. We used four common definitions to define UWL, excluding patients with known causes of weight loss, intentional weight loss, and pregnancy. Unstructured physicians' notes were used to identify both intentional weight loss (e.g. dieting) as well as physician recognition of UWL. Cancer outcomes were identified within 12 months of UWL using diagnostic codes. Physician actions (lab tests, etc.) in response to UWL were identified through manual chart review.

RESULTS

Among 29,494 established primary care patients with a minimum of two weight measurements in 2020 and in 2021, we identified 290 patients who met one or more criteria for UWL (1 %). UWL was recognized by physicians in only 60 (21 %). UWL was more common and more likely to be recognized among older patients. Diagnostic practices were quite variable. A complete blood count, complete metabolic profile, and thyroid stimulating hormone level were the three most common tests ordered in response to UWL. Five patients were diagnosed with cancer within 12 months of UWL (3 in whom UWL was recognized; two in whom it was not.).

CONCLUSIONS

Unintentional weight loss is poorly recognized across a diverse range of patients. A lack of research-informed guidance may explain both low rates of recognition and variability in diagnostic practices.

Association of magnitude of weight loss and weight variability with mortality and major cardiovascular events among individuals with type 2 diabetes mellitus: a systematic review and meta-analysis

Background

Weight management is strongly promoted for overweight or obese patients with type 2 diabetes (T2DM) by current guidelines. However, the prognostic impact of weight loss achieved without behavioural intervention on the mortality and cardiovascular (CV) outcomes in diabetic patients is still contested.

Methods

We searched the PubMed, Embase, and Cochrane Library databases for studies that investigated the association of weight loss or weight variability with mortality and CV outcomes. Results of studies that measured weight loss by percentage weight loss from baseline and stratified it as > 10% and 5–10% or studies that computed weight variability were pooled using random effects model. Study quality was evaluated using the Newcastle–Ottawa Scale.

Results

Thirty eligible studies were included in the systematic review and 13 of these were included in the meta-analysis. Large weight loss (> 10%) was associated with increased risk of all-cause mortality (pooled hazard ratio (HR) 2.27, 95% CI 1.51–3.42), composite of major CV events (pooled HR 1.71, 95% CI 1.38–2.12) and CV mortality (pooled HR 1.50, 95% CI 1.27–1.76) among T2DM patients. Moderate weight loss showed no significant association with all-cause mortality (pooled HR 1.17, 95% CI 0.97–1.41) or CV outcomes (pooled HR 1.12, 95% CI 0.94–1.33). Weight variability was associated with high hazard of all-cause mortality (pooled HR 1.54, 95% CI 1.52–1.56).

Conclusions

Large weight loss and large fluctuations in weight are potential markers of increased risk of mortality and CV events in T2DM patients. Maintaining a stable weight may have positive impact in these patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01503-x.

Unintentional weight loss: what radiologists need to know and what clinicians want to know

Unintentional weight loss (UWL) is a common presenting symptom with a wide differential diagnosis. Causes may be organic (e.g., malignancy or gastrointestinal disease) or inorganic (e.g., psychosocial). The purpose of this review is to provide a guide for radiologists and other clinicians to understand the imaging modalities and laboratory studies involved in the diagnosis and treatment of UWL and the evidence supporting their routine use. Cases illustrating both common and uncommon causes of UWL are presented to emphasize both the breadth of pathology that may cause UWL as well as the importance of a multi-modality diagnostic approach. Imaging studies are crucial in the diagnosis of unintentional weight loss, particularly with regard to evaluating for the presence of malignancy. It is important for both the radiologist and other clinicians to understand the relative prevalence of the various causes of UWL and the utility of different imaging modalities in diagnosis and management.

Frailty related all-cause mortality or hospital readmission among adults aged 65 and older with stage-B heart failure inpatients

BACKGROUND

Frailty increases the adverse outcomes of clinical heart failure; however, the relationship between frailty and stage-B heart failure (SBHF) remains unknown. We aimed to explore the epidemiology and predictive value of frailty in older adults with SBHF.

METHODS

A prospective cohort of SBHF inpatients aged 65 years or older who were hospitalized between September 2018 and February 2019 and were followed up for 6 months were included. SBHF was defined as systolic abnormality, structural abnormality (left ventricular enlargement, left ventricular hypertrophy, wall motion abnormalities, valvular heart disease), or prior myocardial infarction. Frailty was assessed by the Fried frailty phenotype. Multivariable Cox proportional hazards regression was used to explore the independent risk and prognostic factors.

RESULTS

Data of 443 participants (age: 76.1 ± 6.79 years, LVEF: 62.8 ± 4.92%, men: 225 [50.8%], frailty: 109 [24.6%]) were analyzed. During the 6-month follow-up, 83 (18.7%) older SBHF inpatients experienced all-cause mortality or readmission, and 29 (6.5%) of them developed clinical HF. Frail individuals had a 1.78-fold (95%CI: 1.02-3.10, P = 0.041) higher risk of 6-month mortality or readmission and a 2.83-fold (95%CI 1.24-6.47, P = 0.014) higher risk of developing clinical HF, independent of age, sex, left ventricular ejection fraction, and N-terminal pro-B-type natriuretic peptide level.

CONCLUSIONS

Frailty is common in older SBHF inpatients and should be considered to help identify individuals with an increased risk of mortality or readmission, and developing clinical HF.

TRIAL REGISTRATION

ChiCTR1800017204 .

The Risks of Cardiovascular Disease and Mortality Following Weight Change in Adults with Diabetes: Results from ADVANCE

CONTEXT

Weight loss is strongly recommended for overweight and obese adults with type 2 diabetes. Unintentional weight loss is associated with increased risk of all-cause mortality, but few studies have examined its association with cardiovascular outcomes in patients with diabetes.

OBJECTIVE

To evaluate 2-year weight change and subsequent risk of cardiovascular events and mortality in established type 2 diabetes.

DESIGN AND SETTING

The Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation was an international, multisite 2×2 factorial trial of intensive glucose control and blood pressure control. We examined 5 categories of 2-year weight change: >10% loss, 4% to 10% loss, stable (±<4%), 4% to 10% gain, and >10% gain. We used Cox regression with follow-up time starting at 2 years, adjusting for intervention arm, demographics, cardiovascular risk factors, and diabetes medication use from the 2-year visit.

RESULTS

Among 10 081 participants with valid weight measurements, average age was 66 years. By the 2-year examination, 4.3% had >10% weight loss, 18.4% had 4% to 10% weight loss, and 5.3% had >10% weight gain. Over the following 3 years of the trial, >10% weight loss was strongly associated with major macrovascular events (hazard ratio [HR], 1.75; 95% confidence interval [CI], 1.26-2.44), cardiovascular mortality (HR, 2.76; 95% CI, 1.87-4.09), all-cause mortality (HR, 2.79; 95% CI, 2.10-3.71), but not major microvascular events (HR, 0.91; 95% CI, 0.61-1.36), compared with stable weight. There was no evidence of effect modification by baseline body mass index, age, or type of diabetes medication.

CONCLUSIONS

In the absence of substantial lifestyle changes, weight loss may be a warning sign of poor health meriting further workup in patients with type 2 diabetes.

Diagnostic utility of whole body CT scanning in patients with unexplained weight loss

BACKGROUND

Unexplained weight loss is a non-specific complaint with myriad potential etiologies. Increasingly, whole body CT studies are being performed in patients with unexplained weight loss to exclude organic etiologies such as malignancy. Our study aims to assess the diagnostic accuracy and yield of whole body CT in these patients.

METHODS AND MATERIALS

Patients who had a whole body CT scan for investigation of unexplained weight loss as their primary complaint from 2009-2012 were retrospectively reviewed. CT scans were classified into 4 categories: (1) Definite/highly suspicious for underlying organic cause (2) Indeterminate for underlying organic cause (3) No findings accounting for weight loss and only incidental findings and (4) Normal study. Scan findings were correlated with the final diagnosis after all investigations. Univariate logistic regression was performed to determine associations between patient's baseline variables and positive CT scan findings.

RESULTS

Of 301 eligible patients during the study period, 101 patients were excluded due to known history of malignancy, inadequate follow-up or inadequate scan technique. 200 patients were included in the final analyses. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of CT for organic pathology were 72.0%, 90.7%, 87.0%, 78.9% and 82.0% respectively. Additional symptoms, abnormal physical examinations, anemia, and raised tumor markers were significantly correlated with positive CT findings. Overall, the diagnostic yield of whole body CT scan for patients with unexplained weight loss was 33.5%.

CONCLUSIONS

Whole body CT imaging may be a useful investigation for the noninvasive workup of patients with unexplained weight loss, with diagnostic yield of 33.5% and good sensitivity, specificity, positive and negative predictive values for organic etiologies.

Early weight loss in parkinsonism predicts poor outcomes: Evidence from an incident cohort study

Objective:

To compare weight change over time in patients with Parkinson disease (PD), those with atypical parkinsonism, and matched controls; to identify baseline factors that influence weight loss in parkinsonism; and to examine whether it predicts poor outcome.

Methods:

We analyzed data from the Parkinsonism Incidence in North-East Scotland (PINE) study, an incident, population-based prospective cohort of parkinsonian patients and age- and sex-matched controls with annual follow-up. Mixed-model analysis described weight change in patients with PD, those with atypical parkinsonism, and controls. Baseline determinants of sustained clinically significant weight loss (>5% loss from baseline) and associations between early sustained weight loss and death, dementia, and dependency in parkinsonism were studied with Cox regression.

Results:

A total of 515 participants (240 controls, 187 with PD, 88 with atypical parkinsonism) were followed up for a median of 5 years. At diagnosis, atypical parkinsonian patients had lower body weights than patients with PD, who were lighter than controls. Patients with PD lost weight more rapidly than controls, and weight loss was most rapid in atypical parkinsonism. After multivariable adjustment for potential confounders, only age was independently associated with sustained clinically significant weight loss (hazard ratio [HR] for 10-year age increase 1.83, 95% confidence interval [CI] 1.44–2.32). Weight loss occurring within 1 year of diagnosis was independently associated with increased risk of dependency (HR 2.11, 95% CI 1.00–4.42), dementia (HR 3.23, 95% CI 1.40–7.44), and death (HR 2.23, 95% CI 1.46–3.41).

Conclusion:

Weight loss occurs in early parkinsonism and is greater in atypical parkinsonism than in PD. Early weight loss in parkinsonism has prognostic significance, and targeted dietary interventions to prevent it may improve long-term outcomes.

Unintentional weight loss: Clinical characteristics and outcomes in a prospective cohort of 2677 patients

BACKGROUND

Whereas there are numerous studies on unintentional weight loss (UWL), these have been limited by small sample sizes, short or variable follow-up, and focus on older patients. Although some case series have revealed that malignancies escaping early detection and uncovered subsequently are exceptional, reported follow-ups have been too short or unspecified and necropsies seldom made. Our objective was to examine the etiologies, characteristics, and long-term outcome of UWL in a large cohort of outpatients.

METHODS

We prospectively enrolled patients referred to an outpatient diagnosis unit for evaluation of UWL as a dominant or isolated feature of disease. Eligible patients underwent a standard baseline evaluation with laboratory tests and chest X-ray. Patients without identifiable causes 6 months after presentation underwent a systematic follow-up lasting for 60 further months. Subjects aged ≥65 years without initially recognizable causes underwent an oral cavity examination, a videofluoroscopy or swallowing study, and a depression and cognitive assessment.

RESULTS

Overall, 2677 patients (mean age, 64.4 [14.7] years; 51% males) were included. Predominant etiologies were digestive organic disorders (nonmalignant in 17% and malignant in 16%). Psychosocial disorders explained 16% of cases. Oral disorders were second to nonhematologic malignancies as cause of UWL in patients aged ≥65 years. Although 375 (14%) patients were initially diagnosed with unexplained UWL, malignancies were detected in only 19 (5%) within the first 28 months after referral. Diagnosis was established at autopsy in 14 cases.

CONCLUSION

This investigation provides new information on the relevance of follow-up in the long-term clinical outcome of patients with unexplained UWL and on the role of age on this entity. Although unexplained UWL seldom constitutes a short-term medical alert, malignancies may be undetectable until death. Therefore, these patients should be followed up regularly (eg yearly visits) for longer than reported periods, and autopsies pursued when facing unsolved deaths.

Dysmotility Symptoms Are Independently Associated With Weight Change: A Population-based Study of Australian Adults

Background/Aims

Weight loss is a recognized alarm symptom for organic gastrointestinal (GI) disease, yet the association between weight change (loss or gain) and specific GI symptoms remains poorly described. We assess the associations between GI symptoms and weight change in a population-based sample of Australian adults.

Methods

The prevalence of 26 GI symptoms was determined by a postal survey to 5000 residents in western Sydney, Australia (60% response rate). These were classified a priori into 5 symptom groups–abdominal pain, esophageal symptoms, dysmotility symptoms, diarrhea and constipation. Weight change was measured by two items which assessed weight loss and weight gain. Clinically relevant weight change was defined as a loss or gain of 3 or more kilograms in the past 3 months.

Results

Prevalence estimates for clinically relevant weight loss and gain in the past 3 months were 10.3% and 8.1%, respectively. When the 5 symptom groups were evaluated simultaneously, the dysmotility symptoms of fullness after meals emerged as a predictor of both weight loss (OR, 1.57; 95% CI, 1.32–1.88; P < 0.001) and weight gain (OR, 0.85; 95% CI, 0.72–0.99; P = 0.040), which also included bloating (OR, 1.64; 95% CI 1.46–1.84; P < 0.001). The associations remained significant following adjustment for socio-economic status, body mass index, and eating behaviors.

Conclusions

Specific dysmotility symptoms are independently predictive of both weight loss and weight gain. Different pathogenic mechanisms may be involved.

Diagnosing cancer in the symptomatic patient

Finding cancer at its earliest, most treatable stage gives patients the greatest chance of survival. For a number of cancers, screening tests allow for early detection and treatment, and thereby, reduce cancer-related mortality. However, many cancers are discovered by symptomatic presentation rather than screening. This article addresses several symptoms commonly reported in the primary care setting, including rectal bleeding, a breast lump, cough, lymphadenopathy, and weight loss, and offers an evidence-based approach to the consideration and possibly the diagnosis of cancer.

Obesity in the Elderly

OBJECTIVE

Clinical review of the epidemiology, morbidity, mortality, medical and economic costs of being overweight or obese; recommendations on obesity from the National Institutes of Health; and how these factors relate to the elderly.

DATA SOURCES

Medline search was used to identify relevant articles. Additional references were found in review articles and consensus guidelines.

STUDY SELECTION

Fifty-nine articles were identified and 40 were selected based on findings related to geriatric patients or obesity overall. Studies done in the United States as well as in European populations were included.

DATA EXTRACTION

Data were abstracted per findings for: epidemiology of being overweight and obese for adults and elderly, mortality and morbidity of being overweight or obese, issues with weight loss in the elderly, changes in physiology with aging that may impact on weight, whether increased body mass index (BMI) is directly associated with mortality in the elderly, whether the National Institutes of Health guidelines for BMI in obesity should be applied to elderly persons, mortality associated with weight, and costs of obesity.

DATA SYNTHESIS

The main findings suggest that being underweight results in a higher mortality for elderly persons as compared with being overweight.

CONCLUSION

The primary conclusion is that it is still not yet defined if the elderly should be held to the NIH standards for "overweight" and "obesity." More research is needed to determine if overweight and obese elderly benefit from weight loss measures or if they should be kept at their current weight.

Involuntary weight loss. Does a negative baseline evaluation provide adequate reassurance?

BACKGROUND

Involuntary weight loss frequently poses a diagnostic challenge. Patient and physician alike want to exclude malignant and other major organic illness. The present study aimed to evaluate whether a negative baseline evaluation (consisting of clinical examination, standard laboratory examination, chest X-ray, and abdominal ultrasound) lowers the probability of evolving organic illness in patients with significant unexplained weight loss.

METHODS

Prospective observational study of 101 consecutive patients presenting to a general internal medicine department of a university hospital with an unexplained unintentional weight loss of at least 5% within 6-12 months. Laboratory tests of interest included C-reactive protein, albumin, haemoglobin, and liver function tests.

RESULTS

Weight loss of the 101 patients [age (mean, interquartile range): 64 (51-71) years, 46% male] averaged 10 (7-15) kg. Organic causes were found in 57 patients (56%), including malignancy in 22 (22%). In 44 patients without obvious organic cause for the weight loss (44%), a psychiatric disorder was implicated in 16 (16%) and no cause was established in 28 (28%), despite vigorous effort and follow-up of at least 6 months. Baseline evaluation was entirely normal in none of the 22 patients (0%) with malignancy, in 2 of the 35 (5.7%) with non-malignant organic disease, and in 23 of the 44 (52%) without physical diagnosis. Additional testing, oftentimes extensive, after a normal baseline evaluation led to one additional physical diagnosis (lactose intolerance).

CONCLUSION

In patients presenting with substantial unintentional weight loss, major organic and especially malignant diseases seem highly unlikely when a baseline evaluation is completely normal. In this setting, a watchful waiting approach may be preferable to undirected and invasive testing.

Weight loss in the elderly: medications complicating the picture?

An 81-year-old female presented with weight loss as a result of her multiple comorbidities, including a history of congestive heart failure (CHF), coronary artery disease, paroxysmal atrial fibrillation, myocardial infarction, pulmonary embolism, and stroke. She has experienced deep-venous thrombosis in her right leg, severe depression, and dementia and also has suffered a right tibial and fibular fracture. All of these comorbidites and her medication regimen complicated the issue of weight loss. A senior care pharmacist addressed the complexity of her situation with a goal of preventing potentially negative outcome of any prescribed medication. This case demonstrates the importance of a pharmacist taking a focused look at the addition of a new medication.

An approach to the management of unintentional weight loss in elderly people

Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period. A variety of physical, psychological and social conditions, along with age-related changes, can lead to weight loss, but there may be no identifiable cause in up to one-quarter of patients. We review the incidence and prevalence of weight loss in elderly patients, its impact on morbidity and mortality, the common causes of unintentional weight loss and a clinical approach to diagnosis. Screening tools to detect malnutrition are highlighted, and nonpharmacologic and pharmacologic strategies to minimize or reverse weight loss in older adults are discussed.

Molecular-based therapeutic approaches in treatment of anorexia of aging and cancer cachexia

Loss of appetite, or anorexia, has profound implications for older persons, altering social interactions, reducing quality of life, and leading to weight loss with grave health consequences. Two conditions associated with anorexia considered in this article are the multidetermined anorexia of aging and the wasting syndrome termed cachexia induced by cancer. Nutritional interventions may have some benefit in the former, but are of limited value in the latter. Emerging studies at the molecular level relating to appetite regulation and energy balance may offer new approaches to arrest progressive weight loss in the anorexia of aging and cancer cachexia.

Facilitated feeding in disabled elderly

Nutrition and health are major concerns to older individuals. Whereas illness associated with overnutrition has been well characterized, poor health associated with undernutrition has received less attention. Malnutrition continues to plague the elderly in developed and underdeveloped countries alike, and is becoming of more concern as global demographic changes predict increasing proportions of elderly in all societies. Nutrition influences many chronic disease processes affecting older individuals. In addition, changes in physiology, metabolism, and function accompanying aging result in altered nutritional requirements. The enhancement and maintenance of health and function are now more possible with the new knowledge of nutritional needs in old age. Designing nutritional therapy to treat malnutrition associated with illness in older patients requires an understanding of the aging processes, a careful setting of treatment goals, and multidisciplinary collaboration.