The Old Folks are Sneaky An approach to weight loss in the elderly

1
The Old Folks are SneakyAn approach to weight
loss in the elderly

• Thomas Edes, MD
• Geriatrics Extended Care
• VACO

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When to be Concerned

• Unexplained
• Not intentional
• Documented trend longer than a month
• d. Loss of 5 of usual body weight

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83 yo with progressive dementia was living at
home, functioning well, independent.Fell and
broke a hip. Now

• Does not recognize anyone
• Speaks rarely, 1 to 2 words
•  
• No attempt to stand
•  
• Barely eats even when fed
•  
• Weight loss of 30 lbs. in past month

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Weight Loss in the Elderly

• a. Prevalence
• b. Relative frequency of specific causes

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Characteristics of Desired Approach

• Simple
• Cheap - Arrive at the most likely cause with
  minimum expense
• Doesn't point to cancer (80 NOT due to cancer)

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The Big Clue - It will be in one of these

• Decreased intake
• Excessive losses
• Increased Catabolism

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Getting to the Bottom

• Decreased intake
• Think of every step it takes for you to get food
  from the grocery store shelf into your stomach,
  and what might interfere.

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• Lost interest in or appetite for food?
• Depression, meds, illness, change in social
  situation, dementia
•  
• 2. Have difficulty getting to the grocery store?
•  
• 3. Do you have difficulty paying for food?
•  
• Do you have difficulty preparing food?
• Do you have difficulty feeding yourself?

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• Does food taste and smell good?
• Problems chewing food?
• Tooth or denture problems, sores in mouth 
• Difficulty swallowing?
• Does food get stuck on the way down?
• Nausea or abdominal pain when you eat?
• Meds, gallbladder, ulcer, ischemia
• 11. Do you get filled up easily?

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Excessive Losses - Where can calories exit your
body?

• What can cause you to lose calories from your
  body?
• Recurrent vomiting?
• Any signs of malabsorption?
• Where else can calories exit?

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Increased Catabolism - Causes of Excessive or
Inefficient Metabolism

• Infection - What are the sneaky causes?
• TB, SBE, chronic PN, osteomyelitis, HIV
• 2. Metabolic
• Hyperthyroidism (apathetic) Addison's, Diabetes
• 3. Increased activity - wandering, akathesia
• 4. Cancer - Pursue other likely possibilities
  first

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83 yo with progressive dementia was living at
home, functioning well, independent.Fell and
broke a hip. Now

• Does not recognize anyone
• Speaks rarely, 1 to 2 words
•  
• No attempt to stand
•  
• Barely eats even when fed
•  
• Weight loss of 30 lbs. in past month

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Independent in Activities of Daily Living, until

• 2 mo PTA Fell and broke hip, OR IF
• 1 mo PTA Placed in nursing home
•  
• Minimal interaction with staff or family
•  
• Eats almost nothing - 30 lb. Weight loss
•  
• Transferred to VA Geriatric Ward

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Exam

• In wheelchair, barely lifts head when spoken to
• Rarely answered questions, 1 to 2 word responses
• Minimal cooperation with requests
•  
• Lethargic, arousable.
•  
• Foley catheter

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Labs

• WBC 6.8 Hgb 13
• Normal electrolytes, BUN 36, creatinine 1.6,
• TSH 1.8
•  
• U/A 5-10 WBC/hpf
•  
• CXR - negative

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Medications

• Ambien
•  
• Amitriptyline
•  
• Metoclopramide
•  
• Haloperidol
•  
• Darvocet
•  
• Omeprazole

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Medications

• Ambien - stopped
•  
• Amitriptyline - stopped
•  
• Metoclopramide - stopped
•  
• Haloperidol - stopped
•  
• Darvocet - changed to Tylenol every 4 hours
•  
• Omeprazole - stopped
•  
• And foley catheter removed

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• "WHEN ANY NEW SYMPTOM OR PROBLEM DEVELOPS,
•  
•   FIRST SUSPECT
•  
• MEDICATIONS"

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Result

• More Alert
•  
• Recognized his wife
•  
• Began talking
•  
• Feeding himself
•  
• Walking
•  
• Fell and dislocated hip

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85 YEAR OLD FEMALE, PARKINSON'S DISEASE

•  POSTURAL INSTABILITY, WHEELCHAIR BOUND
•  LETHARGIC, POOR APPETITE
•  
•  SERUM SODIUM 162 MEQ/L
•    
• WHY DID THIS PATIENT GET DEHYDRATED ?

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85 YEAR OLD WITH PARKINSON'S DISEASE - DEHYDRATION

• DRUGS HCTZ
• IMPAIRED ABILITY TO DRINK
• DECREASED THIRST PERCEPTION
• DYSPHAGIA
• INCREASED WATER LOSS - DIABETES
• - DIARRHEA
• - TREMOR
• DIFFICULTY WITH ACCESS

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74 yo, Progressive Spinal Atrophy

• 15 years gradual weakness
• 5 yrs becoming wheelchair-dependent
• 1 year difficulty with self-wheeling
• 3 months dysphagia and weight loss

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Dysphagia and Weight Loss

• History
• Exam
• Labs
• Barium swallow severe aspiration

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Dysphagia and Weight Loss

• Chest X-Ray
• What is the likely cause?
• What else is to be considered?

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Tube Feeding in Dementia

• Does tube feeding promote comfort?
• Does tube feeding prevent aspiration?
• Does tube feeding prolong life?
• Are we obligated by law?

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Reasons to place a feeding tube in someone with
dementia

•      
• Prolong life
• Promote comfort
• Prevent aspiration pneumonia
• Belief of obligation for provision of food and
  water

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Tube Feeding in Dementia

• No reduction in aspiration
• Patient frequently resists
• Patient kept from pleasure of eating
• No reduction in morbidity nor mortality
• Feeding tube placement carries risks
• If place tube, what to do when person unaware of
  people and environment?

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Tube Feeding in Dementia

• Feeding tube placement carries risks
• We are obligated to offer food we are not
  obligated to force food.
• If place tube, what to do when person unaware of
  people and environment?
• Advance directives vs family wishes?

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Oral Care and Aspiration

• Enteral feeding tubes reservoir for
  antibiotic-resistant bacteria
• - J Mehall, J Ped Surg 371011, 2002
• Orophayngeal pathogens increase risk of
  aspiration pneumonia
• E Marik, NEJM 344665, 2001
• Much higher prevalence of GN Pathogens in
  oropharynx of TF patients
• A Leibovitz, J Gerontol 58A52, 2003
• Oral care reduces pneumonia in NH
• T Yoneyama, JAGS 50430, 2002

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Weight loss in the Elderly

• Approach Decreased intake, Increased
  catabolism, or Excessive losses
• Usually NOT due to cancer
• Tube feeding not of benefit in advanced dementia
• When any new symptom or problem develops, first
  suspectMEDICATIONS