Endocrinology Book

Growth Disorders

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Unintentional Weight LossAka: Geriatric Failure to Thrive, Cachexia, Wasting Syndrome

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  1. See Also
    1. Cachexia in Cancer
    2. Failure to Thrive (Children)
  2. Epidemiology: Incidence
    1. Nursing home residents: 25-40%
      1. Silver (1988) J Am Geriatr Soc 36:487
    2. Overall over age 64 years: 13%
      1. Murden (1994) J Gen Intern Med 9:648
  3. Causes
    1. See Unintentional Weight Loss Causes
    2. Unintentional Weight Loss due to Medications
  4. History
    1. How much weight loss over how much time?
      1. Patients down play weight changes
      2. Clothing or belt size changes
      3. Impressions of friends and family on weight change
    2. Associated Gastrointestinal Symptoms
      1. Nausea or Vomiting
      2. Chronic Diarrhea
        1. Infectious Diarrhea
        2. Inflammatory Bowel Disease
        3. Malabsorption (e.g. Celiac Sprue)
      3. Abdominal Pain
        1. Peptic Ulcer Disease
        2. Biliary Colic, Cholecystitis or Cholelithiasis
        3. Mesenteric Ischemia
        4. Small Bowel Obstruction
        5. Inflammatory Bowel Disease
    3. Associated Symptoms
      1. Lethargy or weakness
        1. Underlying neuromuscular condition
        2. Alcohol or Drug Abuse
      2. Preoccupation with thinness
        1. Anorexia Nervosa
    4. Dietary history
      1. General Questions
        1. Are meals skipped?
        2. Does the patient need help preparing meals?
        3. Are meals well balanced (Food Pyramid)?
        4. Are any nutritional supplements used?
        5. Is patient following any dietary restrictions?
        6. Is there concurrent drug or Alcohol use?
        7. Unintentional Weight Loss due to Medications?
      2. Food is not appealing
        1. Malignancy
        2. Medication adverse effects
        3. Major Depression
      3. Altered Taste Sensation (Dysgeusia)
        1. Medication adverse effects
        2. Acute Hepatitis or Chronic Liver Disease
        3. Sinusitis
        4. Vitamin B Deficiency
        5. Zinc Deficiency
        6. Mental health concerns
      4. Mechanical problems (affects chewing and swallowing)
        1. See Dysphagia
        2. See Dyspnea
        3. Poorly fitting Dentures
        4. Painful oral lesions (e.g. Candidiasis, Gingivitis)
      5. Weight loss despite increased appetite
        1. Hyperthyroidism
        2. Diabetes Mellitus
        3. Celiac Sprue
        4. Pancreatic Insufficiency
  5. Exam
    1. Record accurate weights on same scale at every visit
      1. Unexplained weight loss >5% should be investigated
      2. Anticipated time for 15% weight loss
        1. Complete starvation: 15% of weight lost in 3 weeks
        2. Half of normal food intake: 3 months
        3. Half food intake and comorbid conditions: 3 weeks
    2. Vital sign clues
      1. Fever
      2. Tachycardia
    3. Body Mass Index (BMI) predicts mortality in elderly
      1. Women: BMI <22 kg/m2 predicts increased mortality
      2. Men: BMI <23.5 kg/m2 predicts increased mortality
      3. Calle (1999) N Engl J Med 341:1097
    4. Head and neck changes
      1. Dentition
      2. Glossitis
      3. Thyromegaly
    5. Cognition
      1. Mini-Mental State Exam
    6. Function: Activities of Daily Living
      1. Katz ADL Scale
      2. Lawton IADL Scale
      3. Six-Minute Walk Test
    7. Geriatric Depression
      1. Geriatric Depression Scale
    8. Malnutrition
      1. See Lab Markers of Malnutrition
      2. Mini-Nutritional Assessment (Nestle Nutrition)
        1. http://www.mna-elderly.com/clinical-practice.htm
    9. Other examination focus areas
      1. Loss of soft tissue mass in face and extremities
      2. Abdominal masses
      3. Lymphadenopathy
      4. Peripheral Neuropathy
  6. Labs: Initial (Directed by history and physical)
    1. Stool studies
      1. Fecal Occult Blood (3 samples)
      2. Stool for Ova and Parasites
    2. Complete Blood Count with differential
    3. Urinalysis
    4. Thyroid Stimulating Hormone (TSH)
    5. HIV Test
    6. Rapid Plasma Reagin (RPR)
    7. Tuberculin Skin Test (PPD)
    8. Chemistry Panel (glucose, electrolytes, Renal Function)
    9. Acute phase reactants
      1. Erythrocyte Sedimentation Rate
      2. C-Reactive Protein
    10. See Lab Markers of Malnutrition
  7. Labs: Diagnostic testing to consider
    1. Growth Hormone
    2. Serum Testosterone in men
    3. Blood Culture (if febrile)
    4. Chest XRay
    5. Upper gastrointestinal series or Upper Endoscopy
    6. Flexible Sigmoidoscopy or Colonoscopy
    7. Mammogram
    8. Screening with CT Scan not recommended (low yield)
  8. Labs: Malabsorption (when indicated)
    1. Fecal fat (sudan stain)
    2. Serum carotene
    3. Serum Folic Acid
  9. Evaluation Resources
    1. Mini-Nutritional Assessment (Nestle Nutrition)
      1. http://www.mna-elderly.com/clinical-practice.htm
    2. Cognition
      1. Mini-Mental State Exam
    3. Function: Activities of Daily Living
      1. Katz ADL Scale
      2. Lawton IADL Scale
      3. Six-Minute Walk Test
    4. Geriatric Depression
      1. Geriatric Depression Scale
  10. Management: Empiric
    1. Identify underlying cause
    2. Referrals
      1. Dietician
      2. Speech Therapy (swallowing evaluation)
      3. Social services
    3. General Measures
      1. Increase meal frequency with manageable servings
      2. Consider flavor enhancers (indicated in Hyposmia)
      3. Eliminate or reduce dietary restrictions
      4. Consider Meals on Wheels or senior dining facility
      5. Choose foods with high calorie density
        1. Consider dietary supplements (e.g. Ensure)
      6. Correct ill fitting dentures
      7. Encourage Physical Activity
    4. Medications
      1. Treat Major Depression: SSRI
        1. Mirtazapine (Remeron)
          1. May be preferred SSRI in Failure to Thrive
          2. Raji (2001) Ann Pharmacother 35:1024
        2. Fluoxetine (Prozac)
        3. Sertraline (Zoloft)
      2. Cannabinoid: Dronabinol (Marinol)
        1. Adverse effects: Sedation and confusion
      3. Megestrol (Megace) 320 mg to 800 mg PO qd
        1. Adverse effects: edema, Constipation and Delirium
  11. Complications of weight loss below 10-20% normal weight
    1. Increased mortality approaches 16%
      1. Sullivan (1991) Am J Clin Nutr 53:599
    2. Overall increase in morbidity
      1. Weakness or Fatigue
      2. Muscle wasting
      3. Immunosuppression
      4. Skin breakdown
      5. Mood changes (Apathy, Irritability)
  12. References
    1. Heizer in Dornbrand (1992) Ambulatory Care, p. 15-18
    2. Karsh in Friedman (1991) Medical Diagnosis, p. 13-16
    3. Dwyer (1993) Am Fam Physician 47(3):613
    4. Grazewood (1998) J Fam Pract 47(1):19
    5. Huffman (2002) Am Fam Physician 65(4):640
    6. Morley (1995) Ann Intern Med 123:850
    7. Robertson (2004) Am Fam Physician 70:343
    8. White (1991) Am Fam Physician 44(6):2087
    9. Zawada (1996) Postgrad Med 100(1):207

Cachexia (C0006625)

Definition (MSH)General ill health, malnutrition, and weight loss, usually associated with chronic disease.
Definition (CSP)state of general ill health characterized by malnutrition, weakness, and emaciation; occurs during the course of a chronic disease.
Definition (NCI)The loss of body weight and muscle mass frequently seen in patients with cancer, AIDS, or other diseases.
ConceptsSign or Symptom (T184)
ICD9799.4
MSHD002100
EnglishCACHECTIC, Cachexia, General body deterioration
Spanishcaquexia, deterioro corporal general
Parent ConceptsSigns and Symptoms (C0037088), Physical findings (C0311392), Disorders, General, Functional and NEC (C0549512), Weight Disorders NEC (C0549570), Other ill-defined and unknown causes of morbidity and mortality (C0159138), Emaciation (C0013911), Symptoms (C1457887), Malnutrition (C0162429), Asphyxia (C0004044), Cachexia (C0006625), Distribution of body fat loss - finding (C1288053), Ambiguous concept (C1274012), Duplicate concept (C1274013)
SourcesCOSTAR, CSP, CST, DXP, ICD9CM, MSH, MTH, NCI, NDFRT, OMIM, PDQ, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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