Endocrinology Book

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Unintentional Weight Loss

Aka: Unintentional Weight Loss, Geriatric Failure to Thrive, Cachexia, Wasting Syndrome
  1. See Also
    1. Cachexia in Cancer
    2. Failure to Thrive (Children)
    3. Nutritional Health Checklist
  2. Epidemiology: Incidence
    1. Nursing Home residents: 25-40%
      1. Silver (1988) J Am Geriatr Soc 36:487-91 [PubMed]
    2. Overall over age 64 years: 13%
      1. Murden (1994) J Gen Intern Med 9:648-50 [PubMed]
  3. Definition
    1. Unintentional Weight Loss of >5% of body weight within 6-12 months
  4. Causes
    1. See Unintentional Weight Loss Causes
    2. Unintentional Weight Loss due to Medications
  5. Precautions
    1. Substantial weight loss should not be attributed to aging alone
      1. See Body Composition Changes with Aging
  6. 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. Dysphagia
        1. See Dysphagia
        2. Poorly fitting dentures
        3. Poor Dentition (e.g. Dental Caries)
        4. Esophageal Stricture
      3. Chronic Diarrhea
        1. Infectious Diarrhea
        2. Inflammatory Bowel Disease
        3. Malabsorption (e.g. Celiac Sprue)
      4. 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. Fever, Fatigue or weakness
        1. Malignancy
        2. Infection
        3. Autoimmune disorder
        4. Diabetes Mellitus
        5. Hyperthyroidism
        6. Underlying neuromuscular condition
        7. Alcohol or Drug Abuse
      2. Dyspnea or exertional Fatigue
        1. Congestive Heart Failure
        2. Lung infection
        3. Chronic Obstructive Lung Disease
        4. Anemia
      3. Preoccupation with thinness
        1. Anorexia Nervosa
    4. Dietary history
      1. See Nutritional Health Checklist
      2. Are meals skipped?
      3. Does the patient need help preparing meals?
      4. Are meals well balanced (Food Pyramid)?
      5. Are any Nutritional Supplements used?
      6. Is patient following any dietary restrictions?
    5. Secondary cause history
      1. Medication and substance use
        1. See Unintentional Weight Loss due to Medications
        2. See Polypharmacy
        3. Over-the-counter medications or herbal supplement use?
        4. Is there concurrent drug or Alcohol use?
      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
  7. 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 341:1097-105 [PubMed]
    4. Head and neck changes
      1. Dentition
      2. Glossitis
      3. Thyromegaly
    5. Other examination focus areas
      1. Loss of soft tissue mass in face and extremities
      2. Abdominal masses
      3. Lymphadenopathy
      4. Peripheral Neuropathy
  8. Labs: Approach
    1. Start with basic lab evaluation
      1. Complete Blood Count
      2. Comprehensive Metabolic Panel
      3. Urinalysis
      4. Thyroid Stimulating Hormone (TSH)
      5. Fecal Occult Blood Testing
      6. Serum Lactate Dehydrogenase (LDH)
      7. Erythrocyte Sedimentation Rate (ESR)
      8. C-Reactive Protein (CRP)
    2. Lab testing should be directed by history and physical
      1. See below for potentially indicated labs
  9. Labs: As directed by history and physical
    1. Stool studies
      1. Fecal Occult Blood (3 samples)
      2. Stool for Ova and Parasites
    2. Complete Blood Count
      1. White Blood Cell Count with differential
      2. Hemoglobin
    3. Acute phase reactants
      1. Erythrocyte Sedimentation Rate
      2. C-Reactive Protein
    4. Endocrine tests
      1. Thyroid Stimulating Hormone (TSH)
      2. Serum Testosterone in men
    5. Comprehensive Metabolic Panel
      1. Serum Glucose
      2. Electrolytes
      3. Renal Function tests
      4. Liver Function Tests
      5. Serum Lactate Dehydrogenase
    6. Infectious disease
      1. Blood Culture (if febrile)
      2. Tuberculin Skin Test (PPD)
      3. HIV Test
      4. Urinalysis
      5. Rapid Plasma Reagin (RPR)
    7. Malnutrition Assessment
      1. See Lab Markers of Malnutrition
    8. Malabsorption
      1. Fecal fat (sudan stain)
      2. Serum carotene
      3. Serum Folic Acid
      4. Celiac Sprue serologies (IgA Tissue Transglutaminase or TTG)
  10. Imaging
    1. Chest XRay
    2. Abdominal Ultrasound
    3. Mammogram
    4. Screening with CT Scan not recommended (low yield)
  11. Diagnostics: Testing to consider
    1. Upper gastrointestinal series or Upper Endoscopy
    2. Flexible Sigmoidoscopy or Colonoscopy
  12. Evaluation
    1. Cognition
      1. Saint Louis University Mental Status (SLUMS)
      2. Mini-Cognitive Assessment Instrument (Mini-Cog)
      3. Mini-Mental State Exam (MMSE)
    2. Function: Activities of Daily Living
      1. Katz ADL Scale
      2. Lawton IADL Scale
      3. Six-Minute Walk Test
    3. Geriatric Depression
      1. Geriatric Depression Scale
      2. Patient Health Questionaire 2 (PHQ-2)
      3. Patient Health Questionaire 9 (PHQ-9)
    4. Malnutrition
      1. See Lab Markers of Malnutrition
      2. See Nutritional Health Checklist
      3. Mini-Nutritional Assessment (Nestle Nutrition)
        1. http://www.mna-elderly.com/clinical-practice.htm
  13. Management: Empiric
    1. Identify underlying cause
      1. Evaluation for secondary cause may stop after initial tests if no obvious etiologies are identified
      2. Empiric management with reevaluation at 3-6 month intervals is recommended approach
        1. At serial evaluations, additional testing should be directed by interval history
    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)
        1. Example: Ham, bacon or roast beef flavors sprinkled on food
      3. Eliminate or reduce dietary restrictions
      4. Consider Meals on Wheels or senior dining facility
      5. Choose foods with high calorie density
      6. Consider liquid oral dietary supplements (e.g. Ensure)
        1. Give 2 hours before a scheduled meal
        2. Should be an adjunct to meals (not a meal replacement)
      7. Correct ill fitting dentures
      8. Encourage Physical Activity
    4. Medications
      1. Treat Major Depression: SSRI
        1. Mirtazapine (Remeron)
          1. Risk of Dizziness, Orthostatic Hypotension and fall risk
          2. May be preferred SSRI in Failure to Thrive
          3. Raji (2001) Ann Pharmacother 35:1024-7 [PubMed]
        2. Fluoxetine (Prozac)
        3. Sertraline (Zoloft)
      2. Cannabinoid: Dronabinol (Marinol)
        1. Adverse effects: Sedation and confusion
    5. Medications that are no longer recommended due to risks outweighing efficacy
      1. Growth Hormone
        1. Increased mortality risk
      2. Megestrol (Megace)
        1. Typical dose: 320 mg to 800 mg PO qd
        2. Adverse effects: edema, Constipation and Delirium; thrombosis risk
        3. Low efficacy in appetite stimulation outside of Cachexia in AIDS and cancer
  14. Complications: Weight loss more than 10-20% below normal weight
    1. Increased mortality approaches 16%
      1. Sullivan (1991) Am J Clin Nutr 53:599-605 [PubMed]
    2. Overall increase in morbidity
      1. Weakness or Fatigue
      2. Muscle wasting
      3. Immunosuppression
      4. Skin breakdown
      5. Mood changes (Apathy, Irritability)
      6. Hip Fracture (women)
  15. References
    1. Heizer in Dornbrand (1992) Ambulatory Care, p. 15-18
    2. Karsh in Friedman (1991) Medical Diagnosis, p. 13-16
    3. Alibhai (2005) CMAJ 172(6): 773-80 [PubMed]
    4. Dwyer (1993) Am Fam Physician 47(3):613-20 [PubMed]
    5. Gaddey (2014) Am Fam Physician 89(9):718-22 [PubMed]
    6. Grazewood (1998) J Fam Pract 47(1): 19-25 [PubMed]
    7. Huffman (2002) Am Fam Physician 65(4):640-50 [PubMed]
    8. Morley (1995) Ann Intern Med 123:850-9 [PubMed]
    9. Robertson (2004) Am Fam Physician 70:343-50 [PubMed]
    10. Stajkovic (2011) CMAJ 183(4): 443-9 [PubMed]
    11. White (1991) Am Fam Physician 44(6): 2087-97 [PubMed]
    12. Zawada (1996) Postgrad Med 100(1):207-25 [PubMed]

Cachexia (C0006625)

Definition (NCI_NCI-GLOSS) The loss of body weight and muscle mass frequently seen in patients with cancer, AIDS, or other diseases.
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.
Concepts Sign or Symptom (T184)
MSH D002100
ICD9 799.4
ICD10 R64
SnomedCT 207558009, 207560006, 158737005, 28928000, 238108007, 285384003
French CACHEXIE, Cachexie
English CACHEXIA, Cachexia NOS, [D]Cachexia, [D]Cachexia NOS, Cachexia, [D]Cachexia (context-dependent category), [D]Cachexia NOS (context-dependent category), cachectic (physical finding), cachectic, cachexia, Cachexia [Disease/Finding], Cachexia (disorder), [D]Cachexia NOS (situation), [D]Cachexia (situation), Wasting, General body deterioration, Cachectic, Cachexia (finding), Cachexia, NOS, Cachexia (disorder) [Ambiguous]
Spanish CAQUEXIA, [D]caquexia, SAI (categoría dependiente del contexto), [D]caquexia (categoría dependiente del contexto), [D]caquexia, SAI, [D]caquexia, SAI (situación), [D]caquexia (situación), [D]caquexia, caquexia (trastorno), Consunción, caquexia (concepto no activo), caquexia (hallazgo), caquexia, deterioro corporal general, Caquexia
German KACHEXIE, Auszehrung, Kachexie
Japanese 悪液質, アクエキシツ
Swedish Utmärgling
Czech kachexie, Kachexie
Finnish Kakeksia
Russian KAKHEKSIIA, КАХЕКСИЯ
Portuguese CAQUEQUEXIA, Consunção, Caquexia
Korean 악액질
Polish Charłactwo, Kacheksja
Hungarian Cachexia
Norwegian Kakeksi
Dutch cachexie, Cachexie
Italian Cachessia
Sources
Derived from the NIH UMLS (Unified Medical Language System)


Wasting Syndrome (C0043046)

Definition (MSH) A condition of involuntary weight loss of greater then 10% of baseline body weight. It is characterized by atrophy of muscles and depletion of lean body mass. Wasting is a sign of MALNUTRITION as a result of inadequate dietary intake, malabsorption, or hypermetabolism.
Concepts Disease or Syndrome (T047)
MSH D019282
ICD10 R64
SnomedCT 207559001, 271878009, 288517002, 28928000
English Wasting Disease, Wasting Diseases, Wasting Syndrome, Wasting Syndromes, [D]Wasting disease, [D]Wasting disease (context-dependent category), WASTING DIS, Wasting generalized, Wasting Syndrome [Disease/Finding], wasting diseases, wasting disease, wasting syndrome, Wasting syndrome, Wasting disease (finding), [D]Wasting disease (situation), Wasting generalised, Malnutrition/starvation/cachexia, Wasting disease, Wasting disease (disorder), disease (or disorder); wasting, disease; wasting, syndrome; wasting, wasting; disease, wasting; syndrome, Wasting disease, NOS
Dutch algehele vermagering, aandoening; slopend, slopend; aandoening, syndroom; uittering, uittering; syndroom, ziekte; uittering, Syndroom, Wasting-, Wasting-syndroom
German Verfall generalisiert, Auszehrungssyndrom, Wasting-Syndrom, Auszehrungskrankheit
Italian Deperimento generalizzato, Wasting sindrome
Spanish Consunción generalizada, [D]enfermedad emaciante (categoría dependiente del contexto), [D]enfermedad emaciante, [D]enfermedad emaciante (situación), Síndrome de Consunción, enfermedad consuntiva (trastorno), enfermedad consuntiva, enfermedad emaciante, Enfermedad Debilitante, Síndrome Debilitante
Swedish Tärande syndrom
Czech syndrom chřadnutí, Generalizované chřadnutí
Finnish Näivetysoireyhtymä
French Syndrome de dépérissement, Cachexie généralisée, Syndrome cachectique, Syndrome de cachexie progressive, Syndrome de cachexie
Russian ISTOSHCHENIIA SINDROM, ИСТОЩЕНИЯ СИНДРОМ
Polish Choroba wyniszczająca, Zespół wyniszczenia
Japanese 消耗疾患, 消耗性症候群, ゼンシンセイショウモウ, 全身性消耗, 消耗症候群, 消耗性疾患, 消耗病
Norwegian Tærende syndrom, Tæring sykdom, Tærende sykdom
Hungarian Generalizált sorvadás
Portuguese Consumpção generalizada, Síndrome do Definhamento, Doença do Definhamento, Doença do Emagrecimento, Doença Consumptiva, Doença de Emaciação, Síndrome de Emaciação
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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