Epidemiology of weight loss in humans with special reference to wasting in the elderly

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Abstract

Unintentional weight loss in older adults is a problem that occurs frequently in clinical practice. Although slight declines in weight have been observed with aging alone, clinically important weight loss (decrements of 5% or more of usual body weight) is almost always the result of disease, disuse, and/or psychosocial factors. Adverse health outcomes associated with weight loss include decreased functional abilities and increased morbidity and mortality. Case series and prospective studies have helped to identify the most common causes of weight loss in older adults, and are reviewed herein. Knowledge of these frequent underlying etiologies can help guide an appropriate and cost-effective evaluation of patients presenting with weight loss. In many cases the causes are remediable and weight loss may slow or reverse with appropriate intervention. In some cases no clear etiology can be identified but the patient may still respond to nutritional support therapies that include hypercaloric feeding and appetite stimulants. Increasing caloric intake alone, however, is usually not sufficient to mitigate against losses in body mass (especially muscle mass) that are the result of chronic inflammatory or other severe disease states (cachexia). Potential strategies to help reduce losses in lean body mass and the functional decline that often accompanies weight loss include anabolic agents, exercise/physical activity, and cytokine inhibition. This article reviews the epidemiology of weight loss in older adults with special attention to the problem of cachexia. Diagnostic and treatment algorithms are provided to help guide clinical evaluation of, and therapeutic interventions for, older adults presenting with weight loss.

Introduction

Weight loss is a common problem in older adults that has been associated with adverse health outcomes such as decreased functional status, institutionalization, and increased mortality [1], [2], [3], [4], [5], [6], [7], [8], [9], [10]. Prospective studies of weight change in the elderly indicate that weight loss can be both a marker of, and an independent contributor to, these adverse health outcomes. The problem of weight loss in older adults appears to be heterogeneous, with different clinical and metabolic effects depending on specific underlying causes. Weight loss may occur in isolation or as a primary feature of a constellation of signs and symptoms that characterize syndromes such as “cachexia” [11] and “failure to thrive” [12]. Weight loss may also contribute to the development of “frailty”, a state characterized by diminished reserve, decreased functional status, and increased risk [13]. This article reviews basic considerations regarding definitions, epidemiology, physiologic processes, and clinical management of weight loss in older adults.

Section snippets

Definition of terms

Weight loss occurs as the result of an imbalance between caloric intake and metabolic requirements. In its simplest form, weight loss is due to inadequate caloric intake that is readily reversible with refeeding. In this circumstance food intake is reduced below usual caloric requirements, and the weight loss that ensues tends to consist of 20 to 30% fat-free (or lean body) mass and 70 to 80% fat mass. Although weight loss is a common feature of “cachexia”, this term more accurately represents

Body composition changes with usual aging

Before reviewing causes and consequences of weight loss in older adults it is important to consider changes in body weight and composition that occur with normal or physiologic aging. A number of population-based studies have measured body mass changes in purportedly healthy older persons, however it is often unclear whether observed changes are due to aging or are the result of inactivity, subclinical disease, or other undetected factors. With this caveat in mind, body mass changes associated

Incidence, clinical definition, and significance of weight loss

Incidence rates of 5 to 15% have been reported in studies of involuntary weight loss in community-dwelling older adults [19], and, not surprisingly, weight loss occurs more frequently in frail populations, with rates of over 25% observed among older dependent persons receiving home care services [2]. Weight loss has been associated with increased mortality and disability rates in numerous studies, but the degree of weight loss used to define “weight losers” has been variable. For instance, Ho

Causes and diagnostic evaluation of weight loss in older adults

Explanations for weight loss in the elderly have ranged from physiologic changes of aging to increased prevalence of poverty, psychosocial problems, and chronic disease [19], [21]. These and other commonly implicated factors behind involuntary weight loss have been summarized using a nmemonic “The nine D’s” of weight loss (Table 2) [22]. Although these may be valid causal factors from a clinical standpoint it is probably more informative to review etiologies that have been noted in case series

Management and therapeutic interventions

Fig. 3 provides an algorithmic approach to help guide treatment options for patients with weight loss. The first step in the management of patients with weight loss is to attempt to identify and treat any specific underlying causative or contributing conditions. In many cases, causative factors are found that are amenable to treatment (e.g., depression or peptic ulcer disease) and weight loss resolves—although incomplete recovery of weight lost during an acute stressful event such as illness,

Summary and future directions

Weight loss is a common problem in the elderly that is associated with increased risk of poor health outcomes. Weight loss can occur as a result of numerous underlying processes and is often associated with, and contributes to, syndromes of functional decline that include sarcopenia, failure to thrive and frailty. Weight loss of more that 5% during a 6 to 12 month period requires investigation. A rational stepwise approach is usually effective in establishing a diagnosis and determining

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