# Presentation: 035506

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

- Thomas Edes, MD
- Geriatrics & Extended Care
- VACO

## When to be Concerned

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

## 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

## Weight Loss in the Elderly

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

## 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)

## The Big Clue - It will be in one of these:

- Decreased intake
- Excessive losses
- Increased Catabolism

## 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.

- Lost interest in or appetite for food?
- 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?

- 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?

## 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?

## 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

## 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

## 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

## 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

## Labs:

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

## Medications

- Ambien
- Amitriptyline
- Metoclopramide
- Haloperidol
- Darvocet
- Omeprazole

## Medications

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

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

## Result

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

## 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 ?**

## 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

## 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

## Dysphagia and Weight Loss

- History –
- Exam –
- Labs –
- Barium swallow – severe aspiration

## Dysphagia and Weight Loss

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

## Tube Feeding in Dementia

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

## 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

## 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?

## 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?

## Oral Care and Aspiration

- Enteral feeding tubes reservoir for antibiotic-resistant bacteria
- 		- J Mehall, J Ped Surg 37:1011, 2002
- Orophayngeal pathogens increase risk of aspiration pneumonia
- E Marik, NEJM 344:665, 2001
- Much higher prevalence of GN Pathogens in oropharynx of TF patients
- A Leibovitz, J Gerontol 58A:52, 2003
- Oral care reduces pneumonia in NH
- T Yoneyama,  JAGS 50:430, 2002

## 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 suspect...MEDICATIONS