Mom isn’t eating well and she’s losing weight. She is down to 85 pounds. I’m completely frustrated. “Mom, please eat, you’re losing weight.” She just sits there and refuses. I feel like I’m forcing her. I took her to the doctor. He did a bunch of tests. He says there’s nothing wrong. Should I be worried?
I’m sorry but the answer is yes. We all notice when a person has lost too much weight. It’s alarming. Poor appetite and weight loss in the elderly result in a downward spiral of weakness, impaired healing, and dependency. In a previous post, I emphasized that sudden loss of appetite is a sign of acute illness. A persistent decline in appetite resulting in weight loss is also a red flag. No matter what the reason is, an unintentional 5% weight loss in 6 months is a problem. For instance, an 8-pound weight loss in a 160-pound patient is worrisome.
When patients lose weight, many physicians start by ordering blood tests and x-rays. Sometimes this ends up being an exhausting wild goose chase with many tests. If the tests eventually come back “normal”, it is common to hear “There’s nothing wrong.” This is reassuring but it’s not correct.
Hmm. What could be wrong?
A lot can be learned by careful observation:
- When did the appetite start to change? What were the circumstances?
- Does the person ever eat well? What’s different about that meal?
- Is eating part of a regular routine? Does the person forget to eat?
Additional information is learned by sitting and eating together. Get a sense of exactly what is happening:
- Does the person look uncomfortable when eating?
- Is there no interest in eating?
- Does the person seem interested in eating but then eats poorly?
- Does eating require a lot of effort? Does the person use utensils well?
These basic questions often give hints why someone is eating less. For instance, a loss of interest in eating may suggest a severe underlying disease. It may also signal a major depression. Because of decline in taste and smell, a senior can become a very “picky” eater. People eat better when there is someone to eat with. This is a point that geriatricians emphasize.
Medicines for Alzheimer’s Disease can cause loss of appetite
Donepezil, galantamine and rivastigine are used to treat Alzheimer’s Disease and dementia. Loss of appetite is a side effect seen with these medicines. This is particularly true when a large dose is given to an underweight patient. In these circumstances, my recommendation is to reduce the dose.
5 Things that geriatricians think of
Medicines, emotions, social factors, debility and “it all adds up”
1. Medicines, medicines, medicines
Geriatricians always worry that medicines cause problems. Many medicines, including those for Alzheimer’s Disease, can cause loss of appetite. Antidepressants also can cause loss of appetite. Pain killers and narcotics commonly upset the stomach. Be sure to review medicines carefully. Some medicines are not high risk. But taking multiple pills together adds up. Some patients take so many medicines and drink so much water that they complain there’s no room left for food. Excess alcohol also results in loss of appetite.
2. Emotions
Have you ever felt so upset that you couldn’t eat. My elderly mother has this problem. When something doesn’t go right, she won’t eat. “I’m so stressed I have an upset stomach”. When problems get worse, people with depression lose the desire to make or eat a meal. Depression is the cause of weight loss in up to 1/3 of seniors. This is a treatable problem.
3. Social Factors
Eating alone occasionally is ok. Eating alone all the time is not. Many older people are isolated. When they eat alone, there is more of a tendency to skip meals, eat irregularly and eat convenience foods. Then, when someone comes over and “watches” to make sure the senior is eating, the response is: “I’m not hungry.”
4. Debility
Older people need help when debility increases. It becomes challenging to buy groceries, make meals, and wash dishes. In addition, people with dementia who live alone may not know that it is time to eat. Old and spoiled food just sits in the refrigerator. These people often improve and gain weight when assistance is provided.
Some seniors have disabling chronic illness, arthritis, or neurologic disease such as Parkinson’s or stroke. Poor dentition is another factor and makes chewing difficult. Eating requires too much effort and meals aren’t finished. This is especially common when patients are acutely ill in the hospital.
When people are severely disabled swallowing can be slow. Eating is uncomfortable and takes a long time.
5. And it all adds up
Appetite tends to decrease with age. Even people with a big appetite start to eat less. A slight weight loss is common and not a problem. But when added together with other issues, a decrease in appetite results.
As seniors age the taste buds deteriorate. The ability to taste and smell decline substantially. Food is no longer as delicious. This is aggravated in patients who smoke or drink heavily. Medicines can also decrease taste and decrease saliva production. In addition, older people burn fewer calories and do not need as much food. The stomach also “ages” and food is digested slowly. The stomach does not empty quickly resulting in a full sensation.
It is ok for seniors to be a little heavier
Severe obesity is unhealthy. But being a bit heavier does not result in more disability nor a shorter life expectancy. In fact, the ideal weight index is slightly higher in seniors. A simple way of thinking of this is that extra weight is a reserve in case of emergency. This has been well studied. For most seniors 75 and older, weight loss is more of a concern than being overweight.
OMG what can I do.
A person can’t live without food. We’ve learned that weight loss is a big concern. Is it hopeless to improve appetite in a frail older person? No. The caregiver plays a vital role for this problem. I will discuss strategies in the next post.
Warmest Aloha,
PS: I say it over and over again: There's no one more important than the caregiver in the daily life of a frail person.