Investigation and management of unintentional weight loss in older adults
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1732 (Published 29 March 2011) Cite this as: BMJ 2011;342:d1732
All rapid responses
Dear Authors,
Thank you for this comprehensive piece on unintentional weight loss.
I note that tumour markers are not included in baseline investigations and
wonder what the opinion on this is. It would seem that it might qualify
as an addition to initial investigations with no extra time/effort
expended by the patient that could add to further reassurance before the
three month period.
Thanks
Competing interests: No competing interests
We were interested to read the comprehensive review of weight loss in
elderly people.
We have been impressed by the number of older people referred with
unexplained weight loss to our department who subsequently are found to
have Giant cell arteritis (Temporal arteritis). These patients may have
minimal symptoms and not have headache(1)but are at risk of visual loss
and permanent blindness. The Systemic nnflammatory disorders may only
represent 4% of patients with unexplained weight loss but this is a very
treatable condition with corticosteroids. If undiagnosed and/or untreated
there is high morbidity and mortality. We wish to bring to the attention
of your readers that connective tissue such as Giant cell arteritis may be
very insidious in onset and should be considered as part of the work-up in
a patient with weight loss. Inflammatory markers such as ESR and CRP may
be helpful although can be normal.
Ref: Arthritis and Rheumatism, June 1980 : L. A. Healey, K. Wiske :
Presentation of Occult giant cell arteritis
Competing interests: No competing interests
Jenna McMinn et al should be commended on their excellent article on
the investigation and management of unintentional weight loss in older
patients.(1)
However, we feel that screening for coeliac disease in older patients with
unintentional weight loss has been wrongly overlooked as part of their
recommended baseline tests.
Coeliac disease remains underdiagnosed in adults. The prevalence in the
general populations is around 1% and delay in diagnosis has been reported
to range from 4.5 years to 9 years.(2)
Symptoms of coeliac disease in adults are varied and can include
unintentional weight loss alone. Serological testing for IgA
transglutaminase antibodies are highly specific and approach 100%
accuracy.(3) This makes it a simple and cost effective test and should be
part of baseline tests for any older patient presenting with unintentional
weight loss.
References
(1)McMinn J et al. Investigation and management of unintentional
weight loss in older adults.BMJ 2011;342:d1732
(2)Hopper AD et al.Adult coeliac disease.BMJ 2007;335:558-62
(3)Celiac Disease.Green PHR,Cellier C.N Engl J Med 2007;357:1731-43
Competing interests: No competing interests
Investigation of weight loss
As a gastroenterology registrar I see a great deal of referrals for
weight loss both in the clinic and endoscopy suite. I was therefore
interested to read the guidance by McMinn et al.1 suggesting history,
examination, chest x-ray and faecal occult blood (FOB) testing as first
line investigations. Of concern was the observation that approximately 13%
of this population will have a gastrointestinal (GI) malignancy and 19% a
non-malignant GI pathology. Given the high incidence, it would be
invaluable to know the sensitivity of anaemia, CRP and ESR in this
population.
The database used to record endoscopy reports at our centre allows
the practitioner to record weight loss as an indication for the test.
Over the last year, 116 oesophagogastroduodenoscopies (OGD) were completed
for indications including weight loss with half (58) for isolated weight
loss. Five malignancies were found, all of whom had other symptoms (pain
or dysphagia) but only one had abnormal bloods (anaemia). Sixteen had
another GI pathology requiring further action (4 presented with isolated
weight loss, 3 being anaemic). One third of those with multiple
indications, including weight loss, were anaemic. In summary, 14% of
patients with weight loss (who received an OGD) had a non-malignant upper
GI pathology and 4% had an upper GI malignancy broadly consistent with the
published data 1 2.
Our colonoscopy reports do not allow weight loss to be recorded as an
indication. Over the last year, 131 patients had been assessed by the
colorectal cancer (CRC) MDT in this non-bowel cancer screening centre. 13
CRC patients had weight loss amongst their presenting complaints and 7 of
these had no distal metastasis. 5 of the patients with weight loss had
normal full blood counts and 3 of these did not have distal metastasis.
Only one patient had weight loss without another indication for
investigation. (CRC was diagnosed after imaging showed metastasis).
Although it is reassuring that patients with CRC presented with another
indication beside weight loss, this could be an example of sampling bias
given that colonoscopy is not recognised as an investigation for weight
loss.
This limited, superficial and retrospective data review does seem to
justify the approach of McMinn et al in selecting patients for OGD.
However, the finding that a significant proportion of patients with weight
loss attributable to CRC had normal blood tests and curable disease was
disconcerting given the low sensitivity of FOB (20% in asymptomatic
individuals3). McMinn asks whether and when "blind" investigations are
indicated. One study showed that when weight loss was confirmed 15 of 41
patients were found to have a GI malignancy (5 upper GI, 4 colonic and 6
pancreatic)2. We were unable to find the sensitivity of CT colonography
for pancreatic cancer but this test might be expected to have a high yield
in this circumstance. The potential early stage of some of these
malignancies should focus decision making on the time interval before
blind investigation is considered.
References
1. McMinn J, Steel C, Bowman A. Investigation and management of
unintentional weight loss in older adults. BMJ 2011: 754 - 759
2. Lankish PG, Gerzmann M, Gerzmann JF, Lehnick D. Unintentional weight
loss: diagnosis and prognosis. The first prospective follow-up study from
a secondary referral centre. J Intern Med 2001; 249:41-6
3. Graser A, Stieber P, Nagel D, Sch?fer C, Horst D, Becker CR et al.
Comparison of CT colonography, colonoscopy, sigmoidoscopy and faecal
occult blood tests for the detection of advanced adenoma in an average
risk population. Gut 2009 58(2):241-8
Jonathan Tyrrell-Price SpR gastroenterology, Imperial College Healthcare
NHS Trust, UK j.tyrrell-price@imperial.ac.uk
Anwen Hills FY1 Imperial College Healthcare NHS Trust, UK
Alison Varey FY1 Imperial College Healthcare NHS Trust, UK
Competing interests: No competing interests
We commend the authors for their review of unintentional weight loss
in the elderly for drawing into focus this important subject. What was
interesting is that the authors found no clinical guidelines or
standardized system for investigating this common and complex problem in
their careful literature review.
Many hospitals don't routinely perform
nutritional assessments on patients on admission. Although the authors
describe a detailed medical management plan for unintentional weight loss,
three simple questions on admission to hospital could flag those at risk:
what is your current weight? have you lost weight recently? have you
recently been missing meals or lost your appetite? The implication of this
study is that policy needs to be introduced to routinely screen for those
who are at nutritional risk including those with unintentional weight
loss. As the authors report, mortality within 1-2.5 years of clinically
important weight loss ranges from 9% to 38%, particularly among those
elderly patients recently admitted to hospital. A simple intervention -
routine nutrition screening on admission to hospital - may save lives.
Competing interests: No competing interests
HIV infection as a cause of unintentional weight loss in the elderly
It was with great interest that we read the clinical review by McMinn
et al on investigation and management of unintentional weight loss in the
elderly (1). However, we would like to highlight that HIV infection can
also be a cause of weight loss in this age group.
The UK National HIV testing guidelines published in 2008 (2) list
weight loss of unknown cause as an indicator condition which should prompt
the offer of an HIV test. National data (3) demonstrates that the
proportion of patients aged >50 accessing HIV services has more than
tripled between 2000 to 2009 and now represents 1 in 5 of all patients.
This is due to an ageing cohort of people previously diagnosed as well as
an increase in new diagnoses among the over 50s. New diagnoses among older
adults more than doubled between 2000 and 2009, and accounted for 13% of
all diagnoses in 2009. Two-thirds (67%) were diagnosed late, with a CD4
cell count less than 350 per mm3 which confers a worse prognosis in terms
of mortality and morbidity.
In our own department, we have diagnosed a number of patients aged
greater than 65 with the oldest patient aged 80. Many of these patients
have had missed opportunities for testing and have been in contact with
various healthcare services without the diagnosis of HIV being considered
or a test offered. Whilst the prevalence of HIV in this age group remains
low, we would suggest that in all patients attending for assessment of
unintentional weight loss, a brief risk assessment be conducted and an HIV
test is offered which, at around ?3 per test, is potentially highly cost
effective.
1. McMinn J, Steel C, Bowman A. Investigation and management of
unintentional weight loss in older adults. BMJ 2011: 754 - 759
2. Palfreeman A, Fisher M, Ong E. Testing for HIV:concise guidance.
Clinical Medicine 2009; 9 :5:471-6.
3. Health Protection Agency Report: HIV in the United Kingdom: 2010
Report. Vol. 4 (47)
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1287145367237
Simon Ellis, Specialty Trainee in Infectious Diseases, Royal Victoria
Infirmary, Newcastle upon Tyne.
Simon.ellis@nuth.nhs.uk
Competing interests: No competing interests