Dr. Paul Nelson Williams (1:33)

Paul. Hi, Matt, how are you?

Dr. Matthew Frederick Frank Watto (1:37)

I'm just thinking about how many puns I had to go through there to just try to get some response from you, but thank you. I'm glad that you're awake and alive and recording with us.

Dr. Paul Nelson Williams (1:47)

Yeah, I mean, if you call this living.

Dr. Matthew Frederick Frank Watto (1:49)

Sure, Paul. We have a great show tonight on abnormal weight loss in older adults. Our guest is Dr. Eva Symansk. And Paul, before we tell the audience about our guest, what is it that we do on Curbsiders?

Dr. Paul Nelson Williams (2:03)

Sure, Matt. A reminder that we are the internal medicine podcast. We use expert interviews to bring you clinical curls and practice changing knowledge. As you mentioned, we talked to Dr. Eva Samanski who is a geriatrician and clinician educator at the University of Pennsylvania Perelman school of medicine. Dr. Symanski works at the Philadelphia VA providing geriatric primary care and consultative memory care and she also attends on Penn's inpatient Geriatrics unit. She co directs the Internal Medicine Residency's aging and Transitions curriculum and and his core faculty for the geriatrics fellowship. The things that bring her joy in life include spreading geri principles to the masses, traveling with her husband, some DIY projects we talk about and spoiling her Duke cats, which spoiler we did not get to see during the episode. She teaches us a bunch of stuff, Matt, in terms of just an initial framework, including using the five M's to sort of think about geriatric syndromes more broadly. But then we sort of hone in on unexplained weight loss as well and talk about her approach, how she talks to patients, how she works them up, and then even some interventions that are relatively easy to accomplish, even though this tends to be a multifactorial process.

Dr. Matthew Frederick Frank Watto (3:01)

And I wanted to just give a Special thanks to Dr. Rachel Miller, who is a geriatrician at the University of Pennsylvania, who came to us with the idea for this episode. Hopefully this will be the first of several geriatric focused episodes that we're going to be doing through the University of Pennsylvania's Geriatric Workforce Enhancement Program. And there's a lot of great topics in geriatric medicine. Comes up a ton in primary care, even if you're not a geriatrician. So really excited to bring this to you as the first one from this series. A reminder that this and most episodes are available for CME for all health professionals through VCU healthcurbsiders.vcuhealth.org and if you haven't done so yet, check out our patreon@patreon.com curbsiders where you can get twice monthly bonus episodes, ad free episodes, access to our Discord server, and a whole bunch of other cool stuff@patreon.com curbsiders Eva, the audience has heard your bio, but they're curious to know a little bit more about you. So can you tell them a hobby or interest that you have outside of medicine?

Dr. Eva Symanski (4:10)

Sure. I am definitely not as hardcore at this hobby as some other people might be, but I do really like DIY projects and crafts and always kind of have throughout my life has ebbed and flowed based on my medical training and everything. But most recently I've been liking doing stuff around my house. My dad and I designed and installed our own closets for the house. My husband and I have been like painted pretty much every room in the house, painted the patio fence. So yeah, it's just obviously there's some planning involved. A lot of times I don't like to have too much thinking in my hobbies, but I feel like once you get going with the painting especially it's like really meditative and I actually really enjoyed it. Plus it's really satisfying that at the end, you're like, I did all of this stuff.

Dr. Matthew Frederick Frank Watto (5:00)

Yeah, you can be proud instead of upset that someone messed up your home improvement project.

Dr. Paul Nelson Williams (5:07)

Like, are you watching YouTube videos? How are you just freestyling it? Like, how are you actually preparing for this if you've not actually done it.

Dr. Eva Symanski (5:12)

Before for the painting? I did watch a lot of YouTube videos. I got pretty good at like cutting the crease for the edge. So I, like, didn't have to use tape to tape out the edges for, you know, the tops of the rooms and stuff. This room is actually an example for anyone who's watching the video. So, yeah, I didn't need to tape anything. I just like got really good at cutting the crease from YouTube.

Dr. Paul Nelson Williams (5:36)

I mean, the fact that you're just throwing out the phrase cutting the crease, like, just shows like, I feel like you're already pro level.

Dr. Eva Symanski (5:40)

So this is, yeah, you know, second career.

Dr. Paul Nelson Williams (5:47)

So that is terrific. Let me ask our other usual question. Can you share any advice or feedback that you've either gotten or that you'd like to give? And it doesn't even necessarily have to be medical centered, but just sort of advice or feedback for our listeners?

Dr. Eva Symanski (6:00)

Yeah, I do think of one that's medical off the bat. And I have been lucky to have a lot of mentors over the course of my pretty short career so far. Hopefully will be longer, especially trying to develop into like academic medical education sphere. And I think, like a lot of people, I have trouble saying no to things. I think we're kind of like fed this idea, especially earlier in our training, that whenever you have an opportunity, you never know when it's going to like turn into the thing that's going to turn into your career. So there's kind of a fear of leaving things behind. And then on the other hand, we're like trying to balance all our wellness and not get burnt out and all of that stuff. So anyways, the advice itself is actually not that good, which is just like, you don't have to say yes to everything. But a couple mentors have really backed it up and been like, text me anytime you have an opportunity when you're not sure about it and I'll tell you if it's worth your time or I'll help you decide if it's worth your time. And that I found super, super helpful, especially as I've started my faculty position.

Dr. Matthew Frederick Frank Watto (7:08)

And part of what goes with that is implied, I guess, is that you don't immediately say yes because we got that advice from. It was the great Dr. Amy Oxentenko.

Dr. Paul Nelson Williams (7:17)

Paul.

Dr. Matthew Frederick Frank Watto (7:17)

Right. She said she tells people. Thank you. And she said she never, she always like at least takes a night to think about it before reflexively just saying yes to things, which I think is good. And then another piece of advice I've heard is like try to imagine that it was tomorrow. Would you still be excited about the opportunity?

Dr. Eva Symanski (7:37)

Those are good ones. Yeah. Lots of different ways to kind of help you with that. I think a lot of us struggle with it.

Dr. Matthew Frederick Frank Watto (7:45)

Yeah, absolutely. I mean a hundred percent. A hundred percent. But thank you for saying yes to this opportunity, which I think you. I think this was a good choice.

Dr. Eva Symanski (7:52)

I mean, I agree.

Dr. Matthew Frederick Frank Watto (7:54)

Yeah.

Dr. Eva Symanski (7:54)

This was not one that I had to think too hard about.

Dr. Matthew Frederick Frank Watto (8:00)

Paul, should we get to a case from Cash like we should?

Dr. Paul Nelson Williams (8:05)

Let's talk about Peter. Peter is a 70 year old gentleman who is being seen for an urgent visit at Cash, like Northeast Primary Care. He and his partner report that he's been losing weight. He looked at the chart and sure enough he was 155 pounds that this visited a year ago and today he's 130 pounds which is about a 16% loss over the past year. His partner also says that he is basically spending all of his time in bed. He seems less engaged overall and she seems kind of at her wits end. She doesn't know what to do. He reports poor appetite, saying I just don't feel like eating. He denies melanin hematophysia. He's not had diarrhea, abdominal pain or really much the way of any sort of gastrointestinal symptoms that we can really anchor in on. He's been without fever or night sweats. On exam, his body mass index is 18, he is edentulous, he's got a flat affect, he has a benign abdominal examination and he has tactical strength throughout. So this is, I feel like this is a really common scenario. We were talking before we started recording. This is something we see in the office all the time of this sort of unplanned or unintentional weight loss. But it'd be good to know if there was just a concrete definition for that. So in your sphere, is there something that actually qualifies as unintentional weight loss? How do you conceptualize this? What kind of framework do you use when you're starting this kind of conversation?

Dr. Eva Symanski (9:11)

Yeah, so first in terms of definitions, definitely agree that it's good to have a definition for it. Technically, unintentional weight loss means losing at least 5% of someone's usual body weight. Over the 6 to 12 month period, obviously, unintentionally, without meaning to. And I think like an important side component to that is a lot of times either us as healthcare providers or our patients themselves will chalk problems like this up to, oh, it's just part of getting older. Like, you get older, you lose weight. Um, but actually in normal aging you might only lose 0.2 to 0.4 pounds per year. So definitely, if you're getting to the threshold of meeting like the 5% of usual body weight, and in this patient, I think you said 16%. Definitely something that needs to be taken seriously.

Dr. Matthew Frederick Frank Watto (10:02)

So unintentional weight loss, Eva, is, is greater than 5% in a 6 to 12 month period. But what about these other terms? Cause you hear people say cachexia, you hear them say failure to thrive, Sarcopenia. Is it important to differentiate between those?

Dr. Eva Symanski (10:19)

Yeah, I'm glad you brought up the other terms because there are a lot of other terms that get kind of like thrown around with unintentional weight loss. And it is helpful to kind of differentiate between them. So sarcopenia was one that you mentioned. That's loss of muscle mass and strength, which can be part of normal aging, but isn't necessarily inevitable if someone, you know, maintains good nutrition and exercise. Cachexia is loss of skeletal muscle more so than fat in the setting of kind of an underlying systemic inflammatory condition. So like cancer, end stage copd, things like that. And then failure to thrive is more of like a global syndrome of decline where the older adult has physical frailty, which might include unintentional weight loss, like we're discussing, may include sarcopenia as part of the physical frailty. Plus they also have a significant impairment in either their day to day function, so like activities of daily living and, or their neuropsych function. So issues with dementia or depression. So for failure to thrive, you really have to have kind of more global issues going on like that. And I think, you know, maybe we'll get into this kind of as we continue to talk about the topic, but I think it's helpful to actually think about that because a lot of times we see these patients, um, with a lot going on, including unintentional weight loss, and we just throw kind of failure to thrive at them without actually thinking like, what is making us call it failure to thrive? And sometimes the label can then make us kind of stop thinking.

Dr. Matthew Frederick Frank Watto (11:55)

Yeah, okay, good point.

Dr. Paul Nelson Williams (11:58)

Um, Eva, this patient is, is presenting to your office. So how, how might the conversation start? So where do you start? What kind of framework do you use as you're working up this, this unplanned weight loss?

Dr. Eva Symanski (12:07)

So I'm usually trying to get kind of like an overall sense of the patient. And I know that's usually what we want to be doing as internists and geriatricians all the time. But there's limitations to our regular practices that we can't always be as broad as we want to sometimes. But I think that this is a case where it's important to try to get a whole context. And I do like to use a framework for that. And I've been using recently the geriatric 5 Ms. Framework for this, which I think is a really helpful way to organize all information relevant to the care of older adults beyond just their past medical history and can be used for lots of other things relevant to older adults beyond just unintentional weight loss. So hopefully people have heard of the geriatric 5Ms, but if not, they are multi complexity mind mobility medications and then what matters most. And they sound like a lot and they do go into a lot. But I think that kind of, like I said, once you get facile with going through those, you can really apply them to lots of different geriatric syndromes. So for me, I'm not very good at learning lots of different mnemonics for different things. I like learning kind of one framework that I can apply to multiple different things. So this for me is one of those. And then I'll kind of tailor it to the specific situation. So I'm happy to kind of talk through what I would, how I would tailor in this situation or.

Dr. Matthew Frederick Frank Watto (13:37)

And the audience, if the audience listened to one of our great Jerry focused episodes in the past with Dr. Leah Witt, who wishes she could be here tonight, was supposed to be here tonight with us as well. We did for COPD and older adults. We used the 5ms. Framework in that episode to talk about it in that context. And then you just mentioned mnemonics that are hard to remember. Paul, There's a Meals on Wheels mnemonic for weight loss in geriatrics. And I just thought it was funny because it's like so many letters and it's clever to put it into Meals on Wheels. But I will not be using that to try to remember.

Dr. Eva Symanski (14:17)

It just gets to the point where you start guessing, like what's a word that starts with a letter and you just have no idea if it's actually related to the thing you're trying to evaluate.

Dr. Paul Nelson Williams (14:28)

I remember teaching the Vindicate mnemonic to medical students to come up with a differential diagnosis. And you're like on the third eye you're like, it's like intoxication or is it infection? It might be inflammation. Is it idiopathic? There's 17 eyes that it could be. I'm like, wait, this is not helpful to us at all. We can stop now. But this mnemonic seems helpful. Sorry to bring us back home. So yeah, if you would sort of go through step by step and let us know how you would apply it to this particular syndrome and then I think I'd like to hear more about other geriatric syndromes when you're done doing that.

Dr. Eva Symanski (14:54)

Yeah, sure. So if I'm kind of trying to apply my geriatric 5 Ms. To unintentional weight loss, I'm going to be tailoring everything a little bit to that. So within multi complexity that's kind of typically where we think about like what are people's medical problems, what are their symptoms? So this is where I'll think about like organic causes of weight loss. So that could be either, you know, a known disease that someone has that could be worsening. So let's say they have COPD and it's becoming end stage, they have heart failure, it's becoming end stage and they're kind of in a inflammatory cachexia state. Or it could be a new disease that, you know, they've developed and we haven't yet diagnosed like a new cancer or malabsorptive issue and other other inflammatory diseases, things like that. And I think within this category, I also like to think about symptoms that older adults tend to have that we're maybe not as good about usually asking in our review of systems, even though we probably should be better at them still, myself included. And that especially relevant for here is things like visual deficits and also dental issues, which can both affect, you know, appetite, eating and weight loss. And this is a, I mean this is a pretty big bucket, you know, for unintentional weight loss. If you look at review articles for causes of unintentional weight loss, organic causes are going to be a pretty, pretty high up there. Malignancy being a common one and then non malignant GI diseases being another common one. So moving on to the other M's because I think that's the important thing too. Sometimes we just think about the organic cause and then we forget to look at other potential things that might be happening within the mind. M I'll think about things like depression or dementia. This is another very common cause that's cited in Review articles It is important to note that I think dementia can affect weight loss in a few different ways. I feel like typically we think about kind of very advanced dementia where someone has dysphagia, maybe they've forgotten how to kind of mechanically swallow, so they're pocketing food. They like physically can't feed themselves at all. Maybe they've developed pressure wounds and have an inflammatory state that's contributing. So I feel like that's kind of what classically we might think about with dementia and weight loss, like kind of that advanced situation. But I've definitely seen folks who've had weight loss associated with earlier stages of dementia too, especially if there are associated neuropsych symptoms. Like if someone has maybe mild dementia, but they have kind of a neuropsychiatric symptom of apathy, that can definitely affect people's appetite. If they have paranoia, that can affect their eating. I've definitely seen patients who have paranoia that their food has been poisoned by their family or things like that and they won't eat. If someone has developed wandering and they're, you know, walking a lot more than usual, that can affect their energy expenditure and can cause weight loss. Someone who maybe doesn't have cognitive skills to put together a meal anymore, there's basically, you know, a million ways you could potentially slice it. Even in those kind of more mild, moderate stages. And then in the mobility M I think about activities of daily living and especially those that affect eating. So, for instance, how are people shopping and getting their groceries? How are they actually getting to the store? Like, what's their transportation situation? Are they having barriers there? How are they cooking? Are they able to cook? How are they physically feeding themselves? And then also within this, I think about kind of physical function, activity level, you know, if someone is maybe not as active as they used to be and losing muscle mass, that can kind of like tie into the sarcopenia weight loss picture in medications that M this is such an important M I think pretty much any new symptom or medical problem in an older adult, you really have to go through the meds with a fine tooth comb. There's a great table in American Academy of Family Physicians. Hopefully I got that acronym right in one of their review articles on this topic that goes through a list of meds that cause issues with, with taste, appetite, dry mouth, GI symptoms like nausea. And it's actually like, when I went through it for the first time, I was really surprised. There were a lot of meds on there that were very common that I never would have thought had GI side effects. And I think the other thing kind of along with meds and their side effects is even if someone's been on the medication for a long time and they've been tolerating it before, as people age, the way that their body processes medications may change as well. Maybe they're on another new med that's causing a drug drug interaction. So they could be developing side effects that they hadn't had before. So it's still, you know, even if it's not a completely new medication, still something to think about.

Dr. Matthew Frederick Frank Watto (20:06)

This episode is brought to you by Quince. You know audience Quint's is a favorite brand for me that I discovered in 2024, and I'm going to continue to buy their stuff and wear their stuff in 2025. I'm in the process of switching over all my polos to the Flowknit Breeze Performance Polos. They're super lightweight, comfortable. I love the way they fit and I wear polos every day to work. And I think everyone needs one of Quince's Mongolian cashmere sweater starting from just $50. I have one myself and I it is super comfortable. It's soft, it looks great. I get compliments on it. All Quince's pieces are priced 50 to 80% less than similar brands. My wife and I love their stuff so much. We bought a lot of Christmas gifts from Quince and my wife bought a lot of stuff for herself from Quince. Quint's is able to offer lower prices because they partner directly with top factories, cutting out the cost of the middleman and passing the savings on to you. Quince only works with factories that use safe, ethical and responsible manufacturing practices. And and of course, they use premium fabrics and finishes for that luxury feel in every piece. I have to say, it was really a step up to my wardrobe. I'm not really known for my wardrobe, but I feel a lot more stylish when I'm wearing quints. So upgrade your closet this year without the upgraded price tag. Go to quince.com curb for 365 day returns plus free shipping on your order. That's Q U I n c e.com curb to get free shipping and 365 day returns. Quince.com curve. This episode is brought to you by Freed.

Dr. Matthew Frederick Frank Watto (21:50)

Have you ever had one of those crazy clinics where you start off with 10 patients but suddenly there are 13? Everyone's sick.

Dr. Matthew Frederick Frank Watto (21:56)

@ the end of the day, charting can be daunting, but Freed is an.

Dr. Matthew Frederick Frank Watto (22:00)

AI scribe that listens transcribes and writes medical documentation for.

Dr. Matthew Frederick Frank Watto (22:05)

You. And instead of trying to remember everything that happened, your notes are already.

Dr. Matthew Frederick Frank Watto (22:08)

There, ready for you to copy and paste into your ehr. Freed saves you time and works across all devices. You can use a phone, tablet, or computer to listen in the room and switch seamlessly to your desktop to review and finalize. Freed has revolutionized the way that I see patients. I'm spending so much less time on my notes, and I just love.

Dr. Matthew Frederick Frank Watto (22:27)

It. Behind Fried are two people who.

Dr. Matthew Frederick Frank Watto (22:30)

Understand Gabby, a family doc who is drowning in documentation, and her husband, Erez. They billed Freed with a simple.

Dr. Matthew Frederick Frank Watto (22:36)

Promise to make clinicians happier, not by.

Dr. Matthew Frederick Frank Watto (22:39)

Pushing them to see more patients or optimize their billing, but by giving them back their time. We're happy to report that thanks to Freed, Gabby has traded the Saturday morning charts for Saturday morning croissants. So at your next clinic, when you put your hand on the doorknob and your patient says one last question, instead of scrambling to type and listen, take a deep breath as Freed writes it all down for.

Dr. Matthew Frederick Frank Watto (22:59)

You. Join more than 15,000 clinicians, doctors.

Dr. Matthew Frederick Frank Watto (23:02)

NPs, and PAs who trust Freed's encrypted HIPAA compliant, high tech and SoC2 certified.

Dr. Matthew Frederick Frank Watto (23:08)

Platform. Start your free trial today. No credit card.

Dr. Matthew Frederick Frank Watto (23:11)

Needed. Visit freed AI. That's freed AI, and use the code curb50 to get $50 off your first month. I was just going to say, on that list, the. Some of the meds, I mean, like, they're. They're meds we prescribe all the time. I mean, metformin's on there under multiple categories for. It's on there for causing anorexia, for causing nausea or vomiting. And then there's antibiotics and allopurinols on there, loop diuretics and antihistamines. Like, things that we just, you know, that patients are going to be exposed to. So lots of different meds. That's why I was having. I don't know, Paul, as America's pcp, does it bring you great joy to remove unnecessary medications or to identify medications that are causing.

Dr. Paul Nelson Williams (24:07)

Symptoms? Yes, a million percent deprescribing is my favorite thing to do, regardless of age category, but yes, especially in older.

Dr. Matthew Frederick Frank Watto (24:13)

Patients. Yeah, Eva, I was talking to a patient the other day about this. I was just like, people think that doctors love prescribing meds. I actually think doctors, like, at least my kind of doctor internists, like to take meds away. Uh, that. That gives us great joy as.

Dr. Eva Symanski (24:29)

Well. You're definitely speaking to me on that. Um, I think the other thing too, as you were reading some of those medication names, some of those are over the counter antihistamines. You can get that over the counter. So I think another plug to like really do a good over the counter med history for your older adults, you can just deprescribe those ones too. And.

Dr. Matthew Frederick Frank Watto (24:52)

Then.

Dr. Eva Symanski (24:53)

Absolutely. I was going to say the other thing I kind of think about in this medication category, even though it's not a prescribed medication, are substances. So things like alcohol, you know, that can cause weight loss as well for various reasons. And then great. In the final M of what matters most. This is where I like to learn about what people's day to day life is like. What do they enjoy doing, what brings value to their lives and also kind of things like are they isolated? Do they have good social support or not? Do they have foods that they like but just can't get for whatever reason? Are there financial barriers? So those kinds of things I feel like play a bit into this.

Dr. Matthew Frederick Frank Watto (25:37)

Category. So should we, should we go through, give you a little more information about our patient and maybe put, put it into the 5Ms.

Dr. Eva Symanski (25:47)

Framework? Sure. I do just want to say too that I feel like I talked about the M's for a long time and a lot of times when I talk to people, especially people who aren't geriatricians, who aren't doing this every day and maybe don't have as much time with patients. I'm very fortunate. At least where I work, I have a decent amount of time with my patients. It can be pretty overwhelming to be like, oh my gosh, I have to go through all five of these categories and all of them are so complicated and I have to do it in a 15 or 20 minute visit. Just want to emphasize that like you can do this over time and you can maybe start with like the multi complexity M for one visit and kind of, you know, do that first and do your evaluation and then bring them back for follow up and do some other M's. So I just want to give that plug for people. If you're like feeling a little overwhelmed right now, you don't have to do it all at.

Dr. Matthew Frederick Frank Watto (26:41)

Once. So our patient here, so his medical history he's got, has high blood pressure, high cholesterol, iron deficiency, anemia. We didn't ask about taste or smell as part of the multimorbidity or organic causes, but that is something too that comes up. You know, patients will tell me, oh yeah, I had Covid and I lost my taste and smell and it didn't really come back as strong. And I'm like, well maybe that's why you're not eating anymore. So that's another one that I think sometimes people don't even realize even though they they sort of know things taste different. Okay. Fermentation. We did a geriatric depression scale. The score was 13 out of 15 and scores of greater than 5 are positive for depression. We did a MOCA and the score was 18 out of 30 with scores under 26 being abnormal. The meds he's on Atorvastatin, lisinopril and ferrous sulfate. For mobility, he was able to walk from the waiting room to the chair and the office, but he had a pretty slow gait. And at home he likes to stay in bed because he just feels weak in his legs and has just needed more help getting around. And with some of his ADL's from his partner. And then for what matters most, he used to work as a cook in a restaurant and would often have meals with his coworkers, which he enjoyed doing. But he ended up with losing his job after they kind of noticed he was slowing down and couldn't keep up and was making some errors in recipes. And you know, he's been a little bit bummed out since losing that job. So anything here that stands out to you as part of what might be.

Dr. Eva Symanski (28:20)

Contributing? There's definitely a lot of potential things from what you just went through. I think again to kind of stick with our EMS categories to keep ourselves organized and feel less overwhelmed. And in the multi complexity piece I think you mentioned he has some vascular risk factors, but also he had iron deficiency anemia. So that could definitely indicate that maybe there's a GI source malignant, non malignant or some other inflammatory condition. So I know you said initially he didn't have any major GI symptoms, but that's something we're definitely going to want to ask about. Focus on during our exam and maybe as part of our workup in the mind you mentioned he screened positive for both depression and cognitive impairment. Kind of unclear to me at this point. You know, are those two separate things? Is it related? Like is the depression causing a pseudo dementia or is the fact that the he has a dementia causing depression as a neuropsych symptom. So I don't think we quite have enough yet to tease that apart. But certainly both of those things could affect, you know, his appetite, ability to eat and things like that and contribute to his weight loss. I think as part of the mobility m it seems like certainly he's not moving around as much. Might be losing muscle mass because of less physical activity. Also might not be working up as much of an appetite. Like, if people are just sitting in bed and, like, you know, not really moving around as much, you just don't work up as much of an appetite, and then you're maybe gonna lose some weight if that's, like, a consistent thing for you. In his meds, he's not on that many, which is pretty amazing. Um, but the lysina pril ACE inhibitors are actually on that list of medications that can affect taste and smell, so that's something to keep in mind for him. Although it kind of seems like for him, we've got some other things that might be, like, bigger drivers for the weight loss in this.

Dr. Matthew Frederick Frank Watto (30:24)

Situation.

Dr. Eva Symanski (30:26)

Mm. And then his ferrous sulfate, too, can cause constipation, which can cause abdominal fullness, nausea, and that might also affect his appetite. And I think the matters most piece at the. That we got to at the end there is maybe one of the more important things as well, that he's really had a huge shift in losing something that brought a lot of meaning to him and sounds like brought structure to his day. He had, like, a social eating habit at his work, and that's now been lost. So that also might be a. A big contributor here.

Dr. Matthew Frederick Frank Watto (31:00)

Too. Yeah. I mean, this one just seems like there's not just, like, one smoking gun to be that that's contributing to this. And I don't know, Paul, do you feel like that's the way it is in practice most of the time where there's not just, like. I mean, maybe sometimes you get a CAT scan and you find, like, a giant tumor, but usually, Paul, that's not. I guess it's a good thing that that's not usually the.

Dr. Paul Nelson Williams (31:24)

Case. Yeah, well, right. I think Phyllis is fairly prototypic and like it's going to be multifactorial. There might be one of those factors that is having more of an impact than some of the others, but are probably all worth addressing. But I guess my question for you, Eva, is even though we have some things to kind of anchor on here, I feel like this patient would not walk away from most internist office without at least some rudimentary labs. I imagine a TSH would probably be in there and a CBC just to see if there's all of a sudden a new anemia or check, you know, renal function to make sure that it has not fallen off a cliff, and maybe even maybe hiv, depending on how. How motivated people are feeling what the patient's history looks like. And so I guess for you, what we can say for this patient. And then sort of more broadly, is there any other sort of lab work or sort of initial review that you do before you start to kind of hone in on the things you're going to intervene.

Dr. Eva Symanski (32:13)

Upon? Yeah, so like most things in geriatrics, and I think with caring for older adults, everything becomes pretty individualized based on the person and the situation and what's important to them. But I do think that it is helpful to do a basic workup in pretty much everyone, mostly with labs is, as you had mentioned, is my kind of first go to for everyone. Um, I definitely do a CBC for anemia, as you mentioned. You can also kind of get a sense if the white count is up, maybe there's some kind of inflammatory process, a cmp to get a sense of, like you said, renal function as well as liver function, thyroid studies. The other thing I like to check is vitamin B12 more so kind of a marker, I guess, of poor nutrition, but can also kind of contribute to depression and cognitive impairment that can, you know, kind of feed into all of this. And then like you said, the other labs, I kind of pick based on what I've kind of turned up in my initial conversation as part of the 5m. So if there are risk factors and they haven't had an HIV screen in the past, maybe that's something that I'll throw in there. Similar with hcv, you know, if they've never had the screener and there's some kind of risk factor. But also sometimes thinking about, like, maybe do I want to check an A1C on this person? Could they have, you know, wildly out of control diabetes? That's like, you know, leading to weight loss. Thinking about, do I want to check a sed rate or a ferritin? I honestly don't order those too much, but they'll turn up. If you read about, like, what lab work should you be doing for these people. But I'm usually doing CBC, CMP, TSH, B12 for everyone, and then adding maybe a couple of others based on the.

Dr. Matthew Frederick Frank Watto (33:59)

Situation. What about imaging? Some of the articles, or most of the articles mention at least getting a chest X ray. And we were talking about this off air a little bit. The article by Gaddy, which is the American or the AAFP article, and it looks like there was one from 2014, then updated in 2021, mentions abdominal ultrasound, which is not something I would have thought to get for someone in this case, you know, I was certainly a CAT scan would be something I would think about. Like if I did my whole workup, the labs and the history, and just really couldn't find anything to point to, at some point I might think about getting a CAT scan. So can you comment on that? The imaging.

Dr. Eva Symanski (34:43)

Piece? Yeah. I also usually think about imaging as kind of like more second pass tests based on kind of what we've turned up from the initial conversation and the initial labs. Maybe we had a follow up and we want to see, you know, have things stabilized or are they still getting worse? And that's where I'll kind of like decide if I want to pull the trigger on imaging. Obviously it might be a little bit different if this person has been admitted to the hospital, but that's kind of not the situation we're talking about here. And first thing that I'll do, honestly, a lot of older adults already have had a ton of imaging. People have gone to the emergency room with a fall. You know, they've gotten a chest X ray, they've gotten head CTs, they've like, there's usually a lot of imaging in the chart. So the first thing I'll do is just take a look through what's already been done and just make a note of when it had been done as it correlates to their symptoms. Because if they had a totally normal chest X ray five months ago, I doubt he's developed a giant thoracic malignancy since then, for instance. So you can often check some of those boxes without actually putting the patient through more testing. That said, kind of the question about the abdominal ultrasound, I had also kind of been chatting with some colleagues about this when we were talking about this topic with our fellows a couple months ago, and we were theorizing that maybe the abdominal ultrasound is still showing up in some of these algorithms because CT scans weren't as common in the past when some of these studies were done about unintentional weight loss. But yeah, I don't think I've ever ordered an abdominal ultrasound specifically for unintentional weight loss. If I'm going to go for the imaging test, I will just do cross sectional.

Dr. Matthew Frederick Frank Watto (36:30)

Imaging. Okay. Yeah, I think that's probably the correct theory as to why it is that way. And I will say the article I mentioned by Gaddy, I think is a fantastic article. Uh, so people, people can check it out. And the figures in there, the, the lists of, and the differential and everything are, are really well made. What about cancer screening? You know, for so this and I guess for geriatric patients, especially with dementia, that's probably a whole different story. But it's. It. I'm sure it comes up especially with family members if they're worried about this weight loss People are always. Their mind always goes to cancer. So how do you, how do you talk about.

Dr. Eva Symanski (37:09)

That? Yeah, that's a great question. Again, one of those things like you mentioned that really has to be contextualized. There are actually some other articles that I can send you as well to link to the show notes, if it's helpful that talk about if basic first pass testing. One article talked about basic first pass testing, which included labs and then fecal occult blood and a chest X ray. If those were all negative, then the likelihood for malignancy or non malignant disease was actually pretty low. And there was another article too that looked at cross sectional imaging like ct, chest, abdomen, pelvis. And if, if all of those were negative, then that also had a pretty strong negative predictive value for malignant disease. And it was pretty good too, actually for non malignant organic causes as well. So I kind of use those articles to tell me that like a fairly modest workup is going to be probably pretty effective, you know, for your malignant and organic causes. So if it's not turning anything up, you know, you still have to think about malignancy, but you don't necessarily want to anchor on, you know, just that the piece about screenings. I feel like it always comes up on the kind of in someone's plan for unintentional weight loss is like, make sure they're up to date on age appropriate cancer screenings. And the way that I think about it is, you know, if you're considering this for weight loss and you think that the cancer is causing the weight loss, like it's no longer a screening test, like you're trying to do a diagnostic test at that point. So you really want to be thinking like, what are the person's symptoms or other, you know, data that you've gotten that's making you concerned and you know, be more targeted and have a more targeted conversation about those things. And certainly there's, you know, pros and cons and risks and benefits to doing various types of testing to look for cancers. Maybe one patient and family would be willing to go through a CT scan, but they wouldn't be willing to go through a procedure for like an endoscopy or colonoscopy. And another family might have a different thought. So has to be very individualized. But I would think about it more like diagnostically than. Than as a screening test. I was actually talking with some colleagues and we were again, while we were kind of doing this talk with the fellows, we were all kind of saying like, it's almost like that reminder of like make sure up to date on age appropriate cancer screenings is more for us to like review has the patient ever had cancer screenings in the past and maybe make sure that we're not missing something. Like maybe they had an abnormal colo like 12 years ago with like really suspicious polyps that never got followed up on. That's probably helpful for us to know, but I don't think it means that we need to go crazy with like ordering PSAs and mammograms on our, you know, 70, 75 year old patients who are having unintentional weight loss. You know, if the situation is appropriate for them to get the screening test and based on their age and their function and their goals, then get the screening test. But I would think about it as like separately from my unintentional weight loss.

Dr. Paul Nelson Williams (40:17)

Workup. It's. You actually hit on something I was going to ask about like the Hail Mary psa, which I just feel like I don't think. I'm not saying it's the wrong thing to do. I'm just saying just be careful. Like just know that you're going to have to deal with the results when they come back. Sort of do that. Or indifferent.

Dr. Eva Symanski (40:30)

Probably. If their prostate cancer is bad enough to be causing weight loss. Like they're going to have other symptoms.

Dr. Paul Nelson Williams (40:38)

Right? Yeah. One would.

Dr. Matthew Frederick Frank Watto (40:39)

Assume. This episode is brought to you By Mint Mobile 2025 is here and Mint Mobile has a resolution for you. Skip the gym. Skip the fad diets. Skip the BS resolutions. You'll forget about those next month. Instead, make a resolution to save some serious cash by making the switch to Mint Mobile. And right now you can get half off their three month unlimited plan. It's time to leave those overpriced wireless plans. They have these jaw dropping monthly bills, unexpected overages and all that other stuff. Just leave it in 2024, Mint Mobile is offering huge savings for the new year with any three month plan for only 15 bucks a month. Even there are unlimited plans. All plans come with high speed data and unlimited talk and text delivered on the nation's largest 5G network. You can even bring your current phone and your number. Switch to Mint Mobile and new customers get half off an unlimited plan until February 2nd to get your new wireless plan for just 15 bucks a month and get the plan shipped to your door for free. Go to mintmobile.com curb that's mintmobile.com curb $45 upfront payment required. Equivalent to $15 per month new customers on first three month plan only. Speed slower above 40 GB on unlimited plan. Additional taxes, fees and restrictions apply. See Mint Mobile for details.

Dr. Paul Nelson Williams (42:13)

Any. Any other. You touched on a couple of things in terms of I love the, the framing of the age per cancer screen just in general, but any other potential pitfalls or things that you see internists do that, gosh, you just, you wish they wouldn't when they're working this.

Dr. Eva Symanski (42:24)

Up. I think some other things are just to make sure and this has come up a little bit as we've been talking about how individualized it is. There is a lot of ageism in our society, both within ourselves as practitioners as well as in our patients. Kind of like as we talked about earlier. So I think just making sure that we're not doing certain things or not doing certain things just based on someone's age, I think we're like recognizing more and more and have more and more data to kind of back up that age is just a number. And a lot of times people's function is much more important for, you know, what their lifespan is going to look like. And also what's important to people and what they value is also important to consider in this. So I think just making sure that we're challenging ourselves to not just make a decision based on age as a.

Dr. Matthew Frederick Frank Watto (43:15)

Number. Yeah. I mean we're totally on board. You're speaking our language. We've talked many times, Paul. Right. About biological age. And I almost, when I, when it comes to cancer screening, I'm almost thinking about someone's biological age and certainly life expectancy. You know, if you have a 75 year old that's like, you know, they're, they have almost no medical problems and they're fully functional and they're more like someone in their 60s then you know, to continue with like annual mammograms seems like something to do if they want to, but if the patient doesn't want to and they're fully informed, then you know, you go with them. But I think, I guess I think for the better medicine has become more you work with the patient, the shared decision making thing. And I really like the point about the just individualizing it to the patient, as you were.

Dr. Eva Symanski (44:05)

Saying. Yeah. I think also I know we've just been talking about, spent a little bit of time talking about cancer screenings, which is definitely an important part. But I think the other pitfall is not getting stuck with that, remembering that was just one of our M's that was just within the multi complexity. So, you know, if you've done your workup for organic causes and cancer and you're not really turning anything up, like, you don't necessarily need to keep digging in that direction, maybe that's a time to look around at your other. Those other four M's and see if you turn anything up there. I think that's another pitfall that maybe we don't dig quite as deeply into those other things as we.

Dr. Paul Nelson Williams (44:43)

Could. So this, this feels because something I didn't want to lose sight of because we touched on this very, very briefly. We mentioned sort of this unexplained weight loss as being a geriatric syndrome. But I' that we actually define that term or sort of what other things might actually fall into that category. So we're talking about these multifactorial things that kind of cluster together in older patients. Can you talk more about this entity as a geriatric syndrome and then sort of more broadly what that means and sort of other things that fall under that.

Dr. Eva Symanski (45:08)

Umbrella? Yeah, I mean, you already kind of hit on it that geriatric syndrome is a clinical condition that's common in older adults. That's multifactorial. Multifactorial etiologies can't be explained by just one organ system. And those things are overwhelming because there's many things that we have to think about. But the thing that's kind of nice is that they, I feel like they tend to track together and they can be evaluated with kind of the same frameworks, kind of as we were talking about at the beginning. So other examples include recurrent falls, urinary incontinence, cognitive impairment, delirium, those sorts of things. And I think everyone's probably seen patients that have multiple of those things going on, which can be really overwhelming. I think when you first see it all, you're like, oh my God, there's so much happening. But the multifactorial issues that contribute to the geriatric syndrome are usually common among the various syndromes. And so you can usually approach them all in a similar way. So for that patient who has both unintentional weight loss and recurrent falls and cognitive impairment and urinary incontinence, if I just do the 5ms. With them and go through it methodically, I'm almost certainly going to find things that are overlapping causes for all of those things, and then My plan, I just have to make the plan focused at those things that I turned up in the 5ms. And it's probably going to help with all of those geriatric syndromes together. So I don't know. For me, thinking about it as a geriatric syndrome and thinking about some of those other problems as geriatric syndromes and then kind of approaching it with the 5M's lens makes an overwhelming situation a little bit more.

Dr. Paul Nelson Williams (46:53)

Manageable. That's great. So we've gone through, we've done our 5Ms, we've given you some more data, and we do this incredibly thorough evaluation. Perhaps takes place over several office visits. The labs come back, they are not terribly exciting. The physical exam is not localizing, and we're leaning more towards maybe untreated depression as a possible contributing factor to this patient's weight loss. But based on the MOCA and just sort of history, we're also concerned about underlying cognitive impairment. So I guess the question is, well, now what? I guess it's nice to have names and something to blame, but in terms of the management of their medications that you would lead with or sort of, how do you wrap your hands around this and where do we start in terms of maybe even possibly managing.

Dr. Eva Symanski (47:32)

It? Yeah, that's always the kicker when you're looking at a multifactorial issue of multifactorial geriatric syndrome, and then you're identifying multiple causes and you're like, oh, my gosh, I have to do now address multiple causes, which is kind of the nature of it. And I feel like we tend to, like, easy fixes when they're available, like just giving someone a medication and waving our magic wand. But, yeah, this doesn't usually have, like, one easy fix. So I like to, you know, again, not good at lots of different mnemonics, just have the same framework throughout. Like, keep using the 5Ns framework, as I'm kind of thinking through my management and what to do. So if we are identifying the depression as maybe a key contributing factor here, I'm going to think about addressing that first, obviously, in, you know, kind of a holistic way. And this is where, you know, for this particular patient, I would start thinking about medications, but I want to be careful about the way that we talk about that, because the medication, the reason I'm picking the medication is because he has depression, not because he has the weight loss. So, for instance, for him, I would think about using mirtazapine because he has depression along with weight loss. And we can kind of take Advantage of the side effects of mirtazapine, which include a little bit of appetite stimulation and weight gain for some people. But mirtazapine has not been shown to be helpful for weight loss alone in the absence of, you know, the primary reason for prescribing it, the depression. So it's not something that I'm just going to use for every single person who has unintentional weight loss. I'm only going to use it if they have kind of a depression. And I want to take advantage of the side.

Dr. Paul Nelson Williams (49:15)

Effects. I, because this will always come up is I will be asked, well, what about an appetite stimulant? So you address this in part with amirtazepine. You wouldn't prescribe it just for appetite. I have not seen me get acetate out in the wild.

Dr. Matthew Frederick Frank Watto (49:27)

Recently. But Paul, all the appetite stimulants work great. They only put muscle, they only put muscle mass on people. I don't know why more people aren't just prescribing them to.

Dr. Paul Nelson Williams (49:38)

Everybody. There's no how dare you cut me off before I get medical.

Dr. Eva Symanski (49:40)

Marijuana. Yeah, it is actually a choosing wisely recommendation to avoid using prescription appetite stimulants for treatment of anorexia or cachexia in older adults. So that includes the discussion of mirtazapine that we had, not using it only for appetite stimulation and also applies to things like magestrel acetate and dronabinol and things like that that really don't have any evidence for, for improving this and come with a lot of potentially harmful side.

Dr. Matthew Frederick Frank Watto (50:13)

Effects. What about supplements? So not quite, not quite a medication, but you know, there's some popular drinks that are promote like meal replacements or high calorie. What do you think about.

Dr. Eva Symanski (50:28)

Those? So those definitely come up a lot, as you said. They are actually also part of that choosing wisely statement that they say avoid using high calorie supplements as well in addition to prescription appetite stimulants. That said, I feel like these I do use more often. They are shown to help older adults gain weight, but it's less clear if there's actually any kind of like mortality or quality of life benefit. The thing that I caution people with is I, I tell people it's always better to eat real food if you can. And the last thing that you want to do is have someone, you know, get all set up for lunch, chug a supplement right before lunch and then have no appetite for their lunch. So if you're going to use supplements, nutritional supplements, I would suggest, I usually suggest using them in between meals. Not as meal replacements. There's also lots of other things you can do to kind of add kind of your own supplementation to your food. A lot of these oral nutritional supplements that you mentioned are come at extra cost to people. And I don't want people to feel like they have to go out and buy, like, cases of these things to help with their weight loss. You can do things like adding extra oil, extra, like, cream, kind of using full fat milk, adding those sorts of things to your regular meals to help kind of, like, boost the calorie content of them. And this is also a situation, too, where, like, a people for a lot of their lives have been told, like, don't eat this, don't eat that. Like, not a lot of sugar, you know, not a lot of fat, all that stuff. This is kind of a situation where you say, let's liberalize all of that. Eat what you feel like. If you feel like eating the ice cream, eat the ice cream. If you feel like eating the cookies, eat the cookies. Obviously you want to be a little cautious, like, if someone has a history of, you know, being prone to significant hyperglycemia or something like that. But in general, you can really have people kind of liberalize and look for ways to add extra calories. Calories to their food without needing to use the oral nutritional.

Dr. Paul Nelson Williams (52:41)

Supplementation. I can't remember if I mentioned this on the show before or not. Matt knows this. I used to work in nursing home kitchens. I was a food service director. And one of the things that we had were they called them enhanced foods. I'm not sure. Hopefully it's not like a trade name or anything, but along those lines. And I can't remember most of the recipes, but the mashed potatoes, just mountains of butter and, like, evaporated milk into them. And, like, it was just. It was as many calories as you cram and sort of a. A low volume that was kind of easy to get down. So it's. I. I love that particular.

Dr. Eva Symanski (53:08)

Attempt. I was just gonna say there are other things you can kind of play around with with people's foods, too. Um, I know we were kind of mentioning earlier, you know, one, this patient was edentulous. Two, maybe it seems like he's just kind of, like, lost his taste a little bit. You can definitely play around with, like, the texture of foods. Maybe there are certain foods that are easier for him to chew or not. Maybe certain foods that just, like, have a better mouth feel to him or don't. You can also play around with taste. I think as You. Yeah, as you had brought up, sometimes people, if they had Covid and they lost their sense of smell and taste, maybe they just need kind of stronger flavorings to their meals. So you can add extra salt, you can add extra sugar, you can try other stuff to, you know, make things spicier and see if any of that kind of, like, piques people to have a little bit of a better appetite. You can also play around with different temperatures. Maybe someone prefers, you know, the food to be hotter or colder, and you just need to kind of find the happy medium. So there's lots of things you can play around with, with people's food to try to, you know, make them more.

Dr. Matthew Frederick Frank Watto (54:17)

Appealing. And this. A lot of this stuff is in. So the great Dr. Josh Wee, who former and probably future guest on the show, was talking about that he has a dot phrase for appetite. And some of these things are in there. So we'll find out if we can share that with the audience. But certainly we can list out some of these things that you're mentioning here as tips to help.

Dr. Eva Symanski (54:40)

People. Yeah, I think the other thing, too here is like, going again, going back to our M's and what we've uncovered and trying to target those as much as possible. So, for instance, if you've, like, maybe also turned up some functional impairments, I mean, this particular patient sounds like he has a partner who's helping him get food, even though he's less mobile. But not everyone has that. Maybe there are financial barriers to getting meals. So there's really opportunities to work with patients, families, social work teams to try to get referred to, you know, alternative ways to get meals and get those provided. The other thing is thinking about, actually, Paul, when you were talking about nursing home kitchens, that made me think about nursing home dining rooms and how you want to try to have a lot of people and kind of with this patient, one of the things we were talking about was social eating that he had kind of lost out of since he doesn't have his job anymore. And really trying to create kind of a social environment around people's mealtime, having other people eating with them. You know, that can sometimes help people improve their appetite as.

Dr. Matthew Frederick Frank Watto (55:53)

Well. So anything else with this guy with the. The cognitive impairment? Is that. Is that anything else you would go at? I mean, we talked about treating the depression. We talked about maybe ways to make the food more appealing or higher calorie to try to help, but anything else that you would target with this guy, as far as the five M's.

Dr. Eva Symanski (56:16)

Go? Yeah, I think in terms of the cognitive impairment. I'm glad you brought that up again. So kind of like we were talking about, kind of unclear if his cognitive impairment is more of a pseudo dementia picture being driven by the depression or if it's true cognitive impairment. He does have vascular risk factors. You know, there's potentially could have a vascular dementia or some other type of dementia. So this is something where we're going to need to try to treat the depression, reevaluate his cognition, and kind of see, you know, if there remain cognitive concerns. I will say from the story I am, I. It did make me worry that there is a true cognitive impairment because it sounded like the very first thing that happened was that he was having trouble with keeping up at work, with following the recipes, with kind of doing some of those cognitive tasks. And then once he lost his job, then the depression kind of kicked in. So for him, it does make me worry that there is kind of a true cognitive impairment underlying. And kind of like we talked about that with geriatric syndromes, thinking about our 5Ms. And talking through that with people can help us address multiple geriatric syndromes. Often our workup for each geriatric syndrome can also be workup for other ones. So the workup that we did for the unintentional weight loss geriatric syndrome with like the CBC, the CMP, TSH, B12, that's. That's pretty much like a reversible causes workup that I would do for his cognitive impairment as well. So you can kind of get multiple birds with one stone for your workups as well sometimes. So we'll have to kind of see how things play out for him and definitely continue to keep an eye on the cognitive impairment piece in general. If you have turned up cognitive impairment or dementia as what you think is part of the driver of the weight loss, there's lots of different things that you can do. Kind of like we were talking about, there's so many different ways that, you know, that can manifest for people. So there's similarly many different ways you can potentially address it. If I'm allowed to say this, the Alzheimer's association website actually has like a great, very patient friendly page and actually they have a lot of pages about kind of symptoms of dementia and daily care for patients with dementia. But they have a great page on food and eating and they have some really nice suggestions like limiting distractions during meal time, keeping the table setting and the plating very simple, using contrasting colors and not a lot of patterns. So it's very Clear. Like what's the plate and what's the food offering? Just one food item at a time to prevent confusion, maybe extending the meal time to give someone, you know, be able to work through it, even at a more slow pace. So there's lots of things you can do for that for various stages of.

Dr. Matthew Frederick Frank Watto (59:07)

Dementia. Oh, fantastic. Yeah, we can plug that. That's no problem. Anything else? I think we're kind of getting towards the. Towards the end here. I'm not sure. Paul, do you think anything we're missing.

Dr. Paul Nelson Williams (59:21)

Here? I guess I'm not sure there's a question here, but I like this case for a lot of reasons. But also to me, weight loss is. This is the presentation that I also like is that this is the patient's partner or spouse or sister or what have you. The main caretaker is the one who knows the weight loss and is more distressed than the patient is typically. And I'm just. I'm wondering if you have a script or anticipatory guidance or you just share with them like you did with us. There. There can be many things that will go after the things that we can. But, like, is there. Is there a way that you kind of frame the conversations for. For those folks? Because they. They are often the ones who notice it, are helping to mitigate it, and are the ones that are often those distressed about it.

Dr. Eva Symanski (59:58)

Too? Yeah, I'm really glad you brought that up, because I think it does often affect families and loved ones a lot. This problem, like eating and especially eating with others and eating with our families is like a very important thing to us as humans. And it can be really distressing when something is interrupting that when someone's not eating or when they're losing weight. So I think in terms of script, it's really, as we've been talking about this whole time, everything is so individualized and multifactorial. So I think just really talking through that, with people talking through all the different things that you're considering for their loved one, what you think might be driving it, what potential next steps are, and going at it, too, with the angle of what's most important to you, what's most important to the patient, what's most important to you as a family, and really just being with them along the way. Oftentimes this ends up being kind of like a prolonged sort of process as we're evaluating, following up to see what's happened, you know, continuing to trend, weights, et cetera, and things might stabilize or they might not. And those are going to look like very different conversations as well. So really just being with there for the families and talking everything, talking through everything with.

Dr. Paul Nelson Williams (61:21)

Them. One more thing and we can certainly cut this out if this is not the appropriate episode for this conversation. But. And I think we've talked about some prior episodes before, but tube feeding I think is always also in the back of minds, especially for patients with dementia and unexplained weight loss. That's something that the family member is always I think kind of thinking about when they're having this kind of conversation. So I, I guess that's another. I know how I approach it. But is there a way that you obviously individualized. But is there a broad way that you kind of frame those conversations.

Dr. Eva Symanski (61:46)

Too? Yeah, very individualized, very tough topic. Really depends on kind of the family and the person in general. I think kind of going back to that piece of eating and weight being like a very emotional thing for people and kind of being able to separate a little bit to like what's emotional and what's kind of factual and being able to address a family's emotions as well and not just kind of giving medical facts. And a big part of this too is uncertainty and facing loss and just lots of emotions that can come up. So I think really addressing those in addition to talking about kind of the medical pieces because I think as kind of what you're alluding to, you know, artificial enteral feeds for advanced stage dementia is not recommended, can cause lots of harms, pressure ulcers, infection, hospitalization, delirium, and does not improve mortality, doesn't decrease aspiration risk, you know, can forcing nutrition into people in that situation can make them feel worse sometimes. So it is worthwhile to go through some of those things with family for sure. But really sussing out like is this a situation where you want to be kind of sharing those facts or where you want to be more addressing the emotion I think is helpful. And then also not just like we're not offering a feeding tube, we're not doing anything, we're just going to throw our hands up. But being able to provide an alternative as well. Like you know, we're not going to offer a feeding tube because we're worried about these various things, but we are going to do careful one to one hand feeding. Lots of those other kind of non pharmacologic strategies that we mentioned, maybe like putting a little bit of ice in the mouth before we feed to kind of like stimulate the, you know, the appetite and the swallow reflux and things like that. So we want to offer other Alternatives and not just say, we're not doing this.

Dr. Paul Nelson Williams (63:54)

Thing. That's great. Thank you for indulging my catastrophizing. But we don't have to take it two feeds for this patient particularly. We can actually. Matt, I think. Do you want me.

Dr. Matthew Frederick Frank Watto (64:02)

To. Yeah, let's bring it home. What's our conclusion to this patient before we get to take home.

Dr. Paul Nelson Williams (64:07)

Points? So for Peter, we actually treated him with mirtazapine for his depression with the hopes that would also help with appetite as well. And we plan to repeat cognitive tests in three to six months and then sort of reevaluate and see if we're dealing with pseudodementia or not. So for his food insecurity, refer him to Meals on Wheels and saw if he could even maybe go back to the restaurant to visit and spend time there socially, as you mentioned, sort of just maybe at least stimulating that part that he had missed out on. Not necessarily getting him back to work, but being back in the social circumstances may be helpful as well. He starts walking more frequently. This helped with his mobility and overall he seems to have a good time being more social and starts to maintain his weight. And we send to the dentist for some dentures. So happy story to end. Things are maintained for right now, so we won't have the two green conversation. So with all of that, are there any particular take home points that you would like our listeners to walk away from this episode.

Dr. Eva Symanski (64:56)

With? I would love if people walked away with keeping the geriatric 5Ms. In mind. They are multi complexity mind mobility medications and then what matters most and using those to help kind of go beyond just the, you know, thinking about your cancer testing and your organic causes, but thinking about all these other things that can contribute to weight loss too. And kind of as, you know, final aside about that, I know there can be a lot of uncertainty with problems like this where we're sometimes not really quite sure exactly what's driving it. We're not able to find like one particular answer. We're like, maybe it's a little bit of this, a little bit of that. And there's, you know, I think all of us as humans and especially as often type A physicians don't love uncertainty. So just to acknowledge that like dealing with these geriatric syndromes and unintentional weight loss in particular, there is sometimes some uncertainty of what exactly is going on. And just being able to acknowledge that both for ourselves and then also as part of our conversations with family.

Dr. Matthew Frederick Frank Watto (66:03)

I feel like people appreciate, all right, anything that you'd like to plug before we let you.

Dr. Eva Symanski (66:10)

Go. Just since we've been Talking about the 5Ms, hopefully you've been able to see that there's merit to applying it for lots of different geriatric syndromes. And I just wanted to say there are a lot of different 5M based tools being created by lots of smart geriatricians that listeners can use in both their clinical lives. And I think it's also helpful like as an educational tool for for when we're trying to teach kind of complex topics to our trainees. So there's things like The JerryKit app, a 5ms. Pocket card, 5ms. Smart phrases. So there's lots of resources out there that you can use to kind of like simplify this and have kind of just in time tools. And I'm happy to share those resources with you so that they can be available for people.

Dr. Paul Nelson Williams (66:59)

Later. This has been another episode of the Curbsiders bringing you a little knowledge food for your brain.

Dr. Matthew Frederick Frank Watto (67:06)

Hole.

Dr. Paul Nelson Williams (67:07)

Yummy. I feel like your heart wasn't in that one, buddy. Still hungry for more? Join our Patreon and get all our episodes ad free plus twice monthly bonus episodes@patreon.com curbsiders. You can find our show notes at the curbsiders.com and sign up for our mailing list to get our weekly show notes in your inbox. This includes our Curbsiders Digest, which recaps the latest practice, changing articles, guidelines and news in internal.

Dr. Matthew Frederick Frank Watto (67:27)

Medicine. And we're committed to high value practice changing knowledge. And to do that we need your feedback. So please email us@askcurbsidersmail.com it also helps a lot when you subscribe, rate and review the show on YouTube, Spotify, Apple Podcasts give us five stars. Come on, you know you want to. A reminder that this and most episodes are available for CME for all health professionals through VCU health@curbsiders.vcuhealth.org A special thanks to our writer and producers for this episode, Dr. Leah Witt and the Penn Geriatrics Fellows, and to our whole Curbsiders team. Our technical production is done by Podpaste. Elizabeth Broder does our social media, Jen Watto runs our Patreon, Chris the Chu Manchu moderates our Discord. Stuart Brigham composed our theme music and with all that, until next time, I've been Dr. Matthew Frederick Frank Watto.

Dr. Paul Nelson Williams (68:19)

And as always I remain Dr. Paul Nelson Williams. Thank you and goodbye.