The Curbsiders Internal Medicine Podcast

Episode #467: Unintentional Weight Loss with Dr. Eva Szymanski

Date: January 20, 2025
Guest: Dr. Eva Szymanski, Geriatrician, University of Pennsylvania

Overview

This episode explores the evaluation and management of unintentional weight loss in older adults, a common and complex clinical problem. Dr. Eva Szymanski guides listeners through practical frameworks, especially the geriatric 5Ms, to approach this multifactorial syndrome. The episode is instructional for primary care, internal medicine, hospital medicine, and those curious about high-yield geriatrics.

Key Discussion Points & Insights

1. Defining Unintentional Weight Loss

• Clinical Definition:

  • Unintentional weight loss is defined as loss of at least 5% of usual body weight over 6–12 months, without intentional dieting or lifestyle changes.
    • (09:11) Dr. Eva Szymanski:

      “Technically, unintentional weight loss means losing at least 5% of someone’s usual body weight over a 6 to 12 month period, obviously, unintentionally, without meaning to… in normal aging you might only lose 0.2 to 0.4 pounds per year.”

• Important Clarification:

  • Normal aging results in minimal weight loss, so significant (>5%) reductions should never be dismissed as “just getting older.”

2. Differentiating Related Terms

• Sarcopenia: Loss of muscle mass and strength, can be part of aging but is not inevitable.
• Cachexia: Loss of muscle (more than fat) due to chronic inflammatory or systemic illness, e.g., cancer, end-stage COPD.
• Failure to Thrive: A global decline—weight loss, impaired function, cognition, mood.
  • (10:19) Dr. Szymanski:

    “Failure to thrive is more of like a global syndrome of decline where the older adult has physical frailty… may include unintentional weight loss… but also significant impairment in day-to-day function or neuropsych function... sometimes the label can then make us kind of stop thinking.”

3. Framework: The Geriatric 5Ms

A universal approach to multifactorial geriatric syndromes:

1. Multi-complexity: Multiple chronic illnesses and symptoms (including “organic” causes)
2. Mind: Cognitive function, mood, depression, neuropsych symptoms
3. Mobility: Physical function, ability to shop, cook, eat
4. Medications: Comprehensive review (prescriptions and OTC), adverse effects
5. Matters Most: Patient’s priorities, social support, access to resources, social isolation, financial barriers

• (12:07) Dr. Szymanski:

  “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… once you get facile with going through those, you can really apply them to lots of different geriatric syndromes.”

Applying the 5Ms to a Case Example:

Patient: 70-year-old with 16% weight loss, poor appetite, bedbound, flat affect, edentulous
Workup & Considerations:

• Multi-complexity: Check for GI malignancy, anemia
• Mind: Depression (GDS 13/15), Cognitive Impairment (MOCA 18/30)
• Mobility: Decreased activity, slow gait, increased ADL assistance
• Medications: Review for taste/smell side effects, suppressants of appetite
• Matters Most: Loss of work, social eating, meaning

• (28:20) Dr. Szymanski:

  “He’s had a huge shift in losing something that brought a lot of meaning to him… and that also might be a big contributor here.”

4. Stepwise Evaluation & Laboratory Work-up

• Basic labs (for most patients):

  • CBC (anemia, white cell count)
  • CMP (kidney, liver function)
  • TSH (thyroid)
  • Vitamin B12

• Contextual labs:

  • A1C (undiagnosed diabetes), HIV/HCV serologies as indicated, others as suggested by history
  • (32:13) Dr. Szymanski:

    “Labs is my first go to for everyone… and then maybe a couple of others based on the situation.”

• Review of Imaging:

  • “Audit” prior imaging before ordering new studies—many older adults already have recent films (falls, ER visits, etc.).
  • Chest X-ray may be considered, CT imaging for more thorough evaluation if indicated by failure of initial work-up.
  • Abdominal ultrasound is rarely helpful unless specific findings suggest its need.
  • (34:43) Dr. Szymanski:

    "If I’m going to go for the imaging test, I will just do cross-sectional imaging.”

5. Cancer Screening in this Context

• Screening vs. Diagnosis:
  • Active weight loss = diagnostic work-up, not screening.
  • Modest negative work-up (labs + chest X-ray + fecal occult blood) greatly lowers likelihood of cancer.
• Individualized conversations based on function, goals, prior screening, and the willingness to pursue interventions.
  • (37:09) Dr. Szymanski:

    “If you’re considering this for weight loss and you think that the cancer is causing the weight loss… it’s no longer a screening test… You really want to be thinking: what are the person's symptoms or other data that you've gotten that's making you concerned?"

6. Management: Practical Approaches

Multifactorial problems require multifactorial interventions:

• Treat contributors:

  • If depression is primary, address depression (potentially with mirtazapine when weight loss and appetite are issues).

    “The reason I'm picking the medication is because he has depression, not because he has the weight loss… Mirtazapine has not been shown to be helpful for weight loss alone.” (47:32)

• Appetite stimulants:

  • Avoid megestrol acetate, dronabinol, mirtazapine solely for appetite/(Choosing Wisely).

    "It's actually a Choosing Wisely recommendation to avoid using prescription appetite stimulants for treatment of anorexia or cachexia in older adults." (49:40)

• Nutrition/Oral supplements:

  • Use between meals, not as meal replacements; better to add calories to real food (extra oil, butter, cream, full-fat milk, etc.).

    “...it's always better to eat real food if you can… use supplements in between meals, not as meal replacements.” (50:28)

• Food Tips:

  • Enhance flavor, adjust texture/temperature, address dental/edentulous status, liberalize diets.
  • Encourage social/mealtime routines, utilize assistance programs (e.g., Meals on Wheels).
  • Resources: Alzheimer's Association has practical tips for feeding in dementia ([57:00]).

7. Role of Tube Feeding & End-of-Life Care

• Not recommended in advanced dementia (no mortality/aspiration benefit, potential harm, emotional/cultural considerations).
  • Provide alternatives: “careful one to one hand feeding”, appealing foods, mouth stimulation.
  • (61:46) Dr. Szymanski:

    “Artificial enteral feeds for advanced stage dementia is not recommended… can make people feel worse sometimes. So it is worthwhile to go through some of those things with families for sure, but really sussing out… is this a situation where you want to be kind of sharing those facts or where you want to be more addressing the emotion?”

Notable Quotes & Memorable Moments

• On frameworks:

  “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 5Ms lens makes an overwhelming situation a little bit more manageable.”
  – Dr. Szymanski, (45:08)

• On uncertainty:

  “There can be a lot of uncertainty with problems like this… we're not able to find one particular answer… just to acknowledge that—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. Szymanski, (64:56)

• On addressing patient and family distress:

  “Eating, and especially eating with others and eating with our families is a very important thing to us as humans. It can be really distressing when something is interrupting that… 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."
  – Dr. Szymanski, (59:58)

Important Timestamps

• Defining unintentional weight loss: 09:11
• Differentiating cachexia/failure to thrive/sarcopenia: 10:19
• 5Ms introduction and explanation: 12:07
• Medications as a contributor: 18:00–24:30
• Applying 5Ms to patient case: 28:20 & onwards
• Lab and imaging work-up: 32:13, 34:43
• Cancer screening debate: 37:09
• Geriatric syndromes framework: 45:08
• Management: Depression, supplements, food tips: 47:32–54:40
• Tube feeding, end-of-life considerations: 61:46

Resources & Tools

• 5Ms Tools: JerryKit app, 5Ms pocket card, smartphrases (contact Dr. Szymanski for resources)
• Patient/family education: Alzheimer's Association (food, eating & dementia care tips)
• Articles & Algorithms:
  • Gaddy AAFP article (2021 update) – recommended for checklists/flowcharts

Take-home Points

1. Think Broadly & Use Frameworks:
   Always consider the full context – medical, cognitive, functional, social, and personal – when evaluating unintentional weight loss in older adults.

2. Apply the Geriatric 5Ms:
   Multi-complexity, Mind, Mobility, Medications, and Matters Most guide your diagnostic and management process.

3. Be Cautious with Medications & Supplements:
   Avoid appetite stimulants (except in carefully selected cases), focus on real food, and be alert for medication side effects.

4. Individualize Cancer Workup:
   Screening is not the same as workup for symptomatic weight loss; go beyond age—consider goals, function, and history.

5. Expect Multifactorial Causes and Need for Sequential Visits:
   You don't have to do all of this in one appointment—deliberate, staged, and collaborative care achieves better outcomes.

6. Acknowledge and Communicate Uncertainty:
   Often there won’t be a single clear cause or easy solution—communicate openly with patients and families, offer support, and revisit goals regularly.

Recommended For...

Clinicians in primary care, geriatrics, hospital medicine, and anyone seeking a pragmatic, patient-centered approach to complex presentations in older adults!

For more, check out the JerryKit app, the AAFP Gaddy article, and resources noted above. Special thanks to the Penn Geriatrics fellows and Leah Witt, MD!