Use the Geriatric 5Ms to Manage Unintentional Weight Loss
This transcript has been edited for clarity.
Matthew F. Watto, MD: Welcome back to The Curbsiders . I'm Dr Matthew Frank Watto here with my great friend and America's primary care physician, Dr Paul Nelson Williams. Paul, I feel like you probably see unintentional weight loss in primary care all the time.
Paul N. Williams, MD: It does come up often and I was happy to learn about it. It can be very frustrating, so I was grateful to learn about a framework I could use to diagnose and manage unintentional weight loss.
Watto: For this topic, we partnered with Penn's Division of Geriatrics — one of their faculty, Dr Eva Szymanski, was our expert and a lot of their fellows helped to write this episode.
Paul, how do we define unintentional weight loss? What amount of weight loss is considered significant?
Williams: It's important to define your terms, especially as the topic of unintended weight loss is typically identified and/or brought up by a family member who's concerned. It might be a little bit tricky to quantify, but the actual definition of unintentional weight loss is weight loss of greater than 5% of a patient's body weight that occurs unintentionally within a 6-12-month period.
If a patient is trying to lose weight, we don't count it. If it has happened over the span of 5 years, it doesn't quite cut mustard. It has to occur in those 6-12 months, it has to be greater than 5% of body weight, and there cannot be an intentional reason as to why they're losing weight.
Watto: On the episode, Dr Szymanski made the point unintentional weight loss does not automatically mean "failure to thrive". Failure to thrive is a geriatric syndrome that involves multiple other symptoms — it's more than just weight loss. So, don't write failure to thrive in the chart just because someone's lost a little bit of weight.
Williams: I like that we got granular about it, because I think these terms are often used interchangeably. Failure to thrive is more of a syndromic picture, cachexia is wasting as a result of illness, and sarcopenia, specifically, is loss of muscle mass. It's good to be super specific when it comes to these conditions, because it does affect your interventions and your workup, to some extent.
Watto: We put this into the 5Ms framework. It's a mnemonic and a simple way to stay organized when you're working up these geriatric syndromes, which are multicomplex, multisystem problems. Given that unintentional weight loss is usually a geriatric syndrome, let's put in the 5Ms framework.
Williams: The 5Ms are:
Mentation: Are there mood issues? Is there cognitive impairment? Are they depressed?
Medications: Medications are our bread and butter, our favorite. We talked a lot about de-prescribing — we love it.
Mobility: How active are they? Can they get around? Can they perform their activities of daily living?
Matters: What matters? What do they value? What makes them happy?
Multimorbidity: What else is going on with this patient? What other illnesses could be contributing to unintentional weight loss?
Watto: When you go through the 5Ms with unintentional weight loss, Dr Szymanski mentioned that it can take a long time to go through all five topics in a single visit. If you only have 15 minutes to talk, going through all the medications, supplements, and substances the patient is taking may end up eating up your whole visit. Although you might not be able to hit every single M in one visit, you should try to cover all 5Ms over the course of your workup.
Williams: Luckily, most of the time this weight loss is happening relatively gradually. This is typically not something that happens between two visits, so you have time to work on this longitudinally.
Watto: I think a good place to start is often the screening questions. ls this person depressed and that's why they're not eating? Are they having memory issues and have trouble remembering how to fix meals or remembering if they've eaten or not?
The next step would be the medication list. Paul, are there any common medications that can cause trouble here?
Williams: Almost all of them — that's kind of the issue. We talked about some of the medications that are on the Beers List, and if you live long enough, eventually you accumulate medications and then you treat the side effects of those medications with other medications and then treat the side effects of the medications for your side effects… and so on and so forth.
It's not unusual to have lots of anticholinergic medications that cause dry mouth, nausea, or constipation. Some of the medications that we use to treat dementia, for example, are commonly associated with gastrointestinal symptoms. Antihypertensives medications classically cause all kinds of side effects that may make eating less appealing. So really take a good, hard look at your patient's medication list and see what absolutely has to be there, because you may be able to de-prescribe and that may help their appetite a great deal.
Watto: I recently had a geriatric patient who was losing weight, so we checked his medication list. He was taking metformin, even though his A1C was around 5.8. He was having a little bit of stomach upset and he was on iron supplements, even though I had not prescribed any iron supplements and I could not find a clinical indication for it. We stopped both the metformin and the iron supplementation. His A1C came up a little bit, but it wasn't concerning, and now he's eating better and his family is happy. Sometimes, it can be that easy.
In terms of laboratory work, you will probably want to do a limited, minimal evaluation. You might run a comprehensive metabolic panel or check for some chronic viral illnesses, like HIV or hepatitis. Checking B12 levels can clue you in to malabsorption issues or explain some cognitive impairment. Paul, what kind of imaging do you order in circumstances like this?
Williams: It's really, truly a case-by-case basis. Oftentimes, imaging has already been done for you. If your patient had a fall, they probably went through the donut of truth, and you can look at the trauma CT scan. Almost everyone has had a chest x-ray at some point!
Some research recommends doing abdominal ultrasound as part of the evaluation, but that recommendation probably occurred at a time when CT scans were not quite as readily available as they are now. Depending on how aggressive the patient and/or the family want to be and depending on what's already been done, I may do cross-sectional imaging — but certainly not every time. Oftentimes, that data is already available for you.
Watto: And finally, I think a lot of the time you're not going to find one specific thing that is causing the weight loss. The diagnostic workup functions mostly to make sure you're not missing anything glaringly obvious, but a lot of the time you won't find much. If you do find a cause, treat that.
If you don't find a clear cause for the unintentional weight loss, liberalizing the diet is a good way to go.
If the patient becomes a picky eater, keep their favorite highly palatable foods on hand. Give them more time to eat and make sure the eating environment remains pretty simple. If a patient has dementia, they can get confused if the place settings are too complicated.
Williams: I really appreciated the emphasis on making eating a social experience, too. I've seen it work in the past and it really can make a difference.
Watto: I have had a couple patients, Paul, where they had lost their sense of taste or sense of smell, and we realized that was the main contributing factor to unintentional weight loss. That can be another factor to look out for.
This is a common condition. You're definitely going to see it in your practice, so if you stay organized, use the 5Ms, and follow some of the steps we talked about, you should be able to work towards correcting the problem and stopping the weight loss.
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