❑ Gastrointestinal (53%) based on one study :
Oesophageal cancer, stomach cancer, colon cancer, and rectal cancer.
❑ Renal:
Renal cancer and renal pelvis cancer.
❑ Pulmonary:
Bronchial cancer and lung cancer
❑ Hepato-pancreatic:
HCC, pancreatic cancer, intra-hepatic bile duct cancer.
❑ Genitourinary:
Ovarian cancer, cervical cancer, endometrial cancer, prostate cancer, ureter cancer, bladder cancer
❑ Hematologic:
Hodgkin’s lymphoma and Non-Hodgkin’s lymphoma
❑ Breast cancer

❑ Malignant neoplasms

❑ Chronic diarrhea
❑ Tuberculosis (TB)
❑ HIV
❑ infective endocarditis

❑ Infective colitis and gastroenteritis.

❑ SLE
❑ Rheumatoid arthritis
❑ Polyarteritis nodosa
❑ Polymyalgia rheumatica

❑ Giant cell arteritis with polymyalgia rheumatica

❑ Depression
❑ Bipolar disorder
❑ Somatoform disorder
❑ Schizophrenia
❑ OCD
❑ Anxiety
❑ Dementia
❑ Social exclusion or rejection
❑ Neglect

❑ Disability

❑ Gastrointestinal (6 – 30%): Cholecystitis, Gastric and duodenal ulcers, IBD, celiac disease, malabsorption, steatorrhea, vascular disorders affecting intestines, non-infective gastroenteritis and colitis, swallowing pathologies, and dental issues.
❑ Renal (4%):
Pyelonephritis, nephritic syndrome, and nephrotic syndrome
❑ Cardiopulmonary (2-10%):
Heart failure, COPD, lung abscess (without pneumonia), interstitial lung disease (fibrotic or idiopathic), pleural effusion, and pyothorax (without fistula).
❑ Neurologic (2 – 7%):
Stroke, parkinson’s disease, and motor neuron disease.

❑ Endocrine (4 – 11%):
Type I diabetes, type 2 diabetes, hyperthyroidism, primary hyperparathyroidism, Addison’s disease, and subacute thyroiditis.

❑ Narcotic analgesics (such as opioids) interfere with cognition and ability to eat
❑ Sedatives also interfere with cognition
❑ Psychedelic drugs
❑ Cocaine
❑ Alcohol (4 – 8%)
❑ SSRIs
❑ Psychotropic drug dose reduction

❑ Other drugs that cause vomiting, anorexia, dysphagia, and dysgeusia

❑ Source of history:
Patient or well-informed caregiver (elderly may be unaware or deny weight loss).
❑ Patient age:
Helps determine age-specific causes, such as malignancy among the elderly.
❑ Duration of symptoms:
(weeks in acute/severe versus years in chronic conditions).
❑ Associated symptoms:
Assess if the patient is nauseated or vomiting/ anorexia/ dysphagia/ odynophagia/ social reasons hindering food supply.
❑ Systemic review:
Cardiovascular, respiratory, renal, hepatic, rheumatologic, and GI exam.

❑ GI: Indigestion, early satiety, altered stool pattern, abdominal pain may demonstrate GERD, peptic ulcer,cholecystitis, and GI malignancy

❑ Past medical history:
Helps assess the nutritional status. May suggest of immunodeficiency (recurrent infections), diagnosed malignancy, malabsorption (chronic diarrhea), HF, dyspepsia.
❑ Past surgical history:
Helps assess nutritional status.
❑ Medication history: Assess the use of medications known to cause weight loss. Polypharmacy may cause anorexia or altered taste.
❑ Family history:
Certain malignant disorders (breast cancer, ovarian cancer, colon cancer, or stomach cancer))
❑ Social history:
Tobacco, alcohol use, opioid, cocaine use
❑ Sexual history:
Suggestive of HIV AIDS

❑ Exposure:
Communicable infectious diseases/ travel to high-risk areas.

❑ Dietary history: Food availability, diet adequacy in the quantity (daily caloric intake), and quality (balance of nutrition), and nutritional supplements.
❑ Weight record: Weight measurement records or best estimate of weight loss accessed by clothing size.
❑ Mini Nutritional Assessment: To assess the nutritional risk among the elderly.
❑ Functional status: Assess the mental and functional status of the patient.

❑ Psychological status: Psychiatric illness screening: Geriatric Depression Scale may be utilized to assess for depression among elderly.

Is BMI<20.5?
Q1: Lost weight within last 3 months?
Q2: Reduced dietary intake in the last week?

Q3: Severe illness?

❑ Appearance of the patient:
Cachexia is observed among patients with malignancy. Surgical scar marks demonstrating previous surgery for intentional weight loss or malignancy treatment
❑ Vital signs

❑ Temperature: Low-grade/ high-grade fever with fatigue may demonstrate infection, autoimmune disorders, thyroid disease, malignancy, diabetes

❑ Heart rate: Tachycardia with regular pulse may demonstrate infection.

❑ Respiratory rate: Tachypnea (infection\ metastasis), dyspnea (heart failure, COPD, and lung infection

❑ Blood pressure: Chronic hypertension or hypotension is common among elders.

❑ Oxygen saturation: Low saturation may demonstrate respiratory system involvement or hematologic malignancies, such as multiple myeloma.

❑ BMI assessment or simply weight among immobile or bed-ridden patients.
❑ HEENT
❑ Cardiovascular examination
❑ Respiratory examination
❑ Gastrointestinal system exam includes oral examination, abdominal examination, and digital rectal exam.

❑ Organomegaly) may demonstrate metastases or primary lesions such as hepatosplenomegaly in IM, Hodgkin’s lymphoma. hepatomegaly is more common in non-Hodgkin’s lymphoma.

❑ Observing the patient having a meal may demonstrate

❑ Distractions by external stimuli may demonstrate dementia.

❑ Inadequate movements of the patient to feed him/herself may demonstrate neuromuscular disorders or functional limitations.

❑ Mini mental state examination to assess the cognitive function, and mood assessment.

❑ Multidisciplinary approach
❑ Anorexia nervosa medical therapy
❑ Counseling

❑ Nephrotic syndrome: 24-hour urine collection (urine protein >3.5 g/day).
❑ Nephritic syndrome: Assess complement levels, HBV, HCV, HIV serologies, c-ANCA and p-ANCA, and anti-dsDNA antibodies.
❑ COPD or interstitial lung disease: PFTs
❑ Pneumonia: Sputum microscopy, culture and sensitivity
❑ Stroke: CT or MRI head.
❑ Hyperparathyroidism: Serum calcium, phosphate levels to identify the type.

❑ Drug-induced

❑ Videofluoroscopy
❑ Dysphagia barium swallow
❑ Visual exam
❑ Dental issues: Refer to the dentist.

❑ Upper or lower GI endoscopy with biopsy
❑ Stool fat, anti-transglutaminase antibodies, elastase, lactoferrin
❑ Upper GI and small bowl series

❑ Geriatric Depression Scale
❑ Clinical depression diagnostic criteria is to be met to diagnose clinical depression

❑ MoCA

❑ CT (chest, abdomen, pelvis, head, etc)

❑PET scan
❑ Colonoscopy
❑ Mammogram

❑ Protein electrophoresis

❑ Serum ferritin
❑ Vitamins: Beta carotene, vitamin D, tocopherol, vitamin B12, and folic acid

❑ Minerals: Serum copper and zinc, manganese, and magnesium

❑ Chronic diarrhea: Stool osmotic gap, culture, ova and parasite, electrolytes, leukocytes, lactoferrin, and C. difficile test.
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❑ Tuberculosis: AFB and sputum culture sputum
❑ HIV:ELISA or Latex Agglutination Test for screening and viral RNA (P24) for confirmation
❑ Endocarditis: Modified Duke Criteria and at least two blood cultures

❑ Gastroenteritis and colitis: Stool exam as in chronic diarrhea.

❑ Nephrotic syndrome
❑ COPD
❑ Pneumonia
❑ Stroke treatment depends upon the cause
❑ Discontinuing or replacing the suspected drug
❑ Hyperthyroidism
❑ medical therapy|Hepatitis
❑ Chronic cholecystitis

❑ Hyperparathyroidism

❑ Food as puree or thickened liquids
❑ Speech therapy for oropharyngeal issues
❑ Dentist referral for dental issues
❑ Esophageal cancer treatment

❑ Peptic ulcer

❑ Celiac disease

❑ Whipple’s disease

❑ Referral to a specialist (psychotherapist and/or a psychiatrist)
❑ Psychotherapy
❑ Clinical depression medications

❑ Mirtazapine is also appetite stimulant

❑ Surgical resection
❑ Chemotherapy

❑ Radiotherapy
❑ TNM staging
❑ Appetite stimulants for wasting syndrome and cachexia : ❑ Oxandrolone or ornithine (not tested among elderly)

❑ Megestrol 320 mg/day (lower dosages for elderly)

❑ Decreased dietary restrictions
❑ Increase oral intake with frequent small servings
❑ Nutritional supplements with regular meals
❑ Community support services if required
❑ Multidisciplinary approach

❑ Chronic diarrhea treatment
❑ Tb treatment
❑ HIV treatment

❑ Dronabinol appetite stimulant.

❑ Infective endocarditis treatment

❑ Gastroenteritis treatment and colitis treatment

❑ Metoclopramide for nausea (side effects include parkinsonism)

❑ Cyproheptadine appetite stimulant