Your progress

Saved on this device.

Target exams

Red flags

• Weight loss greater than 5 per cent of body weight within 6 months is clinically significant and mandates investigation — the Wallace 1995 study of 4714 community-dwelling older adults showed that an involuntary loss above 4 per cent in one year doubled the mortality risk; malignancy is found in 16 to 36 per cent of cases presenting this way.
• Weight loss with PRESERVED or INCREASED appetite points to the hypermetabolic or malabsorptive causes — hyperthyroidism, uncontrolled type 1 diabetes, coeliac disease, chronic pancreatitis, SIBO, HIV, or chronic infection — and the failure to ask about appetite in the first minute is a documented cause of the missed diagnosis.
• Weight loss with fatigue, postural dizziness, and hyperpigmentation of the palmar creases, buccal mucosa, and recent scars is Addison disease until proven otherwise — the undiagnosed Addisonian crisis is fatal; check the 9 am cortisol, the ACTH, and the synacthen stimulation test before any procedure or surgery.
• Weight loss with dysphagia, early satiety, a change in bowel habit, visible blood in the stool, iron deficiency anaemia, or night sweats carries a high probability of malignancy — the upper GI endoscopy, the colonoscopy, and the CT chest abdomen and pelvis are indicated without delay.
• The severely malnourished patient (BMI below 16, unintentional weight loss greater than 15 per cent in 3 to 6 months, minimal intake for more than 10 days) who is rapidly refed develops the refeeding syndrome — the hypophosphataemia, the hypokalaemia, the fluid overload, and the fatal arrhythmia; give the thiamine, start the feeding at 5 to 10 kcal per kg per day, and monitor the electrolytes daily.
• The unexplained weight loss in the older adult is a recognised marker of the elder abuse — the neglect, the financial abuse with the food insecurity, and the psychological abuse; the safeguarding screen and the mandatory reporting (in the Australian and the UK context) are the duty of the clinician.
• Depression is the commonest non-organic cause of the weight loss and is frequently missed because the somatic symptoms are attributed to the medical disease — screen every patient with the PHQ-2 or a direct question about the mood; the untreated depression is a reversible cause of the weight loss.
• Cancer cachexia is NOT starvation and does NOT reverse with the feeding alone — the forced feeding in the refractory cachexia causes the distress without the benefit; the management is the treatment of the cancer, the symptom control, and the palliative approach.