Q: My 88-year-old father lives in his own home about 100 miles from us. He’s been living alone since my mother died five years ago. I thought he looked rather thin last time we saw him. I’m starting to feel worried about his nutrition. Should I be concerned? Would you recommend he start drinking a supplement such as Boost or Ensure?
A: This question comes up a lot for families. It is indeed very common for older adults to experience unintentional weight loss at some point in late-life.
The brief answer is that yes, you should be concerned. But I wouldn’t recommend you jump to purchasing Boost or Ensure.
Now, in most cases, some nutritional supplementation is in order. But before focusing on this, you should first get help figuring out why your father is losing weight.
For doctors, unintended weight loss is a major red flag when it comes to the health of an older person.
So in geriatrics, we usually recommend that an older person — or their caregivers — monitor weight regularly. This enables us to spot weight loss sooner rather than later.
Once we’ve spotted unintentional weight loss, the next step is to figure out what might be causing it. And then we’re in a better position to recommend a treatment plan, which might well include a nutritional supplement.
In this post, I’ll go over each of these steps in more detail.
Why you should monitor for unintentional weight loss
Unintentional weight loss means losing weight without dieting or otherwise deliberately trying to slim down.
This often goes hand-in-hand with malnutrition in aging. Now, they aren’t quite the same thing: it’s possible to be malnourished without obviously losing weight. But they tend to go together.
Both problems are common in older adults. One study found that 39% of hospitalized older adults were malnourished.
It’s important to detect and evaluate weight loss and malnutrition for several key reasons:
- They are often caused by underlying health problems which need to be diagnosed and managed.
- They leave older adults weakened and more vulnerable to additional illnesses and injuries.
- They may be a sign that an older person is impaired, or otherwise needs more support with daily life.
Fortunately, there’s an easy way to screen for these problems: tracking an older person’s weight.
How to track weight and nutrition in an older person
This is a terrific quick-and-easy way to monitor overall health and nutrition in an older adult.
To track the weight of an older person who lives at home or in assisted-living, I usually recommend checking and recording the weight at least once a month.
(Note that nursing homes are usually required to weigh residents monthly; some assisted-living facilities may do so as well.)
You should keep records of the weight checks, preferably in a way that makes it easy to bring the information to the doctor’s office. Some families keep the information in a paper chart, but it’s potentially better to keep it in a shared computer file; see this article on keeping and organizing information for more details.
You can also consider one of the newer “connected” scales. These are devices that can wirelessly connect to a mobile device or even the home’s wifi. The weight record can then be accessed through an app or website.
Once you start tracking weight: at what point should you be concerned?
A general rule of thumb is that unintentionally losing 5% of one’s original body weight over 3-6 months is cause for concern. But it’s also reasonable to be worried if you notice a steady downward trend.
Once you’ve become concerned and documented a change in weight, you’ll want to bring it up with a doctor or other health professional.
Monitoring for unintended weight loss, as detailed above, is probably the easiest way to screen for nutrition problems.
Other red flags to take note of are:
- Loss of appetite.
- Decreased strength and/or ability to get around.
Note: The term “nutrition” can be used differently in different contexts. In geriatrics, the focus is often first on ensuring that an older person is getting enough calories and protein to maintain energy needs and muscle mass. Obviously, there is more to nutrition than just this; it’s also important that people meet their body’s needs for vitamins and minerals, and that they eat a “healthy diet.” Exact definitions of a “healthy diet” differ, but it’s generally one that promotes health and well-being, and doesn’t cause or aggravate health problems. A Mediterranean-style diet can work well for many people.
Common causes of weight loss and malnutrition
It’s important for an older person to get a clinical evaluation, once you’ve noticed weight loss or other signs of possible malnutrition. A simple initial assessment tool that many clinics will use is the Mini Nutritional Assessment.
(You can view and download a “Self-MNA” here.)
Many types of health problems can cause weight loss. According to this Canadian Medical Journal review article, common causes to consider are:
- Depression and other psychiatric conditions (9-42% of cases)
- Cancer (16-36%)
- Gastrointestinal disease (e.g. problems with the stomach or other parts of the digestive tract; 6-19%)
- Thyroid imbalances, diabetes, and other types of endocrine disorders (4-11%)
- Cardiovascular disease (2-9%)
- Alcoholism and other forms of nutritional disorders (4-8%)
- Chronic obstructive pulmonary disease (COPD) and other respiratory disorders (~6%)
- Neurologic disorders, including those that interfere with swallowing (2-7%)
- Medication side-effects (~2%)
- Unknown after extensive evaluation (10-36%)
Some additional issues that particularly come up in older adults include:
- Difficulty leaving the house to purchase food. This can be due to limited mobility (e.g. due to pain, fear of falling, etc), lack of transportation, or cognitive problems.
- Difficulty affording food. Some older adults live on a very limited income.
- Difficulty or pain with chewing and swallowing. Many seniors fall behind on dental care for various reasons. This can lead to painful mouth conditions, or a lack of suitable dentures.
- Constipation. This is quite common in older adults and can interfere with appetite and eating enough.
- Paranoia about food, due to dementia or a psychiatric condition. A fair number of older adults become suspicious of others during early dementia. Occasionally this leads them to not eat enough.
- Forgetting to eat or having difficulty organizing meal preparation. This is especially common for those with Alzheimer’s and other dementias, but can also be due to problems like depression or even mobility limitations.
- Unappetizing food. Sometimes the food is not to an older person’s taste, especially if it is a low-salt, low-fat, low-carb, low-sugar, or other medically “recommended” diet.
Generally, to sort through all these possibilities, doctors will need to interview the older patient and the family. For instance, they will want to know:
- How is the older person’s appetite? Do they like to eat or seem uninterested? How has this changed over the past year?
- Any pain or difficulty with chewing or swallowing?
- Any problems with nausea, vomiting, or feeling full easily? Any abdominal pain?
- Any problems with diarrhea or constipation?
- Who does the shopping for food? Who cooks the meal and organizes the time to eat? Does the older person do this alone or usually with someone else involved?
It’s also very helpful for the doctors to have as much information on what food — and how much food — the person is actually eating.
Last but not least, during the clinical evaluation, the doctor will physically examine the older person and then probably order some bloodwork as well.
How you can help doctors evaluate weight loss
The main way to help doctors is two-fold. One is to bring in a weight record, showing how the older person’s weight has changed over the past several months.
The other is to bring in information related to symptoms and ability to obtain food. You can do this by asking your older relative — and anyone else who is familiar with the person’s daily life — the interview questions listed above.
Of course, the doctor will still need to ask these questions, but it’s extremely helpful for patients and families to have thought through the questions ahead of time.
You can also download and complete the “Self-MNA” (self Mini-Nutritional Assessment) and bring it in to discuss with your health providers.
How to “treat” unintentional weight loss
The best treatment plans are based on a careful evaluation and correct diagnosis of what health problems — and social factors — are causing the weight loss.
Unfortunately, it’s common for many doctors to quickly turn to prescribing high-calorie supplements like Ensure, or even prescription appetite stimulants.
In fact, this is such a common problem that the American Geriatrics Society chose to address it in their Choosing Wisely recommendations:
Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia (loss of appetite) or cachexia (loss of muscle mass) in older adults.
Instead, optimize social supports, discontinue medications that may interfere with eating, provide appealing food and feeding assistance, and clarify patient goals and expectations.
(Learn more here: Choosing Wisely: 5 More Treatments For Older Adults You Should Question)
Now, even when social issues and medical problems are addressed, it’s often necessary to provide some extra nutritional support to those older adults who have been losing weight.
This usually means providing extra protein and extra calories. Fat is dense in calories, so this can be a good way to increase energy intake. Technically it’s better to provide “good fat” like olive oil, but in the short-term, I encourage people to consider whatever fatty foods the older person really likes to eat, which might mean ice-cream or peanut butter.
Research also suggests that many older adults may benefit from supplemental protein, especially if they’ve been showing signs of lean muscle loss. Many studies have used milk or whey protein.
So should you consider Ensure or Boost? You should discuss more with your father’s doctor, but my take is that such commercial supplements should be used only as a last resort. They are expensive, usually contain a lot of sugar, and contain various additives. So it’s better to make your own smoothies or otherwise provide nutrient-dense snacks and protein to your father, if at all possible.
Key take-home points on weight loss in older adults
I’ve provided a lot of information while answering your question, so let me summarize the most important take-aways.
- Tracking monthly weights is a good way to keep an eye on the health of an older adult. Put it on the calendar. A “connected” scale can make it easier to log and share the weight record.
- Unintended weight loss is a major red flag. Take action and consult a doctor if an older person loses 5% of more of their body weight, or if you’re otherwise concerned.
- Be sure to check for problems related to purchasing, preparing, and eating food. These are easily overlooked in older adults. They may be related to mobility difficulties, cognitive impairments, dental problems, depression, or unappetizing diets.
- Commercial supplements and/or appetite stimulants should be used only after careful consideration with the doctor, and after considering alternatives. They often feel like the “easiest” solution (assuming one can afford them) but they’re usually not the best way to maintain an older person’s nutrition and well-being.
If you want a more scholarly take on nutrition in aging, here are a few good articles:
- Assessment and management of nutrition in older people and its importance to health
- Protein Requirements and Recommendations for Older People: A Review
- Position of the Academy of Nutrition and Dietetics: Food and Nutrition for Older Adults: Promoting Health and Wellness
Have you been concerned about an older person’s weight loss? Post your questions and comments below.