During my geri-psych rotation, a surprising common reason for referral was: not wanting to eat, please evaluate. Really? Geri-psych? Is that really a thing?
Sometimes, it is the chief complaint in the emergency department. And most of emergency physicians would probably pause and ask “What do I know about this?”, and answer, “nope, nothing”. I discovered a whole differential diagnosis for this complaint. Lets give you some tools!
In a systematic review (Favaro-Moreira 2016), they stated that the prevalence of malnutrition could reach 1-15% in non-institutionalized older adults to 35-65% in hospital. It is a very common situation with disastrous consequences: general functional decline, decreased bone mass, immune dysfunction, wound healing delay, and increased risk for getting a feeding tube (we will get to that in another post!).
But, is there a normal decreased calorie intake associated with age? Yes. There is a decreased appetite, absorption, metabolism, utilization and storage. Calorie intake for age 70+ is about 2000 for male and 1800 for female (+200 for 50-70 years of age). It is not significant enough to accuse old age for the “tea and toast” problem.
Let’s dig a little deeper to find possible causes.
Here is a summary of a few important diagnosis:
- Cognitive decline. End stage of dementia eventually leads to decrease eating; the last ADLs to be lost. Reasons are not well understood but a few hypotheses are oral dysphagia, pharyngeal dysphagia, swallowing difficulty and decreased appetite. Surprisingly, they can live a few months without eating because their body accommodate with this poor intake. This is usually the moment when we start thinking about feeding tube (I will get to that I promised!)
- Gastric disease. Ulcer and cancer can present with the only symptom of loss of appetite.
- Depression. This is one of the reasons why Geri-psych is involved. Is this person depressed? It is important to screen, but it is rarely the case.
- Constipation. Yes it can be the cause. Easy to diagnose, easy to treat (see constipation post).
- Poly-pharmacy. When you have to take 15 pills in the morning, it can fill a stomach pretty quickly, think about it! There are also some medications that have the adverse effect of causing decreased appetite.
- Basal oral dysphagia. A new stroke that affects swallowing could be a cause of an acute “not wanting to eat” problem.
- Dental dysfunction. A significant lost of weight or change in muscle mass associated with aging can lead to problem with dentures. Evaluate if they still fit.
- Change of taste. I saw a man with a cranial neuropathy that made food taste like garbage! You would not eat either!
- Institutionalization. A new nursing home with different food can also be a reason.
- Socio-economic. Not enough money or resources.
A careful history, a detailed oral, neuro and general physical exam should be enough to diagnose the cause and treat it. Sometimes, a gastroscopy is indicated and the findings can be quite surprising. Atypical presentation of gastric ulcer by the only symptoms of loss of appetite is possible! In the mean time, encouragement to eat and favourite food brought by family are valid strategies to ensure appropriate intake.
This take time. I know.
My point is that we will see more and more elderly patients with declines in various systems. And where do they go? They come to our EDs!
And I totally agree that we can not become geriatrician, but we can become “geriatrically aware”!