Anorexia and weight loss in older persons.

UNINTENTIONAL weight loss represents a cardinal symptom of frailty in older persons (1–6). Even a small decline in body mass in older persons is associated with mortality (7). Protein energy malnutrition is associated with anemia, pressure ulcers, sarcopenia, bone loss and hip fractures, declining immune function, impaired immune response to vaccinations, infections, cognitive impairment, functional decline, and poor quality of life (8–17). Weight loss is a sentinel event in long-term care facilities and associated with particularly poor outcomes (18,19). Despite this, aggressive nutritional management when weight loss is well established is often not associated with improved outcomes (20–24). For this reason, it is important that geriatricians increase their understanding of the pathophysiological processes that underlie weight loss in older persons (25) and increase their vigilance to detect early weight loss and institute-appropriate preventive and health promotion measures (26,27). In this issue of the Journals, Paquet et al. (28) demonstrate the importance of emotional state on food intake in older persons undergoing geriatric rehabilitation. Positive emotions at the time of eating increased food intake, while anxiety, depression, and anger had negative effects on food intake. While previously depression has been shown to have a major negative effect on food intake (29,30), this study extends these findings to demonstrate that much smaller fluctuations of mood at the time of the meal produce major effects on the amount of food ingestion. de Castro (31) found that, in older persons living in the community, social facilitation at mealtimes and palatability were major factors in the amount eaten. He suggested that increasing the number of people present at a meal could enhance food intake. This was found to be true in persons receiving Meals on Wheels by Suda et al. (32), who found that when the meal deliverer stayed while the meal was eaten, nutritional risk and dysphoria were decreased. When staff members spend more time feeding residents in the nursing home and utilize more verbal and physical prompts, food intake increased (33). Under these circumstances, it took an average of 38 minutes to feed a resident compared to 9 minutes under usual conditions. Because of the importance of food intake, it is critical that nursing staff are trained to be able to make accurate estimations of calorie intake in older persons (34). Enhancing the environment in which meals are eaten has been shown to improve food intake (32). Older persons eat more in the morning (31), and this circadian shift is even more marked when they develop cognitive impairment (35). Thus, it is recommended that older persons receive more food at breakfast (36). Increasing palatability of meals later in the day also improves food intake (37). For these reasons, the Clinical Guide to Prevent and Manage Malnutrition in Long-Term Care provides a number of hints to improve social facilitation of eating at mealtime (38). It has been suggested that weight loss is more likely to occur in older persons who are lifelong practitioners of dietary restraint, i.e., the intentional restriction of food intake to prevent weight gain (39,40). In some older persons, this has been associated with recurrence of anorexia nervosa toward the end of their life. In a normalweight older population, Bathalon et al. (41,42) found no major differences between persons who practiced dietary restraint and those who did not. They did, however, have lower hemoglobin levels. Lower hemoglobin levels have been associated with an increase in frailty (43). Some older persons, when made aware of the studies on caloric restriction and longevity in animals, excessively restrain their food intake and develop malnutrition (44–48). Similarly, malnutrition is seen in older persons attempting to lower their cholesterol to prevent heart disease. This condition is known as ‘‘cholesterol phobia’’ (49). In 1988, we suggested that there was a physiological anorexia of aging that universally affected all older persons (50). The existence of a decline in caloric intake over the life span is now well established by multiple epidemiological studies (51). We postulated that this age-related physiological anorexia placed older persons at particular risk for developing malnutrition when they developed a disease process. Roberts et al. (52) showed that older persons had a deregulation of feeding regulation such that they struggled