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
Tracking Weight:
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.
Tracking Nutrition:
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
- Nutrition in the very old
- Nutrition and the gut microbiome in the elderly
- Protein Requirements and Recommendations for Older People: A Review
- Perspective: Protein Requirements and Optimal Intakes in Aging: Are We Ready to Recommend More Than the Recommended Daily Allowance?
- 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.
[This article was reviewed & updated in October 2022.]
Donelda Kahgee says
My mom is 95 living in a nursing home she has dementia and I was told today that she has lost 13 pounds in the last month … they putting her on a supplement to hopefully hold her weight from going any lower … is this part of the dementia ?
Leslie Kernisan, MD MPH says
Sorry to hear of your mother’s weight loss. Well it might be due to her dementia but it could also be due to something else, so they should be checking for the common causes listed in the article.
Re dementia and weight loss: some people with dementia do lose weight because they forget to eat or otherwise have trouble organizing themselves to get food, prepare it, etc. This usually happens to people with mild or moderate dementia who are still living at home; it should not be happening in a facility.
Otherwise, quite advanced dementia (when people are totally bedbound) can indeed be associated with weight loss. This can happen if the person starts to have difficulty swallowing, or if the body otherwise starts to shut down due to quite advanced dementia.
I have more on the stages of dementia here: How to Understand the Stages of Alzheimer’s & Related Dementias.
You may want to ask your mother’s doctors to talk about how she’s doing otherwise, and how they expect her dementia and other health issues to progress over the next few months. Good luck!
Tammy says
Hi Leslie, My 76 year old father is down to 81 pounds now, and my brothers and I are very very concerned. He had a throat issue which they were finally able to fix through surgery. He wasn’t able to swallow due to a flap of skin in his throat. Now he should be able to eat and swallow, but his stomach bothers him when he tries to eat. He continues to lose weight. His doctor authorized a feeding tube, which will
Hopefully help him gain weight, but we are still concerned and wonder if there is anything else we can try. Any advice you can offer would be much appreciated!!
Leslie Kernisan, MD MPH says
Sorry to hear of your father’s weight loss. My main advice would be for you to keep asking lots of detailed questions and keep carefully following how well the doctors’ suggestions are working. You may want to ask his doctors to explain to you why his stomach is bothering him when he eats. Also, you could try to clarify whether it’s his actual stomach that is bothering him, versus some other aspect of his digestive system. And has he been checked for other common causes of weight loss (what have they done to check, what did they find)?
Lastly, you could ask the doctor whether it’s possible to get a consultation with a dietician. Good luck!
Maureen says
Hi
My mother has dementia and lately she will eat very little food.
She spits it out in her napkin ,she gags on it and almost vomits.It as if she is eating
Rancid food. Anything that was sure bet is no longer.. She does not even like her sweets .
Just me making sure she drinks some ensure plus, yougurt with effort, pudding ,tapioca, Homemade soups she rejects. Once in a blue moon she will eat shrimp cocktail.
She has gone from 133 to 117. At this rate I see her going much lower.
Food tastes horrid to her. Why is that? And is there any way to restore her tastebuds?
No new medication has been added.
Leslie Kernisan, MD MPH says
Hm, I can’t say just what is going on with her, but developing eating issues certainly is common in people with dementia and can happen for a variety of reasons. Are you quite sure that it’s the taste of the food that she’s rejecting, or could there be something else? Sometimes people are reacting to pain or discomfort in the mouth or otherwise related to eating. People with dementia can also start to forget how to eat, or have difficulty coordinating the mouth and swallowing movements due to the ongoing degeneration of their brain cells.
I would recommend talking to her doctor and getting her evaluated. Be sure they take a look in her mouth. You could also consider asking about a swallowing evaluation; these are done by speech therapists who have experience identifying difficulties people have with eating and swallowing.
You also don’t say how far along she is in her dementia, but if it’s quite advanced, then it’s important to consider her comfort and whether it’s worth pushing for her to eat more than she feels like. I have more on planning for decline in dementia here:
How to Plan for Decline in Alzheimer’s Dementia:A 5-Step Approach to Navigating Difficult Decisions & Crises with Less Stress
Older adults do experience changes in their sense of smell and taste as they get older, and this might be worsened by dementia. If it’s not due to medication or to another health problem that can be identified and treated, I’m not sure it’s likely to be reversible.
There is more on the physiologic causes of anorexia in aging in this scholarly article:
Mechanisms of the anorexia of aging-a review
Good luck!
Kathleen says
My mother is 77-years old. She had an angioplasty in December and had two stents put in. She is also diabetic. She takes Metformin for blood sugar and ticagrelor for anti-coagulation, along with other medications. Almost immediately, she began having stomach cramps and diarrhea. Since December, however, she has lost her appetite, can eat only a little, ended up with a hemoglobin of 80 that resulted in a blood transfusion and – perhaps most alarming – has lost between 20 and 25 pounds. She still gets occasional lower abdomen cramps and her bowel situation alternates between constipation / normal / diarrhea. Her blood tests are “normal” – except for the anemia – and her fecal occult blood test also showed no blood in the stool. Doctors are quick to place the blame for her anemia and loss of appetite on her ticagrelor, saying that causes angiodysplasia, resulting in microscopic bleeding. They say her 25 – pound weight loss could be ascribed to her medication-induced loss of appetite and, consequently, the fact she’s not eating much. My concern is, doesn’t 20 – 25 pounds of weight loss over 5-6 months seem excessive to just be attributed to loss of appetite / subsequent eating less? Is it just coincidence that her symptoms started immediately post angioplasty? Is a malignancy in the stomach, for example, a more likely reason for such significant weight loss? My Mom weighed around 172 pounds in December and is now down around 149 pounds…Needless to say, I’m quite worried.
Leslie Kernisan, MD MPH says
It does sound like a significant weight loss, so I think it’s reasonable to keep asking the doctors lots of questions.
Regarding her anemia, you could ask them to explain whether she shows signs of iron deficiency on her testing, I explain that more here: Anemia in the Older Adult: 10 Common Causes & What to Ask.
If you are very concerned about malignancy, I would ask them to discuss the possibility of further evaluation to look into that. What tests to do and whether they are appropriate will really depend on your mother’s particular health circumstances and past medical history, but also on what her preferences are as a patient.
You may also want to consult a gastroenterologist, if you haven’t already done so, to make sure it’s not some type of digestive issue that the usual doctors haven’t considered. Good luck!
Asim says
Hi dr. Leslie
I have been having a very slow process of weight loss of about 10 kg in last 5 years .I am middl aged 45 male suffering from anxiety disorders since age of 30 . However this weight loss in the recent 4 years is new . Doesn’t seem to stop. Have seen many doctors but none of them have been able to help. There is no significant finding in the tests.
Not sure what kind of doctor to see and which test to perform further .
Now at o 47 kg at 169cm .any advise will be Helpfull.
Leslie Kernisan, MD MPH says
Sorry to hear of your weight loss. Unfortunately, the only advice I can give is to keep asking the doctors questions. You may want to ask them what they have done specifically to check for the common causes I list in the articles. You may also want to try seeing a different type of doctor or a specialist. There are some people who have digestive issues that prevent them from absorbing their food as well as they could. Good luck!
Eva says
Amazing website. Thank you, Dr. Kernisan!
My mother (74) is unable to eat due to a dental infection. Her dentist has put her on antibiotics, but he won’t be able to work on the affected tooth until the infection and swelling are under control. It may be up to 10 days before she is back to normal, best case scenario. She’s gone without eating for five days so far, and feels tired and weak, spending her days mostly in bed.
Other than making sure she’s getting plenty of water, juice, broth, etc., should I be concerned about her going this long without being able to eat? Or is a 10-day fast considered safe? Thank you again.
Leslie Kernisan, MD MPH says
Sorry to hear about your mother’s dental infection.
I don’t know that 10 day fasts have been studied in women your mother’s age, and presumably the “safety” would depend in part on a person’s underlying health state.
If she can’t chew food, I would recommend talking to her doctor or dentist about other ways for her to get adequate nutrition during this time. Couldn’t she drink bean soups or hearty shakes with fat and protein?
It is definitely not ideal for a person her age to remain mostly in bed, because at this age the muscles get deconditioned very quickly when older adults are in bed due to illness. So I would encourage you to ask her doctors about ways to maintain her energy and nutrition while she’s unable to chew. Good luck and thank you for visiting the site, I’m glad you like it.
Javeria says
Hello. My father is 65 years old and he is loosing weight constantly. In last 1.5 years he has lost around 20 kgs. He was 92 and is now 70 kgs. The weight loss is drastic. Being concerned he got various medical check ups and got to know about diabetes and some stomach problem. Can the weight loss be because of that ? And is it something we should worry about? If yes then what can be done to improve his health? Your reply will be highly acknowledged
Regards
Javeria
Leslie Kernisan, MD MPH says
Sorry to hear of your father’s weight loss. I really can’t say whether diabetes or stomach problems are the likely cause, it depends on a lot of things. I would recommend you ask his doctors whether they think this explains all the weight loss you’ve noticed. You can also ask if/how they checked for the other common causes that I listed in the article. good luck!
Patricia L says
My husband and I have an increasing concern regarding his 90 year old mother’s nutritional intake (she presently looks like a war refugee). For over 5 months now, she’s been at a Christian Science care facility. In our view, the facility’s approach to kitchen-management is resulting in a form of anorexia.
The mom has long been a “picky eater”, always outspoken about not being able to tolerate any food that’s even slightly spicy. Unfortunately, at this facility, the “head cook” is Latina, and by the mom’s account, ALL the prepared dishes are seasoned with hot spices. (She also says the desserts are all “disgustingly sweet”.) The cook also seems to have a large repertoire of “unfamiliar” dishes; due to the apparent onset of dementia, the mom won’t even taste anything she can’t identify. According to her detailed descriptions of recent meals, she often eats nothing, or only one item, from any lunch or dinner. (Example: “So I thought, ‘at least I can eat the roll’ – and then the roll was disgusting.”) Yet, it appears to us, that nobody at the facility is noticing or caring that her plates are going back virtually untouched.
We have asked her why she isn’t making a general complaint, or even demanding a separate, unspiced, simple meal be made for her, that she CAN find palatable, so that she can eat a normal amount. She only gives us vague answers, that “people have tried asking”. We are wondering if the overall decrease in nutrition, combined with this scant energy supply being largely diverted to healing 2 broken bones over the past months, is actually diverting energy from the brain, and and accelerating her dementia, which seems to be worsening week by week.
Now, this menu/nutrition/anorexia situation seems to me, to be a serious red flag for whether the place is providing a truly acceptable level of “care”. And I’m wondering if any facility which takes money from Medicare, and which therefore must have to meet certain standards, is entitled to an overriding religion-based “right” to turn a blind eye to some residents’ wellbeing. (Particularly those who are not fully competent to assert or articulate their needs.) It seems to us, that the mom, at least, is slowly starving herself to death (due to a resistance to the food being offered her). How much “freedom of religion” should be allowed, in this kind of situation? Should it extend to a “right” to employ someone who cannot or will not agree to modify the menu to suit the residents’ needs? Should it extend to a “that’s what we’re serving, take it or leave it”, Oliver-Twist-like institutional insensitivity?
I’d like to find out if there is an “official” way to get government authorities involved, to at least compel the place to address the situation, by (a) assigning someone to record my mother-in-law’s evident food consumption, meal by meal – and her weight on a weekly basis – and make that record available to us, and (b) ordering the cook – who seems to be wilfully ignorant of geriatric residents’ basic nutritional needs – to make a reasonable effort to prepare food that the elderly can all eat and enjoy. Must we go through a long process of formally complaining and demanding corrections to the system (by phone, writing, etc.), or should I try to just “blow the whistle”?
Leslie Kernisan, MD MPH says
Your mother in law’s situation does sound concerning. Especially if you are worried about her mental function, you will likely need to step in and help get the situation resolved…it may not be realistic to expect her to make complaints or otherwise negotiate with the care facility.
I am not sure just how the rules may be different for Christian Science facilities, but in general, nursing homes are required to weigh residents monthly and to make various accommodations to ensure that residents get adequate care.
California Advocates for Nursing Home Reform has a good page summarizing standards of care here: Nursing Home Care Standards. This page also provides resources on how to lodge a complaint.
Generally, every state should have a long-term care ombudsman; the office is required to investigate complaints. Many states also have local advocacy groups. You can find your local LTC ombudsman and LTC advocacy groups here: How to Find a Long-Term Care Ombudsman Program.
It is usually advisable to try to first resolve the issue with the facility…if your parent is going to be staying there, it’s good to try to keep relations as positive as possible, and facility staff may understandably feel frustrated if families report them to the state without first giving them a chance to address a concern. You can start by asking to talk to the head of nursing or of operations; also a good idea to send a letter or email, so that your concerns are in writing.
I have to say that it sounds unusual for a nursing facility to be serving highly spiced food; at such a facility, I would expect the menu and food to be determined by some kind of dietary professional, it should not be up to the whim of the cook. Have you actually sampled the food being served to your mother? It may be a good idea to discreetly do your own research; if her mental state isn’t quite right, she may not be accurately reporting what is happening.
That’s not to say that the facility doesn’t have room to improve or perhaps isn’t living up to required standards. They may well need a reminder and a little persistence in order for your mother to get better care. Good luck!
Julie says
Hi Leslie, this is such great info. Just wondered if you would mind me posting on a local Facebook group I have set up
Bayside community Aged Care and Disability group. Or you are welcome to join. Only 50 members do far but hoping to grow as only just set up.
Leslie Kernisan, MD MPH says
So glad you find this useful. Yes, feel free to share links to the articles on Facebook or elsewhere, I’m always delighted if people want to pass on the link to someone who might benefit.
Good luck growing your group! I appreciate the invitation but don’t generally spend much time on FB as my time is so limited.
Sue says
Leslie,
Yes, there are many items to investigate with elder weight loss. I smiled as I read your list and wondered why you had left out poor dentition.
Medicare does not pay dental bills and dentistry is expensive plus may not be accessible near the patient. If the person can’t chew properly or has gum or other related oral disease, then not doing so causes less pain and subsequently weight loss.
Leslie Kernisan, MD MPH says
Actually, in the article, I list “Difficulty or pain with chewing and swallowing” as an important issue to consider when it comes to weight loss in older adults, and I mention that inadequate dental care is common.
I agree that it’s unfortunate that Medicare does not help older adults with dental care, as it’s certainly important to overall health and wellbeing.