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.]
Blanca Garcia says
Mom is 92 yrs old. She sleeps a lot and she doesn’t eat very much but she had to have sweets everyday and sometimes she has stomach problem first she has acid reflux and also when she eats she has to go to the bathroom or sometimee she is constipation. She has lost weight
Nicole Didyk, MD says
It sounds like there are some symptoms related to the GI tract: variation in bowel habit and reflux symptoms. When I see an older person with complaints about digestion and weight loss, I usually turn to one of my colleagues in gastroenterology to make sure there isn’t an issue that they need to look into. Of course, a thorough evaluation by a primary care provider is the first step.
Here’s an article about constipation that might be helpful too.
Charles R. McConnell says
My wife. Lillian 87 has been losing weight and muscle mass very fast. She is down to 93 lbs. The doctors have given her many, many, many blood tests – all negative. She had a stool test – negative. She had a cat scan of the brain – negative. She had a frontal body scan – negative. If you have any ideas, please help. Thank you Leslie Kernisan, MD, MPH
Nicole Didyk, MD says
I can understand being worried about weight loss, and it sounds as though most of the workup has been very reassuring, although I’m not sure what a “frontal body scan” is. I can’t give medical advice over the internet, but in a situation where there’s a concern about weight loss, it is important to look carefully at dietary intake as well. Sometimes a nutritionist or registered dietician can be helpful if serious causes of weight loss are ruled out. The dietician may also be able to recommend supplements or dietary modifications that can put the brakes on weight loss and encourage healthy weight gain.
Marcy Smith says
My father is 5′ 10″, 82 yo and has parkinsons, heart disease and prostate cancer. In the past 8 months he has gone from mid 140’s to mid 130’s … Two years ago he was at 152, which is a good weight for him. Every time I go to his cardiologist, neurologist and most recently GP, I mention my concern about the weight loss, as I am guessing it could mean a cancer recurrence or could be due to heart failure. Last time I went to cardiologist he said it was likely due to Parkinsons. Neurologist doesn’t say anything when I ask. GP recently said that it was likely due to lower calorie intake but did not do ANY TYPE of evaluation, not even asking if his eating habits had changed. I know they haven’t because I’ve been feeding him for the past 4 months.
Any idea why doctors would not be interested in doing a thorough evaluation to diagnose possible causes of unintentional weight loss? Is there some question I can ask that will inspire them to at least be interested in the situation? Or is a second opinion and a change of doctors the best approach at this point?
Nicole Didyk, MD says
I’m sorry that you’re getting the impression that your concerns about your dad’s weight loss are being dismissed. That must be frustrating. In the article, Dr. Kernisan mentions the MNA (Mini Nutritional Assessment) which is a validated tool for looking at nutritional risk in older adults. There’s a form of it that your dad could complete on his own, or that you could do together. Sometimes it’s helpful to bring these types of tools to a doctor visit to share some objective information and show that you’ve done some research and thinking about the issue.
There are many ways that Parkinson’s disease and heart failure can affect appetite and weight. These can include changes in sense of taste and smell, difficulty with chewing and swallowing, and effects of medications. Unfortunately, many physicians are not trained in interventions for these specific causes of weight loss, and many of those changes that I listed don’t respond to medications. I will often refer my patients to a dietician or speech language pathologist to help with managing weight loss and help discern the causative factors.
In a situation like the one you describe, persistent advocacy about your concerns and asking to see other experts may be the best way to go.
Marcy Smith says
Thank you for your reply. I don’t believe that the weight loss is being caused by the Parkinson’s or the heart failure. I think it most likely means a cancer recurrence. He continues to lose weight. He is down to 129.6 now, and the doctors are beginning to notice, finally. Today he want to see an oncologist, who noticed the weight loss and suggested beginning cancer treatment might help. It is my understanding that once cachexia gets started that it is something of a speeding train. Hopefully, I am wrong and he will stick around for a few more years.
Nicole Didyk, MD says
Sorry to hear about the recurrence, but I’m glad that you feel your concerns are now being heard and addressed.
Cachexia is a form of catabolism, a breaking down of muscle with inflammation, usually related to cancer, AIDS, or another advanced illness. Treatment involves supplementing diet and stimulating appetite, among other things. Cachexia can be hard to reverse, and usually the goal is to enhance the person’s comfort and enjoyment of food as much as possible.
Thanks for the update and I wish your family the best.
Dee says
What do you think…My Mom,88yrs for a good 10yrs was 116-118 . 2yrs ago started losing 2-3 lbs..but in the last 6 months has lost 6 pounds. She has 3 meals a day and a snack at night. She has 1 can of boost plus daily too. She does get full feeling quickly. She does have muscle atrophy and fatigues easily. Is this normal aging process?Anything more to add to diet. Thanks for your help
Nicole Didyk, MD says
As Dr. Kernisan points out in the article, unintentional weight loss sometimes point to a concerning underlying problem, and it can take a comprehensive approach to sort it all out. The numbers you share, seem to add up to about a 5% weight loss over a 6 month period, which is less than the 10% amount in 6 months that is classically considered to be a rate of loss that should set off alarm bells.
Feeling full early can be sign of a problem with digestion or swallowing, and fatigue and muscle atrophy can be a cause or an effect of poor nutritional intake, or there could be something else that is causing all of the symptoms. Normal aging shouldn’t be associated with weight loss.
In a case similar to the one you describe, I would want to rule out another cause of the weakness, fatigue, and weight loss, before just adding another supplement. Keeping close track of weight, activity and intake is a good place to start before talking to a healthcare provider.
Jennifer says
My neighbor has always been very thin but in the last couple of years has been steadily going down in weight. She tells me she now weighs 75 pounds (she is about 5’6″). I am extremely concerned but neither she nor her family seem to be. How dangerous is this?
Nicole Didyk, MD says
It’s hard to get a handle on how dangerous it is for an older adult to have a low body weight, because it really depends on the person. Someone who is frail, for example living in a nursing home, who loses significant weight and/or has a very low body mass, is probably at increased risk of dying compared to a frail person who is heavier and has a stable weight. But that may not be so for a healthy, community-dwelling older adult who has always been thin.
The other thing to remember is that people report incorrect weights all the time, so interpret anything you hear with caution.
Jennifer says
Thank you for your reply. She is not healthy – constant back problems and lately also problems with her gallbladder and recurring lung infections. I’m just wondering what happens to a person when they continue to lose weight – it seems like there must be a weight ‘limit’ when even worse things are going to happen. I’m not sure exactly about the 75 pounds but is stick thin and looks scarily skin-and-bones. Thanks again!
Grant says
Hi i weighed about 70kilo two years ago i noticed lot of muscle loss, now last 9 months 61 to 63 kilo the doctor did not think cancer as i would have other syptoms? Do you agree with this?
Nicole Didyk, MD says
Loss of muscle mass can lower a person’s overall weight, and this could happen slowly, over a period of a few years. When weight loss is related to cancer, we usually hear about other symptoms, such as blood loss, sweating (particularly at night), or pain. Your doctor would best know your health history and risk factors for weight loss, so I would continue the dialogue with them if you’re concerned.
Deepika says
My dad is 55years .. he has lost around 20 pounds in the last 4 months.. he has good appetite and no fatigue .. he has changed his diet a bit for past few months with low carbs nd low fat.. but the weight loss seems to be way too much.. all this blood workup came back normal what shld i do nxt
Nicole Didyk, MD says
It sounds like your dad has made some lifestyle changes that could account for the weight loss. In most situations, that is normal, and can even be a positive step towards better health. Weight loss is worrisome when it is unintnetional.
Sue Calkins says
I’m 55 and 5’3″ the past year that I’m losing weight I went from 107 to like 99 I’m not trying to lose weight I have been trying to grain weight. I have very bad night sweats I wake up 2 to 3 times a night like I have work out for an hour or more. It’s really starting to concern me because I eat more than anyone in the house. I waiting to hear from the doctor he gave me some meds for the night sweats and checking my blood. I’m working on trying to find out the problem. I really getting concern I don’t feel sick and I really don’t do anything just go to work. I know a couple people that lost a lot of weight too, hoping I don’t loss weight like them and I am. feeling worried
Nicole Didyk, MD says
Hi Sue and sorry to hear about your weight loss, and I can understand feeling worried. Being a Geriatrician, I usually care for older adults, and the causes of weight loss in a younger person may be quite different, so I don’t want to speculate about what might be going on. I’m glad you’re working with your doctor to sort it out.
Frances says
My Husband is 85, was a healthy man until he had a heart attack, and had no problems since a triple bypass 10 years ago, however in 2016 diagnosed Aortic aneurysm 5.6cm in abdominal, and as 6 monthly scans. Since 2019 he has blood tests and had borderline anemia twice, first time took iron tablets for 3 months, and returned to normal, then test showed anemia again.For last 6 months he passed blood in urine, he has CT and Bladder test, determined cyst on kidneys and had gynecomastia, scan result no cancer in breasts.Checked with blood test his SHGB levels and has has actinic keratosis on his face, its slowly improving over last 4 months, of using prescription cream. He eats kealthy nutritious food and walks daily for exercise. the problem is over the last 2 years he remains the same weight 12 stone 11 pounds, height 5 feet, 9.5 inches but his body shape is changing, but looks about 3 stone thinner, his clothes are too big, he looks skin on bone, but weight on scales remains the same. He takes daily medication:
40 mg rosuvastatin, 2.5mg bisoprolol, 7.5mg clopidogrel, 400 microgram tamsulosin, modified
release capsules for enlarged prostrate for last 3 years
he was also took lanzoprazole for 7 years, stopped as had no problem with acid
However, he still passes blood in urine and they don’t understand why. He always feels very cold no matter how warm it is. I have been the Dr’s many times and told its his age, I am having sleepless nights with worrying as the weight drops very thin, and his body shape changes. I think he should be checked by a Gastroenterologist and his esophagus.
Please can you advise, many thanks.
Nicole Didyk, MD says
Thanks for your detailed comment. I can imagine it;s very frustrating to be told that a symptom that’s worrying you is due to “old age”. There are many changes that are a normal part of aging but to my knowledge unexplained blood in the urine and unexplained weight loss are not normal.
Sometimes, the weight on the scale stays the same, but a person’s body composition can change. For example, the weight change could reflect a loss of muscle but a gain of fluid. This would show up as swelling, usually in the legs and feet.
In terms of blood in the urine, medications that affect platelet function can make a person more likely to have bleeding but usually only if there is some other vulnerability in the system.
I would advise someone with a story like yours to continue to advocate for answers and seek second opinions if needed.
Destiny Lauren Smith says
My uncle is 69 years old and has told me he has lost a significant amount of weight without changing his diet. He went to the VA hospital and the doctors have no answer either. He smokes and drinks regularly but no cancer was present. Any suggestions would be welcome.
Nicole Didyk, MD says
Hi Destiny. Here is an answer to a similar question from a few weeks ago that may be helpful. You mention smoking which can affect one’s sense of taste and smell, and can contribute to a reduced appetite. Good luck!