Acta Clinica Belgica

International Journal of Clinical and Laboratory Medicine

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Clinical approach to the older person with

anorexia

Annelies Somers, Stany Perkisas, Sophie Bastijns, Femke Ariën & Anne-
Marie De Cock

To cite this article: Annelies Somers, Stany Perkisas, Sophie Bastijns, Femke Ariën & Anne-
Marie De Cock (2023) Clinical approach to the older person with anorexia, Acta Clinica Belgica,
78:6, 486-496, DOI: 10.1080/17843286.2023.2228037

To link to this article: https://doi.org/10.1080/17843286.2023.2228037

Published online: 22 Jun 2023.

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ACTA CLINICA BELGICA
2023, VOL. 78, NO. 6, 486–496
https://doi.org/10.1080/17843286.2023.2228037

REVIEW

Clinical approach to the older person with anorexia

Annelies Somers, Stany Perkisas, Sophie Bastijns, Femke Ariën and Anne-Marie De Cock
University Center for Geriatrics University of Antwerp, Antwerp, Belgium

ABSTRACT ARTICLE HISTORY

Objective: Anorexia is a challenging problem among older people. Apart from being the Received 31 March 2023
consequence of normal ageing, it can also be a symptom of underlying disease. Despite the Accepted 18 June 2023
high prevalence of anorexia, only few recommendations exist on the evaluation in older KEYWORDS
people. The objective of this study is to summarize evidence and provide guidance through Anorexia; anorexia of ageing;
creating a flowchart. unintentional weight loss
Methods: A systematic literature search was performed through combining following key­
words: older people (aged, geriatrics, older adult), anorexia (also loss of appetite, unintentional
weight loss) and diagnosis. After removal of duplicates and case-reports, articles were selected
based on title and abstract by two reviewers. Guidelines, reviews, studies and relevant pub­
lications discussing anorexia or unintentional weight loss were included. Relevant data were
extracted and processed into a flowchart.
Results: Out of 619 hits, 25 articles were included discussing either the evaluation of anorexia
or unintentional weight loss. Consensus in the work-up of unintentional weight loss is to start
with a detailed history and physical examination followed by full bloodwork, urinalysis, chest
x-ray and a faecal occult blood test. In certain cases, ultrasound and upper endoscopy are
further recommended. In the work-up of anorexia, medication, social, psychological, logopae­
dic and neurocognitive aspects need to be taken into consideration.
Conclusions: One of the main challenges of the evaluation of anorexia in older people is the
lack of guidance in existing literature. Therefore, we investigated what is currently known
about the management of anorexia and unintentional weight loss as well and combined best
practices to form a flowchart.

Introduction
Anorexia, defined as the loss of appetite and/or
reduced food intake, causes a challenging problem in
older people. Due to reduced food intake and failure to
meet energy requirement, anorexia is directly linked to
adverse health outcome. Being associated with malnu­
trition, anorexia leads to sarcopenia, higher risk of
pressure ulcers, declining immune function, infections,
osteoporosis, fractures and longer hospital stays [1,2].
All these cause a decline in functionality and loss of
independence, with staying independent being one of
the most important factors to good quality of life
according to older people [1–3].
The prevalence of anorexia is highly variable in
different epidemiological studies, but it affects
approximately 10% to 30% of the community dwelling
older people and the prevalence is even higher in
nursing homes and hospitals [1,4]. Several screening
tools are available to identify people at risk for devel­
oping anorexia. A commonly used tool is the Simplified
Nutritional Assessment Questionnaire (SNAQ). The
SNAQ consists of four questions relating to appetite,
satiety, taste and meal frequency [5]. It’s a self-
assessment screening tool which takes little time and
is therefore useful in daily practice. However, the sub­
jectivity of the result and the limitary use in cognitively
impaired patients might cause an underestimation of
the actual extent of the problem.
The main reason why anorexia is such a complex
problem is because the causes are multifactorial and
often a combination of biological, social, psychological
and environmental factors. Among social factors, lone­
liness and financial status are most frequently seen.
Psychological factors, such as anxiety, bereavement
and depression, occur often in older people and are
powerful inhibitors of appetite [2,6,7].
We can divide biological factors in two main cate­
gories, first one being anorexia due to normal ageing
and secondly anorexia as a symptom of underlying
pathology.
The first category includes normal physiological
change accompanied by ageing and is also known as
anorexia of ageing. Main factors in this process are
delayed gastric emptying, higher presence of satiety
hormones and decreased smell and taste. Negative
feedback mechanisms from the stomach and satiety
hormones dominate the central feeding drive within
the arcuate nucleus in the hypothalamus (the appetite

CONTACT Annelies Somers annelies.somers@zna.be University Center for Geriatrics Antwerp, Ziekenhuisnetwerk Antwerpen, Lindendreef 1,
Antwerp 2020, Belgium
© Belgian Society of Internal Medicine and Royal Belgian Society of Laboratory Medicine (2023)

control center). This primitive mechanism has over the
years led to an evolutionary advantage: the aged and
less active people spontaneously consume less com­
munity food.
The hormones involved in anorexia of ageing are
cholecystokinin (CCK), glucagon-like peptide-1 (GLP-1),
peptide YY (PYY), leptin and insulin. CCK, GLP-1 and
PYY are released in response to food ingestion and
inhibit appetite through stimulating the satiety center
and inhibiting the hunger center within the hypotha­
lamus. Multiple studies have demonstrated higher fast­
ing and postprandial CCK concentrations in older
people. Likewise, GLP-1 and PYY have been shown to
be elevated in the postprandial phase in older people.
Leptin, mainly produced by adipose cells, is an indica­
tor of adequate fat storage. It suppresses appetite in
the hypothalamus and prevents further food intake.
Insulin is another satiety hormone, which acts indir­
ectly by enhancing the leptin signal. Ageing is accom­
panied by reduced glucose tolerance and elevated
insulinemia. Elevated concentrations of both leptin
and insulin lead to anorexia [7–9].
As mentioned before, anorexia can also be
a consequence of underlying pathology. Numerous
diseases can directly cause anorexia, for example gas­
trointestinal disease, kidney disease, or thyroid dys­
function. Inflammatory mediators, such as IL-6 and
TNF-α, as seen in patients with chronic inflammation
or cancer, have a strong anorexigenic effect and can
indirectly cause anorexia [9]. Secondary, many drugs
commonly used by older people may cause anorexia.
Despite its importance and the high number of
cases, anorexia remains too often seen as an inevitable
part of normal ageing. When a patient presents with
anorexia, it’s crucial to explore and to investigate the
underlying mechanisms. Anorexia should not be
ignored, as underlying factors can potentially be iden­
tified and corrected. However, it can be difficult to
determine when to perform extensive investigation
and when to take a wait-and-see approach.
Unfortunately, there currently are no guidelines to
which examinations are suited for the geriatric patient
with anorexia.
The first objective of this article was to investigate
what currently is known about the management of
anorexia in the geriatric patient. The second objective
was to develop a flowchart on this subject.
Methods
A systematic literature search for the existing evidence
was performed. The search strategy existed of three
components: older people, anorexia and diagnosis.
Keywords being older people (aged, geriatrics, older
adult), anorexia (also loss of appetite, unintentional
weight loss) and diagnosis were combined. The search
structure was depicted as followed:
ACTA CLINICA BELGICA 487
(((aged[MeSH Terms]) OR (geriatrics[MeSH Terms])
OR (older adult[MeSH Terms])) AND ((anorexia[MeSH
Terms]) OR (loss of appetite[MeSH Terms]) OR (unin­
tentional weight loss [MeSH Terms])) AND (diagnosis
[MeSH Terms]))
The search was performed in PubMed. All articles up
until the 15th of May 2023 were included. Figure 1
shows the overview of the article selection process,
following the PRISMA guidelines [10]. Duplicates and
case-reports were removed using an automation tool.
The remaining articles were screened for eligibility by
title and abstract by two reviewers. Current clinical or
best practice guidelines, reviews, studies and relevant
publications discussing either the pathophysiology,
causes, evaluation, management or treatment of anor­
exia and/or unintentional weight loss were included.
Case-reports were excluded. Also, articles about anor­
exia or weight loss of a known underlying disease, for
example cancer, were excluded. The reviewers worked
independently and were blinded from inclusion deci­
sions of one another using the Rayyan web-based soft­
ware. Relevant data was extracted from the full texts of
selected articles.
After extraction, a first draft of an evidence-based
flowchart was proposed in an open discussion with
colleagues of the geriatric department. During two
meetings, the structure and content of the flowchart
were discussed. The lay-out was adapted during a final
meeting to make the flowchart more convenient.
Results
Search outcomes
The initial search yielded 619 articles. One duplicate
along with 15 case-reports were excluded using an
automation tool. The 603 remaining articles were
further screened by title and abstract, resulting in 541
articles getting excluded. The full texts of the remain­
ing 62 articles were assessed for eligibility. Five of the
articles were case-reports and therefore excluded.
Thirty-one articles were outside the scope of the sub­
ject. One article without full text was also removed.
Eventually, 25 articles remained, of which 13 had anor­
exia as main subject and 12 discussed unintentional
weight loss.
Search results
Thirteen articles examined anorexia in the older
patient. One article discussed the association between
anorexia and disability [3]. Ten articles dealt with the
pathophysiology and management of anorexia of age­
ing describing both intrinsic and extrinsic factors
[1,2,4,8,9,11–15]. Intrinsic factors are decreased smell
and taste, delayed gastric emptying, dysregulation of
hormones and pro-inflammatory cytokines. Extrinsic
488 A. SOMERS ET AL.
Identification of studies via databases and registers
Identification
Records identified from:
Database (n = 619)
Records screened
(n = 603)
Screening
Reports assessed for eligibility
(n = 62)
Included
Studies included in review
(n = 25)
Figure 1. Overview of the article selection process.
factors are use of medication, social, psychological,
neurocognitive and logopedic.
One article offered ratio in underlying pathology.
The most frequent underlying causes were infection
(mainly pneumonia and urinary tract infection), benign
gastrointestinal disease (peptic ulcers and ileus) and
cardiovascular disease. Malignancy was observed in
6.9% of patients. Additional causes were drug adverse
effects, neurological and psychiatric disease [16].
Twelve articles discussed unintentional weight loss.
The most common causes of unintentional weight loss
were reduced appetite, dementia with behavioral and
psychological symptoms and medication [17]. Eleven
articles discussed the approach of the older person
with unintentional weight loss: seven reviews, three
prospective studies and one retrospective study
(Table 1) [6,18–27]. Consensus is to start with
a thorough history and physical examination.
Essential aspects are the amount of weight loss,
exploration of the symptoms, past and current medical
and social history, review of medication, substance (ab)
Records removed before
screening:
Duplicate records removed
(n = 1)
Records marked as ineligible
by automation tools (n = 15)
Records excluded
(n = 541)
Reports excluded:
Article outside of scope
manuscript (n = 31)
Case-report (n = 5)
No full text (n = 1)
use and review of systems. An interview with care­
givers may elicit additional information, especially in
case of patients with cognitive impairment. Five arti­
cles recommend a dementia and depression screening
as part of the initial evaluation [6,18,21,23,27].
Physical examination should include an oral inspec­
tion for poor dentition, oral ulcers or oral candida. An
abdominal examination for masses, lymph nodes, an
investigation of the heart and lungs, a neurologic evalua­
tion to check for Parkinson’s disease or signs of
a cerebrovascular accident and finally a musculoskeletal
examination.
Following diagnostic studies should be performed
in the work-up of unintentional weight loss: blood
tests (including a complete blood count, kidney func­
tion and electrolytes, liver enzymes, lactate dehydro­
genase (LDH), thyroid function, glucose), urinalysis,
chest radiography and fecal occult blood test [6,18–
21,23,27].
Further investigation of the gastrointestinal tract
with endoscopy or abdominal ultrasound is
Table 1. Summary of the articles discussing the approach of unintentional weight loss.
Recommended Recommended Recommended
Article type History Physical examination baseline investigations additional investigations management
JD Gazewood, DR Mehr: Diagnosis and Review − Amount of − Symptomatic organ systems − Complete blood count, chemistry panel, − Endoscopic or radiographic − Treat underlying pathology
management of weight loss in the weight loss − Vision ultra-sensitive TSH examination of the upper − Withdraw unnecessary medications
elderly. The Journal of family practice − Determine − Mouth and teeth − Urinalysis gastrointestinal tract should that may cause weight loss
1998, 47(1):19–25 [6] symptom − Gastrointestinal tract − Faecal occult blood test be considered in patients with − Discontinuing therapeutic diets,
pattern − Neurologic examination- − Chest film anorexia, absence of other allowing patients free access to
− Review of Mental state examination symptoms and persistent favorite foods and adding flavor
systems (MMSE, GDS) weight loss enhancers
− Review of − Vision − Other testing should be − Supplemental oral or short-term
patient’s − Mouth and teeth directed by findings on history, nasogastric feeding
prescription and − Gastrointestinal tract physical, or initial laboratory
non- − Neurologic examination evaluation
prescription - Mental state examination
medications (MMSE, GDS)
− Dietary habits
− Alcohol use
− Social history
− Interview
caregivers
SM Alibhai, C Greenwood, H Payette: An Review − Document Physical examination − Complete blood count, tests of liver − Endoscopy for patients with − Systematically identify and treat
approach to the management of weight loss enzyme levels (including alkaline iron-deficiency anemia or the underlying causes
unintentional weight loss in elderly − Careful history phosphatase and bilirubin), lactate symptoms likely to originate in − Enabling access to good nutrition
people. CMAJ : Canadian Medical − Screening for dehydrogenase level the gastrointestinal tract − Factors such as poverty, poor
Association journal = journal de dementia and − Chest radiography − Abdominal ultrasound for dental health, difficulty in chewing
l’Association medicale canadienne 2005, depression patients with elevated liver or swallowing, vision or hearing
172(6):773–780 [18]. enzyme levels on initial loss, arthritis, stress and
screening unhappiness, should be targeted
− Involve a dietitian and a social
worker
− Involve a physiotherapist
− Use of supplements, vitamin and
mineral supplement should be
considered
− Role for pharmacotherapy remains
limited
(Continued)
ACTA CLINICA BELGICA
489

Table 1. (Continued).
GB Huffman: Evaluating and treating
unintentional weight loss in the elderly.
American family physician 2002,
65(4):640–650 [19].
GR Wise, D Craig: Evaluation of
involuntary weight loss. Where do you
start? Postgraduate medicine 1994,
95(4):143–146, 149–150 [20].
490
Recommended Recommended Recommended
Article type History Physical examination baseline investigations additional investigations management
Review − Obtain − Inspection of oral cavity − Faecal occult blood test Upper gastrointestinal studies − Directed at the underlying causes
information − Respiratory System − Complete blood count; chemistry (radiography or endoscopy) − Nutritional support
about the − Gastrointestinal system profile, ultrasensitive thyroid- may be warranted in patients − Remove dietary limitations
weight loss − Weight, height, BMI stimulating hormone test with symptoms referable to − Adding flavour enhancers
A. SOMERS ET AL.
− Interview with − An assessment of cognitive − Urinalysis the gastrointestinal system or − The contributions of dietitians,
caregiver function and mood in patients with persistent speech therapists and social
− Dietary history − Watching a patient eat weight loss. services personnel cannot be
with daily − Respiratory System overestimated
caloric intake − Gastrointestinal system − Physical therapy
− Use of − Weight, height, BMI − Drugs should not be considered
nutritional − An assessment of cognitive first-line treatment
supplements function and mood
− Medical and − Watching a patient eat
surgical history
− Functional
status
− Mental status
− A thorough
review of
medications
− A review of
systems
Review − Explore − Attention to the patient’s − Complete blood cell count, erythrocyte Routine cancer screening for If results of these initial tests are
symptoms appearance, mood and affect sedimentation rate, chemistry patients in the appropriate age normal, a period of watchful
− Past medical and − Inspection of the skin multiphasic panel, including renal groups, if initial investigations waiting is preferred
surgical history − Check for lymphadenopathy- function tests and measurement of are negative
− Psychosocial Clinical examination of levels of liver enzymes, albumin,
history cardiovascular and calcium, phosphorus, electrolytes, and
− Habits pulmonary systems, bony blood sugar, ultrasensitive thyrotropin
(especially skeleton, breasts, abdomen, assay, HIV testing, if risk factors are
tobacco and genitalia, pelvis, rectum, present
alcohol use) prostate and extremities − Urinalysis
− Use of − Neurologic examination − Chest film
medications − Mental status assessment
− Thorough − Inspection of the skin
review of organ − Check for lymphadenopathy
systems − Clinical examination of
cardiovascular and
pulmonary systems, bony
skeleton, breasts, abdomen,
genitalia, pelvis, rectum,
prostate and extremities
− Neurologic examination
− Mental status assessment
(Continued)
Table 1. (Continued).
Recommended Recommended Recommended
Article type History Physical examination baseline investigations additional investigations management
J McMinn, C Steel, A Bowman: Review − Establish the − A full physical examination to − Full blood count, urea and electrolytes, − Endoscopy should be reserved − Identify and treat any underlying
Investigation and management of exact amount of exclude major cardiovascular liver function tests, thyroid function for patients in whom it is causes
unintentional weight loss in older weight loss over and respiratory illnesses, as tests, C reactive protein, glucose and indicated on the basis of − If the history, examination and
adults. BMJ (Clinical research ed) 2011, a specified time well as abdominal masses, lactate dehydrogenase history, examination, or baseline investigations are all
342:d1732 [21]. − Questions about organomegaly, prostate − Chest radiography baseline investigations normal, published evidence
appetite enlargement, and breast − Urinalysis suggests that further investigation
− A corroborative masses − Faecal occult blood testing is not warranted immediately, and
history from − Examine lymphnodes − Tumour markers are not useful that three months’ ‘watchful
relatives or − Examine the mouth diagnostic tests; they should not be waiting’ is advisable
carers − Examine lymphnodes used as part of the initial evaluation − Optimal management often
− Previous and − Examine the mouth and may be misleading requires multidisciplinary
current medical assessment (doctors, dentists,
history dietitians, speech therapists,
- Social history, physiotherapists, occupational
including therapists, social services)
alcohol intake − Reviewing drugs
and smoking
− Review of
systems
− Screen all
patients for
cognitive
impairment and
depression
using
standardised
assessment
tools
− Nutritional
assessment by
a dietitian
C Metalidis, DC Knockaert, H Bobbaers, Prospective − Chest X-ray If the baseline studies are entirely
S Vanderschueren: Involuntary weight observational − Abdominal ultrasound normal, a watchful waiting
loss. Does a negative baseline study of 101 − C-reactive protein, haemoglobin, white approach can be discussed with
evaluation provide adequate patientsMean blood cell count, platelet count, the patient.
reassurance? European journal of age: 64 aminotransferases, lactate
internal medicine 2008, 19(5):345–349 Mean age: 64 dehydrogenase, alkalin phosphatase,
[22]. albumin, ferritin, renal and thyroid
function tests, fasting glucose
− Urinalysis
ACTA CLINICA BELGICA

(Continued)
491
 492

Table 1. (Continued).
Recommended Recommended Recommended
Article type History Physical examination baseline investigations additional investigations management
EP Bouras, SM Lange, JS Scolapio: Rational Review − Document − Appearance − CBC/diff, MCV, chemistries (electrolytes, − Additional considerations: − The specific etiologies of weight
approach to patients with weight loss − Cardiovascular- Mood/affect− glucose, calcium, phosphorus), BUN, Laboratory: Iron studies, B12, loss should be treated accordingly,
unintentional weight loss. Mayo Clinic − Chief Pulmonary- Skin/lymphatics- creatinine, AST, ALT, Alk Phos, bilirubin, folate, serum protein with medications, structural or
proceedings 2001, 76(9):923–929 [23]. complaint(s) Abdomen/rectum− ESR/CRP electrophoresis, zinc, functional modifications,
− Medications Musculoskeletal- Genital/ − Urinalysis endomysial antibody, fat- nutritional supplementation,
A. SOMERS ET AL.

− Systems review pelvic- Breasts/prostate- − Chest radiograph soluble vitamins, HIV psychosocial modulation, or
− Diet Neurology (+MMSE) − Stool Hemoccult Stool: Fat collection, leukocytes, multimodal therapy
− Medical history − Cardiovascular etc − For negative evaluations, establish
− Social factors − Mood/affect Other: Pap smear, follow-up in 3 to 6 months
− Surgeries − Pulmonary mammography, PSA
− Mental status − Skin/lymphatics − Consider investigation of upper
− Tobacco/alcohol − Abdomen/rectum and lower gut (based on
use − Musculoskeletal symptoms)
− Genital/pelvic − Radiographic contrast studies
− Breasts/prostate vs upper and lower endoscopy
− Neurology (+MMSE) − Clinical situation dictates
testing
N Abu-Freha, Y Lior, S Shoher, V Novack, Retrospective / / Esophagogastroduodenoscopy and / /
A Fich, A Rosenthal et al: The yield of cohort study colonoscopy should be considered part
endoscopic investigation for of 1843 of the initial evaluation of patients with
unintentional weight loss. European patients unintentional weight loss as it may
journal of internal medicine 2008, detect meaningful gastrointestinal
19(5):345–349 [24]. pathologies especially in older
individuals and those who present with
other gastrointestinal manifestations.
IJ Davis, SJ Marek, S Sridhar, T Wilkins, SM Prospective case / / / The findings suggest that /
Chamberlain: Unintentional weight loss studyReview unintentional weight loss as
as the sole indication for colonoscopy is of6425 the only indication for
rarely associated with colorectal cancer. colonoscopies. colonoscopy may not be
Journal of the American Board of Family Mean age associated with CRC
Medicine : JABFM 2011, 24(2):218–219 57.4 years
[25]. Review of
6425
colonoscopies.
Mean age 57.4
years
P Lankisch, M Gerzmann, JF Gerzmann, Prospective / / − Limited procedures suffice to diagnose
D Lehnick: Unintentional weight loss: study of 158 or to indicate further diagnostic steps.
diagnosis and prognosis. The first patients − The reason for weight loss in every third
prospective follow-up study from patient lies in the gastrointestinal tract.
a secondary referral centre. Journal of Hence, endoscopic investigations of
internal medicine 2001, 249(1):41–46 the upper and lower abdominal
[26]. gastrointestinal tract plus function tests
to exclude malabsorption are
recommendable as second choice
procedures.
(Continued)
Table 1. (Continued).
Recommended Recommended Recommended
Article type History Physical examination baseline investigations additional investigations management
HL Gaddey, K Holder: Unintentional Review − Amount of − Evaluation of the oral cavity − Complete blood count, basic metabolic Abdominal ultrasonography may − Treat underlying cause
weight loss in older adults. American weight loss and dentition.- Heart, lung, panel, liver function tests, thyroid be considered − Multidisciplinary team, including
family physician 2014, 89(9):718–722 − Prescription and gastrointestinal examination function tests, C-reactive protein levels, dentists; dietitians; speech,
[27] over-the- − Neurologic examinations erythrocyte sedimentation rate, occupational, or physical
counter − Heart, lung, gastrointestinal glucose measurement, lactate therapists; and social service
medications examination dehydrogenase measurement workers
and herbal − Neurologic examinations − Urinalysis − Common strategies to address
supplements − Chest radiography unintentional weight loss in older
− A social history − Feacal occult blood testing adults are dietary changes,
focusing on environmental modifications,
alcohol and nutritional supplements, flavor
tobacco use and enhancers and appetite stimulants
the patient’s − When baseline evaluation is
living situation unremarkable, a three- to six-
− MNA month observation period is
− Assessment for justified.
depression and
dementia
ACTA CLINICA BELGICA
493
494 A. SOMERS ET AL.
recommended in patients with gastrointestinal symp­
toms and/or persistent weight loss and anemic patients
through possible iron-deficiency or elevated liver
enzymes [6,18,19,23]. One review recommends endo­
scopy (both upper and lower) as part of a baseline
evaluation [24]. Additional examination, for example
computed tomography (CT) scan or scintigraphic
assessment of gastrointestinal transit, should be per­
formed in specific concern or to follow up abnormalities
identified on initial testing [23]. One review recom­
mends routine cancer screening for patients in the
appropriate age groups if initial screening is negative:
cervical smear, mammography, flexible sigmoidoscopy
and prostate-specific antigen [20]. According to another
review however, tumor markers should not be part of
the initial evaluation [21]. Afterwards, a three- to six-
month observation period is recommended [21,23,27].
Discussion
Anorexia is a common condition among older peo­
ple and is directly linked to adverse health
Figure 2. Flowchart on the approach of the patient presenting or suspected with anorexia. Note: MMSE = Mini Mental State
Examination. GDS = geriatric depression score. LDH = lactate dehydrogenase.
outcome. It’s clear that this condition needs further
exploration. The evaluation of anorexia, however, is
never straightforward with causes being often mul­
tifactorial. Moreover, anorexia might as well just
simply be a result of normal ageing. Unfortunately,
there are currently no guidelines for evaluation.
There is a need for a structured approach towards
the older patient with anorexia. The created flow­
chart presented in this article is designed to support
the clinician in daily practice (Figure 2).
One of the main challenges creating this flowchart
was the lack of guidance in the existing literature.
Limiting the search exclusively to anorexia yielded
little result. None of the articles provided guidelines
on which examinations should be performed to
exclude underlying pathology. One retrospective
study from 2019 investigated the causes of anorexia
but offered no further guidance on the matter.
Therefore, we extended our search to unintentional
weight loss, which provided the needed structured
guidance. We combined best practice on anorexia
and unintentional weight loss to form the flowchart.

The recommendations for the approach of uninten­
tional weight loss were in general comparable in terms
of history, physical examination and diagnostic studies.
A subject of debate was the use of endoscopy as part of
the baseline evaluation. In the flowchart, endoscopy is
not implemented and is reserved for patients with anor­
exia and additional red flags (Figure 2). The reason lies in
the fact that the risk of severe underlying pathology is
low when the baseline evaluation turns out negative.
A watchful waiting approach is preferable as opposed to
expensive and invasive investigations [21,22,27].
Several studies implemented abdominal ultrasound
in their baseline investigation. We choose not to
include ultrasound in the flowchart because the sig­
nificance was not proven and abnormal findings after
abdominal examination or abnormal liver function
tests will prompt further investigation anyway [21].
Another point of discussion was the duration of the
watchful waiting period after exclusion or treatment of
underlying pathology. In this phase, focus lies on
regaining appetite and optimizing intake instead of
performing investigations. Possible approaches are
diet adjustments, use of flavour enhancers and supple­
ments, correction of environmental factors or physical
therapy. The medication list should be reviewed thor­
oughly and medication that may affect the appetite
should be stopped or replaced. A multidisciplinary
approach is recommended, including a dietitian,
a speech therapist, social service personnel and
a physiotherapist. Caregivers should be involved in
every step of the process. The role of pharmacotherapy
remains limited. In general, a three- to six-month
observation period is recommended. In the flowchart,
the duration of the watchful waiting period is shor­
tened to six to eight weeks because malnutrition can
cause a rapid decline in functionality. Through early
assessment, further deterioration can be prevented by
adjusting treatment.
A limitation of this review is that no comparison
could be made as current guidelines are non-existent
for this specific population. This emphasizes the need
for further study even more. Another limitation is that
the literature search was limited to PubMed.
A limitation in the flowchart itself is the wide array of
factors throughout. This, however, is paramount to deal­
ing with geriatric patients who often have multiple
causes for one current problem. Secondly, although this
flowchart was developed to be used in clinical care, this
flowchart has not yet been tested in that setting.
This review offers a novel approach to the evalua­
tion of anorexia as current guidelines are non-existent.
The strength of this flowchart lies in several advan­
tages. The step-by-step approach prevents treatable
causes from being overlooked. Ensuring that no use­
less or expensive investigations are carried out accord­
ingly. Unique is the implementation of the
psychological, social and neurocognitive aspects of
ACTA CLINICA BELGICA 495
the ageing patient. This flowchart is specifically
adapted to the older patient and designed to be used
both in an outpatient basis or hospital setting.
Conclusion
Despite the high prevalence of anorexia in the ageing
patient, there are currently no guidelines for the eva­
luation of it. In this review, a clinically oriented flow­
chart specifically suiting the ageing patient was
created, based on best practices on anorexia and unin­
tentional weight loss.
Disclosure statement
No potential conflict of interest was reported by the
author(s).
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