From the Guidelines
The workup for appetite loss in elderly patients should begin with a comprehensive medical history and physical examination to identify underlying causes, with a focus on screening for depression, medication side effects, oral health problems, and chronic diseases, as recommended by the most recent ESPEN guideline on clinical nutrition and hydration in geriatrics 1.
Initial Evaluation
Initial evaluation should include:
- Screening for depression
- Medication side effects, particularly those caused by cholinesterase inhibitors, SSRIs, digoxin, and opioids
- Oral health problems
- Chronic diseases like cancer, heart failure, or gastrointestinal disorders Laboratory tests should include:
- Complete blood count
- Comprehensive metabolic panel
- Thyroid function tests
- Vitamin B12 and folate levels
- Inflammatory markers like C-reactive protein Additional tests may include:
- Urinalysis
- Chest X-ray
- Abdominal imaging if clinically indicated
Nutritional Assessment
Nutritional assessment using tools like the Mini Nutritional Assessment can help determine the severity of malnutrition, as suggested by the ESPEN guideline on clinical nutrition and hydration in geriatrics 1.
Management
Management should address the underlying cause while ensuring adequate nutrition through:
- Dietary modifications
- Nutritional supplements
- Appetite stimulants like mirtazapine (15-30mg at bedtime) or megestrol acetate (400-800mg daily) in appropriate cases, although the use of appetite stimulants is not recommended by the ESPEN guidelines on nutrition in dementia 1 Social factors including isolation, inability to shop or prepare meals, and financial constraints should be evaluated, as they can contribute to malnutrition and dehydration in older adults, as highlighted by the ESPEN practical guideline on clinical nutrition and hydration in geriatrics 1.
Importance of Prompt Evaluation
Appetite loss in the elderly is particularly concerning because aging is associated with physiological changes that already predispose to reduced food intake, including altered taste and smell, decreased gastric emptying, and changes in hunger-regulating hormones, making prompt evaluation essential to prevent complications of malnutrition, as emphasized by the ESPEN guideline on clinical nutrition and hydration in geriatrics 1.
From the Research
Assessment and Treatment of Appetite Loss in the Elderly
- Appetite loss in older people, also known as the 'Anorexia of Aging' (AA), is a common condition associated with under-nutrition, sarcopenia, and frailty 2.
- A systematic review of interventions for AA found that various methods were used to assess appetite, including Likert and visual analogue scales 2.
- The review also identified nine intervention types, including education, exercise, flavor enhancement, and oral nutritional supplements, with five exhibiting favorable effects on appetite 2.
Pharmacological Interventions for Appetite Stimulation
- Megestrol acetate and mirtazapine are two pharmacotherapeutic options commonly used for appetite stimulation in the elderly 3, 4, 5.
- These medications have been shown to be effective in some settings, but their applicability to elderly individuals is unclear, and adverse events have been reported 3, 5.
- Dronabinol is another medication used for appetite stimulation, particularly in patients with anorexia at the end of life 5, 6.
Management of Anorexia and Weight Loss in Older Persons
- An approach to managing anorexia and weight loss in older persons involves assessing and treating underlying causes, as well as considering the use of appetite stimulants and anabolic agents 5.
- The use of taste enhancers and testosterone replacement therapy may also be considered in certain cases 5.
- A retrospective cohort study found that appetite-stimulating medications, including dronabinol, megestrol, and mirtazapine, may show numerical improvements in meal intake in hospitalized patients, with no serious adverse effects observed 6.