From the Guidelines
Generally, drugs that stimulate appetite should NOT be offered to promote food intake of persons with dementia, as stated in the most recent guideline update 1. This approach prioritizes the patient's quality of life and safety, given the lack of conclusive evidence supporting the use of appetite stimulants in dementia patients. Instead, the focus should be on:
- Ensuring meals are nutrient-dense and visually appealing
- Creating a pleasant eating environment
- Addressing underlying medical conditions that may affect appetite
- Considering nutritional supplements between meals to provide additional calories and nutrients
- Regular monitoring of weight, nutritional status, and medication side effects to adjust the approach as needed. The use of medications like mirtazapine, megestrol acetate, or dronabinol may be considered in specific cases, but their potential benefits must be weighed against their risks, and they should not be used solely for appetite stimulation in dementia patients, as recommended by the latest ESPEN guideline update 1.
From the FDA Drug Label
Megestrol acetate tablets are indicated for the treatment of anorexia, cachexia, or an unexplained, significant weight loss in patients with a diagnosis of acquired immune deficiency syndrome (AIDS). The best approach for managing appetite stimulation in an elderly patient with impaired appetite is to use megestrol acetate as an appetite stimulant.
- Key considerations:
- Dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range.
- The patient should be monitored for potential adverse effects, such as adrenal insufficiency, diabetes, and thromboembolic events.
- Laboratory evaluation for adrenal insufficiency and consideration of replacement or stress doses of a rapidly acting glucocorticoid are recommended in patients receiving or being withdrawn from chronic megestrol acetate therapy 2. Alternatively, mirtazapine may be considered as an appetite stimulant, but its use should be cautious in elderly patients due to the risk of decreased clearance, confusion, and over-sedation 3.
From the Research
Appetite Stimulation in Elderly Patients
- The management of appetite stimulation in elderly patients with impaired appetite is a complex issue, and several approaches can be considered 4, 5.
- Orexigenic agents such as megestrol acetate and dronabinol are commonly used to stimulate appetite in elderly patients 4, 6.
- Megestrol acetate can be effective in improving appetite, but its use should be limited to 3 months due to the risk of deep vein thrombosis 4.
- Dronabinol can be used indefinitely and is particularly useful in patients with anorexia at the end of life 4.
- Mirtazapine is an antidepressant that can also stimulate appetite and is often used in patients with depression and anorexia 4, 6.
Selection of Appetite Stimulants
- The choice of appetite stimulant depends on the individual patient's needs and medical history 4, 5.
- A thorough assessment of the patient's nutritional status and medical history is essential before initiating appetite stimulant therapy 5, 7.
- The use of appetite stimulants should be considered in conjunction with other interventions, such as nutritional support and environmental modifications 5, 8.
Safety and Efficacy of Appetite Stimulants
- The safety and efficacy of appetite stimulants in elderly patients have been evaluated in several studies 6, 5.
- While appetite stimulants can be effective in improving appetite and weight gain, they can also have significant side effects 4, 6.
- The use of appetite stimulants should be carefully monitored, and patients should be regularly assessed for adverse effects and changes in appetite and weight 6, 7.