What medications can cause or treat appetite loss in patients with dementia, particularly considering buproprion (bupropion)?

Medications That Cause and Treat Appetite Loss in Dementia

Medication review should be performed by a qualified practitioner to minimize adverse drug effects on food and fluid intake in persons with dementia, as many medications can cause appetite loss while few are effective at treating it. 1

Medications That Can Cause Appetite Loss in Dementia

Appetite loss is extremely common in dementia, affecting nearly half (49.5%) of patients even in mild stages 2. Several medications can worsen this problem:

Common Culprits:

• Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) - slightly increased risk of weight loss compared to matched controls 1
• Opioids - can cause nausea and reduced appetite 1
• Sedatives - reduce attention and activity at mealtimes 1
• Digoxin - may affect appetite 1
• Metformin - can cause gastrointestinal disturbances 1
• Antibiotics - may disrupt gut flora and reduce appetite 1
• NSAIDs - can cause gastric irritation affecting appetite 1
• Bupropion - while not specifically mentioned for appetite loss in the evidence, it was shown ineffective for treating apathy in Alzheimer's disease and did not improve neuropsychiatric symptoms 3

Mechanism of Medication-Induced Appetite Loss:

• Direct appetite suppression
• Nausea/gastrointestinal disturbances
• Taste and smell alterations
• Reduced attention during mealtimes
• Sedation affecting the urge to eat and drink

Medications That May Help Treat Appetite Loss in Dementia

Despite the 2024 guideline recommendation against routine use of appetite stimulants 1, certain medications may be considered in specific situations:

Potentially Beneficial:

• Mirtazapine - has the strongest evidence for dementia-related appetite loss
  • In a retrospective study, 30mg daily led to weight gain in 77.3% of patients after 3 months (mean gain 1.93kg) and 82.3% after 6 months (2.11kg) 4
  • May be particularly useful when depression coexists with appetite loss 1
  • Side effects include daytime sleepiness 4

Not Recommended Due to Limited Evidence:

• Cannabinoids (dronabinol) - inconsistent effects in small trials 1
• Megestrol acetate - inconsistent effects and potential side effects 1
• Flavor enhancers - not routinely recommended 1

Algorithm for Managing Appetite Loss in Dementia

1. Perform medication review:

   • Identify and reduce/replace medications with appetite-suppressing effects
   • Consider temporal relationship between medication changes and appetite/weight changes

2. Address underlying factors:

   • Treat depression if present (consider mirtazapine if appropriate)
   • Manage pain adequately
   • Address oral health issues

3. Implement non-pharmacological approaches first:

   • Encourage shared meals (strong evidence for improved intake) 1
   • Provide verbal prompting and supervision during meals
   • Ensure adequate time for meals
   • Create pleasant mealtime environment

4. Consider pharmacological intervention only if non-pharmacological approaches fail:

   • If depression co-exists: Consider mirtazapine (30mg daily) 4
   • Monitor for excessive sedation
   • Track weight to avoid excessive weight gain

Important Caveats

• Appetite loss often progresses gradually and may go unnoticed until significant weight loss occurs 1
• Individual vulnerability varies greatly - medication effects depend on dosage, body weight, renal function, and co-medications 1
• The relationship between eating disturbances and dementia severity changes as the disease progresses 2
• Polypharmacy itself is associated with malnutrition in older adults 1
• Medication review should be performed at diagnosis of dementia and whenever changes in appetite or weight occur 1

Remember that social aspects of eating are crucial - shared meals have been shown to significantly improve intake and should be encouraged whenever possible 1.