What is the management of anorexia of aging?

Management of Anorexia of Aging

The management of anorexia of aging requires a targeted approach addressing underlying causes, nutritional interventions, and appetite stimulation, with megestrol acetate (400-800 mg/day) being the most effective pharmacological intervention for severe cases when quality of life is significantly affected. 1, 2

Assessment and Identification

• Screen for anorexia of aging using validated tools such as the 4-item Simplified Nutritional Appetite Questionnaire (SNAQ) 3
• Measure weight at each visit and track weight changes over time (weekly monitoring recommended) 2
• Identify key risk factors:
  • Cognitive changes/dementia (highest risk factor) 4
  • Dysphagia 4
  • Polypharmacy (review medications that may suppress appetite)
  • Depression and psychological factors

Non-Pharmacological Interventions (First-Line)

Nutritional Modifications

• Implement small, frequent meals (5-6 per day) with high-calorie, nutrient-dense foods 2
• Use flavor enhancement to improve food palatability 5
• Increase meal variety and fortify foods with additional protein/calories 5
• Create a pleasant eating environment and encourage social eating 2

Physical Activity

• Implement structured exercise programs to stimulate appetite 5
• Focus on resistance training to help preserve muscle mass
• Tailor exercise intensity to individual functional capacity

Addressing Underlying Causes

• Treat reversible causes of decreased intake:
  • Dental problems and oral health issues
  • Swallowing difficulties (consider speech therapy evaluation)
  • Early satiety (consider prokinetics like metoclopramide) 1
  • Depression (consider mirtazapine 7.5-30 mg at bedtime which has dual benefits for mood and appetite) 1

Pharmacological Interventions (Second-Line)

For Severe Cases with Significant Impact on Quality of Life:

1. Megestrol acetate (400-800 mg/day) 1, 2

   • Most effective appetite stimulant with evidence for weight gain
   • Monitor for side effects: thromboembolic events, fluid retention
   • Discontinue if ineffective after 4 weeks
   • Contraindicated in pregnancy 6

2. Dexamethasone (2-8 mg/day) 1

   • Provides rapid appetite stimulation
   • Limit duration due to side effects (muscle wasting, insulin resistance)
   • Best for short-term use in patients with limited life expectancy

3. Olanzapine (5 mg/day) 1

   • Alternative option with fewer thromboembolic risks
   • Monitor for metabolic side effects

4. Cannabinoids 1

   • Consider when other options have failed
   • Less effective than megestrol acetate but may benefit some patients

Monitoring and Follow-up

• Weigh patients weekly to assess response to interventions 2
• Reassess nutritional status after 2-4 weeks of new therapy 2
• Monitor for complications:
  • Thromboembolic events with megestrol acetate
  • Adrenal insufficiency with prolonged megestrol acetate use 6
  • Fluid retention
• Discontinue ineffective treatments rather than continuing indefinitely 2

Special Considerations

• Avoid bulk laxatives in patients with reduced mobility or fluid intake 1
• Ensure adequate hydration alongside nutritional interventions 1
• Consider the impact of chronic kidney/heart failure when using certain medications 1
• Be aware that 38.7% of healthcare providers incorrectly believe anorexia is a normal part of aging—it is not and should be actively addressed 4

Treatment Algorithm

1. Identify and address underlying causes
2. Implement non-pharmacological interventions
3. If insufficient response after 2-4 weeks, consider pharmacological options
4. Monitor response and adjust treatment accordingly
5. For patients with advanced disease or limited life expectancy, focus on comfort and quality of life rather than nutritional parameters

The goal of treatment should always be to improve quality of life, maintain functional status, and prevent complications of malnutrition such as sarcopenia and frailty.