What are the treatment options for poor appetite in the elderly?

Treatment Options for Poor Appetite in the Elderly

Potential causes of poor appetite in the elderly should be identified and eliminated as the first step in treatment, followed by a multimodal approach including nutritional interventions, physical activity, and in some cases, pharmacological therapy. 1

Identifying and Addressing Underlying Causes

Poor appetite in older adults is multifactorial and requires systematic assessment of potential causes:

Medical Causes

• Acute disease and chronic pain
• Medication side effects (review medications for anorexia, xerostomia, dysgeusia)
• Swallowing difficulties (dysphagia)
• Chewing problems and poor dentition

Psychosocial Causes

• Depression and depressive mood
• Loneliness and social isolation
• Cognitive impairment
• Poverty

Functional Causes

• Restricted mobility
• Impaired upper extremity function
• Inability to shop or prepare meals

Nutritional Interventions

Dietary Modifications

• Avoid restrictive diets as they may limit food choice, eating pleasure, and dietary intake 1
• Provide energy-dense and protein-rich foods to decrease food volume while increasing nutritional content 1
• Offer small, frequent meals with high-calorie, nutrient-dense options 2
• Implement texture modifications for those with chewing or swallowing difficulties 1

Oral Nutritional Supplements (ONS)

• ONS should be offered to elderly persons with malnutrition or at risk of malnutrition to improve dietary intake and body weight 1
• ONS should provide at least 400 kcal/day including 30g or more of protein/day 1
• Continue ONS for at least one month with monthly assessment of efficacy 1
• Adapt type, flavor, texture, and timing of ONS to patient preferences to improve compliance 1

Meal Support Services

• Meals on wheels for home-dwelling elderly should be energy-dense and/or include additional meals 1
• Consider enhanced meal delivery programs that provide three meals and snacks daily rather than traditional programs offering fewer meals 1

Social and Environmental Interventions

• Create a pleasant eating environment 2
• Promote shared meals and social eating opportunities 1
• Provide adequate mealtime assistance for those with functional limitations 1
• Implement protected mealtimes in institutional settings to create a conducive eating environment 1

Physical Activity

• Encourage physical activity and exercise alongside nutritional interventions to maintain or improve muscle mass and function 1
• Implement moderate physical activity programs which can naturally stimulate appetite 2
• Evaluate health status and physical performance level before starting exercise interventions 1

Pharmacological Interventions

When non-pharmacological approaches are insufficient, medication options include:

• Mirtazapine (15-30 mg daily) can treat both underlying anxiety and appetite symptoms simultaneously 2, 3

  • Monitor for side effects including increased appetite, weight gain, somnolence, and QTc prolongation 3
  • Avoid in patients taking MAOIs 3

• Cyproheptadine (2-4 mg three times daily) has an established safety profile as an appetite stimulant 2

  • Consider as first-line pharmacological therapy due to favorable side effect profile 2

• Megestrol acetate (160-800 mg/day) is effective but carries higher risk of thromboembolic events and fluid retention 2

• Dexamethasone for short-term use (1-3 weeks) provides rapid appetite stimulation but should be limited due to side effects 2

Monitoring and Follow-up

• Regularly assess weight changes, appetite improvement, and nutritional status 2
• Use validated screening tools such as the Mini Nutritional Assessment (MNA) 2
• Reassess appetite and weight after 2-4 weeks of therapy 2
• Monitor for medication-specific side effects 2, 3

Implementation Strategy

1. Identify and address underlying causes of poor appetite
2. Implement non-pharmacological approaches (nutritional interventions, social support, physical activity)
3. If insufficient response after 2-4 weeks, consider pharmacological therapy starting with cyproheptadine
4. Monitor response and adjust interventions accordingly

By implementing this comprehensive approach to poor appetite in the elderly, clinicians can help improve nutritional status, prevent weight loss, and enhance quality of life.