How do I manage a nursing home patient with a lack of appetite?

Managing Poor Appetite in Nursing Home Patients

Start with mirtazapine 7.5-15 mg at bedtime as your first-line pharmacological intervention for appetite stimulation in nursing home patients, as it addresses both poor appetite and potential underlying depression. 1

Initial Assessment

Before initiating treatment, identify and address reversible causes:

• Rule out medication-induced anorexia by reviewing all current medications, particularly iron supplements and drugs taken before meals that may suppress appetite 1
• Check for treatable medical conditions including oropharyngeal candidiasis, constipation or fecal impaction, pain, nausea, depression, hypercalcemia, hypokalemia, hypothyroidism, and diabetes mellitus 2
• Assess for dysphagia which occurs in many nursing home residents and may require texture modification 2
• Evaluate nutritional status through body weight monitoring, body mass index, serum protein levels, and caloric counts 2

Non-Pharmacological Interventions (Implement First)

These strategies should be your foundation and can significantly improve intake without medication:

• Optimize the dining environment by seating patients at communal dining tables rather than isolating them in rooms, as social interaction during meals improves food consumption 3
• Provide feeding assistance with increased time spent by nursing staff during meals, verbal prompting, encouragement, and emotional support 2, 3
• Modify meal structure by offering smaller, more frequent meals with favorite foods and energy-dense options to maximize nutritional intake without increasing volume 1, 3
• Make snacks available between meals and provide oral nutritional supplements when dietary intake falls to 50-75% of usual intake 3
• Ensure proper positioning and create a relaxed, comfortable environment during mealtimes 3

Pharmacological Options

First-Line: Mirtazapine

• Dose: 7.5-15 mg at bedtime 1
• Advantages: Addresses both appetite loss and concurrent depression, which is common in nursing home residents 1
• Monitoring: Start with lower doses in elderly patients and monitor closely for sedation 3

Second-Line: Megestrol Acetate

If mirtazapine is ineffective or contraindicated:

• Dose: 400-800 mg/day 1, 3
• Expected outcomes: Approximately 1 in 4 patients will experience improved appetite and 1 in 12 will gain weight 2
• Critical warnings: 1 in 6 patients will develop thromboembolic phenomena and 1 in 23 will die from treatment-related complications 2, 4
• Additional risks: Can cause adrenal insufficiency, new-onset diabetes, Cushing's syndrome, and requires monitoring for signs of hypoadrenalism (hypotension, nausea, vomiting, dizziness, weakness) 4

Alternative: Dexamethasone

For patients with shorter life expectancy (weeks to months):

• Dose: 2-8 mg/day 1, 3
• Advantages: Faster onset of action 1
• Caution: Significant side effects with prolonged use including hyperglycemia, muscle wasting, and immunosuppression 3

Other Options

• Olanzapine 5 mg/day if concurrent nausea/vomiting is present 3
• Metoclopramide 5-10 mg four times daily (30 minutes before meals and at bedtime) for early satiety due to gastroparesis 2

Special Considerations for Dementia Patients

Do NOT use appetite stimulants systematically in patients with dementia unless there is documented depression requiring treatment 2, 1, 3. The evidence shows limited benefit and potential harm in this population 2.

Instead, focus exclusively on:

• Behavioral interventions: Feeding assistance, supervision during meals, verbal prompting 2
• Environmental modifications: Emotional support, specific communication strategies 2
• Caregiver education: Training nursing staff on feeding techniques and mealtime management has shown positive effects on nutritional outcomes 2

End-of-Life Considerations

If the patient is approaching end of life, shift focus entirely to comfort and quality of life rather than nutritional goals. 1 In this context, forcing nutrition may cause more distress than benefit.

Monitoring and Reassessment

• Regular reassessment is mandatory to evaluate benefit versus harm of any pharmacological intervention 1, 3
• Monitor weight weekly and track body mass index 2
• Watch for complications of appetite stimulants, particularly thromboembolic events with megestrol acetate and sedation with mirtazapine 3
• Adjust interventions based on response, with readiness to discontinue medications that are not providing clear benefit 1

Common Pitfalls to Avoid

• Do not skip non-pharmacological interventions in favor of immediate medication use—environmental and behavioral strategies are often highly effective and carry no risk 3
• Do not use appetite stimulants in dementia patients without clear evidence of depression 2, 1
• Do not continue megestrol acetate without weighing the significant thromboembolic and mortality risks against modest benefits 2
• Do not forget to assess for adrenal insufficiency in patients on or being withdrawn from chronic megestrol acetate, especially during stress or illness 4