What is the best appetite stimulant for an elderly man with decreased appetite?

Best Appetite Stimulant for an Elderly Man

Mirtazapine 7.5 mg at bedtime is the best first-line appetite stimulant for an elderly man, particularly if depression is present or suspected, as it simultaneously addresses both conditions with a favorable side-effect profile that includes sedation, appetite stimulation, and weight gain. 1

Clinical Decision Algorithm

Step 1: Assess for Depression and Dementia

• If depression is present or suspected: Start mirtazapine 7.5 mg at bedtime 1, 2

  • This is the ideal choice because it treats both depression and appetite loss simultaneously 1
  • Approximately 80% of patients experience weight gain, with mean gains of 1.9 kg at 3 months and 2.1 kg at 6 months 1
  • The sedating properties make bedtime dosing optimal 1

• If dementia without depression: Do NOT use any appetite stimulants 1, 3

  • Evidence shows no consistent benefit and potentially harmful side effects outweigh uncertain benefits (89% consensus agreement) 1
  • Focus exclusively on non-pharmacological approaches 3

Step 2: Mirtazapine Dosing and Monitoring

• Initial dose: 7.5 mg at bedtime 1
• Maximum dose: 30 mg at bedtime 1
• Trial duration: Requires at least 4-8 weeks to assess efficacy 1
• Reassessment: After 9 months of treatment, consider dosage reduction to reassess need for continued medication 1
• Discontinuation: Taper over 10-14 days to limit withdrawal symptoms 1

Step 3: Alternative Pharmacological Options (If Mirtazapine Fails or Is Contraindicated)

• Megestrol acetate 400-800 mg daily: 1, 3

  • Approximately 1 in 4 patients will have increased appetite 1
  • Approximately 1 in 12 patients will gain weight 1
  • Critical safety concerns: Thromboembolic events, adrenal suppression, fluid retention 1, 3
  • May attenuate benefits of resistance training, causing smaller gains or deterioration in muscle strength 1

• Dexamethasone 2-8 mg daily: 1, 3

  • Faster onset of action, suitable for shorter life expectancy 1
  • Significant side effects with prolonged use: Hyperglycemia, muscle wasting, immunosuppression 3

• Olanzapine 5 mg daily: 3, 2

  • Consider if concurrent nausea/vomiting is present 3

Non-Pharmacological Approaches (Essential Regardless of Medication Use)

Environmental and Social Interventions

• Encourage shared meals with family or other patients to improve intake 1
• Place patients at dining tables rather than isolated in rooms 3
• Provide emotional support, supervision, and verbal prompting during meals 3
• Ensure consistent caregivers during meals when possible 3

Dietary Modifications

• Offer smaller, more frequent meals with favorite foods 1
• Provide energy-dense options to maximize nutritional intake without increasing volume 1, 3
• Consider fortified foods and oral nutritional supplements when dietary intake falls to 50-75% of usual intake 1
• Offer finger foods for patients with difficulty using utensils 3
• Make snacks available between meals 3

Medication Review

• Identify potential contributors to poor appetite (iron supplements, multiple medications before meals) 1
• Consider temporarily discontinuing non-essential medications 1

Critical Safety Considerations for Mirtazapine

• Serotonin syndrome risk: Monitor when used with other serotonergic agents; discontinue immediately if symptoms occur 4
• Angle-closure glaucoma: Pupillary dilation may trigger attacks in patients with anatomically narrow angles 4
• QTc prolongation: Exercise caution in patients with cardiovascular disease or family history of QT prolongation 4
• Somnolence: Reported in 54% of patients; caution about operating machinery or driving 4
• Elevated cholesterol and triglycerides: Monitor lipid levels 4
• Mania activation: Screen for personal or family history of bipolar disorder before initiating 4

Common Pitfalls to Avoid

• Do not use appetite stimulants in dementia patients without depression - the evidence is clear that risks outweigh benefits 1, 3
• Do not start with high doses in elderly patients - always begin with 7.5 mg and titrate slowly 1
• Do not continue indefinitely without reassessment - evaluate benefit versus harm regularly 1
• Do not use megestrol acetate in patients undergoing resistance training - it may worsen muscle strength 1
• Do not ignore non-pharmacological interventions - these should be implemented regardless of medication use 1, 3