Appetite Stimulation in Dementia: Evidence-Based Recommendations
Direct Answer
Pharmacological appetite stimulants are NOT recommended for patients with dementia unless concurrent depression is present, in which case mirtazapine 7.5-15 mg at bedtime is the only appropriate option. 1 For all other dementia patients, focus exclusively on non-pharmacological interventions including oral nutritional supplements, environmental modifications, and behavioral strategies. 1
The Critical Exception: Concurrent Depression
If your patient has dementia WITH depression requiring pharmacological treatment, use mirtazapine 7.5-15 mg at bedtime. 1, 2 This addresses both conditions simultaneously with beneficial side effects including promotion of sleep, appetite, and weight gain. 2
- Start at 7.5 mg at bedtime, with maximum dose of 30 mg at bedtime 2
- Allow 4-8 weeks for a full therapeutic trial to assess efficacy 2
- Limited evidence shows mean weight gain of 1.9 kg at 3 months and 2.1 kg at 6 months, with approximately 80% experiencing some weight gain 2
- After 9 months of treatment, consider dosage reduction to reassess need for continued medication 2
Why Other Appetite Stimulants Should Be Avoided
The American Geriatrics Society explicitly recommends against pharmacological appetite stimulants in dementia patients without depression because potential risks outweigh uncertain benefits. 1
Megestrol Acetate - Do NOT Use
- Despite effectiveness in cancer-related cachexia, megestrol acetate should NOT be used systematically in dementia patients 1
- Associated with thromboembolic events, edema, vaginal spotting, and higher mortality rates compared to placebo 2
- One Cochrane review found higher death rates in the megestrol acetate group 2
- May cause adrenal suppression, with 70-78% of elderly patients developing morning cortisol levels below normal at doses of 400-800 mg 3
Dronabinol/Cannabinoids - Do NOT Use
- Cannabinoid administration in elderly patients may induce delirium 1
- Three small placebo-controlled trials in dementia patients found no significant effect on body weight, BMI, or energy intake 2
- One small study (n=11) showed increased body weight but with unclear clinical significance 1
What You SHOULD Do: Non-Pharmacological Approaches
Stage-Appropriate Nutritional Support
In early and moderate dementia, oral nutritional supplements (ONS) and occasionally tube feeding may contribute to ensuring adequate energy and nutrient supply and preventing undernutrition. 4
- Provide ONS when dietary intake falls to 50-75% of usual intake 1
- Use protein-enriched foods and drinks to improve protein intake 1
- Offer supplements between meals rather than replacing meals 1
In terminal dementia, tube feeding is NOT recommended. 4
Eliminate Treatable Causes First
Conduct a systematic review to identify and address reversible factors: 1
- Oral and dental problems - pain, ill-fitting dentures, poor oral hygiene 1
- Medication side effects - polypharmacotherapy is a common cause of anorexia 4
- Cholinesterase inhibitors - may paradoxically worsen appetite 1
- Depression - often unrecognized but a major cause of undernutrition in elderly 4
- Apraxia of eating - forgetting to eat or how to eat 4
Environmental and Behavioral Modifications
Create a social, supportive dining experience: 1
- Encourage eating with others at a dining table rather than isolated in rooms 1, 5
- Assign consistent caregivers during meals when possible 1, 5
- Provide adequate time for meals with emotional support, supervision, and verbal prompting 5
- Increase time spent by nursing staff on feeding assistance 5
Adapt meals to individual preferences and abilities: 1
- Provide energy-dense meals to meet nutritional requirements without increasing volume 1, 5
- Offer texture-modified foods for patients with chewing or swallowing difficulties 1, 5
- Provide finger foods for patients who have difficulty using utensils 1, 5
- Serve small, frequent meals throughout the day 1, 5
- Honor individual food preferences and cultural traditions 1
Critical Decision-Making Framework for Tube Feeding
The decision for or against tube feeding must be made individually, considering: 4
- Presumed or previously expressed wishes of the patient regarding tube feeding 4
- Severity of the disease (early/moderate vs. terminal dementia) 4
- Individual prognosis and life expectancy 4
- Anticipated quality of life with or without tube feeding 4
- Anticipated complications and impairments due to tube feeding 4
- Mobility status of the patient 4
This decision must involve relatives, caregivers, legal custodian, family doctor, therapists, and in case of doubt, legal advice. 4
Common Pitfalls to Avoid
Do not use formal standardized nutritional assessments in severe dementia - these can be burdensome and cause more harm than good; focus should shift to informal identification of individual needs and problems. 1
Do not continue interventions that increase burden without clear benefit to quality of life - interventions should only be taken as long as clinically appropriate, with potential benefits weighed against risks. 1
Do not assume appetite loss is always part of natural decline - depression is common in elderly patients but often not recognized due to difficulty discriminating it from other symptoms of old age. 4, 6 Anorexia and refusal to eat are integral symptoms of depression and a major cause of undernutrition. 4
Evidence Quality and Nuances
The evidence base for appetite stimulants in severe dementia is weak, consisting primarily of small trials with unclear methodology. 1 Some studies with ONS have shown improvements in body weight, but available trials regarding effects on functional status report no improvement, and most studies show no survival benefit. 4
The outcome and success of nutritional therapy in demented patients are strongly influenced by severity of disease, comorbidities, and general condition. 4 This is why adequate high-quality nutrition is especially important in early and middle stages of dementia to prevent undernutrition and maintain stable general condition. 4
Depression and difficulty maintaining attention while eating are significantly associated with poor appetite in both Alzheimer's disease and mild cognitive impairment. 6 Among persons with Alzheimer's disease specifically, lower vitality, more comorbidities, non-use of antidementia drugs, and use of psychotropic drugs are also significantly associated with poor appetite. 6