What medications can be used to increase appetite in elderly patients with decreased appetite?

Medications to Increase Appetite in the Elderly

Primary Recommendation

Prioritize non-pharmacological interventions first, and reserve pharmacological appetite stimulants for specific clinical contexts only—specifically mirtazapine for elderly patients with concurrent depression (7.5-30 mg at bedtime) or megestrol acetate for hospitalized/seriously ill patients without depression (400-800 mg/day), while avoiding appetite stimulants entirely in patients with dementia who lack concurrent depression. 1, 2

Clinical Context Determines Drug Selection

For Elderly Patients WITH Depression

• Mirtazapine is the first-line agent when appetite loss coexists with depression, as it addresses both conditions simultaneously 1, 2
• Start at 7.5 mg at bedtime, titrate to 15-30 mg based on response 1, 2
• Expected outcomes: mean weight gain of 1.9 kg at 3 months and 2.1 kg at 6 months, with approximately 80% experiencing some weight gain 3, 2
• Requires 4-8 weeks for full therapeutic trial 2
• Sedating properties make bedtime dosing ideal 2
• After 9 months, consider dosage reduction to reassess need for continued medication 2
• Discontinue over 10-14 days to limit withdrawal symptoms 2

For Hospitalized or Seriously Ill Elderly Patients WITHOUT Depression

• Megestrol acetate is the most effective first-line option at 400-800 mg/day 1, 2
• Approximately 1 in 4 patients will have increased appetite and 1 in 12 will gain weight 2
• Patients gain an average of 2.25 kg compared to placebo 4
• Critical safety concerns: thromboembolic events (reported in 2 patients in one trial), edema, vaginal spotting, adrenal suppression, and potentially higher mortality rates 2, 4, 5
• At 400-800 mg doses, 70-78% of patients develop cortisol suppression (morning cortisol <8 ng/mL), which may persist 5
• May attenuate benefits of resistance training, causing smaller gains or deterioration in muscle strength and functional performance 3, 2
• Increases prealbumin levels at 20 days in a dose-response relationship 5

For Patients WITH Dementia

Do NOT use appetite stimulants in patients with dementia unless they have concurrent depression requiring treatment 3, 1, 6

• Evidence shows no consistent benefit on body weight, BMI, or energy intake 3
• Potentially harmful side effects outweigh uncertain benefits (89% consensus agreement among guideline authors) 3
• Three small placebo-controlled trials of cannabinoids in dementia patients found no significant effects 3
• Two studies of megestrol acetate in mixed populations (only 41% with dementia) showed inconsistent results 3
• The one exception: Consider mirtazapine only if the patient has concomitant depressive syndrome requiring pharmacological treatment 6

Non-Pharmacological Interventions (Implement BEFORE Pharmacotherapy)

Medication Review

• Perform systematic medication review to identify drugs affecting appetite: opioids, sedatives, digoxin, metformin, antibiotics, NSAIDs 3
• Cholinesterase inhibitors may cause weight loss in vulnerable patients with dementia 3
• Temporarily discontinue non-essential medications like iron supplements taken before meals 2

Social and Environmental Modifications

• Encourage shared meals with family or other patients—eating in company stimulates dietary intake 3, 1, 6
• Assign consistent caregivers for feeding assistance, as quality of interaction during meals influences food consumption 3, 6
• Provide adequate time for meals with emotional support, supervision, and verbal prompting 3, 6

Nutritional Optimization

• Offer oral nutritional supplements when dietary intake falls to 50-75% of usual intake 1, 2, 6
• Provide energy-dense meals, texture-modified foods, finger foods, and small frequent meals 6
• Use protein-enriched foods and drinks between meals rather than replacing meals 6

Oral Care

• Address dental problems and poor dentition, as oral care may prevent wider health impacts including pneumonia and cognitive decline 3
• Implement oral brushing once or twice daily by specially trained personnel with regular dental visits 3

Medications NOT Recommended

Cannabinoids (Dronabinol)

• Insufficient evidence to support routine use 2
• Three small placebo-controlled trials in dementia patients found no significant effect on body weight, BMI, or energy intake 3, 2
• May induce delirium in elderly patients 6
• One small study (n=12) showed increased body weight but with unclear clinical significance 3

Flavor Enhancers

• Should NOT routinely be used to promote food intake in persons with dementia (73% agreement) 3

Monitoring and Safety

Regular Reassessment Schedule

• Evaluate at weeks 1,2,4,8, and 12 to assess benefit versus harm 1, 2
• Screen for malnutrition using validated tools (NRS-2002, MNA, or MUST) 2

Mirtazapine-Specific Monitoring

• Common side effects: somnolence (54% vs 18% placebo), appetite increase (17% vs 2% placebo), weight gain ≥7% (7.5% vs 0% placebo) 7
• Caution patients about impaired performance, operating machinery, and driving until effects are known 7
• Avoid concomitant benzodiazepines and alcohol 7
• Monitor for serotonin syndrome if combined with other serotonergic drugs 7
• Screen for personal/family history of bipolar disorder before initiating, as it may precipitate mania/hypomania 7
• Monitor for QTc prolongation in patients with cardiovascular disease or family history of QT prolongation 7
• Monitor cholesterol (15% develop increases ≥20% above normal) and triglycerides (6% develop levels ≥500 mg/dL) 7

Megestrol Acetate-Specific Monitoring

• Monitor for thromboembolic events, edema, and vaginal spotting 2, 4
• Check morning cortisol levels, especially at higher doses (400-800 mg), as suppression is common and may persist 5
• Watch for clinical symptoms of adrenal insufficiency 5
• Higher mortality rates reported in some studies compared to placebo 2, 4

Critical Caveats

• Quality of life does not improve with megestrol acetate despite weight gain 4
• No optimal dose of megestrol acetate has been established—lower doses (200 mg) show no difference from higher doses (400-800 mg) in some outcomes 4
• In end-of-life patients, focus on comfort and quality of life rather than nutritional goals, as overly aggressive interventions can increase suffering 2, 6
• Formal standardized nutritional assessments can be burdensome in severe dementia and may cause more harm than good 6