What is the best approach for managing decreased appetite in an 87-year-old patient with dementia, frailty, and polypharmacy, considering the potential use of Remeron (mirtazapine) and elder tonic?

Managing Decreased Appetite in an 87-Year-Old with Dementia, Frailty, and Polypharmacy

Perform a comprehensive medication review first to identify and reduce medications contributing to appetite loss, rather than adding mirtazapine or elder tonic—this is the evidence-based priority for your patient. 1

Why Medication Review Comes First

Your patient's polypharmacy is likely the primary driver of decreased appetite, and adding another medication (mirtazapine) would worsen the medication burden rather than address the root cause. 1

• Polypharmacy is robustly associated with malnutrition in older adults, and nearly all drugs can affect appetite depending on dosage, body weight, renal function, and individual vulnerability 1, 2
• Common appetite-suppressing medications include: opioids, sedatives, digoxin, metformin, antibiotics, and NSAIDs 1
• If your patient is on cholinesterase inhibitors (donepezil, galantamine, rivastigmine), these specifically increase risk of weight loss in vulnerable patients with dementia 1
• Sedatives reduce attention and activity at mealtimes, limiting food intake 1
• Diuretics cause excessive fluid losses and worsen dehydration risk 1

Why Mirtazapine is NOT Appropriate for This Patient

Mirtazapine should only be used in dementia patients with concurrent depression—not for appetite stimulation alone. 3, 4, 5

Critical Evidence Against Mirtazapine in Dementia Without Depression:

• Clinical nutrition guidelines with 89% consensus agreement state that appetite stimulants show no consistent benefit in dementia patients, and potentially harmful side effects outweigh uncertain benefits 3, 5
• The American Geriatrics Society explicitly recommends NOT using appetite stimulants in dementia patients unless concurrent depression exists 3, 5
• A 2023 randomized controlled trial (HTA-SYMBAD) found mirtazapine was not clinically effective for agitation in dementia, and there were more deaths in the mirtazapine group (n=7) versus placebo (n=1) by week 16, which was of marginal statistical significance (p=0.065) 6

If Depression IS Present:

• Start mirtazapine at 7.5 mg at bedtime (not the FDA-recommended 15 mg, which is too high for frail elderly) 3, 4, 7
• Maximum dose is 30 mg at bedtime 4, 7
• Allow 4-8 weeks for full therapeutic trial 4
• Expected weight gain: mean 1.9 kg at 3 months and 2.1 kg at 6 months, with approximately 80% experiencing some weight gain (based on one small retrospective study in 22 dementia patients) 3, 4, 8

Mirtazapine Safety Concerns in Frail Elderly:

• FDA label warns that clearance is reduced in elderly patients, requiring conservative dosing 7
• Sedating properties cause confusion and over-sedation in elderly 7
• Risk of hyponatremia is greater in elderly 7
• Common adverse effects include somnolence (54% vs 18% placebo), weight gain, dizziness, and dry mouth 7
• Requires gradual discontinuation over 10-14 days to limit withdrawal symptoms 4, 7

Regarding "Elder Tonic"

There is no evidence supporting the use of general vitamin/mineral supplements or herbal supplements for appetite stimulation in elderly patients with dementia. 1

• Multiple vitamin/mineral supplements contribute to medication burden and occasionally cause anorexia without substantiated benefit 1
• Herbal supplements are not FDA-regulated, have actual drug interaction concerns, add to medication burden and expense, and have poor to no evidence of pharmacological benefit 1

Evidence-Based Action Plan for Your Patient

Step 1: Medication Review (Highest Priority)

Systematically review all medications with a qualified practitioner to minimize adverse drug effects on food and fluid intake. 1

• Identify medications causing xerostomia, nausea, apathy, altered taste/smell, or gastrointestinal motility disturbances 1
• Assess temporal relationship between medication changes and appetite/weight changes 1
• Consider reducing or discontinuing cholinesterase inhibitors if patient has experienced severe weight loss 1
• Reduce sedatives that impair attention at mealtimes 1
• Adjust diuretics if causing excessive dehydration 1
• Temporarily discontinue non-essential medications (e.g., iron supplements taken before meals) 4

Step 2: Non-Pharmacological Interventions

Prioritize these evidence-based strategies before considering any pharmacological appetite stimulants: 3, 4, 5

Social Dining Strategies:

• Encourage shared meals with family or other patients—this significantly improves intake and quality of life 1, 4
• Assign consistent caregivers for feeding assistance 4
• Provide adequate time for meals with emotional support and verbal prompting 1, 4

Nutritional Optimization:

• Offer oral nutritional supplements when dietary intake falls to 50-75% of usual intake 3, 4
• Provide energy-dense meals and small frequent meals 3
• Offer texture-modified foods if dysphagia is present 1
• Avoid all dietary restrictions that may limit food/fluid intake—these are potentially harmful in dementia 1

Address Reversible Causes:

• Ensure adequate oral care and dental treatment 1
• Treat acute disease and chronic pain adequately 1
• Support with shopping and meal preparation if social problems exist 1

Step 3: Monitoring Protocol

• Screen for malnutrition using validated tools (NRS-2002, MNA, or MUST) 3, 4
• Monitor weight regularly to track response to interventions 8
• Consider referral to nutritionist/dietician, dentist for poor dentition, or speech therapy for swallowing difficulties 4

What NOT to Do

• Do not add mirtazapine unless depression is documented and treated 3, 4, 5
• Do not use elder tonic or general vitamin/mineral supplements 1
• Do not use cannabinoids (dronabinol)—three placebo-controlled trials found no significant effect on body weight, BMI, or energy intake in dementia patients 3
• Do not use megestrol acetate in this outpatient setting—it is reserved for hospitalized or seriously ill patients without depression, and carries risks of thromboembolic events, edema, and higher mortality rates 3, 4

Clinical Bottom Line

For your 87-year-old patient with dementia, frailty, and polypharmacy: conduct a medication review to reduce appetite-suppressing drugs, implement social dining strategies, optimize nutrition with supplements and energy-dense foods, and avoid adding mirtazapine or elder tonic unless depression is documented. 1, 3, 4