In an 88‑year‑old woman with dementia and insomnia who repeatedly demands food despite having eaten and calls emergency services believing she is not being fed, what are the likely causes of this behavior and what pharmacologic treatments are appropriate?

Understanding Eating-Related Behaviors in Dementia

This patient's repetitive demands for food despite adequate intake and false belief that she is not being fed represent classic dementia-related behavioral symptoms stemming from severe memory impairment, impaired appetite regulation, and attention disorders—not true hunger or malnutrition. 1

Pathophysiology of These Behaviors

Memory and Orientation Deficits

• Severe memory loss means this patient retains only fragments of recent events and rapidly loses new information, so she genuinely cannot recall having just eaten 1
• Severe disorientation to time and often to place is characteristic at this stage, contributing to her confusion about meal timing 1
• The false belief that staff are not feeding her reflects both memory loss and impaired judgment/problem-solving abilities that are severely compromised in moderate-to-severe dementia 1

Dementia-Specific Appetite Dysregulation

• Impaired appetite regulation is a direct pathophysiological consequence of dementia, affecting the brain's ability to process satiety signals 1
• Attention deficits prevent sustained focus on eating and drinking, paradoxically leading to both forgetting meals and difficulty completing them 1
• Agnosia (loss of ability to recognize objects) may mean she cannot distinguish between having eaten versus not having eaten 1

Behavioral Symptoms in Moderate-to-Severe Dementia

• Behavioral problems including disturbed eating behavior typically emerge in moderate-to-severe stages 1
• Agitation and repetitive behaviors (like repeatedly demanding food) are common manifestations that increase caregiver burden 1

Critical Assessment Before Any Intervention

Rule Out Treatable Causes First

You must systematically identify and eliminate reversible contributors before attributing behavior solely to dementia: 1

• Medication review: Check for appetite-suppressing drugs (opioids, sedatives, metformin, NSAIDs, antibiotics) or sedatives that reduce attention at mealtimes 2
• Oral/dental problems: Assess for gingival bleeding, periodontitis, stomatitis, or poor dentition that may impair eating 3
• Pain assessment: Chronic or acute pain can manifest as behavioral disturbance in dementia patients who cannot verbally communicate discomfort 1
• Acute medical illness: Rule out infection, metabolic derangement, or other acute conditions 1

Assess Actual Nutritional Status

• Screen for malnutrition using validated tools (Mini Nutritional Assessment, NRS-2002, or MUST) rather than relying on behavioral complaints 3
• Monitor weight trends, not just current weight 1
• The behavior of demanding food does not necessarily correlate with actual nutritional deficiency—memory impairment creates a disconnect between intake and perceived intake 1

Pharmacologic Interventions: What NOT to Do

Antipsychotics Are Contraindicated

Do not use antipsychotic medications (risperidone, quetiapine, haloperidol) to manage these eating-related behavioral symptoms. 4

• Antipsychotics carry a black box warning: elderly patients with dementia-related psychosis have 1.6-1.7 times increased risk of death (cardiovascular and infectious causes) 4
• Increased risk of cerebrovascular events including stroke in this population 4
• These medications do not address the underlying memory and appetite regulation problems 4

Appetite Stimulants Are Not Indicated

Do not use pharmacologic appetite stimulants (megestrol acetate, dronabinol) in dementia patients without concurrent depression. 2, 3

• The American Geriatrics Society explicitly recommends against appetite stimulants in dementia due to limited evidence and potential harms outweighing uncertain benefits 2, 3
• Expert consensus (89% agreement) states these agents show no consistent benefit in dementia patients 3
• Cannabinoids (dronabinol) may induce delirium in elderly patients 3

The One Exception: Concurrent Depression

Mirtazapine is justified only if this patient has concurrent depressive disorder requiring pharmacological treatment: 2, 3

• Start at 7.5 mg at bedtime (can increase to 15 mg) 3
• Expected weight gain: mean 1.9 kg at 3 months, 2.1 kg at 6 months, with ~80% experiencing some gain 2
• This addresses both depression and insomnia while providing appetite stimulation as a secondary benefit 3
• However, if no depression is present, mirtazapine is not indicated for behavioral symptoms alone 2, 3

Pharmacologic Management of Insomnia

Non-Benzodiazepine Hypnotics

• For dementia-related insomnia without behavioral agitation, consider zolpidem 5-10 mg at bedtime as it has demonstrated efficacy in restoring normal sleep patterns in elderly dementia patients 5
• Titrate in 5 mg increments to optimal dose (typically 10-15 mg) 5
• Avoid benzodiazepines due to increased fall risk, cognitive impairment, and paradoxical agitation 6

Alternative Agents

• Agomelatine has shown benefit for insomnia and depression in dementia patients in case reports, though evidence is limited 7
• Trazodone is commonly used but has limited efficacy data and anticholinergic effects that may worsen cognition 5

Non-Pharmacologic Interventions (Primary Approach)

Environmental and Behavioral Strategies

These should be your first-line interventions: 1, 3

• Provide consistent caregivers who can reassure her calmly when she demands food, acknowledging her concern without arguing about whether she has eaten 8
• Offer small, frequent meals and snacks throughout the day to provide reassurance and reduce anxiety about food availability 3
• Keep finger foods and safe snacks visible and accessible so she can eat when she feels the urge 3
• Create a structured meal schedule with visual cues (clocks, meal boards) to help orient her to meal times 1

Communication Techniques

• Use simple, direct language: "Your next meal is at 6 PM. Here is a snack for now." rather than trying to convince her she already ate 8
• Avoid confrontation or correction about her false belief—this increases agitation without improving the behavior 8
• Distraction techniques can redirect attention away from food demands (e.g., offering an activity, going for a walk) 8

For Insomnia: Non-Pharmacologic First

Prioritize these evidence-based approaches before medications: 6

• Light therapy: Bright light exposure (2500-10,000 lux) for 1-2 hours in the morning helps regulate circadian rhythm 6
• Exercise: Regular daytime physical activity improves nighttime sleep 6
• Sleep hygiene: Limit daytime napping, maintain consistent sleep-wake schedule, reduce nighttime noise and light 6
• Avoid caffeine after noon and ensure adequate daytime activity to prevent circadian rhythm inversion 6

Caregiver Support Is Essential

• Caregiver stress directly increases risk of adverse eating behaviors and weight loss in dementia patients 1
• Provide education to staff/family that this behavior stems from memory loss, not actual hunger or neglect 1
• Support caregivers with practical strategies to reduce their burden, as their stress perpetuates the patient's nutritional problems 1

Common Pitfalls to Avoid

1. Do not argue with the patient about whether she has eaten—her memory deficit makes this futile and increases agitation 8
2. Do not assume behavioral symptoms indicate true malnutrition—assess objectively with validated tools 3
3. Do not use antipsychotics for behavioral management given the black box warning for increased mortality 4
4. Do not overlook medication side effects (especially sedatives, cholinesterase inhibitors) that may worsen eating behaviors or insomnia 2
5. Do not use appetite stimulants unless depression is documented and treated 2, 3