Management of Protein-Calorie Malnutrition in Elderly Patients

First-Line Approach: Nutritional Support

The American Society for Nutrition recommends offering oral nutritional supplements (ONS) providing at least 400 kcal/day including 30g or more of protein/day when dietary counseling and food fortification are insufficient 2, 3
Continue ONS for at least one month with regular assessment of efficacy, as recommended by the Clinical Nutrition society 2, 3
Provide texture-modified, enriched foods for patients with chewing or swallowing problems, according to the Clinical Nutrition guidelines 2
Offer additional snacks and finger foods to facilitate dietary intake, as suggested by the Clinical Nutrition society 3
Create a relaxed, comfortable environment during meals with social interaction to stimulate appetite, as recommended by the Praxis Medical Insights 4

Mirtazapine (7.5-15 mg at bedtime) is recommended as the first-line pharmacological appetite stimulant for elderly patients with moderate to severe protein-calorie malnutrition, according to the Praxis Medical Insights 1
The American College of Clinical Pharmacology recommends using lower starting doses of mirtazapine in elderly patients with close monitoring 4
Megestrol acetate (400-800 mg/day) may be considered if mirtazapine is ineffective or contraindicated, with careful risk assessment, as recommended by the Praxis Medical Insights 1, 4, 5
The use of megestrol acetate is associated with improved appetite in approximately 25% of patients, but also with a higher risk of death (RR 1.42) and thromboembolic events (RR 1.84) compared to placebo, according to the Praxis Medical Insights 5
Dexamethasone (2-8 mg/day) may be used as a third-line option for patients with shorter life expectancy, with significant side effects including hyperglycemia, muscle wasting, and immunosuppression, as recommended by the Praxis Medical Insights 4

The American Society for Nutrition recommends screening for malnutrition within 24 hours of hospital admission and evaluating for treatable causes of poor appetite 1
Begin with non-pharmacological approaches (ONS, food fortification, social interventions) and provide at least 30 kcal/kg/day and 1 g/kg/day of protein, as recommended by the Clinical Nutrition society 2, 3, 6
Adapt type, flavor, texture, and time of consumption to patient preferences, according to the Clinical Nutrition guidelines 2
Monitor for side effects, particularly sedation, and assess weight, appetite, and nutritional intake weekly, as recommended by the Clinical Nutrition society and the Praxis Medical Insights 1, 2, 5

Avoid appetite stimulants in patients with dementia without evidence of depression, as recommended by the Praxis Medical Insights 1, 4
Focus on comfort and quality of life rather than nutritional goals in patients at the end of life, according to the Praxis Medical Insights 1
ONS can improve dietary intake and body weight, and lower risk of complications and readmission in hospitalized patients, as recommended by the Clinical Nutrition society 2
Continue ONS after hospital discharge to improve dietary intake and body weight, and lower risk of functional decline, according to the Clinical Nutrition society 2