Medications to Increase Appetite in the Elderly
Primary Recommendation
- The American College of Physicians recommends prioritizing non-pharmacological interventions first, and reserving pharmacological appetite stimulants for specific clinical contexts only, such as mirtazapine for elderly patients with concurrent depression or megestrol acetate for hospitalized/seriously ill patients without depression 1, 2
Clinical Context Determines Drug Selection
For Elderly Patients WITH Depression
- Mirtazapine is the first-line agent for elderly patients with appetite loss and depression, with a recommended starting dose of 7.5 mg at bedtime, titrated to 15-30 mg based on response 1, 2
- Expected outcomes with mirtazapine include a mean weight gain of 1.9 kg at 3 months and 2.1 kg at 6 months, with approximately 80% of patients experiencing some weight gain 3, 2
For Hospitalized or Seriously Ill Elderly Patients WITHOUT Depression
- Megestrol acetate is the most effective first-line option for hospitalized or seriously ill elderly patients without depression, at a dose of 400-800 mg/day 1, 2
- Approximately 1 in 4 patients will have increased appetite and 1 in 12 will gain weight with megestrol acetate 2
For Patients WITH Dementia
- The American Geriatrics Society recommends not using appetite stimulants in patients with dementia unless they have concurrent depression requiring treatment 3, 4, 1, 5
- Evidence shows no consistent benefit of appetite stimulants on body weight, BMI, or energy intake in patients with dementia 3, 6
Non-Pharmacological Interventions
Medication Review
- The American College of Physicians recommends performing systematic medication review to identify drugs affecting appetite, such as opioids, sedatives, and metformin 4
Social and Environmental Modifications
- The American Geriatrics Society recommends encouraging shared meals with family or other patients to stimulate dietary intake 4, 1, 5
- Assigning consistent caregivers for feeding assistance and providing adequate time for meals with emotional support and verbal prompting can also improve food consumption 6, 5
Nutritional Optimization
- The American College of Physicians recommends offering oral nutritional supplements when dietary intake falls to 50-75% of usual intake 1, 2, 5
- Providing energy-dense meals, texture-modified foods, and small frequent meals can also help optimize nutrition 5
Medications NOT Recommended
Cannabinoids (Dronabinol)
- The American Academy of Neurology recommends against the routine use of cannabinoids due to insufficient evidence 2
- Three small placebo-controlled trials in dementia patients found no significant effect of cannabinoids on body weight, BMI, or energy intake 3, 6, 2