Appetite Stimulation in Dementia

Pharmacological Interventions

The American Geriatrics Society recommends against pharmacological appetite stimulants in dementia patients without depression because potential risks outweigh uncertain benefits 1
Mirtazapine 7.5-15 mg at bedtime is the only appropriate pharmacological option for dementia patients with concurrent depression, promoting sleep, appetite, and weight gain 1, 2
Start mirtazapine at 7.5 mg at bedtime, with a maximum dose of 30 mg at bedtime, and allow 4-8 weeks for a full therapeutic trial to assess efficacy 2
Limited evidence shows mean weight gain of 1.9 kg at 3 months and 2.1 kg at 6 months with mirtazapine, with approximately 80% experiencing some weight gain 2
After 9 months of treatment, consider dosage reduction to reassess the need for continued medication 2

In early and moderate dementia, oral nutritional supplements (ONS) and occasionally tube feeding may contribute to ensuring adequate energy and nutrient supply and preventing undernutrition 3, 4
Provide ONS when dietary intake falls to 50-75% of usual intake, and use protein-enriched foods and drinks to improve protein intake 1
Offer supplements between meals rather than replacing meals, and provide adequate time for meals with emotional support, supervision, and verbal prompting 1, 5
Create a social, supportive dining experience by encouraging eating with others at a dining table, assigning consistent caregivers during meals, and increasing time spent by nursing staff on feeding assistance 1, 5
Adapt meals to individual preferences and abilities by providing energy-dense meals, texture-modified foods, and finger foods, and serving small, frequent meals throughout the day 1, 5

The decision for or against tube feeding must be made individually, considering the presumed or previously expressed wishes of the patient, severity of the disease, individual prognosis, and life expectancy 3, 4
Tube feeding is not recommended in terminal dementia 3, 4
The decision-making process should involve relatives, caregivers, legal custodian, family doctor, therapists, and in case of doubt, legal advice 3, 4

Do not use formal standardized nutritional assessments in severe dementia, as they can be burdensome and cause more harm than good 1
Do not continue interventions that increase burden without clear benefit to quality of life, and only take interventions as long as clinically appropriate, with potential benefits weighed against risks 1
Do not assume appetite loss is always part of natural decline, as depression is common in elderly patients but often not recognized due to difficulty discriminating it from other symptoms of old age 3, 4