Appetite Stimulation in Elderly Patients

Introduction to Appetite Stimulation

Appetite stimulation is a concern in elderly patients, particularly those with dementia, depression, or other underlying conditions that affect eating habits 1, 2

The European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines recommend against using drugs to stimulate appetite or weight gain in persons with dementia and very elderly patients, due to potential risks outweighing uncertain benefits 2
The ESPEN guidelines also recommend against using mirtazapine solely for appetite stimulation in elderly patients without depression, due to potential risks outweighing uncertain benefits 1, 2
The American College of Nutrition recommends addressing underlying causes of poor appetite and implementing nutritional support strategies, such as more frequent, smaller meals, energy-dense meals, supervision during meals, and emotional support during eating 3

Mirtazapine has been shown to cause weight gain as a side effect, but its use in elderly patients is concerning due to increased risk of sedation, potential for QTc prolongation, and lack of placebo-controlled trials in this age group 2
Mirtazapine may cause weight gain, but there are no placebo-controlled trials supporting its use specifically for appetite stimulation in elderly patients, and patients should be monitored for excessive weight gain and sedation 1, 2
Potential risks of mirtazapine, including sedation, discontinuation syndrome, and QTc prolongation, outweigh uncertain benefits in extremely elderly populations, such as 100-year-old patients with decreased eating due to depression 2

For elderly patients with poor appetite without depression, consider food and drink fortification using natural foods (oil, cream, full-cream milk, nuts, butter, eggs) and non-pharmacological approaches, such as more frequent, smaller meals with energy-dense options, supervision during meals, and emotional support during eating 2
The American College of Nutrition recommends implementing nutritional support strategies, such as more frequent, smaller meals, energy-dense meals, supervision during meals, and emotional support during eating 3

Mirtazapine may be appropriate for elderly patients with both depression and poor appetite, as it addresses both conditions simultaneously, with the ESPEN guidelines recommending its use for patients with depression 1, 2
Mirtazapine is effective for treating depression, with efficacy comparable to other second-generation antidepressants, and may have a faster onset of action compared to SSRIs, with significant improvements observed as early as 1-2 weeks into treatment 4
In palliative care settings, mirtazapine may be useful for anorexia when patients also have sleep difficulties or mood disorders, particularly for patients with end-stage cardiovascular disease 5
A small retrospective non-controlled open-label study in dementia patients showed mean weight gain of 1.9 kg after three months and 2.1 kg after six months with 30 mg daily mirtazapine 2