Appetite stimulation in dementia with reduced appetite
Drugs intended to stimulate appetite or cause weight gain should not be used for reduced appetite in persons with dementia. [1] When an antidepressant is clinically indicated for coexisting depression in dementia, mirtazapine may be considered because weight gain and increased appetite are established adverse effects. [1] Pseudobulbar affect should be treated with dextromethorphan/quinidine rather than with appetite stimulants. [2]
Core recommendation for medication choice
- Drugs to stimulate appetite or weight gain should NOT be used in persons with dementia and reduced appetite. (Grade not specified in the section text; recommendation statement is explicit.) [1]
- Mirtazapine should NOT be used for appetite stimulation alone when depression is not being treated. [1]
- Megestrol acetate should be avoided in older adults because it increases the risk of thrombotic events and possibly death. [3]
Medication selection algorithm
- If reduced appetite occurs in dementia without depression: no appetite-stimulating drug is recommended. [1]
- If reduced appetite occurs in dementia with clinically significant depression requiring an antidepressant:
-
Mirtazapine (weight gain and increased appetite adverse effects; antidepressant therapy context). [1]
-
If symptoms primarily reflect pseudobulbar affect:
- Dextromethorphan/quinidine (FDA-approved therapy for PBA in appropriate neurologic conditions). [2]
Key evidence supporting this recommendation
- ESPEN (dementia nutrition and hydration guideline update 2024) states that evidence for drugs as appetite stimulants in persons with dementia is very limited and concludes that the use of appetite stimulants cannot be recommended. [1]
- ESPEN reports that placebo-controlled trials of cannabinoids in dementia were small and did not show consistent benefits on body weight, BMI, or energy intake. [1]
- ESPEN reports that data supporting mirtazapine in dementia for weight/appetite are limited and that benefit is framed as potentially relevant only when antidepressant treatment for comorbid depression is required. [1]
Monotherapy vs combination therapy
- Combination strategies that add appetite-stimulating medications solely to increase intake in dementia are not recommended because appetite stimulants should not be used for reduced appetite in dementia. [1]
- Treatment of pseudobulbar affect should use an evidence-based PBA medication rather than appetite-stimulating drugs. [2]
Important clarifications and nuances
- Mirtazapine is positioned as a potential option only when depression requires antidepressant therapy. [1]
- Mirtazapine’s propensity for increased appetite and weight gain is documented as an adverse effect. [4]
- Megestrol acetate has geriatric safety concerns that make it an inappropriate appetite-stimulation strategy in older adults. [3]
Initiation thresholds and indications
- No medication threshold for appetite stimulants applies because these drugs should not be used for reduced appetite in dementia. [1]
- Mirtazapine may be considered when depression is present and antidepressant treatment is clinically indicated. [1]
Common pitfalls to avoid
- Megestrol acetate should not be selected because of thrombotic-event and possible mortality risk in older adults. [3]
- Cannabinoids and other appetite-stimulant strategies should not be selected as routine therapy in dementia-related reduced appetite because of limited and inconsistent evidence of benefit. [1]
Treatment goals
- The goal in dementia with reduced appetite is to avoid appetite-stimulating drugs and instead use non-drug nutritional care approaches aligned with dementia nutrition guidance. [1]
- The goal in pseudobulbar affect is symptomatic control using dextromethorphan/quinidine when indicated for PBA. [2]