Portal de Periódicos da CAPES

Developing an Appetite

2019; Elsevier BV; Volume: 20; Issue: 5 Linguagem: Inglês

10.1016/j.carage.2019.05.008

2377-066X

Jeffrey Nichols,

Nutrition and Health in Aging

Dear Dr. Jeff: Our facility’s interdisciplinary team routinely reviews the charts of every resident with significant weight loss, as required by the Centers for Medicare & Medicaid Services standards. Frequently a team member will suggest an “appetite stimulant” as the solution, perhaps to ward off a feeding tube discussion with the family or simply under the theory that no stone should be left unturned. My impression is that none of them work very well, although each of our doctors has a favorite. What do you think? Dr. Jeff responds: We live in a society that believes there is a pill for every problem. Weight loss, weight gain, too skinny, too fat, cellulite — every human condition should have a capsule, tablet, medicated lotion, or medical procedure to correct it. Most of these conditions are essentially cosmetic with a genetic component, but weight loss in a frail geriatric resident — regardless of whether the baseline weight is above or below the recommended body weights on charts — is a genuine problem that must be addressed. The interdisciplinary team is the correct mechanism to approach this problem, and adding another pill is almost never the answer. Of course, every resident with weight loss is not the same. Occasionally, weight loss represents the clearing of edema or excessive fluids in the lungs or peritoneum. This is a desired loss and does not represent the loss of mass from muscle or bone represented by most weight loss in older nursing home residents. Even when a resident is losing undesirable fatty tissue, physiologic mechanisms in nursing home residents may reduce desirable tissue as well, with resultant functional decline and shortened life expectancy. Sometimes weight loss is noted after a resident has experienced an acute illness with decreased calorie consumption or after an acute symptomatic bacterial or viral infection, surgery, or gastrointestinal disorder. In those cases, we expect appetite to recover within days to weeks with stabilization of weight and gradual return to near baseline. The treatment of the weight loss is, of course, the treatment of the acute illness, occasionally with added supplements to speed the recovery. Unexplained weight loss is a different issue. Often this weight loss occurs in the context of advanced disease and is quite problematic to address, particularly because residents can rarely verbalize their concerns and issues. Occasionally it is a manifestation of an as yet undiagnosed illness or a manifestation of the significant worsening of a known illness. With the exception of apathetic hyperthyroidism, this is unlikely to be treatable beyond a physical examination and routine laboratory tests; a medical workup hunting for an occult malignancy is not indicated. However, a few recurrent issues should be considered during the team reevaluation of the care plan. One important issue is that the diet being provided is not the food the patient wishes to eat. Many nursing home residents have been placed on “therapeutic” diets intended to benefit or control chronic medical problems. These include dietary restrictions that frequently remove sweets, fried foods, and salt — the three major food groups of a traditional American diet. For example, a cheeseburger with fries, depending on the portion sizes and ingredients, represents 800 to 1,000 calories; because of the cheese, it contains perhaps 600 milligrams or more of sodium. There might be additional calories, sugar, and salt if ketchup is added. The ubiquitous Ensure supplement, by contrast, is only 240 calories, with 355 calories in an Ensure Plus. But if a resident with a poor appetite could be enticed to eat the burger and fries for lunch and a large milkshake for dinner, adding in another 600 to 1,000 calories with little additional sodium, the total daily consumption would be that of a low-salt diet with enough calories to prevent weight loss and a healthy protein intake. Despite this, we often see the persistence of 1,200- or 1,400-calorie, no-concentrated-sweets (NCS) diets for residents, when if they actually consumed 1,200 calories in a day we would have a celebration. My suggestion for a high-junk-food diet is only a little frivolous: a serious attempt to add favorite foods and treats should be considered as an approach to maintaining or regaining lost weight. I once admitted a Chinese resident with early dementia to the nursing home who had undergone placement of a percutaneous endoscopic gastrostomy tube in the hospital after he rejected all meals. When asked (in his dialect) why he had not eaten, he explained that they “never brought me any food.” He did not consider a meal tray without rice to be food, and he militantly rejected the little mounds of light brown and green mush presented with a spoon when he was offered a pureed diet. But he rapidly cleaned his plate when he was offered steamed fish with vegetables over rice, using his chopsticks to consume every grain. The tube was rapidly removed. Certainly, a well-balanced diet with multiple portions of vegetables and fruit constitutes a “healthy” diet, and control of carbohydrates and saturated or monosaturated fats can limit some complications of diabetes mellitus and arteriosclerosis, but none of these suggestions promote health for a patient with inadequate intake of calories. Indeed, they make little sense for any resident near the end of life when 10- or 20-year complication rates are essentially irrelevant and quality of life should be paramount. Family and friends can often identify a resident’s favorite foods and treats, and residents with memory loss are unlikely to complain if they get the same treat every night! When dietary interventions are unsuccessful — or in parallel to trials of dietary manipulations — the team should also explore three common causes of appetite loss: medication side effects, unrecognized pain, and unrecognized depression. Nearly every prescription medication used in your community includes appetite loss and gastrointestinal side effects among the listed potential side effects. Even if the risk is only 1%, when the typical nursing home resident is taking 10 medications that becomes 10%. Actually, it is much higher because the potential for drug–drug interactions in any resident taking nine or more medications approaches 90%. Many of these side effects are totally unknown and unpredictable: metabolic interactions or additive effects are, at most, known with the simultaneous use of two medications, but no evidence exists regarding the actual combinations that any of your residents might be taking. Certain medications are well-known to reduce appetite, such as codeine preparations, metronidazole and many other antibiotics, methylphenidate, calcium phosphate, carbidopa-levodopa combinations, and pentamidine. Many medications are associated with significant gastrointestinal side effects, such as bloating and gas with statins or gastric irritation from nonsteroidal inflammatory drugs, bisphosphonates such as alendronate, or iron supplements, which may manifest as decreased oral intake. A major attempt at deprescribing should be made, ideally with the assistance of the consulting pharmacist. Medications not required for the patient’s comfort or for the immediate preservation of life should be considered for discontinuation. Conversion to a palliative prescribing model is probably the major cause of the frequently described “hospice honeymoon,” when patients dramatically improve in oral intake, alertness, mood, and function after admission to a hospice program. The high prevalence of depression is well known to those who work in a long-term care environment. Depression in the geriatric population characteristically presents with loss of appetite while many of the other cardinal symptoms, such as fatigue and anhedonia, may be difficult to recognize due to confounding illnesses. Although the Patient Health Questionnaire (PHQ-9) screen for depression is embedded in the Minimum Data Set obtained for all residents, it is a relatively insensitive screening tool that has never been validated for use in the geriatric population. The team should reconsider this diagnosis and, if uncertain, consider consultation with a clinical psychologist or psychiatrist. Even residents who have been treated with antidepressants without improvement in appetite may actually have had their appetite decreased by the treatment. Serotonin and norepinephrine both decrease appetite. Popularly used antidepressants in the selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) categories such as fluoxetine, sertraline, duloxetine, and venlafaxine will suppress appetite, particularly in the first several months of their use. The atypical antidepressant bupropion has been used specifically as an adjunct to encourage weight loss. Conversely, the old tricyclic antidepressants, which are infrequently used now due to anticholinergic side effects and postural hypotension, were associated with weight gain. The atypical antidepressant mirtazapine appears unique among newer agents for a profile of neurotransmitter effects that increase appetite at low dosages without the adverse effects of the older tricyclic medications. This medication will typically require 2 to 4 weeks for the other antidepressant effects to be noticed, but nocturnal sedation and appetite improvement may be seen earlier. Although increasing the dose may improve mood, whatever appetite improvement is noted will usually be seen at the lowest dose and will not increase if the medication dosage is gradually increased. Most facilities periodically evaluate all patients for evidence of unaddressed pain. Pain is a publicly reported quality measure, so residents who complain of pain must and usually do have these complaints addressed. However, many residents are unable to verbalize their pain, and a small number will deny their pain, even severe pain, for a variety of reasons. Pain interferes with appetite on a central level, probably at appetite centers in the hippocampus, so pain relief will restore appetite and reverse a weight loss pattern. There are no medications approved by the Food and Drug Administration with an indication to improve appetite in the geriatric population. Nevertheless, multiple existing approved drugs are used for their supposed orexigenic properties (orexigenic, the opposite of anorexia, is the technical name for appetite stimulants), and all these drugs have been used in the post-acute and long-term care setting. One of the first was cyproheptadine, a first-generation antihistamine that also decreases serotonin levels. Histamine also plays a role in decreasing appetite, so there is a physiological justification for cyproheptadine use. Several controlled trials weakly supported its use in treating failure to thrive in infants and children. However, cyproheptadine is extremely anticholinergic, producing significant sedation, worsening cognition, and inducing urinary retention and constipation. It has been on the Beers list of medications to avoid in geriatric patients for many years. Megestrol is a powerful progestational agent used for the treatment of breast and uterine malignancies. It has been used with modest success in the treatment of unexplained weight loss in patients with acquired immunodeficiency syndrome (AIDS) and some malignancies. However, as might be expected from a medication that raises hormone levels to ranges seen in pregnancy, it can induce both food cravings and nausea with bloating. Also as might be expected, it powerfully induces blood clotting. Between 5% and 32% of patients on megesterol will experience symptomatic proximal deep vein thrombosis; the higher number came from a study of nursing home residents, including some who were ambulatory (J Am Med Dir Assn 2000;1:248–252). Approximately 1 in 23 patients on this medication will die from a thrombotic episode unrelated to their underlying medical condition. Dronabinol has been approved by the FDA to prevent or treat nausea and vomiting associated with cancer chemotherapy and as an orexigenic for patients with AIDS. As a derivative of cannabis, it is expected to induce the “munchies” often described in users of the parent drug. Its use in the geriatric population has been limited by its cardiac side effects and the expected mood and perceptual changes. The latter in particular are often highly troublesome for residents with dementia. However, even when the baby boomer generation predominates in the nursing home — including many current or former marijuana users who are presumably accustomed to a cannabis high — there is little likelihood that dronabinol or medical marijuana will be useful as an appetite stimulant. Population studies have shown that stoners have an average waist size and body mass index below those of age-matched peers (think Sean Penn in Fast Times at Ridgemont High). Thalidomide, anabolic steroids, and corticosteroids have also been suggested as orexigenics for nursing home residents, without any evidence to support their use and with obvious severe potential side effects. The American Geriatrics Society has included avoidance of all appetite stimulant use in the geriatric population on its Choosing Wisely list (https://www.choosingwisely.org/societies/american-geriatrics-society/). Faced with a significant problem, there is an understandable desire to do something. Fortunately, there are a variety of care plan changes that the team should consider, but adding more pills should not be one of them. Dr. Nichols is past president of the New York Medical Directors Association and a member of the Caring for the Ages Editorial Advisory Board. Read this and other columns at www.caringfortheages.com under “Columns.”