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Should I worry that my appetite for pizza is gone?!? An approach to the older adult with loss of appetite.

Pizza, dark chocolate, fresh warm baked bread (with butter of course...mmm, butter), and a variety of other foods bring pleasure and nutrition to life. Well, the pizza and bread probably don't contribute much to nutrition, but we do have appetites for them and look forward to eating them.

But what happens, as some of us get older, and start losing our appetites? Is it a process of normal aging? Does it signify underlying disease or illness? Should we worry?

A colleague recently reached out to me with this very question. What is the approach to take when an older adult starts losing their appetite? It's a difficult question, but in this post, I present some basic things to think about when dealing with appetite loss.

As we age, there can be a natural change in appetite due to some underlying processes in our body. Our sense of smell can diminish over time and smell is naturally connected to appetite. So, when foods that normally triggered hunger or an appetite are presented, our reaction to consume them might be off. Coupled with this, our sense of taste can change because of diminished sensitivities of certain taste receptors on our tongue. Additionally, a decreased sense of smell can result in a decreased sense of taste- think of how your taste buds are "off" when you are congested or have a cold.

But, there may be other factors involved as well. For example, if our physical activity levels diminish, we naturally may not get as hungry as we used to- there's just less demand for calories. Digestion can also slow along with the motility of the bowels, making us feel more full and less hungry. Changes in our vision may impair how we perceive foods.

And, we haven't even begun to factor in things like chronic medical conditions. Diseases and syndromes like heart failure, diabetes, kidney failure, cancer, and even dementia can reduce our appetites at times. Furthermore, if we have to follow certain restrictions (calorie, fluid, protein, electrolyte- potassium/sodium, sugar/carbohydrate, etc.), we might not be able to eat the foods that we enjoyed in the quantities we would like.

As we all may know, medications can also be the culprit for appetite loss. They can either directly suppress the appetite due to their underlying properties or side effects or they can alter the sense of taste, making foods less appealing. Unfortunately, many older adults have experienced this during the Pandemic when they may have taken Nirmatrelvir/Ritonavir (Paxlovid) for COVID-19. It is notorious for causing a very metallic taste in the mouth along with nausea that makes eating unappealing.

Finally, the social aspect of eating is a critical factor. As humans, eating together and sharing a meal is a central experience of life. As we age, we may lose loved ones and our companions or find it harder to be together with them at mealtimes. Preparing a meal for one and eating alone over a long period of time can be very difficult- ask anyone who has been through it. And so, if this is what an individual has to look forward to every day, think how discouraging it can be and why that person may no longer relish eating (pun intended).

So, when an older adult starts losing his/her appetite- when that craving and love for pizza is gone, here are a few questions to start thinking about and discussing with your doctor or health care provider:

  1. Is this due to an underlying medical illness or condition?

  2. Is there a dental issue- poor condition of teeth, poorly fitting dentures, pain, that is making eating difficult or unappealing?

  3. Is there a medication or several medications contributing to the loss of appetite?

  4. Could there be an underlying cognitive impairment/dementia that is resulting in altered appetites/taste preferences. & even loss of ability to feed oneself or understand the different foods laid out on a plate?

  5. Is there an underlying depression?

  6. Are there psychosocial barriers to eating- financial access to foods, social isolation, inability to get out to get groceries/meals, inability to prepare meals, etc.?

One of the central challenges in caring for older adults, especially frail adults with multiple medical problems is that there is often no one clear solution to the question; it's often the result of multiple factors from all of the questions above.

Another key thing to understand is what are the goals of care for the patient at this point? If this is an older adult who is physically, cognitively, & functionally independent and would like to maintain good control of their chronic conditions, then dietary restrictions may need to be part of the plan. However, if this is an older adult who is frail, has multiple chronic medical conditions and is having trouble functionally and cognitively, then their life expectancy may be more limited and a conservative approach to care may make more sense. In this case, we can consider "liberalizing" their diet to allow more choice. While we don't want certain conditions to go out of control to the point of causing discomfort, we also don't need to be very strict about them. It's important to work with the doctor and health care providers to figure out the balance.

Of course, as a physician, I also get asked about medications that might help stimulate an appetite- I tend to use these as a last resort. This has to be considered with caution, remembering that medications themselves may further worsen the appetite and can also come with their own side effects and interactions.

However, some medications that can be used include:

  1. Mirtazapine (Remeron). This is an anti-depressant that, at low doses, can stimulate the appetite and cause some weight gain as well.

  2. Megestrol Acetate (Megace) is a synthetic form of progesterone. It can stimulate appetite and has been used for this in patients with advanced cancers and AIDS. In my clinical experience, the response to it has been "iffy."   It can interact with many medications, increase the risk of throwing off some of the body's natural hormone reflexes, and also significantly increase the risk of blood clots.

  3. Dronabinol (Marinol) is a synthetic THC (tetrahydrocannabinol)- the active ingredient of marijuana. It is approved for appetite loss in patients with HIV/AIDS and also to reduce nausea/vomiting associated with chemotherapy. Its use in older adults with appetite loss due to other issues is off-label, And as you can imagine, it comes with a host of side effects and interactions. I have not seen a consistent positive response to it.

  4. Steroids (usually Prednisone) can also help as they can increase appetite. However, I've usually reserved this for patients with advanced or end-stage conditions as there are significant risks associated with them- suppressing the immune system, increasing blood sugars, retaining fluid, bone loss, muscle atrophy, & throwing off natural hormone pathways in the body.

So, the approach to the older adult is a complex one. Here's a basic outline to follow:

  1. Make sure the medical, functional, cognitive, & psychosocial domains are all covered and issues that can be addressed or treated easily are managed.

  2. See if any food restrictions can be lifted- work with your doctor, dietitican/nutritionist/speech therapist.

  3. Support the older adult in terms of getting food & shopping along with food choices that suit their individual tastes.

  4. Be creative about supplementing the diet- nurses, dietitians, & speech therapists have a wealth of knowledge in this arena.

  5. Consider a liquid or other nutritional supplement. BUT- make sure that these don't replace a meal...they are supplements.

  6. Investigate medication options if all else is not working. These should be a last resort as their efficacy is not 100% and they come with their own side effects and interactions.

As you can tell, this is not an easy issue to address and will take a lot of time and team work. However, hopefully, some of these questions and tips will help guide you to a better understanding of where to start and go. And, of course, Geriatrics Planning & Solutions can help you with this so reach out if you have concerns about an older adult with appetite loss.

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