Management of Weight Loss in Hospitalized Older Adults

Fall 2022 Newsletter

By Lisa C. Hutchison, Pharm.D., MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Weight loss is often identified during hospitalization when older adults are assessed. Up to 60% of hospitalized older adults are malnourished or at risk for malnutrition, and this is associated with threefold increased costs and co-morbidities such as pressure injuries, infections, and falls.1 Length of stay and mortality increase as a result. Appetite often diminishes when illness develops and patients are admitted to the hospital. Families and caregivers become more vigilant as their loved one has an acute illness, requesting interventions that would improve appetite and nutritional status.

Non-pharmacological methods often implemented during hospitalization to combat nutritional deficits usually include addition of protein/calorie supplements. An approach used less often is to liberalize the diet. For example, a low sodium diet is a standard order for individuals with cardiac disease. A low sodium diet can significantly decrease blood pressure in individuals with hypertension by 4.5mmHg/2.4mmHg on average,2 but a recent randomized controlled trial, SODIUM-HF, did not verify dietary sodium restriction to 1500mg/day was associated with a reduction in mortality or cardiovascular hospitalization/emergency department visits in ambulatory care patients over a year.3 Removing a dietary sodium restriction and encouraging family members and caregivers to select food items the patient likes should be considered. Mealtime is often a social event, and having family or friends eat along with the older adult can improve the amount of food ingested.

Careful review of a patient’s medication list may reveal drug therapy that is contributing to anorexia. Drugs well-known to cause anorexia include amiodarone, SSRI’s, SNRi’s, phenothiazines, opioids, acetylcholinesterase inhibitors, and digoxin.4 Drug-induced nausea may present with anorexia. Stopping these medications, or reducing them to their lowest effective dose, may aid in restoring a patient’s appetite. Another contributor may be drug-induced constipation which can present as anorexia. Finally, some medication regimens include a large number of oral tablets or capsules with a volume that equates to a small meal. A focused attempt to reduce pill burden or to spread out their administration may help to improve appetite.

Medications are sometimes used off-label to stimulate appetite and induce weight gain in older adults. Most commonly used are mirtazapine, megestrol, and dronabinol.4,5 Dronabinol works as a cannabinoid to increase appetite, but as would be expected, causes significant central nervous system side effects. Megestrol is approved by the US Food and Drug Administration for anorexia or cachexia associated with AIDS or cancer. As a synthetic progestin, it can increase appetite, however, small studies and retrospective data show mixed results with increasing weight or strength in older adults. So while it may cause increased dietary intake, any gain of weight is likely increased body fat. Megestrol can increase blood pressure, blood glucose, and risk for thromboembolism.

Mirtazapine is a popular choice for improving appetite due to its safety profile. This antidepressant is relatively well-tolerated with significant side effects of marked sedation, xerostomia, increased cholesterol, and constipation. Increased appetite as a side effect is reported in 17% of patients, therefore, clinicians began trying it in older adults for anorexia.6 Most studies have been in older adults with depression, and results were mixed. A retrospective study of hospitalized patients evaluating use of mirtazapine, megestrol and dronabinol showed improvement in percentage meal intake but no differences between these agents. A control group was not included so authors were unable to assess the effect of other changes, particularly the effect of improvement in admission disease/symptoms.7

So what is best practice? The Choosing Wisely campaign suggests we optimize social supports, provide feeding assistance, and clarify patient goals and expectations instead of prescribing appetite stimulants or high-calorie supplements for treatment of anorexia in older adults.8 Furthermore, we should first assess if this symptom is an adverse drug event of an already prescribed medication. Finally, as with all medications, if pharmacological interventions are subsequently tried, periodic assessment of benefit and risk is important to consider if the appetite stimulant should be continued.

References:

1. Shrader E, Baumgartel C, Gueldenzoph, et al. Nutritional status according to Mini Nutritional Assessment is related to functional status in geriatric patients—independent of health status. J Nutri Health Aging, 2014; 18:257-63.
2. Lai JS, Aung YN, Khalid Y, Cheah SC. Impact of different dietary sodium reduction strategies on blood pressure: a systematic review. Hypertens Res, 2022; doi: 10.1038/s41440-022-00990-5. Online ahead of print.
3. Ezekowitz JA, Colin-Ramirez E, Ross H, et al. Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF):an international, open-label, randomized, controlled trial. Lancet, 2022; 399:1391-1400.
4. Cheung NC, Noviasky JA, Ulen KR, Brangman SA. Efficacy and safety of megestrol in the hospitalized older person. Sr Care Pharm, 2022; 37:284-92.
5. Fox CB, Treadway AK, Blaszczyk AT, Sleeper RB. Megestrol acetate and mirtazapine for the treatment of unplanned weight loss in the elderly. Pharmacotherapy, 2009; 29:383-97.
6. Mirtazapine In: Lexicomp® Wolters Kluwer Copyright 2022 UpToDate, Inc.
7. Howard ML, Hossaini R, Tolar C, Gaviola ML. Efficacy and safety of appetite-stimulating medications in the inpatient setting. Ann Pharmacother, 2019; 53:261-7.
8. American Geriatrics Society/American Board of Internal Medicine Foundation. Choosing Wisely. www.ChoosingWisely.org.