Use of Appetite Stimulants in Long-term Care+ a. o8 z, E, c3 e
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When a resident in a long-term care facility exhibits unintended weight loss, dietitians assess the patient and recommend additional food, changes in eating environment, nutrition supplements, speech or occupation therapy, and other interventions. In some cases appetite-stimulant medications are recommended. But are they safe for the long-term care population, and are they effective?* m4 \/ W: Z% ^% C5 o
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The role of appetite stimulants in treatment of anorexia in the elderly is not clear. Despite limited research, several medications are used to promote weight gain in the elderly. However, none are specifically indicated for the treatment of weight loss in the elderly (Huffman, Rehman, Niedert, Zanni). The US Food and Drug Administration (FDA) has not labeled any drugs for use in elderly patients with weight loss (Huffman, Zanni). Nonetheless, these drugs often are prescribed for this purpose.7 O. v& K, a5 x; c3 e
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Appetite stimulant medications that often are prescribed include Megace® (megestrol), Marinol® (dronabinol), Periactin® (cyproheptadine), Oxandrin® (oxandrolone), Remeron® (mirtazapine), and Eldertonic®. Each drug has specific dose recommendations and contraindications that are beyond the scope of this article. Megace and Marinol are both documented to improve the anorexia associated with weight loss in acquired immunodeficiency syndrome (AIDS) and cancer patients. Oxandrin is an anabolic steroid that also is successfully used in AIDS and cancer patients. Remeron is an antidepressant that corrects chemical imbalances found in depression and may increase appetite in the process. Periactin is an antihistamine that appears to increase appetite, although the mechanism of action is not identified. Eldertonic is a sherry-based beverage containing a mix of vitamins and minerals that often serves to stimulate the appetite. Other medications are known to increase appetite in some patients, but are not prescribed for that purpose. In those cases, increased appetite or weight gain often is listed as a side effect of the medication.6 E* h5 f" @6 _1 {1 \& q- O
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Dietitians should consider the facts before ordering appetite stimulants in the elderly population. The first consideration is a person’s medical condition, advance directives, and plans for palliative care. Is the patient otherwise healthy and cognitive? Does the patient and/or family want aggressive treatment of weight loss or poor food intake? If so, the patient is perhaps a candidate for an appetite stimulant. Is the weight loss part of an inevitable decline because of a medical condition? If so, an appetite stimulant medication is perhaps not appropriate.5 B- l- d9 H* }
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It is necessary to factor in the patient’s currently prescribed medications when making a decision about whether to recommend an appetite stimulant. Perhaps the patient is already taking a medication that causes anorexia and involuntary weight loss. A number of commonly prescribed drugs, including Lasix®, Coumadin®, and digoxin (Niedert), can result in anorexia.
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( X, d a- t6 l6 B3 D% r8 C& H# RIf weight loss is a side effect of one medication, should the patient receive another medication to offset that side effect? If a patient is taking several medications already, adding another to the mix to increase appetite sometimes is contraindicated because of drug/drug interactions. If the patient has difficulty swallowing medications or frequently refuses medications, adding another to the medication regimen may not prove helpful.
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/ u# z% p7 z. i* _) X* WDietetics practitioners should know that many products used as appetite stimulants are used beyond the approved product labeling (Niedert). In some cases, the research supporting the medication for appetite stimulation is anecdotal. A pharmacist is an excellent resource for information on prescribing medications as an appetite stimulant. c5 m& l. B0 I4 e/ E! l( k; l
% v: ^1 J( U# l" I( X" nPatients who have diabetes and are taking appetite stimulants should have their blood sugar monitored carefully. An increase in food intake might result in blood sugar fluctuations that will requirement adjustment of diabetes medications. 2 L' Z' t2 P1 w$ j2 L6 F
Although medications may help promote appetite and weight gain in the elderly, health care professionals should not consider them as the first line of treatment (Huffman) and consider them only after all other approaches have failed. It appears that appetite stimulants are not effective in some elderly patients, although the scientific evidence is not conclusive (Rehman). However, if the medications result in an increased appetite and prevent involuntary weight loss without unwanted side effects, appetite stimulants are perhaps a good idea for some patients. Health care facilities should evaluate each resident to determine which medication to use based on medical history, current medications, and prognosis for improvement of health and quality of life.
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, R$ T2 ?( F$ j& z. ?+ EImplications for dietetics practitioners- c7 w/ g: _' R8 I0 `6 C; Q
Because of the issues surrounding the use of appetite stimulants in long-term care, including polypharmacy and labeling issues, dietitians should seek input from other health care professionals, including pharmacists, when recommending use of appetite stimulants. I+ i' A, X8 s- J
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References and recommended readings
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American Medical Directors Association. Altered Nutritional Status in the Long-term Care Setting Clinical Practice Guidelines. Columbia, MD: American Medical Directors Association; 2010.
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Huffman G. Evaluating and treating unintentional weight loss in the elderly. Am Fam Physician [serial online].2002;65:640-650. ) |0 s; X8 v; S" {
Available at: http://www.aafp.org/afp/2002/0215/p640.html.
& B! J" ^. H" O: R4 S v3 g9 N, a9 ]Accessed May 24, 2011.
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. e& O* D" o, j* m& R! nNiedert KC, Dorner B. Nutrition Care of the Older Adult. 2nd ed. Chicago, IL: American Dietetic Association; 2004.# j U* P& O' C- [2 y
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Rehman HU. Involuntary weight loss in the elderly. Clin Geriatr [serial online]. 2005;13:37-45.- H- D+ Y. [* o% H9 X) y& C0 v! R" Z C
Available at: http://www.imsersomayores.csic.e ... 9/art-05-08-01.pdf. 1 @0 W& _8 M; s- P( o
Accessed May 24, 2011.
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# \2 w1 ^5 D/ j3 {# kThomas DR. Guidelines for the use of orexigenic drugs in long-term care. Nutr Clin Pract. 2006;21:82-87.
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$ r+ u+ H# `! e! \Zanni GR. Involuntary weight loss—an ignored vital sign in seniors. Pharmacy Times [serial online].
0 g; F7 T9 y3 ?0 O6 [' M9 YAvailable at: http://www.pharmacytimes.com/pub ... cusWeightLoss-0110.
' r0 t0 T6 B, f, }/ ? mAccessed May 24, 2011. r7 S5 y* |5 @0 V0 ? K
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