It’s normal for older adults to eat less than they did when they were in their 20s and 30s. After all, this is in counterbalance to the decrease in physical activity and resting metabolic rate that is part of aging. However, there’s a point at which a reduction in appetite becomes worrisome and when resulting weight loss can become life threatening. For example, nursing home patients who lost 10% of their body weight were found to have a significantly higher mortality rate in the six months following this weight loss, irrespective of diagnoses or cause of death, according to a study published in the November 1994 issue of the Journal of General Internal Medicine. Another study, published in the April 1995 issue of the Journal of the American Geriatric Society, found a 13.1% annual incidence of involuntary weight loss in outpatient male veterans aged 64 and older. The mortality rate among veterans who lost weight was significantly higher than in those who didn’t lose weight.
What can you do to predict and prevent what some professionals call the “anorexia of aging”? First, become familiar with the many reasons older adults may lose their appetites. “Causes may be psychological or physical. If it’s psychological, for example, it could stem from depression. Depression can occur for exogenous reasons such as loss of independence, loss of a spouse, moving out of their family home, or transitioning to another level of care. Or the depression could be endogenous or due to a chemical imbalance in the brain,” explains Janis A. Barnes, RN, BSN, executive director of Prospect Place, a 16-bed assisted-living facility in Keene, N.H.
There are several physical causes of anorexia. Marie A. Bernard, MD, deputy director of the National Institute on Aging in Bethesda, Md., says, “These can include medical disorders such as congestive heart failure, chronic obstructive pulmonary disease, diabetes, malignancies, and gastrointestinal complaints ranging from a gastric ulcer to bowel obstruction.”
More in-depth studies have shown that elders aged 75 and older may not respond to the hunger regulatory hormones ghrelin and cholecystokinin in the same way they did when they were younger and that this may contribute to early satiety.1
Loss of appetite can also stem from the side effects of medications. For example, says Kristen Binaso, RPh, CCP, FASCP, a community pharmacist in Clinton, N.J., and spokesperson for the American Pharmacists Association, “Antidepressants such as Zoloft and Paxil can affect appetite negatively. This can be a problem when an older person’s anorexia is caused by depression. However, there are newer classes of antidepressants that don’t have this side effect.”
In general, says Binaso, “Any time a medication is at a toxic level, it can affect appetite. This is especially true of medications such as warfarin, digoxin, and thyroid medications. A warning sign is when seniors express that they don’t feel like themselves, but they don’t have obvious signs of a cold or flu. It could be medication toxicity.”
There’s always a strong chance that medications will interfere with an elder’s appetite. Binaso says, “The average pill burden of those aged 65 and older is 15 tablets per day. Compound this by the fact that we make less saliva and the ability to swallow decreases as we age.”
Look for Simple Causes
“Ask a lot of questions of the client or family members or caregivers of the client,” says Barnes. “For example, find out when the decrease in appetite started. Sometimes we’ll actually monitor how much a client eats at each meal by recording their intake. We monitor bowel habits too.”
Bernard advises regularly weighing patients. “Remember that all weights should be taken in a similar state of undress. Research has shown as much as a 20-pound difference in weights in a nursing home population in summer vs. winter and this had to do with the amount of clothes the patients were wearing. In patients aged 65 and older, significant weight loss is not usually attributable to simply dieting.”
Ask elders to provide lists of all the medications they take so the information can be reviewed. Binaso says, “Until we have electronic medical records, there is no way for all healthcare providers to know what meds a person takes. Ask seniors to put over-the-counter drugs as well as vitamin, mineral, and herbal supplements [on their lists] too. This may uncover a drug-drug or other type of interaction that can be changed and thereby alleviate an appetite problem.”
Practitioners should make efforts to help elders regain their appetites. “Don’t overwhelm seniors with big portions. Five or six small meals a day is optimal; and provide choices at each meal,” Barnes says. “Also, we try to find the foods our clients like best. For example, if they grew up in a Polish household, we find out what those comfort foods are. Our chef is very good about making dishes from recipes families bring from home.”
Liquid dietary supplements can be an important tool to encourage appetite and weight gain. “Be sure patients drink these between meals for a net gain, not as a meal replacement,” Bernard advises.
Something as simple as Carnation Instant Breakfast added to milk is an effective way to boost calorie intake, says Barnes. “We often add ice cream and other flavorings to make these drinks tastier. If the client is lactose intolerant, then we offer them a milk like supplement such as Ensure or Boost Plus.” Some research indicates that pharmacological stimulants may help boost appetite in older adults.2
Finally, there’s nothing like socialization to spark the desire to eat. “We’ll create a nice social time for the clients at mealtime with food hot off the stove served on plates rather than trays and music of their generation,” says Barnes.
For seniors living at home, this may mean encouraging a friend or family member to share mealtimes, says Binaso. “Some families may stay in touch with older family members by phone, but you have to realize that this isn’t the electronic generation; this is a generation that is used to visiting in person. Mealtime makes a good excuse.”
— Carol M. Bareuther, RD, is a St. Thomas, U.S. Virgin Islands-based writer who contributes to a variety of regional, national, and international publications.
2. Thomas DR. Anorexia: Etiology, epidemiology and management in older people. Drugs Aging. 2009;26(7):557-570.