Clahrc-wessex.nihr.ac.uk

Continuing professional development An overview of appetite decline in older peopleNOP697 Pilgrim AL, Robinson SM, Sayer AA et al (2015) An overview of appetite decline in older people. Nursing Older People. 27, 5, 29-35. Date of submission: March 6 2015. Date of acceptance: April 17 2015.
Poor appetite is a common problem in older people living at home and in care homes, as well as hospital Anna L Pilgrim is senior research
assistant
inpatients. It can contribute to weight loss and nutritional deficiencies, and associated poor healthcare outcomes, including increased mortality. Understanding the causes of reduced appetite and knowing how to measure it will Sian M Robinson is professor
enable nurses and other clinical staff working in a range of community and hospital settings to identify patients of nutritional epidemiology
with impaired appetite. A range of strategies can be used to promote better appetite and increase food intake.
Both at National Institute for Health
Research (NIHR) Southampton
Biomedical Research Centre,
Aim and intended learning outcomes Control of appetite University of Southampton and
The aim of this article is to review knowledge and Regulation of the appetite is complex and not University Hospital Southampton
NHS Foundation Trust; MRC
understanding of appetite in older people. After reading completely understood. It has control systems linking Lifecourse Epidemiology Unit,
this article you should be able to: the brain, digestive system, endocrine system and University of Southampton
Discuss the normal control of appetite.
sensory nerves. These systems act to govern appetite in Avan Aihie Sayer is professor
Summarise the potential implications of poor appetite the short and long term. In the short term, appetite is of geriatric medicine
in older people.
thought to be mostly controlled by sensors in the gut that Helen C Roberts is associate
Identify what physiological, social and psychological respond to the physical presence or absence of food, professor of geriatric medicine
factors can cause appetite impairment.
and to the different components of the food, such as Both at NIHR Southampton
Describe how to measure appetite.
Biomedical Research Centre,
Discuss what options are available to manage In response to signals from these sensors the gut University of Southampton and
secretes a variety of hormones, for example, ghrelin University Hospital Southampton
NHS Foundation Trust; MRC
Before reading on, do time out 1. is secreted by the stomach in response to fasting and Lifecourse Epidemiology Unit,
increases appetite, peptide-YY is secreted by the ileum University of Southampton;
and colon in response to food intake and suppresses Academic Geriatric Medicine,
University of Southampton;
appetite, and cholecystokinin is secreted by the small NIHR Collaboration for
Consider what the consequences of poor intestine in response to fat and protein and suppresses Leadership in Applied Health
appetite might be for an older person. appetite. Insulin is secreted by the pancreas in response Research and Care: Wessex
to high blood glucose and also suppresses appetite Conflict of interest
(Parker and Chapman 2004). Different hormones are released before, during and after eating, controlling feeding behaviour and how much Appetite, eating, malnutrition, nutritional deficiencies, strategies, is eaten. In the long term, appetite may be controlled by the composition of the body. Signals from the fat mass This article has been subject to Appetite is the desire to fulfil a bodily need and can be inhibit appetite through the hormone leptin, which is double-blind review and checked divided into three components: hunger, satiation and secreted by fat cells. There is some early evidence that using antiplagiarism software. For satiety. Hunger is the sensation that promotes food fat-free mass (all the body components that are not related articles visit our online archive and search using the keywords consumption, satiation is the sensation of fullness during fat, including muscle, bones and organs) may increase eating that leads to meal termination and satiety is the the desire to eat but the mechanism is unknown fullness that exists between eating (Mattes et al 2005). (Blundell et al 2012). These short and long-term NURSING OLDER PEOPLE June 2015 Volume 27 Number 5 29
Continuing professional development systems can be thought of as homeostatic; maintaining Box 1 Consequences of nutritional deficiencies
the nutritional status of the body by helping it to meet and weight loss in older people
its needs for energy and nutrients. These homeostatic Increased risk of: systems can all be overridden by ‘pleasure' signals, which are called hedonic systems. For example, the smell of a favourite food or being offered a tasty treat can stimulate appetite and cause a person to eat when they Longer length of hospital stay do not ‘need' to. Mood is an important part of the hedonic system, but mood will affect appetite in different ways: some people eat more when they are sad or anxious, whereas these moods will suppress appetite for other people. Social and environmental cues such as walking past a shop selling food or it being ‘mealtime' can also stimulate appetite. Conversely, people may ignore their appetite and inhibit their own eating for various reasons, such as wanting to lose weight (Berthoud 2011). Appetite decline (Wilson et al 2005, Holick 2007, Agarwal et al 2013) Many older people experience a decrease in appetite. This decline was first described as the ‘anorexia of circumstances, acute illness, chronic diseases and use of ageing' in 1988 by John Morley (Morley and Silver medication (Malafarina et al 2013). 1988). Between 15% and 30% of older people are estimated to have anorexia of ageing, with higher Physiological The physiological changes that occur with
rates in women, nursing home residents, hospital ageing that can impair appetite include changes to the inpatients and with increasing age (Malafarina et al digestive system, hormonal changes, disease, pain, 2013). Reduced appetite can lead to reduced food and changes to smell, taste and vision and decreased need nutrient intake (Payette et al 1995), increasing risk of weight loss and nutritional deficiencies (Wilson et al Changes to the digestive system can contribute to 2005, Brownie 2006). declining appetite. An estimated one third of people over Nutritional deficiencies and weight loss have 65 years of age have reduced saliva production, causing serious consequences for older people and these are difficulties in eating that may impair appetite (Ship et al summarised in Box 1. 2002). Decreased saliva production is not a part of Older people may also find it difficult to regain lost normal ageing and is most often caused by the side weight (Roberts et al 1994). Appetite may also decline effects of medication (Ship et al 2002). sharply in response to an acute illness. Detecting loss of Older people are more likely to have poor dentition, appetite before weight loss and nutritional deficiencies and wearing dentures and chewing difficulties are occur will enable healthcare staff to intervene at an early associated with loss of appetite (Lee et al 2006). Poor stage, preventing a decline in health. oral health is more common, reducing sense of taste Now do time out 2.
and can contribute to poor appetite (Solemdal et al 2012). Gastric emptying is slower so food remains in the stomach longer, prolonging satiation and reducing 2 Awareness
appetite (Nieuwenhuizen et al 2010). Think about the patients you are caring for Constipation can cause reduced appetite (Landi et al now. How many of them do you think have 2013), with between 30% and 40% of community- impaired appetite? How do you know this? dwelling older people and more than 50% of nursing home residents complaining of chronic constipation (Gallagher and O'Mahony 2009). Changes in levels of and responsiveness to some of the hormones involved in appetite control have been found in older people. There is some evidence that fasting levels of ghrelin are lower (Di Francesco et al Many changes occur as a person ages that can be 2008), fasting and post-prandial levels of cholecystokinin responsible for loss of appetite. These include changes are higher (de Boer et al 2013) and baseline levels of to physiology, psychological functioning, social leptin are higher (de Boer et al 2013). Additionally, 30 June 2015 Volume 27 Number 5
NURSING OLDER PEOPLE cholecystokinin suppresses appetite more strongly in and social changes that can occur with ageing will older people (Parker and Chapman 2004). influence appetite. All these hormonal changes will contribute to appetite Depression is known to impair appetite (Engel et al impairment with ageing. 2011) and is common, with reported rates of 9% in Any acute illness can affect a person's appetite, community-dwelling older people, 27% in those who live especially infection (Langhans 2007). Many chronic in care homes in the UK (McDougall et al 2007) and diseases can also worsen appetite and these include 24% in older inpatients (Goldberg et al 2012). People cardiac failure, chronic obstructive pulmonary disease, with dementia can have reduced appetite (Ikeda et al renal failure, chronic liver disease, Parkinson's disease 2002). Delirium is associated with poor nutritional and cancer. All of these conditions are more prevalent intake (Mudge et al 2011), but it is not clear if this is in older people. Anorexia in acute and chronic disease is connected with reduced appetite. Living and eating alone mainly caused by pro-inflammatory cytokines (Langhans can cause reduced appetite, possibly because those who 2007) and also by nausea, sensory changes (Lee et al have difficulties with shopping and cooking lack support 2006) and medication side effects. to overcome these problems and become less motivated Chronic disease can also impair appetite through to cook and eat. impaired dexterity and pain. Impaired dexterity interferes Additionally, eating alone is less pleasurable and with the eating process: food takes longer to eat people living alone have fewer social cues to eat. and may become cold, reducing the appetite usually As more than one third of over 65s and half of over 75s stimulated during a meal. live alone (Age UK 2015), this may affect their appetite. Chronic pain is associated with poor appetite and Determination to eat to maintain weight and health is an since as many as half of all community-dwelling older important factor in the eating behaviour of older people, people have chronic pain (Bosley et al 2004), this helping to overcome any reduction in appetite (Wikby may contribute significantly to loss of appetite. Pain and Fägerskiöld 2004). is most commonly experienced in the back and knee Finally, large portion sizes may be off-putting, (Patel et al 2013). particularly where standard portion sizes are used, such Smell, taste and vision are all involved with the as in hospitals. Robison et al (2015) found this was a enjoyment of food, and impairments of these senses with common issue in their study involving hospitalised older ageing can cause reduced appetite. The smell of food women. Retirement can also alter meal patterns and stimulates appetite and taste promotes the enjoyment food choices because of change in routine, location, of food and further stimulates appetite during eating. social contact and finances (Alvarenga et al 2009).
Many older people have an impaired sense of smell Now do time out 4. and taste that will cause them to have worse appetite (Nieuwenhuizen et al 2010). Pharmacological Older adults are likely to be taking at
Good eyesight helps to stimulate appetite and least one medication (Qato et al 2008). More older adults with poor vision are more likely to report than 200 commonly used drugs are known to alter taste poor appetite (Lee et al 2006). Visual impairment is increasingly common with increasing age, with one in 3 Physiological causes
five people aged over 75 years and one in two aged over 90 years reported as having sight loss (Royal National Pause to review what you have learned Institute of Blind People 2015). about the physiological causes of impaired Individuals' energy needs are determined by their appetite. Make a list of the main causes and body composition, especially fat-free mass, and their check your answers. Have you or levels of physical activity (Campbell et al 1994). Most Time out your relatives noticed changes to your older people lose fat-free mass as they age, with skeletal appetite as a result of changes in health? muscle being lost at a rate of around 1% per year in those over 70 (Goodpaster et al 2006) and many are less physically active (Taylor et al 2004). Therefore 4 Psychosocial risks
older people have lower requirements for energy, which may contribute to a reduction in appetite. This will vary Reflect on the patients you care for. Can you between individuals, reflecting differences in their body identify any with risk factors for developing composition and levels of physical activity. Now do time out 3.
Psychosocial Appetite is influenced by the environment
and mood. Therefore, many of the psychological
NURSING OLDER PEOPLE June 2015 Volume 27 Number 5 31
Continuing professional development Box 2 Drugs that can impair appetite
Ampicillin, macrolides, quinolones, trimethoprim, tetracycline, metronidazole Fluconazole, posaconazole, amphotericin, caspofungin, micafungin, griseofulvin, terbinafine, itraconazole Ganciclovir, foscarnet sodium, valganciclovir, telbivudine, boceprevir, ribavarin Baclofen, dantrolene sodium Migraine medications Eletriptan, frovatriptan, rizatriptan Hydralazine hydrochloride, iloprost Amiloride hydrochloride Heart failure medication Angiotensin-converting enzyme inhibitors Adenosine, dronedarone, amiodarone, propafenone hydrochloride Thyroid medications Tricyclic antidepressants Amitryptyline, clomipramine, dosulepin, doxepin, imipramine, lofepramine, Trifluoperazine, aripiprazole, risperidone Lithium carbonate, lithium citrate Zaleplon, zopiclone Formoterol fumarate, tiotropium Celecoxib, etoricoxib (Douglass and Heckman 2010) and smell or cause nausea, and may therefore affect other measurements such as food intake, nutritional appetite (Schiffman 1997). Some of the drugs that can assessment, weight or body mass index (Mattes et al impair appetite are shown in Box 2.
2005). Clinical laboratory studies have used visual Now do time out 5.
analogue scales or a single question such as ‘how hungry are you right now?' but these are not validated for use in other settings to measure usual appetite. 5 Appetite measurement
The Simplified Nutritional Appetite Questionnaire Have you ever asked an older person about (Wilson et al 2005) was developed to predict greater their appetite? Discuss with a colleague than 5% weight loss over six months in community- the challenges of measuring appetite in an dwelling older people and asks four simple questions older person.
(Box 3). Those identified as having poor appetite using this screening tool will need further investigation to identify the cause. Now do time out 6. Measurement of appetite Measuring appetite is challenging because it is Management options subjective and experienced differently by individuals. The first line of treatment should always be to identify Previously appetite was inferred from the results of and treat any underlying cause. Patients with a dry 32 June 2015 Volume 27 Number 5
NURSING OLDER PEOPLE 1997). Patients can also be encouraged to eat a wide 6 Management
variety of foods at each meal to help sustain appetite Before reading the next section think about (Nieuwenhuizen et al 2010). the patients you care for who have poor If the patient is visually impaired then make sure appetite. Consider the reasons that their he or she has the correct spectacles and is referred appetite might be poor and how you might for further investigation if necessary. Using crockery help them improve their appetite. What of a colour that contrasts with the colour of the food Time out measures to promote appetite do you already and good lighting will also help visually impaired use and what could supplement these in patients, and plate sides and non-slip mats will promote independence, which should all improve appetite. Plate sides and non-slip mats will also benefit patients with impaired dexterity (Connolly and Wilson 1990). mouth can be helped by offering them regular sips Depression and dementia should be identified and of water, avoiding hard, dry foods, and using saliva managed. The diagnosis and management of delirium replacement products (Gupta et al 2006). Check will be especially important in hospital patients. There the patient has dentures if needed and that they fit is some preliminary evidence that coloured crockery comfortably. Nurses can help patients to maintain oral can increase the dietary intake of older patients hygiene and refer to a dental hygienist if necessary. Treat with dementia in hospital (Rossiter et al 2014). constipation if present (Gallagher and O'Mahony 2009). Encouragement, serving finger foods and physical Acute infections should be treated as appropriate and assistance may also help. Older people who live alone chronic illnesses managed, with particular attention paid can be encouraged to use lunch clubs and to eat meals to symptoms such as nausea and pain. with friends or family if possible. If a patient has impaired smell or taste then appetite There are many recognised health benefits to may be improved by enhancing the flavour of food. increasing physical activity levels at all ages, including This can be done on an individual basis, as likings for improved wellbeing, which may help to improve appetite certain flavours vary. Adding extra salt and sugar is not (Netz et al 2005). Behaviour change techniques recommended, but pepper, herbs and spices can be to improve motivation to eat, such as setting goals, safely used, according to personal preference (Schiffman providing feedback and monitoring and planning social Box 3 Simplified Nutritional Appetite Questionnaire (SNAQ)
1. My appetite is:
3. Food tastes:
2. When I eat:
4. Normally I eat:
a. I feel full after only a few mouthfuls a. Less than one meal a day b. I feel full after eating a third of a meal b. One meal a day c. I feel full after eating half a meal c. Two meals a day d. I feel full after eating most of a meal d. Three meals a day e. I hardly ever feel full e. Four or more meals a day Administration instructions: Ask the person to complete the questionnaire by circling the correct answers and then
tally the results based on the following numerical scale: a=1, b=2, c=3, d=4, e=5. The sum of the scores for
the individual items constitutes the SNAQ score.
SNAQ score <14 indicates significant risk of at least 5% weight loss within six months in community-dwelling people aged >60 years.
(Wilson et al 2005) NURSING OLDER PEOPLE June 2015 Volume 27 Number 5 33
Continuing professional development support, could also be used (National Institute for Health pleasant eating environment. There is evidence that food and Care Excellence 2014). Serving smaller portions form has an effect on appetite: ‘beverage' meals leave may tempt appetite but risks causing reduced intake. older people less satiated than ‘solid' meals (Leidy et al This can be prevented by ensuring the smaller portion 2010), and using enriched soups or drinks may be is enriched with, for example, cream, butter or cheese useful in increasing the energy intake of someone with (Nieuwenhuizen et al 2010). As many medications can reduced appetite. It is important to ask patients, and reduce appetite (Box 2), reviewing medication is useful their families, what foods they like to eat and what their because it may be possible to substitute one medication usual meal patterns are. for another or stop it altogether. Trying to serve the most liked foods in a similar Having addressed possible causes of poor appetite pattern to the patient's usual one could help to stimulate we can now consider ways in which appetite can be appetite (Wikby and Fägerskiöld 2004). There is interest improved whatever the cause. The environment in which in using drugs or alcohol to stimulate appetite. No drugs food is served plays an important role in appetite and are licensed in the UK to improve appetite in older therefore improving it should help to improve appetite. people and there is no evidence to support their use, nor No studies have measured the effect on appetite of that of alcohol (Berenstein and Ortiz 2005, Gee 2006).
improving the mealtime environment, but a systematic In some instances it will not be possible to improve review of mealtime interventions in care homes found appetite and food intake, for example, when a person is that improving the dining environment tended to acutely ill (Nieuwenhuizen et al 2010). In this case oral improve residents' weight/weight status and food/ nutritional supplements will need to be used while the calorie intake. Improvements included using tablecloths, patient is being treated and until appetite returns. attractive crockery, protected mealtimes, improved Now do time out 7. choice of and access to food and mealtime assistance (Nieuwenhuizen et al 2010). Some, or all, of these strategies could be used in UK There are several reasons why an older person may care homes and hospitals. Community-dwelling older have an impaired appetite, which can be related to people should be encouraged to take time to create a physical and psychological changes that accompany Agarwal E, Miller M, Yaxley A et al (2013) Bosley B, Weiner D, Rudy T et al (2004) Is Douglass R, Heckman G (2010) Drug-related Gupta A, Epstein J, Sroussi H (2006) Malnutrition in the elderly: a narrative review. chronic nonmalignant pain associated with taste disturbance: a contributing factor Hyposalivation in elderly patients. Maturitas. 76, 4, 296-302.
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at risk of nutritional deficiency? International well-being and their association with appetite Alvarenga L, Kiyan L, Bitencourt B et al (2009) Ikeda M, Brown J, Holland A et al (2002) Journal of Nursing Practice. 12, 2, 110-118.
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Role of resting metabolic rate and energy expenditure in hunger and appetite control: Di Francesco V, Fantin F, Residori L et al Goodpaster B, Park S, Harris T et al (2006) Lee J, Kritchevsky S, Tylavsky F et al (2006) a new formulation. Disease Models (2008) Effect of age on the dynamics of acylated The loss of skeletal muscle strength, mass, Factors associated with impaired appetite in and Mechanisms. 5, 5, 608-613. ghrelin in fasting conditions and in response and quality in older adults: the health, aging well-functioning community-dwelling older to a meal. Journal of the American Geriatrics and body composition study. The Journals adults. Journal of Nutrition for the Elderly. Society. 56, 7, 1369-1370. of Gerontology. Series A, Biological Sciences and Medical Sciences. 61, 10, 1059-1064.
34 June 2015 Volume 27 Number 5
NURSING OLDER PEOPLE 7 Care plan
8 Practice area
Write a care plan that can be used to identify Consider the environment in which you care and treat patients with poor appetite in for patients. Are there any improvements your clinical setting. Consider which other that could be made to benefit the appetite members of staff could help with the plan of all patients? How could you work with Time out and also the role of family members in caring Time out colleagues to implement those changes? for the individual.
What barriers to change do you envisage? ageing. Poor appetite is important because it increases they usually eat. Encouraging an increase in levels of risk of nutritional deficiencies and weight loss, with the physical activity when appropriate might also help. latter being particularly difficult to reverse. Nutritional Finally, oral nutritional supplements may need to be deficiencies and weight loss are associated with worse used to support patients who are acutely ill and have health outcomes for patients and also an increased risk very poor appetite.
Now do time out 8 and 9.
Nurses are well placed to identify those patients with poor appetite, identify and treat any underlying 9 Reflective account
cause and use various strategies to help improve appetite and adequacy of the diet. These include Now that you have completed the article enhancing the flavour of food with herbs, spices and you might like to write a reflective account. sauces, improving mealtime ambience, serving smaller Guidelines to help you are on page 36.
portions of enriched foods, finding ways to help people have company at mealtimes, serving ‘beverage' meals and serving foods people are known to like at the times Leidy H, Apolzan J, Mattes R et al (2010) National Institute for Health and Care Qato D, Alexander G, Conti R et al (2008) Ship J, Pillemer S, Baum B (2002) Xerostomia Food form and portion size affect postprandial Excellence (2014) Behaviour Change: Individual Use of prescription and over-the-counter and the geriatric patient. Journal of the appetite sensations and hormonal responses Approaches. Public health guidance 49. tinyurl.
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Taylor A, Cable N, Faulkner G et al (2004) mortality. A systematic review. Maturitas. Nieuwenhuizen W, Weenen H, Rigby P et al Robison J, Pilgrim A, Rood G et al (2015) Physical activity and older adults: a review 74, 4, 293-302.
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