Appetite loss in the elderly: is there anything else we can do?
June 18, 2018 6:19 AM   Subscribe

My mildly depressed, intensely private, hypochondriac and cynical but otherwise physically healthy 82-year-old dad got sick in early April, and has been in a steep nosedive ever since. The immediate threat to his recovery seems to be loss of appetite; he eats and drinks a fraction of normal, is dehydrated and has lost a bunch of weight. Is there some strategy or specialist we should be applying that we don't know about?

Right around the first of April my dad started turning yellow. His bile duct was restricted, but the root cause evaded every non-invasive diagnostic approach for a few weeks. Surgery finally revealed a cancerous gall bladder, which was removed. He still needs chemo, if we can get him healthy enough to tolerate it.

Trouble is, he isn't eating or drinking much despite a lot of cajoling and offers of foods he's always liked. Nothing appeals, and various flavors of indigestion cause him to lose some of the little he does consume. My mom says he's eating about 10% of normal. He's become frail, hollow-cheeked, sunken-eyed, and isn't getting better. The gall bladder surgery was almost three weeks ago. He's very weak, and has fallen a few times. This morning he fell out of bed, hit his head, and bled a lot.

Dad has always been uncannily physically healthy; this is the first time he's ever been in a hospital as a patient. However he has also always been a hypochondriac, obsessively thinking and reading about illnesses that might eventually kill him. He distrusts service providers of every stripe, from doctors to plumbers, and is always resistant to getting help. When considering his current circumstances, his hypochondria sets him up for fatalistic confirmation bias; his worst fears seem to be coming true, which is both miserable and validating.

He has a surgeon, who's seeing him for follow-ups. He has a regular GP he's seen for years. An oncologist is on the horizon, but hasn't been seen yet. A physical therapist visits the house a few times each week. The medical team clearly knows he's not eating enough, but none of them seems to have done much more than to tell him to eat more. Is there anything else we can do for him? Some specialist we should ask to see? In case it comes up, his insurance is pretty good, and he lives in a state where medical marijuana is still illegal.
posted by jon1270 to Health & Fitness (29 answers total) 3 users marked this as a favorite
 
Junk food, especially liquid junk food, can be a handy tool in this battle. When my uncle had cancer over the past few years, he just couldn't make himself eat, but he was more than okay with having milkshakes whenever he could, so we all brought him milkshakes all the time and didn't pressure him, just had them available. Any calorie in this situation is a good calorie, so whatever things he could "get away with" can often break through enough to put some weight on.
posted by xingcat at 6:27 AM on June 18, 2018 [6 favorites]


My grandma would eat if I (her adorable little teenage grandddaughter) cooked grilled cheese sandwiches for both of us. In my family, we aren't above emotional blackmail when it comes to your health.
posted by Green Eyed Monster at 6:29 AM on June 18, 2018 [5 favorites]


Some different background but some similar issues here. In the case of my dad, antidepressants ended up being the ticket, and he has gained 40 pounds since I asked that question. I know this sucks, my thoughts are with you.
posted by ftm at 6:29 AM on June 18, 2018 [11 favorites]


Liquid drinks like an Ensure? or Carnation Instant Breakfast? Meals in a can or powder.
posted by AugustWest at 6:34 AM on June 18, 2018 [4 favorites]


Ensure over ice cubes. Vanilla seemed to be least offensive.
posted by Dashy at 6:43 AM on June 18, 2018


Ask his doctor if Megace is an option. It's an appetite stimulant. My elderly father had a similar issue of extreme weight loss after a medical emergency. I asked about medical marijuana but instead the doctor prescribed Megace. It was very effective for my father.
posted by kbar1 at 6:55 AM on June 18, 2018 [3 favorites]


Cannabis is used as an appetite stimulant and anti-nausea agent.
posted by pseudostrabismus at 7:06 AM on June 18, 2018 [8 favorites]


Is he nauseous? Even mildly so? After having a condition where I had extreme nausea for 3 months, I can tell you it feels almost impossible to eat. If this is the case, you may have to do IV nutrition or a less invasive option of nausea medication which might allow for a reduction in food aversion. Be careful, though, Zofran will make you constipated almost immediately and requires use of laxatives or other such aids. PM me if you have questions.
posted by rglass at 7:39 AM on June 18, 2018


Could he have dental issues? My father hid his successfully from everyone until he required intubation.
Maybe his dentures are no longer a good fit.
This is hard, wishing you strenght
posted by 15L06 at 7:43 AM on June 18, 2018 [2 favorites]


The doctors got my dad to eat during his throat cancer treatment by threatening him with putting in a feeding tube. He most definitely did not want that, and worked really hard to make sure he didn't get one. Unfortunately, he contracted pneumonia and nearly died and had to have a feeding tube put in anyway, but before that, the threat of one made him guzzle Ensure and Boost like it was his job.
posted by cooker girl at 7:43 AM on June 18, 2018


This is the sort of question best posed to a nutritionist, who may have some good ideas about how to get calories into your dad. IIRC, loss of appetite is a fairly common side effect of gallbladder surgery. But it also occurs to me that, given his history of remarkably good health, the symptoms in the lead-up to the surgery and the surgery itself may seem to him to be the "beginning of the end". If so, antidepressants could be very helpful and the GP he trusts should be able to prescribe these for him.
posted by DrGail at 8:14 AM on June 18, 2018 [1 favorite]


I'm sorry to ask this, but since it hasn't been asked... is your father dying? Loss of appetite in the way you describe is generally seen as a sign that someone is in the final stages of their life. It is extremely common in hospice care, but it sounds like your dad is not in hospice. You can fight his loss of appetite using many of the above methods, but it's not too early to think about medical power of attorney, advanced directives, and getting honest with doctors about prognosis and palliative care.
posted by juniperesque at 8:24 AM on June 18, 2018 [6 favorites]


Surgery involving anesthetic can lead to post surgery depression in elderly people, well in everyone but the elderly are more prone to it. Talk to his doctor about your concerns if you can. Antidepressants can help.

There are special high calorie drinks you can get for such occasions. Can he tolerate fruit juices. One small 6oz glass of juice with each meal can up his calories for the day by around 600. If he can drink milk with no issues, then Ensure milkshakes with lots of icecream and whole milk are great. Throw in a banana too & make a smoothie out of it. 2 of those & you've got an extra 600 calories easy. Remember use things like ensure to supplement an actual meal. They are great snacks in between meals.

You really need to get him drinking his calories that will solve 2 problems in one. Dehydration can also lead to not feeling like eating.

By the way, I'm a big believer in emotional blackmail. We totally used my niece to get my mother eating again after a bad health scare. She literally pulled the, but you have to be at my University graduation in a few years or I'm not going to Uni card. My mother also got a lot of help out of speaking to a therapist the hospital put her in touch with as she had bad almost anxiety with nightmares after the sudden health downturn put her in the ICU for a couple of days. Is that an option through your hospital?

Also make sure he's doing his physical therapy. That will help build up strength so help his balance & can increase appetite. Also rebuilding his strength will help him feel less helpless. Do slow gentle walks with him, if he's a fall risk does he have a walking frame? My mother is currently in a similar situation in hospital, they are having her walk around the halls of the hospital several times a day with her walker & are fanatical about her doing her physical therapy to keep her muscle tone & balance.
posted by wwax at 8:34 AM on June 18, 2018


A common issue among the elderly is a decrease in the ability to swallow safely: they end up inhaling bits of food or liquids (leading to pneumonia). As a result, drinking is uncomfortable and they often end up dehydrated. This was an issue for my father, and we couldn't figure out why he was so hesitant to drink water, and why he kept passing out from dehydration, until he ended up in the hospital and they gave him a swallow test.

So I recommend that you ask your father's physicians for a swallow test.

Treatment for the syndrome is that liquids get thickened and food gets mashed. It's not perfect, but it's better than dehydration or malnutrition.
posted by suelac at 8:57 AM on June 18, 2018 [3 favorites]


Given his attitude towards healthcare in the past, are you sure he is wanting to eat? It's not unheard of for people to deliberately not eat if they feel their health will not improve and believe the treatment risks being worse than the cure. I agree that a medically oriented therapist/counselor may help sort through these complicated issues, and can help arrange further testing if indicated and desired.
posted by beaning at 9:10 AM on June 18, 2018 [1 favorite]


We just went through something similar with my grandmother and she was given a glucose drip which not only helped with her dehydration it also gave her an energy boost which in turn helped with her eating.
posted by doublenelson at 9:10 AM on June 18, 2018


Are you in a part of the world where marijuana is an option?
posted by mollymayhem at 9:26 AM on June 18, 2018 [1 favorite]


You don't say whether he's been asked why he isn't eating. There could be a lot of reasons. Has anyone done a swallow study?

My grandmother started spitting out everything when she had dementia. Ice cream turned out to be the one food she would eat. My family didn't believe in seeking medical help and she wasn't coherent at the time, so I don't know if there was a particular reason she wasn't eating.
posted by FencingGal at 9:29 AM on June 18, 2018


What medications is he in? There are a number of things that could be upsetting his stomach. For my mother-in-law, cholesterol meds were a huge problem. Her weight stabilized and she started enjoying food again when she got off of that.
posted by SLC Mom at 9:37 AM on June 18, 2018


Depression is a big cause of not eating, and it can be caused by illness; it's a physical thing, not necessarily emotional.

When my Mom lost interest in food, I would make a piece of cinnamon toast, cut in triangles, and set it down next to her. She'd usually eat some. Then maybe some of her favorite olive & cream cheese spread on ritz crackers, just a few, and she'd eat some. A little piece of brownie. Make milkshakes with ice for hydration and ice cream, but just a small portion at a time; big portions can be intimidating. Very frequent small portions help.

Can you ask him if he has lost interest in living? The physical toll of illness, age, possible loneliness, may be wearing him down.
posted by theora55 at 9:48 AM on June 18, 2018


Maybe a long shot, but does your dad seem confused or irritable? Urinary tract infections can cause additional problems for the elderly, including cognitive problems and loss of appetite. If he just had surgery, he was probably catheterized, which could be a contributing factor. Best wishes for your dad's health, and hope you figure out his eating soon.
posted by loop at 10:00 AM on June 18, 2018


Also if he's concerned about not being able to make it to the bathroom in time, he may be (consciously or unconsciously) restricting his input to compensate.
posted by loop at 10:05 AM on June 18, 2018


Does he WANT to live? This may sound like a silly question, especially if YOU want him to live. But it's a real thing. When elderly folks decide they're done living, they can simply stop doing anything that would help them live. Like eating. It might be worth a private conversation with him - without his spouse or anyone else present. We all ultimately have power of attorney over how we care for our own bodies, and knowing honestly what he wants to happen would give you a perspective to his care that you wouldn't have otherwise.
posted by summerstorm at 10:21 AM on June 18, 2018 [1 favorite]


Response by poster: Thanks for all the thoughts and advice so far. To address a few questions:

Ensure was recommended by the hospital staff after the surgery. I know he had some, but I think he stopped taking it. I'm 150 miles away and even though I'm visiting when I can, I'm not current on every change in habit.

Very early stages of some flavor of dementia or other cognitive deficit is a possibility. He has no problem participating in conversation, but his short-term memory has seemed unreliable for a while now. Discerning this is complicated by the fact that he's got some hearing loss, which he refuses to have treated or addressed technologically. Often I find myself wondering whether he's forgotten something, or maybe didn't hear it clearly in the first place. He also downplays his symptoms when talking to medical providers, and it's hard to tell whether he's confused or just trying to avoid being poked and prodded.

He's also coping with several hemorrhoids which (surprise!) he's refused to have treated. It's possible he's reducing food intake in part to compensate for that eventual discomfort. I don't get the sense that this is an overriding factor, though.

I'd say it's premature to think he's lost interest in living. He's scared of dying, but of course that isn't the same as saying he wants to go on living. I don't think anyone has put the question to him directly. If asked, I doubt he'd answer. He's certainly emotionally worn down by all of this. I'd say he's been refusing to address a handful of relatively minor problems for a long time, and until the jaundice kicked in he was able to compensate. Now suddenly these entirely treatable symptoms he's been tolerating for years are suddenly seeming intolerable, and some are at the same time becoming more difficult to treat. He's incapacitated, and feels bad about being a burden, which contributes to depression and resistance to help, wash rinse, repeat...
posted by jon1270 at 11:03 AM on June 18, 2018


Response by poster: Oh, and a call to his family doc this morning got him sent to the emergency room, so he's getting IV fluids, blood tests and a fresh round of attention. I'm crossing my fingers that this is a good thing.
posted by jon1270 at 11:13 AM on June 18, 2018 [2 favorites]


ftm's antidepressant suggestion is a good one. If your dad is resistant to the idea of antidepressants, mirtazapine (branded: Remeron) is also prescribed for insomnia and chronic, tension-type headache, and is known for stimulating appetite and causing fairly swift weight gain.
posted by Iris Gambol at 12:40 PM on June 18, 2018


until he ended up in the hospital and they gave him a swallow test

The same thing happened to my mom's long-term companion. He was hospitalized for aspiration pneumonia several times, and finally it was determined that mashed food, Ensure, and similar things were not safe for him to consume either. He was fitted with a g-tube and taught how to use it himself (3 meals daily like a "normal" person, but consisting of a nutritive liquid going through the g-tube directly into his stomach), and had a nurse do home visits 3x weekly to check the hole for irritation and cleanliness, and he actually lived a fairly fulfilling life for another 10 years. His ability to feed himself gave him a good deal of independence and assuaged feelings of being a "burden." I do hope your father is checked for swallowing issues while he is hospitalized. In any case, I am glad to hear he is getting IV fluids. It's important not to underestimate how damaging dehydration can be, especially in the elderly. It could actually be contributing to his memory issues.
posted by RRgal at 2:25 PM on June 18, 2018 [1 favorite]


Could it be that he’s not just being “fussy” but that his complaints about indigestion have some basis in fact, and that he’s Eg suffering from complications after the surgery, like postcholecystectomy syndrome?

(One could understand his reluctance to trust healthcare providers if his cancer was initially missed, and if he has problems communicating due to hearing problems. How does he respond if you validate his concern, and then ask him what alternative he suggests?)

I hope he gets the care he needs!
posted by cotton dress sock at 5:37 PM on June 18, 2018


Response by poster: For anyone still watching, this did turn out to be indicative of a tangible physical complication. There's some sort of blockage where the small intestine connects to the stomach, so everything was backing up rather than moving along through the system. They're addressing it, but aside from a short-term improvement in his comfort it's not sounding like particularly good news; it means another endoscopy, possibly another surgery, and could be a result of cancer having spread more than we'd known.

All the thoughts and sympathies are more appreciated than I can say.
posted by jon1270 at 5:36 AM on June 19, 2018 [5 favorites]


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