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Palliative Care: Anorexia Palliative Care: Anorexia

Palliative Care: Anorexia - PowerPoint Presentation

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Palliative Care: Anorexia - PPT Presentation

amp Cachexia Hong Phuc Tran MD g013 Learning Objectives Identify reversible causes of anorexia Learn management of anorexia Explain features of cachexia Understand that cachexia is often caused by same factors that cause anorexia ID: 677451

cachexia anorexia cancer weight anorexia cachexia weight cancer amp patients appetite loss care nutrition management disease effect day reversible

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Slide1

Palliative Care:Anorexia & Cachexia

Hong-

Phuc

Tran, M.D.

g013Slide2

Learning Objectives

Identify reversible causes of anorexia

Learn management of anorexia

Explain features of cachexia

Understand that cachexia is often caused by same factors that cause anorexia

Understand that increased calories, and enteral /

parenteral

nutrition cannot reverse cachexiaSlide3

DefinitionsAnorexia: loss of appetite and reduced caloric intake

Cachexia: involuntary loss of more than 10% of

premorbid

weight and loss of muscle, visceral protein and

lipolysis

Starvation: loss of weight and loss of

needed

caloriesSlide4

Anorexia: Introduction

Anorexia is a decrease or loss of appetite

Can be a symptom of a terminal disease process, such as cancer & end-stage CHF

Prevalence of anorexia is 66% in patients with advanced cancer.

Anorexia may occur in isolation or as part of anorexia-cachexia syndrome

Management involves evaluating for reversible causes Slide5

Causes of Anorexia

Medication side

effects:GI

causes

Constipation, fecal Impaction

Nausea, vomiting

GERD, gastritis,

gastro paresis

Malabsorbtion

: Pancreatic ca, diarrhea

Dysphagia

Depression, anxiety

Oral problems: dry mouth,

candidiasis

,

stomatitis

, dental pain, ulcers, poorly fitting denturesSlide6

Metabolic disordersThyroid problemsDiabetesAdrenal insufficiency

Altered taste and smell

Odors (e.g. certain smells of food)

Generalized weakness, lethargySlide7

Cachexia: Introduction

A wasting syndrome characterized by disproportionate loss of skeletal muscle over fat

Primary cause of death in about 20% of all patients with cancer

Often occurs concomitantly with anorexia, as it caused by same factors that cause anorexia

Multi-factorial etiology not clearly understood, but chronic inflammation is core mechanism

Tends to be very distressing for patients & familiesSlide8

Some Examples of Causes of Cachexia

Cancer

AIDS

Chronic obstructive pulmonary disease

Chronic renal insufficiency

Congestive heart failure

Cirrhosis

Dementia

Chronic infections

Autoimmune diseaseSlide9

Cachexia: Biochemical markers

Biochemical markers may be helpful in assessing cachexia

Primary cachexia/anorexia is associated with high CRP, low albumin

Increasing levels of CRP provide a measure of chronic inflammation

Anemia & decreased lymphocyte count often present

In patients with weight loss, normal albumin & normal/slightly elevated CRP raise concerns for other causes of weight lossSlide10

Dietary habits in dying people

Prospective study 151 advanced cancer patients dietary records

aprox

7 mo before death

Even patients with highest intakes had weight loss

Frequency of eating was important in total energy intake

Patients preferred typical foods over supplementsSlide11

Anorexia-Cachexia from Cancer

Distinct from other secondary causes of anorexia-cachexia

Includes correctable problems, including pain, infection, emotional disorder, obstruction, constipation

Not reversible with aggressive feeding / increased calories

Enteral and

parenteral

nutrition offer no significant benefits & do not improve survival or comfort

Weight loss correlates with cytotoxic effects of & poor tumor response to chemotherapy

Often present at diagnosis of certain cancers

Non-small cell lung, upper GI, pancreatic

Concomitant presence of anxorexia carries a poorer prognosisSlide12

Management of Anorexia

Identify and treat reversible causes

Educate families, caregivers on natural progression of disease

Evaluate whether anorexia is bothersome to patient

Anorexia may be more bothersome to families & caregivers than to patient

Offer favorite foods

Smaller, frequent meals and snacksSlide13

Supplements and Medications

Nutritional supplements

Oral protein shakes, protein powders

Take in ADDITION to food not instead of meals

Calorie dense supplement (

Benecalorie

)

Add to pureed foods, adds calories, no nutrition

Appetite stimulants

Megesterol

acetate

Marinol

DexamethasoneSlide14

Megesterol acetate (Megace)

Improves appetite and weight gain

Most of weight gain is from fat not lean muscle

Best absorbed when taken with high-fat meal

Start with 400mg/day. If appetite not better in 2 weeks, then increase to 600-800mg/day.

Takes a few weeks to take effect but longer duration of benefit than steroids

Side effects: Increase risk of venous thromboembolism, fluid retention

Contradictions: history of DVT , thrombophlebitis

Do not discontinue abruptly if used more than 3 weeks (adrenal suppression); taper off slowlySlide15

Cannabinoids

Marinol

(

tetrahydrocannabinol

, THC) improves weight gain and appetite in patients with AIDs & cancer

Start with small dose and up titrate to effect and tolerability

7.5mg to 15mg /day

Example dosing:

Marinol

2.5mg po TID one hour after meals

Adverse side effects: anxiety, somnolence, neurotoxicitySlide16

Corticosteroids

Stimulates appetite short-term

Dexamethasone

preferred over other corticosteroids for appetite stimulation due to its relative lack of

mineralocorticoid

effect

Rapid effect, long half life but effect limited 2-6 weeks

Doses of 2-16 mg/day

dexamethasone

Side effects: fluid retention, increased infection risk, gastritis, insomnia, proximal muscle wasting with prolonged treatment, steroid psychosis

Consider 1 week trial

If no improvement, then discontinue

If helps, then reduce to lowest effective dose.

Reassess need frequently; discontinue when no longer effectiveSlide17

Other agents

Psychotropics

-

Mirtazapine

, atypical antipsychotics

Mirtazapine

can increase appetite , but also may cause drowsiness, constipation

Atypical antipsychotics cause weight gain side effect, caution diabetes, blood sugars

Fish oil –small study in pancreatic ca patients showed increase in lean body mass

Thalidomide 200-400mg/day increased weight in HIV/AIDS cachexiaSlide18

Anorexia/Cachexia from Cancer: Examples of Correctable Causes & Management (1)

Emotional disorders

Anxiolytics

, antidepressants, counseling for patients & families

Eating issues

Dietitian referral, multivitamin, zinc / flavoring food with spices (for disturbed sense of smell or taste)

Oral problems

Oral moisturizers, antifungal meds to treat thrush (if present), change meds that may cause dry mouth

Swallowing difficulties

Esophageal dilation, antifungal med for thrush (if present)Slide19

Anorexia/Cachexia from Cancer: Examples of Correctable Causes & Management (2)

Stomach issues

GERD- proton pump inhibitors

Gastric stimulants (for early satiety), treat n/v

Bowel issues

Treat constipation / obstruction

Malabsorption

Pancreatic enzymes

Fatigue

anxiolytics

, exercise protocol, sleep protocol

Motivation issues

methylphenidate, exercise

Pain

appropriate analgesics, nerve blocks, counselingSlide20

Artificial nutrition and Hydration?(ANH)

ANH is a medical treatment

Some states make it more difficult to withdraw than other life sustaining treatments

Patients should have goals discussion of risk benefit regarding long term ANH

Insertion of

Gtube

, NG tube

Risk aspiration with decline in condition

Unclear benefits for dying patientsSlide21

Summary

Don’t focus on appetite and weight

Let patient guide new eating habits

Liberalize dietary restrictions

Maintain muscle function

Intervene early in disease

Nutritional supplements

Exercise

Consider medical therapies

Address patient and families fears

Identify alternative non food methods of expressing love, caringSlide22

References & Suggested Readings

AMA EPEC (Education for Physicians on End-of-Life Care) at http://www.cancer.gov/cancertopics/cancerlibrary/epeco/selfstudy/module-3/module-3b-pdf

Holms S. A difficult clinical problem: diagnosis, impact and clinical management of cachexia in palliative care. Int J Palliat Nurs. 2009 Jul; 15(7):320, 322-6.

Lasheen

W, Walsh D. The cancer anorexia-cachexia syndrome: myth or reality? Support Care Cancer. 2010. Feb; 18(2):265-72. doi: 10.1007/s00520-009-0772-6.

Loprinzi CL, Laurie JA, Wieand HS, et al. Prospective evaluation of prognostic variables from patient-completed questionnaires. J Clin Oncol. 1994;12:601­607.

McGeer AJ, Detsky AS, O'Rourke K. Parenteral nutrition in cancer patients undergoing chemotherapy: A meta-analysis. Nutrition. 1990;6:233.

Morrison RS, Meier DE. Clinical Practice: Palliative Care.

N Engl J Med.

2004 Jun 17;350(25):2582-90

Nelson K, Walsh D, Deeter P, et al. A phase II study of delta-9-tetrahydrocannabinol for appetite stimulation in cancer-associated anorexia. J Palliat Care. 1994 Spring;10(1):14-8.

Ruiz GV, Lopez-Briz E, Carbonell SR et al.

Megesterol

acetate for treatment of anorexia-cachexia syndrome. Cochrane Database

Syst

Rev. 2013 Mar 28;3:CD004310. doi: 10.1002/14651858.CD004310.pub3.

Shoemaker LK, Estfan B, Induru R, et al. Symptom management: an important part of cancer care. Cleve Clin J Med. 2011 Jan; 78(1):25-34. doi: 10.3949/ccjm.78a.10053.Slide23

Effective response to caregivers’ fears that loved ones are “starving” to death

Listen and assess for feelings of guilt

Ask about cultural and religious values

Explain physiologic differences between starvation and anorexia-cachexia

Explain artificial nutrition nor increased oral intake will not likely improve survival or weight gain in end stage disease

All of the aboveSlide24

Answer ESlide25

Primary anorexia –cachexia differs from starvation in that

Less protein synthesis occurs in anorexia cachexia due to decreased production of acute phase

Decreased

cortisol

levels suggest a chronically altered

neuroendocrine

state

Proinflamatory

cytokines are commonly involved, causing immune dysfunctionSlide26

Answer CAnorexia cachexia MORE protein synthesisCortisol

levels do not reflect changeSlide27

Mr. K is a 67 year old male with metastatic colon ca, referred to hospice. Family is concerned he had no appetite and continues to lose weight.

Insert NG tube and start tube feedings

Reassure the family his weight loss is normal

Complete a history and physical

Order

nystatin

suspension swish and swallow tidSlide28

Answer CComplete a H and P first to assess any reversible causes for anorexia cachexiaThen consider possible treatments