Anorexia and Cachexia

KEYPOINTS

  • Cancer and other diseases, such as HIV/AIDS, can often cause a lack of appetite (anorexia) and weight loss with muscle wasting (cachexia)
  • These are often accompanied by fatigue
  • The process of anorexia/cachexia is complex and involves numerous metabolic changes
  • Anorexia/cachexia is present in up to 80% of patients with cancer
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  • Children with solid tumours are more likely to develop cachexia than children with haematological malignancies
  • Seeing a child not eating may be very distressing for the family

ASSESSMENT

(see Foreword)

  • A good history and clinical assessment is important to try and identify any reversible cause of the anorexia/cachexia
    • Assess appetite
    • Assess ability/difficulty in swallowing and chewing
    • Identify any other symptoms such as pain, constipation, depression, or nausea and vomiting that may be causing decreased appetite
    • Examine the mouth for any sores, lesions or infection
  • Treatable causes of anorexia/cachexia include:
    • Ongoing pain
    • Nausea and vomiting
    • Depression
    • Oral problems
      • Dry mouth
      • Mucositis secondary to chemotherapy
      • Thrush/candidiasis
      • Oral herpes
    • Gastrointestinal motility problems
      • Reflux oesophagitis
      • Gastric stasis
      • Constipation
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  • As in adults: evaluate possible correctable conditions that affect appetite and feeding such as nausea, pain, oral conditions, constipation and depression

MANAGEMENT

  • Consider treatment of the underlying cause if one is identifiable
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Consider if patient is well enough to benefit

Nonpharmacological Approaches

  • Patient and family education
  • Eliminate dietary restrictions
  • Encourage patient to eat their favourite foods

Pharmacological Approaches

  • Ensure good pain and nausea/vomiting control, treat constipation
  • Stimulate appetite
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  • As in adults: corticosteroids may help appetite. However, because of potential significant adverse side effects they should probably not be used if anorexia/cachexia is the only symptom they might benefit

PITFALLS/CONCERNS

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  • Increasing calorie intake is unlikely to increase body weight and quality of life in advanced cancer cachexia

PALLIATIVE TIPS

  • Despite the appearance of malnutrition, anorexia/cachexia is usually not simply reversed with improved nutrition
  • Aggressive feeding can often make symptoms such as nausea, vomiting and pain worse
  • Educating the family that wasting is a part of the disease process and not the result of the family not providing enough nutrition for the patient is important
  • Anorexia can cause significant anxiety and distress for family members and caregivers who may not understand that loss of appetite is a common symptom of dying
  • There is no evidence that providing nutritional support either enterally or parenterally decreases morbidity or mortality in terminally ill patients
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  • Smaller, more frequent meals of the child’s favourite foods may help
  • Small plates and using straws may also help

SOURCES/REFERENCES

  1. Del Fabbro E, Dalal S, Bruera E. Symptom control in palliative care - part II: Cachexia/anorexia and fatigue. J Palliat Med 2006;9(2):409-421. http://www.ncbi.nlm.nih.gov/pubmed/16629571
  2. Hardy J, Rees E, Ling J, Burman R, Feuer D, Broadley K, Stone P. A prospective survey of the use of dexamethasone on a palliative care unit. Palliat Med 2001;15(1):3-8. http://www.ncbi.nlm.nih.gov/pubmed/11212465
  3. Lopez A, Figuls M, Cuchi G, Berenstein E, Pasies B, Alegre M, Herdman M. Systematic review of megestrol acetate in the treatment of anorexia-cachexia syndrome. J Pain Symptom Manage 2004;27(4): 360-369. http://www.ncbi.nlm.nih.gov/pubmed/15050664
  4. Nelson KA, Walsh D. The cancer anorexia-cachexia syndrome: a survey of the prognostic inflammatory and nutritional index (PINI) in advanced disease. J Pain Symptom Manage 2002;24(4):424-8. http://www.ncbi.nlm.nih.gov/pubmed/12505211
  5. Poole K, Froggatt K. Loss of weight and loss of appetite in advanced cancer: a problem for the patient, the carer, or the health professional? Palliat Med 2002;16(6):499-506. http://www.ncbi.nlm.nih.gov/pubmed/12465697
  6. Plonk W, Arnold R. Terminal care: the last weeks of life. J Palliat Med 2005;8(5):1042-1050. http://www.ncbi.nlm.nih.gov/pubmed/16238518
  7. Shragge J, Wismer W, Olson K, Baracos V. The management of anorexia by patients with advanced cancer: a critical review of the literature. Palliat Med 2006;20(6):623-629. http://www.ncbi.nlm.nih.gov/pubmed/17060256
  8. Strasser F. Eating-related disorders in patients with advanced cancer. Support Care Cancer 2003;11(1):11-20. http://www.ncbi.nlm.nih.gov/pubmed/12527949
  9. Strasser F, Bruera ED. Update on anorexia and cachexia. Hematology/Oncology Clinics of North America 2002;16(3):589-617. http://www.ncbi.nlm.nih.gov/pubmed/12170570
  10. Sutton LM, Demark-Wahnefried W, Clipp EC. Management of terminal cancer in elderly patients. Lancet Oncol 2003;4(3):149-57. http://www.ncbi.nlm.nih.gov/pubmed/12623360
  11. Tomíska M, Tomisková M, Salajka F, Adam Z, Vorlícek J. Palliative treatment of cancer anorexia with oral suspension of megestrol acetate. Neoplasma 2003;50(3):227-33. http://www.ncbi.nlm.nih.gov/pubmed/12937858

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