Transcript cancer anorexia cachexia-michelle kralt

Cancer anorexia and its
impact on the survival
journey
Palliative Care Rounds
October 30, 2003
Michelle Kralt, RN MN
[email protected]
The World Heath Organization explains that
Palliative care:
“…provides relief from pain and other
distressing symptoms, integrates the
psychological and spiritual aspects of care and
offers a support system to help patients live as
actively as possible until death”
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The goal of palliative care is achievement of
the best quality of life for patients and
families.
Session objectives
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1. Examine pathophysiologic changes
associated with cancer-related anorexia
2. Discuss interventions for cancer-related
anorexia
3. Appreciate the impact anorexia has on
quality of life in people with cancer.
What is anorexia?
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“orexis” – Greek for “appetite”; “A” –
“without” = anorexia; meaning to be without
appetite
Appetite is psychological, dependent on
memory and associations, as compared with
hunger, which is physiologically aroused by
the body’s need for food.
One can feel hungry and have anorexia
simultaneously
Cachexia
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is derived from the the Greek “kakos” meaning
“bad” and “hexis” meaning “condition”
Is a debilitating state of involuntary loss of
adipose tissue and skeletal muscle mass.
Is usually diagnosed when pts have weight loss
more than 5% of preillness weight in previous
2 to 6 months.
Different types of Anorexia
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1. Anorexia nervosa: refusal to eat, most
commonly occurs in pubescent girls in
developed countries.
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2. a form of starvation related to malnutrition
caused by impaired intake due to pain, GI
obstruction, n/v, altered GI motility,
medication s/e, depression/stress, swallowing
difficulties, thyroid irregularities, constipation,
poor sleep, severe fatigue
Cancer-related anorexia
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3. primary anorexia is the absence of appetite
despite obvious nutritional needs
It is directly caused by the cancer
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It is most commonly seen in individuals with lung,
pancreatic, and gastric cancers
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Anorexia is not dependent on a large tumor burden
 May also occur with infections, renal failure, AIDS, CHF,
IBD,COPD
Significance of anorexia
Anorexia has been reported in 6% of early
diagnosis to 85% of advanced cancer patients
(Watanabe & Bruera, 1996, Starsseer & Bruera, 2002).
Anorexia effects both the patient and carer; for
the carer, it can seem like the pt is “giving up.”
Anorexia may often be the first presenting sign
of cancer 50% of the time (Damsky Dell, 2002)
Continued…
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Anorexia is associated with asthenia, fatigue
and weakness
Change in body image
Cognitive impairment
Clinical significance of weight loss
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Weight loss of >5% of pre illness state
significantly increase symptom distress and
functional status in patients. (Sarna et al, 1994).
People with significant weight loss have a
severely impaired tolerance to both radiation
treatment and chemotherapy (Stepp & Pakiz, 2001)
A BMI of <18.5 severely reduces physical
work capacity, significantly impairing a
person’s quality of life
Clinical significance of weight loss
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Malnutrition leads to 1) gastrointestinal
impairment, 2) respiratory problems, 3)
cardiac problems and 4) decreased immune
function.
Anorexia and malnutrition lead to deterioration
in psychologic function which manifests as
apathy, lassitude, lack of self help motivation,
depression and anxiety
Meguid & Laviano, 2001
Anorexia
Anxiety
Weakness
Depression
Fatigue
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Pt’s with significant weight loss experience 40-60%
increase in frequency of complications in response to
surgical/medical treatments
 They have higher hospital admissions
 They have a twofold to threefold higher death rate than
their well nourished counterparts.
(Meguid & Laviano, 2001)
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Median survival was significantly shorter in pts with
weight loss
Chemotherapy responses are lower in pts with weight loss
(Dewys, et al , 1980).
Anorexia-cachexia syndrome
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Anorexia and cachexia are associated and
often experienced together; however it is
possible that one can experience anorexia or
cachexia independently of the other.
Protracted anorexia will eventually lead to
cachexia (Morris, 1999)
ACS is one of the most common causes of
death in cancer
Physiology of appetite
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Appetite is the desire to eat and is influenced
by cultural, sensory, and physiological
consequences on choices and intakes of foods
Decreased plasma
glucose
Net Effect:
Plasma fatty
acids and
glucose
Glucose receptors in the
hypothalamus
Spinal
Cord
Liver
Muscle
Adipose
Sympathetic
Tissue
Neurons
Adrenal
medualla
Pathophysiology of
primary anorexia (&
cachexia)
Yesterday’s theory
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Cancer steals nutrients from body
metabolism increases to meet demand
toxins secreted that depress appetite
Dispelling the Myths of Cachexia
-Cachexia ≠ Anorexia
-Cachexia is not caused by the tumor consuming
the nutrients
-Cachexia ≠ Starvation
Characteristics of Cancer Versus Starvation
Cachexia
Variable
Starvation
Cancer
(
Energy intake
*)
Energy Expenditure (resting)
Body fat
Skeletal muscle
Liver
†
atrop
Increased
size and
metabolic
hy
activity
‡
Todays’ Theory
Cytokines
Metabolic Abnormalities
Neurohormonal
Alterations
1. Inefficient metabolic alterations
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Energy expenditure in relation to lean body
mass is increased.
Glucose turnover is present via hepatic
gluconeogenesis and lipolysis
Whole body protein turnover increased, amino
acid turnover is altered
Increase in production of c-reactive protein
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Elevated amino acids levels in
the plasma may decrease
appetite
2. Neurhormonal regulation and
food intake
LHA = Lateral
Hypothalamic Area
VMH = Ventral
Medial
Hypothalamic Area
Hypothalamus
Satiety
Center
VMH
Homeostasis
LHA
Hunger
Center
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Anorexia is associated with low
dopamine and high serotonin levels
in the VMH
Cytokines
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Nonantibody proteins released by one cell
population on contact with a specific antigen,
which acts as cellular mediators in the
generation of an immune response
Cytokines
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TNF-α (tumour necrosis factor alpha)
IL-1 (Interleukin 1)
IL-6 (Interleukin 6)
CCK (Cholecystokinin)
CRF (Corticotropin releasing factor)
A
Anorexigenic
Neuropeptide
Anorexigenic
Neuropeptide
Orexigenic
Neuropeptide
Neurotensin
MCH
Neurotensin
MCH
Melanocortin
AGRP
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Melanocortin
CNS Cytokinase
AGRP
IL-1
IL-6
TNF-
_
CRF
NPY
+
_
+
CNS Cytokinase
_
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CRF
CNTF
IL-1
NPY
+
INF-
+
B
Orexigenic
Neuropeptide
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+
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ACTH
Tryptophan
Seratonin
Food Intake
Food Intake
Energy Expenditure
Energy Expenditure
Blood Brain Barrier
Glucocorticoids
Blood Brain Barrier
+
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+
+
Glucogon
+
Cytokinase
IL-6
Glucogon
CNTF
Leptin
+
CCK
Leptin
+
CCK
+
IL-1
+
Taste Changes
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Taste and smell aversions are also common with
cancer related anorexia
Possible link between high levels of serotonin and
taste aversions (Edelman et al, 1999)
A large tumor burden can increase the degree and
duration of taste alterations (Sherry, 2001)
Etiology of taste changes
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1. Presence of malignant cells or cancer tx may
reduce # of taste buds
2. Dividing cancer cells secrete amino acidlike substance, causing a bitter taste sensation
3. Cancer-induced deficiencies in zinc, copper,
nickel and vitamin A, which are heavy metals
involved in normal taste function
Comprehensive assessment of
anorexia
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1. detailed hx of involuntary weight loss
2. Hx of nutritional intake
3. perceived change in body image?
4. presence of anorexia? (Visual analog scale)
5. Anxiety/depression?
6. Taste or smell changes?
7. Dysphagia or painful mouth problems?
Assessment continued
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8. thyroid function test
9. early satiety?
10. nausea and vomiting?
11. constipation?
12. Sleep patterns
13. Fatigue?
14. Functional status?
15. pain?
Experiential
Why not TPN/EN?
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TPN/EN causes further anorexia
Complications (ie: mechanical, metabolic and
infection)
Expensive
Does not improve survival
Does not cause weight gain
How does one make the decision to
discontinue TPN – very hard for pt & family
Orexigenic agents
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Megace
Corticosteroids
Dronabinol
Cyproheptadine
Thalidomide
Melatonin
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NSAIDS/COX-2
Fish oils
(Eicosapentaenoic acid)
Metoclopramide
Ginger root
Essiac
Nursing interventions
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Acknowledge the losses the patient and family
are experiencing and help them explore these
losses, including time to explore the
possibilities of the future
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Encourage family members to focus their
energies on other activities that convey
nurturing
Nursing interventions continued…
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Educate that failure to eat is not “giving up,”
and that the pt will not “starve to death”.
Explaining the nature of ACS as irreversible
and caused by metabolic abnormalities, and
that eating more food will not help the pt gain
weight
Conclusion
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By offering nutritional support and
pharmacological advice, symptom control and
psychological support to individuals with
cancer at risk for anorexia, nurses can reduce
the distress experienced even if symptoms of
anorexia or cachexia do not appear.