Anorexia, Cachexia & Mouth Care

Hannie David RN, MSc, PG cert

Advanced Nurse Practioner

April 2015

Learning Outcomes

By the end of the session participants will have an understanding of :-

• Anorexia and cachexia within the palliative population

• Principles of assessment

• Management strategies

Background

• Cachexia & Anorexia

Prevalent in advanced cancer and chronic disease

Common symptoms

Not self inflicted

Linked with fatigue

“The flesh is consumed and becomes water,…the shoulders, clavicles, chest and thighs melt away…the illness is fatal “ (Katz & Katz 1962)

Does it matter?

• Body image

• Perception of self

• Confidence

• Psychological issues

• Survivorship

Physical signs and symptoms of malnutrition

• Changes in condition of hair

• Changes in skin

• Poor delayed wound healing

• Muscle wasting

• Weakened hand grasp

• Depressed mood

• Loss of balance

• Altered heart rate, rhythm or blood pressure

(Dudek 2010)

Anorexia and Cachexia

Anorexia

• Common symptom

• Loss of appetite

• Aversion to food

• Multiple factors associated with anorexia

• Anorexia-cachexia syndrome

Causes of anorexia

• Pain

• Dysphagia

• Nausea and vomiting

• Infection

• Obstruction

• Altered taste

• Dyspepsia/gastritis

• Constipation

Causes of anorexia

• Low mood/ depression

• Secondary causes

• Sore mouth

• Altered biochemistry

Cachexia

• Derived from Greek Kaxos and Hexis meaning bad and condition

• Complex metabolic syndrome

• Associated with poorer outcomes

• Impacts on survival

– 20% of pts will die from cachexia (Tisdale 2002, Muscaritoli et al 2006)

• Frequently seen in pts with solid tumours

• Most prevalent in cancer

• Present in chronic disease COPD, CKD, HIV, AIDs

• Psychological and social impact

• Unexplained weight loss defines cachexia

• Fundamental difference between cachexia and secondary weight loss

– Cachexia does not reverse with nutritional intervention

Anorexia Cachexia syndrome

• Top 5 most distressing symptoms

• Shorter prognosis

• Respond poorly to chemotherapy

• Experience more toxicity from chemo

• Psychological distress

Assessment of Anorexia Cachexia

• Thorough history

• Weight loss

• Nutritional intake

• Symptoms

• Severity of symptoms

Nursing role in management of anorexia cachexia

• Assessment

• Treatment

• Education

• Evaluation

• Reporting

• Assistance

• Nursing care

• Referrals to other HCP

Nutritional supplements

• Milk based – nutritionally complete

• Fibre enriched

• Maintain bowel function

• Juice based – supplement

• Powered – can add to foods/ fluids

• Puddings – useful in dysphagia

• Soups – savoury option

Try some supplements

Management of Anorexia Cachexia

• Aimed at stimulating appetite

• Steroids

• Prokinetics

• Hormones

• ACE inhibitors – found to help reduce weight loss in CHD patients

• Thalidomide

Non pharmacological interventions

• OT input – meal planning, adaptation aids

• Physiotherapy-

• Counselling

• Education

• Exercise

• Nutritional supplements

Pharmacological interventions

Food and the dying process

• Anorexia upsetting for patient and family

• Artificial/ forced nutrition will not prolong life

• Natural process

Xerostomia

• Subjective feeling of a dry mouth

• Causes- – Medication

– Oral thrush

– Mouth breathing

– Anxiety

– Oxygen therapy

– Radiotherapy

– Dehydration

Management of Xerostomia

• Local measures

• Saliva substitutes

– Water

– Saliva Orthana

– Glandosane - acidic, can increase dental caries

• Salivary stimulants

– Sugar free chewing gum

– Pilocarpine

– Accupuncture

– Salivix

↑

Mouthcare

• Aims of mouth care are

– Minimise infection

– Minimise halitosis

– Alleviate discomfort

– Moisten oral mucosa & lips

– Small soft toothbrush most effective

– Gentle scrubbing with gentle pressure

– Involve family

Further reading/ references • Oxford Handbook of Palliative Care. 2005

• Nicholas, M. (2004). Heart failure: pathophysiology, treatment and nursing care. Nursing Standard. Nov24/vol 19/ No 11.46- 53

• Porter, S. Millar, C. Reid, J. (2012). Cancer Cachexia Care. Cancer Nursing. Vol 35, No 6. 30-38

• Carlson, H. Dahlin, C. (2014). Managing the effects of cardiac cachexia. Journal of Hospice & palliative Nursing. Vol 16. No 1 pp 15-20 www.jhpn.co

• Tsai, L. lin, I. Lai, Y. liu, C. Chang, T. Tu, C. (2007). Fatigue and its associated factors in hospice cancer patients in Taiwan. Cancer Nursing. Vol 30, No 1 pp 24-30

• Bruera, E. (1998). Pharmacological treatment of cachexia: any progress? Support Cancer Care. 6: 109-113

• Solheim, T. Blum, D. Fayers, P. Hjermstad, M. Stene, G. Strasser, F. Kaasa, S. (1014). Weightloss, appetite loss and food intake in cancer patients with cancer cachexia: Three peas in a pod? – analysis from a multicentre cross sectional study. Acta Oncologica: 53: 539-546

• Blum, D. Omlin, A. Baracos, V. Solheim, T. Tan, B. Stone, P. Kaasa, S. Fearon, K. Strasser, F. European Pallaitive Cancer Research Collaborative. (2011). Cancer cachexia: A systematic literature review of items and domains associated with involuntary weight loss in cancer. Critica Reviews in Oncology/ Haematology. 80, 114-144

• Balstad, T. Solheim, T. Strasser, F. Kaasa, S. Bye, A. (2014). Dietary treatment of weight loss in patients with advanced cancer and cachexia: A systematic literature review. Critical reviews in Oncology ? Haematology 91, 210-221

• Dudek, S. (2010). Nutrition Essentials for Nursing Practice.. Lippincott Williams & Wilkins