Anorexia, Asthenia and Cachexia

Definitions

Brief descriptions

Assessment

Management

Explanation to patient and family

Non-pharmacological interventions

Pharmacological interventions

Other medical non-pharmacological interventions

Review assessment and manage

Involve interdisciplinary team

Referral to appropriate services

Definitions

Anorexia is the loss of desire to eat. In cancer patients anorexia & cachexia are interrelated and described as the anorexia-cachexia syndrome. 

Cachexia is the ongoing, involuntary loss of body mass (with or without anorexia), declining muscle strength and inflammation (G. Hanks et al 2010). Cachexia is now recognized as a spectrum ranging from pre-clinical to late (irreversible) cachexia. The primary metabolic anorexia-cachexia syndrome is a complex, multidimensional process, with ongoing research into the sequelae and interactions between inflammation-catabolism, anorexia and anabolic dysbalance. Secondary anorexia-cachexia may result from starvation, deconditioning or infections. 

Asthenia, or fatigue, can be caused by cancer and its treatment. As with cachexia, there are complex interactions between the cancer and host which are thought to play a role in fatigue. Many patients suffer from fatigue and cachexia simultaneously. However, there are numerous cases where patients with cachexia may not suffer from fatigue and vice versa. The pathophysiology of fatigue is also multifactorial with numerous possible causes as listed below. 

Note that: “In the terminal phase of progressive illness there is virtually always a profound loss of appetite (and therefore an absence of hunger). The literature is clear that the body cannot use calories to become stronger or to gain weight. Instead, it breaks down its own energy stores (muscle, fat, carbohydrates) regardless of caloric intake. Efforts to improve caloric intake by enteral or parenteral means have no role in addressing comfort, functional status, or survival in such end-of-life scenarios”. (Harlos M, 2010) 

Brief Descriptions: 

Asthenia: 

• Generalised weakness 
• Physical fatigue 
• Mental fatigue 

Anorexia: 

• Loss of appetite 

Cachexia: 

• Loss of weight, including adipose and muscle tissue 
  • Catabolic processes 
  • Poor appetite 

Aetiology 

• Tumour-related anorexia and cachexia 
  • Gastrointestinal tumours 
  • Catabolic metabolism mediated by cytokines increases basal metabolic rate with lipolysis, glucose intolerance and hepatic gluconeogenesis using proteins. 
  • Cachexia, due to tumour factors, may occur without anorexia 
• Tumour-related asthenia 
  • Chemical mediators related to the tumour 
  • Raised intracranial pressure 
  • Asthenia may occur independent of anorexia and cachexia 
• Indirect causes of anorexia, cachexia and/or asthenia 
  • Treatment-related e.g. chemotherapy, radiation therapy, surgery, drug side effects 
  • Nausea and vomiting 
  • Dysphagia for any reason e.g. dry mouth, stomatitis 
  • Infections 
  • Anaemia 
  • Respiratory distress 
  • Sleep disturbances or overexertion 
  • Psychological problems and emotional state 
• Non Cancer causes 
  • Chronic obstructive pulmonary disease 
  • Cardiac cachexia in cardiac failure 
  • HIV/AIDS and related complications 
  • Other co-morbid diseases/illnesses 

Assessment

Detailed history including; history of illness, and treatments, other chronic illnesses, psychosocial and spiritual assessments and the extent of patient and family distress related to the problems of loss of appetite, weight loss and fatigue. Carry out meticulous examination to identify any causes as listed above and to check for complications of anorexia-cachexia or asthenia. Conduct appropriate investigations to identify any reversible causes. 

Management 

Correct Reversible Causes

• Nausea and vomiting 
• Constipation 
• Dysphagia 
• Anaemia 
• Depression and anxiety 
• Stop or reduce causative drugs 
• Reverse or treat possible medical or endocrine complications 
• Hypercalcaemia 
• Treat hypoxia 
• Treat and control pain 
• Antibiotics for infection 
• Vitamin supplements as required 
• Aberrant sleep patterns 

Explanation to patient and family 

• Be open and honest, explain the disease process and reassure and support the patient and family 
• Discuss causes for declining appetite and nutritional requirements to attempt to alleviate anxiety over mealtimes 
• Explain declining activity and discuss ways to alleviate boredom 
• If the patient is in the terminal phase explain that the body can no longer use the calories provided in food (or through artificial nutrition) and that feeding the patient does not improve his comfort, that it is more important to ensure good mouth care than to insist on feeding. 

Non-Pharmacological interventions 

• Advice to family: 
  • Encourage eating little and often, and when hungry 
  • Offer foods that patient enjoys 
  • Plan meals, offer variety 
  • Make food easily chewable 
  • Make mealtimes emotionally light and enjoyable 
• Consider nutritional supplements; discuss with a dietician 
• Encourage and maintain appropriate mobility 
  • Role of exercise in addressing anorexia/cachexia 
    • It appears that physical exercise may be a feasible intervention for fatigue in cases where muscle deconditioning is a contributing factor. (G. Hanks et al, 2010) 
    • A physiotherapist may be involved to devise a suitable exercise routine. 
  • Occupational therapists to help maintain independence and mobility as long as possible 
  • Aids to mobility; walking, continence, mobility in and out of bed 
  • Pressure area care 
  • Foot care 
• Counselling regarding adaptation to declining function and how to avoid over-exertion exacerbating fatigue 
• Be aware of depression and assess regularly, offering continued psychosocial support 

Pharmacological interventions 

• Progestogens: Megestrol acetate 80-160 mg daily, can increase up to 800 mg daily, or medroxyprogesterone acetate 400 – 960 mg daily 
  • Consider if prognosis is weeks to months 
  • May increase appetite and cause weight gain, however slower onset than steroids but beneficial effects may last longer 
  • More expensive than steroids 
  • Side effects such as hypertension, oedema and insomnia may limit use 
• Megestrol acetate is preferred for asthenia without anorexia-cachexia Periactin (cyproheptadine) 4 mg tds PO; an antihistamine, which may be considered as an appetite stimulant, does not significantly stimulate appetite in advanced malignancy. 
• Steroids: Dexamethasone 2-4 mg daily, or prednisone 10-20 mg daily, to increase appetite and energy 
  • May increase appetite as well as cause weight gain. Also reduces fatigue. Effects last 2-4 weeks. 
  • If clear benefit after a few days, reduce dose to minimum required to maintain benefit. If no benefit, stop steroids. 
  • Side effects may limit use 
  • Review regularly whether benefit outweighs risk. Once there is no further beneficial response (usually after a few weeks), wean off the steroids. 
• Eicosapentanoic Acid (EPA) 
  • Current clinical reviews are inconclusive but a recent large study showed a non-significant but clinically relevant effect on lean body mass of 2g EPA/ day. (G Hanks, et al 2010). 

Asthenia 

• There is increasing evidence supporting the use of methylphenidate for cancer- related fatigue as well as the possibility of treating opioid related sedation and depression. Starting dose: Methylphenidate 2.5-5 mg daily or bd PO, increase every few days to a maximum of 40-60 mg per day. Usually doses of not more than 30 mg a day are required. Side effects include anorexia (usually transient), insomnia and euphoria although it may paradoxically improve anorexia and insomnia. Insomnia is more common at the beginning of treatment and may be improved by reducing the doses. Contra-indications include anxiety, agitation, concurrent antiphsychotic medications and cardiac arrhythmias. Methylphenidate potentiates the effects of TCAs and antagonises the neuroleptic action of phenytoin. 

Other medical non-pharmacological Interventions 

• Total parenteral nutrition or nasogastric feeding is generally not encouraged in palliative care unless the patient is expected to have a favourable outcome with a good prognosis, such as before or after surgery. It may result in short-term weight gain, however is not advisable in patients with a poor prognosis as it does not significantly improve comfort or survival. Patients with a good prognosis, but with upper GIT obstructions or problems swallowing may benefit from a percutaneous gastrostomy tube. Family should be counselled about reducing feeds and fluids as the patient becomes terminal. 
• Hydration of a dying patient is often an emotional issue to be resolved with the family. Over-hydration at this time often causes unnecessary complications such as respiratory secretions. The family needs to be well counselled with regard to fluid requirements and the risks of over-hydration. A dry mouth is managed with good mouth care. In some difficult situations, hypodermoclysis (subcutaneous fluid administration) may be considered. 

Review assessment and management 

Regularly re-assess the patient. Always consider the risk/benefit of any intervention. Review interventions as the patient’s condition changes and progresses. Be aware of and try to anticipate new complications that may arise in the course of the illness. 

Involve interdisciplinary team 

Anorexia, cachexia and asthenia are multifactorial problems. Psychosocial and emotional issues often play a role both in the cause as well as the effects of these symptoms. It is important to involve all members of the team as required; the social worker, spiritual counsellor, physiotherapist, occupational therapist, dietician. 

Referral to appropriate Services 

Consider surgical consultation for patients, who may benefit from surgical interventions such as relieving obstruction or for placement of feeding tubes, e.g. percutaneous gastrostomy tube.