___________________________________________ Palliative Care and Pain Management at the End of Life
Etiology Across life-limiting diseases, anorexia may develop second- ary to several other symptoms, such as fatigue, constipation, xerostomia, dysphagia, mucositis, and nausea. Endocrine disorders as well as psychological, social, and spiritual distress can diminish the desire to eat [187; 345]. Changes in taste sensations (leading to food aversions), altered sense of smell, and early satiety have been common among people with cancer and anorexia [345; 346]. Studies have shown that multiple factors contribute to cachexia. Abnormal metabolism is thought to lead to a negative protein and energy balance, with subsequent loss of muscle mass [201; 339; 342; 343]. Inflammation, increased neurohor- monal activity, insulin resistance, and increased muscle protein breakdown are often associated with cachexia [339; 343; 347]. The role these factors play in the development of cachexia may differ according to the underlying chronic condition. Prevention Preventive measures for anorexia include effective manage- ment of symptoms that are known to have a potential impact on the desire and/or ability to eat. No appropriate measures to prevent cachexia are available.
intake, whereas cachexia refers to a loss of lean body mass resulting metabolic derangement rather than nutritional deficiency [340]. Complications of cachexia include asthenia (weakness), hypoalbuminemia, emaciation, and immune sys- tem impairment [310]. Cachexia is associated with a poor prognosis in many life- limiting diseases. In fact, unintentional, progressive weight loss of more than 10% of body weight over the past six months, with an albumin level less than 2.5 mg/dL is a prognostic indicator for hospice referral [76]. Despite this relationship between cachexia and poor prognosis, the condition is under- recognized and underdiagnosed [341]. Cachexia has also been challenging to define. The lack of an operational definition led to a consensus conference at which a definition was crafted [339]. This definition joins others for disease-specific cachexia ( Table 16 ). The diagnosis and management of anorexia/cachexia has been studied the most in the settings of cancer and HIV infection. Prevalence Anorexia occurs in 21% to 92% of adults with life-limiting disease, with the highest rates found among patients with cancer [207; 211; 307]. Cachexia has been reported in 16% to 57%, again with the highest rates found among people with cancer [341].
DEFINITIONS AND DIAGNOSTIC CRITERIA FOR CACHEXIA
Condition Definition and/or Diagnostic Criteria All patients with chronic disease Cachexia is a complex metabolic syndrome associated with underlying illness and characterized by loss of muscle with or without loss of fat mass. Chronic disease AND Loss of body weight of 5% or more within the past 3 to 12 months AND Presence of at least three of the following: Reduced muscle strength Fatigue Anorexia Low fat-free mass index Abnormal inflammatory marker levels, anemia, or low albumin level Cancer cachexia
A multifactorial syndrome defined by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment. Its pathophysiology is characterized by a negative protein and energy balance driven by a variable combination of reduced food intake and abnormal metabolism.
Cardiac cachexia
6% non-edematous, nonvoluntary weight loss over 6 months
HIV-associated wasting
At least one of the following: 10% unintentional weight loss over 12 months 7.5% unintentional weight loss over 6 months 5% body cell mass (BCM) loss within 6 months Body mass index (BMI) <20 kg/m 2
BCM <35% body weight AND BMI <27 kg/m 2 (men) BCM <23% body weight AND BMI <27 kg/m 2 (women)
Source: [339; 340; 342; 343; 344]
Table 16
43
MDCA1525
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