Hospice Palliative Care HPC Consultation Services Waterloo Wellington Tip of the Month [email protected] May 2019 Palliative Approach to Care Tips: Symptom Management for Cardiac Anorexia/Cachexia • Focus interventions on treatment of Anorexia symptoms and reduction of psychological and social burden for patient and family. Anorexia is a syndrome characterized by loss of appetite, nausea, early satiety, weakness, fatigue, food aversion, and • Cachexia is not starvation. In cachexia, significant physical and/or psychological symptoms. Causes are complex and can include fatigue, dyspnea, medication side- effects, nausea, depression, anxiety and sodium-restricted diets, which are common to patients with heart failure. catabolism and subsequent weight loss continue to occur, even if caloric intake is Cachexia maintained or increased. Cachexia is a syndrome characterized by severe body weight, fat and muscle loss and increased protein catabolism due to • Educate patient/family about the underlying disease. This occurs in both chronic right-sided heart failure and the advanced stages of heart failure. difference between weight loss related to How is cachexia diagnosed? The patient with cachexia has: cachexia versus diuresis. • >5% non-edematous weight loss in <12 months; or body mass index (BMI) <20kg/m2; and • Artificial nutrition in the context of • 3 out of 5 of the following: fatigue, decreased muscle strength, anorexia, low muscle mass, abnormal biochemistry advanced cachexia is ineffective and will Screening not improve quality of life. • Screen with Edmonton Symptom Assessment System (ESAS-r) for issues with appetite, nausea, fatigue, depression. Assessment Figure 1: Understanding the Effects • of the Cachexia Cycle Obtain a thorough history of nutritional intake, weight loss, and symptoms (nausea, early satiety, dyspnea, poor oral hygiene, dysphagia, malabsorption, bowel habits). • Ask how mood has been affected by weight loss? • Ask about other anorexia/cachexia-inducing factors e.g. cancer, hypothyroidism, liver disease, infection, depression. • Review medications known to contribute to anorexia/cachexia. e.g., amiodarone, digoxin. Inflammatory Response • Assess functional capacity for signs of early fatigue and muscle weakness, using the Palliative Performance Scale (PPSv2) Management: Non -Pharmacological Approach Pharmacological Approach Anorexia : Refer to a registered dietitian (RD); Standard heart failure therapies are known to improve quality of life and Muscle Breakdown ensure dietitian is aware of goals of care. may reduce symptoms even at advanced stages of disease. Consider focus on maintenance of food and Although many guidelines refer to the use of appetite stimulants and fluid intake for social and psychological steroids in the treatment of anorexia and cachexia, there is insufficient benefits; liberalize dietary choices as much as evidence of the benefit of these therapies in heart-failure patients. possible (e.g., low fat diet unnecessary). Fatigue, Early satiety/nausea: Metoclopramide 10 mg PO or subcutaneous, 30-45 Tiredness, Less Cachexia: Emphasis should be placed on minutes prior to meals and at bedtime - (reduce dosage in renal Activity maintaining and/or improving quality of life. impairment). If able, gentle physical exercise is recommended to improve peripheral blood If patient has co-occurring depression/anxiety/ insomnia, the flow, metabolism and cachexia-associated antidepressant Mirtazapine may have the added benefit of increased neurohormonal changes. appetite and weight gain. Starting dose of Mirtazapine 7.5 mg PO may be Reduced Quality titrated up to Mirtazapine 30 mg PO at bedtime with consideration of of Life Sources: potential sedative effects. • http://www.bcheartfailure.ca/ • Carlson, H. & Dahlin, C. (2014). Managing the effects of cardiac cachexia. Journal of Hospice and Palliative Nursing, 16 (1) 15 – 20. https://www.nursingcenter.com/cearticle?an=00129191-201402000-00005&Journal_ID=260877&Issue_ID=1653839 .