Chapter 11.1 Treatment of Cachexia in the Elderly Shing-Shing Yeh,Michael W.Schuster Treatment of Weight Loss and Cachexia in the intake in the elderly may be due to the following Elderly [10, 11] (Tables 1, 2): 1. Changes associated with normal aging Numerous studies have shown that weight loss is (reduced basal hunger, decreased gastric emp- associated with an increase in mortality [1–4]. tying time, failure to adjust food intake after Treating weight loss in the elderly can ameliorate periods of overfeeding or underfeeding) many medical conditions. For example, rehabilita- 2. Endocrine disturbances (hyperthyroidism, tion time following post-hip fractures has been hyperparathyroidism, hypoadrenalism) shown to decrease with nutritional supplementa- 3. Medications (theophylline, lithium, digoxin, tion [5]. In hospitalised geriatric patients, nutri- chemotherapy agents for cancer treatment, tional supplementation resulted in improvement in antibiotics, and many other medications that serum protein, nutritional status, and decreased distort normal smell and taste perception) mortality [6]. In a subset of geriatric inpatients, low 4. Dementia and related behavioural disturbances serum albumin with weight loss predicts those 5. Psychiatric problems (depression, anorexia patients at highest risk for dying during the subse- nervosa, alcoholism, late-life paranoia) quent 2 years [7]. Riquelme and Torres et al. [8] 6. Gastric, intestinal, and related problems (swal- carried out a multivariate analysis of risk and prog- lowing disorders, missing dentures, pain, mal- nostic factors in community-acquired pneumonia absorption, diarrhoea, constipation) in the elderly and found that age by itself was not a 7. Systemic-disease-related dysphagia (strokes, significant factor related to prognosis. Among the Parkinson’s disease, achalasia, scleroderma) significant risk factors, only nutritional status is 8. Dysgeusia (age-related decline in taste and amenable to medical intervention. In the cachectic smell) elderly, medical, cognitive, and psychiatric disor- 9. Chronic diseases (chronic obstructive pul- ders may diminish self-sufficiency in activities of monary disease, congestive heart failure, daily living (ADL), thus reducing the quality of life rheumatoid arthritis, HIV,cancers) and increasing the frequency of secondary proce- 10. Dysfunction (inability to feed oneself, limited dures, hospitalisations, and need for skilled care [2, income, poor eyesight, poor diet) 9]. The understanding of the pathophysiology of 11. Infections (acute and chronic diseases, HIV, geriatric cachexia has increased and has resulted in gastritis, cholecystitis). effective and safe nutritional measures. The Council for Nutritional Strategies in Long- Term Care has developed an algorithm for the assessment of undernutrition in long-term care Physiological Causes of Weight Loss in the settings. This algorithm was published in a supple- Elderly ment to the Annals of Long-Term Care, 2004, and addresses the diagnosis of weight loss. The first The regulation of food intake changes with age step in the management of weight loss in the eld- and involve mechanisms that are complex and erly is to attempt to identify and treat any specific multifactorial, making the treatment of weight loss underlying treatable or contributing conditions more challenging. Weight loss and poor food (e.g. endocrine diseases, medication, polypharma- 702 Shing-Shing Yeh,Michael W.Schuster Table 1. Causes of involuntary weight loss in the elderly; These are some of the important issues that need the 9 ‘D’s’. (Adapted from [11]) to be addressed first. Dysgeusia Dentition Nutritional Supplementation Dysphagia Depression Rolls and Dimeo found that even healthy elderly Drugs men consumed significant less baseline energy com- Dementia pared to young men [13–16]. Roberts et al. found that healthy elderly men had both a short-term (7 weeks) Diseases and a long-term (6 months) impairment in adjust- Diarrhoea (malabsorption) ing their food intake after an episode of either over- Dysfunction feeding or underfeeding.Encouraging the elderly to take in extra food (with verbal prompts, physical as- sistance, or appetite stimulants) at mealtime over a Table 2. Treatable causes of malnutrition (‘meals on period of 4–6 weeks, then allowing them to eat at wheels’). (Adapted from [10]) their own volition could promote weight gain. Since the elderly are not able to adjust their food intake af- M Medication effect ter a period of overfeeding for at least 6 months, E Emotional problems (depression) they will continue exceeding their eating needs and A Anorexia tardive (nervosa, alcoholism) thus, increase weight [14–16]. The elderly men in the study did not decrease food intake even after L Late-life paranoia they were given supplements before meals. As a re- S Swallowing disorders sult, they obtained 10–30% extra energy from the ‘preload’ (supplements) and still were able to take in O Oral factors (e.g., poorly fitting dentures, caries) their usual amount of food at mealtime. Providing an N No money energy-dense nutritional supplement 30–90 min be- fore a meal can thus increase energy intake in elder- W Wandering and other dementia related behaviours ly people. H Hyperthyroidism, hypothyroidism, hyperparathy- McCrory et al. found that a wide variety of roidism, hypoadrenalism sweets, snacks, condiments, and high-carbohydrate E Enteric problems (malabsorption) entrees coupled with a smaller variety of vegeta- bles promoted long-term increase in energy intake E Eating problems (inability to feed oneself) and body fat [17]. Providing nutritional supple- L Low-salt, low-cholesterol diets ments consisting of a wide variety of sweets and S Stones, social problems (e.g., isolation, inability to carbohydrates may be helpful as the second step obtain preferred foods) for the treatment of weight loss. In addition, loss of taste and smell are common in the elderly, and medications and medical conditions play a major role in taste losses and distortions [18]. Thus, the use of flavour-enhanced food has a corresponding- cy, depression, dentition, constipation, dehydration ly positive effect on food intake. diarrhoea, systemic diseases, infections, and social Resistance at meal times in demented patients support for providing food and feeding). However, is widely reported [19],and behavioural distur- Kayser-Jones et al. found that a lack of attention to bances play a role in low body weight and weight individual food preferences, inadequate staffing, loss in demented patients [19]. Providing feeding and a lack of feeding assistance were major factors assistance and using feeding assistants may pro- accounting for weight loss in the elderly [12]. mote intake in the demented population [20]. 11.1 Treatment of Cachexia in the Elderly 703 Tube Feeding and (5) miscellaneous agents as metabolic stimu- lants or supplements (Table 3). Tube feeding has been indicated in persons with neuromuscular diseases (with impaired swallow- ing or gag reflex), postoperative patients, individu- Treatment with Appetite Stimulants als who are unable to eat, and patients using venti- Megestrol Acetate lators. Feeding-tube-associated side effects include aspiration, diarrhoea, and vomiting [21]. Megestrol acetate (MA) is a synthetic derivative of Numerous studies have been aimed at determining a naturally occurring progestational agent and is the benefits of tube feeding [22]. Mitchell et al. similar to progesterone. MA treatment of patients found no evidence that tube feeding prolonged with cancer increases appetite and non-fluid survival, especially if dysphagia is the main indica- weight gain in a dose-dependent manner, and is tion [23]. Only a small subset of nursing-home res- well-tolerated in patients with advanced malignant idents benefit from tube feeding [23]. diseases [39–44]. Von Roenn et al. found that treating patients with MA for AIDS-related anorexia/ cachexia not Parenteral Nutrition only increased weight, but also improved body image, sense of well-being, and pleasure from eat- Parenteral nutrition can be given to the elderly ing [45–47]. The Food and Drug Administration immediately after acute disease if they are inca- (FDA) has approved the use of MA for the treat- pable of taking in adequate calories or fluid for a ment of anorexia, cachexia, and/or an unexplained short period of time [24]. This must be only a tem- significant weight loss in patients with a diagnosis porary measure and cannot be sustained for more of AIDS. A few studies have shown that treating than a few weeks. Peripheral parenteral nutrition cachexia in the elderly with MA improved quality only provides a limited amount of calories and the of life and weight gain [48–51]. Lambert et al. infusion site has to be changed frequently; thus, its found that MA appears to have an anti-anabolic benefit is restricted [25, 26]. effect on muscle size, even when combined with testosterone replacement. Resistance exercise attenuated this reduction in muscle mass [52]. Pharmacological Interventions Although the mechanism(s) by which MA pro- motes weight gain is unknown, Hamburger et al. The effects of nutritional support on the preven- suggested that it either blocks tumour necrosis tion and treatment of cancer and AIDS cachexia factor (TNF) or reverses the effects of TNF by have been extensively investigated [27–33]. inducing adipocyte differentiation [53]. Reitmeier However, nonselective nutritional support with and Hartenstein found that MA increases body total parenteral nutrition