ABC of palliative care: Anorexia, cachexia, and nutrition

doi:10.1136/bmj.315.7117.1219

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Eduardo Bruera

Introduction

Cachexia is a complex syndrome that combines weight loss, lipolysis, loss of muscle and visceral protein, anorexia, chronic nausea, and weakness. Severe cachexia occurs in most patients with advanced cancer or AIDS. This article covers approaches to cachexia other than treatment of the underlying disease. In those patients who are eligible for tumouricidal treatment, cachexia may resolve as the disease responds.

Patient with cachexia

When faced with a cachectic patient, the clinician may approach the problem with four questions:

Does the patient have cachexia?
Why is the patient cachectic?
Which treatments are effective?
How should treatment be individualised?

Does the patient have cachexia?

Frequency of cachexia

More than 80% of patients with cancer or AIDS develop cachexia before death. At the moment of diagnosis, about 80% of patients with upper gastrointestinal cancers and 60% of patients with lung cancer have substantial weight loss. In general, patients with solid tumours (with the exception of breast cancer) have a higher frequency of cachexia. Cachexia is also more common in children and elderly patients and becomes more pronounced as disease progresses.

Assessing nutritional status

Because of the chronic nature of cancer cachexia, the diagnosis is simple. A patient's clinical history, the presence of substantial weight loss, and physical examination are adequate for an accurate diagnosis.

Effects of cachexia

Decreased survival
Increased complications of surgery, radiotherapy, and chemotherapy
Weakness, anorexia, chronic nausea
Psychological distress in patient and family

Plasma albumin concentration is usually decreased. Simple bedside measurements—such as triceps or subscapular skin folds (for body fat) and arm muscular circumference (for body lean mass)—may be useful to monitor nutritional changes or the effect of treatments in patients in whom body weight might be unreliable (such as those with ascites or oedema).

More sophisticated laboratory investigations are usually unnecessary. Immunological tests are unreliable markers of nutritional status in patients with cancer or AIDS because of the immunological abnormalities due …