ANOREXIA

Anorexia occurs in about 65% of hospice patients.

Management options include:

1. Consider causes

2. Consider steroids

3. Consider metoclopramide

4. Increase attractiveness of meals

5. Explain to patient and family

6. Seek advice from dietitian

1. Causes – Exclude oral thrush, nausea, constipation, hypercalcemia. Stop all unnecessary drugs. Anorexia occurs after chemotherapy or radical radiotherapy, but it is rare after low-dose palliative radiotherapy. Often no cause can be found.

In some cases anorexia maybe due to tumor peptides that affect metabolism (since plasmapheresis has been shown to improve appetite for 24 hours). Psychological factors are important, and anorexia may reflect the morale of the patient; it is common to see patients who have had severe anorexia eat well as soon as they enter the secure environment of a hospice or a day-care program.

2. Steroids – Patients often find anorexia upsetting – a daily reminder that they are “fading away”. Eating well often boosts morale. Steroids (dexamethasone 4mg per day or prednisolone 30mg per day) help about 80% of patients. Cyproheptadine is sometimes used as an appetite stimulant, but it is rarely effective. There is some evidence that megestrol acetate (480mg to 1,600mg per day) improves appetite and produces weight gain in patients with advanced breast cancer. There is some evidence that high dose Vitamin C (500mg 4 times a day) for 6 weeks or more may improve appetite and well-being.

3. Metoclopramide – If anorexia is due to a feeling of fullness or heartburn, it may be due to a small stomach, and metoclopramide 10mg before meals can help. (see Small Stomach Syndrome)

4. Meals – Attractive preparation and serving of favorite foods with strong tastes (salty or spicy) often helps. An alcoholic drink with the meal is appropriate if that is the patient’s usual practice. Small portions are important. Large helpings are a demoralizing reminder of healthier days, and can bring on nausea in some patients. Eating whenever hungry is better than observing strict traditional mealtimes. (A microwave oven can be helpful for a quick response). Eating in a room other than the sickroom can also help.

Avoid strong smells of cooking food at mealtimes. As the patient becomes less well, ice-cold food is sometimes preferred. Patients sometimes need permission to eat less. Liquid supplements may suffice. (see Diet)

5. Explanation – It is very important to explain anorexia to the family. Rejection of lovingly prepared food can feel like rejection of love. Explain that taste abnormalities are common in the very ill, and therefore the patient may develop new preferences. The body needs less food when inactive. There is no danger of wrong foods – the patient senses what he needs. Family members can encourage fluids right up to the end, but eating can become a difficult event, so do not allow family members to force food on a dying patient.

6. Dietitian  – Advice from a dietitian is usually welcomed. The dietitian can give advice about a balanced diet, provide suggestions on overcoming problems from taste changes or a sore mouth, and advise on the use of the growing number of available oral nutritional supplements.

«  Hyperalimentation and/or intravenous parenteral feeding do not improve appetite or weight experimentally, and have little or no place clinically in far advanced illness. (see Nutrition)

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.