Key messages

  • Loss of weight (cachexia) and appetite (anorexia) are significant concerns for many palliative care patients, and independently predict a poorer prognosis. [1-3]
  • The validated Patient Generated Subjective Global Assessment tool has been recommended for nutritional assessment in people with cancer-related cachexia. [4]
  • Often cachexia is poorly managed by health care professionals due to a lack of knowledge about screening and interventions and a lack of available resources, such as referral pathways. [5-7]
  • There is evidence to support the use of either progestogens (megestrol acetate or medroxyprogesterone acetate) [8] or corticosteroids [9,10] as appetite stimulants in advanced cancer, but less evidence to suggest that they are associated with any improvement in quality of life. [6,11]
  • Guidelines for managing anorexia and cachexia in advanced cancer patients are available. [6]
  • Nutritional counselling has been shown to improve some outcomes, including quality of life but evidence is limited. [7]
  • Artificial feeding in advanced dementia is ethically problematic and does not provide good palliation. In general, the focus should be on offering whatever oral intake the patient will accept, and on good mouth care. However, families and aged care staff may both require support and education in this area. [12,13]

Evidence summary

Definition and prevalence

Loss of weight (cachexia) and appetite (anorexia) are significant concerns for many palliative care patients, and independently predict a poorer prognosis. [1-3] The palliative conditions in which cachexia and anorexia occur most frequently are progressive malignancy, HIV/AIDS, end-stage cardiac failure, end-stage respiratory failure, chronic renal failure, chronic liver disease, and advanced dementia. A focus on weight gain on its own may not result in meaningful clinical changes for palliative care patients. [14]

Potentially reversible contributors to appetite problems should be sought and treated as appropriate. These may include:

  • Mouth problems - mucositis, oral thrush
  • Nausea
  • Pain
  • Dysphagia
  • Constipation
  • Depression
  • Family, social and cultural expectations related to food, diet, and body weight
  • Inappropriate presentation of food
  • De-conditioning / reduced level of activity
  • Dysgeusia - changed sense of taste and smell
  • Malabsorption
  • Dyspnoea
  • Medication effects.

Assessment and treatment

The relationship between catabolic state, hyper-metabolism, anorexia and nutritional intake, is extremely variable, complex and unpredictable. Appetite is a subjective symptom. Simple validated assessment tools are available, such as the Patient Generated Subjective Global Assessment. [15,16] However, expert consensus does not recommend any one tool over others. [6] With better understanding of cachexia anorexia syndrome, future treatments are likely to be multidimensional and initiated earlier. They may include appetite stimulants, tailored nutritional support and exercise, [17] and treatments to reverse the inflammatory drive associated with the syndrome. [18]

Assessment and treatment issues related to Cachexia Anorexia Syndrome, Appetite Stimulants and Nutritional Support are covered in more detail in the respective sub-section pages.

Practice implications

See individual subsections for practice implications in Cachexia Anorexia Syndrome, Appetite Stimulants and Nutritional Support

Evidence gap

  • The European Association for Palliative Care (EAPC) is refining definitions of cachexia for palliative care, reviewing the significance of secondary nutritional impact syndromes, and studying the psychosocial outcomes of cachexia and anorexia, and developing a decision tool. [15]
  • Some screening tools for appetite require external validation, and specific Quality of Life assessment tools are needed. [19]
  • Study of the differences between specific cachexia syndromes - cancer, chronic renal failure and cardiac failure - is evolving. [15]
  • Many studies with weight gain as an outcome do not identify how weight is gained - whether as muscle, fat, or oedema. Skeletal muscle mass, rather than total weight, is most closely associated with functional status. Other relevant outcomes such as quality of life, performance state, exercise and activity levels are now being studied in addition to changes in weight. [14]
  • Significant muscle wasting (sarcopenia) may occur in patients with maintained body weight due to fat; the possibility of assessing this with CT scanning is being studied in order to identify those patients with early stages of cachexia who might benefit from earlier intervention. [20]
  • 'Early satiety' is when a person wants to eat but can only take small amounts due to a sense of fullness. It is common in cancer patients and may be separate from other appetite problems, or it may co-exist with anorexia or nausea. Autonomic neuropathy may be a contributing factor. Early satiety is not well understood, but has been identified as an area for further research. [21]
  • Dysgeusia (abnormalities of the sense of taste) have been found to be common during cancer treatment (56 - 76% estimated prevalence). It is often associated with other oral symptoms, and with a worse quality of life. Treatments that have been studied include prophylaxis with zinc and amifostine, which have been shown to be of small benefit. Dietary and educational counselling may be of some assistance. [22]
  • The benefits of NSAIDs may be enhanced when used in combination with other appetite stimulators, although evidence for particular combinations remains low. [6,11]
  • Inflammatory markers, including C-reactive protein and others, are being studied for potential clinical use as screening and monitoring tools in the cachexia anorexia syndrome, and as a possible intervention target. [23,24] Genetic polymorphisms are being investigated in the search for susceptibility biomarkers. [24]

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Last updated 27 August 2021