DIETARY

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DIETARY & NUTRITIONAL ASPECTS IN PALLIATIVE CARE:

DIETARY & NUTRITIONAL ASPECTS IN PALLIATIVE CARE DR.S.SREENIVASARAO MD,C.C.P.P.M, ASSIST PROFESSOR, DEPT.OF ANAESTHESIA, S.V.R.R.G.G.H.&S.V.M.C, TIRUPATI

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‘ IT WAS SO FRIGHTINING FOR ME TO SEE HER LOSE WEIGHT, I KNEW SOMETHING WAS DRASTICALLY WRONG, I BLAME MYSELF FOR NOT FEEDING HER THE RIGHT THINGS’ ( CARER WHOSE WIFE HAD ADVANCED CANCERA)

ANOREXIA CACHEXIA SYNDROME:

ANOREXIA CACHEXIA SYNDROME PRIMARY METABOLIC NEUROENDOCRINE ANABOLIC MODIFICATIONS SECONDARY STARVATION/MALNUTRITION IMPAIRED ORAL INTAKE IMPAIRED GASTROINTESTINAL ABSORPTION SIGNIFICANT LOSS OF PROTEINS LOSS OF MUSCLE MASS OTHER CATABOLIC STATES

IMPAIRED ORAL INTAKE:

IMPAIRED ORAL INTAKE STOMATITIS,TASTE ALTERATIONS DRY MOUTH,DEHYDRATION DYSPHAGIA,ODYNOPHAGIA SEVERE CONSTIPSTION BOWEL OBSTRUCTION AUTONOMIC FAILURE VOMITING SEVERE PAIN DYSPNOEA DEPRESSION,DELERIUM,COGNITIVE IMPAIREMENT SOCIAL & FINANCIAL OBSTACLES

PRIMARY ACS -PATHOGENESIS:

PRIMARY ACS -PATHOGENESIS TUMOUR TUMOUR HOST CYTOKINES/ INFLAMMATION CACHETIC FACTORS ACUTE PHASE PROTEINS HYPERMETABOLISM MUSCLEPROTEOLYSIS NEUROHORMONAL CONTROLE FOOD INTAKE ALTERATION ANABOLIC HORMONES ANOREXIA ORAL INTAKE LOSS OF MUSCLE MASS &FUNCTION & LOSS OF FAT

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CYTOKINE EFFECTS ON DIFFERENT ORGANS BRAIN ANOREXIA/FOODINTAKE INSOMNIA/DELIRIUM FATIGUE/MALAISE BODY TEMPRATURE GUT GASTRIC EMPTYING INTESTINAL TRANSIT TIME LIVER PROTEIN SYNTHESIS ACUTE PHASE PROTEINS GLUCONEOGENESIS VLDL MUSCLE CYTOKINE RECEPTOR PROTEIN GEGRADATION AMINOACID UPTAKE INSULIN RESISTANCE PROINFLAMMATORY CYTOKINES BONE MARROW HAEMOPOIESIS METABOLISM RESTING ENERGY EXPENDITURE GLUCOSE TURNOVER CORI CYCLE ACTIVITY ADIPOSE TISSUE LIPOPROTEINLIPASE ACIVITY WHITE ADIPOSE TISSUE LIPOLYSIS INSULIN RESISTANCE ALTERED CIRCULATING AA PATTERN STRESS HORMONES METABOLISM RESTING ENERGY EXPENDITURE GLUCOSE TURNOVER CORI CYCLE ACTIVITY ,ADIPOSE TISSUE LIPOPROTEINLIPASE ACIVITY WHITE ADIPOSE TISSUE LIPOLYSIS INSULIN RESISTANCE ALTERED CIRCULATING AA PATTERN STRESS HORMONES

PREVELANCE:

PREVELANCE IN CANCER PAIN----89% WEIGHTLOSS----58% ANOREXIA----55% CONSTIPATION---40% EARLY SATIETY---40%

GOAL:

GOAL RELEIVING NAUSEA & OTHER CORRECTABLES IMPROVING APPETITE MAINTAINING/GAINING WEIGHT PYCHOSOCIAL SUPPORT & EDUCATION TO ASSIST THE PATIENT & FAMILY IN UNDERSTANDING AND ACCEPTING BENEFITS AND LIMITS OF TREARMENT INTERVENTION

EUROPEAN ASSOCIATION OF PALLIATIVE CARE---THREE STEP APPROACH:

EUROPEAN ASSOCIATION OF PALLIATIVE CARE---THREE STEP APPROACH STEP---1 ASSESSMENT OF ONCOLOGICAL/CLINICAL CONDITION SYMPTOMS EXPECTED SURVIVAL HYDRATION AND NUTRITIONAL STATUS ORAL NUTRIENT INTAKE PSYCHOLOGICAL PROFILE G.I.FUNCTION & POTENTIAL ROUTE OF ADMINISTRATION SPECIAL SERVICES AVAILABLE FOR NUTRITIONAL SUPPORT STEP---2 OVERALL ASSESSMENT OF PROS & CONS FOR AN INDIVIDUAL PATIENT STEP---3 PERIODIC REEVALUATION OF THE TREATMENT APPROACH

APPROACH TO CLINICAL DECISION MAKING:

APPROACH TO CLINICAL DECISION MAKING IS THE PATIENT’S NUTROTIONAL STATUS IS ADEQUATE OR NOT -- WHAT IS THE EXTENT OF THE DISEASE ? ---HOW AGGRESSIVE IS THE DISEASE ? ---ESTIMATE THE LIFE EXPECTANCY BASED ON CLINICAL JUDGEMENT ? ---DOES THE PATIENT HAVE A CONCERN ABOU LOSS OF WEIGHT/APPETITE ? IF SO WHAT DO THESE SIGNIFY FOR THE PATIENTS ? & CONSIDER USING THE FALLOWING BEDSIDE MEASUREMENTS SUBJECTIVE GLOBAL ASSESSMENT OF NUTRITION BODY WEIGHT & HISTORY OF FOOD INTAKE SKINFOLD THICKNESS ALBUMIN LEVEL ASSESS APPETITE,ABILITY TO SWALLOW & EAT,NAUSEA & OTHER SYMPTOMS ADEQUATE BORDERLINE/MILDLY INADEQUATE SEVERELY INADEQUATE NO WEIGHT LOSS OTHER PARAMETERS NORMAL MILD WEIGHT LOSS(<10% OF BW) MILD CHANGES IN ONE OR MORE OF THE PARAMETERS SEVERE WEIGHT LOSS(>10% OF BW SIGNIFICANT CHANGES IN OTHER PARAMETERS

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ADEQUATE BORDERLINE SEVERY INADEQUATE REGULAR NUTRITIONAL ASSESSMENT AND NUTRITIONAL COUNSCELLING CONSIDER USING ADDITIONAL ASSESSMENT METHODS ADVANCED DISEASE IS THE PATIENT NUTRITIONA STATUS IS ADQUATE OR NOT YES UNSURE NO YES NO UNSURE ADDRESS UNDERLYING PROBLEM & CONSIDER TRIAL OF NUTRITIONAL SUPPORT NUTRITIONAL SUPPLEMENTATION PHARMACOLOGICAL MANAGEMENT OF ACS ARTIFICIAL NUTRITION REGULAR NUTRITIONAL ASSESSMENT AND NUTRITIONAL COUNSCELLING PHARMACOL MANAGEMENT OF ACS

OBJECTIVES:

OBJECTIVES PSYCHOSOCIAL ASPECTS OF EATING / NOT EATING STARVATION,WASTING etc; APPROACH TO PATIENTS & FAMILIES NUTRITION CHALENGES IN GRAVELY ILL CACHEXIA VERSES STARVATION ROLE OF ARTIFICIAL NUTRITION PHARMACOLOGICAL INTERCENTION PALLIATIVE PERSPECTIVES

I. Psychosocial issues:

I. Psychosocial issues “Nothing would be more tiresome than eating and drinking if [they were not] a pleasure as well as a necessity.” Voltaire

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Meals/eating highly “loaded” celebrations, milestones, happy times, sad times, memories Many or most patients with terminal illness ultimately are unable to eat enough to avoid weight loss and maintain activity levels PSYCHOSOCIAL ISSUES

II. Approach to patients/families :

II. Approach to patients/families

II. Approach to patients/families:

WHO definition: …improves quality of life of patients and their families ……prevention and relief of suffering …..early identification,… assessment and treatment of …. problems, physical, psychosocial and spiritual. II. Approach to patients/families

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Patients Body image? Sexuality? Embarrassment, shame, guilt, frustration Weaker and weaker, smaller and smaller “I’m wasting away…” PSYCHOSOCIAL ISSUES

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Families Frustration, anger LO weaker, smaller, frailer, but “won’t eat” Try harder, vicious circle Conflict “We can’t just let her/him starve…” PSYCHOSOCIAL ISSUES

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Nutrition is a basic animal need Is feeding a fundamental component of care? A right? PSYCHOSOCIAL ISSUES

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73 male, metastatic hepato-cellular Ca., Frail, bedbound, cachectic, icteric “Doctor, he no eat. Make him eat” 53 female, metastatic breast Ca., bowel obstruction (multiple omental mets, abd/pelvic adenopathy) Looks well, ambulating “So now I just starve to death?” 53 female, metastatic ovarian Ca., bowel obstruction Obese, eating (copiously) around NG Increasing emesis… “How will we feed her now?” PSYCHOSOCIAL ISSUES

II. Approach to patients/families:

II. Approach to patients/families Comfort always Prolong life Restore function Cure

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Failure to achieve balance Decreased PO intake Anorexia, xerostomia, altered taste/smell, odyno/dysphagia Decreased absorption Altered energy utilization NUTRITION CHALLENGES

NUTRITION CHALLENGES:

NUTRITION CHALLENGES Inadequate ingestion “Developed” countries: medical reasons Worldwide: lack of food

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Anorexia (loss of appetite) Multi-factorial “Cytokines”: central (hypothalamic) and peripheral (via vagus nerve) influences Huge frustration for families, source of much tension DECREASED PO INTAKE

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Approach: Symptom control (nausea, pain) Meal selection, timing, portion/presentation Avoid/reduce conflict (eat, drink, be merry): “eat what, where, when, as much/little as you want” ANOREXIA (LOSS OF APPETITE )

PHARMACOLOGICAL INTERVENTION:

PHARMACOLOGICAL INTERVENTION ESTABLISHED AGENTS METACLOPRAMIDE PROGESTATIONAL DRUGS CORTICOSTEROIDS EMERGING DRUGS CANNABINOIDS THALIDOMIDE MELATONIN NSAIDS OMEGA-3 FATTY ACIDS BETA-2-ADRENERGIC AGONISTS ANDROGENIC ANABOLIC STEROIDS GH & ILGF ATP DRUGS LIMITED PROVEN EFFICIENCY HYDRAZINE SULPHATE CYPROHEPTADINE

METACLOPRAMIDE:

METACLOPRAMIDE ANTIEMETIC PROKINETIC REVERSING TUMOUR ASSICIATED GASTROPERISIS NAUSEA DUE TO AUTONOMIC FAILURE/OPIOID REGULAR USE OF SC/ORAL METACLOPRAMIDE CAUSES SIGNIFICANT IMPROVEMENT IN APPETITE &FOOD INTAKE PROBLEM===SHORT ELIMINATION HALF LIFE

PROGESTATIONAL GRUGS:

PROGESTATIONAL GRUGS REDUCING NAUSEA INDUCING APPETITE—STIMULATION OF NEUROPEPTIDE-Y IN THE HYPOTHALAMUS MODULATION OF CALCIUM CHANNELS IN THE VENTROMEDIAL HYPOTHALAMUS INHIBIT THE ACTIVITY OF CYTOKINES INCREASING CALORIC INTAKE INCREASING BW,CALF CIRCUMFERENCE INCREASING THYROID BINDING PRE-ALBUMIN LEVELS SENSATION OF WELLBEING GLUCOCORTICOID/ANABOLIC ACTIVITY EX= MAGESTRAL ACETATE, MEDROXYPROGESTERONE ADVERSE EFFECTS INDUCE THROMBOEMBOLIC PHENOMENON, BREAKTHROUGH BLEEDING PERIPHERAL OEDEMA,HYPERGLYCEMIA,HYPERTENSION CUSHING’S SYNDROME,ALOPECIA,ADRENAL SUPPRESION

CORTICOSTEROIDS:

CORTICOSTEROIDS BENEFICIAL EFFECT ON SYMPTOMS SUCH AS APPETITE,FOOD INTAKE,SENSATION OF WELLBEING,& PERFORMANCE STATUS CENTRL EUPHORIANT ACTIVITY EFFECT ON PG METABOLISM/ INHIBITION OF CYTOKINE RELEASE NONSPECIFICANTIEMETIC EFFECT DRUGS==PREDNISALONE,DEXAMETHASONE

POSSIBLE MECHANISM OF ACTION OF DRUGS:

POSSIBLE MECHANISM OF ACTION OF DRUGS POSSIBLE MECHANISM DRUG CNS EFFECTS METACLOPRAMIDE CORTICOSTEROIDS PROGESTATIONAL AGENTS CANNABINOIDS ,THALIDOMIDE MODULATE IMMUNE RESPONSE/REDUCE INFLAMMATION CORTICOSTEROIDS PROGESTATIONAL AGENTS POLYUNSATURATED FA THALIDOMIDE,MELATONIN NSAIDS,ATP ANABOLIC EFFECT GH /ILGF-1 ANDRGENIC ANABOLIC AGENTS BETA-2 ADRENERGIC AGENTS ATP STIMULATE GIT/ INCREASES GASTRIC EMPTYING METACLOPRAMIDE

4. Pharmacology in anorexia Tx:

Appetite stimulants may increase intake, body weight, and quality of life, but they do not affect prognosis in the terminally ill 4. Pharmacology in anorexia T x Dy, M. “Enteral and Parenteral Nutrition in Terminally Ill Cancer Patients: a Review of the Literature.” American Journal of Hospice and Palliative Medicine . 2006; 23 (5): 369-377

NUTRITION SUPPORT:

NUTRITION SUPPORT DIETARY SUPPORT ENTERAL NUTRITION PARENTERAL NUTRITION

V. Role of Artificial Nutrition:

Two Potential Benefits Prolong life Palliate: improve comfort, enhance quality of life (for patients and their care-givers/loved ones) V. Role of Artificial Nutrition

CONCLUSION:

CONCLUSION FOUR CARDINAL PRINCIPLES RESPECT FOR PATIENT AUTONOMY (PT CHOICE) BENEFICIENCE (DO GOOD) NON-MALEFICENCE(MINIMISE HARM) JUSTICE(FAIR USE OF AVAILABL RESOURCES)

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