Assessment and nonpharmacological management for patients with cancer anorexia-cachexia syndrome: a best practice implementation project.

INTRODUCTION AND AIMS: Cancer anorexia-cachexia syndrome (CACS) is a common multifactorial syndrome, which affects up to 80% patients with advanced cancer. At present, evidence to support the benefit of pharmacological intervention in the management of CACS is limited. Patients would benefit from standard procedures for early assessment and identification of cancer anorexia-cachexia, and using nonpharmacological strategies to manage patients with CACS. This best practice implementation project aimed to implement an evidence-based practice in assessing and managing patients with CACS, thereby improving the compliance of clinical practice with the best evidence and the quality of life of patients with CACS. METHODS: This was an evidence-based audit and feedback project that used a three-phase approach at a public hospital in China. Phase 1 included the development of seven evidence-based audit criteria and carrying out a baseline audit on 30 patients using the JBI's Practical Application of Clinical Evidence System in the Department of Radiation Oncology of Nanfang Hospital. Phase 2 utilized the Getting Research into Practice component of the Practical Application of Clinical Evidence System to identify barriers to compliance with best practice principles and developed strategies and resources to improve compliance. Phase 3 involved conducting a follow-up audit using the same sample size and audit criteria to assess the results of interventions implemented to improve practice and identify issues that would be addressed in future audit. RESULTS: The compliance rates of audit criteria 1, 2 and 6 were 100% at both baseline and follow-up audit. After the application of evidence, the compliance rate increased from 0 to 100% for audit criterion 3, from 0 to 76.6% for audit criterion 4, from 23 to 70% for audit criterion 5, and from 0 to 40% for audit criterion 5. CONCLUSION: The best evidence for the assessment and nonpharmacological management of cancer patients with CACS can improve clinical practice, the quality of clinical nursing, and patient satisfaction. The application of electronic informatization promotes the implementation and maintenance of best practice.

Validation of the functional assessment of anorexia/cachexia therapy instrument to assess quality of life in maintenance hemodialysis patients with cachexia.

BACKGROUND: Many patients on maintenance hemodialysis (MHD) eventually suffer from cachexia. The Functional Assessment of Anorexia/Cachexia Therapy (FAACT) is a tool used to evaluate the quality of life of patients with cachexia related to various diseases, but its suitability for use in MHD patients has yet to be verified. This study aimed to explore the validation of the FAACT in MHD patients by conducting reliability and validity tests. METHODS: Qualified MHD patients were selected to complete the FAACT and Kidney Disease Quality of Life Short Form 36 (KDQOL-36) questionnaires, and their demographic data and biochemical test results were collected from electronic medical records. Next, the Cronbach's alpha coefficient, paired sample t test and ICC were used to analyze the scale consistency. Additionally, the association between the KDQOL-36 and FAACT was analyzed using Bland-Altman plots and Pearson correlation analysis. Finally, the patients were divided into groups to evaluate discriminant validity. RESULTS: A total of 299 patients were included in this study. The Cronbach's alpha coefficients of the FAACT and its anorexia-cachexia subscale (ACS) were 0.904 and 0.842, respectively, and their ICC exceeded 0.90. The correlation coefficients between the FAACT and its items ranged from 0.146 to 0.631, and the correlation coefficients between the FAACT and KDQOL-36 dimensions ranged from 0.446 to 0.617. The Bland-Altman plots between the FAACT and KDQOL-36 showed that only 3.3% of the points were outside the 95% limits of agreement. The effects of cachexia status (present or absent) on FAACT and ACS scores had effect sizes of 0.54 (P < 0.001) and 0.60 (P < 0.001), respectively. The FAACT and ACS also significantly discriminated between patients with and without inflammation (P < 0.001). CONCLUSIONS: The FAACT and ACS have acceptable reliability and validity in MHD patients and are suitable for measuring the quality of life of MHD patients with cachexia.

Comprehensive validation of the functional assessment of anorexia/cachexia therapy (FAACT) anorexia/cachexia subscale (A/CS) in lung cancer patients with involuntary weight loss.

PURPOSE: Comprehensive (qualitative and quantitative) assessments of the 12-item functional assessment of anorexia/cachexia therapy (FAACT) anorexia/cachexia subscale (A/CS) and relevant subscales were undertaken for use in constructing potential endpoints in clinical trials of non-small cell lung cancer (NSCLC) with involuntary weight loss. METHODS: Eleven participants (≥ 18 years) from six clinical sites with a diagnosis of stage III unresectable or stage IV NSCLC and involuntary weight loss (either ≥ 5% body weight loss within six months prior to screening or screening BMI < 20 kg/m2) were interviewed to evaluate the content validity of the A/CS domain. A psychometric evaluation was conducted on the A/CS domain, and symptoms and concerns subscales, using data from previously completed phase III clinical trials (ROMANA1 [N = 474] and ROMANA2 [N = 488]). RESULTS: Anorexia-related symptoms were highly relevant to participants and had important impacts on their lives including energy levels, and physical, social, and psychological functioning. The majority of participants endorsed the A/CS domain items and found them to be easily understood, relevant, and comprehensive. Confirmatory factor analyses established that the A/CS symptoms and concerns subscales provided an acceptable fit as single factor models in ROMANA1 and ROMANA2. Reliability, validity, and responsiveness were established for the 12item A/CS domain, 5item anorexia symptoms subscale, and 4-item anorexia concerns subscale. CONCLUSIONS: These scales have good content validity, favorable psychometric properties, and can be used for characterizing the effect of treatment on anorexia symptoms and/or anorexia-related concerns in patients with NSCLC.

Assessment and Treatment of the Anorexia of Aging: A Systematic Review.

(1) Background: Appetite loss in older people, the 'Anorexia of Aging' (AA), is common, associated with under-nutrition, sarcopenia, and frailty and yet receives little attention. This review had two aims: describe interventions for AA and their effectiveness, and identify the methods of appetite assessment. (2) Methods: Study inclusion: participants aged ≥65, intervention for AA, and appetite assessment, any design, and comparator. Exclusion: studies on specific health cohorts. Searches in four databases with hand searching of references and citing works. Two researchers independently assessed eligibility and quality. (3) Results: Authors screened 8729 titles, 46 full texts. Eighteen articles were included describing nine intervention types: education (n = 1), exercise (n = 1), flavor enhancement (n = 2), increased meal variety (n = 1), mealtime assistance (n = 1), fortified food (n = 1), oral nutritional supplement (ONS) (n = 8), amino acids (n = 1), and medication (n = 2). Three studies evaluated combinations: education + exercise, ONS + exercise, and ONS + medication. Five intervention types exhibited favorable effects on appetite but in single datasets or not replicated. Appetite was assessed predominantly by Likert (n = 9), or visual analogue scales (n = 7). (4) Conclusions: A variety of interventions and methods of appetite assessments were used. There was a lack of clarity about whether AA or undernutrition was the intervention target. AA is important for future research but needs standardized assessment so that effectiveness of a range of interventions can be fully explored.

Allocating a scarce mental health treatment to the underweight and overweight.

BACKGROUND: This is one of a number of programmatic studies on the allocation of scarce medical resources. AIMS: This study investigated whether certain characteristics about patients influence the priority they are assigned for a scarce mental health treatment. Similar studies for physical treatments have found that young, poor, and mentally healthy patients are given the highest priority. METHOD: Each participant completed one questionnaire where they ranked a list of eight hypothetical patients in order of priority for treatment for anorexia or obesity. The patients varied on three dimensions: age, social class and mental health history. This involved a ranking of prioritisation for treatment. RESULTS: Participants gave the young patients, from a low social class background, who had a mental health history the highest priority for treatment. This is in contrast to previous studies indicating that the mentally unwell are discriminated against. CONCLUSIONS: Participants seemed to be using social class as a proxy measure of ability to pay which they weighted very highly.

Anorexia of Aging: Assessment and Management.

Older people often experience loss of appetite and/or decreased food intake that, unavoidably, impact energy metabolism and overall health status. The association of age-related nutritional deficits with several adverse outcomes has led to the recognition of a geriatric condition referred to as "anorexia of aging." Anorexia is an independent predictor of morbidity and mortality both in the community and across clinical settings. Multidimensional interventions within personalized care plans currently represent the most effective option to ensure the provision of adequate amounts of food, limit weight loss, and prevent adverse health outcomes in older adults.

Impact of cancer anorexia-cachexia syndrome on health-related quality of life and resource utilisation: A systematic review.

INTRODUCTION: Cancer anorexia-cachexia syndrome (CACS) negatively impacts patients' quality of life (QoL) and increases the burden on healthcare resources. OBJECTIVES: To review published CACS data regarding health-related QOL (HRQoL) and its economic impact on the healthcare system. METHODS: Searches were conducted in MEDLINE, EMBASE, DARE, and NHS EED databases. RESULTS: A total of 458 HRQoL and 189 healthcare resources utilisation abstracts were screened, and 42 and 2 full-text articles were included, respectively. The EORTC QLQ-C30 and FAACT instruments were most favoured for assessing HRQOL but none of the current tools cover all domains affected by CACS. Economic estimates for managing CACS are scarce, with studies lacking a breakdown of healthcare resource utilisation items. CONCLUSIONS: HRQoL instruments that can better assess and incorporate all the domains affected by CACS are required. Rigorous assessment of costs and benefits of treatment are needed to understand the magnitude of the impact of CACS.

The Symptoms Prevalence, Medical Interventions, and Health Care Service Needs for Patients With End-Stage Renal Disease in a Renal Palliative Care Program.

A retrospective study was conducted to evaluate the symptoms prevalence and interventions initiated in the last 2 weeks of life, health care service utilization, and causes of death of patients with end-stage renal disease (ESRD under a renal palliative care (RPC) program. A total of 335 RPC patients were included, of which 226 patients died during the study period. The 5 most prevalent symptoms were dyspnea (63.7%), fatigue (51.8%), edema (48.2%), pain (44.2%), and anorexia (38.1%); and the 5 most prevalent interventions initiated were oxygen (69.5%), parenteral infusion (67.3%), antibiotics (53.5%), bladder catheterization (44.7%), and analgesic (39.8%) in the last 2 weeks of life. Each patient received 3.5 ± 4.4 outpatient clinic visit, 3.4 ± 10.3 home care visits, and 3.1 ± 2.7 hospital admissions. Besides ESRD (51.8%), the most common causes of death were cardiovascular events (18.6%) and infection (17.2%).

[Effects of inpatient treatment on eating disorder symptoms, health-related quality of life and personal resources in anorexia and bulimia nervosa]. / Effekte stationärer Psychotherapie auf Essstörungssymptomatik, gesundheitsbezogene Lebensqualität und personale Ressourcen bei Anorexia und Bulimia nervosa.

The aim of the present prospective-naturalistic study was the evaluation of psychosomatic inpatient treatment for anorexia nervosa (AN) and bulimia nervosa (BN). 128 patients with eating disorders (n=59 AN and n=69 BN) were investigated on admission and discharge using the following standardized questionnaires: eating disorder symptoms (EDI), general psychopathology (BSI), quality of life (SF-12), and personal resources (SOC-13, SWE). Moderate to large effect sizes were achieved for the eating disorder symptoms; in addition, general psychopathology was substantially reduced at the end of treatment, and quality of life as well as personal resources were enhanced. Personal resources were found to be the strongest predictors for therapy outcome. Based on our data, important insights and recommendations may be gained for the inpatient treatment of eating disorders, especially with regard to the potential influence of personal resources.

Symptoms in the palliative phase of children with cancer.

BACKGROUND: The aim of the study was to make a comprehensive inventory of the physical, psychological, and social symptoms of children with cancer and their parents during the palliative phase and the extent to which health professionals address those symptoms. PROCEDURE: Forty parents of children who died 1-3 years prior to data collection (structured questionnaire) were invited to participate in the study. RESULTS: The response rate was 32 out of 40 parents (80%). Most frequently mentioned physical symptoms were pain, poor appetite, and fatigue. The children's most mentioned psychological symptoms were sadness, difficulty in talking to their parents about their feelings regarding illness and death and fear of being alone. The symptoms of fear of death of the child and fear of physical symptoms were most frequently mentioned parents' psychological symptoms. Health professionals addressed 82% of the children's physical symptoms, 43% of the children's psychological symptoms, and 56% of the parents' psychological symptoms. Parents indicated that after professional attention the proportion of children's physical symptoms that were completely or partially resolved was 18 and 26%, respectively. For children's psychological symptoms the figures were 9 and 25%, respectively, and for parents' psychological symptoms 2 and 23%, respectively. CONCLUSIONS: The burden of symptoms of the child with cancer during the palliative phase and their parents is high. Health professionals focus mainly on the physical symptoms of the child. Relief of symptoms could not be achieved for a large proportion of symptoms. Further prospective research is necessary to investigate the kind, frequency and intensity of symptoms in order to tailor optimal palliative care to the needs of both child and parent.

The Functional Assessment of Anorexia/Cachexia Therapy (FAACT) Appetite Scale in veteran cancer patients.

Anorexia and appetite assessment is an important priority in supportive oncology. A series of 156 veterans participating in a hematology oncology service completed the Functional Assessment of Anorexia/Cachexia Therapy (FAACT), the Functional Assessment of Cancer Therapy-General scale, the Memorial Symptom Assessment Scale Short Form (MSAS-SF), and the Zung Self-Rating Depression Scale and were followed for survival. The FAACT score correlated well with Karnofsky performance status, quality of life, and symptom distress subscales. A single appetite distress item from the MSAS-SF correlated well with these measures. Both appetite measures correlated with the presence of other symptoms and with concurrently measured hemoglobin, serum sodium, albumin, and cholesterol levels. These self-reported appetite measures were univariate predictors of survival and contributed additional prognostic information to data related to weight-loss distress. In a smaller study, the FAACT score correlated with a visual analogue measure of appetite and with the North Center Cancer Treatment Group appetite instrument. These data support use of these tools for the evaluation of appetite concerns among patients with advanced cancer.

[A multicenter study of expenditure and success in psychodynamic therapy of eating disorders. Study design and initial results]. / Eine multizentrische Studie zu Aufwand und Erfolg bei psychodynamischer Therapie von Essstörungen. Studiendesign und erste Ergebnisse. Studiengruppe MZ-ESS.

UNLABELLED: Evaluation of psychodynamically oriented treatment of anorectic and bulimic patients, taking into account both quality and cost of therapist ("How much therapy is applied to which patients for a successful treatment?"). Criteria for indication of the kind of therapy and of amount of therapy ("dosage") are provided. METHOD: Prospective naturalistic longitudinal study (comparable to phase IV of effectiveness studies on pharmaceuticals) including 2.5 year follow-up. Consecutive sample (Anorexia nervosa and bulimia nervosa, DSM-III-R). Multidimensional outcome measures including self-rating and expert-ratings. Operationalisation of outcome is layered. Differentiated measurement of amount of therapy and treatment elements. Survival analysis, logistic regression. RESULTS: 1171 completely documented treatment episodes of 43 institutions (30.3% Anorexia nervosa, 55.3% bulimia nervosa, 14.4% double diagnoses). Patients are chronically ill (M = 7.6 years; SD = 6.3 years) and at the beginning of (mostly inpatient) treatment of the index episode 25.5 years of age (SD = 6.0 years). Therapies last appr. 11 weeks (median) and encompass a broad range of therapy measures. DISCUSSION: Study conduction as well as data collection and analysis of this worldwide largest study on treatment of eating disorders is discussed by presenting preliminary results.