NUTRITIONAL ISSUES IN THE ELDERLY CANCER PATIENT

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NUTRITIONAL ISSUES IN THE ELDERLY CANCER PATIENT

• Federico Bozzetti

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• in 2002, Italy replaced Sweden as the worlds
  oldest country, with 18 of italians having
  celebrated at least their 65 birthday

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BACKGROUND

• Undernutrition is common in elderly subjects both
  in community and in hospital
• Hypophagia of whatever origin (social condition,
  poor dentition, hypogeusia, gastric atony, basic
  disease, medications) is an important cause for
  weight loss
• Undernutrition is worse if patients are confined
  to bed, are hospitalized or take several drugs

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• Organs functions which are especially vulnerable
  during a regimen of forced nutrition (TPNgtEN) in
  the frail elderly include
• cardiovascular
• renal
• respiratory

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AGING and CARDIOVASCULAR SYSTEM

• afterload increases
• early diastolic filling is impaired
• reduction in ejection fraction reserve
• beta-adrenergic responsiveness decreases
• systolic pressure increases

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AGING and ALTERATIONS in RENAL PHYSIOLOGIC
FEATURES

• Decrease in GFR
• Decreased response to aldosterone and ADH
• Increase in ADH
• Decreased secretion of K and H
• Impairment in Na excretionconservation (tendency
  to overexpansiondepletion of ECF)
• Impairment in free-water clearance

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AGING and PULMONARY PHYSIOLOGICAL FEATURES

• Decrease in respiratory muscle strength and
  consequently in FEV1 and forced vital capacity
• Increase in residual volume
• Decrease in arterial PO2
• Decrease in ventilatory response to hypercapnia
  and hypoxia

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AGE as a RISK FACTOR in ELECTIVE SURGERY
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AGE as a RISK FACTOR in ELECTIVE SURGERY

• Author N pts Disease
  Complications p
• 
  lt 65-yr 65-79-yr ?80-yr
• Marusch (2002) 3756 CR tumors
• 36.5 43 50.0
  lt0.001
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  ?59-yr 60-74-yr
  ?75-yr
• Pessaux (2003) 4718 Abdominal
• non-CR
• 11 17 20
  lt0.001

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CAVEATS of NUTRITIONAL SUPPORT in the ELDERLY

• Do not exceed with calories
• Do not exceed with glucose (? blood glucose,
  respiratory distress from increased pCO2 )
• Do not exceed with water and sodium

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Do not exceed with calories
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Do not exceed with glucose (? blood glucose,
respiratory distress from increased pCO2 )
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Do not exceed with water and sodium
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SPECIFICITY of NUTRITIONAL SUPPORT in the ELDERLY

• Protein pulse feeding improves protein retention
  vs fractioned administration (Arnal 1999)
• Nutritional supplements containing only AA are
  preferable to AA-glucose supplements because they
  increase muscle protein synthesis and net muscle
  anabolism (Volpi and Rasmussen 2000)
• Protein intake (10 g) within 2 h postexercise
  potentiates muscle mass and strength (Esmarck
  2001)
• A specialized AA mixture (HMB, Arg, Gln) enhances
  collagen synthesis (Williams 2002)

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SPECIFICITY of PERI-OPERATIVE NUTRITIONAL
SUPPORT in the ELDERLY

• WATER 30mL/kg/day
• ENERGY 30-35 kcal/kg/day
• glucose to fat
  ratio1-2 to 1
• PROTEIN 1-1.5 g/kg/day
• SODIUM lt 1 mmol/kg/day

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Case history

• 79-yr old lady with cancer of the
  antrumSymptoms signs
• intractable vomiting and dysphagia
• extreme asthenia
• dehydration
• oedema of the ankles and feetNutritional
  assessment
• weight loss 7 kg (12)
• serum albumin 3 g/dLClinical decision
• urgent admission,
• nasogastric suction
• rehydration with saline and 5 glucose plus
  vitamins for 3 days

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WHAT TO DO?

• To go on with IvN and to potentiate TPN for 10
  days before operation?
• To put a post-pyloric tube (if it is possible)?
• To proceed without further delay with surgery,
  but which type of surgery?
• - a very limited resection only?
• - a radical resection regardless of the
  extension of the procedure?
• - just a bypass?
• - a simple jejunostomy?

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WHAT KIND of SURGERY?

• Since the general status of the patient and
  especially her well-being rapidly improved thanks
  to the IvN and rehydration, the staff almost
  unanimously agreed to proceed quickly with
  surgery (third option).
• At laparotomy an antral carcinoma invading the
  duodenum was found. This possibly required a
  subtotal gastrectomy plus a Whipple procedure, to
  entirely remove the tumour.
• What to do?
• To proceed with an extended procedure?
• To perform a nonradical distal gastrectomy?
• To perform a simple gastrojejunostomy?
• To perform a catheter needle jejunostomy?

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WHAT KIND of SURGERY?

• There was not agreement within the staff.
• Finally we did a simple jejunostomy at
  approximately 30-40 cm from the ligament of
  Treitz.
• The patient was discharged on the 7 day, with a
  diet providing 2 kcal/mL so that a limited volume
  allowed her to receive at home 35 kcal/kg/day.
  Per os only small sips of fluid were permitted.

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OUTCOME

• She entered a program of chemotherapy (ECF) for 4
  months.
• After 4 months she had completely recovered her
  usual body weight, and she underwent a radical
  subtotal gastrectomy with free margins.
• Enteral nutrition was never discontinued (even
  during the operation). Postoperative course was
  uneventful. The patient was discharged on the 9
  day and only on the 20 day she came back to the
  outpatient unit to remove the catheter of the
  jejunostomy.

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LESSONS LEARNED

• A multistep multidisciplinary approach
  (rehydration-surgery-nutrition -chemotherapy-surge
  ry) finally proved to be a wise decision and
  guaranteed a safe treatment and a successful
  outcome.