Loss of Appetite in Life-Threatening Illnesses

Decreased appetite and its resulting weight loss is common with many life-threatening illnesses. It’s a symptom that some patients say is just as distressing, if not more so, than pain. Sick patients know they need to eat but sometimes can't bring themselves to do it.

You may find yourself wondering how you can help get your loved one to eat and stop or even reverse the weight loss. But before intervening, it’s important to understand what is happening in your loved one's body and why they may be having a hard time eating.

This article goes over the causes of appetite loss in life-threatening conditions. It also discusses the difference between anorexia and cachexia.

Anorexia vs. Cachexia

• Anorexia is defined as the “lack or loss of appetite, resulting in the inability to eat.” This type of anorexia is different than the mental illness anorexia nervosa. It can occur with nearly all forms of life-limiting illnesses but is most common in advanced cancers. If caught early on, anorexia may be treated and weight loss reversed with nutritional supplements or increased consumption of food.
• Cachexia is defined as a state of “general ill health and malnutrition, marked by weakness and emaciation.” It is also common in advanced cancers and AIDS as well as other advanced life-limiting illnesses such as congestive heart failure. Cachexia occurs in more than 80% of cancer patients before death and is the main cause of death in about 20% of these patients.

Anorexia-cachexia syndrome (ACS) describes the condition of being unable to eat and experiencing weight loss and muscle wasting as a result.

What Are the Causes of ACS?

Anorexia-cachexia syndrome can have causes that range from the medical condition itself to the therapies used to treat the condition.

Metabolic Alterations 

In illnesses such as advanced cancers and AIDS, certain chemicals called cytokines are released by the body. The cytokines cause an inflammatory response within the body that can alter how the body metabolizes nutrients.

Physical Symptoms

Symptoms of the disease can cause decreased appetite and thus weight loss. Common symptoms that can result in anorexia include:

• Pain
• Dysgeusia, a change in taste, usually including an aversion to meat
• Ageusia, loss of taste
• Hyperosmia, sensitivity to smells, often causing aversion to foods
• Dysphagia, difficulty swallowing foods
• Dyspnea, shortness of breath
• Nausea and/or vomiting
• Constipation or diarrhea

Medication Side Effects

Medications used to treat illnesses or increase comfort can have side effects that cause anorexia. Many of the side effects are similar to the physical symptoms listed above.

Psychological or Spiritual Distress

Emotional, psychological, or spiritual distress can play a role in anorexia. The effects of the illness and the treatment, coupled with psychological responses such as anxiety or depression and spiritual reactions such as hopelessness, may result in diminished enthusiasm for food and/or a lack of energy to prepare and eat it.

Other Causes

Other causes of anorexia can easily be missed but may be significant. Examples include poorly-fitting dentures and infections of the mouth or esophagus.

How Is ACS Treated?

The first thing you should do is discuss the problem with your nurse or physician. They will help you develop a plan of care to address the contributing factors.

The approach will usually be multidimensional, focusing on:

• Symptom management
• Nutritional support
• Medications
• Social services
• Spiritual support

It’s important to remember that approaches to treating anorexia and cachexia in advanced diseases don’t always work.

Symptom Management

If there are symptoms of illness that are contributing to decreased appetite and weight loss, those should be addressed first. Pain, nausea, fatigue, and depression are the most common anorexia-inducing symptoms and they are usually easy to treat.

If symptoms are a side effect of medication, the person's physician may want to stop the medication (if it’s not necessary) or try a different one.

Nutritional Support

There are two schools of thought regarding eating towards the end of life: One believes the ill person should only be eating nutritiously dense foods and the other believes the ill person should eat whatever he wants.

Many people will hover in the middle, offering nutritious foods and snacks but allowing indulgences from time to time. This is probably the most prudent approach. If your loved one is losing weight and has no interest in eating meals but loves chocolate pudding, for example, there is no reason to deprive them of it.

You can purchase highly nutritious supplements that also taste good. (Ensure and Boost are probably the most popular.) Adding supplements to your loved one's diet can increase their overall calorie intake and help make up for any nutritional deficiencies.

Artificial nutrition in the form of tube feedings is a controversial treatment for ACS. As noted above, once a patient is cachexic, nutritional supplementation, including tube feeding, does not reverse it. Tube feedings can also have unpleasant or dangerous side effects and often increase a dying patient’s discomfort. 

Medications

Several medications may help patients with ACS increase their appetite and gain weight. Common ones include:

• Megace (megestrol)
• Steroids like Decadron (dexamethasone)
• Cannabinoids (marijuana)
• Reglan (metoclopramide)

Ask your loved one's physician if any of these medications could help. Physicians will usually try one or more of these medications for a time and discontinue them if they are ineffective. It’s important to note here that the smoked form of marijuana is still illegal in some states.

Psychosocial and Spiritual Support

Anxiety, depression, family stressors, and other emotional and spiritual factors may contribute to ACS. Decreased appetite can also lead to a patient feeling isolated from loved ones as meals are times for socialization.

A medical social worker (MSW), chaplain, or psychotherapist may be able to help your loved one work through such feelings.

Home Remedies

It's important to keep in mind that your efforts at increasing appetite may not work, but it's equally as important to not give up hope.

There are a few things you can do at home to help support your loved one and encourage them to eat. Some of these include:

• Offering their favorite foods
• Encouraging them to eat small, frequent meals rather than three larger ones
• Avoiding foods with a strong odor
• Offering nutrient-rich liquid supplements
• Asking their healthcare provider about medications that can help
• Making sure symptoms like nausea and constipation are under control
• Being supportive but never insistent or pushy
• Considering natural remedies like peppermint tea, chamomile, or cannabis

Working together with your loved one's healthcare provider will prove the most effective way of rescuing a fading appetite.

Tips for Caregivers

Loss of appetite is normal and to be expected at the end of life. As the body begins to shut down, it can no longer absorb the nutrients from food.

If your loved one is approaching the end of life, they will no longer need to eat nor will they have any interest in eating. Though you may worry that the person is starving, this is not an accurate way to describe what is happening. Starvation happens when a person is deprived of food despite feeling intense hunger. People at the end of life do not feel hunger. 

When to See a Healthcare Provider

If you're concerned about your loved one's food intake or you believe it is too soon for them to be experiencing end-of-life loss of appetite, contact their healthcare provider. They can discuss strategies to help them continue to get the nutrients they need. These may include suggestions for providing supplemental nutrition or medication changes or additions.

Summary

It is common for a person with a serious illness to experience loss of appetite. When this is severe enough to lead to weight loss and muscle wasting, it's called anorexia-cachexia syndrome (ACS). ACS can be caused by the illness itself or by the therapies that are used to treat the illness.

Treatment strategies for ACS include symptom management, nutritional support, medications, and different types of therapy. It is also important to remember that as someone nears the end of life, it is normal for them to stop eating.