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NUTRITIONAL ISSUES IN THE ELDERLY CANCER PATIENT

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Title: NUTRITIONAL ISSUES IN THE ELDERLY CANCER PATIENT


1
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

3
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

  • ?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

28
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.
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