Interhospital Geriatric Meeting29th January 201029 January 2010

“I Want to Eat ! ”I Want to Eat ! Speaker: Dr May Tang Wing Hany g gChairman: Prof Jean WooDepartment of Medicine and GeriatricspShatin Hospital

BackgroundBackgroundM d M• Madam Ma

• F/85• Widow. Mother of 7 Children

S• Retired School Janitor• Lives alone. Stick Walker. ADL-ILives alone. Stick Walker. ADL I• Ex drinker: Previously Drink Whisky

d t l d il Q itt d faround one tales daily. Quitted for over 10years.

• Non smoker

Past Medical HistoryPast Medical History• FU GOPD / Surgery SOPD

– HypertensionDyslipidaemia– Dyslipidaemia

– Peripheral Vascular Disease

• Drug History: – Moduretic 0.5mg dailyg y– Senna 15mg nocte– Lopid 600mg BD

• NKDAD Al t Mi i i d d di i• Drug Alert: Minipress induced dizziness

Presenting Symptom (D 0)Presenting Symptom (Day 0)

• Attended Prince of Wales Hospital (PWH) AED on 4/09/2009 due to abdominal distention and poor oral intake

• Assessment done in AED• Assessment done in AED– Multi-stix: Positive nitrate and WCC– MSU C/ST: Negative– AXR suggested constipationAXR suggested constipation– Treated with fleet enema and direct discharge

Unresolved Abdominal Distention (Day 2)

• Admitted to Union Hospital (UH) on 6/9/2009 due to persistent abdominal distention

• Blood tests were as follow:

Na 113

K 3 0

TB 10.8

ALP 80

TP 63

Alb 35

WCC 11.5

Plt 505

TSH 1.57

T4 22 5K 3.0

Ur 3.7

ALP 80

ALT 14

Alb 35

Amylase 107

Plt 505

Hb 13.3

T4 22.5

CEA N

Cr 60 AST 21 AFP N

Investigation in UH (D 2)Investigation in UH (Day 2)

• AXR on 6/9/2009– Bowel pattern within normal limit– Small gas distended large bowel loops are shown.– No definite small bowel loop dilatation is

demonstrated– The Psoas shadows cannot be clearly defined

b bl d t itprobably due to some ascites

• CXR on 6/9/2009– Mild Left pleural effusion

Investigation done in UH (Day 3)g ( y )

CT bd ith t t 7/9/2009• CT abdomen with contrast on 7/9/2009– Gross ascites is demonstrated in the abdomen and

pelvispelvis.– A 1.8cm haemangioma in left lobe of liver.– Liver is normal in size with smooth outlineLiver is normal in size with smooth outline.– Pancreas / Spleen / Adrenal Glands / Gall Bladder /

Kidneys are unremarkabley– No pelvic mass or abnormal collection shown– Bowel pattern is within normal limit.– No obstructive bowel pattern is noted.

Investigation done in UHInvestigation done in UH (Day 3)

• USG guided abdominal paracentesis on 07/09/2009– AFB: Smear negative. Culture pending

Cytology: Pending– Cytology: Pending– No cell count a/v

Transferred to PWH AEDTransferred to PWH AED (Day 4)

• Transferred to PWH AED on 8/9/2009 due to hyponatraemia, hypokalaemia and yp , ypincreased abdominal distention with vomitingvomiting.

Physical ExamPhysical ExamC di l HS d l• Cardiovascular: HS dual, no murmur

• Chest: mild decreased AE overChest: mild decreased AE over LLZ

• Abdomen: Distended. Bowel sound sluggish. Mild tenderness over RLQ

• PR: Empty• PR: Empty• LN: No Axillary / Cervical /

Groin LNGroin LN• No Breast lump / Neck lump• No joint effusionj• Calves soft

Blood TestBlood Test6/9/09 9/9/09

Na 113 126HCV Negative

HBsAg Negative

UrineNa <10

K 3.0 3.9Ur 3.7 2.6

g g

CA 125 PendingOsmo 138

Cr 60 50Osmo 254TP 63 59

6/9/09 9/9/09

TP 63 59Alb 35 29Amy 107 74

pH 7.5

pCO2 4.6

WCC 11.5 11.8

Plt 505 449Amy 107 74

TB 10.8 5ALP 80 56

pO2 12.1

BE 4

Hb 13.3 13.9

ESR 50ALP 80 56ALT 14 <10

BE 4 ESR 50

AXR on 9/9/2009 (D 5)AXR on 9/9/2009 (Day 5)

• Surgeon Assessment– AXR: No dilated BowelAXR: No dilated Bowel– Mild RLQ tenderness

over the tapping sitepp g• ? Due to previous tapping. • ? Sealed off perforation.

– No active surgical intervention

– Suggest RT if vomiting

Ascites (D 6)Ascites (Day 6)

• Arranged USG guided abdominal paracentesis on 10/9/2009p– Only trace amount of ascites in left

subphrenic space with no safe access forsubphrenic space with no safe access for percutaneous aspiration.

• Transferred to Shatin Hospital on 11/9/2009 (Day 7)

Shatin Hospital 11/9 – 21/9 (Day p ( y7 – 17)

• Increased abdominal distension• Repeated USG on 15/9/2009p

– Gross ascites with large Right pleural effusion • Diagnostic Abdominal paracentesis was done onDiagnostic Abdominal paracentesis was done on

16/9/2009– Cell count: Nucleated cell 611/cmmCell count: Nucleated cell 611/cmm– Culture: Moderate growth of E-Coli / Candida / Gram

positive bacillip• Transferred back to PWH on 21/9/2009 due to

suspected gut perforationsuspected gut perforation

CT abdomen on 21/9/2009 (Day ( y17)

• Urgent CT abdomen with contrast was done on 21/9/200921/9/2009– Gross Ascites– No pneumoperitoneump p– Increased Mesenteric

streakiness predominantly at the anterior mesentaryat the anterior mesentary.

– DDX: Inflammatory / Peritoneal metastasis

CT abdomen on 21/9/2009 (Day ( y17)

• Urgent CT abdomen with contrast was done on 21/9/200921/9/2009– Gross Ascites– No pneumoperitoneump p– Increased Mesenteric

streakiness predominantly at the anterior mesentaryat the anterior mesentary.

– DDX: Inflammatory / Peritoneal metastasis

Others OpinionsOthers Opinions…S b S• Seen by Surgery– No active surgical problem.– Insert RT if vomiting

• Seen by O&GSeen by O&G – Transvaginal scan/ PV: No adnexal mass but

small intrauterine collectionsmall intrauterine collection– Endometrial aspiration: insufficient

Differential DiagnosisDifferential Diagnosis…

• Malignancy– At least Stage IV disease with malignant g g

ascites.– Her physical condition is too frail for surgery /Her physical condition is too frail for surgery /

chemotherapy.

• Inflammation / Infection – ? Tuberculosis– Treatable!

Time is Muscle (D 17)Time is Muscle (Day 17)

• On going cachexia– BW 44.3kg 40.6kg

Alb 35 25– Alb 35 25

• Poor appetite due to abdominal distensionabdominal distension

• Started vomiting biliary substance (~500ml daily)substance ( 500ml daily) despite on regular intravenous maxolon

• Sluggish bowel sound but could maintain daily BOBO

Hospitalized Elderly are at Risk!Hospitalized Elderly are at Risk!

U t 44% f h lth ld l l t i k f• Up to 44% of healthy elderly people are at risk of malnutrition.

• The prevalence may be over 50% in hospitalized elderlyThe prevalence may be over 50% in hospitalized elderly patients.

• Malnutrition was under-diagnosed in 50% of the elderly g ypatients in acute geriatric ward.

M l i i i i d h li i i d• Malnutrition can impair wound healing, immunity and functioning, and can contribute to sarcopenia, failure to thrive, high medical cost, prolonged hospital stay andthrive, high medical cost, prolonged hospital stay and death.

B K M l t iti i Eld l B Kong. Malnutrition in Elderly.

Medical Bulletin 2005: Vol 10 No.9 SEP 2005.

What Should We Offer?What Should We Offer?E t l R t• Enteral Route– More physiology

• Parenteral Route– Non functioning GI tract.

Si f B l b t ti– Sign of Bowel obstruction.

– Repeated vomiting.Poor appetite

– Need IV infusion

– Poor appetite.– Need RT insertion.– May not meet the

nutritional requirementsnutritional requirements adequately

Parenteral Nutrition (PN)Parenteral Nutrition (PN)• Does the patient enteral route is not fit forDoes the patient enteral route is not fit for

feeding?

• Does the patient suffer from a condition that is likely to benefit from PN?– E g Will PN improve outcome and /or– E.g. Will PN improve outcome and /or

accelerate recovery?

• Does the anticipated benefit out weight the potential risks?

• Does PN accord with the expressed or presumed will of the patient?p p

Parenteral Nutrition (PN)Parenteral Nutrition (PN)D th ti t ff f i bl• Does the patient suffer from an incurable disease but nevertheless, quality of life and wellbeing can be maintained orand wellbeing can be maintained or improved by PN?

• If long term PN implies a different living situation (eg institution vs home) will thesituation (eg institution vs home), will the patient derive benefit from it?

• Are there sufficient resources available to manage PN properly?manage PN properly?

Th E S i f P l d E l N i iThe European Society for Parenteral and Enteral Nutrition

ESPEN Guidelines onESPEN Guidelines on Parenteral Nutrition: Geriatrics

Clinical Nutrition 2009; Vol 28: 461-466

Is PN Indicated in Geriatrics Patients?

Y• Yes– PN should be consider in the elderly who facing a

period of starvation of more than 3 days when oralperiod of starvation of more than 3 days when oral or enteral nutrition is impossible

– Or when oral or enteral nutrition has been or likely to ybe insufficient for more than 7-10days.

• However, Pharmacological Sedation / Physical Restraining of the patient to make PN

ibl i NOT J tifi dpossible is NOT Justified.

Is PN a Useful Method in Older Malnourished Patients?

• Yes– Several studies showed the mean age of patient

using PN is actually > 60• England: Mean age 67 (range 20-90)

It l M 60 1 / 14 2• Italy: Mean age 60.1 +/- 14.2

• However, the reported prevalence rate of PN ld l lamong elderly are very low.

• When compared to EN and Oral nutritional supplements, PN is much less often justifiedin geriatric patients.

Are there any Metabolic / Physiological Features in Older Subjects that may AffectFeatures in Older Subjects that may Affect Their Response for PN?

• Insulin Resistance– Leading to a lower glucose utilization and

hyperglycaemia together with impairment of cardiachyperglycaemia together with impairment of cardiac and renal function.

• Deficiencies in vitamins, trace elements and mineralsminerals

• The effect of nutritional support on restoration of• The effect of nutritional support on restoration of depleted body cell mass is lower

Can PN Maintain or Improve Nutritional St t / F ti l St t ?Status / Functional Status?

• Yes– Although it could improve nutritional status, g p ,

active physical rehabilitation is essential for muscle gain.g

Can PN Reduce Morbidity & Mortality?

• YesPN d t lit d bidit i– PN can reduce mortality and morbidity in older as well as in middle-aged subjects.

– However, PN has more complications, pthan EN. The oral and enteral route should be used whenever possiblep

Can PN Reduce Length of Hospital Stay & Improve Quality of Life?

• No Specific data– In malnourished elderly patients, it is

i ifi tl l d i t d ithsignificantly longer and associated with a doubling of costs.

– This is so in relation to delayed physical– This is so in relation to delayed physical recovery, worse tolerance to and more intensive pharmacological treatments, as well

i d t li tias increased proneness to complication.– PN does not influence QOL of older patients

more negatively than it does in youngermore negatively than it does in younger subjects.

Are there Specific Complication of PN in Older People?

• No– There are no specific complications of PN in p p

geriatric patients compared to other ages.– However complications tend to be moreHowever, complications tend to be more

frequent due to associated comorbidities.

Clinical outcome of geriatric patients in the United States receiving home parenteral and enteral nutrition

AM J Clin Nutr 1997;Vol 66: 1364-1370

Are There Ethical Problems of Artificial Nutrition and Fluid Management in Terminal Demented or DyingFluid Management in Terminal, Demented or Dying Old Persons?

• PN and Parenteral Hydration should be considered as medical treatment ratherconsidered as medical treatment rather than as basic care.– Both require intravenous cannulation and

a physician’s prescription.• Be Realistic

MoreoverMoreover….• Invasive• Costly

I t i i• Intensive nursing care• Glycaemic control and electrolytes balance

P t ti ll i li ti• Potentially serious complications:– Cellulitis / Septicaemia

– Hepatic complications such as fatty liver

Epidemiology of Bloodstream Infections in Patients Receiving Long-term Total Parenteral Nutrition.

Journal of Clincial Gastroenterology Jan 2007. Vol 41 Issue 1 19-28

Hepatic complications such as fatty liver, cholestasis, and nonspecific triaditis

Hepatic complications of total parenteral nutritionThe American Journal of Medicine, Volume 82, Issue 3, Pages 489-497

– Refeeding syndromehttp://www.aic.cuhk.edu.hk/web8/nutrition.htm

NeverthelessNevertheless…• Enteral and Parenteral nutrition are NOT

Mutually Exclusive but may complement one another.

• Time is Muscle

Initiation of PN (Day 18)Initiation of PN (Day 18)

• Put on Kabiven Peripheral on 22/9/2009 via peripheral veinp p

Abdominal ParacentasisAbdominal Paracentasis

• USG guide tapping was done onwas done on 22/9/2010 (Day 18)

– Cell count 610 180Cell count 610 180– Culture: Negative– Output around 1000mlOutput around 1000ml

daily– Decreased abdominalDecreased abdominal

distension with better sleep

Diagnosis (D 21)Diagnosis… (Day 21)

• Ascitic fluid cytology report was finally available on 25/9/2009– Atypia Cell– Immunohistochemical finding showed some of the

atypical cells with positive staining for CEA.– Suspicious of malignancy, notably adenocarinoma.

• CA 125 Report available on 30/9/09 (Day 26)

– 776 (Normal <21 )– Tamoxifen started

Further InvestigationFurther Investigation• Seen by GI team, unlikely

upper or lower GI tract pathologypathology– Suggested consult Surgery

for Peritoneal Biopsy +/-diagnostic laparoscopy.

• RT was inserted on 29/09/2009 d t29/09/2009 (Day 25) due to repeated vomiting

• Decreased distension• Decreased distension

Further InvestigationFurther Investigation

• Reviewed by Surgeon:– CT films showed mild thickening of Pylorus. g y– ? Primary CA stomach vs primary from ovary

OGD d 2/10/2009• OGD was done on 2/10/2009 (Day 28)

– No antral / pyloric lesion– Likely metastasis adenocarcinoma with

unknown primary. p y

PIZZAPIZZA…

– Currently multiple level obstruction due to adenocarcinoma.

– Just like a Pizza.– Likely inoperable. – Suggest symptomatic

treatment: • Keep RT and PN

Oncology Opinion (D 26)Oncology Opinion (Day 26)

• Seen by Oncology on 30/9/2009– Clinically compatible with metastatic y p

adenocarcinoma (? Peritoneal / Ovarian origin)– Not fit for palliative chemo in view of poorNot fit for palliative chemo in view of poor

morbid status.For supportive care– For supportive care.

– Start Tamoxifen– Suggestion: Continue your expert care.

DiagnosisDiagnosis

• Adenocarcinomatosis with malignant intestinal obstruction

• Not TB / InfectionI bl di• Incurable disease…

Break Bad NewsBreak Bad News

• Family asked not to disclose the diagnosis to Madam Ma as they worried the ydisclosure would cause emotional outbreak of the patientoutbreak of the patient

Break Bad NewsBreak Bad News

• MMSE 15/30 (2-3-3-1-1-5)• Poor motivation and mood due toPoor motivation and mood due to

prolonged hospitalization.M d M t ll f h• Madam Ma was actually aware of her poor condition, though she hope for cure, she also had prepared death.

Should Elderly Patients be Told They Have Cancer?

270 ld l• 270 elderly (From Clinics / elderly centers)

• Mean Age 79.9 (65 -94)88% Wanted to be informed• 88% Wanted to be informed – 62% wanted to know as much as possible

• 11% Did not want to be informed• 11% Did not want to be informed– Age >75 (6.4% vs 13.7%)– Limited mobility (7% vs 28%)Limited mobility (7% vs 28%)

• 70% wanted their relatives to be informed– Widowed / Lives alone

Sh ld ld l ti t b t ld th h ? Should elderly patients be told they have cancer? Questionnaire survey of older people.

BMJ. Vol 232: Nov 2001

Si P i t P t l f Breaking Bad NewsSix-Point Protocol for Breaking Bad News

How to Break Bad News: A guide for health care professionals. By Robert Buckman. 223 ppBaltimore, Johns Hopkins University Press, 1992.

Break Bad News to an ElderlyBreak Bad News… to an Elderly

• Explained to patient in a easy way– Cancer is a kind of geriatrics disease: you are old

enough to have uncontrolled cell growth– Your gut is getting old and failed to move. That’s why

it d ld t tyou vomit and could not eat.– Currently no treatment to cure your problems. Just

like there is no treatment to make you young againlike, there is no treatment to make you young again.– It tells you that time is limited, instead of sudden

death Therefore treasure every momentdeath. Therefore, treasure every moment.

Break Bad News to an ElderlyBreak Bad News… to an Elderly

A i• Anxiety – Reassurance that could use

medications to set your free from distress at any stages.y g

• Reinforce what she hasS pporti e famil n mbero s– Supportive family, numberous grandchildren

• Set a Target– Aims Home (leave)s o e ( ea e)– Oral feeding again.

Break Bad News to an ElderlyBreak Bad News… to an Elderly

• Sitting is better than Standing.

However sitting posture alone is unlikely to– However, sitting posture alone is unlikely to compensate for poor communication skills and lack of other respectful gestures during aand lack of other respectful gestures during a consultation.

A d i d t ll d t i l f h i i t A randomized, controlled trial of physician postures when breaking bad news to cancer patientsPalliative Medicine 2007; 21: 501–505

Main ConcernsMain Concerns…

• Madam Ma: Oh Doctor! I know my guts are too old for moving… butg– I want my abdomen less distend…

I want to stop vomiting– I want to stop vomiting…– I want to eat…– I want to go home…

Malignant Intestinal Obstruction (MIO)

• Surgery – Not for those with poor prognostic criteria forNot for those with poor prognostic criteria for

surgical intervention such as intra-abdominal carcinomatosis, poor performance status and massive ascites.

• Nasogastric drainage g g– A temporary measure only

• Self-expanding metallic stentsSelf expanding metallic stents – Mainly for obstruction over gastric outlet,

proximal small bowel and colon. pManagement of malignant bowel obstruction

Vol 44 issue 8 May 2008

Medical measures for MIOMedical measures for MIO

• Analgesics – For pain relief

• Vomiting – Anti-secretory drugs or/and anti-emetics. y g– Somatostatin analogues (e.g. octreotide) infusion

could reduce gastrointestinal secretions very rapidly and have a particularly important role in patients with high obstruction if hyoscine butylbromide fails.

Management of malignant bowel obstructionVol 44 issue 8 May 2008

Commonly Symptoms in Geriatrics Oncology

Symptom Management in Geriatric Oncology:Practical Treatment Considerations and Current Challenges.Symptom Management in Geriatric Oncology:Practical Treatment Considerations and Current Challenges.

Current Treatment Options in Oncology (2008) 9:204–214

Commonly Symptoms in Geriatrics y y pOncology

• Shortness of breath– Pleural effusion / Anxietyy

• ConfusionB i t / El t l t di t b /– Brain met / Electrolytes disturbances / Delirium / Infection

• Depression

Treatment Plans for Madam MaTreatment Plans for Madam Ma

• Dexamethasone was started for decreasing the edematous of gutsg g

• Plan to use Octreotide if increasing vomitingvomiting.

• Gradually increase tube feeding and decrease the amount of PN

• Aim Home leave as soon as possible• Aim Home leave as soon as possible

When to stopWhen to stop…• Family were struggled for stopping PN as they

though patient would die if she could not eat. • However, patient expressed her wish for

stopping PN as she felt pain and distressed gabout repeated intravenous cannulation.

• On the other hand, she could tolerate smallOn the other hand, she could tolerate small amount oral intake daily gradually.

When to StopWhen to Stop…

• PN was off on 16/10/2009 (Day 42)– Total 24daysy

• Could tolerate home leave for few hours in weekendweekend.

• Bradbury Hospice inpatient hospice y p p pservice was available.

Transfer to BBH on 19/10/2009 (D 4 )Transfer to BBH on 19/10/2009 (Day 45)

• Able to tolerate oral intake after admission• NG tube was off and patient had day leaveNG tube was off and patient had day leave

onceR i d f il d k M i l• Remained frail and weak. Mainly bedbound state

• Repeated vomiting of yellowish fluid again after back from day leaveafter back from day leave

Final StageFinal Stage…

• Commenced syringe drive of SC dexamethasone, haloperidol and maxolon , pfor symptoms control: Repeated vomiting and abdominal distensionand abdominal distension

• Finally passed away peacefully on 29/10/2009 (29/10/2009 (Day 55)

DiscussionDiscussion

• How far should we go for the case which is likely due to malignancyy g y– The balance between making proper

diagnosis and arranging never-endingdiagnosis and arranging never ending investigation

InvestigationInvestigation…• Blood checking x N times• AXR / CXR x N times• CT Abdomen with contrast x 2• Abdominal paracentesis x 3p• RT insertion • Intravenous Cannulation x N times for IVFIntravenous Cannulation x N times for IVF

/ Antiobiotic / PN• OGDOGD• PV / TVS• Transfer to and from PWH – SH• Transfer to and from PWH – SH• Need to stay in hospital

DiscussionDiscussion

• Commence of Parenteral Nutrition Supplementpp– Highly suspicious of malignancy

Buy Time– Buy Time• Slower the rate of sarcopenia

M i t i t i f ti l t t• Maintain certain functional status– Psychological support

The Role of Geriatrician in Oncology

• Most Studies have focused on the ability of Comprehensive Geriatric Assessment p(CGA)

Comprehensive Geriatric Assessment (CGA)Assessment (CGA)

Undernutrition in Elderly Patients with Cancer: Target for Diagnosis and Intervention

Critical Reviews in Oncology/Hematology 67 (2008)

Comprehensive Geriatric Assessment (CGA)

Comprehensive Geriatric Assessment (CGA)

The Giants Of Geriatric Medicine -Oncology

I t bilit d F ll• Instability and Fall– Postural hypotension– Electrolyte disturbance – Peripheral neuropathyp p y– Proximal Myopathy– Bleeding RiskBleeding Risk

• Intellectual Decline• Intellectual Decline– Perioperative delirium

M b l d f– May become an excuse to exclude for cancer treatment

The Giants Of Geriatric Medicine -

Vi l d H i P bl

Oncology• Visual and Hearing Problems

– Understanding the consent / instruction.Diff t i ti ti d F ll i t t– Different investigation and Follow up appointment

– Polypharmacy

• IncontinenceConstipation– Constipation

– Post RT colitis / CystitisHandle Stoma / Urinary catheter– Handle Stoma / Urinary catheter

– Diuresis after chemotherapy

Contribution of the Geriatrician to the Management of Cancer in Older Patients. European Journal of Cancer. Vol 43 2007

The Role of Geriatrician in Oncology

• We need to be involved through thewhole process from diagnosis to, inp g ,some circumstances, hospital palliativecare The involvement with older patientscare. The involvement with older patientswith cancer will challenge our knowledge

d l d t d l i i thand lead us to deal ing with somespecialties that we are not usually linked to.

Professor Margot Gosney

The Role of Geriatrician in Oncology

• The Hong Kong Geriatrics Society Annual Scientific Meeting 2009– Management of Solid Tumor in the Elderly – Beyond Surgery.

Prof Brigette Mag

• Contribution of the Geriatrician to the Management of Cancer in Older Patients.

E ropean Jo rnal of Cancer Vol 43 2007European Journal of Cancer. Vol 43 2007

• Symptom Management in Geriatric Oncology: Practical Treatment Considerations and Current Challenges.g

Current Treatment Options in Oncology (2008) 9:204–214

• Geriatric OncologyAge and Ageing 2009; 38Age and Ageing 2009; 38

• How and Why to Perform a Geriatric Assessment in Clinical PracticeAnnals of Oncology 2008. vol 19 (supp 7)

ReflectionReflection

• Stop Parenteral Nutrition in an earlier stagestage

• May avoid unnecessary investigation even suggested by other specialist.

• Strengthen the knowledge on handling• Strengthen the knowledge on handling cancer related symptoms

ConclusionConclusion

• Brief introduction about using Parenteral Nutrition among elderlyNutrition among elderly.

• How to Break Bad News to the elderly.

• The Role of Geriatrician in Oncology.gy