Synopsis
Distinguish reduced appetite, inflammatory cachexia and fatigue, identify reversible contributors, support food and activity without coercion, and use nutrition, transfusion, corticosteroid or other interventions only when their time to benefit matches the person's goals.
- Anorexia is reduced desire to eat; cachexia is a multifactorial loss of muscle with or without fat that nutrition alone does not fully reverse; fatigue is subjective exhaustion.
- First-line assessment asks what prevents eating or activity, examines mouth and swallow, reviews weight trajectory and fluid, and checks symptoms, medicines, mood and social access.
- Treat contributors that can improve a valued outcome: pain, nausea, constipation, thrush, dysphagia, infection, anaemia, endocrine disturbance, sleep and depression.
- Explain cachexia physiology early: smaller intake is part of illness and pressure to eat can increase nausea, conflict and guilt.
- Offer small preferred energy-dense portions, flexible timing, taste adaptation and drinks between rather than with meals when early satiety dominates.
- Dietitian review is first-line when nutrition can improve treatment tolerance, function or recovery; artificial nutrition requires a functional route, sufficient prognosis and explicit goal.
- Use light resistance or functional exercise and energy conservation when feasible to preserve muscle and independence; bed rest worsens deconditioning.
- A short dexamethasone trial may improve appetite and wellbeing for days to weeks, but benefit wanes and toxicity rises; stop if no rapid meaningful response.
- The gold-standard plan states whether the goal is comfort, strength, treatment support or survival and matches food, supplements, feeding route and medicine time to that goal.
Key red flags
New focal weakness, dysarthria, choking or wet voice suggests neurological or swallowing emergency and requires aspiration-safe assessment.
Fever, hypotension, confusion or abrupt functional collapse suggests infection, metabolic disturbance or adrenal insufficiency rather than cachexia alone.
Melaena, haematemesis, heavy bleeding, angina or breathlessness with anaemia may require urgent haemoglobin and source assessment.
BMI and weight loss can conceal oedema or ascites; rapid scale change does not always represent tissue gain or loss.
Starting nutrition after prolonged minimal intake can cause refeeding syndrome and requires phosphate, potassium, magnesium, thiamine and fluid planning.
Corticosteroids can worsen infection, delirium, hyperglycaemia and proximal weakness, making prolonged appetite treatment self-defeating.
Megestrol increases venous thrombosis, oedema and adrenal suppression and should not be used as an unreviewed routine appetite stimulant.
Very low BMI, major recent weight loss, little intake, alcohol use or low phosphate, potassium or magnesium requires controlled nutrition initiation.
Investigation priorities
Separate appetite, taste, chewing, swallowing, nausea, early satiety, bowel, access, preparation and family pressure.
Management branches
The person reports poor appetite, weight loss or fatigue or family raises concern about intake.
- Clarify appetite versus ability, examine mouth, swallow, abdomen, fluid and muscle and review symptoms, medicines, mood, access and disease trajectory.
- Treat reversible contributors and agree whether the priority is enjoyment, strength, treatment tolerance, recovery or survival, including the person's information preference.
- Use dietitian, therapy, psychological and palliative support to create small practical actions and a review measure, explaining cachexia to family.