Multiple Myeloma in Older Adults: Effect of Therapies on Nutritional Status

Sodexo Mid-Atlantic Dietetic Internship

Major Case Study

Amanda Schroeder Hege

January 27, 2014

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ABSTRACT

A 90 year old Caucasian female, DL, was transferred to Hebrew Home of Greater

Washington (HHGW) on December 13, 2013, with IgG kappa multiple myeloma with worsening

renal function. Multiple myeloma is a neoplastic proliferation of plasma cells characterized by

an increase in calcium levels, renal dysfunction, anemia, and bone pain. DL visited her primary

care physician on November 8, 2013 with extreme fatigue, was found to be anemic, and a

subsequent workup revealed an IgG kappa paraprotein with bone marrow consistent with

multiple myeloma. She was admitted to Suburban Hospital from November 26th

to December

13th

for treatment. After stabilization, she began combination chemotherapy recognized as

CyBort-D therapy. Upon admission to HHGW, her nutrition diagnoses were inadequate energy

intake R/T increased nutrient needs due to catabolic illness, poor appetite, and dysgeusia AEB

stated energy intake <50% of estimated energy needs, along with unintended weight loss R/T

increased nutrient needs due to catabolic illness, dysgeusia, nausea AEB 7% weight loss x 10

days. After discussion with the patient, the intervention consisted of continuing a regular diet,

adding a 10am vanilla Resource 2.0 and 2pm chocolate pudding, and educating DL on methods

to manage signs and symptoms associated with cancer. Goals included tolerating the diet,

adequate nutrition/hydration to meet estimated energy needs, and greater than 50%-75% intake

of meals and supplements. The nutrition team monitored, evaluated, and followed-up on her

weight, % intake, signs and symptoms, and nutrition-related lab values.

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INTRODUCTION

DL is a 90 year-old Caucasian female admitted to Suburban Hospital from November

26th

to December 13th

and transferred to Hebrew Home of Greater Washington (HHGW) on

December 13th

for further rehabilitation and care. Her primary diagnosis was IgG kappa multiple

myeloma (MM) with worsening renal function.

DISCUSSION OF THE DISEASE

Multiple myeloma is a neoplastic proliferation of the plasma cells1. Bone marrow

produces the three types of blood cells: red blood cells, white blood cells, and platelets. Plasma

cells are mature B-lymphocyte cells, which are a type of white blood cell. The physiology of

multiple myeloma involves the interaction between myeloma plasma cells and bone marrow

stroma cells. The interaction between these two cells produces growth factors and cytokines

including vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF),

interleukin-6 (IL-6), tumor necrosis factor (TNF-α), and interleukin-1β (IL-1 β). Overproduction

of IL-6 is central to the pathogenesis of multiple myeloma because it is the plasma cell growth

factor that promotes growth of myeloma cells. In a healthy individual, plasma cells consist of

less than 10% of bone marrow. In a patient with multiple myeloma, their bone marrow is

comprised of greater than 10% plasma cells. The overproduction of myeloma cells causes them

to “crowd out” healthy red blood cells, white blood cells, and platelets.2

A plasma cell’s main function is to produce antibodies that fight infection. Multiple

myeloma plasma cells produce one type of antibody: a monoclonal “M” protein that encodes the

structures of immunoglobulin G and A. Multiple myeloma is characterized by the

overproduction of monoclonal immunoglobulin G (IgG) and IgA, which is referred to as the “M”

spike. It is also characterized by destructive lytic bone lesions that appear on an x-ray as

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“punched-out” holes on the bone and a decrease in bone density (Figure 1). This type of cancer

is not confined to a specific bone or location within a bone, may involve the entire skeleton, and

accounts for 10% of all hematologic cancers3.

ETIOLOGY

The precise etiology has yet to be

determined and many researchers believe

it occurs spontaneously. Research has

shown that most individuals with MM

have genetic abnormalities in plasma

cells that may contribute to cancer such

as a defect or translocation in

chromosome 14, extra copies of chromosomes, and an abnormality in chromosome 13 in which

part or all is missing. Genetic, environmental, or occupational factors may contribute to a patient

developing MM. It is typically thought to be a disorder in older adults with a median age of

approximately 65 years. Males and African-Americans have twice the risk and incidence of this

type of cancer as females and Caucasians. Exposure to ionizing radiation, uranium5, chronic

infection with a virus such as HIV or Herpes 8, or farmers exposed to herbicides, insecticides,

and the pesticide dioxin causes an individual to be at a high risk. Approximately 19% of patients

with the benign condition monoclonal gammopathy of undetermined significance (MGUS),

which is a disease that resembles multiple myeloma but with lower levels of plasma and

monoclonal plasma cells and no symptoms, will develop multiple myeloma within two to

nineteen years.6

Figure 1: Lytic MM Bone Lesions in Skull4

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Complications associated with MM

are related to an overproduction of

malignant plasma cells in bone marrow.

One complication is an impaired immunity

due to malignant myeloma cells inhibiting

the production of healthy plasma cells and

antibodies needed to fight infection and promote normal immunity. Various bone problems

occur including the erosion of bone mass, fractures, lytic bone lesions, a compression of the

spinal cord, weakness or paralysis of legs, bone pain in the chest or spine, and “punched out”

areas of bone most commonly found in vertebral bodies, skull, ribs, humerus, and femur (Figure

2).4 Approximately 50% of patients experience altered renal function due to eroding bones

causing an increased level of calcium in the blood. Hypercalcemia interferes with the kidney’s

ability to filter blood’s waste and proteinuria is present in 90% of patients with MM. A further

complication is anemia due to bone marrow replacement of healthy plasma cells with malignant

myeloma cells. Erythropoietin and vitamin deficiencies may contribute to the development of

anemia in the body.7

SIGNS AND SYMPTOMS

MM may be expected in older adults presenting signs and symptoms known as the CRAB

complex; calcium elevation, renal dysfunction, anemia, and bone pain. Hypercalcemia occurs

may cause patients to feel nauseous, tired, confused, constipated, and/or experience frequent

urination. Renal dysfunction related to hypercalcemia leads to high levels of blood urea nitrogen

(BUN) and creatinine (Cr). Myeloma cells overcrowding healthy blood cells causes anemia,

which is characterized by low serum red blood cell, white blood cell, hemoglobin, and

Figure 2: Bone Lesions in Areas of the Leg4

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Figure 3: Bone Marrow Biopsy8

© 2002 by the American Society of Hematology

hematocrit levels. Patients with anemia may feel weak, fatigued, and experience shortness of

breath during exercise. Bone tenderness occurs around the sternum and pelvis and is normally

accompanied by back and leg pain. Some patients may experience numbness or weakness in the

legs. These symptoms are due to compression of the spinal cord and it occurs in 10-15% of

patients. Pathologic fractures, those caused by tumors, occur frequently and most commonly in

the spine, but they also may occur in the ribs and pelvis. Advanced cases may experience weight

loss and recurrent infections.

DIAGNOSIS

Diagnosis of MM involves a series of tests that may include an x-ray, magnetic resonance

image (MRI), bone scan, bone biopsy, blood test, serum protein electrophoresis, and/or a

urinalysis. X-rays are used to diagnose multiple myeloma in most cases by looking for a

decrease in bone density and “punched out” holes in the bone. The lesions shown on an x-ray

are not surrounded by the white rim of the bone. Bone scans are used to show which bones are

involved with MM but will not show specific

bone lesions. If a bone scan is negative, the

next step is to order an MRI or skeletal survey

in order to determine where MM occurs in the

body. An MRI is more sensitive than an x-ray

and will be able to detect the exact location of

bone lytic lesions, if they are present.

Bone biopsies are used to determine if there are a large number of abnormal plasma cells in the

patient’s bone marrow (Figure 3). The serum blood test tests for anemia, leukopenia,

thrombocytopenia, hypercalcemia, and renal function by looking at levels of red blood cells,

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white blood cells, platelets, calcium, BUN, and Cr. Serum protein electrophoresis (SPEP) will

show if the IgG or IgA levels are spiked, an indicator of the “M” spike associated with MM. The

IgG or IgA levels may be checked by a urinalysis.

REGIMEN OF THERAPIES

The treatment of MM is complex as there are a variety of treatment methods available

specific to the patient. There is no cure for MM and many patients undergo multiple different

treatment regimens during the course of their illness. Options of therapy include standard

chemotherapy medications, corticosteroids such as prednisone or dexamethasone, stem cell

transplantation, and supportive care. It is important to weigh the options carefully, and the first

step to deciding on a treatment plan is to determine if the patient is a candidate for a stem cell

transplant. Stem cell transplants involve a transfusion of previously collected immature blood

cells, stem cells, to replace the diseased/damaged marrow. The cells can be from the patient or

donor. Patients are not considered good candidates for stem cell transplants due to an advanced

age of greater than 77 years, elevated direct bilirubin levels above 2.0 mg/dL that indicate the

liver may not tolerate high dose of chemotherapy, and/or elevated serum creatinine levels above

2.5 mg/dL (unless on chronic, stable dialysis) that indicate the kidney may not tolerate high

levels of aggressive treatment. Once it is determined that the patient is a candidate, then the

patient and health care team weigh the options of combination treatments for chemotherapy.

Table 1 shows a variety of chemotherapeutic medications available (Appendix B).

If a patient is not a viable candidate for a stem cell transplant the initial therapy includes

melphalan and prednisone, which has been used on patients for over four decades. Melphalan is

used for those who are not candidates for stem cell transplantation because it may have a toxic

effect on stem cells that makes it impossible to collect enough cells. Combination therapy of

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melphalan, prednisone, and thalidomide (MPT) is common for non-candidates and is normally

given for 12-18 months. Melphalan and prednisone are chemotherapy drugs that function by

killing and attacking tumor cells. Thalidomide functions by slowing the growth of new blood

vessels forming to a tumor and may slow or stop the growth of tumor cells. The median survival

rate with this treatment is around 2.5 years.

If the patient is a candidate for a stem cell transplant, then one of the combination

treatments available is dexamethasone, cyclophosphamide, and bortezomib (CyBort-D). This

three-drug combination therapy shows a rapid response for those with recently diagnosed

multiple myeloma, and patients experienced an 80% decline in monoclonal protein levels. It

demonstrates an improved response rate better than with melphalan and prednisone alone, has

manageable toxicities, and shows to improve renal function. The survival rate is approximately

three to five years.11

There are a variety of other combination treatments available to patients

with MM. After the patient has undergone three to four months of treatment with the initial

agents, they have a transfusion of previously collected stem cells to replace the damaged cells.

Table 1: Chemotherapeutic Regimens

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Supportive care is another important type of therapy and focuses on improving quality of

life and managing signs and symptoms associated with the disease. One type of supportive

therapy is a medication, bisphosphonates, which binds to the surface of the bone in order to

manage bone pain and prevent further destruction of bone and spine fractures. Erythropoietin or

blood transfusions may stimulate the production of red blood cells and manage anemia. Patients

with recurrent infections can be treated with antibody infusions and vaccinations.

Corticosteroids such as prednisone 50mg every other day may decrease levels of calcium in the

blood and increase survival time. Pain can be managed with the use of narcotics, and patients

with severe kidney dysfunction may require the treatment of dialysis.

EFFECT ON NUTRITIONAL STATUS

One of the most severe and devastating aspects of the disease are the complications and

side effects that impact a patient’s nutritional status (Table 2). Common side effects include

depression, nausea, vomiting, diarrhea, constipation, dysgeusia, peripheral neuropathy, decreased

appetite, pain, and fatigue. If a patient is experiencing some or all of these side effects, then

he/she may also have a decrease in intake, altered GI absorption, or an inability to self-feed.

Alterations in a person’s intake may lead to cancer cachexia, advanced calorie protein

malnutrition associated with anorexia, muscle wasting, involuntary weight loss, weakness,

psychological distress, and a lower quality of life. Approximately 80% of patients with

advanced-stage cancer experience this debilitating condition and it is estimated to be the cause of

death in 20%-40% of cancer patients.12

Table 2: Side Effects’ Impact on Nutritional Status

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Cancer cachexia is the primary condition in which dietitians address when treating

patients with cancer. The Academy of Nutrition and Dietetics’ Evidence Analysis Library

evaluated over forty-five research studies that studied the impact of nutritional status on

outcomes in adult oncology patients. The EAL concluded that poor nutritional status is

associated with higher rates of hospital admissions and re-admissions, length of hospital stay,

lower quality of life, mortality, and a decreased tolerance to chemotherapy.13

Iverson, Wisloff, and Gulbrandsen completed a prospective cohort study to determine the

nutritional status among unselected multiple myeloma patients undergoing intensive treatment

and examined if nutritional status was associated with a health-related quality of life. They

found that body mass index (BMI) remained constant throughout the period, and hand-grip

strength declined significantly during treatment. Vitamin D and vitamin E levels dropped

significantly during treatment and remained low until after stem cell transplant and bone marrow

recovery. There were no significant changes in vitamins B6, B12, or C. Thyroxin and thyroid

stimulating hormone fell significantly during treatment. The authors concluded that patients

with multiple myeloma undergoing intensive treatment experience a decline in nutritional status

as measured by anthropometrical changes.14

A cross-sectional study completed by Nourissat, et al. (2008) assessed the quality of life

as a function of nutritional status of patients with cancer. The researchers recruited patients with

cancer from six university hospitals in 23 departments. Indicators for nutritional status included

weight loss since the start of illness or onset of initial symptoms, weight loss over the last week,

and BMI. Their key findings showed that weight loss occurred for 22% of participants,

significant weight loss of more than 5% of usual body weight was reported in 24% of

participants, and weight loss of at least 10% since the start of the illness was reported in 30% of

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the patients. A diagnosis of moderate to severe malnutrition was made for 43% of the patients.

Participants who lost less than 10% of weight since the start of the illness experienced a higher

quality of life compared to those who loss more than 10% of their usual body weight. The study

concluded that there is an association with significant weight loss and an impaired quality of life.

In order to improve the quality of life in patients with cancer, nutrition intervention is important

and necessary. Nutritional therapy should be part of the initial oncological support.15

The impact of nutritional status on quality of life of advanced cancer patients in hospice

care was evaluated in a cross-sectional study by Shahmoradi, Kandiah, and Peng. The research

participants were screened by palliative care physicians and nurses at selected hospice centers

and were evaluated based on weight, food intake, symptoms, activities, function, disease,

metabolic demand, and physical examination. Their nutritional status was categorized into three

groups: well-nourished, moderately malnourished, and severely malnourished. The authors

concluded that there is a significant correlation between poorer nutritional status and impaired

quality of life and that nutrition assessments should be carried out on cancer patients in hospice

care to plan a targeted intervention and improve a patient’s quality of life.16

NUTRITION INTERVENTIONS

Nutrition interventions help patients manage symptoms associated with cancer and

chemotherapy treatment (Table 3). Plastic utensils are helpful for those with dysgeusia and who

are suffering from a metallic taste. Patients should be aware of the effect temperature extremes

of hot and cold have on their sense of taste. Pineapple chunks between foods may help change

and stimulate taste sensation. Increased taste can occur by adding spices and flavorings such as

sugar, lemon, herbs, and wine. Patients can control nausea and vomiting by eating small,

frequent meals, foods that are cold or at room temperature, separating liquids and solid foods by

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at least one hour, staying upright one to two hours after eating, and trying ginger ale and ginger

foods. The Inner Gate pressure point on the wrist is shown to be effective in fighting symptoms

of nausea.17

Patients can purchase wrist bands that use acupuncture to relieve nausea and

vomiting. Avoiding fatty foods, trying soluble fiber (bran, granola, nuts, seeds, vegetables), and

using low-lactose dairy products may reduce diarrhea.

Nutritional requirements of cancer patients are higher than that of healthy individuals due

to the catabolic illness. Estimated needs can be calculated by 25-35 kcal per kg body weight and

1.2-2.0 gm protein per kg of body weight. Nutritionally dense foods are important in order for

the patient to have a high-kilocalorie, high-protein diet and to prevent further weight loss. Tips

for patients to increase their intake include eating small, frequent meals, keeping snacks handy,

using nutrition supplements, and adding high-fat foods such as butter, whipped cream, half and

half, cream cheese, sour cream, salad dressings, mayonnaise, honey, jam, sugar, granola, dried

fruits, cheese, whole milk, yogurt, eggs, peanut butter, and guacamole to foods. The provision of

oral nutrition supplements (ONS) are shown to improve a patient’s body weight, total energy

Table 3: Managing Symptoms

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intake, and body function in individuals with a BMI less than 20.18

Further research is needed to

determine the specific type of oral nutrition supplement recommended for patients with cancer.

DISCUSSION OF THE CASE

DL is a retired secretary/bookkeeper and has a high school education. The patient is

widowed with one daughter, with whom she lives. Her religious affiliation is Jewish. DL has no

history of alcohol, substance abuse, or cigarettes. Activities of daily living include needing

assistance with shopping, cooking, and cleaning.

PAST MEDICAL HISTORY

Past medical history was significant for a merkel cell tumor that was removed from her

right ear with no evidence of reoccurrence, as well as anemia, depression, hypothyroidism,

hyperlipidemia, dyslipidemia, osteoporosis, benign essential hypertension, generalized muscle

weakness, and an automatic implantable cardioverter-defibrillator, a device used to monitor the

heartbeat and can deliver an electrical impulse. Her family history was noncontributory.

She visited her primary care physician on November 8, 2013, due to extreme fatigue and

was found to be anemic. A subsequent workup revealed an IgG kappa paraprotein with bone

marrow consistent with multiple myeloma. At this time, she was noted to have a high serum

creatinine of 2.0 mg/dL (normal 0.5-1.1 mg/dL), which indicates reduced renal function. On

November 26th

, she was admitted to Suburban Hospital with deteriorating renal function with a

new diagnosis of IgG kappa multiple myeloma. Nephrology visited her to discuss the possibility

for plasma phoresis or hemodialysis and neither felt appropriate at the time. She was seen by

oncology and was further diagnosed with multiple myeloma with CRAB complex. DL had a

mediport placed to treat her with CyBort-D therapy. Due to the rapid progression of renal

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failure, anemia, and the disease progression, she was initially treated with blood transfusions and

hydration. As soon as was feasible and after stabilization, she was treated with

cyclophosphamide 300 mg/m2, dexamethasone 40 mg total, and bortezomib 1.5 mg/m2. The

doses were based on body surface area of 1.53m2 calculated with a weight of 53.6 kg and a

height of 62 inches. She received bortezomib 2.3 mg subcutaneous and cyclophosphamide 460

mg orally on November 27, December 4, and December 11, which were days 1, 8, 15, and 22.

During her hospitalization at Suburban, she received a total of three units of packed red blood

cells with pretransfusion hemoglobin of 8.8.

DL was admitted to Hebrew Home of Greater Washington from Suburban Hospital for

further rehabilitation, treatment, and care. The dietetic intern completed the initial nutrition

assessment on December 16th

. Her weight was 108 pounds, 49.1 kg, for a height of 62 inches--

ideal body weight (IBW) of 120-158 (139) pounds for ages greater than 65 years; she was within

78% of IBW. DL’s body mass index was calculated to be 19.8 and indicated that she was

underweight for height and age. Her stated usual body weight (UBW) of 120 pounds, 54.4 kg

showed she was 90% of UBW. Upon admission, she was on a regular (no added salt), regular

texture, thin liquids diet and, per the nursing record, she had suboptimal PO intake of 25-75%.

She received a nighttime snack with 100% intake and 6 ounces of fluid between meals with

mostly 100% intake. DL’s skin was unremarkable with no rashes or suspicious lesions, no

pressure ulcers, no signs of edema, and the abdomen was soft, non-tender, non-distended. She

appeared under-nourished and skinny with mild temporal and clavicle wasting.

WEIGHT HISTORY

Over the course of DL’s hospital stay at Suburban and HHGW, her weight fluctuated

between 53.6 kg and 48.6 kg (Graph 1). On November 27, she experienced a significant weight

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loss of 2.3kg/4% over the course of one day. The patient had another significant weight loss on

December 12th

of 3.8kg/7% over a 10-day period. The accuracy of the patient’s admitting

weight on December 13th

to HHGW was questionable because of the significant change in

weight, and identifying that it could have been stated instead of measured. The weight was

clarified by asking for a re-weigh on the 14th

that revealed a more accurate weight of 49.1 kg,

which is the weight used for the initial assessment.

LABORATORY TESTS

An ultrasound of the kidney, including the bladder, was completed on November 27th

,

and the findings showed that the kidneys were normal size and shape with no hydronephrosis or

stone disease. The urinary bladder was unremarkable and partially filled. Results were negative

for the kidneys, no findings of obstructive uropathy, and no explanation for the patient’s renal

failure. Immunoelectrophoresis on December 12th

showed a low IgA of 15 mg/dL (normal range

85-385 mg/dL), high IgG of 2128 mg/dL (normal range 565-1765 mg/dL), and low IgM of 19

mg/dL (normal 55-375 mg/dL). A low IgA indicates the use of immunosuppressive drugs or

steroid use, a high IgG indicates multiple myeloma, and low levels of IgM indicate drug

4546474849505152535455

We

igh

t (k

g)

Date

Graph 1: Weight (kg)

Weight (kg)

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immunosuppressive use and multiple myeloma.20

On December 16th

, blood serum CBC without

differential and basic metabolic profile (BMP) tests were completed. Her CBC showed low

levels of white blood cells, red blood cells, hemoglobin, and hematocrit, which indicate anemia.

Her BMP was within normal limits, except for her BUN and Cr being high and trending up, and

her GFR was low at 8.1, which indicated worsening renal function (Figure 4). Urinalysis on

December 20th

showed urine color of red, hazy appearance, urine protein 100-200 mg/24hr

(high, normal 50-80 mg/24hr), large urine blood, moderate urine leak esterase, high >182 urine

RBC, and high 13 urine WBC.

MEDICATIONS

Medications necessary for the treatment of DL’s disease condition included treating her

hyperlipidemia, hypothyroidism, gastroesophageal reflux (GERD), hypertension, heartburn,

insomnia, nausea, constipation, and multiple myeloma (Table 4).

Figure 4: Serum Blood Test on 12/16

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NUTRITION ASSESSMENT

On December 16th

, the dietetic intern visited the patient and completed a 24-hour dietary

recall (Appendix H). The recall showed her average intake was approximately 650 kcal and 24

grams of protein per day. The patient stated that the recall was an adequate measure of her

current intake and that she was experiencing dysgeusia, a metallic taste, poor appetite, an

aversion to dairy, nausea, and significant weight loss related to chemotherapy treatment. The

dietetic intern estimated her needs to be 1348-1815 kcal/day based on the Mifflin St. Jeor

equation with an activity factor of 1.3-1.5 (light activity), and stress factor of 1.2-1.4 (cancer).

The estimate is similar to using 30-35 kcal/kg/day for cancer patients as recommend in The

Clinical Dietitian’s Essential Pocket Guide (2009), which is 1473-1719 kcal/day. Her protein

needs were 59-69 gm based on 1.2-1.4 gm/kg/day and fluid needs estimated were 1473 cc

fluid/day (30 cc/kg/day).21

DL’s nutrition diagnosis 1 is inadequate energy intake related to increased nutrient needs

due to catabolic illness, poor appetite, and dysgeusia as evidence by stated intake less than 50%

of estimated energy needs. Nutrition diagnosis 2 is unintended weight loss related to increased

nutrient needs due to catabolic illness, dysgeusia, and nausea as evidence by a 7% weight loss x

Table 4: Medications and their Use

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10 days. Interventions included working with the patient to find oral nutrition supplements that

work well by bringing the nutrition supplements available to the patient for her to taste and try.

Education was provided by the dietetic intern in regard to using plastic utensils to relieve the

metallic taste, the importance in practicing oral hygiene, sitting upright before and after meals,

separating liquids and solids by an hour, eating small, frequent meals, trying ginger ale, and

avoiding dairy and high fat foods. After discussion with the patient, the decision was made to

continue her regular diet as ordered and add a 10am vanilla Resource 2.0 and 2pm chocolate

Boost pudding (715kcal/28gm protein) per the patient’s food preferences and to meet her

increased needs. Goals comprised of tolerating the diet, adequate nutrition/hydration to meet

estimated energy needs, and greater than 50%-75% intake of meals and supplements. The

dietetic intern monitored and evaluated the patient’s weight, percent intake, signs and symptoms,

and nutrition-related labs, and planned to follow-up in the next seven to ten days.

NUTRITION FOLLOW-UP

On December 27th

, the patient’s follow-up necessitated a change in her supplements

related to the patient stating that the Resource 2.0 was “too much to drink”, the Boost pudding

was good but “getting old”, and her family brought Ensure to her. The decision was made to

discontinue the Resource 2.0, change the Boost pudding to four times a week, and recommend

her drink an Ensure at least once a day. DL’s weight was trending down, which was to be

expected with the disease condition, and her laboratory values were improving with a BUN of 60

mg/dL, Cr of 4.7 mg/dL, and a GFR of 8.7ml/min. Her nutrition diagnoses from the initial

assessment were ongoing for continuing follow-up, monitoring, and evaluation.

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CONCLUSION

Nutrition care provided to DL at HHGW corresponded to research associated with

managing symptoms of multiple myeloma and chemotherapy. DL was very receptive to the

suggestions in order to manage her dysgeusia, metallic taste, and nausea. The ability to taste

supplements in advance increased her total oral supplement intake. Several follow-up visits with

DL showed that her overall mood and quality of life improved while at HHGW. Providing her

with information to purchase an anti-nausea acupuncture bracelet, if interested, was the one piece

of advice that may have been beneficial. On January 7th

, DL was discharged home in her

daughter’s care with potential for provision for JSSA Hospice.

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http://www.cancer.gov/cancertopics/pdq/supportivecare/nutrition/HealthProfessional/pag

e4#Section_117.

20. Pagana, K. Pagana, T. Diagnostic and Laboratory Test Reference. 9th

ed. Mosby Elsevie:

2009.

21. Width, M. Reinhard, T. The Clinical Dietitian’s Essential Pocket Guide. Lippincott

Williams & Wilkins: 2009.

Hege 22

APPENDIX A

Benign – a disease that is not harmful and lacks the ability to metastasize

Cancer cachexia – cancer-associated progressive weight loss, anorexia, muscle wasting

Corticosteroids – class of medications that closely resemble cortisol, a hormone that the adrenal

gland produces naturally

Dysgeusia – distortion of sense of taste

Erythropoietin – naturally occurring hormone made in the kidneys that stimulates the production

of red blood cells

Hematologic – disease or disorders that primarily affect the blood

Hydronephrosis – literally “water inside the kidney”, distension and dilation of the renal pelvis

and calyces

Malignant – characterization of cancer

Monoclonal – cells produced from a single clone by repeated cellular replication

Multiple myeloma – MM, neoplastic proliferation of plasma cells

Neoplasm – “new creation” or tumor, abnormal mass of tissue from division of cells

Stroma of bone marrow – tissue in bones not directly involved in the formation of blood cells

Hege 23

APPENDIX B

Table 1: Chemotherapeutic Regimens

Hege 24

APPENDIX C

Table 2: Side Effects’ Impact on Nutritional Status

Hege 25

APPENDIX D

Table 3: Managing Symptoms

Hege 26

APPENDIX E

Graph 1: Weight (kg)

45

46

47

48

49

50

51

52

53

54

55

We

igh

t (k

g)

Date

Graph 1: Weight (kg)

Weight (kg)

Hege 27

APPENDIX F

Figure 4: Serum Blood Test on 12/16

Hege 28

APPENDIX G

Table 4: Medications and their Use

Hege 29

APPENDIX H

Nutrition History: 24-hour Dietary Recall

¼ bagel w/ cream cheese

Decaf coffee – black

50% cranberry juice

½ pudding

Ensure

1 ½ meatballs

2 bites spaghetti w/ sauce

640 kcal/24.25gm

PES Statements

Nutrition Diagnosis 1:

Inadequate energy intake R/T increased nutrient needs due to catabolic illness, poor

appetite, and dysgeusia AEB stated energy intake of<50% of estimated energy needs.

Nutrition Diagnosis 2:

Unintended weight loss R/T increased nutrient needs due to catabolic illness, dysgeusia,

and nausea AEB 7% weight loss x 10 days.