Assessment and Management of Patients with Eating Disorders in the Emergency Department

Dr Lisa Miller – Consultant Liaison PsychiatristW.A. Eating disorders Outreach and Consultation Service (WAEDOCS)

Case – Miss S

• 17 y.o. brought to ED by SJA after “nearly fainting” at school. – BP 89/66, PR 50/min, temp 35.5 – Looks “slim”. ? Mild dehydration– FBP, U+E, other physical exam – NAD

• Now bright and alert “feeling fine”. – Happy to see her GP if it happens again.

What’s the plan - ?Home

Further assessment…– Weight “about 46kg” (actually 43kg)– Height – “not sure” (actually 170cm)

• BMI 14.8 (> 85% IBW for 17 y.o. BMI>17.4) – Has lost about 12kg in the past 6 months (>25% total

body weight), 4 kg in 1 month– Mum says eating only rice crackers and berries

• Saw GP who said “try to eat more”, but vomits after trying to eat larger meals– “On the waitlist to see a psychologist”What’s the plan?

• Highest mortality of any mental illness (approx 20% - from suicide and malnutrition)

• No comprehensive public eating disorders service in W.A. for > 16yo – Only WA and NT have no beds/ multidisciplinary outpatients / day program

• Centre for Clinical Interventions (CCI) has a 6 month waitlist. Few GPs / Psychs aware of eating disorder assessment & treatment.

• With peak onset age 15-24 and average duration 7 years, around 85 % of patients with an ED are over age 16

• Medical stabilization & treatment of starvation syndrome essential for addressing cognitive effects and ambivalence, but very difficult to access inpatient nutrition outside of private sector in W.A.

Dire situation in W.A. with respect to management and outcomes for public patients with severe eating disorders.

Lack of consistent pathways to care big problem for patients ambivalent about seeking care due to impaired perceptions re: health – average 7 year delay to seek help

Inconsistent approaches and limited access to suitable care options creates frustration and lack of trust for all.

“Crisis of Confidence” – blocks efficient care Lack of access to reliable specialist medical care/support discourages GPs and MH services from managing ANY patients with Eating disorders, reducing outflow options and increasing inpatient LOS

What are eating disorders?• Illnesses which sit at the interface of physical and mental health.

• Associated with high morbidity, mortality and suffering in both patients and carers / families.

• Often develop as strategies to deal with a variety of distressed emotions and personal conflicts, esp. a sense of lack of adequate control and effectiveness for life situations.

• Disordered eating develops out of an overvaluation of the benefits of slimness to deal with these issues.

• Anorexia Nervosa (AN), Bulimia Nervosa (BN) and Binge eating disorder (BED) are all part of one overarching disorder of eating dysregulation driven by cognitive distortions, especially shared irrational fear of fatness, a drive for thinness and a distortion in body perception. (Andersen and Yager 2005)

Screening toolSCOFF (2 or more)

SICKCONTROLONE STONE (loss >6kg in 3 months)FAT FOR THINFOOD

Reference: Morgan JF, Reid F & Lacey JH (1999). The SCOFF questionnaire: assessment of a new screening tool for eating disorders. British Medical Journal, 319: 1467-68

The Vicious Cycle of Eating Disorders

Treating Eating Disorders: The Big Picture1. Medical monitoring: to keep patient alive2. Feed the brain: to reverse cognitive effects of starvation

(impaired capacity)3. Rehabilitate normal eating

A. Repeated multiple exposures to normal adequate eating B. Observe and support during mealsC. Keep diary of eating as outpatient

4. Psychotherapy: to help patient resist future urges to cut back (evidence suggests needs BMI >16)

Risk Assessment• The biggest risk is unintentional death due to the effects of

starvation or purging• Person can feel great and have normal bloods just before sudden

death due to arrhythmia• Best indicators of cardiac risk are easily assessed:

o BMI < 14 (<16 for adolescents)o No oral intake for more than several days (always ask in detail about

food intake)o Purging several times dailyo BP < 90mm systolico HR < 50 bpm or > 110 bpmo Postural tachycardia/hypotension > 20 bpm/mm Hgo Serum potassium, phosphate or glucose below normal rangeo Prolonged QT interval on ECG

History Ask…

o Have you had any medical or physical problems in last few months?

o Fainting*o Lightheadednesso Chest paino Palpitationso Ankle Swellingo Weaknesso Tirednesso Regular periods? (doesn’t count if

on the pill) or sexual desire/ performance affected in males

o Bone scan?

*Admit

• The Minnesota Semi-starvation Study (Keys) - Loss of 25% of body weight led to profound cognitive changes, obsessive preoccupation with food and eating, loss of perspective and insight. Only reversed when weight restored.

• Thus cornerstone of initial treatment of severe eating disorders is nutritional rehabilitation. Strongest predictor of clinical outcome for many psychological tx is BMI at entry (ideally >16).

•  Many treated on a compulsory basis later agree that treatment was necessary and remain therapeutically engaged (Guarda et al).

Effect of Starvation on Decision-Making, Self-perception and Insight

Effects of starvation on the brain

• In Minnesota semi-starvation study normal men all became mentally disturbed– Obsessed with food– Nitpicky about detail– Lost touch with the big picture– Depressed– Suicidal– Withdrawn– Bingeing– Purging– Body Image Issues

Brain-flexible thinking

Heart-BP 100 systolic.-HR>60 -no postural changes

Bone Marrow-Neutrophils 2-8

Liver-BSL>4LFTs Normal

Ovaries-menstruating

Bones-Normal density

Weight-BMI 20-25

Intake vs output-adequate

Electrolytes (K,Na,Hco3,P04,Mg) normal

Brain-struggle between sensible and crazy

Heart-BP 90 systolic.-HR 41-59 postural changes 10 -20K3-3.5*

Bone Marrow-Neutrophils 1.0 – 2.0

Liver-BSL3-4LFTs elevated

Ovaries- a few missed periods

Bones-osteopenia

Weight-BMI 14-18

Intake vs output-inadequate

Electrolytes (Na,Hco3,Mg) mildly abnomal

Brain-rigid terrified thinkingNa < 125*=fatal seizures

Heart--BP <90 systolic*-HR<50* or > 120 bpm-postural changes>20*-Potassium <3*-Phosphate below normal*

Bone Marrow-Neutrophils <1.0*

Liver-BSL<3*LFTs>500*

Ovaries-no periods

Bones-osteoporosis

Weight-BMI <14*

Intake vs output-grossly inadequate intake, out of control purging or exercise

*admit

Treating medical complicationsComplication TreatmentCardiac decompensation Nutrition + cardiac monitoring if

HR <40 adults, <50 in kidsNeutropenia Nutrition

Raised LFTs Nutrition

Amenorrhea Nutrition + Bone Scan

Constipation Nutrition

Depression/Insomnia/Anxiety/ Terror of gaining weight

Nutrition

Hypoglycemia Thiamine then nutrition

When it’s too dangerous to eat……..and too dangerous not to eat…..

•REFEEDING SYNDROME– In first 1-2 weeks of refeeding body can rapidly use up phosphate,

potassium, magnesium, glucose and thiamine– Can result in heart failure, brain injury and death– Prevent by

• Awareness• Thiamine • Checking serum phosphate, magnesium, potassium daily and

replace if low• Lowish meal plan to start (1500Kcal) but get up to 3000kcal

within 2-3 weeks (don’t want ‘underfeeding syndrome’)

Psychiatric admission Medical admissionWeight Body Mass Index (BMI) <14 (*16) BMI <12 ( *14)Weight loss

Rapid weight loss (i.e. 1 kg/wk over several weeks) or grossly inadequate nutritional intake (<1000kCal daily)

Re-feeding risk Low HighSystolic BP <90 mmHg <80 mmHgPostural BP >10 mmHg drop with standing >20 mmHg drop with standing

Heart rate ≤40 bpm or > 120 bpm or significant postural tachycardia

Temp <35.5 c <35 c12-lead ECG Normal sinus rhythm Any arrhythmia including

QTc prolongation, or non-specific ST or T-wave changes including inversion or biphasic waves

Blood sugar <3.5 mmol/L < 2.5 mmol/LSodium <130 mmol/L* <125 mmol/LPotassium <3.5 mmol/L* <3.0 mmol/LMagnesium 0.7 – 1.0 mmol/L* <0.7 mmol/LPhosphate 0.8 mmol/L* <0.8 mmol/LeGFR >60ml/min/1.73m2 and stable <60ml/min/1.73m2 or rapid drop (25% drop within a week)Albumin <35 /L <30 g/LLiver enzymes Mildly elevated Markedly elevated (AST or ALT >500)Neutrophils <2.0 x 109/L <1.0 x 109/LOther Not responding to outpatient treatment

Lessons we’ve learnt at SCGH• Beware the “compensated” patient - Most of our patients

become much more unwell once they start nutrition!• ISOBAR charts and RANZCP guidelines are persuasive• Consistency and team work around “non-negotiables”

crucial – eating disorders are great at exploiting “chinks in the armor”

• Externalise dysfunctional behaviour of the “eating disorder” separate to the person

• Be transparent about use of the MHA and what is likely to trigger this, 1: 1 specials are important to contain compensatory behaviours and support healthy eating

Guidelines for use of the 2014 Mental Health Act

• “The person is experiencing a mental illness for which the person is in need of treatment”

• “Because of the mental illness there is a significant risk to health and safety / or a significant risk of harm to the person”

• “The person does not demonstrate that they have the capacity to make treatment decisions”

• “There is no less restrictive way to provide the treatment that the person needs”

Guidelines for Use of the Mental Health Act 2014 - continued

• “There is no less restrictive way to provide the treatment that the person needs”

• People with eating disorders exhibit cognitive distortions regarding self-perception of body image and nutrition, which can drive intense ambivalence regarding engagement with nutritional rehabilitation and psychotherapy.

• Patients may acknowledge a need for treatment but struggle to engage consistently or engage in use of compensatory measures.

• Assessment of decision-making with respect to setting and restriction of care should take into account an individual’s ability or lack thereof, to engage safely with treatment in that setting.

The Important Role of Early Admission for Complex / High Risk Patients with Eating Disorders

• For high risk individuals, assertive community engagement and monitoring, with a plan for rapid facilitation of medical admission at the first sign of nutritional deterioration, represents an essential component of treating starvation syndrome.

• Early assessment and intervention can result in reduced length of inpatient stay and reduced duration of illness.

• Thus while BMI is a consideration, all factors are important

Summary of Initial Medical Management (for the First 24 Hours after Presentation)

MEDICAL PARAMETERS•Reduce the risk of refeeding with daily medical monitoring•Monitor blood tests•QID Observations including lying & standing heart rate and BP •ECG on admission •BSLs QID (1-2 hrs. post prandial) and 0200 •Manage any hypoglycaemic events. If rehydration required refrain from using IV Dextrose to minimise rebound hypoglycaemia

PHARMACOLOGICAL MEASURESCommence daily supplementation •Thiamine •Multivitamin & Mineral Supplement, B Complex Supplement•500mg Phosphate SandozReplace potassium and magnesium levels once re-feeding commenced if below acceptable range

Summary of Initial Medical Mgnt (cont)

NUTRITIONAL MANAGEMENTRoute of Nutrition Restoration will depend on medical stability and BMI. Consult the facility dietitian•Initial continuous NGT feeding is indicated if: Medically unstable regardless of BMI OR Unable to tolerate any oral diet OR Medical co-morbidities complicated by an eating disorder (ED) OR BMI <13.5kg/m2

•May be able to start oral diet or a combination of oral diet and enteral feeding if: medically stable AND able to tolerate oral diet AND If BMI >13.5kg/m2

NURSING MANAGEMENT•1:1 special ideal (especially during and after meals; record intake)•No leave off ward•Monitor and contain food avoidance, exercise, vomiting, laxatives•Supervise toilet/shower•Weigh twice weekly in morning after voiding

Audit of 12 pts admitted for nutritional rehab at SCGH (Feb 2012-Jan 2014)

These patients required extensive multidisciplinary input throughout

Acutely Medically Compromised

Treatment / Clinical Recommendations

Observe For Recommended Destination

Medically unstable regardless of BMI •Unable to tolerate any oral diet •Medical co-morbidities complicated by eati disord•Or BMI <13.5

Continuous nasogastric tube feeding (NGT)

1:1 supervision recommended

May need MHA in general health setting (Form 6B)

Bed

Cardiac arrhythmias/ sudden deathThromboembolismRe-feeding syndromeSkin integrityHigh falls riskDistress/compensation

Medical Admission with Psychiatric input

Progress To Medical Stability

Treatment / Clinical Recommendations

Observe For Recommended destination

Medically stable >48hrs May be tolerating oral dietResolving medical and/or psychiatric co-morbidities complicated by eating disorderBMI 13.5 –15 (may be higher, esp. in 16-18 yr /precipitous wt loss)

Commence oral diet - may still require a combination of NGT feeding and oral diet •Meal supervision for 60 mins after meals & snacks – may still require close supervision to contain compensatory behaviours•Limited supervised physical activity

High falls risk Hypoglycaemic

rebound Dizziness Weight loss Compensatory behs Distress / self harm

ideation secondary to nutritional gain

Either medical or psychiatry admission

Decision guided by medical stability and comorbid mental health needs

 

Medically Stable Treatment Observe For DestinationMedically stable >48hrs

• Able to tolerate full oral diet +/- nutritional supplements

Resolving cognitions related to starvation

BMI 15-18 (or higher)

• Most likely tolerating full oral diet however may still require NGT feeding

• Supervised/unsupervised activity dependent on ability to self- manage compensatory

Dizziness Falls risk Weight loss from

↑exercise ↑purging or ↓ intake in a less restrictive environment

Psych ward? Work towards

d/c to ommunity (if tolerating full oral diet & ED cognitions manageable)

Admission Goals and Treatment

BMI band Recommended Phys Activity Criteria for physical activity Associated risk factors BMI

<13.5

• Bed rest recommended (toilet privileges, will be dependent upon medical stability)

Medical stabilisation is overriding priority

(high risk of cardiac arrhythmias / sudden death)

Thromboembolism Muscle wasting Re-feeding Oedema Skin integrity High falls risk (↓ BP)

BMI 13.5 – 15

 

• Lying and sitting exercises (gentle stretches) 5 mins 2x per day

• Toilet privileges • Seated showering 1x daily • Gentle walk 10 minutes 1x

per day within ward environment (if med stable)

Supervised - Med stable for 7 days Blood Pressure ≥ 90 Heart Rate ≥ 50 and no significant postural tachycardia (i.e. <20bpm) Blood Sugar Levels ≥4 Electrolytes in normal range Consuming 100% of the nutrition Reduce compensatory behs

High falls risk (↓ BP, Muscle wasting)

Hypoglycaemic rebound

Dizziness Weight loss

BMI 15 – 17

• Non aerobic stretch/tone exercises (5 min 2x daily)

• Toilet privileges • Showering 1x per day • Gentle walk 10 min 2x daily

within ward environment

Supervision dependent on ability to self- manage compensatory behaviours

Medical Stability Ax of muscle strength Walking with a defined

purpose

Dizziness Falls risk (↓ BP) Joint stiffness Muscle tears/stress Fractures Weight loss

BMI >17 • No aerobic exercise until BMI> 19

• Gentle walking (10 min 3x per day) off ward or

• Mindful exercises - Gentle (max 20 mins per day)

• Independent showering 1x daily

Unsupervised in preparation for discharge Medical stability Walking with a defined purpose (wandering, pacing not permitted).

Dizziness Falls risk (↓ BP) Dehydration Joint stiffness Injuries to muscle,

joints, tendons, ligament

Stress fractures

BMI-related Guide for inpatient management of physical activity