Download AED REPORT 2016, 3rd Edition Eating Disorders

Medical and Psychiatric
Emergencies in Eating Disorders
Suzanne Dooley-Hash, M.D.
Jocelyn Hart, M.D.
October 14,2016
4th Annual SJMH Eating Disorders Conference
Disclosures
• None
• Acknowledgement – some slides
adapted/used with permission from Angela
Guarda, MD, Johns Hopkins Eating Disorder
Program
Objectives
• Recognize signs and symptoms of potentially
life-threatening medical and psychiatric
complications of eating disorders.
• Understand the indications for referral for
emergent medical or psychiatric evaluation of
patients with eating disorders.
• Understand the high rates of medical and
psychiatric comorbidities and high risk of
mortality associated with eating disorders.
Scenario 1
Your outpatient with severe anorexia nervosa (AN) has lost
another 5 lb in the past 3 months. BMI is now 13.5. Her
potassium was low (2.9) last week at her PCPs office. Today she
presents to your office with a bruise on her forehead. At first
she denies any injury, but when pressed for information she
admits that she fainted this morning in the shower and hit her
head when she fell.
• Does this patient require a medical evaluation?
• Would you refer this patient to:
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–
–
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Her PCP?
An urgent care?
An emergency department?
Somewhere else?
Red Flag Signs and Symptoms in EDs
• Weakness/fatigue
• Dizziness/syncope
(fainting)
• Bradycardia (slow heart
rate)
• Hypotension (low blood
pressure)
• Orthostasis (dizziness or
fainting with standing)
• Chest pain
• Palpitations (sensation of
heart racing or skipping a
beat)
• Arrhythmias (abnormal
heart rhythm)
• Peripheral edema
(swelling)
• Dyspnea (shortness of
breath)
• Decreased exercise
tolerance
Red Flag Signs and Symptoms in EDs
• Abdominal pain
• Hematemesis/MalloryWeiss tear (blood in
vomit)
• Hypoglycemia (low
blood sugar)
• Poor blood sugar
control in insulindependent diabetics
• Hypothermia (low body
temperature)
• Seizures
• Altered mental status
(confusion, lethargy)
• Suicidal thoughts, plan
or attempt
• Severe self injury
Syncope (Fainting)
• ALWAYS needs urgent medical evaluation
• Multiple possible causes
– Hypotension (low blood pressure)
– Orthostasis (excess change in blood pressure and/or heart
rate with postural changes)
– Hypovolemia
– Electrolyte disturbances
– Arrhythmias (irregular or abnormal heart rhythm/rate)
– Cardiomyopathy/heart failure
– Vasovagal syncope (neurocardiogenic syncope)
– Hypoglycemia
Cardiovascular (CV) Complications in EDs
• Common in patients with EDs
• Up to 30% of deaths in AN are due to CV causes
• Patients may complain of:
–
–
–
–
–
Chest pain
Difficulty breathing
Edema (swelling)
Dizziness
Syncope (fainting)
Cardiovascular Complications
• Electrical changes
– 75% of hospitalized patients
– Some associated with potentially fatal arrhythmias
• Structural Changes
– Cardiac muscle atrophy
• Functional Changes
– Decreased cardiac output
• Decreased heart rate variability
– Predictor of sudden death
• Sudden cardiac death
CV Complications - Common
• Sinus bradycardia
– Heart rate less than 60
beats per minute (bpm)
– Adaptive response to
starvation
– Correlates with severity of
illness
– Often mistakenly
attributed to athleticism
• Hypotension (low blood
pressure)
– BP < 90/60 mmHg (agedependent)
– Multifactorial
• Orthostasis
– Heart rate increases > 15
bpm
– Blood pressure decreases >
20/10 mmHg
– Patients complain of
dizziness or “blackouts” on
standing
– May persist after weight
restoration
Scenario 1, continued
When you tell your patient that she needs
medical stabilization and admission to an ED
specialty program ASAP due to her recent
fainting, BMI of 13 and hypokalemia she says
there is no need for you to worry because she is
fine and her body is “used to this” and the ER
fixed her electrolytes
– Does this patient have capacity to refuse, or to
make an informed decision regarding her need for
treatment?
Ambivalence Towards
Treatment in Anorexia Nervosa
•
•
•
•
Dieting is ego-syntonic and driven
Treatment avoidance is in essence a symptom of anorexia
Attempts to normalize weight or eating are threatening
Patients uncommonly “engage” fully in treatment of their
own accord
– prefer to talk about than to change their behavior
Competence to Refuse Treatment
• Informed consent for medical treatment
– Ability to adequately understand treatment options
and respective risks and benefits
– Ability to make a voluntary decision
– Appreciation of the consequences of her choice
• Competence (legal term) is task specific and implies the
cognitive capacity (medical term) to make an informed
rational decision.
Competence to Refuse Treatment in AN
• “Subtle”
• Rarely grossly incompetent and neither suicidal nor
psychotic.
• Good reasoning in most areas
• Provide seemingly rational explanations for their
treatment refusal
• Appreciate need for others with AN to receive treatment
but appear unable to recognize their own need for weight
restoration.
(Gutheil and Bursztajn 1986, Appelbaum and
Rumpf 1998, Tan et al., 2003)
Lack of Capacity in AN is State Dependent
• In life threatening AN, patients are often incompetent to
make treatment decisions regarding their eating and
weight as a result of their starved state
• This lack of capacity often reverses with weight gain.
– Once weight restored many involuntarily treated patients
retrospectively view their treatment as justified (Watson et al. 2000)
– 41% of patients with AN who felt coerced into admission to a
behavioral specialty program converted to believing they needed
treatment within two weeks (Guarda et al., Am J Psychiatry 2007)
From Persuasion to Coercion
Ethical dilemma in AN --- high
morbidity and mortality
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–
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\
Clinicians
Family members
Educators
Employers
\
Medical Ethics
• Autonomy vs. Paternalism
• Beneficence vs. Do No Harm
– Paternalistic acts that restrict autonomy may be
justified only when a patient’s capacity to consent to
treatment is impaired and the act is expected to
ensure good or prevent significant harm.
Involuntary Treatment
• Remains controversial and only employed by few
treatment centers
• Research on outcomes is limited but suggests no
differences in BMI at discharge (Clausen and Jones 2014; Elzakkers et
al., 2014)
• Higher long term mortality may be due to differences in
case severity, and attenuates over time (Ramsay et al. 1999, Ramsay
et al., 2015)
• No empirical data exists indicating harm from involuntary
treatment
• Often met with gratitude on behalf of patients and
families (Tiller et al., 1993)
Other Considerations
• Involuntary treatment
–
–
–
–
Know the law in your state/country
Is family in support of involuntary treatment?
Is there access to an appropriate behavioral program?
What is the patient’s past treatment history?
• Guardianship
– Can be problematic in adults
Documentation
• Behavior, statements made, collateral information from
other providers and family
• Severity of illness and escalation in behavior
• Knowledge of past expressed wishes and treatment
plans
• Factors that support lack of capacity in reasoning
• Alternatives considered
• Reference evidence-base
Scenario 2
• Your patient with bulimia nervosa (BN) and bipolar
disorder has been struggling with worsening depression
and bulimia over the recent weeks.
• She presents to your office today 10 minutes late for
her session and admits that she has been feeling
increasingly suicidal in the past few days.
• You notice that her speech is slow and slightly slurred
and she seems to be disoriented.
Scenario 2
• Does this patient require a medical evaluation?
• Would you refer this patient to:
–
–
–
–
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Her PCP?
An urgent care?
An emergency department?
Somewhere else?
How would you get her there?
Altered Mental Status
• Aka “confusion/disorientation/lethargy”
• ALWAYS needs urgent medical evaluation
– Possible exception – intoxication with sober ride
• Multiple possible causes
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A - Abuse of alcohol/other substances, acidosis
E - Environmental , epilepsy, electrolytes, encephalopathy, endocrine
I - Infection
O - Overdose, Oxygen deficiency
U - Underdose (withdrawal), uremia (kidney failure)
T - Tumor, trauma, toxins
I - Insulin (excess or insufficient)
P - Psychogenic, poisons (carbon monoxide, iron, lead)
S - Stroke, shock
Metabolic and Electrolyte
Abnormalities
• Hypokalemia (low
potassium)
– K+ < 3.5 mEq/L
– Most common
– Suspect purging
behaviors if more than
mildly decreased
– Tx - Oral vs IV
supplementation
• Hyponatremia (low
sodium)
– Na+ <135 mEq/L
– Causes:
•
•
•
•
•
Dehydration,
“Water-loading”
Kidney dysfunction
Diuretics
SSRI’s
– Tx – fluid replacement or
restriction
Metabolic and Electrolyte
Abnormalities
• Acid-base disturbances
– Most common is
metabolic alkalosis most common
– Serum bicarbonate of
> 38 is highly suggestive
of self-induced vomiting
– Starvation ketoacidosis
• Other electrolytes:
– Hypochloremia (low
chloride)
– Hypocalcemia (low
calcium)
– Hypomagnesemia (low
magnesia)
– Hypophosphatemia (low
phosphate)
– Micronutrient
deficiencies
Endocrine Complications
• Hypoglycemia (low blood sugar)
– Poor prognostic factor
• Hyperglycemia (high blood sugar)
– “Diabulimia”
– Poor glucose control
– Recurrent diabetic ketoacidosis (DKA)
– High incidence of long term complications of diabetes
– Suicide by insulin overdose
Guide to the Eating Disorder Patient’s Medicine
Cabinet
• Laxatives
• Diuretics
• Stimulants
• Ipecac
• Psychotropic medications
Toxins
• Alcohol
• Illicit drugs
• Over-the-counter
medications
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–
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Acetaminophen (Tylenol)
Ibuprofen (Advil, Motrin)
Aspirin
Diphenhydramine
(Benadryl)
• Prescription
medications
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–
–
–
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Benzodiazepines
Opiates
Antidepressants
Antipsychotics
Mood stabilizers
Stimulants
Psychotropic Medications
• Most have significant
physical effects
• CV effects
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Orthostasis
Hypotension
QTc prolongation
Bradycardia
Tachycardia
Cardiomyopathy and
myocarditis
• GI effects
– Nausea/vomiting
– Diarrhea
– Constipation
•
•
•
•
Weight gain or loss
Appetite suppression
Somnolence
Toxicity
Scenario 2, continued
Your patient with bulimia and confusion has
been medically evaluated, treated and stabilized
in the emergency department. The ER calls you
and says they plan to discharge her home. Her
lithium level was too high but is stable now.
– Is this patient safe for discharge home?
– Does she require further evaluation?
– If so, what would you recommend?
Suicide in Eating Disorders
• Suicide accounts for 20-50% of deaths from EDs
• Most common means is overdose
• In 15-34 year old females, AN has
– 5X risk of premature mortality by any cause (SMR=5.2)
(Keshaviah A et al., 2014 meta-analysis)
– 18X risk of death by suicide
Suicide Rates are High in Mentally ill
Individuals
Rates of selected physician diagnosed mental
disorders in people who died by suicide in
Manitoba, Canada, 1996-2009 compared with
score matched living controls from the general
population (Randall JR et al., Can J Psychiatry
2014;59:531-8.)
Suicide risk is high for several months following hospital
discharge
Number of suicides a week in patients with mental illness recently discharged from inpatient
hospital wards in England during 2003 to 2013 (Bolton et al., BMJ 2016)
National Comorbidity Survey-R
Completed Suicide
• 70% of suicide victims communicated their intent
• Predicting suicide risk is difficult because prevalence of
completed suicide is low compared to suicidal ideation
• History of prior attempt is strongest correlate of future
attempts.
– 60% of completed suicides had no prior attempt
– 90% of past attempters do not suicide and 7% do
• 90% of unplanned and 60% of planned attempts occur
within a year of onset of SI.
Suicide
• Ideation
– Female
– One or more psychiatric
diagnoses
– Previously married
– Age <25y
– Poorly educated
• Completed
– Male
– Living alone
– History of prior
attempt
– Hopelessness
– Recent interpersonal
loss
What Does the Low
Prevalence of Suicide vs. SI Mean?
• It is not a violation of the standard of care to fail to
predict a suicide but
• It is a violation of the standard of care to either
inadequately perform a risk assessment, or fail to
take appropriate clinical interventions based on that
risk.
Assessment of Suicidal Risk
• Do you ever feel hopeless about the future or as though your life
is not worth living?
• Have you had thoughts of suicide or of killing or hurting yourself?
• What have you thought of doing? When did you first have these
thoughts? How frequent are they? How persistent? Can you
control them?
• Have you procured the means to enact your plan?
• Have you thought of a date or time?
• How often do you have these thoughts?
• Have you ever tried to kill yourself?
• Do you feel able to control these thoughts?
Assess Lethality
• High risk
– Belief in lethality of plan
– Detailed plan
– Has collected the means
– More violent means
– Access to firearms
• Lower Risk
– Low risk : rescue ratio
– Low intent
Clinical Interventions to Reduce Risk
• Safety planning/risk reduction
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–
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Remove access to means
Involve significant others (family, providers)
Discuss consequences of suicide on others
Increase frequency/level of care
• Emergency petition/law enforcement
• Hospitalize
• What about Suicide contracts?
Documentation
Document your decisions and the reasoning behind
them:
• Facts
• Judgments
• Risks : Benefits
• Alternatives
• Reflections
Scenario 3
The mother of a 22 year old college student with an eating
disorder and self injurious behavior calls you. Her daughter has
cut herself again on her forearm with a boxcutter. The wound is
7 cm long, and near the wrist, she can see yellow fat but there is
not much blood.
• The patient adamantly denies it was a suicide attempt and cut
because she was upset about a fight with her boyfriend and
felt “fat”. She says she is fine now.
• The mother is asking you what she should do.
– Does she need to take her to an ER?
– Should psychiatry see her?
– Does she need to be admitted?
Non-Suicidal Self Injury in ED
Non Suicidal Self-Injury (NSSI)
• Common in EDs
– 22% in AN and 33% in BN
– 2.6 X more likely in specialist intensive treatment than in general
practice/community ED patients
– h/o attempted suicide predicted NSSI (Cucchi et al, 2016)
• NSSI is a motivated behavior
• Treatment should focus on stigmatizing the behavior rather
than justifying it
• Be alert to illness behavior and to contagion effects.
Scenario 4
You are seeing an 18 year old girl with a history of severe AN (BMI
13.6) who recently started FBT. The patient has been compliant with
meals over the past 2-3 weeks and before that was eating very little.
Her mother suspects she might be sneaking food and bingeing in
secret. Mom calls you and is worried because the patient is
complaining of leg swelling and fatigue. She gets winded walking up
the stairs to her bedroom.
• Does this patient require a medical evaluation?
• What is your primary concern?
• Would you refer this patient to:
–
–
–
–
Her PCP?
An urgent care?
An emergency department?
Somewhere else?
Dyspnea/Decreased Exercise Tolerance
• Aka “shortness of breath or difficulty
breathing”
• ALWAYS needs urgent medical evaluation
• Multiple possible causes
– Pulmonary
– Cardiovascular
– Respiratory muscle weakness
– Refeeding syndrome
Refeeding Syndrome
• Increased risk:
– Minimal or no nutritional intake for > 10 days
– History of alcohol abuse
wiki.triastelematica.org
– Use of medications including insulin, chemotherapy, antacids or
diuretics
– Severe malnutrition at presentation (< 70% median BMI in
adolescents, BMI <15 most at risk in adults)
– History of refeeding syndrome
– Patients with rapid or profound weight loss, including those who
present at any weight after rapid weight loss (> 10-15% of total body
mass in 3-6 months)
– Post-bariatric surgery patients with significant weight loss
– Patients with abnormal electrolytes prior to refeeding
Refeeding Syndrome
• Hypophosphatemia (low phosphate) is key
• Multiple electrolyte abnormalities
• Symptoms:
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–
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Neurologic - confusion, seizures, coma
Cardiac - arrhythmias, heart failure
Hematologic - hemolysis
Muscular - weakness, rhabdomyolysis, diaphragm weakness
leading to respiratory failure
Refeeding Syndrome
• Treatment
*** Avoid overly aggressive administration of IV fluids***
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Slow administration of IVF (50-70cc/hr of NS)
Aggressive replacement of electrolytes
Admit to monitored bed vs. intensive care
Do NOT attempt to manage refeeding syndrome as an
outpatient
Edema (Swelling)
• Multiple potential causes
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Severe malnutrition (protein deficiency)
Excess fluid intake (water loading)
Withdrawal from diuretics and/or laxatives
Decreased cardiac function
Refeeding syndrome
Stasis (decreased activity)
Increased vascular permeability
Gastrointestinal Emergencies
• Trauma
– Mallory-Weiss (esophageal) tears
– Boerhaave’s Syndrome
•
•
•
•
•
•
•
Acute gastric dilatation/gastric rupture
Acute hepatitis
Fulminant hepatic (liver) failure
Pancreatitis
Superior mesenteric artery (SMA) syndrome
Biliary colic and/or cholecystitis
Cholestasis
Scenario 5
You have a patient with AN-P who is a severe laxative
abuser. Her PCP tells you that her glucose was 30 and
potassium 3.0 last week. She is a home IV therapy
nurse and tells you she feels faint, dizzy and
orthostatic. She backed into a parked care and had a
fender bender yesterday while working. She refuses
admission. Who should you consider contacting?
• Spouse
• Employer
• Motor vehicle administration
• Police?
What communication with a patient’s family, friends, or other
persons involved in the patient’s care is allowed under HIPAA in an
emergency setting?
• When the provider perceives a serious and imminent threat to the
health or safety of the patient or others and the family members are
in a position to lessen the threat
• Disclosure should be limited to what the carer needs to know based
on their involvement in the patient’s care
• Where a patient is incapacitated a provider can share information
with family if in the best interest of the patient based on professional
judgment of the provider
• Psychotherapy notes stored separately from the medical record
require a separate written consent for release.
Can the provider contact family or law enforcement if concerned
about suicide risk or harm to others?
• When a health care provider believes in good faith that such a warning is
necessary to prevent or lessen a serious and imminent threat to the
health or safety of the patient or others, the Privacy Rule allows the
provider, consistent with applicable law and standards of ethical conduct,
to alert those persons whom the provider believes are reasonably able to
prevent or lessen the threat
HIPAA: non-emergent communication with a patient’s family,
friends, or other persons involved in the patient’s care
•
•
•
may ask the patient’s permission to share
relevant information with family members or
others
may tell the patient he or she plans to discuss
the information and give them an opportunity
to agree or object
may infer from the circumstances, using
professional judgment, that the patient does
not object e.g. when a family member or
friend is present in the treatment room, with
apparent consent of the patient.
What information can family provide without
consent of patient?
•
•
•
•
HIPAA only covers disclosure of PHI
Family members can always provide information to providers
Do you have to disclose this information to the patient?
What if the family does not know the patient is hospitalized?
HIPAA Privacy Regulations Coordination of care
• Do not apply when sharing PHI for treatment coordination
between providers who are treating a patient eg for a
consultation referral, transfer planning or referral back to PCP.
• Your state may have more restrictive law than HIPAA
• Use clinical judgment
• http://www.hhs.gov/hipaa/for-professionals/specialtopics/mental-health/index.htm
Medical Evaluation of the Eating
Disorder Patient
• Thorough history and
physical examination
• Laboratory studies
– Complete blood count
– Electrolytes including
magnesium and
phosphorus
– Kidney and liver function
tests
– Thyroid function tests
– UA
– Pregnancy test (if
applicable)
• ECG
• Other studies as indicated
– Chest x-ray
– Echocardiography
– Bone density testing
Ask About ED Behaviors
• Bingeing/Self-induced
vomiting
– Paired?
– Frequency?
• Diuretics, laxatives,
ipecac
– Type?
– Frequency?
• Exercise
– Type?
– Frequency?
– Symptoms?
• Caffeine intake
• Fluid intake
Criteria for Hospitalization for Acute
Medical Stabilization
• ≤ 75% median BMI for age, sex, and height
• Hypoglycemia
• Electrolyte disturbance (hypokalemia,
hyponatremia, hypophosphatemia and/or
metabolic acidosis or alkalosis)
• ECG abnormalities (e.g., prolonged QTc > 450,
bradycardia, other arrhythmias)
• Hemodynamic instability
• Bradycardia
AED REPORT 2016, 3rd Edition
• Hypotension
Eating Disorders: A Guide to Medical Care
Criteria for Hospitalization for Acute
Medical Stabilization
• Hypothermia
• Orthostasis
• Acute medical complications of malnutrition (e.g., syncope,
seizures, cardiac failure, pancreatitis, etc.)
• Comorbid psychiatric or medical condition that prohibits or
limits appropriate outpatient treatment (e.g., severe
depression, suicidal ideation, obsessive compulsive disorder,
type 1 diabetes mellitus)
• Uncertainty of the diagnosis of an ED
AED REPORT 2016, 3rd Edition
Eating Disorders: A Guide to Medical Care
Criteria for Hospitalization for Acute
Psychiatric Stabilization
• Presence of one or more of the following:
– Acute food refusal
– Suicidal thoughts or behaviors
– Other significant psychiatric comorbidity that
interferes with ED treatment (anxiety, depression,
obsessive compulsive disorder)
AED REPORT 2016, 3rd Edition
Eating Disorders: A Guide to Medical Care
Other Considerations Regarding
Hospitalization:
• Failure of outpatient treatment
• Uncontrollable bingeing and/or purging by any
means
• Inadequate social support and/or follow up
medical or psychiatric care
AED REPORT 2016, 3rd Edition
Eating Disorders: A Guide to Medical Care
What to tell the emergency
department
• CALL whenever you send a patient to the
emergency department!!!
• Information shared for transfer of care is
HIPAA compliant
• EMTALA – federal regulations on transfer of
care – requires accepting physician
What to Tell the Emergency
Department
• Tell them your concerns
– Be specific
– Include any dangerous behaviors
• ED Behaviors (purging frequency)
• History of abnormal labs or other relevant medical
conditions
• Misuse of psychotropic meds or other substances
• Suicide risk
• Give advice on disposition if relevant
Take Home Points
• Eating disorders are serious mental illnesses
with high rates of medical and psychiatric
complications and comorbidities
• ALWAYS err on the side of caution
• Provide all relevant information to accepting
healthcare provider
• Document your clinical reasoning