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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: – – – – 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 – – – – \ 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: – – – – – 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 – – – – – – – – – 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 – – – – Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin) Aspirin Diphenhydramine (Benadryl) • Prescription medications – – – – – – Benzodiazepines Opiates Antidepressants Antipsychotics Mood stabilizers Stimulants Psychotropic Medications • Most have significant physical effects • CV effects – – – – – – 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 – – – – 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: – – – – 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*** – – – – 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 – – – – – – – 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