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MARSIPAN Management of Really Sick Patients with Anorexia Nervosa

Why written?. AN patients on general medical wards don't always do very wellSome confusion over respective rolesGuidance to primary care over when to refer (no GP on task group). . Recognition and awareness. ?Patients with anorexia nervosa can seem deceptively well ? they may have an extremely pow

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MARSIPAN Management of Really Sick Patients with Anorexia Nervosa

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    1. MARSIPAN – Management of Really Sick Patients with Anorexia Nervosa Royal College of Psychiatrists and Royal College of Physicians – Oct 2010

    2. Why written? AN patients on general medical wards don’t always do very well Some confusion over respective roles Guidance to primary care over when to refer (no GP on task group)

    3. Recognition and awareness “Patients with anorexia nervosa can seem deceptively well – they may have an extremely powerful drive to exercise which sometimes seems to override their lack of nutritional reserve...” Patients can deteriorate very quickly. Any patient with weight loss with or without amenorrhoea may have AN, especially of there are signs of weight preoccupation, lack of concern about weight loss or compensatory behaviours such as vomiting. Differential diagnosis includes depression and infectious mononucleosis.

    4. Observations and tests BMI Anorexia <17.5 – consider referral; if <15 urgent referral Medium risk 13-15 High risk <13 Physical examination Low pulse, BP, core temperature Muscle power reduced SUSS (sit up – squat – stand) Blood tests Sodium low: suspect water loading (<125 = high risk) Potassium low: vomiting or laxative abuse (<3 = high risk) (low Na and K can occur anyway in malnutrition) Raised transaminases Hypoglycaemia: blood glucose <3 (suspect occult infection, esp if low albumin or raised CRP ECG – if BMI <15 Bradycardia Raised QTc (>450ms) Nonspecific t-wave changes Hypokalaemic changes

    5. Refeeding Rapid re-feeding may precipitate electrolyte changes – would need daily bloods (no GP on the panel…)

    6. Compulsory admission and treatment Presence of a mental disorder (e.g. anorexia) In-patient treatment is appropriate (for re-feeding) The condition presents a risk to the health and safety of the patient “Under the MHA, feeding is recognised as treatment for anorexia nervosa and can be done against the will of the patient as a life-saving measure.”

    7. Time for discussion…

    8. Our invisible addicts First Report of the Older Persons’ Substance Misuse Working Group of the Royal College of Psychiatrists College Report CR165 22 June 2011

    9. The rationale Between 2001 and 2031, there is projected to be a 50% increase in the number of older people in the UK. The percentage of men and women drinking more than the weekly recommended limits has also risen, by 60% in men and 100% in women between 1990 and 2006 (NHS Information Centre, 2009a).

    10. Key issues (1) Mortality rates linked to drug and alcohol use are higher in older people compared with younger people High rates of mental health problems in older people (including a high prevalence of cognitive disorders) result in frequent, complex psychiatric comorbidity accompanying substance use disorders Concurrent medications – interactions Older people use large amounts of prescription and over-the-counter medication and rates of misuse (both intentional and inadvertent) are high, particularly in older women

    11. Key issues (2) Older men are at greater risk of developing alcohol problems than older women. Physical health problems and the long-term prescription of medication (especially hypnotics, anxiolytics and analgesics) are important factors in the development of substance misuse in older people Psychiatric comorbidities of substance misuse are common in older people (including intoxication and delirium, withdrawal syndromes, anxiety, depression and cognitive changes/dementia) Among older people, psychosocial factors (including bereavement, retirement, boredom, loneliness, homelessness and depression) are all associated with higher rates of alcohol use

    12. So what do they suggest? Older people with substance use problems have high levels of unmet need. GPs should screen every person over 65 years of age for substance misuse as part of a routine health check, using specific tools such as the Short Michigan Alcoholism Screening Test – Geriatric version (SMAST-G); screening should also incorporate cognitive testing using tools such as the Mini-Mental State Examination (MMSE)

    13. …and the bit that hit the headlines… Because of physiological and metabolic changes associated with ageing, the upper ‘safe limit’ for older people is 1.5 units per day or 11 units per week In older people, binge drinking should be defined as >4.5 units in a single session for men and >3 units for women

    14. What do you think? Public health priority? or Nanny state gone mad?

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