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Medical Implications & Management of Eating Disorders

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(1)

Medical Implications &

Management of Eating

Disorders

The physical and medical implications of eating disorders are complex and carry a high mortality rate regardless of weight. As the length of the disorder increases, as in Severe and Enduring, the more complex they can become at end of life, especially in conjunction with

(2)

What are we Managing

 High Mortality from medical compromise and high comorbidity

 Complex medical concerns affecting all organs of the body

 Bio-adaptation to starvation and malnutrition whereby medical stability is maintained by the body adjusting to starvation

 In Severe and Enduring Eating Disorders, with increased and prolonged malnutrition, more complex medical conditions caused by general loss of muscle and fat pads supporting organs may occur.

 Again in Severe and Enduring ED the increased vulnerability of age and

decreasing resilience (of the body) over many years, years of bio adaption, will lead to a poor prognosis

 Body will react with energy saving mechanisms and/or structural failure of body organs

(3)

 Due to the high mortality rate of patients suffering from eating disorders there is high medical risk not

dependent on weight.

 Causes of death are most commonly due to:

 Starvation

 Cardiac failure

(4)

Working alongside the Co-morbidities

 Approximately 60% of patients with an eating disorder have a comorbid diagnosis, the eating disorder may be providing a sense control.

 When the enduring primary psychiatric diagnosis is seen to be responding to treatment, the risk of the disordered eating may increase

 Be mindful of the medical risks of the primary diagnosis (may not be the eating disorder)

 Drugs

 Alcohol

(5)

Managing the Medical Risk

In non specialist settings

 Services working together to provide care, with focus on the primary diagnosis and consult into the eating disorder

 May require an Acute Management Plan in collaboration with Physicians via ‘Healthpathways’ and/or Advance Care Planning if the patient has a medical instability which is life threatening

 Monitoring for deterioration by the GP if increased weight loss or increase in physical symptoms – working with GP and Practice Nurses

 Include level of medical monitoring required on the Treatment Plan, to manage risk. Adhering to these boundaries, ending treatment if non compliant – non negotiable

 Being mindful of destabilisation of emotions – exacerbating self harm/suicidal ideation and intent, with loss of control of the eating disorder and how to manage this risk

(6)

Medical Monitoring

Medical monitoring of a patient with an eating disorder includes Weekly weight – be mindful of water loading, weights etc

Heart rate and Blood pressure lying and standing (at 2 minute intervals) Normal heart rate for an adult is between 60 and 100 bpm

Normal blood pressure for an adult is around 120/80

Patients with stable medical parameters may be monitored on a less frequent basis due to the bio-adaption of the body to the starved state and they may remain medically stable for long periods.

(7)

Initial Physical Assessment by Service or

GP

 Weight (without shoes or heavy outer clothing)

 Height (without shoes)

 BMI (calculate by BMI = Weight (kg) / Height (m)²)

 ECG

 Pulse (lying and standing after 2 mins) and any pulse differential

 Hydration

 Blood Pressure (lying and standing after 2 mins)

 Temperature

 Respirations

 Squat test

 Menstruation – bone density scan –female triad

(8)

When to

Medically Monitor

 At the assessment to establish base lines

 Again during treatment if

▪ There is further weight loss ▪ Become symptomatic

▪ If medical instability is identified at assessment and needs to be

monitored more regularly by the GP

(9)

Barriers to medical monitoring

 Finances – benefits available (ie Disability Allowance – WINZ)  Non Attendance

 Weight gain fear – Declining to be weighed

(10)

Presenting Signs and Symptoms

General

Marked weight loss, gain or fluctuations

Cold intolerance

Generalised weakness

Fatigue or lethargy/tired all the time

Fainting/Dizziness

Hair loss

Hot flashes, sweating episodes

Lanugo

(11)

Osteoporosis

(12)
(13)

Severe and Enduring

Eating Disorders

Duration of eating disorder studies show anything between 5.5

and 10 years, with at least two evidence based treatments

Identity intertwined with AN

Low BMI with associated medical risks increasing with longevity

Entrenched patterns of behaviour

Co-morbidities

Biological adaptation to starvation

Poor quality of life

(14)

Severity: significant impairment to

Quality of Life

Impact on Nutritional Health

Medical and psychological impacts

Employment

Family relationships

Housing

Social connections

Hobbies

Financial implications

Co-morbidities

 (Robinson 2009)

(15)

Optimal Pie Chart

Friends Church God Family Work Hobbies Health School Home Stuff Finances Me

(16)

Eating Disorder Pie Chart

Client's Current Self-Evaluation Pie Chart

(17)

What treatment

might look like

 Holding Hope

 Crisis/medical management

 Personal goals – focus on ‘their’ goals and pie chart and how ‘they’ might want it to look

 Primary focus of treatment is not always weight gain to a normal BMI but to increase the person’s sense of autonomy for living their best life and developing self-responsibility for managing their health and wellness challenges

 Supportive psychotherapy (studies show both CBT

and SSCM to be effective) – usually 4 sessions in an outpatient setting

 Inpatient short stay to address ‘their goals’

(18)

What Might Work

 Impact of the disorder on QOL – primary target of interventions

 Client may be more motivated in these areas

 Secondary outcomes include weight gain and increased BMI

 Weight gain encouraged but not mandated or primary focus

 Focus on regular eating, psycho-education and motivation

 Improvements can be monitored in QOL questionnaire

 Working on the purpose of the eating disorder and formulation

(19)

What might Not Work

 Clinician’s ‘own’ goals or expectation of weight gain or ‘recovery’

 Existing treatment focus on medical symptoms and weight gain

 Ill matched to offer treatment where Client is focussed on unrealistic recovery ie ‘the magic pill’

 Leads to low retention and engagement and non achievement resulting in further shame

(20)

Keep Calm and Carry

on

 Seek supervision for yourself

 Take to MDT

 Beware change may not happen  Be aware that ACP and Advance

Directives may be required

 Does not mean end of treatment but putting things in place

References

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