Experience of management of anorexia nervosa patients with extremely severe malnutrition in a transdisciplinary eating disorders inpatient unit

Abstract

Background: The question of where to hospitalize extremely malnourished patients with anorexia nervosa (AN) is a real dilemma. On one hand, psychiatrists have to deal with severe medical complications that are not within their competences and that justify hospitalization in an internal medicine ward. On the other hand, medical doctors have to face psychic decompensations that would justify admission to a psychiatric ward. In this context, we share our experience of management of severely malnourished AN adult patients in a transdisciplinary specialized eating disorders (ED) unit, referral center for AN associated with somatic severity.Method: First, we described the modalities of care proposed to patients with AN hospitalized in the medical unit. Intensive medical care, both somatic and psychiatric, are provided thanks to a transdisciplinary therapeutic program, where objectives are to: medically stabilize the patient, initiate progressive refeeding and start supportive psychotherapy before being transferred to a psychiatric ED unit. Secondly, we conducted a retrospective descriptive study that included all adult patients with AN admitted for the first time to the unit, between November 1997 and January 2014, for severe malnutrition and/or complications of the ED. Objective was to specify patients characteristics: demographic, nutritional status, history of ED, care pathway. Finally we discussed the value of such a unit.Results: Among a cohort of 386 adult patients with AN (21 males and 365 females) admitted for the first time in the unit, mean age was 29.4 (± 11.5) years, mean BMI was 12.7 (± 2.2) kg/m². Before being supported in the unit, 78.2% of patients had already been hospitalized in other hospitals. Mean length of stay was 35.2 days. Patients were clinically serious and unstable because of life-threatening somatic complications due to a low BMI. During hospital stay, a temporary transfer to medical intensive care unit was necessary for 25.6% of patients. Average patient weight gain was 0.777 kg per week and 81.9% of patients benefited from enteral nutrition.Conclusion: This specialized transdisciplinary unit where physician nutritionists and psychiatrists coordinate medical care together, allow a better understanding and management of extreme malnutrition associated with AN. Thanks to their expertise, care teams are less critical and less rejecting towards patients. Thus, therapeutic alliance could be optimized.

Adding mini meals to a nasogastric refeeding protocol for patients with eating disorders can be achieved on general hospital wards

“…Although enteral feeding is beneficial for those patients who are severely malnourished and/or medically unstable, 16 providing oral nutrition has clear benefits, particularly as the period of hospital stay lengthens. 17,18 By staging the return to consuming nutrition orally, similar to the method used in the present study, both the patient and healthcare team have time to address disordered eating behaviours, and the patient has time to climatise to seeing food again, as well as to partake in regular meal times. 8,17 Because there is yet no evidence on the best time to reintroduce an oral diet to medically unstable patients, further research is warranted.…”