III.1. Patient characteristics
Initially, 395 patients were selected but 9 of these were excluded because they declined use of their data in the study. Finally, we included a total number of 386 patients: 365 (94.6%) were female and 21 (5.4%) were male. Mean age at admission was 29.4 (± 11.5) years old and 46.6% of patients had AN-R subtype while 48.2% had AN-BP subtype. Duration of AN at admission was 9.9 (± 9.3) years. Before this first admission in the clinical nutrition-ED-unit, 302 (78.2%) patients had already been admitted to other hospitals for AN. BMI at admission was 12.7 (± 2.2) kg/m². BMI at discharge was 14.2 (± 1.9) kg/m². During hospitalization, average weight gain was 3.8 ± 4 kg (0.777 kg per week). Patient characteristics are presented in Table 1.
Table 1. Patient characteristics (N=386).
Characteristics
|
Mean ± SD or N (Percentage)
|
Female /Male
|
365 (94.6 %)/ 21 (5.4 %)
|
Age at admission (years)
|
29.4 (± 11.5)
|
Subtype of anorexia nervosa:
|
|
Restrictive
|
180 (46.6 %)
|
Binge purging
|
186 (48.2 %)
|
Atypical AN
|
20 (5.2 %)
|
Age at AN onset (years)
|
19 (± 7.6)
|
Duration of AN at admission (years)
|
9.9 (± 9.3)
|
History of hospitalization for AN in other hospitals (before admission in the unit)
|
302 (78.2 %)
|
Number of hospitalizations for AN (before admission in the unit)
|
2.9 (± 3.4)
|
Patient's regular behavior:
|
|
Self induced vomiting
|
162 (42 %)
|
Laxative misuse
|
81 (21 %)
|
Potomania
|
54 (14 %)
|
Diuretic use
|
15 (3.9 %)
|
Problematic exercice
|
175 (45.3 %)
|
BMI (kg/m²):
|
|
Admission
|
12.7 (± 2.2)
|
Discharge
|
14.2 (± 1.9)
|
Weight gain during hospitalization (kg)
|
3.8 (± 4)
|
Psychiatric comorbidities:
|
|
Personality disorders
|
84 (21.8 %)
|
Obsessive-compulsive disorders
|
32 (8.3 %)
|
Mood disorders and/or Anxiety disorders
|
181 (46.9 %)
|
History of suicide attempt
|
81 (21 %)
|
Self-mutilations (nonsuicidal self-injury disorder)
|
28 (7.3 %)
|
Attention Deficit Hyperactivity Disorder
|
5 (1.3 %)
|
Kleptomania
|
3 (0.8 %)
|
Addictions:
|
|
Alcohol use disorder
|
34 (8.8 %)
|
Substance use disorder
|
24 (6.2 %)
|
Tobacco use disorder
|
127 (33 %)
|
III.2. Patient’s referral to the unit
Among the patient cohort, the most frequent reason for admission was extremely severe undernutrition. Patients were sometimes hospitalized for other reasons such as the treatment of one or more medical complications related to undernutrition or to the process of refeeding itself initiated outpatient or inpatient in other hospitals. Short admissions were also organized for nutritional evaluation and development of a treatment regime. Finally, a few admissions were done in order to wean purging behaviours (self-induced vomiting, laxative or diuretic abuse). Distributions of reasons for hospitalization in the unit are presented in Table 2.
Table 2. Distribution of reasons for hospitalization in the unit (N=386).
Reason for hospitalization
|
N (Percentage)
|
Severe undernutrition
|
295 (76.4 %)
|
Medical complications
|
54 (14 %)
|
Nutritional evaluation
|
19 (4.9 %)
|
Weaning of purging behaviours
|
18 (4.7 %)
|
The protocol for the treatment of patients in the unit was individualised following an initial consultation or evaluation in psychiatric or general medicine day hospital. In case of emergency, the patient could be also admitted after a transfer from an inpatient unit in another hospital (e.g., an emergency room, medical ward, medical intensive care unit (MICU), or psychiatric ward), (refer to Table 3).
Table 3. Distribution of medical units that referred the patients to the unit (n=366).
Medical unit that referred the patients to the unit
|
N (Percentage)
|
Psychiatric inpatient unit
|
54 (14.8 %)
|
Emergency department
|
25 (6.8 %)
|
Medical Intensive Care Unit
|
65 (17.8 %)
|
Medicine outpatient clinic
|
100 (27.3 %)
|
Psychiatric outpatient clinic
|
59 (16.1 %)
|
Medical ward
|
51 (13.9 %)
|
Student medical and psychiatric clinic
|
2 (0.5 %)
|
Adolescent care inpatient unit
|
3 (0.8 %)
|
Surgical ward
|
1 (0.3 %)
|
Obstetrics and gynecology inpatient unit
|
2 (0.5 %)
|
General pediatrics inpatient unit
|
4 (1.1 %)
|
III.3. Length of stay, Number of admission
Our unit has 180 to 200 admissions per year with an average length of stay of 35.2 (± 30.2) days. Patients can be hospitalized multiple times in the unit if necessary. Among the cohort, 127 (32.9%) patients were re-hospitalized one or more times in the unit after their first admission because of a relapse of the disease resulting in a life-threatening clinical condition.
III.4. Inpatient Treatment and Management
III.4.1. Objectives of treatment in a full-time hospitalization
Inpatient treatment has the following objectives:
- Begin a careful and gradual refeeding to stabilize critically ill patients suffering from severe malnutrition before they are transferred to a psychiatric inpatient unit specialized in ED. Psychiatric units are not usually sufficiently equipped and do not have the medical competence to handle the first stage of intensive care in case of severe malnutrition (6).
- Diagnose and treat any medical complications.
- Initiate, continue or resume psychiatric care. The objectives of psychiatric intervention at this stage of undernutrition are limited to: detecting and preventing any suicidal behaviour, taking security measures to protect the patient if necessary, providing supportive therapy and creating specific a short-term and long-term treatment plan.
- Decrease invasive binging and purging behaviors, (self-induced vomiting, laxative or diuretic abuse), potomania, and problematic exercising, as necessary.
- Effort to preserve and improve the socio-professional integration of the patient (if deficient) in anticipation of his discharge from the hospital.
To achieve these goals, medical care should be multifocal and therefore transdisciplinary including meetings to coordinate planning. Two different transdisciplinary staff meetings are organized regularly to optimize and coordinate patient care:
- Weekly staff meeting attended by nurses, auxiliary nurses, medical doctors, psychiatrists, residents, psychologist, physiotherapist, and all students
- Monthly staff meeting coordinated by a psychologist and a psychiatrist to discuss the difficulties encountered by the medical and paramedical team in providing patient care; psychological and psychiatric support help the team deal with difficulties: improve coping, discuss the emotional impact of working with this patient population, strengthen the collective dimension of the team.
In addition, the therapeutic alliance between the patient and the healthcare team is essential to the efficacy of the treatment program. Ideally, (except in cases of emergency hospitalization), the conditions of hospitalization are discussed in advance with the patient and his family during a pre-admission consultation.
III.4.2. The individualized therapeutic program
A written care contract is agreed between the patient and his caregivers and signed by both. It sets out weighted objectives and the steps needed to combat anorexic cognitions. The conditions of hospitalization are also detailed. They are individualised according to the patient, depending on the severity of his symptoms and the psychiatric comorbidities. The limited access to sanitary facilities is outlined and explained in the contract including the prevention of postprandial vomiting compulsions and food spills, as well as naso-gastric tube and feeding by EN. Access to mobile phones, use of laptops, access to the Internet, frequency of family visits and off-premises passes are also determined in agreement with the patient, with the patient’s family (as appropriate) and detailed in the contract.
Discharge planning for the continuation of medical care (specifying the medical team and treatment facility) is determined progressively based on discussions with the patient and his family as clinical improvement of the patient progresses.
III.4.3. Enteral nutrition
When a patient’s BMI is below 13, artificial nutrition support is usually indicated to initiate the refeeding of the patient (7). However, in the unit, when a patient’s BMI is between 12 and 13, the prescription of artificial nutrition is discussed and decided according to the patient's situation, taking into consideration his clinical condition (presence of edema, physical exhaustion), his calorie intake and his blood test results (8). The existence of medical complications weighs in favor of instituting nutritional support therapy. When a patient’s BMI is less than 12, artificial nutrition is proposed from the start (8).
Assuming the patient has an accessible and intact digestive tract (which is true in most cases) (9), the choice of nutritional support is typically enteral nutrition (EN) administered via a small-caliber nasogastric tube as recommended (6,10). Parenteral nutrition is not used nor recommended in AN (11,12), except in cases where intestinal pathology makes EN impossible. PN exposes the patient to a risk of infectious, mechanical and metabolic complications (13) . Vomiting is not a contraindication to EN.
The good tolerance of EN (14), its effectiveness on both weight gain (a weight gain between 500 g and 1 kg per week is recommended (6)) and on the reduction of the duration of hospitalizations, have been demonstrated (15) in AN malnourished patients. EN is therefore widely prescribed in the unit. In our cohort, 316 (81.9%) patients benefited from EN during their hospital stay.
EN is prescribed in the following manner:
- A standard polymeric product, isocaloric (providing 1kcal / ml), normoprotidic, without fiber is most often prescribed
- In cases of impaired renal function or particularly in very low weight patients, a paediatric product less rich in protein is preferred.
To improve its performance and clinical and metabolic tolerance, EN is administered in a continuous flow over 24 hours using a flow control pump. When undernutrition is severe (BMI <12), refeeding is exclusively enteral in the first days. An oral diet is gradually introduced later (see dietary management).
Calorie intake is started at 10 kcal / kg body weight / 24 hours during the first 48 hours as recommended with severely malnourished patients (16). Then it is increased gradually, in increments of 250 kcal, according to the patient’s clinical and biological tolerance, to reach 45 kcal / kg body weight/ 24 hours.
III.4.4. Hydration, vitamins and trace elements
During the first 48 hours of hospitalization, intravenous supplementation with vitamins, trace elements and phosphorus is carried out to correct potential micronutrient deficiencies and to prevent RS as recommended (16). Intravenous rehydration with a 5% glucose polyionic solution is also administered, limited to 30 ml / kg body weight / 24h. Patients are put on a low sodium diet (sodium intake <1 mmol / kg body weight / 24h) to prevent water inflation. Daily intake of phosphorus, vitamins and trace elements is continued orally.
Additional intravenous contributions of potassium, magnesium and phosphorus are added in case of hypokalemia, hypomagnesemia or hypophosphatemia.
III.4.5. Oral nutrition
Dietary management is an integral part of overall care and it becomes more and more important with the progression of the patient’s hospitalization, in parallel with the decrease in EN. The reintroduction of oral feeding is done gradually, once refeeding has begun and in the absence of critical metabolic abnormalities, at a rate adapted to the physiological and psychological capacities of the patient. The reintroduction of food must be progressive, as under-nutrition is severe.
Protein foods are re-introduced last (after vegetables and carbohydrates), in order to limit protein intake at a level under 2.5 g/kg of body weight per day. Oral feeding is carried out with 3 meals per day and, if necessary, a snack at 4 pm. The meal duration must not exceed 30 minutes for lunch and 45 minutes for dinner.
A food-monitoring sheet is displayed in the patient's room which notes the current oral intakes of the patient. Once established, the composition of the meal can only be changed after the dietician has interviewed the patient. As oral nutrition and weight gain are acquired, enteral caloric intakes are progressively reduced. However, we have observed that more than one-third of patients are still on EN on discharge. Among our cohort, 137 (35.5%) patients were still receiving EN when they left the unit. Hence, EN was ongoing in their transfer unit to continue the refeeding process. It is recommended to interrupt EN if the oral intake is satisfactory when the BMI is around 14 kg/m (16).
III.4.6. Prevention of refeeding syndrome
The severe and chronic undernutrition of the AN patient (BMI <16) exposes the patient to an increased risk of RS at the initial phase of refeeding (6,17). The metabolism of the patient, which was idling in a state of adaptation to prolonged fasting, faces a new situation: the reintroduction of nutrients and its resulting increase in insulin levels (18). This metabolic change puts the patient at risk, especially if the increased calorie intake is not introduced gradually with movement of water and electrolytes from the extracellular sector to the intracellular sector. RS can manifest with ionic disorders, (mainly hypophosphatemia, hypokalemia and/or hypomagnesemia), fluid retention and one or more organ dysfunction(s) (acute heart failure, renal failure, respiratory failure, liver failure, convulsion or even coma) (19).
To prevent RS, various measures are implemented:
- Refeeding is started with a minimum calorie intake, then increased very gradually, following the rule "start slow, advance slow." (18)
- Adjustment of calorie intake is individualized to the patient's metabolic tolerance and weight gain. Ideally, the weight gain should be 0.5 to 1 kg / week (6,18)
- Supplementation with multivitamins, trace elements, potassium, phosphorus, and magnesium is started empirically from the first day of admission, and then adapted, based on the biological results.
- Comprehensive clinical monitoring with special attention to heart rate, edema and hydration status.
- Regular biological monitoring (initially daily) of blood glucose, creatinine, liver enzymes, plasma electrolytes, and phosphorus (6,18).
III.4.7. Psychotropic treatment
There is no specific psychotropic treatment for AN (6,20) and those medications can have severe side effects in case of malnutrition. This is the reason why psychotropic medications are not systematically ordered in the unit. However, as recommended in all international guidelines (20), antidepressant medications are sometimes used when the patient still presents anxious depressive symptoms leading to an anxious or depressive disorder diagnosis despite improvement in his nutritional status (22). When the patient’s anxiety symptoms are so severe that it is a barrier to his refeeding process, a small dose of anxiolytics can also be prescribed.
III.4.8.Prevention of decubitus ulcers and deep vein thrombosis
Strict bed rest is ordered in the beginning of hospitalization. It can be extended for some patients. Daily nursing care provided by nurses and nursing aids, and the use of air mattresses are the main measures to prevent bedsores in the unit. In addition, a prophylactic dose of anticoagulant treatment is ordered to prevent deep vein thrombosis.
III.4.9. Blood analysis and imaging
Some analyses are carried out during the early phase of the hospital stay:
- Blood analysis (CBC, platelets count, electrolytes, urea, creatinine, calcium, phosphorus, magnesium, albumin, transthyretin, glycemia, liver enzymes, PT, PTT, CRP, Thyroid Function Tests, folate, vitamin B12, vitamins A, D and E, zinc, copper, selenium)
- ECG
- Chest X Ray to verify the NGT position; (if an NGT is inserted)
A bone densitometry is done to assess the patient’s bone mineralization status and to detect potential osteoporosis. It may be the first time a patient has had a bone densitometry in his medical history. If the patient had already a bone densitometry done in the past, a waiting period of two years is needed before repeating it (6).
An echocardiogram is also provided in the presence of clinical signs of cardiac insufficiency and/or ECG abnormality.
III.4.10. Clinical and bio-clinical monitoring
An internal medicine doctor and a psychiatrist perform daily ward rounds together. All the patients present in the ward are seen every day by the team of doctors who provide physical examinations, discussions about hospitalization conditions, adjustment and revaluation of treatment, management of acute medical issues. Thus, each medical complication is managed adequately.
Complementary investigations are repeated according to patient needs and changes, but systematically, three to six times per day, capillary blood glucose monitoring and vital signs monitoring are provided. Indeed, an isolated tachycardia can be an early sign of sepsis or cardiac dysfunction. Other complications include patients who are hypothermic and others who develop severe hypoglycemia because of severe malnutrition.
Body weight monitoring is done twice a week, on fixed days, before breakfast with patients wearing only their underwear.
During the first week of hospitalization, daily blood tests are performed specifically for phosphorus, electrolytes, creatinine and liver enzymes monitoring. Later, blood tests are repeated once a week if there is no acute abnormality.
A Nitrogen balance is done regularly to check the patient metabolic status, which should be anabolic during the refeeding process.
III.4.11. Psychiatrist’s role
Psychiatrists assess the psychiatric comorbidities. They manage acute psychiatric symptoms. They are responsible for prescription of psychotropic medications when needed, according to the patient’s biological and clinical tolerance. In cases of compulsory hospitalization, they write medical certificates in collaboration with the medial doctor.
In cooperation with psychologists, psychiatrists provide supportive psychotherapy. Structured therapy is difficult and may be impossible in case of extremely severe malnutrition. In fact, some psychiatric symptoms can be caused by malnutrition. Moreover, in the early phase of hospital, cognitive functions are altered by undernutrition itself (18).
III.4.12. Psychologist’s role
The psychologist is responsible for individual psychotherapy support for each patient at least once a week. The frequency of these interviews is adjusted taking into account both the patient’s preferences and the medical and psychiatric teams’ evaluation. The psychologist also coordinates group activities or occupational therapy (3 times per week) to enable the patient to build alliances with the team and develop social relationships based on mediational activities. Different themes are explored through these activities. The different workshops include: group therapy focused on life and treatment in the unit, a newspaper workshop, cultural mediation, creative arts, and writing. Patients are invited to participate as soon as their physical conditions allow it.
III.4.13. Medical management difficulties
Because of the extreme severity of the patients’ medical conditions and despite all the precautions taken during the refeeding process, some acute medical complications can appear. It was rarely a refeeding syndrome (23 cases in our cohort-5.9% of patients); most often, these complications corresponded to: hemodynamic instability, electrolyte imbalance, anemia, severe neutropenia, acute organ dysfunction (cardiac, hepatic, renal) or sepsis linked to the relative immunosuppression induced by the malnutrition.
All these situations are managed individually. In cases of critical or unstable clinical parameters or vital organ dysfunction, a transfer to the MICU is organized.
Among our cohort, 99 (25.6%) patients were transferred to the MICU during their hospitalization in the unit. Reasons for these MICU transfers are presented in Table 4.
Consultations to other sub-specialties such as infectious diseases or hepatology may also be required to optimize the management of patients at times.
Table 4. Reasons for MICU transfer during the hospitalization in the unit.
Reason for medical intensive care unit (MICU) transfer during hospitalization in the unit
|
Number of patients
|
Percentage of the total number of MICU transfers (N=99)
|
Hypokalemia complicated by ECG changes
|
21
|
21,2%
|
Hypophosphatemia complicated by ECG changes
|
11
|
11,1%
|
Severe hyponatremia
|
9
|
9,1%
|
Severe hypertransaminasemia and/or hepatic failure
|
20
|
20,2%
|
Acute cardiac failure
|
6
|
6,1%
|
Hemodynamic instability and / or cardiac arrhythmias
|
24
|
24,2%
|
Hypothermia
|
5
|
5%
|
Acute renal failure
|
10
|
10,1%
|
Suicide attempt
|
8
|
8,2%
|
Acute pancreatitis
|
1
|
1%
|
Severe sepsis
|
14
|
14,1%
|
Anasarca
|
3
|
3%
|
Severe neurological disorders
|
5
|
5%
|
Severe symptomatic hypoglycemia
|
6
|
6,1%
|
Gastric distension
|
1
|
1%
|
Parenteral nutrition use
|
1
|
1%
|
III.4.14. Psychiatric care difficulties
AN is primarily a psychiatric disorder characterized by poor compliance, opposition to care and denial of the severity of the clinical condition by the patient. These situations can lead to some runaways (9 cases in our cohort - 2.3% of patients) and to discharges against medical advice before the end of the care protocol (46 cases among our cohort – 11.9% of patients without immediate life-threatening conditions). However, in cases of vital risk, (when the patient’s condition is compromised and the continuation of refeeding is urgently required), if the patient does not agree to the continuation of care, a legal procedure for compulsory treatment under French Law can be implemented in the unit. This procedure is developed in collaboration with the regional reference psychiatric center and implemented in our medical unit until the clinical state of the patient allows other modalities of treatment. In our cohort, 24 (6.2%) patients were affected by this procedure.
Some factors make hospitalization difficult for the patient including following the treatment plan, conforming to hospital regulations. Weight gain can be anxiogenic and patients frequently develop problematic physical activity.
In addition, AN patients admitted in the unit had frequent psychiatric comorbidities (refer to Table 1). Anxiety, depression and personality disorders were the most frequent disorders observed and were much more frequent than in less severe samples (22,23).
III.4.15. Discharge from the unit and continuation of care
When a patient leaves the zone of critical danger, and his clinical condition is stable, he can be discharged. The refeeding process should achieve a minimum BMI of 13. From then on, usually patients are transferred to an ED psychiatric unit to continue the refeeding process and initiate ED specialised therapies. This transfer is organized when the patient agrees. But some patients are unwilling to accept the transfer. When this occurs, there are two possibilities: if their clinical state is still critical, a compulsory treatment is implemented in the ED psychiatric unit; if not, they are discharged to ambulatory treatment. When the transfer takes place, it is preceded by a pre-admission consultation or 2 to 3-day hospital sessions in the designated psychiatric unit. Follow-up care can also be provided in a conventional psychiatric unit. In our cohort, 44% of patients benefited from a transfer to a psychiatric ward after their hospitalization in the unit (refer to table 5). In all cases, medical follow-up is organized in consultation and/or outpatient hospitalization in the clinical nutrition-ED- unit in RP hospital.
Table 5. Distribution of facilities receiving patients after discharge from the unit (N=386).
Facility receiving the patient after discharge from the unit
|
N (Percentage)
|
Home
|
169 (43.8 %)
|
General psychiatry
|
45 (11.7 %)
|
Psychiatric unit specialized in eating disorders
|
116 (30.1 %)
|
Medicine rehabilitation center
|
6 (1.5 %)
|
Nutrition rehabilitation center
|
8 (2.1 %)
|
Psychiatry Day Hospital
|
14 (3.6 %)
|
Endocrinology department
|
1 (0.3 %)
|
Surgical ward
|
4 (1%)
|
Psychiatric rehabilitation center
|
9 (2.3 %)
|
Internal medicine ward
|
3 (0.8 %)
|
Clinical nutrition unit
|
1 (0.3 %)
|
Home hospitalization
|
1 (0.3 %)
|
Obstetrics and gynecology department
|
2 (0.5 %)
|
Medical Intensive Care Unit
|
1 (0.3 %)
|
Death during the hospital stay
|
6 (1.5 %)
|