II.1. Study Design and Aims
The primary objective was to to describe the modalities of somatic and psychiatric care proposed to AN patients hospitalized in the clinical nutrition unit.
The secondary objective was to specify characteristics of AN patients hospitalized in the clinical nutrition unit: demographic, nutritional status, history of ED, care pathway. In order to do so, we conducted a monocentric retrospective observational study in the cohort of adult AN patients admitted to the clinical nutrition unit in RP hospital for severe malnutrition and/or complications of the ED.
II.2. Description of inpatient treatment and management
II.2.1. 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.
II.2.2. 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.
II.2.3. 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) (9). The existence of medical complications weighs in favor of instituting nutritional support therapy2. When a patient’s BMI is less than 12, artificial nutrition is proposed from the start (8) (9).
Assuming the patient has an accessible and intact digestive tract (which is true in most cases) (10), the choice of nutritional support is typically enteral nutrition (EN) administered via a small-caliber nasogastric tube as recommended (6,11). Parenteral nutrition is not used nor recommended in AN (12,13), except in cases where intestinal pathology makes EN impossible. PN exposes the patient to a risk of infectious, mechanical and metabolic complications (14) . Vomiting is not a contraindication to EN.
The good tolerance of EN (15), 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 (16) in AN malnourished patients.
EN is prescribed in the following manner:
- A standard polymeric product, isocaloric (providing 1kcal / ml), normoprotidic, without fiber is most often prescribed2
- In cases of impaired renal function or particularly in very low weight patients, a paediatric product less rich in protein is preferred2.
To improve its performance and clinical and metabolic tolerance, EN is administered in a continuous flow over 24 hours using a flow control pump2. When undernutrition is severe (BMI <12), refeeding is exclusively enteral in the first days2. An oral diet is gradually introduced later2 (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 (17). 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.
II.2.4. 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 (17) (18). 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.
II.2.5. 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 patient2. The reintroduction of food must be progressive, as under-nutrition is severe.
Protein foods are re-introduced last (after vegetables and carbohydrates)2, 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 dinner2.
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. It is recommended to interrupt EN if the oral intake is satisfactory when the BMI is around 14 kg/m (17).
II.2.6. 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 (6,19). 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 (20). 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) (21) (18).
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." (20)
- 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 (6,20)
- 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 (18)
- Comprehensive clinical monitoring with special attention to heart rate, edema and hydration status (18)
- Regular biological monitoring (initially daily) of blood glucose, creatinine, liver enzymes, plasma electrolytes, and phosphorus (6,20).
II.2.7. Psychotropic treatment
There is no specific psychotropic treatment for AN (6,22) 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 (22), 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 (24). 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.
II.2.8.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.
II.2.9. 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)
- 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.
II.2.10. 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.
II.2.11. 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 (20).
II.2.12. 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.
II.2.13. 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 all cases, medical follow-up is organized in consultation and/or outpatient hospitalization in the unit in RP hospital.
II.3.1. Inclusion criteria
We selected all patients hospitalized for the first time in the CNU in RP Hospital between November 1997 and January 2014, aged 15 years or older, diagnosed with AN according to the DSM IV criteria. The patient selection was provided by the hospital’s department of statistics and medical information.
II.3.2. Exclusion criteria
We excluded from the study any patients who did not allow the use of their data for the study.
II.3.3. Parameters studied
For each patient, we performed a retrospective chart review and we recorded demographic and anamnesic data. Type of AN (restrictive, “AN-R” or purging/binging, “AN-BP”), duration of disease, purging behaviours, history of hospitalization for AN were detailed. Anthropometric data on admission and on discharge were noted as were patient psychiatric comorbidities, referral, length of stay and any intercurrent events which occurred during hospital stay.
II.4. Procedures and ethical approval
This study was conducted in accordance with the relevant French guidelines and regulations. It is part of a mortality study for which protocol was approved by the French data protection authority (CNIL, Commission Nationale de l’Informatique et des Libertés) and by two independent review boards (CCTIRS, Comité Consultatif sur le Traitement de l’Information en matière de Recherche dans le domaine de la Santé and CPP, Comité de Protection des Personnes). An information letter was sent to all patients selected for the study. Patient non-opposition was a prerequisite for the use of their data. Written informed consent for publication was obtained.
II.5. Statistical analysis
Analyses were performed with R software (version 3.5.3. 2019-03-11, R Foundation for Statistical Computing Platform: x86_64-w64-mingw32/x64 (64-bit)). Univariate statistics were used to describe the sample. Data were expressed as frequencies and percentages for nominal variables, and as means ± standard deviations (SDs) for continuous variables.
 : Specific practice in the unit based on expert opinions (and not on standard feeding protocols)