The Early Nutritional, Psychological, and Medical Stabilization of Critically Ill Patients with Anorexia Nervosa


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Thursday, March 21, 2013: 9:00 AM-12:00 PM
Rabat A/B (Westin Lake Las Vegas Resort)
Handout

Background: Patients with the severest forms of anorexia nervosa often receive suboptimal early care. Complicated medical problems may overshadow patients’ early needs for expert nutritional and psychological engagement. In this case-based workshop, we discuss our multi-disciplinary approach, outlining strategies of tube-free nutritional rehabilitation, psychotherapeutic approaches, and fundamentals of definitive medical stabilization.

  1. Role of RD, Philosophy of providing medical nutrition therapy
    1. RD role: meal planning, management of caloric goals, nutrition education
    2. Main Focuses:
      1. Nourish the body
      2. Correct underlying macronutrient and micronutrient deficiencies
      3. Empower client to choose for self
      4. Introduce variety & some fear foods
    3. Management of low body weight complications
      1. Where to start kcals
      2. Protein vs fat vs carbohydrate, low Na, low fiber
      3. Allergies
    4. Role of labs
      1.  Prealbumin, albumin
      2. REE from indirect calorimetry
    5. Nutrition Education
      1. Objective outcomes from ED vs. nutrition
      2. Using indirect calorimetry to educate

II. Psychotherapy in inpatient medical setting

  1. Role of psychologist
    1. Support patients during adjustment to hospitalization
    2. Provide psychological insight to team regarding patient behaviors, strategies to address individual patient needs

B. Assessment of patient history of eating disorder and psychiatric/medical comorbidity

  1. Develop understanding of patient tolerances and personality to guide collaborative treatment planning for acute phase of treatment
  2. Assessment and adjustment of treatment modalities based on degree of cognitive functioning

C. Intervention

  1. Psychotherapy adapted as patients refeed
  2. Utility of individual IPT,  ACT , DBT, CBT, and occasionally insight orientation
  3. Comprehensive daily assessment for capacity and mental status

D. Utility of psychotherapy for the severely medically ill 

  1. Helps patients establish and practice boundaries, stabilize mood and manage anxiety, increase frustration tolerance, decrease behaviors, incorporate coping skills and mindfulness, increase understanding of the role of values
  2. Support patients as decisions are made regarding choice of treatment program or other care arrangements following medical stabilization

E. Outcomes

  1. Provides skills, structure for patients, fewer discharges against medical advice, more patients continuing on to treatment
  2. Patients arrive to treatment with a foundation that may help during initial adjustment period

III. Medical stabilization: Use of objective measures of illness to combat denial of disease and incentivize recovery

  1. Refeeding syndrome
  2. Pseudobartter syndrome aka detoxing off of laxatives
  3. Gastroparesis and constipation
  4. Osteoporosis
  5. Hypoglycemia
  6. Pancytopenia
  7. Liver abnormalities

Patients with the severest forms of anorexia nervosa often receive suboptimal care from medical, nutritional, and therapeutic providers.  This is due to the clinicians’ lack of familiarity with the myriad of comorbidities associated with profound starvation, with and without purging. Complicated medical problems may overshadow patients’ early needs for expert nutritional and psychological engagement, and may force patients into suboptimal early treatment experiences. In this case-based workshop, we discuss our multi-disciplinary approach to even the most critically ill patients with anorexia nervosa, outlining successful strategies of tube-free early nutritional rehabilitation, psychotherapeutic approaches, and fundamentals of definitive medical stabilization. Jennifer L. Gaudiani, MD, CEDS, the Assistant Medical Director of the ACUTE Center for Eating Disorders at Denver Health, and an Associate Professor of Medicine at the University of Colorado, will present the most important medical complications of severe starvation and purging, and how to achieve definitive medical stabilization. Susan Bennett, PhD, the staff psychologist for ACUTE, will review the utility, and indeed vitality, of early psychologic engagement even when  client is profoundly underweight. Amy Winkelman, the lead dietician for ACUTE and a licensed psychotherapist, will review the techniques used for early patient education and dietary planning, with the intent of minimizing physical symptoms from organ dysfunction as a result of severe underweight, establishing rapport with the patient, and allowing early nutritional rehabilitation in as natural a way as possible.

Primary Presenter:
Jennifer L. Gaudiani, MD, CEDS

Jennifer L. Gaudiani, MD, CEDS, is the Assistant Medical Director of ACUTE and is an Associate Professor of Medicine at the University of Colorado School of Medicine. She oversees the clinical, strategic, and administrative management of ACUTE, attends on the service, and maintains engagement with the patients when not attending clinically. Dr. Gaudiani completed her undergraduate work at Harvard College, earned her medical degree from Boston University School of Medicine, and completed her residency and chief residency in Internal Medicine at Yale. Dr. Gaudiani has lectured and published extensively on the medical complications of eating disorders.



Co-presenters:
Susan Bennett, PhD

Susan Bennett, Ph.D. is a clinical psychologist at the ACUTE Center for Eating Disorders at Denver Health Medical Center. Dr. Bennett earned her undergraduate degrees in Psychology and Organization Development at Regis University and her master’s and doctoral degrees at the University of Denver. Dr. Bennett is a specialist in eating disorders, as well as a mental health generalist. She has practiced in outpatient and inpatient settings for 10 years. Her research is in the field of health psychology, impulse control, and collaborative treatment planning. Dr. Bennett is a member of IAEDP and AED.



and Debbie Andersen, MS, RD

Debbie Andersen has a Bachelor of Science degree in Nutrition and Food Management from Oregon State University. Debbie completed a dietetic internship program and obtained a Master of Science degree in clinical nutrition through New York University. She has been a practicing Registered Dietitian (RD) since 2001. She has worked as one of the lead Clinical Dietitians for the A.C.U.T.E Centers for Eating Disorders at Denver Health Medical Center since the program started. Her specialties include eating disorders, critical care, and nutrition support.



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