medical assessments in adolescence junior marsipan dr mark anderson
TRANSCRIPT
Medical Assessments in Adolescence
Junior MaRSiPAN
Dr Mark Anderson
Background
• 0.5% of adolescent females have anorexia nervosa
• 1-5% of adolescent females have bulimia nervosa
• 5-10% of eating disorders occur in males
• Early recognition and intervention are thought to improve outcome
Whose problem is it?
• Psychiatric disorder• Significant physical issues
– Starvation– Growth– Re-feeding syndrome – Long term sequelae
• Acute medical issues• Safety in community• Multi-disciplinary approach
What can paediatricians offer?
• Medical assessment– Junior MaRSiPAN– Determine “risk”– Investigations
• Admission– At risk– Medical complications– Risk of re-feeding syndrome– Break the cycle, relieve pressure
Newcastle routes of referral
• CYPS (CAMHS)
• GP
• Emergency department
• Mostly via myself
Initial assessment
• Full history and medical assessment• Blood tests and ECG
• Risk assessment according to Junior MaRSiPAN– Management of Really Sick Patients with
Anorexia Nervosa (Junior!)
Junior Marsipan Risk Assessment
• Semi-objective• Aims to give an overall assessment of risk• It is not:
– A scoring system– Validated to predict need for admission,
specific management or outcome• Needs to be seen as part of the gestalt of
assessment
Measurements
• Percentage median BMI– >85%– 80-85%– 70-80%– <70%
• Recent weight loss– No change– Up to 500g/week for 2 weeks– 500-999g/week for 2 weeks– >1kg for 2 weeks
Cardiovascular 1
• Heart rate (awake)– >60 bpm– 50-60 bpm– 40-50 bpm– <40 bpm
• Cool peripheries
Cardiovascular 2
• Blood pressure– Normal– <2nd centile– <0.4th centile
• Syncope– No symptoms– Presyncopal symptoms– Occasional syncope with postural drop in BP– Recurrent syncope with marked postural drop
Cardiovascular 3
• Arrhythmia– Normal– Irregular heart rhythm
• ECG changes– QTc <450ms– QTc <450ms and taking QT prolonging
medication– QTc >450ms– QTc >450ms and evidence of arrhythmia or
electrolyte disturbance
Other physiological parameters
• Hydration– Not dehydrated– Mild dehydration– Moderate dehydration or peripheral oedema– Severe dehydration
• Temperature– <36°C– <35°C
Biochemical abnormalities
– Hypophosphataemia– Hypokalaemia– Hyponatraemia– Hypocalcaemia
– Severe abnormalities of above
Calorie intake
• Moderate restriction or bingeing
• Severe restriction (<50% of requirement)• Purging
• Acute food refusal or <600kcal/day
Activity & exercise
• No uncontrolled exercise
• Mild uncontrolled exercise (<1h/day)
• Moderate uncontrolled exercise (1-2h/day)
• Severe uncontrolled exercise (>2h/day)
Muscular weakness
• SUSS test– No difficulty– Unable to get up without noticeable difficulty– Unable to get up without using arms– Unable to get up at all
Engagement with management plan
• Some insight and motivation, not ambivalent
• Some insight and motivation, but ambivalent
• Poor insight and motivation; parents unable to implement meal plan
• Violent when parents try to implement plan; parental violence
Co-morbidities
• Deliberate self harm
• Suicidal ideation
• Other major psychiatric co-diagnosis
Outcomes of medical assessment
• Mostly blue-green, no red– Outpatient follow-up
• More amber, or some red– Admission for period of assessment
• No definite “admission criteria”
Admission
• Decision re: feeding method• Dietitian input – daily• Set nursing guidance – obs, bed rest,
“rules”• Make plan with YP (and family)• Daily review – close medical monitoring• Regular input from CYPS• Plan discharge
What we have learnt…
• AN is very difficult• The illness makes it hard• Staff often feel manipulated• Nursing time is a major issue• 16-18 year olds fall through the gaps
Longer term issues
• General health• Bone health
Bones
• Low bone mineral density• Critical time
• Risk of later osteoporosis• Back pain • Chronic ill health
Bones
• Nutrition• Hypogonadism• Relative hypercortisolaemia• Low IgF1
• Weight and nutrition improve BMD• Residual defect left
Bones
• Possible options– OCP (high dose OE)– Bisphosphonates– Low dose OE– Transdermal OE– Calcium/Vitamin D
Toronto study 2011
• Randomised placebo controlled study• 40 girls normal weight - controls• 110 girls AN – randomised
– OE +– OE –
• OE transdermal 100mcg patch twice weekly OR escalating doses of oral OE 3.75mcg daily increasing over 18 months
• OE + given medroxyprogesterone 2.5 mg daily for 10 days every month
• OE – placebo patch and placebo medroxyprogesterone• Controls followed for 18 months no intervention• ALL had calcium carbonate and Vit D
Results BMD change
Results
• No change in weight• No change in lean body mass• No change in percentage fat mass• No change in BMI• No change in IgF1
Recommendations
• DEXA scan – ?when
• Commence OE replacement – ?when
– Who should do this/monitor progress– What happens >18 years of age– What about the boys?
Conclusions
• Acute management • Good liaison• Easy for <16 year old• Need to support 16-18 year olds• Long term input• Bones and future health
Questions?
• Junior MARSIPAN: MAnagement of Really Sick Patients under 18 with Anorexia Nervosa– College report CR 168, January 2012 RCPSYCH
• Norrington, Stanley, Tremlett, Birrell. Medical management of acute severe anorexia nervosa Arch Dis Child Educ Pract Ed 2012;97:48-54
• Physiologic Estrogen Replacement Increases Bone Density in Adolescent Girls With Anorexia Nervosa. Misra M, Katzman D, Miller K , Mendes N, Snelgrove D, Russell M, Goldstein, Ebrahimi M, Clauss L, Weigel T, Mickley D, Schoenfeld D , Herzog D, Klibanski A. Journal of Bone and Mineral Research, Vol. 26, No. 10, October 2011, pp 2430–2438