Transcript (PPTX, 9.39MB)

2015
Three patients to see . . .
A. 24 year old female with multiple superficial
lacerations to left arm. Boyfriend called police,
apparently was in an argument and locked herself
in the bathroom threatening suicide. Brought by
police. The triage nurse has known her for years.
VS 78, 130/70, 22, O2 sat 97% pain 15/10. GCS=15.
B. 43 year old male fell off a ladder and had a brief
period of unresponsiveness. Awoke with moderate
headache and walked into the kitchen. 20 minutes
later his wife noted he seemed a bit confused and
staggered a bit walking to the living room. When he
didn’t seem to know where he was, she called the
ambulance. He is now insistent that he be allowed
to go home, gets up off the stretcher and pushes
away the nurse.
VS 68, 140/105, RR 12, O2 sat 94%, GCS=14.
B.
C. A 36 year old male presents with his wife, who says
that they are having difficulty at home. He is
demanding and argumentative, and his wife is
worried especially over money he has spent lately.
He has run out of medications and his family doctor
is away for two weeks. He hasn’t been sleeping
more than 1 or 2 hours per night. He has plans to
sell his business and start a new one. One night he
was out driving his car all night.
VS 110, 145/90, 20, O2 sat 97%, GCS=15.
1. Discuss the approach to the agitated
psychiatric patient.
2. Discuss the approach to the agitated
medical/ surgical patient.
3. Display knowledge of the appropriate therapeutic
choices for various scenarios.
4. Discuss the concept of “medical clearance”.
5. Display knowledge of suicide risk stratification.
6. Discuss the indications and contraindications for
emergency psychiatric consultation.
7. Display knowledge of involuntary commitment and the
legal aspects of this act.
8. Discuss the approach to and treatment of the anxious patient.
9. Knowledge of the differential diagnosis for confusion in the elderly.
 Managing Violent Patients
Acute Agitation:
Psychosis
Organic
Behavioral
Emergency Psychiatric Assessment Steps
Safety and stabilization
Identification of homicidal, suicidal, or
other dangerous behavior
Medical evaluation
Psychiatric diagnosis and severity
assessment
Psychiatric consultation
What are potential causes of agitation or violent behavior?
 Organic - deriving from medical disorders,
including substance abuse and other toxidromes.
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Drug/etoh withdrawal
Toxidromes
Endocrinopathies
Metabolic derangements
Substance abuse
Infections
Neurologic illness
 Psychotic – schizophrenic, manic, delusional.
 Non- organic, non-psychotic – personality
disorders, impulse control disorders.
Risk Factors for Violence
List some risk factors for violence:
 Previous history of violence
 Intoxication
 Paranoid delusions
 Drug/etoh withdrawal
 Personality Disorder
Taylor—psychosis vs violence
 The risk of being violent is raised by psychosis: what is the
likelihood that a violent episode is due to psychosis?
 95% to 99% of society’s violence must be explained otherwise.
 When violence is a problem, who is most at risk?
 immediate social circle of a patient with psychosis are most at risk.
 What are the 2 main routes by which psychosis is related to
violence?
1.
2.
Individuals unremarkable before the onset of illness and their
violence is driven by psychotic symptoms;
conduct, emotional difficulties and/or childhood abuse preceded
the psychosis; lifestyle and substance misuse may be more
prominent factors in the violence.
De-escalation Principles
 Perceived threat is a major driver
 Act as an advocate, not an adversary
 Make patient comfortable
 Create a therapeutic alliance
Recognize Agitation
Early
Escalating
 Tension
 Angry
 Hostility
 Pacing/restlessness
 Uncooperativeness
 Clenched fists
 Excitement
 Loud speech/shouting
 Poor impulse control
Prevention
 See them fast
 Disarm patient
 Private but not isolated bed
 Safe room= no weapons
 Keep door open
 Security nearby
 You and patient equidistant to door
 Safe you = no weapons
De-escalation Principles: CANIT
 C=Containment & Safety
 A=Assessment
 N=Nonviolent De-escalation
Techniques
 I=Intervention
 T=Takedown & Control
De-escalation 10 Techniques
 Respect personal
 Agree or agree to
space
 Don’t provoke pt.
 Establish verbal
contact
 Be concise
 Identify
wants/feelings
 Listen closely
disagree
 Set clear limits
 Offer choices and
optimism
 Debrief patient and
staff
PO Drugs
 Offers patient choice and control
 Strengthens the therapeutic alliance
 Preferred by patients
 Fast acting
 Benzos & Antipsychotics
Physical Restraint
 Systematic, consistent, protocol-driven and
practiced techniques are best.
 Preserve the physician- patient therapeutic
alliance where possible.
 Restraint team – at least 5 trained members and
an experienced leader.
 team should enter the room in unison.
 Leader moves to the head and other members
each take a limb.
Restraint Documentation
 Time limited order
 Patient’s presentation and reason for restraint,
including the potential danger to patients or others.
 The plan of care.
 Assess decision making capacity.
 Nursing notes:
 injuries
 frequent assessment
 vital signs,
 medical and behavioural status;
 readiness for discontinuation of restraint.
Really Agitated
 benzos still preferred, PO if possible
 Lorazepam
 0.5 – 2 IM/PO mg q 30 min.
 reliable IM absorption, no metabolites
 Consider midazolam
 quicker onset IM, lasts 45 mins.
 5 mg IM q 15 min
 haloperidol 5 mg + lorazepam 2 mg IM
 More rapid sedation
 Alternative:
 Olanzepine 10 mg IM
Delirium
84 year old female
 Brought in by daughter because she has is more
sleepy in the daytime than usual, not getting out
of bed as much, appetite is markedly decreased
 Says she feels quite well, but has a cough
 Daughter says she seems slightly confused off and
on in last three days.
Delirium
and
Dementia
Compare dementia & delirium
 Dementia—
 chronic
 impaired cognitive functioning in several areas, including
memory, abstract thinking, judgment, personality, and other
higher cortical functions such as language
 Delirium ==
 acute
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impairment in cognitive function &
clouding of consciousness, a reduction in the awareness of the
external environment (manifest as difficulty sustaining attention),
varying degrees of alertness ranging from drowsiness to stupor, and
sensory misperception
Delirium is Common!
 up to 70% of cases missed
 11%-42% of medical inpatients have delirium
 Increased mortality, readmission, complications,
falls, institutionalization, length of stay, aggression
 drugs are most common reversible cause of delirium
 especially anticholinergics, benzodiazepines and narcotics

diphenhydramine (Benadryl) associated with cognitive decline and
urinary retention in hospitalized elderly (also dimenhydrinate)
Two Types of Delirium
 25 % --Agitated
 usually identified
 Most: Hypoactive
 often missed
 higher mortality
Delirium Risk Factors
 Admission Characteristic vs Odds Ratio (95% Confidence Interval)
 Fracture
 Cognitive impairment
 Age >80
 Severe illness
 Age >65
 Infection
 Vision impairment
Neurohospitalist. 2013 October; 3(4): 194–202.
6.6 (2.2-19.3)
6.3 (2.9-13.7)
5.2 (2.6-10.4)
3.5 (1.5-8.2)
3.0 (1.2-7.7)
3.0 (1.4-6.1)
1.7 (1.0-2.8)
AEIOU M&M TIPS
Mnemonic for Delirium Etiology
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E - epilepsy (especially post-ictal)
I - infection
O - oxygen (hypoxia)
U - uremia
M - myocardial infarction
& - anesthesia
M - metabolic
T - trauma/fracture
I - Insulin
P - polypharmacy
S - stroke
All cases of
Delirium require
investigation for
underlying
organic cause
Mental Status and
Mini-Mental State Examinations
Behavior
What is the patient doing?
Affect
What feelings is the patient displaying?
Orientation
Does the patient know what is happening, where, and when?
Language
Is the patient understanding and being understood?
Memory
Can the patient recall historical details, recent and remote?
Thought content
Is the patient reporting beliefs that make little sense?
Perceptual abnormalities Is the patient experiencing unusual sensory phenomena?
Judgment
Is the patient able to make rational decisions?
MMSE: Cognitive testing
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the MMSE consists of a series of tasks that assess
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orientation,
immediate and short-term memory,
attention,
calculation,
language,
visual construction.
A score of 23 or less (out of a maximum possible of 30) = cognitive impairment.
Confusion Assessment Method (CAM)
Shortened version
A.
Acute onset
and
Confusion Assessment Method
Fluctuating course
CAM
CAM
for
delirium
The diagnosis of delirium by CAM requires the presence of BOTH features A and B
B.
Inattention
Is there evidence of an acute change in mental
status from patient baseline?
Does the abnormal behavior:
come and go?
fluctuate during the day?
increase/decrease in severity?
Does the patient:
have difficulty focusing attention?
become easily distracted?
have difficulty keeping track of what is said?
AND the presence of EITHER feature C or D
C.
Disorganized
thinking
Is the patient’s thinking
disorganized
incoherent
For example does the patient have
rambling speech/irrelevant conversation?
unpredictable switching of subjects?
unclear or illogical flow of ideas?
D.
Altered level of
consciousness
Overall, what is the patient’s level of
consciousness:
alert (normal)
vigilant (hyper-alert)
lethargic (drowsy but easily roused)
stuporous (difficult to rouse)
comatose (unrousable)
Adapted with permission: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The
Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948.
Confusion Assessment Method: Training Manual and Coding Guide, Copyright 2003, Hospital Elder Life Program, LLC.
Delirium in the Older Person: A Medical Emergency. (2006). VIHA
CAM.v3 Reviewed 2012.
www.viha.ca/mhas/resources/delirium/
Prevention
 nonpharmacological intervention may prevent
delirium in hospitalized older patients
 education of family members about delirium,
presence of clock, calendar, familiar objects,
glasses in patient's room, reorientation of patient
by family members, and extended visitation times
 Reduced delirium (NNT 13), falls

Age Ageing 2012 Sep;41(5):629
Delirium in Elderly Dementia
 Training, environmental intervention by
guideline decreases use of restraints, increases
family & patient satisfaction.
 Antipsychotic use increases mortality
 No clear benefit to any medication interventions
Geri-EM Education Program
Delirium Rx
 Support:
 Quiet room, low lights, familiar people/ objects,
re- orientation.
 Avoid physical restraints.
 Low dose haldol or risperidone . Treat pain, cause.
 Caution re: drugs in elderly dementia—risk vs
benefit
 Increased mortality with antipsychotics
 Benzos and anticholinergics can worsen sx.
 No evidence cholinergics work
Two patients to see . . .
 Case 1. Police bring in a 43-year-old male to the
ED after he threatened to kill his wife and then
shoot himself. He insists that he just “lost his
cool” but now feels better and wants to leave. He
lost his job and has been drinking more heavily in
the past couple months leading to arguments.
 Case 3: 23 year old female complains of chest
pains, palpitations, dizziness, nervousness and
tremors over the past several months. Says family
doctor not listening to her.
Clinical Assessment in the ED
Clinical Assessment of the Patient with Suicide Risk
1. Medical history
2. Psychiatric history
3. Suicidal behavior history (previous attempts)
4. Substance use history
5. Psychosocial history --life stressors, impulsivity, aggression, relationships
6. Family psychiatric history to include history of suicide
7. Physical examination
8. Mental status examination (MSE)
9. Relevant laboratory tests
10. Drug inventory, including over-the-counter (OTC) drugs and supplements
Anxiety Disorders
 Panic/Agoraphobia
 GAD
 Phobias
 OCD
 ASD/PTSD
Anxiety
Shearer SL. Recent Advances in the Understanding and Treatment of Anxiety Disorders. Prim Care Clin Office Pract 34(2007) 475.
•
•
•
•
•
•
most common mental health disorders,
more prevalent than both affective and substance abuse disorders.
1-year prevalence 16%
lifetime prevalence is 28.8%
median age of onset among mood disorders (age 30),
median age of onset among anxiety disorders is much younger (age
11).
Anxiety disorders can adversely affect quality of life, mobility,
education,
employment, social functioning, health care, and physical well being.
•
a primary anxiety disorder often contributes to secondary
depression or substance abuse.
•
comorbidity with physical conditions associated with poor quality of
life and disability.
•
Anxiety disorders impose a societal economic burden comparable
with the cost of depression
Generalized Anxiety Disorder
 GAD is the anxiety disorder linked to the highest
frequency (35.6%) of self-medication with alcohol
and drugs,
 associated with greater comorbidity and suicidality
 in one sample, 87% of primary care patients with
GAD did not present with the complaint of
anxiety or worry;
 most had nonspecific somatic complaints (eg,
insomnia, head/muscle aches, fatigue, GI Sx)
Panic Disorder/ Agoraphobia
Treatment
Patient Education important!
Feelings vs cognition
Cognitive Behavioral Therapy
True remission of panic disorder with high functioning
occurs in 50% to 70% of patients who receive CBT
SSRIs, SNRI’s
highly effective compared with placebo
high rate of discontinuation syndrome
Benzodiazepines are considered second-line or adjunctive
treatment
• failure to address frequent comorbid depression,
• tolerance or abuse potential,
• effects on driving, and
• possible deleterious effects on cognitive–behavioral
treatment (CBT), especially with as-needed use
Switch: nonresponder to CBT, SSRI trial may work, & vice versa
Acute intervention
 Anxiety—avoidance—relief cycle
 Face fears—cognitive reframing & education
 Normalize feelings vs cognition
 Teach patience & ability to delay and reflect vs react
 “Wagon wheel in a rut”
 Positive messages need repetitive reinforcement &
support
Depression vs Anxiety
Major Depressive Disorder
 Insomnia/ sleep disturbance
 Anhedonia
 Depressed mood
 Suicidal thoughts
 BHP 9 tool
 Time
 (SAD PERSONS mnemonic)
Comorbid—Medical Illness
Cafarella, et al Treatments for anxiety
and depression in patients with chronic
obstructive pulmonary disease: A
literature review. Respirology 2012. 17:
627.
COPD
How do YOU
Treat
Depression?
Treat:
• to bear oneself toward : use <treat a horse
cruelly>
• to care for or deal with medically or surgically
<treat a disease>
Spirito A. CognitiveBehavioral Therapy for
Adolescent Depression and
Suicidality
Child Adolesc Psychiatric Clin N
Am 20 (2011) 191–204
NNT=4
Hollon S. et al Effect of Cognitive Therapy
With Antidepressant Medications vs
Antidepressants Alone on the Rate of Recovery
in Major Depressive Disorder A Randomized
Clinical Trial
JAMA Psychiatry. doi:10.1001/jamapsychiatry.2014.1054
online Aug 20, 2014
Cuijpers P Combined pharmacotherapy and
psychotherapy in the treatment of mild to
moderate major depression?
JAMA Psychiatry 2014;71(7):747-8
Management: Depression
 CBT—as effective as Psychopharm
 Start in mild to moderate
 May need reduction of symptoms first in severe
depression
 Psychopharmaceutical
 SSRI: first line (caution in Bipolar illness)
 SNRI
 Caution re benzodiazepines
Simkin D, Black N. Meditation and Mindfulness in Clinical Practice Child Adolesc Psychiatric Clin N Am 23 (2014) 487–534
Miller. Neuroanatomical Correlates of Religiosity and Spirituality. JAMA Psychiatry, 2013; 1 DOI:
10.1001/jamapsychiatry.2013.306
Rasic, D et al. Longitudinal relationships of religious worship attendance and spirituality with major depression, anxiety
Williams N et al.
Interventional psychiatry: how
should psychiatric educators
incorporate neuromodulation into
training? Acad Psychiatry. 2014
Apr;38(2):168-76.
Nyer M What is the Role of AlternativeTreatments in Late-lifeDepression?
Psychiatr Clin N Am 36 (2013) 577–596
Yinger, el al. Music Therapy and Music Medicine for Children and
Adolescents Child Adolesc Psychiatric Clin N Am 23 (2014) 535–553
Gow R, Hibbeln J.
Omega-3 Fatty Acid and
Nutrient Deficits in
Adverse
Neurodevelopment and
Childhood Behaviors
Child Adolesc Psychiatric Clin N
Am 23 (2014) 555–590
X
Popper CW.
Single-Micronutrient
and Broad-Spectrum Micronutrient Approaches for Treating
Mood Disorders in Youth and
Adults
Child Adolesc Psychiatric Clin N Am 23
(2014) 591–672
Diamond, P et al. Ketamine infusions for treatment resistant depression: a series of 28
patients treated weekly or twice weekly in an ECT clinic J Psychopharmacol June 2014 28: 536544
Price R et al Effects of ketamine on explicit and implicit suicidal cognition: a randomized
controlled trial in treatment-resistant depression. Depression and Anxiety 31:335–343, 2014
Ketamine had a rapid antidepressant effect in
some patients with severe depression
http://www.scientificamerican.com/article/is
-ketamine-next-big-depression-drug/
https://itunes.apple.com/us/app/safe
ty-plan/id695122998?mt=8
SAFETY PLAN
SAFETY PLAN
I will cope, calm & soothe myself by:
I will cope, calm & soothe myself by:
I will tell myself:
I will tell myself:
I will call:
I will call:
I will go to:
I will go to:
SAFETY PLAN
SAFETY PLAN
I will cope, calm & soothe myself by:
I will cope, calm & soothe myself by:
I will tell myself:
I will tell myself:
I will call:
I will call:
I will go to:
I will go to:
SAFETY PLAN
SAFETY PLAN
I will cope, calm & soothe myself by:
I will cope, calm & soothe myself by:
I will tell myself:
I will tell myself:
I will call:
I will call:
I will go to:
I will go to:
SAFETY PLAN
SAFETY PLAN
I will cope, calm & soothe myself by:
I will cope, calm & soothe myself by:
I will tell myself:
I will tell myself:
I will call:
I will call:
I will go to:
I will go to:
http://www.therapistaid.com/therapyworksheet/safety-plan/suicide/none
Mental Health & Suicide
 Over 90% of suicide victims have a mental health
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and/or substance use disorder
50-75% receive inadequate treatment
Risk increased in Mood Disorders, Anxiety Disorders,
PTSD, and comorbid states with medical illness
Highest in elderly
3rd most common cause of mortality in young adults
Independent of diagnosis, targeting and treating
suicidal ideation and behaviors may have benefit.
Suicidal Continuum
 Best identified before any suicidal behavior occurs.
 Early identification of suicidal ideation presents the
greatest opportunity to reduce the risk of suicide
attempt and death.
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Continuum begins with suicidal thoughts,
evolving into a wish to die,
consolidated into an intention to act,
resulting in a methodology or plan formulated to end
one’s life.
 The evolution of these steps can occur over minutes
or years.
 Each step along the continuum presents an
opportunity to intervene and prevent the act of
suicidal self-directed violence.
Treatment Targets
 Brent D et al. The Treatment of Adolescent Suicide
Attempters Study (TASA): Predictors of Suicidal
Events in an Open Treatment Trial J. Am. Acad.
Child Adolesc. Psychiatry, 2009;48(10):987-996
 suicidal ideation,
 family cohesion,
 sequelae of previous abuse.
 “40% of events occurred with 4 weeks of intake: an
emphasis on safety planning and increased
therapeutic contact early in treatment may be
warranted”
 Wren et al: concept of multiple risk intervention
 Safety Box concept IFEM Hong Kong
Suicide Assessment:
SAFE-T
Direct Warning Signs
Three signs with highest likelihood of suicidal
behaviors in the near future:
Suicidal communication - writing or talking about suicide, wish to die, or
death (threatening to hurt or kill self))
• Seeking access or recent use of lethal means: such as weapons,
medications, or other lethal means
• Preparations for suicide - evidence or expression of suicide intent, and/or
taking steps towards implementation of a plan. Makes arrangements to divest
responsibility for dependent others (children, pets, elders), or making other
preparations such as updating wills, making financial arrangements for paying
bills, saying goodbye to loved ones, etc.
Worse with a history of previous or multiple attempts
Suicide Risk
Assessment &
Action
† Modifiers that increase the level of risk for suicide of any defined level :
• Acute state of Substance Use: Alcohol or substance abuse history is associated with impaired
judgment and may increase the severity of the suicidality and risk for suicide act
• Access to means :(firearms, medications) may increase the risk for suicide act
• Existence of multiple risk factors or warning signs or lack of protective factors
†† Evidence of suicidal behavior warning signs in the context of denial of ideation should call for concern
(e.g., contemplation of plan with denial of thoughts or ideation)
1. Ideation Questions
Example of Questions on Ideation:
• “With everything that has been going on, have you been
experiencing any thoughts of killing yourself?”
• When did you begin having suicidal thoughts?
• Did any event (stressor) precipitate the thoughts?
• How often do you have thoughts of suicide?
• How long do they last?
• How strong are the thoughts of suicide?
• What is the worst they have ever been?
• What do you do when you have these (suicidal) thoughts?
• What did you do when they were the strongest ever?
• Do thoughts occur or intensify when you drink or use drugs?
2. Intent Questions
Example of Questions on Intent:
• Do you wish you were dead?
• Do you intend to try to kill yourself?
• Do you have a plan regarding how you might kill
yourself?
• Have you taken any actions towards putting that
plan in place?
• How likely do you think it is that you will carry
out your plans?
3. Preparatory Behavior Questions
(may need collateral hx)
Examples of Questions on Preparation:
• Do you have a plan or have you been planning to kill yourself?
If so, how would you do it? Where would you do it?
• Do you have the (drugs, gun, rope) that you would use?
Where is it right now?
• Do you have a timeline in mind for killing yourself?
• Is there something (an event) that would trigger acting on the
plan?
• How confident are you that your plan will end your life?
• What have you done to begin to carry out the plan?
• Have you made other preparations (e.g., updated life
insurance, made arrangements for pets)?
Safety Plan
Component of Safety Plan:
The Safety Plan should consist of a written, prioritized list of coping
strategies and sources of support that patients can use to alleviate a
suicidal crisis.
Patients are instructed first to recognize when they are in crisis (Step 1)
and then to utilize Steps 2 through 5 as needed to reduce the level of
suicide risk:
1. Recognizing warning signs of an impending suicidal crisis
2. Employing internal coping strategies
3. Utilizing social contacts and social settings as a means of distraction
from suicidal thoughts
4. Utilizing family members or friends to help resolve the crisis
5. Contacting mental health professionals or agencies
6. Restricting access to lethal means.
Safety
PLan
Suicide Focused Therapy
 Suicide-focused psychotherapies that have been
shown to be effective in reducing risk for repeated
self-directed violence should be included in the
treatment plan of patients at high risk for suicide,
if the risk for suicide is not adequately addressed
by psychotherapy specific to the underlying
condition.
Goals of Consultation
& Hospitalization
 Diagnostic Clarification
 Treatment initiation
 Maintenance of Safety
 Note Risk vs Benefit: regression, damage to
therapeutic alliance
Benzodiazepines in Suicidal Risk
• Use caution when prescribing benzodiazepines
to patients at risk for suicide.
• It is important to pay attention to the risk of
disinhibition from the medication, and respiratory
depression (particularly when combined with
other depressants) by limiting the amount of
benzodiazepines dispensed.
• Avoid benzodiazepines with a short half-life and
the long-term use of any benzodiazepine to
minimize the risk of addiction and depressogenic
effects.
Depression and Suicide in Children and Adolescents
Can send home if:
The patient is not imminently suicidal.
The patient is in medically stable condition.
The patient and the parents agree to return to the ED if suicidal intent
recurs.
The patient is not intoxicated, delirious, or demented.
Potentially lethal means of self-harm have been removed.
Treatment of underlying psychiatric diagnoses has been arranged.
Acute precipitants to the crisis have been addressed and attempts
have been undertaken to resolve them.
The physician believes that the patient and family will follow through
on treatment recommendations.
The patient's caregivers and social supports are in agreement with the
discharge plans.
Borderline PD
 mood instability, impulsivity, aggressivity and
prone to intense anger.
 Tendency toward self injury.
 Major risk factor for suicide.
 Associated with as many as 55 % of attempted
suicides.
 More likely to make repeated attempts than
actually complete one.
Anorexia nervosa

Refusal to maintain weight within a normal
range for height and age (>15% below ideal body
weight)
 Fear of weight gain
 Severe body image disturbance in which body
image is the predominant measure of self worth
with denial of the seriousness of the illness
 In females, secondary amenorrhea for greater
than three cycles or primary amenorrhea
Eating Disorder Questions--SCOFF
1. Do you make yourself Sick because you feel
2.
3.
4.
5.
uncomfortably full?
Do you worry you have lost Control over how
much you eat?
Have you recently lost more than One stone (6.4
kg or 14 lb) in a 3-mo period?
Do you believe yourself to be Fat when others say
you are too thin?
Would you say that Food dominates your life?
Eating Disorders Complications
Cachexia
Loss of subcutaneous fat
Impaired cell-mediated immunity
Neurologic complications
Muscle wasting
Peripheral neuropathy
Hypothermia
Seizures
Pitting edema
Wernicke encephalopathy
Dehydration
Cortical atrophy
Starvation ketosis
Growth retardation
Euthyroid sick syndrome
Dermatologic complications
Osteopenia and fractures
Dry, brittle hair and nails
Primary or secondary amenorrhea
Lanugo
Cardiac complications
GI complications
Bradycardia
Delayed gastric emptying
Orthostatic hypotension
Fatty liver infiltration
Arrhythmia
Metabolic complications
Prolonged QTc interval
Electrolyte abnormalities
Conduction abnormalities
Ketonuria
Mitral valve prolapse
Impaired glucose control
Pericardial effusion
Bone marrow suppression
Anemia
Leukopenia
Thrombocytopenia
Suicide is one of the
leading causes of death
for patients with
anorexia.
Involuntary Admission
 Involuntary hospitalization is considered when:
 The patients words or behaviours suggest that they
are at imminent risk of harm to themselves or
others,
 There is a mental health illness
 Specific guidelines are governed by individual
provinces/ states.
 Is not a determination of competency
Questions?