MARSIPAN – Management of
Really Sick Patients with
Anorexia Nervosa
Royal College of Psychiatrists and
Royal College of Physicians – Oct
2010
Why written?
• AN patients on
general medical
wards don‟t always do
very well
• Some confusion over
respective roles
• Guidance to primary
care over when to
refer (no GP on task
group)
Recognition and awareness
• “Patients with anorexia nervosa can seem deceptively
well – they may have an extremely powerful drive to
exercise which sometimes seems to override their lack
of nutritional reserve...”
• Patients can deteriorate very quickly.
• Any patient with weight loss with or without amenorrhoea
may have AN, especially of there are signs of weight
preoccupation, lack of concern about weight loss or
compensatory behaviours such as vomiting.
• Differential diagnosis includes depression and infectious
mononucleosis.
Observations and tests
BMI Blood tests
• Anorexia 450ms)
• Nonspecific t-wave changes
• Hypokalaemic changes
Refeeding
• Rapid re-feeding may precipitate
electrolyte changes – would need daily
bloods (no GP on the panel…)
Compulsory admission and
treatment
• Presence of a mental disorder (e.g. anorexia)
• In-patient treatment is appropriate (for re-
feeding)
• The condition presents a risk to the health and
safety of the patient
“Under the MHA, feeding is recognised as
treatment for anorexia nervosa and can be done
against the will of the patient as a life-saving
measure.”
Time for discussion…
Our invisible addicts
First Report of the Older
Persons‟ Substance Misuse
Working Group of the Royal
College of Psychiatrists
College Report CR165
22 June 2011
The rationale
• Between 2001 and 2031, there is projected to be a 50%
increase in the number of older people in the UK.
• The percentage of men and women drinking more than
the weekly recommended limits has also risen, by 60%
in men and 100% in women between 1990 and 2006
(NHS Information Centre, 2009a).
“Given the likely impact of these two
factors on health and social care
services, there is now a pressing
need to address substance misuse
in older people.”
Key issues (1)
• Mortality rates linked to drug and alcohol use are higher
in older people compared with younger people
• High rates of mental health problems in older people
(including a high prevalence of cognitive disorders) result
in frequent, complex psychiatric comorbidity
accompanying substance use disorders
• Concurrent medications – interactions
• Older people use large amounts of prescription and
over-the-counter medication and rates of misuse (both
intentional and inadvertent) are high, particularly in older
women
Key issues (2)
• Older men are at greater risk of developing alcohol
problems than older women.
• Physical health problems and the long-term prescription
of medication (especially hypnotics, anxiolytics and
analgesics) are important factors in the development of
substance misuse in older people
• Psychiatric comorbidities of substance misuse are
common in older people (including intoxication and
delirium, withdrawal syndromes, anxiety, depression and
cognitive changes/dementia)
• Among older people, psychosocial factors (including
bereavement, retirement, boredom, loneliness,
homelessness and depression) are all associated with
higher rates of alcohol use
So what do they suggest?
• Older people with substance use problems
have high levels of unmet need. GPs
should screen every person over 65
years of age for substance misuse as
part of a routine health check, using
specific tools such as the Short Michigan
Alcoholism Screening Test – Geriatric
version (SMAST-G); screening should also
incorporate cognitive testing using tools
such as the Mini-Mental State Examination
(MMSE)
…and the bit that hit the
headlines…
• Because of physiological
and metabolic changes
associated with ageing,
the upper „safe limit‟ for
older people is 1.5 units
per day or 11 units per
week
• In older people, binge
drinking should be
defined as >4.5 units in a
single session for men
and >3 units for women
What do you think?
Public health priority?
or
Nanny state gone mad?