Psychiatric Bulletin (2007) 31: 209-211. doi: 10.1192/pb.bp.106.009878
© 2007 The Royal College of Psychiatrists
Risks and pitfalls for the management of refeeding syndrome in psychiatric patients
Marco Catani, Lecturer in Psychological Medicine and Neuropsychiatry and Honorary
Specialist Registrar
Institute of Psychiatry, De Crespigny Park, London SE5 8AF, email:
m.catani{at}iop.kcl.ac.uk
Roger Howells, Consultant Psychiatrist
Sloane Court Practice, London SW3 4TD and Research Associate, Institute
of Psychiatry, London SE5 8AF
Declaration of interest
None.
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Abstract
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AIMS AND METHOD
We present two patients who developed refeeding syndrome following
admission to a general psychiatry ward. The practical implications of
assessing and managing medical consequences in patients with mental illness
who start refeeding after a period of starvation are discussed.
RESULTS
Patients presented with overlapping clinical manifestations of mental
illness and refeeding syndrome that were difficult to recognise and
manage.
CLINICAL IMPLICATIONS
Awareness of refeeding syndrome in patients with mental illness may prevent
fatal physical complications.
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Introduction
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Refeeding syndrome can be defined as severe electrolyte and fluid shift
associated with metabolic abnormalities in patients with malnutrition
undergoing realimentation, whether orally, enterally, or parenterally
(Crook et al, 2001).
Historically, refeeding syndrome was first described in starving wartime
prisoners and victims of famines
(Schnitker et al,
1951). More recently this syndrome has been well documented in
surgical and oncology patients undergoing parenteral nutrition
(Crook et al, 2001;
Hearing, 2004). In psychiatry,
refeeding syndrome occurs in people with eating disorders and alcoholism
(Cumming et al, 1987),
but it is often missed in other psychiatric patients where malnutrition is
relatively common. Up to 50% of patients admitted to acute psychiatric wards
are at risk of malnutrition (Abayomi &
Hackett, 2004). This can be extreme in the context of
self-neglect, alcohol and drug dependency, depression, schizophrenia and
dementia (Gray & Gray,
1989). The consequences of missing a diagnosis of refeeding
syndrome in these patients may be serious, as complications range from
neurological disability (for example Wernicke-Korsakov syndrome) to metabolic
complications (for example hypophosphataemia) and death
(Crook et al, 2001).
We describe refeeding syndrome in two patients routinely admitted to a general
psychiatric ward and illustrate the potential pitfalls in the prevention,
diagnosis and management of severe malnutrition and refeeding complications in
patients with mental illness.
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Case report 1
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A 60-year-old White man was transferred from a medical ward after being
admitted with severe dehydration and malnutrition associated with a major
depressive episode and suicidal ideation. He had stopped eating completely for
3 weeks after about 4 months of eating poorly, but had continued to drink
water up to a few days before he was found unconscious at home by a neighbour.
Rehydration and refeeding were begun and he was started on vitamin
supplementation and potassium chloride. He was admitted to a general
psychiatric ward on the fifth day when the depression was treated with 75 mg
venlafaxine daily. Physical examination revealed diplopia, ataxia with severe
muscle weakness and peripheral oedema. Despite a weight of 81 kg on admission
(BMI=24) he stated that he had lost 20 kg in 4 months. During his stay in
hospital his weight increased to 89 kg in 2 weeks (BMI=27). An
electrocardiogram on the third day of hospitalisation showed a tachycardia of
98 beats per minute and was low voltage. The phosphate level fell to 0.36
mmol/l, and the haemoglobin fell to 8.4 g/dl (see
Fig.1). A specific diet for
hypophosphatemia was instigated and the patient was screened for possible
gastrointestinal bleeding - faecal occult blood and full endoscopy were
normal. His recovery was uneventful.
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Case report 2
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A 54-year-old African-Caribbean man was transferred to a general
psychiatric ward following medical admission for collapse at home. He had
systematised persecutory delusions which had prevented him from eating for 5
weeks. He had no past psychiatric history. He had a past history of muscle
pain for which he took simple analgesics. On admission he weighed 57 kg
(BMI=19). Following realimentation he developed diplopia associated with
bilateral horizontal nystagmus and palsy of the right sixth cranial nerve.
Generalised weakness and ataxic gait were noticed. Examination of the abdomen
revealed mild hepatomegaly and tenderness in the right hypocondrium. Diagnoses
of delusional disorder and Wernicke’s encephalopathy were made. He was
treated with parenteral thiamine for 7 days and 5 mg olanzapine daily. He had
been cooperative and was allowed to start refeeding without any particular
dietary restriction. On admission, routine blood tests were normal but on the
fourth day the phosphate levels were markedly reduced at 0.26 mmol/l. The
phosphate levels returned to normal without adverse medical complications,
except for an acute anaemia - haemoglobin levels fell from 13.3 to 10.1 g/dl
(see Fig. 1). The patient
refused further investigations for the anaemia.
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Discussion
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Psychiatric training has traditionally emphasised the importance of
identifying and effectively treating Wernicke’s encephalopathy in
patients with alcohol dependency. However, it is important to be aware of
other serious consequences of refeeding in patients with malnutrition, such as
electrolyte imbalance, in particular hypophosphataemia, and acute anaemia.
During refeeding, a shift from fat to carbohydrate metabolism occurs (see
Fig. 2;
Crook et al, 2001). A
glucose load stimulates insulin release, causing increased cellular uptake of
glucose, phosphate, potassium, magnesium and water, and protein synthesis.
Severe hypophosphataemia may cause a deficit in adenosine triphosphate (ATP)
and 2,3 diphosphogycerate synthesis with widespread neuromuscular and
haematolgical consequences (Mallet,
2002). Thiamine deficiency occurs due to increased cellular
utilisation of thiamine in response to carbohydrate refeeding and is
associated with the precipitation of Wernicke’s encephalopathy, and the
potential development of Korsakov syndrome with its attendant lifelong
neuropsychiatric disability.
As in the two case reports presented a range of clinical events may go
unrecognised. (See Fig. 3 for
clinical representations of refeeding syndrome.) Severe hypophosphataemia is a
prime feature, and usually this is what alerts the clinician. The other facets
to the metabolic disorder include thiamine and other vitamin deficiencies,
hypokalaemia, hypomagnesaemia, as well as glucose and fluid balance
abnormalities (Crook et al,
2001). The severe hypophosphataemia may present with
rhabdomyolysis and cardiomyopathy. It may cause epilepsy, delirium and
paraesthesia (Knochel, 1981).
Haemolysis and platelet dysfunction are rare complications that usually follow
severe hypophosphatemia (Jacob &
Amsden, 1971; Knochel,
1981), although in the two cases we described haemolytic anaemia
followed moderate reduction of phosphate levels. The exact mechanism is
unknown but probably is due to increased rigidity of membranes
(Jacob & Amsden, 1971) and
metabolic acidosis induced by reduced levels of ATP
(Knochel, 1981). Hypokalaemia
may be associated with the development of cardiac arrhythmias, hypotension,
and cardiac arrest. It may also cause ileus, weakness, paralysis, delirium and
rhabdomyolysis. Hypomagnesaemia when severe may cause potentially fatal
cardiac arrhythmias as well as neuromuscular symptoms, ataxia, epilepsy and
delirium. Fluid intolerance in refeeding syndrome may result in cardiac
failure, dehydration or fluid overload, hypotension, pre-renal failure and
sudden death. Abnormal glucose and lipid metabolism can potentially trigger
hyperglycaemia and hypercapnic respiratory failure
(Crook et al,
2001).
The lack of understanding and recognition of refeeding syndrome may result
in psychiatrists and psychiatric nurses considering physical complications of
this syndrome such as fatigue, ataxia, paresthesias and delirium to be a
manifestation of mental illness. Blood tests should be taken before and after
refeeding to monitor haemoglobin, plasma electrolytes (in particular sodium,
potassium, phosphate, and magnesium), glucose, alanine aminotransferase,
aspartate aminotransferase, creatinine phosphokinase. Laboratory findings such
as raised creatinine phosphokinase and hypophosphataemia, if detected, can be
wrongly attributed to neuroleptic malignant syndrome
(Harsch, 1987).
| Box 1. Practice points in the management of refeeding syndrome in
patients with mental illness
- Malnourishment is common in subjects with anorexia and alcoholism but also
in depression, schizophrenia and elderly patients with cognitive
impairment
- An increase in appetite is usually considered a good prognostic factor in
patients with psychiatric disorders who are malnourished. For this reason
nutritional repletion is usually encouraged in acute psychiatric wards and
other psychiatric settings. However, it should be planned with the help of a
dietician
- Refeeding syndrome is a largely unrecognised cause of Wernicke’s
encephalopathy, epileptic seizures, and cardiac and respiratory failure in
psychiatric patients with low body weight. It has the potential to cause
sudden death
- Refeeding syndrome may start through the positive impact of psychotropic
medication and the ward milieu before the ward staff have properly considered
the potential development of refeeding syndrome
- The clinical manifestations of mental illness and refeeding syndrome
overlap; emergent symptoms of refeeding syndrome may be misattributed to
mental illness
- Blood tests may be normal on admission, and should be taken serially
- Psychotropic medications may contribute to complications of refeeding
syndrome such as rhabdomyolysis, hypotension, arrhythmia, seizures, and
hypophosphataemia
- The management of refeeding syndrome in psychiatric patients may be
challenging through their potential non-cooperation with blood tests,
intravenous infusions or nutritional restrictions; prevention is therefore
paramount
- Standardised management protocols that take into account the special
circumstances of patients with psychiatric disorders are required
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Psychotropic drug treatment, which can stimulate appetite, may increase the
risk of refeeding syndrome being precipitated and aggravate electrolyte
imbalance.
The management of refeeding syndrome has been described using intravenous
phosphate regimens and parenteral thiamine
(Faintuch et al, 2001;
Hearing, 2004). However there
is a lack of consensus as to who should be treated, how, and where, but it
would seem important that hospital nutrition teams should be involved early
(Hearing, 2004). Patients with
mental illness may refuse physical investigation, and fail to adhere to
dietary restrictions. Close liaison between medical and psychiatric teams is
required.
It is not uncommon for psychiatric in-patients not to be weighed, and for
the significance of nutritional assessment not to be understood. However the
first case we present illustrates that a refeeding syndrome can occur with an
apparently normal body weight and highlights the importance of taking a
detailed history.
Psychiatrists and mental health workers require specific training in this
area (see Box 1), and textbooks
of psychiatry and guidelines will need to include reference to refeeding
syndromes in psychiatric patients who are malnourished.
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Top
Abstract
Introduction
- - - Case 1, phosphate; - - -
- - - Case 1, haemoglobin;
—
— Case 2, phosphate; —
— Case 2,
haemoglobin).
