22. Mental health
Ursula Philpot
LEARNING OBJECTIVES
By the end of this chapter the reader will be able to:
• Give an overview of the key drivers, stakeholders and changes to mental health services;
• Critically discuss the changing role of the dietitian within mental health services;
• Critically evaluate the key issues in assessment, communication and treatments in serious mental illness and eating disorders; and
• Critically discuss some of the ethical and legal issues involved in treating mental illness.
Outlines
The area of mental health (MH) and nutrition is vast, and cannot be covered within the remit of this chapter. Instead this chapter aims to give a critical overview of recent changes to MH services, the key drivers for change and the advanced practice role of the MH dietitian within mental illness and eating disorders. There is a strong focus on the areas of eating disorders, practical assessment approaches and new ways of working. The more complex and challenging aspects of dietetic practice within each area is critically discussed. Emerging new developments are also examined.
Introduction
MH dietetics covers three large areas: learning disabilities, eating disorders and more general mental health. A high percentage of MH dietitians sit within services for eating disorders, chronic fatigue, learning disabilities and serious mental illness. Dietitians in MH work with individuals from all age groups and within a wide range of clinical specialties. They work across many sectors and settings including health, education, social services, primary care, secondary care, and the independent and voluntary sectors. These are clinically very different, but share commonality in complexity, policy, treatment approaches and ways of working.
The white paper ‘Choosing Health: Supporting the Physical Health Needs of People with Severe Mental Illness’ states:
People with diagnoses of severe and enduring mental illness (SMI) such as schizophrenia and bipolar disorder are at increased risk for a range of physical illnesses and conditions, including coronary heart disease, diabetes, infections, respiratory disease and greater levels of obesity. They are almost twice as likely to die from coronary heart disease as the general population and four times more likely to die from respiratory disease. 1
Medication used to treat mental illness can have marked side effects including hyperglycaemia, hyperlipidaemia, diabetes, obesity and gastrointestinal disorders, which need long-term dietary management. Self-neglect, cognitive impairment and disorganised lifestyles may also result in malnutrition or overnutrition. In addition the above disorders may be exacerbated by food refusal and other disordered eating patterns such as high caffeine intakes, polydypsia and food phobias. The most common types of mental illness that dietitians are likely to encounter are:
• Mood affective disorders (depression, bipolar disorder, anxiety and mania);
• Schizophrenia;
• Dementia;
• Anxiety;
• Personality disorders (PD); and
• Borderline personality disorders (BPD).
PD and BDP, although not categories of mental illness but disorders of personality and behaviour, are also likely to be met and require an understanding of the diagnosis and management issues. The impact of some of the above conditions on nutritional status is outlined in Table 22.1.
| MGH advanced practice MH training 2008 (Helen Webb). | ||
| Mood disorder | Possible influences on food intake | Possible nutritional consequences |
|---|---|---|
| Depression | Apathy and disinterest in food | Undernutrition, weight loss |
| Anorexia | ||
| Feeling not worthy of food | ||
| Food refusal | ||
| Loss of thirst sensation | Dehydration | |
| Fluid refusal | Constipation; impacted faeces | |
| Distorted food intake | Unbalanced diet, weight gain | |
| Carbohydrate craving | Obesity | |
| Anxiety | Frequent loose stools | Selective food avoidance |
| Abdominal pain or discomfort | Food refusal | |
| Mania | Drug side effects causing dry mouth or altered taste | Difficulties in chewing or swallowing Altered taste sensation |
| Increased appetite | Weight gain | |
| Hyperactivity | Increased energy requirements | |
| Erratic eating habits | Unbalanced diet; weight gain | |
The impact of drug treatments on physical health is enormous. Drug-induced weight gain, leading to an increased risk of metabolic syndrome and type 2 diabetes, is one of the most common problems. Examples of these are outlined in Appendix 22.1. Also refer to Chapter 6 on Drug Nutrient Interactions.
The evidence base for many MH interventions is very limited. With a paucity of high quality evidence on which to base decisions, clinical consensus, clinical reasoning and critical thinking are essential skills. Evaluation of emerging evidence, its quality and its implementation are key skills for the advanced level practitioner in the field of mental health.
Background
There is a changing paradigm within mental health services in the UK that has seen an overhaul of psychiatric services and the physical health needs of service users put high on the agenda for many MH trusts. This has led to a number of sweeping changes in the way that services are delivered and a significant increase in the number of Allied Health Professionals (AHP) employed in MH services. This is creating an exciting and dynamic time for dietitians working in this area.
The initiative ‘New Ways of Working’ (NWW), from the Department of Health, was established in 2005 as part of the National Institute for Mental Health for England’s workforce programme. 2 It aims to change workforce practice and is a current key driver for change in the mental health sector. NWW, together with a growing evidence base linking physical and mental health, is driving a shift towards a broader, holistic, and more multidisciplinary team (MDT) approach to MH services as discussed below.
Significantly there has been a move away from the traditional medical modes of working and the emergence of models for new ways of working. An example of this changing philosophy is the use of the ‘recovery model’. This model challenges conventional thinking around recovery and cure, providing a holistic view of mental illness that focuses on the person and not just their symptoms, believing recovery from severe mental illness is possible. It aims to help people with MH problems, not to become symptom free, but rather despite symptoms, to move forward and carry out activities and develop relationships that give their lives meaning.
Reflecting the principle that physical and mental health is intrinsically linked, the previously overlooked physical heath agenda has now been given a very high priority within MH settings. New policies and key documents such as ‘Choosing Health: Supporting the Physical Needs of People with Severe Mental Illness’ from the Department of Health in 2006 highlight the need for change and for physical health needs of service users to be addressed in order to support their mental health. 1 This has led to an increase in physical monitoring and new developments such as healthy living groups.
Following on from this is a fast-growing interest in the link between nutrition and MH. Increasing numbers of high quality trials are providing evidence to support the link, and large stakeholders such as ‘Food and Behaviour Research’ and ‘Sustain’ are beginning to influence policy at a parliamentary level. 3
In summary there is a cultural change in the delivery of MH services which includes the development of new, enhanced and changed roles for staff and the redesigning of systems and processes to support staff to deliver effective, person-centred care. Rather than looking at traditional services, teams and roles, new approaches place the service user at the centre and redesign around the holistic needs of the service user. It is a person-centred values-based approach where services and roles are responsive and flexible and provides the most benefit to service users and carers. In practice this means that AHPs, such as dietitians, will take on extended or non-traditional roles, for example, dietitians as the clinical lead for an eating disorders or learning disabilities service, passing and changing feeding tubes, taking service users out to eat/shop/cook, running group therapy sessions and undertaking home visit assessments. This has also led to a blurring of traditional professional roles and management structures. For example, a dietitian may be professionally led by an occupational therapist, operationally managed by a nurse and supervised by a psychologist. This situation may bring with it both opportunities and threats. It can both enhance and broaden MDT working, offering a greater understanding of close MDT working and enhanced service user care. Or it may increase difficulties where clashes in working style or work priorities, or misunderstanding regarding roles leads to tensions between professional groups.
Ways of working
Strategic working
Despite a significant increase in the number of dietitians in MH services, there is a chronic shortage in certain specialist and geographic areas. 3 Dietitians may need to shift focus from traditional ways of working and instead work very strategically in their role. In some cases doing no service user work at all, but instead focusing on the creation of a trust-wide food and nutrition policy. Such efforts include influencing trust processes and infrastructure, and implementing National Institute for Health and Clinical Excellence (NICE) guidance, screening tools, and training and education programmes through trust steering groups and clinical governance at board level.
Embedding nutrition into essential physical monitoring and assessment at ward level may involve the development of complex care pathways and adaptations of tools such as the Malnutrition Universal Screening Tool (MUST) for use in particular patient groups. 4 This also includes designing, implementing and evaluating training for staff based upon Skills for Health competence-based approaches (see http://www.Skillsforhealth.org.uk).
Ethical considerations
One of the most contentious barriers to change that dietitians must manage comes from the tension between ‘human right’ and ‘duty of care’ in MH services. Is it a service user’s human right to eat only takeaways that are impacting on his/her health, or is it our ‘duty of care’ to support them to follow a diet that improves mental well being? Working through policy and clinical governance is essential to resolving such difficult conflicts within MH settings.
Assessment
Like complex physical conditions, assessments are largely multidisciplinary in approach, with much greater emphasis on holistic assessment and integrated treatments. Assessment in MH is similar in approach to assessing physical health for long-term lifestyle conditions, with service users managing an array of symptoms that fluctuate, with the emphasis on self-management. The dietitian uses enhanced communications skills to assess the impact of disease on the life of the service user and explore the underpinning psychopathology, with a focus on establishing the background to the condition, current scenario and support and to eliciting thoughts and feelings that relate to food behaviours, to aid insight into what is important to the service user.
Training and education for fellow healthcare professionals (HCPs) is vital and screening tools are often an invaluable first-line assessment tool. To meet NICE and Quality Improvement Scotland (QIS) Standards for Food, Fluid and Nutritional Care in Hospitals the use of MUST or a similar tool is recommended5:
The initial assessment includes screening for risk of under-nutrition. This screening is carried out using a validated tool appropriate to the patient population, and which includes criteria and scores that indicate action to be taken. (QIS Standard 2.2) 4
However, such tools are not validated for MH settings. They often fail to capture service users who are obese and thus need dietetic and physical activity support, as well as those who were undernourished. Consequently, screening tools have been adapted by many services in MH and learning disabilities in partnership with clinical effectiveness departments. The QIS and NICE specify the use of a ‘validated’ screening tool. The validity of any assessment tool can be described in a number of ways. In some cases, validity can be assessed qualitatively, but for others quantitative analysis is required. Table 22.2 shows an example of the process of validating a new screening tool.
| An example of a validated screening tool can be found in Appendix 22.2 | |
| ‘Qualitative’ validity | |
| Face validity | Does it seem like a realistic assessment of nutritional needs? |
| Content validity | Is it based on a checklist of things that should be included in a tool like this? The screening tool should be based on current best practice, outlined in: NICE, Nutrition Support in Adults (Clinical Guideline 325) |
| External validity | Would this tool work for other people, in other places, and at other times? Does it pick up obesity? It would seem reasonable to assume that this tool could be used by other organisations |
| Convergent validity | Is it similar to comparable projects? The screening tool shares certain characteristics of the MUST tool, e.g. both attempt to identify malnourished and obese patients; both use BMI as part of the assessment; both check for any unplanned weight loss; both consider ability to consume food and fluid, and the patient’s general physical health |
| ‘Quantitative’ validity | |
| Predictive validity | Is it able to predict who will have additional nutritional requirements in the future? This tool does not require predictive validity, as it is an assessment of current, rather than future, needs |
| Construct validity | Does it measure what it claims to measure? |
Identification of the number of patients who are referred, and the reasons for referral Analysis of dietetic input for referred patients Dietetic opinion on the appropriateness of referral Further audit work could also include reviewing the patients identified above after one year. This could consider whether any referrals were made to dietetics after the initial assessment. This would help to identify any additional factors to include when the tool is reviewed | |
Single assessment
With a move towards single assessment within MH services, dietitians may find that they form part of a wider holistic assessment of the service user, where health professionals cross-populate areas of the assessment tool. Many HCPs working in the field of MH are dual trained (OT, medical and nursing), which allows them to take on the role of care coordinator and to undertake risk assessments. Very few dietitians are dual trained and so cannot be legally responsible for certain areas of assessment such as risk to self. An example of a MDT single assessment tool is provided in Table 22.3.
| Multidisciplinary holistic single assessment |
|---|
| Reason for referral (who from, why now, any known previous history) |
| Client’s perception (Why do they think they have been referred/are being assessed? What do they hope to gain from the meeting?) |
| Emotional health (mental health state, coping styles, etc.) |
| Social health (accommodation, finances, relationships, genogram, employment status, ethnic background, support networks, etc.) |
| Physical health (general health, illnesses, previous history, appetite, weight, sleep pattern, diurinal variations, alcohol, tobacco, street drugs; list any prescribed medication with comments on effectiveness) |
| Spiritual health (Is religion important? If so, in what way? What/who provides a sense of purpose?) |
| Intellectual health (cognitive functioning, hallucinations, delusions, concentration, interests, hobbies, etc.) |
| Risk assessment (self-harm, suicidal ideation, history/treats of violence, environment/relationship abuse) |
| Summary/formulation of difficulties (to include nursing diagnosis where possible) |
| Action plan (outcome of assessment, who else involved or to be contacted, follow-up appointment, etc.) |
Nutrition and aetiology of mood disorders
There is growing interest in the hypothesis that nutritional deprivation may contribute significantly to psychiatric disorders, with the implication that enhanced nutrition may exert a positive influence on mental health.
Converging lines of evidence from epidemiologic studies, clinical samples and treatment outcome studies suggest that nutrition may play a role in mental health. They may also offer new hypotheses about the aetiology and treatment of certain psychiatric conditions, particularly those that involve deregulated affect, for example: bipolar disorder, depression and borderline personality disorder.
Epidemiological evidence suggests that sugar intake is positively correlated with the incidence of depression and other recent dietary changes may be partly responsible for an increase in mood disorders due to increased consumption of processed foods. 6,7 For example, there has been an increased intake of sugar, trans fats, saturated fats and omega-6 fatty acids and a reduction in the intake of fibre, folate and omega-3 fatty acids. 8
Emerging data regarding the role of omega-3 fatty acids suggest effects of nutrition on mood. 9.10.11.12. and 13. Rates of both unipolar and bipolar depression have been correlated inversely with seafood consumption and it is proposed that omega-3 fatty acid deficiencies may result in changes in membrane structure that could impair serotonin release and uptake. 14.15.16. and 17.
Brain serotonin affects mood and low levels contribute to the aetiology of depression in some people. 18 It is therefore postulated that a high carbohydrate load leads to increased tryptophan levels (precursor of serotonin) in the brain and may therefore elevate mood. 19,20 However, currently there is no evidence that this occurs in humans. 21 Folic acid deficiency has been shown to lower brain serotonin in rats and may have some effect in humans, whilst Benton and Donohue in 1999 also associated poor thiamine status with low mood. 18,21
Caffeine intakes in excess of 600 mg/day can produce anxiety, psychomotor agitation, excitement and rambling speech. It is proposed that caffeine may elevate mood through increasing noradrenalin release and excessive consumption may even precipitate mania. Depressed patients may be more sensitive to the anxiogenic effects of caffeine, creating tolerance. Withdrawal symptoms develop when doses are reduced. 22
This emerging data suggest that correction of deficiencies, ensuring a balanced diet and in some cases using nutritional supplementation, may be a helpful strategy in the management of psychiatric disease states. Future studies are needed to evaluate the reliability of initial findings and to investigate the long-term safety of supplementation within various subpopulations of psychiatric patients. Where the balance of possible benefit outweighs risk, supplementing multivitamin/minerals, and omega-3 oils (500 mg/day) may be seen as good practice in the vast majority of cases and routine supplementation in mood disorders is now more common in trust nutrition policy and prescribing guidelines. 22
Managing behaviour change in mental illness
Behaviour change work within mental health must be underpinned by enhanced dietetic skills in motivational, behavioural and cognitive approaches. Working with complex needs or serious mental illness such as personality disorders and eating disorders requires skills in both cognitive behavioural and dialectical behavioural approaches and a high level of clinical supervision. 23 Therefore specialist dietetic postgraduate training in the area of MH and supervision by experienced practitioners or peers is essential. In addition to clinical supervision, psychological supervision is also recommended. Psychodynamic phenomena such as transference, counter-transferance and splitting are common in teams and individuals that work with mental illness. One of the primary tasks of psychological supervision is to help understand and manage the complexities of the setting and multiprofessional working, in order that the clinical work can be thought about and understood. This type of supervision may be offered from within the team and/or externally by regional networks.
Specialist and masters level training in the areas of assessment, treatment and psychological approaches that underpin working in MH can be accessed locally or nationally. The Mental Health Specialist Group (MHG) of the British Dietetic Association have developed courses in MH, learning disabilities and eating disorders at masters level, which dovetail with the accredited behaviour change training developed by Dympna Pearson, to form a complete postgraduate training package within this area. For further guidance, refer to the Chapter 3 on changing behaviour, by Dympna Pearson.
Working with personality disorders and borderline personality disorder
Personality disorders are a set of disorders characterised by deeply rooted patterns of thoughts, feelings and relating. Life experiences such as early and severe trauma, carers abusing drugs or alcohol, carers having MH problems, poor parenting skills, sexual abuse or neglect can lead to a child with a damaged personality and multiple problematic core beliefs develop. These may then interact with certain biological and genetic factors to form adult personality disorders.
Personality disorders are difficult to treat because they involve deeply rooted patterns of thoughts, feelings and relating. Research shows that people with personality disorders may change, although this may take a number of years and the focus may be more on managing current behaviours and feelings than on exploring the past. Psychological treatments include dialectical behavioural therapy (DBT), cognitive behavioural therapy (CBT), psychodynamic therapy, social skills training and problem solving. 23 Treatment should begin with minimising the biggest risks to self as outlined in Table 22.4.
| Example from binge eating | |
|---|---|
| Decrease suicide risk—focus on making life worth living | |
| Decrease therapy interfering behaviours | |
| Decrease behaviours that interfere with the quality of life | Stop binge eating Regular eating Chain analysis |
| Improve self-esteem | Eliminate mindless eating Decrease cravings, urges and preoccupation with food Emotional regulation |
| Set individual goals and targets | Decrease capitulating (giving up and acting as if there is no alternative to binge eating) Decrease ‘apparent irrelevant behaviours’ (buying favourite binge foods for friends/family) |
People with a personality disorders are not easy to work with. They can challenge morally and emotionally and can create feelings in those working with them of self-doubt, anxiety, helplessness, avoidance, guilt, shame and dependence.
The dietitian should be aware that people with serious mental illness, eating disorders, PD or BPD could exhibit the following:
• Behaviour experienced by others as manipulative, selfish or dishonest;
• Behaviours that cause the splitting of teams; showing very different aspects of personality to different team members;
• Passivity or inappropriate activity (e.g. cutting); taking little responsibility or ownership of the problem, but instead tries to make others responsible;
• Engagement in self-defeating behaviours that perpetuate the problem;
• Voicing of threats or incitement of guilt when problems are not resolved;
• If they do take ownership, they can become obsessive and extreme, e.g. with exercise and diet; individuals exhibiting this behaviour may also have obsessive compulsive PD;
• Request for something that will make them look and feel special and different to others, e.g. a nutritional supplement, a Halal meal, more time even when not clinically or ethnically indicated;
• Behaviours such as food refusal as a means of control or self-harm to demonstrate distress;
• Eating disorders behaviours, which are relatively common, particularly amongst females with BPD and those who self-harm;
• Easily dissociate and may not have heard what you have said;
• Impulsive behaviours that alleviate difficult feelings in the short term, e.g. drinking, drugs, self-harm, binging, vomiting or starvation;
• Dysfunctional and damaging relationships; and
• Making of multiple formal complaints and can be very litigious.
Dietitians working with these client groups require close supervision, peer support and skills in CBT and DBT approaches. The following points should be considered:
• Recovery is always possible; there is always hope.
• Treatments may involve team risk-taking and creative thinking.
• Service users with mental illness may need more clinic time and take longer to build rapport with. Diet changes need to be clearly linked to what is important in the day-to-day life of the service user. Change may be slow and all goals must be realistic.
• During an acute phase of mental illness such as depression, mania or psychosis, the service user will be mainly inaccessible to establishing rapport, dietary assessment and management. They may become non-attendees and so appointments need to be rearranged when the service user is better able to engage. Delusional or paranoid beliefs about food cannot be changed by logical argument or scientific evidence. The dietitian must work with the belief until the patient is more cognitively accessible. Service users experiencing withdrawal and lack of motivation will be very difficult to communicate with and elicit change.
• The involvement of support workers, family, friends, carers and other HCPs is vital in the assessment and planning of change. Always work as a team, do not work in isolation and agree approaches and boundaries. If possible, interview the service user with another member of the team, preferably their primary nurse or key worker.
• Always speak to a member of the team for an update prior to a dietetic consultation and feed back to the rest of the team after an interview.
• Set boundaries clearly and keep to them. Make sure service users are aware of the scope of your involvement and that you are part of the team and as such will share information.
• Do not treat individuals favourably over others or give in to demands when not clinically indicated.
• Build rapport and trust, be warm but firm. Show resolve, perseverance and consistency.
• Be prepared and well planned.
• Give plenty of warning for a change of appointment or dietitian and avoid frequent changes of any staff.
• Try to effect a small change early on to demonstrate that change is possible and use this to refer back to.
• Keep accurate and full written records.
Eating disorders
Eating disorders (ED) are highly complex disorders that involve psychological, physical, behavioural and psychosocial problems. Professionals working in this field need to be experienced within it, trained and supervised well. Multidisciplinary working is key as all professionals need to work as a team.
The role of the dietitian with ED is multifaceted and employs a wide range of advanced skills and knowledge. This cannot be discussed fully within the scope of this chapter; therefore the focus is on ways of working and the complexity of work.
The Quality Improvement Scotland (QIS) report of 2006 entitled ‘Eating Disorders in Scotland: Recommendations for Management and Treatment’ outlines the broad areas of work that dietitians are involved in: 24
• Dietetic treatment should be offered to both in-patients and outpatients;
• The dietitian has an essential role in assessment, treatment and monitoring;
• Poor eating patterns and unhealthy views are primary symptoms that need addressing; and
• The dietitian has a key role in diet and weight management.
Most patients with anorexia nervosa can be managed on an outpatient basis with psychological component, medical monitoring and dietetic advice.
Dietitians working in child and adolescent MH and eating disorder services work with the patient (and families) on all food-related issues, thus enabling other therapists to work on the underlying issues of the disorder without being distracted by food-related issues.
Dietitians also have a critical role to play in helping service users meet their nutritional needs to ensure normal physical development and growth, establish normal eating behaviours, develop normal attitude to food, stop compensatory behaviours, develop appropriate responses to hunger and satiety cues and ultimately help patients to trust food again.
Ways of working in eating disorders
Anorexia nervosa is egosyntonic in nature, closely bound to a sufferer’s identity and core values, and experienced as a solution to their problems. Therefore, behaviour change in this client group is difficult and treatment is often fraught by ambivalence about change.
Ways of working within eating disorders are underpinned by enhanced communication skills, which necessitate the use of motivational interviewing and cognitive behavioural approaches. Embedding these principles and practices into dietetics is essential for advanced level working. The following are some examples of how these can be achieved:
• Focusing on biological/global aspects of nutrition and separating out the emotional entanglement;
• Establishing expectations of self-monitoring and client responsibility as part of treatment;
• Presenting both sides of the picture and discussing choices in an open and honest way;
• Validating current experiences and ways of coping, whilst pushing towards the future and change;
• Discussing behaviours in the context of associated thoughts and feelings;
• Explaining and interpreting symptoms, giving alternative explanations for events or beliefs;
• Reframing and challenging beliefs about food and the body;
• Exploring the function of food rules and safety behaviours;
• Exploring the current situation in detail, eliciting associated thoughts, feelings and motivation;
• Planning, goal setting and problem solving;
• Increasing self-efficacy by giving practical advice to support self-efficacy—portioning, shopping, cooking;
• Setting up behavioural experiments around specific beliefs about food and weight;
• Using step-wise and graded approach to behaviour change;
• Being curious and noticing rather than judging;
• Establishing boundaries such as ‘safe’ diet, fluid and weight;
• Psycho-education, for example exploring specific behaviours such as binges and their meaning (dieting/deprivation punishing/opportunity/pleasure, etc);
• Identify trigger foods/situations;
• Teaching distress tolerance techniques/active alternatives alongside MDT members; and
• Identifying and dealing with cravings.
Multidisciplinary working is essential and close liaison in designing a co-ordinated rehabilitation service is the cornerstone to effective patient centred working. Professional roles vary from team to team and will inevitably overlap. Patient centred working, good communication, liaison and team working allow for fluid boundaries between disciplines without effecting professional integrity or moving towards generic working.
Eating disorders assessment
Decision making is a whole team approach, driven by psychological formulation and based upon careful ongoing assessment of needs and the service user’s wishes. In 2007 the Scottish Dietitians Eating Disorders Clinical Forum (SDEDCF) produced documentation for the initial dietetic assessment of patients with eating disorders, which aims to standardise assessment practice and provide dietitians with a means to collect the relevant information required to make a thorough assessment (see Appendices 22.3 and 22.4). Additional advanced assessment techniques for eating disorders include a detailed timeline of weight from childhood onwards matched across to significant life events and detailed description of family mealtimes and their meaning. The dietetic assessment should be summarised and fed back to the patient, forming part of early motivational enhancement work.
Refeeding at low weights
The challenge of refeeding in anorexia nervosa at very low weight, combined with the psychological needs of the service user who is extremely distressed or even under section, is enormous. MDT assessment and involvement is essential. The decision to nasogastrically feed is a difficult one and needs careful planning. A range of treatment options should be considered after a risk assessment of each option. Indicators for nasogastric feeding are:
• Life threatening low weight (BMI of < 13.5) and weight falling;
• High physical risk; 25
• Minimal nutritional intake with no recent increase;
• Disengagement with psychological work;
• Poor cognitive functioning; and
• All other options exhausted.
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