Neurological Considerations for the Care of Patients With Severe Obesity

Abstract

Patients with severe obesity tend to have higher rates of morbidities which can complicate and even lengthen their hospital admission course. Hospitals which do not have the resources to efficiently manage bariatric patients due to equipment weight-restrictions should be proactive in their care and knowledgeable about their options to avoid long delays in treatment. Amid this obesity epidemic, the neurologist plays a role in the inpatient management of patients with severe obesity and could serve as a channel to improve the quality of care and reduce the length of stay. We present a case of a patient with severe obesity who presented with visual loss secondary to idiopathic intracranial hypertension. The patient’s treatment was delayed several weeks from the time of admission until his weight decreased enough to safely undergo CT imaging in the operating room, developing complications throughout the course of his stay. This paper highlights the identified barriers of care and potential solutions to ensure improvement in the quality of care of patients with severe obesity, in order to reduce preventable complications.

Introduction

In 2017-2018, the prevalence of obesity in adults is 42.4% in the US. ¹ However it is projected that close to half of US population will be obese by 2030, of whom nearly 1 out of 4 will have severe obesity. ² Hospital systems must increase the resources at their disposal to accommodate the challenges of treating obese patients. In the case of neurohospitalists who often care for patients with obesity in association with different neurological conditions, it is important to recognize areas of potential healthcare quality improvements specific to the impact of obesity, especially severe obesity. Here, we present a case report of a patient with severe obesity who presented with visual loss secondary to idiopathic intracranial hypertension (IIH). His severe obesity offered unique challenges in the timely diagnosis and treatment of his neurological condition. We then discuss the overall impact of obesity on the healthcare system, reviewing the potential problems and solutions affecting a neurohospitalist’s approach to caring for this unique patient population. This manuscript was exempted from review per the Georgetown University Institutional Review Board Case Report Policy.

Case Presentation

A 26-year-old man with a history of systemic hypertension and morbid obesity (BMI 89, weight 295 kg) was admitted to our hospital with diffuse positional headache, pain between the eyes, and unilateral vision loss. His funduscopic examination revealed bilateral papilledema. A lumbar puncture was performed at an outside hospital prior to his presentation, with an opening pressure of 50 mmHg. His CSF was unremarkable with normal cell count, protein, and glucose. Serum labs were unremarkable. While he had a working diagnosis of presumed IIH, it was difficult to rule out secondary causes of increased intracranial pressure (ICP) in a timely manner without brain imaging. His weight and size surpassed the safety limits of the available equipment for either a computed tomography (CT) scan or magnetic resonance imaging (MRI) at our facility, and no regional hospitals or other facilities in the area could accommodate his body weight and habitus on their scanners. A skull x-ray was performed which was unremarkable but insufficient in quality.

While admitted, his vision loss continued to deteriorate despite maximal medical therapy and a surgical approach was considered, which was again delayed given inability to perform adequate brain imaging in a timely manner. The patient also developed several complications during his hospital course as he waited nearly 3 weeks for imaging, including hypercapnic respiratory failure requiring endotracheal intubation, hypercapnia induced encephalopathy, acute kidney injury, deep venous thrombosis and pulmonary embolism despite chemoprophylaxis, and oral thrush attributed to a short course of steroids to further decrease intracranial pressure.

He eventually underwent a CT head scan when he had lost enough weight after several weeks in the hospital with a restrictive diet. This limited CT head scan was performed on an intraoperative CT scanner in the operating room, which revealed no obvious masses (Figure 1). A nerve sheath fenestration was performed to prevent further vision loss. The surgeon was unable to perform the standard amount of fenestrations given difficult access due to excess subcutaneous fat surrounding his eyes. The patient’s post-operative vision unfortunately did not improve and he remained legally blind in both eyes. A ventriculo-peritoneal shunt surgery was recommended by the neuro-ophthalmologist, but the patient and his family deferred pursuing further surgery. Patient was ultimately discharged with referral to a low vision clinic.

Figure 1.

CT head with poor resolution quality due to technical challenges.

Discussion

Overall Impact of Obesity on Health Care

Patients admitted with morbid obesity has been observed to have poorer outcomes. In an observational study in Australia, patients with overweight admitted as an emergency have worse outcomes than their counterparts, including greater ICU admission rates (18.5% vs 6.93%), length of stay (10.46 vs 5.46 days), and 28-day readmission risk (9.04% vs 5.70%). ³ In addition, there are formidable financial and health consequences to living with obesity. Approximately 5%-10% of US health care spending represents the direct medical costs of treating patients meeting the definition of overweight (BMI 25-29.9) and obese (BMI ≥30 kg/m²). ⁴ These 2 demographics incur higher per-person direct medical cost of as much as $1723 per year, an aggregate of $113.9 billion per year. ⁴ Higher BMIs predispose to more comorbidities and complications, including obstructive sleep apnea, IIH, diabetes mellitus type 2, cardiovascular diseases, and premature death. ⁵

Challenges of Inpatient Management

The inpatient management of morbid obesity elicits unique challenges. The ability of hospitals to manage and treat patients with morbid obesity is critical to patient care. Bed weight limits prohibited our patient from safely undergoing imaging that could confirm his diagnosis. The delay in care resulted in several complications. To better accommodate patients with obesity in the hospital setting, some facilities are investing in equipment to better serve their needs. Such equipment can include wheelchairs that can carry up to 204 kg, beds up to 453 kg, and MRI scanners up to 249 kg. A limited number of hospitals provide CT scanners that safely accommodate up to 300 kg, but this does not take into account size restrictions (e.g., waist circumference). Several studies have found that bariatric patients treated in appropriately equipped centers have a lower inpatient mortality rate. ⁶ For this reason, the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery have created a national registry of accredited institutions for the treatment of patients who are morbidly obese, which can be used by local providers in the prehospital phase to transport patients to the most capable facility. ⁷ Although the accreditation system was created to ensure better outcomes specifically in bariatric surgical patients, the principle should be extrapolated and applied to any patient with severe obesity.

Challenges for the Neurologist

The impact of obesity in the neurology practice is now being recognized. Increased visceral adiposity is a risk factor for Alzheimer’s Disease, mild cognitive impairment, decreased grey matter volume in frontal and temporal lobes, polyneuropathy and mood disorders. ⁸ Moreover, obesity increases the risk of stroke and deep intracerebral hemorrhage, mostly through an indirect effect on hypertension and other obesity-related comorbidities. ⁹ When a potential stroke is activated in a hospital without specific policies to address the needs of morbidly obese patients, the potential consequences can be detrimental. Typical scenarios when treating an obese stroke patient are shown in Table 1. ¹⁰ Other neurological diseases can also pose a unique challenge in the obese patient, including status epilepticus and the appropriate dosing regimens in the morbidly obese patient. In the particular case of phenytoin, data suggest a disproportionate distribution into excess body weight without changes of unbound phenytoin. ¹¹ Another medication that must be adjusted for obesity in the case of seizures is diazepam. A study comparing 23 obese patients with 25 controls showed that the half-life of diazepam was greatly prolonged in obese patients (90 vs 45 hours, p < 0.001) mainly due to an increase in the volume of distribution. ¹²

Table 1.

Potential Challenges and Strategies to Reduce Complications in Patients With Severe Obesity and a an Acute Ischemic Stroke.^a

Case scenario	Potential solutions
Inability to place a peripheral IV	Ultrasound guided peripheral IV placement in any patient with severe obesity.
Transfer to the neuroIR suite	Additional helpers are often needed to lift the patient. Use of extra equipment if the patient cannot be fully moved onto the table.
Inability to obtain an arterial femoral access	TRA
Complications in the IR suite	An expanded “time out” verification process to address risk factors and potential complications, dosing regimens and equipment to be used.
Post procedure bleeding	Early sheath removal, manual compression, consider vascular closure devices, avoid venous sheaths.

Abbreviations: IV = intravenous, neuroIR = neurointerventional, TRA = transradial access.

^a Adapted from Kern, Morton. “Reducing Complications in the Very High ‘BMI’Patient.”

One of the most difficult scenarios for the neurologist arises when a patient with severe obesity presents to the acute care setting requiring a diagnostic or therapeutic lumbar puncture (LP). A previous study have shown that up to 14% of patients have a skin to subarachnoid space greater than 9 cm which is longer than the length of traditional spinal needles. The failure rate among junior doctors is 68% when performing a LP in an obese patient. ¹³ Therefore, the provider should consider using of a long spinal needle (>9 cm) or perform an IR-guided LP in these patients.

Weight Loss in the Acute Setting

Our patient eventually lost enough weight while inpatient to be able to receive a CT scan. However, addressing acute weight loss in the inpatient setting is a unique challenge because of time limitations. Even with appreciable non-surgical intent to speed weight loss, hospitalized patients commonly lose weight regardless. A study analyzing nutritional intakes of patients in a 1200-bed hospital found that while the hospital menu provided over 2000 kcal/day, there was a high wastage rate of 40% of hospital food. This meant that patients were not meeting their recommended intakes regardless of an intention for weight loss. ¹⁴

While the demand for surgical approaches for weight loss is increasing, bariatric surgery is usually not done in an inpatient setting. The indications for bariatric surgery require a BMI of 40-50 or less than 35-40 with at least one severe obesity-related medical complication. Patients must be unable to achieve weight loss with conventional therapy and be able to comply with long-term postoperative follow-up. Even with bariatric surgery, it can take 1-2 years to observe maximum weight loss, and hence it is an unrealistic approach in the acute inpatient setting. ¹⁵

Conclusion

The prevalence and severity of weight problems are increasing in the US and around the world. Neurohospitalists are increasingly caring for patients with severe obesity, which requires a unique approach in ensuring optimal diagnosis and treatment strategies. Hospitals without the resources to efficiently manage patients with severe obesity should be proactive and knowledgeable in their care. A planned strategy should include the use of local and national registry of appropriately equipped centers, early identification of patients with severe obesity, transfer to better equipped hospitals if needed, and implementation of outpatients and inpatient programs of weight loss.