Anorexia Nervosa in an Older Woman: Eating Disorders as Chronic Conditions
A 68-year-old widowed woman was referred to a psychologist for counseling by her primary care physician. The physician was concerned that Mrs. R was dieting and exercising excessively. Mrs. R is a nurse who retired two years ago. She moved to an assisted living facility one year ago following the death of her husband. Mrs. R has two daughters who live nearby. She was referred to both a psychiatrist and psychologist many times, but refused to see them. Her daughter convinced her to see a psychologist and came with her to the appointment. Mrs. R arrived early for her appointment and drank many glasses of water while she was waiting. She appeared thin, but was neatly dressed and groomed.
Mrs. R was extremely verbal and relayed her history in great detail, often using medical terminology. She described being concerned about her weight since the age of 10, when she was teased in school after she began developing breasts. Mrs. R started restricting her intake of food to one meal per day. She recalled being admitted to the hospital at the age of 14 after fainting in school. She reported that she learned to drink large amounts of water before being weighed to give the illusion of gaining weight. At 5’ 1’’ tall, Mrs. R recalled that her typical weight throughout high school and nursing school was 84 lbs. She typically ate one meal per day, and if she exceeded this, she would exercise by riding a bicycle, running up stairs, or jogging.
Mrs. R noted that while in nursing school she fainted several times and was often hypotensive and anemic. She learned to eat and drink enough to have the ability to work, while keeping her weight at 84 lbs. She spent large amounts of time planning her one daily meal, calculating the calories it would contain. Mrs. R was able to function as a nurse, and enjoyed working in the maternity ward of a university hospital. She married a sales representative from a baby formula company when she was 28. Mrs. R had two children, and was able to gain weight during her pregnancies with support from her husband. She reported that she hated being pregnant, and constantly thought of how she was going to lose the weight she gained, but realized that she needed to eat more to have healthy children. Mrs. R stayed home to raise her daughters, and resumed her pattern of eating one meal daily.
After her daughters left home to attend college, she tried to resume her nursing career, but found the work too physically demanding. Mrs. R saw a physician for lower back pain and was found to have severe osteoporosis at the age of 52. She suffered several spinal compression fractures, and was less able to exercise. She started feeling increasingly anxious that she would “become fat” after her weight increased to 92 lbs. Mrs. R recalled that she went on a “liquid fast” of fruit juice diluted with water. After several days, she fell down the stairs in her home and sustained fractures of her left hip and left arm. She was hospitalized, required several surgical procedures, and was given tube feedings. Mrs. R recalled that she was so anxious in the hospital that she was given sedatives. She left the hospital weighing 100 lbs, but was able to recover from her fractures. She had a period of stability for several years after this, in part because she was fearful of falling and sustaining more fractures.
She and her husband traveled, spent time with their grandchildren, and Mrs. R was able to eat in restaurants for the first time in many years. She resumed working part-time as an employee health nurse. Her husband died following a series of heart problems, and she moved to the assisted living facility. While living alone she resumed her previous pattern of eating only one meal per day, and started using an exercise bicycle to reduce her weight back to a goal of no more than 84 lbs. The nurse and administrator of the facility grew concerned and referred her to the consulting physician. They tried to restrict her use of the gym and exercise equipment, which angered her. She agreed to see the psychologist after the administrator told her she had to have an evaluation to use the facility gym. Mrs. R’s younger daughter reported that her mother is now thinner than ever and has refused to be weighed. The daughter is concerned that her mother is going to starve herself and reported that her older sister suffers from severe anorexia nervosa. Her sister had been treated at several residential facilities after dropping out of college and had never been able to work. Mrs. R refused to discuss her other daughter and instead focused on her desire to be able to use the exercise room. She asked the psychologist to write a note for her about this, and stated that as a nurse she knows how much weight she can lose.
As our population lives longer, older adults with chronic psychiatric conditions will present us with increasing challenges. Eating disorders are typically considered to be problems of adolescents. Eating disorders are chronic illnesses that often persist well into midlife and beyond.1 The first reports of anorexia nervosa date back to the 17th century when a syndrome of nervousness accompanied by refusal to eat and the perception of being unattractive was reported among young women in Europe.2 Eating disorders include anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified, which include behavior such as pathologic binge eating.1
Anorexia nervosa affects about 1% of the population and is characterized by refusal to maintain a normal body weight, fears of gaining weight, and a distorted body image.3 Bulimia nervosa has a prevalence of 4% and includes symptoms of binge eating with a loss of control during episodes of excessive eating, followed by periods of induced vomiting, laxative or diuretic abuse, fasting, or excessive exercising to prevent weight gain. The onset of these disorders is typically in adolescence or young adulthood, but they are chronic in nature.4 Women represent 90% of those affected.1 Patients with eating disorders often present with a complex pattern of behavioral and emotional features. They often do not recognize or admit to having an illness and resist treatment.
The clinical course of these disorders is highly variable, with periods of exacerbation and remission. One extensive review of the literature of studies involving patients with anorexia over a 45-year period revealed that 40% of patients improved, 30% had a course characterized by remissions and exacerbations, and 20% remained chronically ill.4 The mortality rate associated with the chronically ill group is high, as it appears that 5% of patients with anorexia nervosa die as a result of their eating disorder.3,4 Genetic research using studies of identical twins has found evidence for a genetic linkage to anorexia nervosa located on chromosome 1. Chromosome 10 appears to contain a gene or genes associated with bulimia nervosa, identified using family studies.5
Many psychosocial and environmental factors have been implicated in eating disorders. The constant exposure of children to images of extremely thin models and television and movie characters is believed to increase distorted perceptions of body image.2 Family issues play a role, as the eating behavior and body image of parents and siblings has significant influence on the patient.1 Issues of poor self-esteem and a desire for control are common among all patients with eating disorders and must be addressed in treatment. A clinician may encounter an older adult with a chronic eating disorder who has had periods of remission and relapse throughout adulthood. These patients often have developed many medical complications including osteoporosis, anemia, metabolic disturbances, arrhythmia, hair loss, and edema (Table I).1-4
Cases of late-onset anorexia nervosa have been reported among patients as old as 90 years.6-8 A common feature among these cases is a history of suffering significant life trauma, including physical, sexual, and emotional abuse, or having experienced severe deprivation. Medically supervised weight gain as part of a comprehensive treatment program including group, individual, and nutritional counseling is vital (Table II).1,6-8
Involvement of family members, particularly those who live in the same household, is also important. A positive focus on gaining a sense of control through the development of healthy routines and food choices is a goal of treatment. Patients with eating disorders may also suffer from comorbid mood and anxiety disorders and, in some cases, paranoia. These symptoms warrant psychiatric evaluation and treatment.9 It is important that primary care physicians maintain continuity, monitor the patient’s progress, and serve as a stable source of medical care for those patients who often have avoided treatment for decades.
Outcome of the Case Patient
The psychologist arranged for a session with the patient, her primary care physician, and the facility director to discuss a treatment plan. The physician arranged for a dietician with experience in treating patients with anorexia to meet with Mrs. R and assist her with meal planning and making well-balanced food choices. She also met weekly with the psychologist. The facility director was willing to allow her to use the exercise room if it was part of the treatment plan. An initial target goal of 90 lbs was chosen in order for the patient to have 15 minutes of exercise time. The patient was initially compliant with the plan and over one month gained 5 lbs to reach her initial goal. Following this, she was found walking rapidly up and down the stairs of the facility at night, and suffered a fall with multiple fractures of the femur, tibia, and pelvis. Mrs. R required a lengthy hospital stay, with multiple surgeries. A gastrostomy tube was placed to provide feeding. She was transferred to a nursing facility for rehabilitation. She continues to focus on her weight, as she gained 15 lbs as a result of enteral feeding. It is unclear if she will be physically capable of returning to the assisted living facility because she requires significant assistance with all aspects of daily living. The psychologist continues to see her and has helped the facility staff formulate a plan to give the patient more control over her food choices and accept supplemental tube feedings when she does not eat enough. Both of her daughters visit regularly, and Mrs. R has started discussing her anorexia more openly.