Nutrition in the Elderly
Weight Loss Caused by Eating Disorders in Older Adults
1Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
2Department of Medicine, Mayo Clinic, Rochester, MN
3Psychiatry and Obstetrics & Gynecology Division; Psychiatric Outpatient Services; OHSU Center for Women’s Health Clinical, Portland, OR
Abstract: Eating disorders are frequently underdiagnosed and underreported in older persons; however, when patients present with significant, unexplained weight loss, eating disorders should be considered in the differential diagnosis so that patients are treated appropriately. Differentiating an eating disorder, such as anorexia nervosa or bulimia, from anorexia of aging or other conditions causing unexplained weight loss in older adults presents a clinical challenge to healthcare providers. This is because the presentation of eating disorders in older adults differs greatly from the presentation in younger adults due to physiological changes associated with normal aging, the presence of comorbidities, and the use of multiple medications—all of which can cause weight loss, but do not create the clinical picture needed to diagnose an eating disorder. Once an eating disorder is identified as the cause of the patient’s weight loss, appropriate management can begin. Treatment for eating disorders includes psychotherapy, pharmacotherapy, and nutrition counseling. In this article, the authors discuss the epidemiology and etiology of eating disorders in older persons, including late-life onset eating disorders, review the diagnostic criteria for eating disorders and the factors that contribute to anorexia of aging, and give an overview of evaluating and managing disordered eating behavior in older adults.
Key words: Eating disorders, anorexia of aging, anorexia nervosa, bulimia.
There is a common misconception that eating disorders most frequently affect young women, but eating disorders also affect men and women in middle age and late life. Eating disorders are often underrecognized in the elderly because they frequently present in the setting of comorbidities and the presentation tends to differ from that of younger patients. An eating disorder is generally understood as a psychological disorder causing a disturbance in normal eating behavior,1 although medical conditions can also cause eating disorders. An eating disorder can become a cause for concern in older patients when it leads to severe, life-threatening weight loss and other adverse outcomes. Anorexia nervosa, bulimia nervosa, and other patterns of disordered eating have been associated with significant weight loss in older persons, leading to increased morbidity and mortality.
This review focuses on the clinical features, evaluation, and management of anorexia (anorexia nervosa and anorexia of aging) and bulimia in older adults. Binge-eating and other eating disorders that tend to cause weight gain also occur in older patients but are beyond the scope of this review. As the population rapidly ages, eating disorders must be considered when excessive weight changes occur in geriatric patients. A brief discussion of the epidemiology and etiology of eating disorders in older adults is also provided to underscore the urgency and timeliness of these disorders in geriatric clinical practice today.
Defining Eating Disorders
Released in May 2013, the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, the DSM-5, has revised the diagnostic criteria of eating disorders.2 The fourth edition of the DSM, which has been used since 2000, divided eating disorders into three main types: anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified (NOS)3; however, the DSM-5 recognizes that a significant number of people with eating disorders NOS may actually have a binge eating disorder. Thus, binge eating disorder, defined as recurring episodes of eating a larger amount of food in a shorter period of time than most people in similar circumstances, has been added as its own category of eating disorders. Binge eating is marked by feelings of lack of control, guilt, embarrassment, and disgust, and some affected persons may attempt to hide their behavior by eating alone. The disorder is associated with distress and persists, on average, for at least once a week over 3 months.
Anorexia nervosa is defined by the DSM-5 as distorted body image, pathological fear of fatness, and excessive dieting leading to severe weight loss. Diagnosis relies on behaviors, such as restricting caloric intake. The DSM-5 has removed the word “refusal” with regard to maintaining normal body weight for age and height because it implies intention on the part of the patient and can be challenging to assess. The DSM-5 also removed the diagnostic criterion of amenorrhea because some individuals can exhibit the other symptoms of anorexia nervosa but still report some menstrual activity; furthermore, the criterion does not apply to men, premenarchal female patients, women taking oral contraceptives, and postmenopausal women.
Bulimia nervosa is defined as frequent episodes of binge eating, followed by compensatory behaviors to avoid weight gain, such as self-induced vomiting. Per the DSM-5, individuals with bulimia nervosa must exhibit these behaviors once weekly; the DSM-IV had required these behaviors to be exhibited twice weekly.3
When patients present with eating disorders that do not meet the diagnostic criteria of anorexia nervosa, bulimia nervosa, or binge eating, it may be diagnosed as an eating disorder NOS. For example, it is important to note that many older adults experience anorexia of aging, which is distinguishable from anorexia nervosa. Anorexia is defined as a medical condition characterized by reduced appetite or aversion to food, leading to the inability to eat4; however the hallmarks of anorexia nervosa, including fear of fatness and distorted body image, are absent. Anorexia of aging, a syndrome associated with involuntary weight loss and protein-energy malnutrition, encompasses the normal physiologic changes that cause an increase in the proportion of body fat and a decrease in lean muscle mass and extracellular fluid mass. This shift in body composition is typically caused by a decrease in energy needs, thus leading to decreased appetite and intake of calories.5 A number of pathological, psychological, and sociological factors can increase the risks of anorexia of aging.
Epidemiology of Eating Disorders in Older Adults
The medical literature on anorexia nervosa in individuals older than 40 years date back to 19306; the earliest published case report of anorexia nervosa occurred in a 59 year-old-woman in 1936.7 Although an increasing number of case studies on eating disorders in older persons have been published since the 1930s, data are still lacking. A review of the literature conducted by Lapid and colleagues8 revealed only 48 published cases of eating disorders in individuals older than 50 years. With so few published cases, one may assume that eating disorders are rare in the elderly; however, a report by the US National Center for Health Statistics suggests otherwise: of more than 10 million deaths recorded between 1986 and 1990, 724 death reports mentioned anorexia nervosa as a primary or contributing cause of death.9 This is equivalent to a rate of 6.73 per 100,000 deaths. The majority of anorexia-associated deaths (n=532) were in adults older than 55 years, comprising 73% of all deaths, with 200 of these cases seen in adults aged 85 years of age or older. Additionally, this study reported two fatal forms of anorexia nervosa: an early-onset form comprising 89% of women and a late-onset form comprising 24% of men.9
Given the high number of deaths in this population, it is surprising that eating disorders are so rarely diagnosed or researched in older patients. Muir and Palmer10 purported that underdiagnosis and underreporting of anorexia may be attributed to flawed national mortality statistics derived from death certificates; although their study was based in England and Wales, it still raises concerns about the true number of deaths in older patients due to anorexia nervosa.
Another European study evaluated the eating behaviors and body attitudes in a randomly selected nonclinical sample of 1000 women, aged 60 to 70 years.11 The researchers found that nearly half of women (48%) desired, on average, a body mass index (BMI) of 23.3 kg/m2, which was lower than their actual BMI (25.1 kg/m2 on average). Additionally, this study reported that more than 80% of women controlled their weight in some way, such as weight check, regular physical activity, fasting, laxatives or diuretics, vomiting, and/or spitting out food; more than 60% stated body dissatisfaction; and 3.8% met criteria for eating disorders (anorexia nervosa, bulimia nervosa, or eating disorder NOS).11
In a nationally representative sample of Canadian women, the prevalence of eating disorder symptomatology (ie, frequent dieting behavior, preoccupation with food intake and body shape) was 2.6% in women between the ages of 50 and 64 years and 1.8% in women aged 65 years and older.12 In another Canadian study, strong differences among women of different ethnicities were observed with respect to BMI, body shame, and eating disorder symptomatology13; this study, which evaluated a nonclinical sample of 601 women from different ethnic backgrounds, found that women aged 65 years and older had lower rates of bulimic behavior and greater body satisfaction than other age groups across ethnic groups. Although these older women were found to have a lower incidence of dissatisfaction with their bodies, this study shows that the social and societal pressure on younger women to be thin and beautiful does not dissipate with age, although it might become less pronounced.
Although eating disorders mainly affect young women, with cases in men being far less common across all age groups, eating disorders can affect elderly men. One reported case involved a 72-year-old man who was admitted to a geriatric psychiatry service for grave passive neglect with mild dementia thought to be due to nutritional deficiency, but which was later discovered to be an eating disorder NOS, most closely resembling anorexia nervosa.14 As this case shows, eating disorders should not be discounted based on a patient’s age or sex.
Etiology of Eating Disorders in Late Life
There is much debate surrounding the question of whether late-life onset of eating disorders exists. Despite the controversy, a case can be made for dividing the study of eating disorders in older adults into two groups: eating disorders that began in early life and recur into later life; and eating disorders with its first onset in later life. Regardless of when an eating disorder starts, it is extremely difficult to fully recover from, with approximately one-third of people maintaining a chronic lifetime eating disorder and one-third retaining subthreshold symptoms; only an estimated one-third of patients fully recover.15 The exact cause of eating disorders in either of the two groups has not been determined. However, as with most psychiatric illnesses, there are likely biological, psychological, and social factors that lead to both early-life and late-life onset eating disorders. How each of these domains is currently understood to play a role in the etiology of eating disorders has been extensively reviewed16 but not specifically in older adults. A discussion of some of these intrinsic and extrinsic causes of disordered eating in older adults is provided later in this review.
Patrick and Stahl17 noted that current knowledge is limited regarding adult-onset eating disorders. Their study involved 125 community-dwelling adults who were divided into four age groups (late adolescence, emerging adulthood, middle age, and late life). They suggested that overall, adults in midlife, especially women, may be at particularly high risk for disordered eating behavior; however, no significant associations were found between age and appearance satisfaction, or age and eating-associated cognition.
Scholtz and colleagues18 did not find evidence of late-life onset anorexia nervosa in a small study involving 32 patients (age >50 years) who were evaluated in an eating disorder clinic, as they were all lifelong cases. They concluded, “anorexia nervosa is a chronic and enduring mental illness that, although rare, can be found in older people.”
Family, twin, and genetic studies provide evidence for a genetic vulnerability toward developing anorexia nervosa and bulimia nervosa.19,20 Psychological causes that have been proposed include body dissatisfaction, a need for control, a plea for attention, and a coping mechanism for personal losses or life changes. Single case reports have indicated that the drive for thinness and a positive body image are maintained throughout life and often increase with the fear of aging.16,21-23
There is a high prevalence of cognitive deficits in persons with anorexia nervosa.24,25 These impairments are characterized by decreased awareness and understanding of the patient’s own symptoms and situation,24 and have been demonstrated through impairment in organizational strategy, memory, learning, problem solving, visual/spatial skills, attention, and executive function.25
Continued on next page
Clinical Presentation of Eating Disorders in Older Persons
Weight loss and failure to thrive secondary to poor oral intake or metabolic changes are commonly encountered in the elderly population. It has been reported that almost 85% of long‑term care residents, 62% of hospitalized elderly patients, and 15% of community-dwelling older adults who are seemingly able to prepare their own meals are malnourished.26 Weight loss is considered a sentinel event in long‑term care facilities that has been associated with increased risk of functional decline, frailty syndrome, poor quality of life, and mortality.
The differential diagnosis of significant, involuntary weight loss is quite broad, underscoring the importance of a thorough medical history, physical examination, and appropriate laboratory testing. When older patients present with suspected eating disorders (ie, bulimia or anorexia nervosa), the clinical features that are consistently observed are low body weight, fear of fatness, disturbed body image, and compensatory weight loss behaviors, such as self-induced vomiting, laxative misuse, and excessive exercising. However, stressful precipitating events, including difficulty handling life transitions, losses (ie, death of loved ones), and medical problems are additional characteristics consistent with cases of eating disorder in the elderly.16,21-23
The presence of comorbid psychiatric conditions can include depression, anxiety, posttraumatic stress disorder, bipolar disorder, and personality disorder. While depression and anxiety commonly lead to decreased appetite and weight loss, in such cases weight loss is usually unintentional and not associated with distorted body image or the preoccupation with food commonly seen in patients with eating disorders. Rarely, severely depressed or psychotic patients may develop paranoia about food intake (eg, food being poisoned), but in these cases, the level of psychosis is usually quite obvious to the examiner and a typical eating disorder behavior is not present.
Factors That Contribute to Anorexia of Aging
Anorexia, weight loss, and protein-energy malnutrition may be caused by a multitude of factors involving a complex web of psychological, social, and medical etiologies. Due to these compounding factors, it is important to understand the natural physiological changes of aging as well as fully evaluate each aspect of a patient’s life for potential contributions. Advancing age is accompanied by the presence of numerous physiological changes, an increasing number of chronic medical comorbidities, polypharmacy, and social challenges, all of which may negatively impact one’s inability to eat. What follows is a brief discussion of the important physiologic, pathologic, sociologic, and psychologic considerations to help guide clinicians on the appropriate investigations in the evaluation of older individuals with significant weight loss.
Physiological Causes of Anorexia in the Elderly
A number of interrelated physiological causes have been associated with anorexia in older adults. These include hormonal changes, cytokine excess, physiologic gastroparesis, and altered sensory function.
Hormonal changes. Changes in hunger with advancing age support the concept that there is a physiologic nature to the anorexia of aging. Multiple immunologic and hormonal changes have been described to contribute to this process. A global physiologic change in the regulation of energy intake that increases the elderly population’s susceptibility to energy imbalance has been described.27 In general, there is a global decline in activity and energy expenditure, reduced resting metabolic rate, changes in hormonal composition, and reduced body mass. Factors involved in the pathogenesis of anorexia related to advancing age include interleukin-1 (IL-1), insulin-like growth factor 1, tumor necrosis factor-alpha (TNF-α), and nitric oxide. It is postulated that nitric oxide, which is responsible for the adaptive relaxation of the fundus, decreases in older individuals, resulting in impaired fundal compliance. Cholecystokinin levels (a satiating hormone) are recognized to be increased in animal models. Sex hormones, which increase appetite, decline in both postmenopausal women and hypogonadal men.
Cytokine excess. Cytokines play a major role in immunomodulation and have been implicated in the involvement of anorexia, weight loss, cognitive dysfunction, anemia, and frailty.28 Excessive cytokine release is probably the most common cause of cachexia observed in acutely ill patients. Aging is associated with increased concentrations of TNF-α, IL-6 and IL-1 receptor antagonists, C-reactive protein, and overall increased activation of the entire inflammatory cascade. These proinflammatory cytokines are also postulated to play a role in the pathogenesis of other age-related diseases, such as Alzheimer’s disease, Parkinson’s disease, sarcopenia, and osteoporosis.
Physiologic gastroparesis. With age, there are changes to the gastrointestinal sensory function that lead to premature feelings of fullness in older adults. Studies suggest that the increased prevalence of delayed gastric emptying in older persons compared with younger persons is caused by antral distension and decreased adaptive relaxation, leading to early satiation. Hence, older adults often perceive satiation before they have consumed enough calories to satisfy their nutritional needs.27
Altered sensory function. The enjoyment of food depends on taste, texture, temperature, and odor, all of which produce the ultimate sensory experience. In older persons, however, the senses are altered to some extent by aging.29 Early studies suggest that there is a reduction in the number of lingual papillae (ie, taste buds) with aging, and the ability to smell also declines progressively. Understandably, with the alteration of flavor, smell, and olfactory function, there is decreased enjoyment of food. In addition, persons with dementia experience alterations to taste and smell to a greater extent than cognitively intact persons.
Dentition/Oral Health Issues
Underlying dental and oral conditions are often overlooked in the elderly population. Issues such as poor oral hygiene, thrush, ill-fitting dentures, xerostomia, and other mouth conditions often make tasting, chewing, and swallowing a challenge. It is estimated that in the United States, 30% of adults older than 65 years have lost all of their natural teeth and 36% of adults older than 75 years have severe periodontal disease.30 Dentures may also cause problems, such as traumatic ulcerations, denture stomatitis, inflammatory papillary hyperplasia, and epulis fissuratum, often making chewing painful.30
Clinicians must also take into account patients’ comorbidities when they present with significant weight loss, as many chronic diseases can negatively impact maintenance of healthy muscle mass, normal gastrointestinal function, and other functions of eating, such as appetite. If clinicians can recognize these comorbidities as contributing to significant undesired weight loss, they can institute the appropriate therapies.
Diabetes mellitus is associated with gastroparesis, autonomic dysfunction, and neuropathy, often worsening preexisting physiologic gastroparesis. Hypermetabolic conditions that accelerate resting metabolic rate (eg, cancer) can cause progressive loss of muscle mass and lead to an anorexia-cachexia syndrome. This is associated with rapid weight loss, and, therefore, malignancy should be considered in the differential diagnosis for anorexia in the elderly.
Patients with end-stage renal disease commonly present with both anorexia and catabolic state caused by a facilitative interaction between proinflammatory cytokines, alteration in central nervous system regulation of appetite, acidosis, uremia, anemia, and other hormonal derangements.31 Approximately 32% of dialysis patients have poor appetite, which is also associated with overall poor long‑term outcome.32
Cardiac cachexia is a common complication of chronic congestive heart failure and is associated with increased catabolic state, weakness, and fatigue. Evidence points to immune and neurohormonal abnormalities involving elevated levels of norepinephrine, epinephrine, cortisol, and inflammatory cytokines.
Weight loss is a frequent complication seen in patients with chronic obstructive pulmonary disease from both metabolic and mechanical inefficiency leading to increased energy expenditure. Outcomes are generally improved with a treatment approach involving a combination of oral nutritional supplements and anabolic stimulants.33
Studies have shown that 67% of subjects with rheumatoid arthritis in the United States are cachectic.29 This is likely related to cytokine excess, increased resting energy expenditure, and reduced physical activity from pain, resulting in a progressive loss of body cell mass.
Common gastrointestinal problems, such as dyspepsia, are extremely prevalent in older persons and are associated with anorexia. Helicobacter pylori is a common cause of dyspepsia and gastritis; after appropriate treatment, the symptoms of anorexia have been shown to improve. Similarly, patients with intestinal bacterial overgrowth have weight loss associated with both anorexia and malabsorption.
Progressive anorexia and weight loss is highly common in patients with neurodegenerative diseases such as Alzheimer’s disease, Parkinson’s disease, Lewy body dementia, and vascular dementia. The severity of weight loss and the options for treatment depend on stage of the disease. In the early stages of dementia, patients are usually able to maintain their body weight. Depression may set in during this time and should be identified and treated early. During the middle stages of dementia, patients frequently lose weight related to inability to consume enough food, forgetting to eat, loss of interest in eating, or inability to recognize food. Many patients develop feeding apraxia (ie, forgetting how to use utensils or how to put food in their mouths). Often, they are unable to communicate their underlying discomfort, such as denture problems, unrecognized esophagitis, ulcer disease, diverticular disease, constipation, or other gastrointestinal problems that may be causing physical discomfort. Weight loss from end-stage dementia is complex and difficult to treat. Feeding apraxia and mechanical ability to chew food is often lost. There is loss of drive to eat and recognize food as sustenance to life. There is a higher prevalence of oral problems and dysphagia in this patient population, placing these patients at high risk for aspiration.
Anorexia is a reported side effect of more 250 prescription and over-the-counter medications.34,35 In addition, many medications may result in nausea, constipation, gastrointestinal irritation, and stomach ulcers as a side effect, which may contribute to anorexia. Certain drugs may also cause malabsorption, increasing metabolism, or a combination of the aforementioned gastrointestinal symptoms. If there is a high degree of suspicion that certain medications may be contributing to a specific symptom, the clinician may choose to switch to a different agent; however, if the risks of continuing this medication clearly outweigh the benefits, especially in an older adult with limited life expectancy, it would be reasonable to withdraw the medication. Physicians should carefully evaluate the medication lists of their elderly patients for side effects and interactions that can cause anorexia or weight loss, and withdraw any medications that are suspected to cause these disorders.
Social and Environmental Factors
Many community-dwelling elders live alone and face different challenges from those residing in long‑term care facilities. Many adults experience declining income after retirement as well as some degree of functional impairment, both of which may contribute to less frequent eating due to difficulty traveling to the grocery store, affording groceries, and cooking/preparing their own meals. Socially isolated elders are often deprived of the pleasures surrounding social meal times; an occasion for sharing, enjoyment and socialization, which all factor into the overall enjoyment of food. Other social factors to consider are history of elder abuse and having overall poor knowledge of food nutrition.
Diagnosing an Eating Disorder in an Older Patient
Although eating disorders are typically not the first and most pressing diagnostic consideration for elderly patients experiencing significant weight loss, they should be included in the differential diagnosis, especially when patients present in the setting of cognitive distortion and impairment and excessive emphasis on maintaining a “perfect, youthful” body image. Evaluation of eating disorders should involve history-taking, physical examination, and laboratory work-up.
It is not uncommon for individuals with eating disorders to withhold information about restrictive or purging eating behaviors, conflict about weight and body image, or how frequently they exercise. Some patients may attempt to conceal physical evidence of an eating disorder such as anorexia by wearing loose-fitting clothing that makes them look heavier. On the other hand, some patients may not even recognize that these behaviors or thoughts are unusual or problematic. Anorexia nervosa can be difficult to diagnose in patients who may not express their obsession with being thinner or achieving a particular body shape or weight; instead, clinicians might make note of other psychological issues, such as being overly scrupulous about diet, pursuing excessive cosmetic surgeries, and showing emphasis on exercise or self-control.
It is important to understand why many persons with eating disorders feel the need to conceal their problem. Patients may believe that discovery of their eating disorder means that they will be forced to gain weight—the very thing that they fear. From their perspective, to be discovered as having an eating disorder means being doomed to a life of anxious misery. Some patients may feel embarrassed over what they regard as a weakness (eg, vomiting, laxative use, binging) so they are hesitant to be open. Once a person starts pursuing medical work-ups and treatment for weight loss, nausea, vomiting, diarrhea, or other symptoms of an eating disorder, he or she might feel progressively worse about being “caught in deception” and having to reveal to family and friends that these signs and symptoms are self-induced. The prospect of disappointing family and friends, especially those who are paying for their medical care, can create a tangled web.
For recurrent, lifelong eating disorders, it is essential to extend history back to the patient’s teenage years and 20s—the peak years of the development of eating disorders. Early-onset eating disorders may wax and wane, or they can become fixed and chronic for years, becoming unstable and requiring medical attention later in life. Late-life onset requires having a deeper discussion with family members regarding circumstances surrounding the onset of the abnormal eating behaviors. One revealing behavior commonly gleaned from history-taking that includes discussion with the patient’s family and/or friends is the patient’s avoidance of eating by leaving the table early or constantly moving about during mealtimes.
Consultation with a nutritionist, particularly one familiar with eating disorders, sometimes uncovers unusual beliefs about food and markedly restrictive diets; direct observation of a patient’s eating can also be very valuable. Patients with eating disorders may classically prepare food for family but not eat any of it. They may limit themselves to a small number of low-calorie foods, eat excessive amounts of high-fiber or filler foods, and declare food allergies, vegetarian preferences, or lactose intolerance to avoid eating a balanced diet.
A complete physical examination should be performed to identify underlying medical diseases. Physical examination alone is not going to differentiate the marked weight loss of anorexia nervosa from that caused by a multitude of other medical problems; however, it can reveal several findings that might point the physician in the appropriate direction. For instance, an examination of the oral cavity may reveal dental problems indicative of chronic purging by vomiting, and inspection of the hands may show the calluses on the dorsum of the hand that is used to induce the gag reflex for vomiting. In addition, a history of osteoporosis or osteopenia or the physical finding of stress fractures and overuse injuries should invite careful questioning and pursuit. Clinicians may also inquire about the patient’s exercise regimen to see if there is a history of excessive physical activity out of fear of weight gain.
There is no specific laboratory test to differentiate marked weight loss in a geriatric medically ill patient from one with an eating disorder. Basic laboratory testing should include a complete blood count, electrolytes, sedimentation rate, thyroid stimulating hormone, liver enzymes, and prostate specific antigen (for men). In all patients with unexplained weight loss, esophagogastroduodenoscopy, colonoscopy, and computed tomography scans of the abdomen and pelvis should be considered. If diarrhea is a prominent symptom, testing for the presence of laxatives occasionally leads to productive discussions with the patient.
Management of Eating Disorders
Presently, there is no generally agreed upon approach to managing geriatric eating disorders based on published trials. Clinical efficacy of current interventions is based only on case reports, which provide a wide variety of treatment methods.8 Because treatment strategies for eating disorders in the geriatric population are generally extrapolated from that of the younger population, many of these treatment methods are consistent with techniques for younger sufferers. However, successful treatment of geriatric eating disorders is especially challenging, as late-onset and extended duration of illness predict poor outcomes.36 Eating disorders in the elderly are often superimposed on preexisting chronic or acute medical or other psychiatric conditions, which may confer a higher risk for morbidity and mortality in this population. Consequently, one must treat the comorbid conditions as vigorously as one treats the eating disorders. This starts with recognizing the high incidence of these comorbidities and then applying the appropriate treatment for the condition identified. The most successful outcomes are derived from a combination of interventions, including integrated psychotherapy and behavioral interventions, pharmacologic management for psychiatric comorbidity, and nutritional therapy. Optimal management relies upon well-coordinated interdisciplinary team efforts of psychologists and psychiatrists to recommend and oversee psychotherapy and psychopharmacologic management; primary care physicians to help monitor and treat emerging medical complications; dietitians to provide ongoing nutritional counseling and coaching; and family members and caregivers to provide support in all areas of care.
Psychotherapy is an essential part of treating eating disorders. Cognitive behavioral therapy is typically a short-term (15-20 sessions), structured treatment to help patients address thoughts, feelings, and behaviors that sustain eating disorders. Patients learn to deal with distorted thinking, replace destructive eating habits with healthy ones, and stop purging. Interpersonal psychotherapy focuses on resolving relationship issues that may influence the eating disorder. Psychodynamic psychotherapy helps to resolve underlying problems linked to the eating disorder. Family therapy provides family with understanding of the eating disorder and helps establish healthy roles in promoting recovery. Group therapy format has been used with all the above modalities and has some unique beneficial attributes. For elderly individuals with cognitive impairment that limits utility of the above psychotherapeutic interventions, it is essential to adjust the psychotherapy strategies accordingly in a way that still enables a therapist to address life transitions, losses, and fear of aging.
There are currently no medications that are FDA-approved to specifically treat anorexia nervosa37; thus, psychopharmacologic interventions are indicated in the presence of psychiatric comorbidities. Antidepressant medications are used to treat depression, anxiety, and obsessive-compulsive disorders that often accompany anorexia and bulimia nervosa. Antianxiety medications, such as benzodiazepines, may help with the initial fear associated with eating that otherwise erodes efforts at re-establishing healthy eating patterns. Antipsychotic medications have been used in severely underweight, anxious patients who have not responded well to other medications and treatments. Treatment options run in a continuum from inpatient through residential, partial hospitalization, and outpatient.
In a 2011 position paper, the American Dietetic Association recommends nutrition intervention, including counseling by a registered dietitian (RD), as an essential component of the interdisciplinary treatment of eating disorders.37 The RD’s responsibilities can include performing a nutrition assessment to identify nutrition problems related to the eating disorder; implementing a care plan or intervention that normalizes eating patterns and restores healthy weight; monitoring and re-evaluating the patient’s progress with the care plan; and working collaboratively with care plan members to communicate nutrition needs during care transitions.
Eating disorders in the elderly have historically been overlooked and seemingly underdiagnosed. If left untreated, eating disorders can lead to a variety of health complications and even death. The prevalence of these disorders is expected to increase as the elderly population rises and as patients diagnosed in their youth begin to age. Consequently, clinicians need to be aware that eating disorders do occur in elderly patients, and they need to have the tools to properly evaluate, diagnose, and treat this population. Awareness of the warning signs, symptoms, and clinical features will be especially important for those working with geriatric patients, as it is the key to recognizing the disorder before the patient deteriorates to a point of hospitalization. Additionally, the inclusion of eating disorders in the differential diagnosis for cases of unexplained weight loss in the elderly will be important for a swift and accurate diagnosis.
- University of Maryland Medical Center. Eating disorders: introduction. www.umm.edu/patiented/articles/what_eating_disorders_000049_1.htm. 2011. Accessed May 14, 2013.
- American Psychiatric Association. Feeding and eating disorders. www.dsm5.org/Documents/Eating%20Disorders%20Fact%20Sheet.pdf. Published May 2013. Accessed June 18, 2013.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000.
- Anorexia nervosa. The Free Dictionary. http://medical-dictionary.thefreedictionary.com/anorexia. Accessed May 14, 2013.
- Champion A. Anorexia of aging. Ann Longterm Care. 2011;19(10):18-24.
- Berkman JM. Anorexia nervosa, anorexia, inanition and low basal metabolic rate. Am J Med Sci. 1930;180(3):411-424.
- Ryle JA. Anorexia nervosa. Lancet. 1936;2:893-899.
- Lapid MI, Prom MC, Burton MC, McAlpine DE, Sutor B, Rummans TA. Eating disorders in the elderly. Int Psychogeriatr. 2010;22(4):523-536.
- Hewitt PL, Coren S, Steel GD. Death from anorexia nervosa: age span and sex differences. Aging Ment Health. 2001;5(1):41-46.
- Muir A, Palmer RL. An audit of a British sample of death certificates in which anorexia nervosa is listed as a cause of death. Int J Eat Disord. 2004;36(3):356-360.
- Mangweth-Matzek B, Rupp CI, Hausmann A, et al. Never too old for eating disorders or body dissatisfaction: a community study of elderly women [published correction appears in Int J Eat Disord. 2007;40(2):193]. Int J Eat Disord. 2006;39(7):583-586.
- Gadalla TM. Eating disorders and associated psychiatric comorbidity in elderly Canadian women. Arch Womens Ment Health. 2008;11(5-6):357-362.
- Franco KN. Eating disorders. Cleveland Clinic Center for Continuing Education. www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry-psychology/eating-disorders. Published March 2012. Accessed June 18, 2013.
- Zerbe KJ. Integrated Treatment of Eating Disorders: Beyond the Body Betrayed. New York, NY: WW Norton & Company; 2008:192-220.
- Patrick JH, Stahl ST. Understanding disordered eating at midlife and late life. J Gen Psychol. 2009;136(1):5-20.
- Scholtz S, Hill LS, Lacey H. Eating disorders in older women: does late onset anorexia nervosa exist? Int J Eat Disord. 2010;43(5):393-397.
- Klump KL, Kaye WH, Strober M. The evolving genetic foundations of eating disorders. Psychiatr Clin North Am. 2001;24(2):215-225.
- Klump KL, Miller KB, Keel PK, McGue M, Iacono WG. Genetic and environmental influences on anorexia nervosa syndromes in a population-based twin sample. Psychol Med. 2001;31(4):737-740.
- Zerbe KJ. Eating disorders in midlife and beyond: transition and transformation at a crucial developmental stage. Psychoanal Psychother. 2002;19:9-20.
- Zerbe KJ. Eating disorders in middle and late life: A neglected problem. Primary Psychiatry. 2003;10(6):76-78.
- Zerbe KJ, Marsh SR, Coyne L. Comorbidity in an inpatient eating disordered population: clinical characteristics and treatment implications. Psychiatr Hosp. 1993;24(1-2):3-8.
- Jones BP, Duncan CC, Brouwers P, Mirsky AF. Cognition in eating disorders. J Clin Exp Neuropsychol. 1991;13(5):711-728.
- Nikendei C, Funiok C, Pfüller U, et al. Memory performance in acute and weight-restored anorexia nervosa patients. Psychol Med. 2011;41(4):829-838.
- Ahmed T, Haboubi N. Assessment and management of nutrition in older people and its importance to health. Clin Interv Aging. 2010;5:207-216.
- Morley JE. Pathophysiology of anorexia. Clin Geriatr Med. 2002;18(4):661-673, v.
- Roubenoff R, Parise H, Payette HA, et al. Cytokines, insulin-like growth factor 1, sarcopenia, and mortality in very old community-dwelling men and women: the Framingham Heart Study. Am J Med. 2003;115(6):429-435.
- Morley JE, Thomas DR, Wilson MM. Cachexia: pathophysiology and clinical relevance. Am J Clin Nutr. 2006;83(4):735-743.
- Hatton ER, Gogan CM, Hatton MN. Common oral conditions in the elderly. Am Fam Physician. 1989;40(5):149-162.
- Axelsson J, Carrero JJ, Lindholm B, Heimburger O, Stenvinkel P. Malnutrition in patients with end-stage renal disease—anorexia, cachexia and catabolism. Curr Nutr Food Sci. 2007;3:37-46.
- Burrowes JD, Larive B, Chertow GM, et al. Self-reported appetite, hospitalization and death in haemodialysis patients: findings from the Hemodialysis (HEMO) Study. Nephrol Dial Transplant. 2005;20(12):2765-2774.
- Anker SD, Sharma R. The syndrome of cardiac cachexia. Int J Cardiol. 2002;85(1):51-66.
- Schiffman SS, Graham, BG. Taste and smell perception affect appetite and immunity in the elderly. Eur J Clin Nutr. 2000;54(suppl 3):S54-S63.
- Lewko M, Chamseddin A, Zaky M, Birrer RB. Weight loss in the elderly: what’s normal and what’s not. P T. 2003;28(11):734-739.
- Halmi KA, Casper RC, Eckert ED, Goldberg SC, Davis JM. Unique features associated with age of onset of anorexia nervosa. Psychiatry Res. 1979;1(2):209-215.
- American Dietetic Association. Position of the American Dietetic Association: nutrition intervention in the treatment of eating disorders. J Am Diet Assoc. 2011;111(8):1236-1241.
- Boisvert JA, Harrell WA. Ethnic and age differences in eating disorder symptomatology among Albertan women. Can J Behav Sci. 2009;41(3):143-150.
- Manejías Parke SG, Yager J, Apfeldorf W. Severe eating disorder initially diagnosed in a 72-year-old man. Int J Eat Disord. 2008;41(4):376-379.
Disclosures: Dr. Zerbe reports having received speaker honoraria from the Minnesota VA Medical Center. The other authors report no relevant financial relationships.
Address correspondence to: Maria I. Lapid, MD, Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; email@example.com