Eating Disorders in Late Life: Implications forCliniciansPublished on Psychiatric Times(http://www.psychiatrictimes.com)

Eating Disorders in Late Life: Implications for Clinicians

November 27, 2014 | Eating Disorders [1], Geriatric Psychiatry [2]By Fragiskos Gonidakis, MD [3] and Dafni Karapavlou, MSc [4]

There are a considerable number of aging patients with an eating disorder who have only partialsymptom remission or who remain ill for many decades. Here is a case in point. Source:

Eating disorders, especially anorexia nervosa, have traditionally been considered an illness of theyoung, and their etiologies have been linked to the stress of the transition from childhood toadolescence and adulthood. The literature on eating disorders in the elderly is sparse, with only afew studies and case reports published during the past decades. There are a considerable number ofaging patients with an eating disorder who have only partial symptom remission or who remain ill formany decades. Moreover, although quite infrequent, there are cases of tardive eating disordersthat manifest in middle age or late in life.1

CASE VIGNETTEMrs K is 68 years old, married with 2 children and 3 grandchildren. She has suffered from bingeeating disorder and obesity since her early 30s. During her first visit, she confesses that the mainreason for her decision to return to treatment was that because of the disorder, she is constantlygaining weight and losing her ability to act independently.During her 40s and 50s, she had had 10 years of group psychodynamic psychotherapy and 5 yearsof individual psychodynamic-oriented psychotherapy that helped her with her marital problems butnot with the binge eating disorder. She says, I know that I am old and you are probably thinkingthat nothing can be done with me, but I think I deserve another chance to try to get well. I do notwant to just accept my condi-tion. I want to deal with it.

As illustrated in this brief case vignette, eating disorders not only exist in late life, but there is also alegitimate demand from the patients to get the best possible treatment rather than just palliativecare.Epidemiological dataMost of the studies conducted in populations of elderly women found that eating disorders were farless frequent in late life than in adolescence or early adulthood. Gadalla2 found that symptoms ofdisordered eating were present in 2.6% of women aged 50 to 64 years and in 1.8% of women aged65 years or older. Disordered eating symptomatology was positively associated with stress level andnegatively associated with physical health.The British National Psychiatric Morbidity Survey showed that rates of eating disorders were 4.3%,2.1%, and 1.1% in those aged 50 to 59, 60 to 69, and 70 or older, respectively.3 Mortality fromeating disorders, and specifically from anorexia nervosa, in the elderly was found to be quite high:10% in the 55 to 64 age-group, 12% in the 65 to 74 age-group, and 28% in the 85 and older group.4

Clinical symptomsIn an early report on eating disorders in late life, Hsu and Zimmer5 found that the symptoms ofanorexia nervosa and bulimia nervosa in the elderly closely resemble those in younger patients.Findings indicate that overall body dissatisfaction is somewhat stable across the life span.5-8 Acommunity study of 60- to 70-year-old women found that 60% of the participants were dissatisfiedwith their bodies and 80% practiced some form of weight control.8 An increased level of bodydissatisfaction was associated with higher BMI in mid-life and in older women.7 It should be notedthat body dissatisfaction in both men and women in late life is attributed to the aging process (eg,wrinkles, hair loss, muscular atrophy).Stressful life events and depression seem to be the most common precipitating events in late-onseteating disorders.9,10 In a study by Lapid and colleagues,1 54% of the patients reported that somekind of stressful events had occurred before the development of the eating disorder. The mostfrequent precipitating stressful events were widowhood and bereavement (42%), medical illnesses(23%), marriage-related difficulties (19%), and children-related issues (15%).The perpetuating factors of late-life anorexia nervosa may include relief from social and domestic

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Eating Disorders in Late Life: Implications forCliniciansPublished on Psychiatric Times(http://www.psychiatrictimes.com)responsibilities, control over others, and reduced social involvement.9-12 Older adults with eating

disorders may use disordered eating as a mechanism to regain power that has been lost as a resultof aging.1,12 For some patients, eating disorders are a way of gaining control over loved ones throughprotest and by drawing attention to the discontent they feel for their current circumstances. It mayeven be that in the elderly, eating disorders are a method of indirect suicide.1,12

ComorbiditiesWhile the eating disorder symptoms in the elderly are similar to those of younger individuals,diagnosis of eating disorders can be difficult in a complex geriatric patient. Eating disorders in olderwomen are highly comorbid with affective and anxiety disorders. Scholtz and colleagues13 found thateating disorders in women older than 50 years were comorbid with depression (46%), anxietydisorders (31%), alcohol dependency syndrome (19%), and personality disorder (19%). The mostcommon comorbid psychiatric disorder in elderly patients with eating disorders is MDD, which can bepresent in up to 69% of patients.1

Women older than 50 who have an eating disorder often report comorbid medical conditions that arerelated to aging and a prolonged eating disorder.13 The most frequently reported comorbidities areosteoporosis (38%) and GI problems (17%).5

Differential diagnosisIn elderly patients, weight loss is often attributed to a known medical condition and/or itspharmacological treatment or to a psychiatric condition such as depression.1 Moreover, malnutritionis common in the elderly, especially in medical inpatients, with an estimated prevalence between17% and 65%.14 Many physical and social factors that are associated with old age make the elderlyperson nutritionally vulnerable, including social isolation, poverty, reduced mobility, decreased GIreserve, and impaired taste sensation.Social isolationThe management and treatment of eating disorders in late life present a number of adversities thatthe clinician has to take into consideration. Most of the elderly patients with early-onset eatingdisorders live alone, with very few and often distant social relations. If they have been able to createa family of their own, spouses or children are often the primary caregiverswhich may bechallenging and sometimes exhausting.1 However, nearly half of elderly patients who have an eatingdisorder are not in a relationship.13 Moreover, these patients have limited contact with friends and/orextended family and limited time devoted to leisure activities.StigmatizationElderly patients with an eating disorder suffer double stigmatization: the disorder itself is highlystigmatized, and because it is considered a disorder of the young, further stigmatization is enduredbecause of advanced age. Many patients report that the first reaction of the clinician is oftendisbelief and frustration. You are too old to have an eating disorder or you are too old to betreated for an eating disorder are quite often the responses to their plea for help. Web sites are alsoseen as unhelpful because they are focused solely on younger patients.1

Treatments that work?Treatments that were regarded as beneficial by elderly patients with an eating disorder includedgroup therapy, couple therapy, practical support, and inpatient care on medical wards.1 A studyconducted in inpatient middle-aged women found that older women gained more benefit fromtherapy targeting grief and loss than did younger patients.15

The role of pharmacotherapy is limited and should be used with caution. Most older patients takemultiple medications for medical conditions, and the use of psychotropics may lead to adverseeffects or drug interactions.1 Dementia or symptoms of dementia are common in the elderly and canlimit the effectiveness of some psychotherapeutic strategies, such as cognitive-behavioral therapy.Consider a variety of medical, psychological, and social factors that can influence the effectivenessof the treatment strategies to propose to the patient a suitably adjusted treatment plan.ConclusionsAs illustrated in the following case vignette, eating disorders in late life can frequently beunrecognized or masked behind medical conditions, depression, or the natural changes of aging.Early recognition and proper treatment of eating disorders in the elderly are essential to reduce thepsychosocial and medical impact of the disorder and improve the patients quality of life.CASE VIGNETTEAn 18-year-old patient with anorexia nervosa wrote about her grandmother: Ever since I rememberher, she was very thin. She was always dieting, avoiding certain foods, not eating in social situations.On several occasions, I saw her chewing and spitting out foods that she did not allow anyone else inher family to eat. I understand that she was ill, but I cannot forgive her for persuading my mother to

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Eating Disorders in Late Life: Implications forCliniciansPublished on Psychiatric Times(http://www.psychiatrictimes.com)forbid me to eat a proper amount of food for my age. I see now in my grandmother all the signs of

anorexia that the rest of my family is not willing to admit. I do not blame her, I just do not want togrow old and be afraid, as she is, to eat a bowl of ice cream.

Late-Life Eating Disorders Disclosures: Dr Gonidakis is a Lecturer of Psychiatry and Ms Karapavlou is a psychology PhD candidate in theEating Disorders Unit, 1st department of psychiatry of the Athens University Medical School inGreece. They report no conflicts of interest concerning the subject matter of this article. References: 1. Lapid MI, Prom MC, Burton MC, et al. Eating disorders in the elderly. Int Psychogeriatr.2010;22:523-536.

2. Gadalla TM. Eating disorders and associated psychiatric comorbidity in elderly Canadian women. Arch Womens Ment Health. 2008;11:357-362.

3. Ng IS, Cheung KC, Chou KL. Correlates of eating disorder in middle-aged and older adults:evidence from the 2007 British National Psychiatric Morbidity Survey. J Aging Health.2013;25:1106-1120.

4. Hewitt PL, Coren S, Steel GD. Death from anorexia nervosa: age span and sex differences. AgingMent Health. 2001;5:41-46.

5. Hsu L, Zimmer B. Eating disorders in old age. Int J Eat Disord. 1988;7:133-138.

6. Webster J, Tiggemann M. The relationship between womens body satisfaction and self-imageacross the life span: the role of cognitive control. J Genet Psychol. 2003;164:241-252.

7. Gagne DA, Von Holle A, Brownley KA, et al. Eating disorder symptoms and weight and shapeconcerns in a large web-based convenience sample of women ages 50 and above: results of theGender and Body Image (GABI) study. Int J Eat Disord. 2012;45:832-844.

8. Mangweth-Matzek B, Rupp CI, Hausmann A, et al. Never too old for eating disorders or bodydissatisfaction: a community study of elderly women [published correction appears in Int J EatDisord. 2007;40:193]. Int J Eat Disord. 2006;39:583-586.

9. Dally P. Anorexia tardivelate onset marital anorexia nervosa. J Psychosom Res.1984;28:423-428.

10. Gonidakis F, Georgantopoulos G, Konstantakopoulos G, Varsou E. Late onset anorexia nervosaand the role of parental family: presentation of two cases. Eat Weight Disord. 2014;19:409-412.

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Eating Disorders in Late Life: Implications forCliniciansPublished on Psychiatric Times(http://www.psychiatrictimes.com)11. Nicholson SD, Ballance E. Anorexia nervosa in later life: an overview. Hosp Med.

1998;59:268-272.

12. Harris M, Cumella EJ. Eating disorders across the life span. J Psychosoc Nurs Ment Health Serv.2006;44:20-26.

13. Scholtz S, Hill LS, Lacey H. Eating disorders in older women: does late onset anorexia nervosaexist? Int J Eat Disord. 2010;43:393-397.

14. Clarke DM, Wahlqvist ML, Rassias CR, Strauss BJ. Psychological factors in nutritional disorders ofthe elderly: part of the spectrum of eating disorders. Int J Eat Disord. 1999;25:345-348.

15. Forman M, Davis WN. Characteristics of middle-aged women in inpatient treatment for eatingdisorders. Eat Disord. 2005;13:231-243. Source URL: http://www.psychiatrictimes.com/eating-disorders/eating-disorders-late-life-implications-clinicians

Links:[1] http://www.psychiatrictimes.com/eating-disorders[2] http://www.psychiatrictimes.com/geriatric-psychiatry[3] http://www.psychiatrictimes.com/authors/fragiskos-gonidakis-md[4] http://www.psychiatrictimes.com/authors/dafni-karapavlou-msc

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