July/August 2013

Eating Disorders’ Prevalence Increases

By Stanley J. Dudrick, MD, FACS
Today’s Geriatric Medicine
Vol. 6 No. 4 P. 18

Eating disorders, particularly in the institutionalized elderly, are frequently overlooked or missed by providers, often with grave consequences.

Eating disorders such as anorexia nervosa and/or bulimia can occur insidiously and surreptitiously in the elderly, often because of the multiple other causes of unintentional weight loss that commonly accompany the aging process.

Furthermore, the underlying psychological or behavioral issues that can precipitate and fuel geriatric anorexia can infiltrate the lives of the susceptible elderly and can progress undetected by these patients, their families, and their caregivers, a camouflaged and potentially lethal invader if not recognized and treated judiciously. These include affective illnesses, paranoid psychosis, obsessive-compulsive disorders, and dementia, among others.1

Moreover, voluntary or involuntary weight loss in the elderly is well known to predispose them to muscle wasting, frailty, diminished immunocompetence, depression, and increased susceptibility to diseases and disorders, and strongly correlates with consequent morbidity and mortality.

Increasing Prevalence
In the past 50 years, anorexia nervosa usually has been associated with adolescent girls and young women; however, more recently, it has been increasingly detected and identified in the geriatric population, especially in elderly women but also in elderly men. Indeed, eating and anxiety disorders have increased to the point that the majority of deaths currently secondary to anorexia nervosa in this country occur in people aged 65 or older.

The primary factor underlying anorexia in younger individuals is the distress caused by a distorted self-perception of body image, which is of less importance in the elderly. More prevalent factors that can lead to elderly anorexia or other eating disorders include alterations in taste and smell, especially secondary to medications; incompletely treated psychological problems persisting from younger years; cognitive and memory impairment; attention seeking; loss of a loved one, especially the person who prepared and shared meals, which may induce feelings of isolation and loneliness that can escalate to depression; refusing to eat as the only remaining form of control; rejecting food as a protest against relatives or caregivers; and even a conscious or subconscious attempt at suicide to escape depression, their environment, and/or feelings of despair.2

Unfortunately, eating disorders in the institutionalized elderly frequently are overlooked or missed by health care professionals, with potentially grave consequences. Conscientious, disciplined attention must be paid to fluctuations in weight, especially losses; daily balanced food intake, especially total calories, protein, vitamins, micronutrients, and fiber; activities of daily living, especially caring for personal appearance and hygiene; cognitive and social engagement; mood, attitude, and temperament; and maintenance of moderate exercise and physical activity to keep or stimulate appetite.3

Contributing Factors
Physicians and care team members routinely check vital signs but often overlook taking a comprehensive dietary history; thus, the elderly often are malnourished and undertreated. Further, it is estimated that more than 75% of adults aged 89 and older have significantly impaired gustatory senses of smell and taste. Additionally, saliva production usually decreases in the elderly, causing dry mouth, thick secretions, and poor oral and dental hygiene, leading to diminished food intake. Caries, poorly fitting dentures, and absent teeth can impair feeding and mastication. Dysphagia and other swallowing disorders can be discouraging and difficult to overcome. Various other gastrointestinal tract problems also occur in 50% to 75% of the elderly, leading to indigestion, reflux, and ultimately poor food and fluid intake.

The differential diagnosis of unintended weight loss in the elderly can be extensive.3 The most common causes identified include psychotic disorders (depression), cancer, and benign gastrointestinal disorders.3 Pulmonary diseases, cardiovascular disorders (especially congestive heart failure), alcoholism, dementia, and prescribed medications also have contributed to the problem.4 Although acute and chronic physical and psychiatric disorders account for unexplained weight loss in most elderly patients, other psychological and social factors may be involved.5,6 However, no cause was apparent or discovered in about 24% of 45 ambulatory patients, according to one study.7

The causes of weight loss in ambulatory patients may differ from those of long term care facility residents.3 In one study, depression was identified in 36% of nursing home residents with unintentional weight loss.8 In another study, overall, psychiatric disorders, including depression, accounted for 58% of the cases of involuntary weight loss in nursing home patients.3 Lower socioeconomic status and functional disabilities also can contribute to involuntary weight loss in elderly patients.5

Older patients who depend on others for their daily care are more likely to suffer unintended weight loss than those who are demented but less dependent on others or by those who are not demented.9 It is important to recognize that a loss of 5% to 10% of body weight in the previous one to 12 months may indicate a serious problem in an elderly patient, and this degree of weight loss should not be considered a normal consequence of the aging process.3

Identifying the Cause
Common treatable causes of weight loss in the elderly should be sought conscientiously.3 An initial approach is to distinguish among the four basic causes of weight loss: anorexia, dysphagia, socioeconomic factors, and weight loss despite normal intake, although these causes are often interrelated.3,10 Whatever assessment or diagnostic approach is used, the initial evaluation can yield a reason for weight loss in most patients.3,11

Various medications have been implicated as the cause of nausea and vomiting, dysphagia, dysgeusia, and anorexia.  Polypharmacy can cause unintended weight loss but so can a reduction in psychotropic medication by unmasking previously controlled anxiety or paranoia.3

A reasonable initial workup includes tests indicated by the history and physical examination, a fecal occult blood test, a complete blood count, a chemistry panel, an ultrasensitive thyroid-stimulating hormone test, and a complete urinalysis.3 Upper gastrointestinal studies, including a videofluoroscopic swallow study, can have a reasonably high yield in selected patients.3

In some ways, the issues of anorexia nervosa in the elderly are similar to those in young anorexia nervosa patients.2 Patients in both age groups tend to refuse meals, saying that they are too full to eat, not hungry, or feel ill.2 Both have somewhat distorted views of their bodies, perceiving themselves as heavier than they are or weighing more than they actually do; usually have family conflicts; and engage in secretive behaviors to hide their disease or disorder from others. Both age groups also may engage in purging behaviors, although the elderly are more likely to use laxatives rather than engage in self-induced vomiting (bulimia), which is a more common practice among younger people.

Unique Concerns
Some challenges specific to the elderly may be difficult for the clinician to diagnose. Medical problems may exist that affect elderly patients’ ability to consume food, such as infections, stomach or bowel problems, loss of teeth or poorly fitting dentures that make it painful to chew and eat, a loss of smell and/or taste, swallowing problems, medications that reduce or alter appetite, alcohol addiction, dementia-related memory problems that affect the ability to remember whether and when they have eaten, and various wasting diseases, such as cancer and other chronic illnesses.2 They also may be adversely affected by social problems, such as an inability to shop for groceries, cook meals, or even feed themselves as well as poverty, social isolation, or elder abuse in which a caregiver deliberately and maliciously withholds adequate food.2

As with younger people, the elderly develop eating disorders for various reasons.2 A loss of independence or ability to care for themselves coupled with the death of spouses, family, friends, and significant others can cause them to feel isolated and lacking or losing control over their lives.2 Refusing food can be a way of trying to regain a sense of control or, in severe cases, a passive means of solving their problems by ending their lives.2 Food refusal is thought to be distinct from a pure anorexic pattern of behavior and may be a separate psychobehavioral entity of old age.1

Undiagnosed depression, unresolved issues from the past, and stress triggers related to retirement, such as having to adjust to a lower level of income, also can cause eating disorders in this population.2 An eating disorder also can represent a form of attention seeking; a way to protest restrictions placed on the elder by his or her family, caregivers, or the care facility; or a revolt against the challenge of limited family visits.

Additionally, festering anger often is an underlying issue for elderly men. It has been documented that eating disorders can undergo remission for years, or even decades, then resurface in later life when an individual experiences unexpected stressors related to aging.2

Eating disorders in the elderly are particularly serious because chronic disorders or diseases may already compromise a patient’s health. Inadequate nutrition can result in memory deficits; cognitive decline; decubitus ulcers; impaired healing of sores, wounds, or infections; and dizziness, disorientation, and falls,2 which can initiate a cascade of pathophysiological events leading to 30% to 40% mortality rate.

Accordingly, it is important that caregivers remain alert and recognize signs and symptoms of depression, such as a loss of motivation to eat; making excuses for skipping meals, such as frequent claims of not being hungry or feeling sick; a fixation on death; unexplained weight loss; and chronic dizziness.2 Other indications of eating problems include a kitchen that appears unused, little or no food in the cupboards or refrigerator, and unopened packages of meals from a meal delivery service.2

Identifying Motivation
Treatment of unintentional weight loss must be directed at the underlying causes. While the workup is proceeding or if a cause is not well defined, the goal is to prevent further weight loss, and early initiation of nutritional support may help avoid or minimize related complications.3

Among the elderly, suicide often has been a surreptitious occurrence that has not received much attention from clinicians, in part related to the generally negative attitude toward older adults’ mental health and the assumption that little can be done to prevent them from taking their lives.12

Furthermore, a more perplexing problem for families and caregivers is “silent suicide,” which can be defined as a person’s efforts to kill himself or herself, often insidiously, by intentional starvation and/or noncompliance with prescribed supportive medical therapy. This is especially likely to occur among the elderly who are depressed, confined to institutional living or to bed, and/or suffering from other psychological, pathophysiological, social, cultural, economic, or situational problems that render continuing to live unbearable.12

The suicide rate in the United States rises steadily with advancing age but, unlike teenagers, who may contemplate or attempt suicide as a manifestation of situational distress, an older adult’s decision to die typically is much more determined and more likely to be successful. As a result, the success-fail outcome for elderly individuals who attempt suicide through violent means approaches 100% compared with adolescents, who succeed only approximately 1% of the time.12

 Moreover, it is thought that the attempt/success ratio of silent suicide by nonviolent means among the elderly approaches 100%. The problem of detecting or preventing silent suicide is further compounded by the fact that elders who refuse to eat or comply with medical treatment do so without warning or apparent manifestations of their true motives.12

Legitimate medical problems, together with recent personal losses, may mask suicidal warning signs by creating the clinical illusion that the patient has justifiable reasons for appearing to be depressed. Therefore, the caregivers and family may not suspect an elderly patient’s self-destructive intentions and attribute the patient’s clinical decline to other nebulous causes, such as the nonspecific failure to thrive, “giving up/given up” complex, or psychogenic mortality syndrome.12

Finally, even family members may intentionally or unintentionally aid and/or abet silent suicide by resisting or objecting to potentially therapeutic measures in their conscious and/or subconscious, well-intentioned zeal to spare an elderly loved one from enduring extended agony and grief.12 This most unfortunate, persistent, perplexing lethal problem among the elderly mandates vigilance and conscientious attention to the prevention, correction, and treatment of this subtle and disturbing ongoing tragedy.

Managing the Disease
Solutions for treating older people with eating disorders can be established rationally.2 As with young people with anorexia nervosa, working with the elderly to overcome or navigate their psychological issues has proven to be more effective than dealing with the weight loss or merely the food choices.2 Providing supportive counseling can help an elderly person cope with perceived loss, anger, lack of purpose, family conflicts, and self-esteem.2

For patients who exhibit signs and symptoms of anorexia, physicians may consider reviewing their prescriptions, prescribing medications that increase appetite, addressing depression, supporting the family constellation in resolving any conflicts, and providing recommendations for shopping and cooking.2 While depression can be treated with medication, the focus of anorexia nervosa treatment should revolve around psychotherapy.

Nutritional supplements may be necessary to remedy deficiencies and should preferably be in liquid form and given between meals. In severe malnutrition, hospitalization and even parenteral feeding may be necessary to reestablish the normal nutritional status and homeostasis essential to reinitiating an effective nutritional feeding regimen.

Anorexia nervosa in the elderly can be associated with serious complications, especially in the presence of preexisting diseases or disorders. Patients’ medication regimens often are compromised by their aberrant, unreliable food and fluid intake. Therefore, treatment must be initiated as soon as an eating disorder has been identified, particularly if it has been overlooked during days or weeks of weight loss.

It is important for a patient’s family and friends to be supportive and to understand that anorexia nervosa in the elderly is not merely a manifestation of a person’s stubbornness and refusal to eat but a serious and potentially lethal mental disorder. Attempting to force feed or being aggressive with an elderly anorexia nervosa patient actually can aggravate or worsen the condition and can more likely accelerate rather than prevent death.

The contributions of dietitians, speech therapists (for oropharyngeal and swelling evaluations), and social service personnel cannot be overestimated because these professionals’ efforts can improve strategies to increase food intake.3 In a long term care facility, the foodservice manager and caregivers frequently can offer innovative individualized suggestions for facilitating food intake.3 An early intervention can consist of removing dietary limitations such as restrictions on the intake of salt and/or high-cholesterol, high-saturated-fat foods.3

A less restrictive diet also may be given to patients with diabetes mellitus. In fact, sometimes weight loss in elderly patients with diabetes mellitus actually results from overzealous blood glucose control. However, blood glucose and glycosylated hemoglobin levels must be closely monitored in elderly diabetes mellitus patients.

Patients also may benefit from being offered frequent small servings of foods they like rather than larger portions or meals that may overwhelm them and actually discourage intake.

The use of additives to enhance the appearance, aroma, and taste of foods may be especially helpful for patients with impaired senses of smell and taste.3,13 In some patients with dysphagia or other swallowing difficulties, puréed foods and thickened liquids may be useful adjuncts in improving nutrient intake. Moreover, gastric emptying is quicker and total caloric intake is more likely to be maximized with liquid or puréed diets.3

Various medications have been used to promote weight gain; however, none is specifically indicated or recommended for the treatment of weight loss in elderly patients, and few have been studied specifically in this population.3,14 Moreover, the FDA has not approved any of these drugs “on label” for therapeutic use in elderly patients with weight loss.3

Finally, as part of a comprehensive therapeutic program, older patients can be encouraged to attend and participate in day programs to be more socially active, eat healthy meals prepared for them, dine with others for socialization and to help ensure that individuals with poor memories are eating adequately, and participate in a physical rehabilitation program to increase endurance, mobility, strength, and balance, all of which will likely improve their overall sense of well-being and increase independence as well as increase appetite and food intake.2

Final Thoughts
Loss of appetite is not intrinsically a normal characteristic of aging.2 However, with an increasingly older population, more cases of eating disorders in the elderly are being reported. Recognition of this fact is key to making an early and accurate diagnosis and providing older patients and their families and loved ones the optimal means and support for a better quality of life for the remainder of their time together.2

— Stanley J. Dudrick, MD, FACS, is the Robert S. Anderson, MD, Endowed Chair and Professor and medical director of physician assistant studies in the College of Arts and Sciences at Misericordia University in Dallas, Pennsylvania. He also is professor emeritus of surgery from the Yale University School of Medicine and chairman emeritus and program director emeritus from the department of surgery at Yale-affiliated Saint Mary’s Hospital in Waterbury, Connecticut.

References
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2. Rosen N. Anorexia nervosa in the elderly. Eating Disorders Review website. http://www.eatingdisordersreview.com/nl/nl_edt_3.html. 2010.

3. Huffmann GB. Evaluating and treating unintentional weight loss in the elderly. Am Fam Physician. 2002;65(4):640-651.

4. Chapman KM, Nelson RA. Loss of appetite: managing unwanted weight loss in the older patient. Geriatrics. 1994;49(3):54-59.

5. Fischer J, Johnson MA. Low body weight and weight loss in the aged. J Am Diet Assoc. 1990;90(12):1697-1706.

6. Markson EW. Functional, social, and psychological disability as causes of loss of weight and independence in older community-living people. Clin Geriatr Med. 1997;13(4):639-652.

7. Thompson MP, Morris LK. Unexplained weight loss in the ambulatory elderly. J Am Geriatr Soc. 1991;39(5):497-500.

8. Morley JE, Kraenzle D. Causes of weight loss in a community nursing home. J Am Geriatr Soc. 1994;42(6):583-585.

9. Fabiny AR, Kiel DP. Assessing and treating weight loss in nursing home patients. Clin Geriatr Med. 1997;13:737-751.

10. Gazewood JD, Mehr DR. Diagnosis and management of weight loss in the elderly. J Fam Pract. 1998;47:19-25.

11. Marton KI, Sox HC Jr, Krupp JR. Involuntary weight loss: diagnostic and prognostic significance. Ann Intern Med. 1981;95(5):568-574.

12. Simon RI. Silent suicide in the elderly. Bull Am Acad Psychiatry Law. 1989;17(1):83-95.

13. Schiffman SS. Taste and smell losses in normal aging and disease. JAMA. 1997;278(16):1357-1362.

14. Carr-Lopez SM, Phillips SL. The role of medications in geriatric failure to thrive. Drugs Aging. 1996;9(4):221-225.