Anorexia among the elderly

Anorexia nervosa vs. anorexia in the elderly

Before examining how AN impacts older patients, it's important to make the distinction between anorexia nervosa and anorexia.

Anorexia nervosa is a medically recognized mental health disorder. It involves a number of interconnected mental, physical, and emotional causes and symptoms. Limited food intake is often part of how the disorder presents, but it also commonly manifests as a fixation with body image, an extreme fear of gaining weight, and other symptoms.

On the other hand, anorexia simply describes the symptom of not eating. It's almost always part of an AN diagnosis, but it can present as part of many other medical complications and conditions.

It's possible for older patients to experience anorexia—as a reaction to certain medications, for example—without having anorexia nervosa. But both issues are dangerous and should be treated appropriately.

What causes anorexia in the elderly?

A diminished food intake is very common among older patients. One study found that, for patients 65 or older, anorexia impacts as many as:¹

• 25% of people who live at home
• 65% of people in hospital settings
• 85% of people living in nursing homes

The shocking prevalence among this age group is likely connected to the numerous mental and physical changes that take place during the aging process. In fact, anorexia seen in older patients is often called anorexia of aging (AA).¹

In some patients, this loss of appetite can also work to develop, support, or revive a case of anorexia nervosa.

Depression

Anorexia is considered one of the major symptoms of depression in the elderly, with everything from changing biology to living arrangements has been suggested as a contributing factor.²

Certain neurotransmitters can contribute to the issue, with different areas of the brain becoming more active during bouts of depression, leading to decreased appetite or motivation to eat.⁵ And some studies mention a number of frequently co-occurring risk factors, including general weakness and frequent stomach aches and nausea, as potential reasons for the high overlap.⁶

Chronic illness

As people age, they are unfortunately more susceptible to developing chronic health conditions. As much as 80% of older adults are dealing with at least one chronic condition, and up to 50% are dealing with two or more.⁴ And a number of these illnesses can contribute to developing or sustaining anorexia.

Chronic health conditions as people age can contribute to developing anorexia. As much as 80% of older adults have at least one chronic health condition. Up to 50% have two or more.

Gastrointestinal diseases, acute and chronic infections, and thyroid-related conditions, such as hypothyroidism, have all been tied to the development of anorexia in older people.⁶ Malabsorption syndrome, a condition where the body has difficulty absorbing the proper nutrients needed to function, can also come into play.⁶

Chronic low-grade inflammation, which affects many people as they get older, can be another contributing factor to fluctuating appetite.⁶ This can be especially triggering for people who previously experienced anorexia nervosa or those who may still struggle with undiagnosed AN.

Persistent body image concerns

Sadly, the desire to maintain a certain body weight, shape, or size doesn't always lessen with age. One study found a group of women aged 61 to 92 collectively named weight as their greatest concern.⁷

A study of Swiss women found as many as 63% of participants age 65 or older still expressed a desire to lose weight. And 31% of them had recently engaged in a diet, despite a majority of that group being considered a "normal" weight.⁷

Yet another report found that 20% of participants age 70 or older were actively dieting, despite no pressing need to lose weight and the actual threat of weight loss complicating their health conditions in some cases.⁷

These types of concerns are contributing factors to anorexia nervosa and other common eating disorders, regardless of age.

Medication side effects

Older people are much more likely to take a number of medications to help ease or address the various symptoms of aging. Unfortunately, these drugs—while intended to help—can sometimes interfere in other ways.

Some drugs, including antibiotics, can lead to malabsorption and other gastrointestinal issues. Many others include a loss of appetite or interest in food as potential side effects.⁶

Still others, including proton pump inhibitors, which are commonly prescribed for gastrointestinal problems, have been found to cause hypochlorhydria in some patients. This leads to a slower emptying of the stomach, which can both decrease appetite and alter satiety signals in the small intestine.⁶

Dementia and Alzheimer’s disease

Dementia—and, in particular, its expression as Alzheimer’s disease—has also been noted as a leading factor in changing eating habits among the elderly, including the potential development of anorexia nervosa in older people.

The connection between the two conditions can be both complex and layered, with dementia touching on a number of physiological, psychological, and social factors that may dictate the way people eat.

Complicating factors potentially brought on by dementia include, but are not limited to:⁸

• Biologically driven changes in hunger and satiety levels
• Fluctuating flavor and texture preferences
• Changes in a person’s intrinsic attitude, motivation level, and personality

People with dementia may also simply forget to eat or forget whether they have already eaten, leading to further confusion and behavioral change.

As the disease progresses, it can also impact someone’s level of socialization, which can affect the amount of food a person typically eats. Finally, as dementia enters its late phases, even the act of swallowing food may become difficult, causing additional barriers to eating enough.⁸

Age-related lifestyle changes

Up to 27% of people aged 60 and older in America live alone, according to some studies. That number reaches 45% by age 65 and climbs as high as 58% for those aged 80 and older.^9,10

The loneliness associated with this type of living arrangement in and of itself has been linked to potential mental and physical health complications, including depression and Alzheimer’s.¹⁰ And the isolation can make it easier for someone to hide or deny symptoms associated with anorexia nervosa.

Living alone in older age

More and more people end up living alone as they grow older:^9,10

• At age 60 and older, up to 27% of people live alone
• By age 65, 45% of people live by themselves
• At age 80 and above, as high as 58% of people live alone

Living alone can also make it harder for elderly folks to shop for or prepare food for themselves, especially if there are functional deficiencies that are caused by aging.⁶

Age-related biological changes

As the body continues to age, the way people perceive smell and taste is also impacted. Taste buds begin to atrophy, starting with those detecting sweet and salty flavors, which can cause someone to lose interest in eating and, therefore, eat less frequently.⁴

Saliva production also decreases as the body ages, making it harder for foods to dissolve in the mouth and interact with what taste buds remain.⁶ This can also lead to difficulty chewing or swallowing, which can play a role in both the decrease in eating and the absorption of certain important nutrients.⁶

The aging process also impacts hormone regulation in ways that could potentially affect someone’s eating patterns. The levels of key hunger- and satiety-related hormones, including ghrelin, leptin, and insulin, are all in flux during this time. As a result, these hormones send different types of signals to the body that have been theorized to lead to either developing or supporting anorexia in older age.⁶

Anorexia nervosa risk factors for older patients

Aside from the many aging-related factors that may make someone susceptible to developing AN or experiencing anorexia, there are other risks that could lead to disordered eating patterns in older people.

Potential health complications related to anorexia in the elderly

Anorexia and AN can have a number of adverse health effects on anyone. But older people may be even more vulnerable to these conditions, or at higher risk for encountering their worst impacts, due to their advanced age.

Why anorexia nervosa in the elderly may go undiagnosed

While recent anecdotal evidence points to large numbers of older people struggling with anorexia nervosa, the scientific exploration of this subject is still relatively new. 

Aside from this group not historically receiving the same type of clinical recognition in this area as younger or adolescent people, there may be several other reasons why older people with AN may not get properly diagnosed.

Living arrangements

As previously noted, it is much more likely for elderly people to live on their own. This type of living arrangement can make it difficult for a friend, family member, or loved one to tell when or whether someone has developed an unhealthy relationship with food.

Further, living alone can allow someone to ignore the signs and symptoms of their own disorder much longer or create a lifestyle that caters to their disordered eating patterns, further ingraining the behavior.

Comorbid conditions/overlapping side effects

Many older people tend to struggle with at least one chronic health condition, and many of these conditions have similar signs and symptoms of anorexia nervosa, including weight loss, loss of appetite, aversion to food, or even depression or anxiety.

The medications many older people take for any number of reasons can also produce side effects that overlap with AN symptoms, such as malnutrition, weight loss, and loss of appetite.

Either co-occurring conditions or medications can interact with a person’s biology and genetics, working to activate potential pre-existing susceptibilities for developing anorexia nervosa.

These types of complicated relationships and overlapping effects can mask the true face of AN in an older person. This makes it difficult for a friend, family member, or even physician to pinpoint the disorder as the true cause of these signs and symptoms.

Unrecognized long-term cases

It's possible that many older people who struggle with anorexia nervosa have already been dealing with the condition for a long time. These people may have disordered eating patterns or behaviors that were never clinically addressed, allowing them to continue unabated.

If this type of behavior has been longstanding, it can be even more difficult for friends and relatives to detect symptoms or understand how serious someone's condition may be. Their symptoms may have already been well developed by the time they married or had a family, establishing an initial impression of the person’s eating behaviors that were never questioned.

It’s also possible for the person to have addressed the issue and recovered from anorexia, only to relapse when entering older age as a result of the social, psychological, and physiological stressors of the transition.

Anecdotal evidence supports this theory, though peer-reviewed research on the subject is lacking.

Treatment for older patients with anorexia nervosa

Treating anorexia nervosa, or almost any other health issue, in an older adult often includes several different courses of treatment to address each issue separately. This is mostly due to the high likelihood of co-occurring health conditions. 

Some methods may lend themselves better to dealing with the difficulties that impact older people struggling with anorexia.

Cognitive remediation therapy

One of the leading forms of therapy for treating anorexia nervosa in any type of patient, cognitive remediation therapy (CRT) attempts to help people by targeting both someone’s cognitive abilities and social functioning.

CRT works to bolster someone’s attention and perception, logic, memory, and motor control, with the hope of improving their ability to manage the stressors of daily life and rely less on their eating disorder for a sense of control or stress relief.¹⁹

Primarily, the goal of CRT is to help someone with AN improve their cognitive flexibility, the mental skill that allows them to be more adaptive to current situations and less reliant on routines, rituals, or other forms of rigid thinking. It also addresses issues with central coherence, a condition many people with anorexia share that leads them to focus—or even obsess—over details rather than see the bigger picture.

Interpersonal therapy

Interpersonal therapy (IPT) examines a person’s broader role in society, with a specific focus on how that role changes during times of transition—including the transition into older age.

IPT does not try to directly change harmful thoughts or behavioral patterns, such as those associated with disordered eating, which may be triggered by the stressors of this change. Instead, IPT starts with helping someone explore their feelings and attitude about their current and changing position and how change impacts the dynamics of their personal relationships.²³

The hope of this therapeutic approach is that, by helping to cultivate acceptance of change, it will help bring about a greater acceptance of where a person currently is in life. This can allow for the inner peace needed to work through any emotional issues that may be perpetuating an eating disorder or other comorbid conditions.

Environmental adaptation

Environmental adaptation isn’t a type of psychotherapy. Rather, it is a form of intervention intended to help people make changes by literally changing their environment.

Created primarily for elderly or disabled people who still wish to live at home, environmental adaptation involves changing someone’s living space in ways that may make it easier for them to live more fully and independently. This can include everything from adding certain objects to removing certain objects, and incorporating special equipment or tools throughout a living space. The individual and any family members or close friends are also trained in how to use this special equipment.²⁴

These types of changes have been found helpful for elderly people wishing to live at home, though data on how these changes may specifically impact someone struggling with anorexia is limited.²⁰ Still, other research on the subject has found that environmental changes, coupled with broader adaptations of mealtime routines and further behavioral modifications, have offered benefits for older people struggling with anorexia.²⁰

Potential barriers to treatment

Finding the right kind of treatment to help elderly people with anorexia or anorexia nervosa is one thing, but ensuring they receive that treatment is another. Unfortunately, there are a number of difficulties that may complicate that aim. 

Finding help for an eating disorder

If you or a loved one are struggling with disordered thoughts or behaviors around food, it's important to seek help. This may be even more urgent for an older person struggling with anorexia nervosa or another common eating disorder.

Many older people have silently struggled with anorexia or other eating disorders for years, with the illness having had decades to harm their physical and mental health. Even those who develop anorexia in older age are at a much higher risk of enduring the worst possible consequences of the disorder.

Yet, recovery is always possible, for any person, at any age. Even in later life, there are still plenty of reasons to ask for help, to live as long, healthfully, and happily as possible.

If you think you or a loved one is struggling with anorexia, you should seek the proper treatment as soon as possible.