Understanding elderly with eating disorders
Eating disorders in adults over the age of sixty present unique physical and psychological health risks that are important to address in a specialized care plan.
The cause of eating disorders in the elderly may include:
- Divorce or death of a partner
- Empty nesting of children or grandchildren
- A new diagnosis of a chronic or terminal illness
- Difficulty coping with or accepting age-related changes
- Financial hardship
- Reduced mobility
- A change in living situation or environment
- An extension of an untreated eating disorder from earlier life
It is important to note that many newly diagnosed patients are not necessarily new to eating disorders. Many elderly patients confirm they have struggled with disordered eating throughout their lives, some having never sought out treatment. In some cases, elderly patients have previously been in treatment and had negative or even traumatizing experiences, and have even vowed to never have treatment again.
Elderly people with eating disorders fall into three primary categories:
- Undiagnosed and untreated: those who have had an untreated eating disorder for years.
- Diagnosed and treated: those who were treated but experienced a relapse or never sufficiently recovered
- Newly diagnosed: those who have never been diagnosed with an eating disorder.
Stats & trends in elderly people with eating disorders
Most patients with eating disorders receive a diagnosis before the age of 25, but there are exceptions. One study found that as many as 4% of women over the age of 60 met the diagnostic criteria for an eating disorder. (3) Similarly, another study found that midlife eating disorders—those occurring after the age of 40—have a prevalence of 1.8% to 3.8%. (4)
The most common type of eating disorder presenting in the elderly population is anorexia nervosa, with depression being the most common related condition. (5) The use of laxatives as a purging behavior is also higher in late-life patients. (4)
The development of eating disorders in elderly patients has been associated with age-related body changes and shifts in family relationships. (14)
Elderly eating disorder signs & symptoms
Due to eating disorders being less common in the elderly, they are frequently overlooked by health care providers as a cause of weight loss. For this reason, it’s important to know how to recognize the signs and symptoms associated with disordered eating behaviors.
The following are common signs and symptoms of eating disorders in the elderly, which are really no different than the signs in a younger person:
- Pushing food around on their plate, or hiding food
- Taking naps or disappearing during mealtimes
- Using the restroom immediately after meals
- Talking about their weight frequently
- Dieting or using diet pills
- Unexplained weight loss
- Avoidance of meals
- Rigidity about food choices
- A fixation on exercise, or extreme exercise routines
- A need to exercise in order to “compensate” for eating
Identifying eating disorders in the elderly can be particularly challenging because there are many causes for weight loss in older people.
Some of the most common causes of weight loss in the elderly include the following:
- Medications that decrease appetite
- Cognitive impairments that interfere with remembering when or how to eat and prepare meals
- Difficulty chewing or swallowing
- Difficulty breathing
- Mood changes or other co-occurring psychiatric presentations
Many older patients with eating disorders also have other medical conditions that interfere with appetite and digestion. These can become barriers to maintaining the nutritional needs of their body.
Regardless of the cause, weight loss in older individuals may increase risks for serious medical complications if allowed to continue. Losing even modest amounts of weight, such as 3% in one week or 5% in one month, is a significant concern for older people. (6) Plus, some elderly patients may struggle with a severe exercise fixation, especially in order to compensate for caloric intake, which can also be detrimental to their health. In fact, over-exercising can cause mood swings, irritability, getting more frequent colds, overuse injuries like tendonitis or osteoarthritis. (17)
And regardless of age, any amount of restrictive eating and interference with the body receiving adequate nutrition places the body at risk, impacts the brain. A small amount of weight loss can bring about a significant amount of suffering.
Weight loss and dehydration have been linked to falls, urinary tract infections (UTIs), deconditioning, and confusion. It can also result in poor-fitting dentures, which further impedes food intake and often leads to more weight loss, not to mention the mental suffering and psychological distress.
Treating elderly people with eating disorders
While there are many different treatment formats for eating disorders, not all are appropriate for the elderly.
Comprehensive eating disorder treatments for the elderly will consider related factors, such as living conditions, caregiver status, financial constraints, and any other health conditions being concurrently managed, to achieve the best outcomes.
Elderly patients are sometimes isolated, making them more susceptible to mental health issues. It is recommended that comprehensive treatment programs be equipped to offer referrals to other health disciplines when related health conditions surface during treatment.
Comorbid mental health illnesses occur in approximately 60% of elderly patients with eating disorders. (5) Depression and anxiety are also more common in elderly patients with disordered eating behaviors. (4)
There are many causes for weight loss in the elderly, with eating disorders being just one of them. Dysphagia, a swallowing disorder, can lead to malnutrition and weight loss. Dementia, which often leads to changes in eating habits, is also a common cause of weight loss in aging populations. (15)
Mortality risks are higher for elderly patients with eating disorders. (4) For this reason, eating disorders may be explored as a differential diagnosis in elderly patients who experience weight loss. (5)
Cognitive behavioral therapy (CBT)
Strong evidence suggests that cognitive behavioral therapy (CBT) is the most effective treatment for eating disorders, particularly for patients with Bulimia nervosa, Night Eating syndrome, and Binge Eating disorder. (8) For late-life eating disorder patients with significant cognitive impairment, however, treatment may be less effective.
Interpersonal psychotherapy primarily focuses on the patients’ current interpersonal difficulties that may be contributing to or perpetuating their eating disorders. Interpersonal problems may maintain an eating disorder in a myriad of ways. Firstly, due to the isolating nature of eating disorders, patients may lack peer influence that can challenge cognitive distortions. Additionally, interpersonal strife may exacerbate poor self-esteem, which can intensify disordered eating behaviors. Interpersonal psychotherapy, which can occur in both individual and group settings, and can help rectify relational problems and facilitate eating disorder recovery. (18)
Acceptance and commitment therapy (ACT)
Acceptance and Commitment Therapy (ACT) is a mindfulness-based therapy used to increase mental flexibility and to accept negative thoughts and feelings. (19) It typically occurs in a group setting. The therapist encourages the patients to make choices that are aligned with their personal values. They may ask the patients what motivates them in life, what they want to achieve, or how they want to live, and then may ask them what is currently hindering them. ACT groups help promote patient authenticity, awareness, and sense of self.
Dialectical behavior therapy (DBT)
Originally created to treat people with borderline personality disorder, DBT has been adapted to treat a wide variety of mental health conditions, including eating disorders. DBT, which also has a mindfulness component, aims to help patients improve their emotional regulation, distress tolerance, and interpersonal effectiveness. Overall, DBT can help patients to manage intense negative feelings and distress, as well as learn communication skills, boundary-setting, and self-respect. (20)
Nutritional counseling is a key component of eating disorder treatment, and it includes two features: medical nutrition therapy, which may include weight restoration or stabilization, as well as anything else that is deemed medically necessary for the patient, and nutritional therapy and planning, which involves choosing the meals for patients as a part of their exposure to all types of healthful foods. Nutritional counselors work closely with their patients to debunk any myths the patients may believe are true.
Cognitive-behavioral couples therapy (CBCT)
In married or partnered patients with eating disorders, cognitive-behavioral couples therapy (CBCT) has been shown to improve communication, emotional regulation, and problem-solving skills. (9)
Couple-based therapies can also strengthen support systems, which is essential for patients throughout the treatment process, especially for older individuals struggling with age-related challenges.
Residential care facilities
Some patients require considerable medical care and monitoring and would benefit from transitioning into a residential care facility that provides eating disorder treatment, in addition to the general care and support provided for older individuals. However, not all residential programs offer the same quality and comprehensive medical care, and it is vital to understand both the medical and psychiatric aspects of any residential program being considered.
When patients are medically compromised, hospitalization may be necessary. Inpatient stays are common in cases of severe dehydration, malnutrition, unstable medical conditions or in extremely low-weight patients. It is important, however, to realize that being lower weight or higher weight is not the determinant of medical stability and that weight cycling itself is associated with poor medical outcomes. (21)
How to help elderly people with eating disorders
Without proper treatment, eating disorders can lead to serious health decline – and even death. This is why getting proper medical care is critical. Eating disorders also cause extreme psychological distress and are associated with a suicide risk that is 5-6 times higher than the general population. (22)
Unfortunately, many elderly people with eating disorders don’t seek professional treatment. There may be many reasons for this.
One of the biggest reasons older patients are hesitant to enter treatment is they don’t believe programs will address their needs properly. Eating disorder programs traditionally target younger people, with topics often focusing on challenges that arise in early and mid-life. Unless treatment program facilitators reassure older patients that the program will address a wide variety of life challenges and stressors, they may not see the value.
Another reason elderly people may be reluctant to enter treatment is that many are caregivers. A survey conducted by the U.S. Bureau of Labor Statistics found that more than 60% of the 40.4 million eldercare providers in the U.S are over the age of 55. (11) That number doesn’t account for those who are caregivers for neighbors, children, or grandchildren.
Caregivers often feel selfish for tending to their own needs, and instead worry about how the disruption will affect others. (13)
In addition, it may be implausible for a caregiver to stop providing care, and that very same person’s income may be tied to an entire family's sustainability, so leaving for treatment is totally impractical.
If you suspect someone you love is struggling with an eating disorder, it may be helpful to talk with a clinician who specializes in eating disorder treatment vs staying silent. Early intervention saves lives.
Here are a few more ways you can help when you suspect someone you care about has an eating disorder:
- Ask: Asking questions may reveal more details about disordered eating patterns.
- Observe: Pay attention to behaviors during mealtimes and when topics around food or weight are being discussed.
- Refer: Make a referral or a suggestion to connect with a program, organization, or provider who specializes in eating disorders.
- Follow Up: Check in periodically to see if they’ve received the help they need to begin recovery
Within Health offers virtual eating disorder treatment programs for people of all ages. If you or someone you love is looking for care attuned to their needs, Within Health is here to help. Contact our team to learn more about our treatment programs.
Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.
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