Synonyms

Dementia; Eating disordered behaviors; Eating disorders; Older adults

Definition

Eating disorders are characterized by severe and persistent disturbances in eating behavior that may significantly impair physical health and psychosocial functioning in both men and women. According to the DSM-5 there are different types of feeding and eating disorders: pica, rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder (American Psychiatric Association 2013). Eating disorders are common among women and have gradually increased over several years worldwide.

Disordered eating includes a variety of problematic eating behaviors ranging from dieting and extreme weight control methods (i.e., fasting, binge eating, and purging) to clinically diagnosed eating disorders (e.g., anorexia and bulimia nervosa). Accompanying these behaviors is also a range of disordered eating attitudes, such as the need to be thin as well as weight and shape fears. The majority of research on eating disorders concentrates on adolescents or young adult women, however, in the recent years data has emerged focusing on middle-age and older adults who may be experiencing eating disorders, namely anorexia nervosa, bulimia nervosa, and binge-eating disorder.

Eating Disorders as Defined by the DSM-5

The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 2013) made several recent changes to the criteria for feeding and eating disorders to better characterize symptoms and behaviors of patients across the lifespan. Some of the changes included recognizing binge eating as a disorder, revising the diagnostic criteria for anorexia nervosa and bulimia nervosa, and including pica, rumination and avoidant/restrictive food intake disorder (the latter three were originally included in the Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence section of the DSM-IV-TR).

Anorexia nervosa is defined by a distorted body image, a pathological fear of gaining weight, and excessive dieting that leads to severe weight loss. This disorder mostly affects adolescent girls and young women. Some of the changes that were made from the DSM-IV-TR include taking out the word “refusal” in terms of weight maintenance since that signifies intention on the part of the patient and is difficult to determine. In addition, in the DSM-IV-TR a diagnosis of anorexia nervosa required amenorrhea, or the absence of at least three menstrual cycles. This criterion was taken out, because it cannot be applied to males, premenarchal females, females taking oral contraceptives, and postmenopausal females. Moreover, some women may report some menstrual activity but still show signs and symptoms of anorexia nervosa (American Psychiatric Association 2013).

It is important to understand that older adults may experience anorexia of aging, which is different from anorexia nervosa. Anorexia is a medical condition that is characterized by reduced appetite or dislike of food therefore leading to the inability to eat. Symptoms such as fear of gaining weight or distorted body image, which are key in anorexia nervosa, are absent in anorexia of aging. Anorexia of aging, which is involuntary weight loss and protein-energy malnutrition, includes the normal physiological changes that cause an increase in the proportion of body fat and decrease in lean muscle mass and extracellular fluid mass. This change in body makeup is usually a result of decrease in energy needs and therefore a decrease in appetite and calorie intake (Champion 2011).

Bulimia nervosa is characterized by recurrent episodes of binge eating followed by inappropriate behaviors such as self-induced vomiting to avoid weight gain, and self-evaluation that is disproportionately influenced by body shape and weight. In contrast to the DSM-IV-TR criteria, which required the frequency of binge eating and compensatory behaviors to occur twice a week, the DSM-5 specifies that these behaviors must occur once a week (American Psychiatric Association 2013). Older adults may especially engage in the inappropriate behaviors as they move further away from the “cultural ideal” of looking young and thin.

Binge eating disorder is characterized as recurring episodes of eating significantly more food in a short period of time than most people would eat in the same circumstances. These episodes are also defined by feelings of lack of control over eating (e.g., a feeling that one cannot stop eating or control how much one is eating). A person with a binge eating disorder may eat more rapidly than normal whether he or she is hungry or not. The individual may experience feelings of guilt, embarrassment, or disgust and may binge eat alone to cover the behavior. Marked distress is usually associated with binge eating. Additionally, this disorder occurs, on average, at least once a week over three months (American Psychiatric Association 2013). Older adults suffering from binge eating disorder may feel lack of control or willpower. In addition, loneliness, depression, and other psychiatric or medical comorbidities may impact older adults’ eating habits.

Prevalence Rates of Eating Disorders and Older Adults

Anorexia nervosa and bulimia nervosa are 10 times more common in females than males, and binge-eating disorder is three times more common (Treasure 2007). Though in recent years studies have shown that one in six males also suffer from an eating disorder (Andersen 2002). Eating disorders have become a major public health issue as it is the third most common illness in adolescent females, and is affecting more women of all ages worldwide. Research suggests that more than 20% of women aged 70 and older were dieting and experiencing unhappiness with one’s body image and the desire to be thin; and these concerns do not disappear with age (Fisher et al. 1995). Anonymous questionnaires were administered to 1,500 Austrian women between the ages of 40 and 60 assessing for eating disorders (as defined by the DSM-IV), subthreshold eating disorders, body image, and quality of life. Subthreshold eating disorder was defined by the presence of either binge eating with loss of control or purging behavior, without requiring any of the other usual DSM-IV criteria for frequency or severity of these symptoms. Of the 715 middle-aged to older adult women that responded, 33 (4.6%) reported symptoms meeting full DSM-IV criteria for an eating disorder. None indicated symptoms or behaviors consistent with anorexia nervosa, possibly due to the DSM-IV criteria of requiring amenorrhea. Another 34 women (4.8%) displayed subthreshold eating disorder (Mangweth-Matzek et al. 2013).

There are different patterns or categories into which older adults may fit with regard to eating disorders. Some older adults have struggled with an eating disorder since adolescence and never received treatment. Others likely received treatment in their younger years but relapsed later on in life as a result of a stressful life event (e.g., death or illness of family member or friend). Another group may be older adults who were always preoccupied with food and weight throughout their lives but experienced limited consequences of eating disorders when they were younger. Lastly, there is a small subset of older adults who developed an eating disorder later in life (American Psychiatric Association 2013).

Similar to adolescents and younger adults, middle aged and older adults also face devastating physical and psychological consequences of eating disorder. Issues such as social isolation, physical illness, bereavement, and minimal support are just a few factors that can impact the onset of late-life eating disorder (Cosford and Arnold 1992). Additionally, eating disorders in older adults are associated with anxiety, depression, and suicidal ideation and attempts (Hudson et al. 2007). Eating disordered behaviors may also increase the risk of medical morbidity, such as cancer and obesity (Ng et al. 2013).

Biology of Eating Disorders

Research on the biology of eating disorders has primarily focused on anorexia nervosa and bulimia nervosa. Studies show a genetic predisposition and a variety of environmental risk factors that contribute to eating disorders. Clinical studies with twins show an agreement for anorexia nervosa of 55% in monozygotic twins and 5% in dizygotic twins, and bulimia nervosa being 35% and 30%, respectively. In addition, much of the research focuses on the neurobiology of eating disorders, looking specifically at neuropeptide and monoamine (especially 5-HT) systems, which are thought to play a central role in the physiology of eating and weight regulation.

Studies incorporating functional imaging of the brain show altered activities in the frontal, cingulated, temporal, and parietal cortical regions in both anorexia nervosa and bulimia nervosa, and there is some suggestion that these changes persist after recovery. Whether these changes are a result of the eating disorder or have somehow contributed to the risk of developing an eating disorder is not well researched (Lapides 2010; Kaye and Strober 1999).

Eating Disordered Behaviors: Signs and Symptoms in Older Adults

It can be difficult to determine or diagnose an eating disorder in older adults. However, some signs and symptoms can be recognized as clues to changes in eating behavior in older adults. For example, significant change in weight over a short period of time; behavior changes such as disappearing after a meal or using the restroom after eating; new use of laxatives, diet pills, or diuretics; wanting to eat alone rather than with family; skipping meals; loss of concentration; physical symptoms such as enamel loss, chronic sore throat, cracked lips, sensitivity to cold, excessive hair loss, dental damage, or heart and gastrointestinal problems (e.g., constipation); excessive consumption of high-calorie foods that are sweet (especially prominent in people with binge eating disorders). Furthermore, osteopenia and osteoporosis are common symptoms of longstanding anorexia nervosa and are associated with an increased fracture risk in older adults. Additionally, it is suggested that physicians complete a physical for medical conditions and review medications as medical conditions (e.g., thyroid and gastrointestinal conditions), medications, and substance use can mimic symptoms of an eating disorder (e.g., nausea, weight gain or loss) (Lapides 2010; Lapid et al. 2010).

Contributing Factors to Eating Disorders in Older Adults

Triggers of eating disorders may appear similar for younger and older adults; however specific differences occur, as life stressors change as people age. Body image issues and body dissatisfaction are some of the common risk factors for eating disorders and increase with age as the human body experiences natural changes (e.g., wrinkles, graying hair, and weight gain). Additionally, the development of eating disorders in midlife can be due to other changes or transitions that occur as one ages. For example, loss of loved ones, widowhood, divorce, traumatic illness or disability, children moving out of the house, growing old and facing mortality, and loss of independence can all have an impact on eating behaviors of midlife or older adults (Lapides 2010; Zerbe 2008).

Certain medical conditions can also contribute to developing an eating disorder. For example, older adults are at a higher risk for developing high cholesterol, diabetes, and other cardiovascular diseases and may be advised by their primary care physicians to be mindful of and careful with their diet. Some older adults may become anxious about their diets, but also lack knowledge about proper nutrition that lower the risk for cardiovascular diseases. They may begin restricting their diets and lose weight unintentionally. Their anxiety may maintain their eating disordered behaviors. Other contributing factors to eating disorders for older adults may be lack of enthusiasm for life, attempts to obtain attention from family members, financial difficulties, medical problems, and dissatisfaction or objection of living situations (i.e., nursing home, skilled facilities) (Lapides 2010).

Overall, stress is the most common trigger of eating disorders in both younger and older adults; stressors often change as one develops and become more prominent. Eating disorders are usually not about weight or food, but a way of coping with other stressors in life that the individual does not know how to handle. Disordered eating behaviors are often a way to avoid and numb emotions and feelings. If during adolescence or young adulthood the individual learned maladaptive coping mechanisms to tolerate stress, then the individual may utilize these unhealthy coping methods later in life as an older adult (Lapides 2010).

In one study, 50 women who were treated in a residential program and who eating disorder symptoms began after the age of 40 were examined. On an eating disorder inventory, midlife women scored higher than younger women on scales of ineffectiveness, perfectionism, interpersonal distrust, and asceticism, but scored lower on drive for thinness, bulimia, and body dissatisfaction. Both midlife women and younger women reported moderately severe depression and anxiety symptoms. On the Minnesota Multiphasic Personality Inventory (MMPI), midlife women indicated more denial than younger women. These midlife women also endorsed a higher frequency of sexual abuse (63%) than reported by younger women with eating disorders. There was no significant difference between midlife and younger women in alcohol or other substance use; however, midlife patients abused cannabis much less and opioids more than younger patients. Though not statistically significant, midlife patients more often abused sedatives, hypnotics, and anxiolytics suggesting a higher tendency to abuse calming/sedating medications. About 22% of older women reported a history of self-harm and 28% had attempted suicide. Though this study was limited to only patients who were seeking treatment in a facility, this suggests that older adults with eating disorders may under report some of their distress and need serious consideration and treatment in the community (Cumella and Kally 2008).

Eating Disorders and Neurocognitive Disorders

Dementia is not one specific disease; rather, it is a clinical syndrome characterized by a loss of cognitive functioning that negatively impacts a person’s abilities to complete day-to-day activities. Dementia can affect many body systems and produce a variety of problems, such as poor or inadequate nutrition. Individuals with dementia may decrease the amount of food they eat, forget to eat and drink, or believe they have already eaten. Changes in an older person’s daily routine (e.g., such as meal time) or other distractions (e.g., how the food smells or tastes, environmental issues such as too much confusion) may affect their eating patterns. In some cases, people with advance dementia may lose control of the muscles used to chew or swallow and this could put the person at risk of choking. Additionally, people with dementia may lose the feeling of hunger and the desire to eat. Other comorbid factors such as depression, medication side effects, and constipation, can decrease the individual’s interest in food (Ikeda et al. 2002).

Frontotemproal dementia (FTD) encompasses several clinical syndromes all sharing frontal pathology. The FTDs include behavioral variant FTD (bv-FTD), progressive nonfluent aphasia (PNFA), and semantic dementia (SD). A variety of behavioral changes noted in bv-FTD, include loss of insight, disinhibition, impulsivity, apathy, poor self-care, mood changes, mental rigidity, and stereotypic behavior. Some research with bv-FTD individuals has also found a high prevalence rate of changes in food preferences, appetite, and eating behaviors. Individuals with semantic dementia characterized by anomia and impaired comprehension, also show behavioral changes, such as changes in appetite and food preferences that are similar to those observed in bv-FTD (Ikeda et al. 2002).

One of the most prevalent dementia syndromes, Alzheimer’s disease (AD), accounts for about 35% of all dementia cases. AD is characterized by early onset of memory impairment (poor consolidation and recognition of information), poor confrontation naming (dysnomia), deficits in visuoconstructional skills, social withdrawal, and mood changes (symptoms of depression) can occur. Eating changes in AD have been shown to be less common. However, some research indicated anorexia is more common in AD (Ikeda et al. 2002). Research found more significant changes in eating behaviors in both bv-FTD and semantic dementia in contrast to Alzheimer’s disease. Individuals with semantic dementia first typically see a change in food preference, whereas individuals with bv-FTD show changes in food preferences as well as alterations in appetite (Ikeda et al. 2002).

Though there is limited research on other types of dementias (e.g., vascular dementia) and eating disorders, overall, individuals with any type of dementia may suffer from a diminished interest to eat or forgetting to eat. Changes in food intake can lead to malnourishment and dehydration, increasing the risk of infections, abnormally low blood pressure, and other medical problems. Proper nutrition does not necessarily prevent weight loss in people who suffer from dementia, nor will it slow down the progression of the neurodegenerative process, however continuing to maintain a healthy weight and diet can support overall health and better quality of life. Primary care physicians, psychiatrists, psychologists, dieticians, family members and other caregivers play an important role in some of the treatment options for eating disorders in older adults.

Treatment Options for Eating Disorders

As people age, their interest in eating and enjoying food changes. Individuals with dementia have pronounced changes in taste or food preferences as well as changes in mood, behavior, and physical functioning, which can impact eating. Some general treatment goals for eating disorders in individuals both with and without dementia are to restore adequate nutrition, and weight to a healthy level, reduce excessive exercise, and stop binging and purging behaviors. Additionally, individuals that suffer from dementia may benefit from specific memory strategies (e.g., following a specific routine everyday or incorporating various reminders or cues to remember to eat) or feeding tubes in later stages of the neurodegenerative disease. Multidisciplinary treatment teams such as a primary care practitioner, psychiatrist, dentist, nutrition specialist or dietician, and a mental health care professional may be needed to manage eating disorders (Fairburn 2010; Shapiro et al. 2007). In addition, health care professionals treating patients with eating disorders have to be mindful of different cultural and religious values and practices patients may possess.

Several psychological theories have been proposed to account for the development and maintenance of eating disorders, with cognitive behavioral theory being one of the most prominent with regard to treatment. Cognitive behavioral theorists propose that there are two main origins for the restriction of food intake. The first is the need to feel in control of life, which transfers into the need to control eating. The second is over evaluating one’s shape and weight. In both cases, a dietary restriction is reinforcing. Following this, other processes such as social withdrawal, binge eating due to extreme and rigid dietary restraint, and negative impact of binge eating or concerns about shape and the sense of being in control, begin to play a role and serve to maintain eating disorders (Fairburn 2010; Shapiro et al. 2007).

Cognitive and behavioral approaches have been shown to successfully treat eating disorders based on studies with younger and middle-aged women and men. In addition, antidepressant medications may also be effective for some eating disorders as well as treating comorbid anxiety or depression. Medical consequences of an eating disorder can be devastating and life threatening, however, the internal dialog within the person and specific behavioral rituals that are constantly repeated can cause suffering and pain. The constant fear of judgment, self-imposing rules and demands can take over and cause negative emotions and perpetuate negative behaviors. Individuals with eating disorders often maintain negative view of themselves and their bodies. These negative thoughts can cause feelings of shame or anxiety that can then trigger behaviors to control weight. Cognitive behavioral therapy can focus on the specific factors that are maintaining the disorder and set specific goals throughout the therapy. Three phases can occur over the course of cognitive behavioral therapy: behavioral phase, cognitive phase, and maintenance and relapse prevention phase. During the behavioral phase the patient and therapist come up with a plan to stabilize eating and eliminate symptoms. In the cognitive phase, the therapist begins cognitive restructuring where the individual begins to recognize and change problem thinking patterns. Negative thoughts and beliefs (e.g., I will only be happy if I can lose weight) are identified and restructured. In addition, other concerns and issues such as relationship difficulties, self-esteem concerns, and emotion regulation are focused on. The last stage of CBT focuses on minimizing triggers, preventing relapse, and maintaining progress previously made (Fairburn 2010; Shapiro et al. 2007).

In addition to psychotherapy, psychotropic medications have also been shown to play a role in treating eating disorders. Research on medication use for anorexia nervosa have not found medication to promote weight gain, though some studies suggested fluoxetine as an option in preventing relapse in patients after normal weight is restored. In contrast, fluoxetine has shown to reduce binging frequency in bulimia nervosa, as well as anxiety and depressive symptoms (Zhu and Walsh 2002).

While research demonstrates the benefits of medication, the best results were seen with a combination of psychotropic medication and psychotherapy (Zhu and Walsh 2002; Maine et al. 2010). Research shows that patients who received cognitive behavioral therapy demonstrated more improvement in symptoms than those who only received medication. However, medication is efficacious for patients who have not responded to psychotherapy. When patients who did not benefit from cognitive behavioral therapy or interpersonal therapy were administered a placebo or fluoxetine, significant results in favor of fluoxetine were found (Walsh et al. 2000). While older adults have not been the focus of eating disorder randomized control trials, interpersonal and cognitive behavioral therapies were successfully used to treat other later-life psychiatric disorders, such as depression (Hudson et al. 2007), which often co-occur with eating disorders.

In addition to psychotherapy and medication, nutrition intervention, such as counseling by a registered dietitian is an important aspect of multidisciplinary treatment of eating disorders, and would certainly contribute to determining the course of treatment in older adults. The dietitian can perform a nutrition assessment to identify nutrition problems related to the eating disorder and implement a care plan that might establish healthy eating patterns and restore the individual back to a healthy weight. In addition, the dietitian can monitor and re-assess the individual’s progress with the plan and jointly work with other health professionals to address the individual’s needs. The trained dietician can recommend keeping a daily food, hydration, and exercise log and this information can help identify if any new physical or medical problems may arise that can impact food intake and changes in weight. A full workup by a dietician is critical given the complexity of eating disordered behaviors and disorders in older adults. A dietician can monitor and refer older adults to other physicians or specialists as eating disorders can arise due to various causes (Walsh et al. 2000).

Conclusion

This chapter focuses on late-life eating disorders and eating disordered behaviors in older adults, and issues that have been largely overlooked or potentially under diagnosed. The dearth of information on eating disorders and related issues suggests that, although these issues are not common, it is possible for an older adult to have a disorder or issue with their eating. Those issues could be caused by various life stressors (e.g., abuse, loss of a loved one, loss of independence) and/or medical (e.g., neurodegenerative diseases, diabetes) or psychiatric (e.g., depression, anxiety) conditions, as is the case in many instances. Older adults are also not as physiologically resilient as younger adults. Physiological changes and vulnerability of an aging person could lead to more serious consequences of eating disorders much more rapidly than in a younger person. In rare instances, but certainly possible, the eating issue could be a longstanding disorder or newly diagnosed condition. For these reasons, health care professionals need to be cognizant of the possibility of eating disorders in the elderly, given the serious consequences of misdiagnosing or leaving them untreated in any population.

Cross-References