Anorexia Nervosa in The Elderly
I hadn’t seen my father for a couple of months. I was shocked by how much weight he had lost in that time.
“Dad.” I asked quite concerned. “Are you eating?”
“Yes, of course. Too much.”
“Can you tell me what you ate today?”
I watched as he tilted his head to the side trying to remember back to this morning. My mother turned to me. “He hasn’t eaten anything today. Nor yesterday. He keeps telling me he’s not hungry. It isn’t good what he’s doing.”
“Why aren’t you eating Dad?”
“Look.” He smiled as he unfastened his belt buckle and pulled his pants out in front to show how big they had become.
“But you’re losing too much weight.” I tried to reason with him.
“I like this. I like that I am finally thin.”
All his life my father had been a big man. Oversized. I often heard people crack jokes about his weight and tell him to stop eating so much. But now, I was worried. At 80 years old, he was depriving himself of food. He had fallen a number of times this past year and had sustained a fractured shoulder and a few broken ribs. Many times when I had phoned him, he told me he felt dizzy, weak and light-headed. Now I understood why. He was refusing food.
Much has been written on Anorexia Nervosa, a potentially lethal condition characterized by distorted body image, fear of weight gain, and food restriction. It has been thought to affect mostly young females, but elderly people, both females and males, are also vulnerable.
Associate Professor Paul Hewitt and Professor Stanley Coran of the University of British Columbia, looked at 10.5 million death certificates in the United States from 1985-1990 to see how many listed Anorexia Nervosa as a contributing cause of death. Their findings showed that Anorexia Nervosa strikes more elderly people than previously thought, and that both men and women are affected. In their findings, the average age of death from the disease was age 69 for women and age 80 for men.
In some ways, the issues of Anorexia Nervosa in the elderly are similar to those of the young. Both groups tend to refuse meals by saying they’re too full, not hungry, or feeling ill. Both have a distorted view of their bodies, see themselves as heavier than they are, have difficulty expressing their feelings, usually have family conflicts, and engage in secretive behaviors to hide their disease from others. Both also may engage in purging behaviors, although the elderly are more likely to use laxatives rather than engage in vomiting, which is more common amongst younger people.
Yet older people face unique challenges, some of which might prevent them from being diagnosed. They may have medical problems which affect their ability to consume food, infections, bowel problems, loose or poorly fitted dentures that make it painful to eat, a loss of smell or taste, swallowing problems, medications that reduce their appetite, an addiction to alcohol, memory problems as a result of dementia so that they can’t remember if they had eaten a meal, and wasting diseases like cancer or other illnesses. Social problems might be involved, such as an inability to grocery shop, cook meals or even feed themselves, poverty, social isolation, or elder abuse in which a caregiver withholds adequate food.
Similar to young people, the elderly develop eating disorders for a variety of reasons. A loss of independence or ability to care for themselves, coupled with the death of spouses, family and friends, could leave them feeling isolated and lacking control over their lives. Refusing food can be a way of trying to regain that sense of control or, in some cases, a passive means of ending their lives. Other reasons include: undiagnosed depression, unresolved issues from their past, and stress-related triggers from retirement, such as adjusting to a lower income level. An eating disorder can also be a form of attention seeking, a way to protest restrictions placed on an older person by their family or care facility, or a challenge of limited family visits. Anger is often an underlying issue for elderly men. Studies have also suggested that eating disorders can go into remission for years, even decades, and resurface in later life when the individual experiences unexpected stressors related to aging.
Living environments don’t seem to make a difference. According to www.agingincanada.ca/anorexia.htm, one woman living in supportive housing was found to have chronic issues with gagging, vomiting, and bouts of diarrhea. Staff discovered she had a collection of laxatives in her room.
Eating disorders in the elderly are particularly serious because their health is already compromised. Inadequate nutrition can result in falls, memory deficits, cognitive decline, slow healing from sores or infections, dizziness, and disorientation. For this reason, it is important that caregivers be on the lookout for signs and symptoms such as depression, loss of motivation to eat, 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. Other indicators might be a kitchen that looks unused, little food in the fridge or cupboards, and unopened packages of meals in the fridge from a meal service such as Meals on Wheels.
Solutions for treating older people with eating disorders can be put in place. As with young people, working through psychological issues has proved more effective than dealing with weight loss or merely food choices. Providing supportive counselling can help with feelings around loss, anger, purposelessness, family conflicts, and self-esteem. Caregivers of older people who are exhibiting possible signs and symptoms might consider: reviewing prescriptions, prescribing medications that increase appetite, addressing depression, supporting the family in resolving any conflicts, and providing help with shopping and cooking. Finally, older people can be encouraged to:
- Attend day programs to be more socially active
- Eat healthy meals that are prepared for them.
- Dine with others for socialization and to ensure that those individuals with poor memory are actually eating adequately.
- Participate in a physical rehabilitation program to increase endurance, mobility and balance. This will improve an overall sense of well-being and increase independence as well as increase appetite and food intake
In my father’s case, getting a proper diagnosis was difficult. The health team involved with his care wasn’t sure his refusal to eat was related to an eating disorder. However, when another fall landed him back in the hospital, his determination to lose more and more weight became clear.
So, a plan was put in place to help him increase his food intake. The dietitian provided better food choices. Family was asked to bring in some of his favorite dishes. A social worker worked with him around issues of loss, anger, and depression, and his medications were reviewed and adjusted. When my father continued to refuse food, even becoming quite angry if the subject was broached, a feeding tube was inserted and he was given medication to increase his appetite. Slowly he began eating. He gained weight, his mood lifted, and once he reached a healthy weight, he was discharged back home.
Unfortunately, after a few weeks of doing really well, he started to refuse food again. When he was readmitted to the hospital after another fall, he died from a heart attack two days later—so emaciated that I didn’t recognize him anymore. Had he been diagnosed with anorexia earlier, the disease might not have progressed so far.
Loss of appetite is not a normal characteristic of growing older. However, with an increasingly aging population, more cases of eating disorders in the elderly are being reported. Recognizing this fact is key to making an early diagnosis and providing our elder population, and their families, with better quality of life in the years they still have together.
By Nikki Rosen R.S.W.
Reprinted with permission from ©2010 Gürze Books
Dr. Gnap website editor eatingdisordersrecoverytoday.com. Dr. Gnap is a family practice physician and behavioral medicine specialist in suburban Chicago. Dr. Gnap developed the Inner Control™ Program in 1970 and has worked with thousands of people to improve and correct medical, emotional, behavioral and learning problems including performance.