Eating disorders in later life - Pavilion Health Today

Eating disorders are often associated with younger age groups, but people of any age can be affected. Research shows eating disorders – such as anorexia nervosa, bulimia and binge eating disorder – are becoming more common in the older population, with a related mortality of 21%.¹

However, differentiating an eating disorder from other conditions in older adults presents a clinical challenge for healthcare professionals. This is because the presentation in older adults can differ greatly from the presentation in younger adults.²

Awareness of eating disorders in older adults has historically been limited.³ While there is now growing recognition of the issue, eating disorders in older adults may still be overlooked in clinical settings.¹ There is therefore still a need for greater awareness of eating disorders in older adults so that tailored approaches can be implemented at the earliest possible opportunity.

Types of eating disorder

According to NICE, eating disorders are defined by negative beliefs and behaviours that cause people to have negative thoughts about themselves, their eating, body shape and weight.⁴

Research suggests eating disorders affect between 1.25 and 3.4 million people in the UK.⁵ The most well-known eating disorders are anorexia nervosa, bulimia and binge eating disorder. However, not everyone with an eating disorder fits neatly into one of these boxes.

If a person has symptoms of an eating disorder that do not exactly fit one of the above disorders, they may be diagnosed with an ‘other specified feeding or eating disorder’, also known as OSFED. OSFED is the most common eating disorder, making up around 44% of all eating disorder diagnoses.⁶

For this year’s Eating Disorder Awareness Week (26 February – 3 March), the eating disorder charity BEAT is raising awareness of a lesser-known eating disorder – avoidant/restrictive food intake disorder (ARFID). People with ARFID avoid certain foods, limit how much they eat, or both.

ARFID is different from other eating disorders as it not driven by a desire to alter body shape or weight. Common reasons for developing ARFID include negative feelings about the smell, taste or texture of certain foods; a response to past experience with food (such as choking or being sick); and not feeling hungry or a lack of interest in eating.

Other types of eating disorder include:

Orthorexia: characterised by an unhealthy obsession with eating ‘pure’ food
Rumination: involving a repetitive, habitual bringing up of food (not associated with nausea or disgust)
Pica: eating non-food substances, such as paper, soap, paint, chalk, or ice.

Each of these disorders are associated with poor quality of life, social isolation, and a substantial impact for family members and carers. Eating disorders can become life-long conditions if they are not treated effectively.⁴

Eating disorders in older people

The typical age at onset of eating disorders is between 16 and 25 years, however, eating disorders may be present at any age.⁷ Onset after the age of 40 is generally considered late onset.⁷

There is limited research on eating disorders in older adults in the UK population, but a study by Yale School of Medicine reports that almost 3% of US women aged 50 to 64, and almost 2% of women 65 and older, have an eating disorder.⁸

Risk factors in older patients

Factors such as body image concerns, societal pressure, and life changes can contribute to disordered eating. One study by Luca et al identified several risk factors for eating disorders in later life.⁷

The fear of ageing has been positively related to disordered eating in middle-aged women, and Luca et al found that bodily changes associated with ageing, including wrinkles, hair loss, changes to body fat distribution, seem to play a role.⁷ However, several factors seemed to exert a “protective” role from body dissatisfaction, including being a mother, having a stable partner and having a secure career.⁷

The researchers say some critical life stages must also be considered as stressors that could facilitate the onset of an eating disorder. Among these are menopause, separation and divorce.

Previous research has found that menopause is associated with the development of eating disorders.⁹ A common symptom of menopause is weight gain and a redistribution of body weight. On average, women may gain half a kilo per year during the perimenopause, in the absence of HRT, which can lead to negative beliefs about eating and body shape.¹⁰

Sex hormones also exert a fundamental role in the control of eating behaviours.⁷ During the menopause transition, oestradiol and progesterone concentrations not only decrease substantially, but also fluctuate significantly on a day-to-day basis.¹¹ Baker et al therefore conclude that the menopause transition may be an additional vulnerability period for eating disorder symptoms.¹¹

Unique challenges

Lapid et al report that eating disorders are frequently underdiagnosed and underreported in older people.² This is partly because there are numerous medical and pharmacological causes of weight loss in older people, including neurological challenges, physical challenges with eating and polypharmacy.

Weight loss in older people is known to predispose to muscle wasting, frailty, diminished immunocompetence, depression and increased susceptibility to diseases and disorders.¹ These problems may affect food and fluid intake, creating a vicious cycle.

Identifying the cause of weight loss is therefore important, and Lapid et al recommend that eating disorders are considered in the differential diagnosis for all older patients presenting with significant, unexplained weight loss.²

Diagnosing eating disorders in older patients

The clinical presentation of eating disorders in older adults can differ greatly from the presentation in younger adults due to physiological changes associated with normal ageing, the presence of comorbidities, and the use of multiple medications. Lapid et al say all of these factors can cause weight loss, but do not create the clinical picture needed to diagnose an eating disorder.¹

If bulimia or anorexia is suspected, healthcare professionals should look for consistent clinical features including low body weight, fear of fatness, distorted body image and compensatory weight loss behaviours, such as self induced vomiting, laxative misuse and excessive exercise.¹

It is therefore important to involve family members and friends where possible, and ask them about any changes in behaviour, such as going to the toilet immediately after eating; using laxatives, diet pills of diuretics; avoiding meals; and preferring to eat alone.¹

Physical signs to look out for include malnutrition, excessive hair loss, dental damage, heart or gastrointestinal problems, as well as poor circulation, dizziness, palpitations, fainting or pallor.⁴ NICE recommends all healthcare professionals conduct a physical examination to check for malnutrition or compensatory behaviours such as vomiting.⁴

NICE also recommends asking the patient about their mental health, as depression, anxiety, self-harm and obsessive-compulsive disorder are commonly associated with disordered eating. The possibility of alcohol or substance misuse should also be considered.⁴

If an eating disorder is suspected after an initial assessment, the patient should be immediately referred to a community-based, age-appropriate eating disorder service for further assessment or treatment.⁴

Treating eating disorders in older adults

Early detection and seeking professional help are crucial for the effective treatment of eating disorders. Treatment will vary depending on the diagnosis, but in every case, a multidisciplinary approach will be required to ensure that the patient is treated effectively. This includes:

Addressing and treating physical health issues resulting from the eating disorder, such as nutritional deficiencies and complications.
Offering mental health support, commonly through talking therapies such as Cognitive Behavioural Therapy.
Providing nutritional advice to establish balanced and healthy eating patterns.⁴

It is important to note that there may be a need for emergency care for people whose physical health is compromised or who have a suicide risk.

All patients should be regularly followed up and assessed using standardised outcome measures such as the Eating Disorder Examination Questionnaire (EDE Q). They should also be monitored for treatment adherence as well as their weight, mental and physical health, and risk factors.⁴

Conclusion

Eating disorders have significant emotional and physical consequences, and it is important for healthcare professionals to consider the unique challenges and factors associated with eating disorders in older individuals to tailor the treatment approach effectively.

A patient-centred approach is key to identifying and treating eating disorders in older adults, as this will ensure diagnosis and effective treatment can be implemented as early as possible.

References

Aziz VM, Rafferty D, Jurewicz I. Disordered eating in older people: Some causes and treatments. BJPsych Advances. 2017;23(5):331-337. doi:10.1192/apt.bp.116.016568
Maria I. Lapid, Ying-Ying C. Chen et al. (2013). Weight loss caused by eating disorders in older adults. Consultant 360. Available at: https://www.consultant360.com/articles/weight-loss-caused-eating-disorders-older-adults
Mulchandani M, Shetty N, Conrad A, Muir P, Mah B. Treatment of eating disorders in older people: a systematic review. Syst Rev. 2021 Oct 25;10(1):275. doi: 10.1186/s13643-021-01823-1.
National Institute for Health and Care Excellence. (2017). Eating disorders: Recognition and treatment. Available at: https://www.nice.org.uk/guidance/ng69/chapter/Context
Priory Group. (n.d.). Eating disorder statistics. Available at: https://www.priorygroup.com/eating-disorders/eating-disorder-statistics
Cecchele, T. (2022). What is OSFED (Other Specified Feeding or Eating Disorder)? Available at: https://www.taliacecchele.com/post/what-is-osfed
Luca A, Luca M, Calandra C. Eating Disorders in Late-life. Aging Dis. 2014 Feb 5;6(1):48-55. doi: 10.14336/AD.2014.0124.
Mulcahy, L. (2023) Older Women and Eating Disorders: A Growing Problem. Available at: https://www.webmd.com/mental-health/eating-disorders/news/20230302/older-women-and-eating-disorders
Khalil J, Boutros S, Kheir N, Kassem M, Salameh P, Sacre H, Akel M, Obeid S, Hallit S. Eating disorders and their relationship with menopausal phases among a sample of middle-aged Lebanese women. BMC Womens Health. 2022 May 10;22(1):153. doi: 10.1186/s12905-022-01738-6.
Balance Menopause. (n.d.). Eating disorders and menopause. Available at: https://www.balance-menopause.com/menopause-library/eating-disorders-and-menopause/

Eating disorders in later life: challenges and strategies for healthcare professionals