Issue 137 eating disorders in older adults

CONDITIONS & DISORDERS

EATING DISORDERS IN OLDER ADULTS Nikki Brierley Specialist Dietitian and CBT Therapist

Nikki has been a HCPC Registered Dietitian for 10 years and more recently gained BABCP accreditation as a CBT Therapist.

She currently works in a dual role within the Adult Community Eating Disorder Service at Cheshire and Wirral Partnership NHS Foundation Trust.

REFERENCES Please visit the Subscriber zone at NHDmag.com

Eating Disorders (ED) are serious mental health (MH) conditions that can develop at any age, across genders, ethnicity and cultural backgrounds. They are most commonly associated with young women (12-20 years of age); however, it has been suggested that there is possibly a hidden epidemic in older adults.

ED involve disordered eating patterns (i.e. restrictions, bingeing and/or purging) and concerns about body image (BI). They can significantly impact on the quality of life, cause serious harm and are associated with the highest rates of mortality of all MH illnesses.1 There are various stereotypes, stigma and misunderstandings that surround ED and this can prevent individuals seeking help and accessing appropriate treatment.

For the older adult, this can be further compounded due to the misconception that they are no longer at risk. This can result in warning signs and symptoms being missed and can leave individuals struggling without support. Add to this the importance of early identification and treatment, and it is clear to see the importance of raising awareness and understanding of ED in older adults.

RISK FACTORS

As previously mentioned, ED are most commonly associated with young women (12-20 years). It is easy to assume that with age and wisdom body acceptance increases and the risk of ED reduces. However, research suggests that this is not the case and some risk factors associated with the development of an ED may actually increase with age.

Body image issues As an ageing body moves further away from the projected cultural ideals (i.e. young, thin, firm, unblemished), the risk of body dissatisfaction may increase.

Difficult life events With age, there is an increased risk of 36

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being exposed to a variety of difficult life events (i.e. possible loss of partners, parents and friends, moving home, divorce/separation, loss of employment, finanical concerns, loneliness and illness). These have the potential of significantly increasing stress levels and reducing overall wellbeing.

STATISTICS AND RESEARCH

There appears to be a growing number of women aged 30+ years who are struggling with disordered eating and, alarmingly, this trend is predicted to increase. It may be surprising to know that an estimated 80% of women, aged between 60-70 years, control their body weight and that 60% are dissatisfied with their bodies.2 Perhaps a little less surprising is the estimate that 70% of women >50 years of age are trying to lose weight.3 These figures suggest that, unfortunately, body acceptance does not appear to increase with age and that body dissatisfaction can potentially increase over time.

Prevalence estimates of ED in older adults (defined as >40 years) range from 1.8 to 3.8%, with binge eating disorder (BED) cited as being the most common category in this age group.4 Recent research to identify the prevalence of ED in women in midlife (40s and 50s) suggested that 15.3% of women meet criteria for a lifetime ED, with a 12 months’ prevalence of 3.6%.4 Worryingly, this research also suggested that only 27.4% of all the women with ED had sought or received ED treatments, with only 4.9% receiving psychological treatment for ED and 4% receiving psychological treatment for

an alternative diagnosis.4 These results suggest a higher occurrence than previously reported, but are comparable to former estimates. They also highlight that a significant proportion of women will experience an ED by midlife, but that many are not seeking or receiving treatment.

This research only included females and, unfortunately, there currently does not appear to be comparable research across the genders. It is, however, possible to hypothesis that some of the same increased risk factors may be present when ageing, regardless of gender. Statistics suggests that approximately 25% of those experiencing an ED are male,5 so this would suggest that older females would be at greater risk, but highlights the importance of considering ED pathology in older males also.

ED AND MENOPAUSE

An additional factor which may increase the risk of ED in midlife females, is the changing hormone levels associated with the menopause (i.e. reduced oestrogen levels, increased testosterone and progesterone levels), potentially increasing appetite, altering metabolism and resulting in weight gain and/or a changing body shape.

This, combined with an increase in the visible signs of ageing (wrinkles, hair loss and changes in body fat distribution), may further increase the awareness and emphasis on appearance and thus potentially increase body dissatisfaction.4 This gives rise to the possibility of increased efforts to manipulate and control eating and/ or exercise, in an attempt to prevent the natural body changes that are taking place at this time (which is indeed, not too dissimilar to the increased risk associated during puberty).

A further consideration is the notion that women become increasingly devalued by society in later life which can have a negative impact on their mental health and wellbeing.4 LATER LIFE

The presence of ED in the elderly is also recognised, but there is a lack of research in the prevalence in this population. There are a number of additional factors that can potentially occur in later years which could contribute to the development of disordered eating and increase the risk of an ED.

Loss of purpose Retirement, children leaving home, perceived or actual reduced contributions to society, can all have a negative impact on mental health and wellbeing, resulting in changes in dietary intake.

Loss of independence/control over life The reduced ability to meet one’s own needs and an increasing reliance on others to contribute to safety and wellbeing potentially increase the risk of a desire to control eating as a means of asserting some control.

Perceived or actual cognitive impairment and memory loss This increases the risk of skipping meals, forgetting to eat or overeating and potentially allows for irregular, avoidant or overeating due to ED cognitions going undetected.

Ill health/medical conditions and medications An increased risk of the development or deterioration of chronic health conditions potentially increases anxiety around eating (i.e. trying to follow a strict/restrictive diet after a diagnosis of a physical health condition).

Prescription medications may impact on appetite, resulting in changes to taste and/or increased nausea, all of which may lead to the concealment of changes in eating behaviours.

Changes in digestion and/or bowel habits This potentially increases awareness and anxiety surrounding the digestive process (i.e. needing access to facilities, or concerns about infrequent bowel movements, feeling bloated/ uncomfortable). The use of laxatives and possible restrictive changes in diet and avoidance of certain foods can contribute towards, or conceal, disordered eating/body image issues.

A literature review of ED in those >50 years (age range 50-94 years, mean age 68.6 years), suggested that a late onset ED is more common (69%) than early onset. It also suggested that anorexia nervosa accounts for 81% of cases in this age group and bulimia nervosa for 10%.6 There is an increased risk of weight loss and malnutrition in the elderly for a variety of reasons and there is the possibility that weight loss experienced due to adverse conditions, www.NHDmag.com August/September 2018 - Issue 137

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Table 1: SCOFF questionnaire Do you ever make yourself Sick because you feel uncomfortably full?

Do you worry you have lost Control about how much you eat?

Have you recently lost more than One stone in a three-month period?

Do you believe yourself to be Fat when others say you are too thin?

Would you say that Food dominates your life?

such as ill health, or a difficult life event, could be viewed in a positive light and trigger an ED. Laxative use is also more common in the elderly population and can become problematic if used as a method of purging. As such, it is suggested that laxative use is monitored and that if unexplained weight loss occurs, ED should be included in the differential diagnosis.6 IDENTIFICATION OF ED IN OLDER ADULTS

ED can easily go undetected in older adults and the health risks can be greater, due to a less resilient and ageing body. The presence of ED behaviours can also progress chronic illnesses which are more common in elderly (i.e. osteoporosis, arthritis). Warning signs can easily be missed, as they can be attributed to other factors. Some of the key signs/symptoms to consider are as follows: • Change in behaviour (i.e. using the bathroom after eating, eating alone rather than with friends/family) • Increased sensitivity to cold • Excessive hair loss • Gastrointestinal problems including laxative use • Heart problems • Dental damage If the presence of an ED is suspected, the SCOFF screening tool (Table 1) may be a useful aid in considering the suitability of referral for specialist support within an Eating Disorder Service (EDS). The SCOFF screening tool was designed

by Professor John Morgan to indicate a possible eating disorder. A score of two or more positive answers is considered a positive screen (i.e. ED indicated). It is, however, important to remember that an individual may not be comfortable disclosing the information, or answering direct questions. As such, it is also useful to include

open questions around eating behaviours and any concerns regarding weight, shape and size. If an ED is suspected, making contact with local EDS to discuss possible referral might prove useful.

DISCUSSION

As dietitians and healthcare professionals, it is important for us to remember that individuals can present with an ED at any age and that this may be an initial onset, chronic or a relapsing ED. It is also essential to understand that it is often difficult for those struggling with ED to disclose their difficulties and that stigma, lack of understanding and other internal and external factors can make the process of asking for support even more difficult.

When considering ED in older adults, it might also be useful to reflect on our own views and opinions concerning ageing and explore the common held belief that body image issues reduce with age. We need to accept that many older individuals are indeed dissatisfied with their weight, shape and/or size and that some of the risk factors for developing an ED increase with age. This will help us to keep in mind the possibility of an ED when working with any patient group. It may also be useful to consider previous interactions and reflect on the possibility that ED cognitions might have been present and, therefore, could be preventing dietary changes.

SUMMARY

There is a common belief that ED mainly effect the young and that older adults are no longer at risk. However, research contradicts this and suggests that many older adults are experiencing body dissatisfaction and that the ageing process can indeed increase this further. The risk of experiencing difficult life events also increases over time, as do several other risk factors that can contribute/trigger the onset of ED. There is a risk that the warning signs and symptoms of ED can be overlooked in the older adult. This increases the risk of ED remaining undetected and untreated across this age group. Keeping all this in mind and completing simple screening questions (regardless of age, gender, ethnicity or cultural background), could help to identify those struggling with ED and will ensure that suitable treatment is then made available. www.NHDmag.com August/September 2018 - Issue 137

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