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• To enhance your awareness of the manifestations of eating disorders in older people
• To better understand why eating disorders in older people may remain undetected
• To explore the assessment of older people presenting with altered eating behaviours, weight and/or mental health
Changes in eating behaviours, weight and mental health in older people may be related to psychological distress and indicate the presence of a diagnosable eating disorder, rather than ‘anorexia of ageing’. Eating disorders in older people may be overlooked because signs and symptoms are assumed to be part of normal ageing. The role of nurses in the care of older people with eating disorders is likely to be detection, referral and support in accessing specialist intervention. This article offers an overview of eating disorders in older people and discusses why they may arise, why they may not be detected and how to recognise them. The authors describe a framework that nurses can use when assessing older people to determine whether they may have an eating disorder.
Nursing Older People. doi: 10.7748/nop.2022.e1399
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondencelouisa.shirley@manchester.ac.uk
Conflict of interestNone declared
Shirley L, Lord N, Cheung L et al (2022) Recognising eating disorders in older people. Nursing Older People. doi: 10.7748/nop.2022.e1399
Acknowledgement The authors would like to acknowledge the contribution of Safiya Alyas to the referencing of this article
Published online: 26 October 2022
EATING DISORDERS in older people are under-recognised and the topic is under-researched. In older people, changes in eating behaviours, weight and/or mental health may not be ascribed to an eating disorder because it is assumed that they are part of normal ageing. Not recognising eating disorders in older people means that they may not receive the interventions they require.
Nurses are likely to be the first and/or the most regular healthcare contacts for people with eating disorders across age groups. The role of nurses in supporting people with eating disorders is under-researched (Foà et al 2019). One systematic review of the perspectives and experiences of people with eating disorders, their families and healthcare professionals found that patients and families want healthcare professionals to have an optimal understanding of eating disorders and pay attention to psychological factors, weight and eating behaviours (Johns et al 2019).
The role of nurses in the care of older people with eating disorders is likely to be detection, referral and support in accessing specialist intervention, not delivering interventions themselves, unless they are trained in psychological therapies or have relevant experience or post-qualification training in working with people with eating disorders. Eating disorders, like other mental health conditions, can cause people to lose hope about their situation, so nurses can support older people with eating disorders to regain a sense of hope by being non-judgemental, listening and showing care (Stavarski et al 2019).
This article supports nurses to recognise eating disorders in older people. It describes what an eating disorder may look like, and possible reasons why it may develop, in an older person. It explains how to structure the assessment of older people who may have an eating disorder and what nurses need to do if the assessment shows an eating disorder is likely.
• Assuming that changes in eating behaviours, weight and/or mental health are part of normal ageing can mean that eating disorders in older people are not detected
• Signs and symptoms of an eating disorder may differ between older people and younger people
• Nurses can use the ‘5 Ps’ framework to assess older people who present with altered eating behaviours or weight
• If an eating disorder is suspected in an older person, they need to be referred to their GP for further management
In the fifth (and latest) edition of the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association (2013) lists eight types of eating disorders. Table 1 lists the four main types – anorexia nervosa, bulimia nervosa, binge eating disorder and avoidant/restrictive food intake disorder – and their diagnostic criteria. In this article the authors refer generically to ‘eating disorders’, as is common in the literature. When they refer to a specific eating disorder, they use the diagnostic term.
(Adapted from American Psychiatric Association 2013)
In some older people, a change in eating behaviours will be related to an eating disorder. This can be surmised from the incidence of eating disorders in the general population – it is estimated that around 1.25 million people in the UK have an eating disorder (Beat Eating Disorders 2022) – and from the fact that eating disorders tend to be ongoing or reoccur (Carter et al 2012). A literature review of the relationship between body image and associated mental and physical health problems and behaviours in adult women suggested that many women in midlife and later life experience body dissatisfaction and are concerned about their weight and body shape (Kilpela et al 2015), which are risk factors for eating disorders, notably anorexia nervosa.
Little is known about the prevalence of eating disorders in older people. Anorexia nervosa is thought to be the most common eating disorder in older people (Lapid et al 2010) and is likely the most threatening to their health and well-being, given that significant weight loss in an older person can result in a decline in activities of daily living (Ritchie et al 2008) and an increased risk of death (Roh et al 2014). It is possible that the physical risks posed by anorexia nervosa mean that this type of eating disorder is more often diagnosed in older people than any of the other types. Lapid et al (2010) and Mulchandani et al (2021) reported in their review articles that bulimia nervosa was the second most reported type of eating disorder, and that binge eating disorder was the least likely type of eating disorder, in older people.
Evidence suggests that older people with eating disorders are more likely to have a lifelong unresolved eating disorder, or a resolved eating disorder that re-emerges in later life, than to develop an eating disorder in later life (Luca et al 2014, Schaeffer 2021). Avoidant/restrictive food intake disorder should be considered as a potential diagnosis in an older person for whom other mental health conditions present as ‘sub-threshold’, that is, when clinically relevant depressive symptoms do not meet the criteria for a major depressive disorder (Meeks et al 2011).
There is an important distinction to be made between anorexia nervosa – which is characterised by altered eating behaviours and/or weight loss related to psychological distress and disturbance of body image – and anorexia of ageing – a term used in the literature to describe weight loss specifically associated with physical, environmental or social issues arising in later life (Landi et al 2016). Physical issues contributing to weight loss in older people include taking medicines with appetite-suppressant or malabsorption side effects; experiencing gastrointestinal disorders; dental issues that make eating painful; and physical changes related to dementia (Stroebele and De Castro 2004, Landi et al 2016). Social and environmental issues include social isolation and stress due, for example, to a change in living situation (Landi et al 2016). Some articles on anorexia of ageing (Donini et al 2003, Hays and Roberts 2006) mention psychological aspects, but these aspects are not given a central position. Anorexia of ageing is associated with negative outcomes including frailty and increased mortality (Landi et al 2017, Cox et al 2020). Although it can be regarded as disordered eating, it is not classified as an eating disorder.
It is important to detect and treat all eating disorders affecting older people, since eating disorders are associated with anxiety, depression and obsessive compulsive disorder (American Psychiatric Association 2013) and with deleterious effects on physical health and well-being, including an increased risk of death (Demmler et al 2020).
In adolescents, early diagnosis and intervention have been associated with a better prospect of recovery (Treasure and Russell 2011). Early diagnosis and intervention are crucial in older people, who are physically less resilient to the negative effects of an eating disorder than younger people (Somes et al 2002). A systematic review of the literature on the treatment of eating disorders in older people (Mulchandani et al 2021) identified 35 articles, 33 of which were case studies or case series. Mulchandani et al (2021) concluded that the limited amount of information on the subject and the low quality of the evidence made it challenging to make recommendations on assessment or treatment.
Healthcare professionals may not recognise an eating disorder in an older person because older people with eating disorders present with different signs and symptoms than younger people. Luca et al (2014) reported that older people with eating disorders may have fewer episodes of vomiting but higher rates of purging through laxative use than younger people with eating disorders. Luca et al (2014) also noted an increased likelihood of past or current obesity in people diagnosed with an eating disorder later in life.
Other reasons why eating disorders in older people may be overlooked include misconceptions, among healthcare professionals and the public, about what causes changes in eating behaviours, weight and/or mental health in older people. Weight loss and changes in eating behaviours may be incorrectly attributed to the ageing process, while psychological distress may be assumed to originate from adverse environmental and social circumstances rather than being rooted in earlier life events (Strachan et al 2015).
Various organisations are working with expert clinicians to ensure that older people’s mental health needs are recognised and addressed. The Royal College of Psychiatrists (2022) has developed training materials to increase awareness of older people’s mental health needs, while the Community Mental Health Framework (NHS England 2019) mapped out the transformation of community services required to meet the needs of adults and older adults, including those with eating disorders. As members of the Faculty of Psychology of Older People (one faculty of the British Psychological Society’s Division of Clinical Psychology), three of the four authors of this article (LS, NL and GG) have worked with NHS England and NHS Improvement to develop a webinar designed to raise awareness of eating disorders in older people and are consulting with NHS England and NHS Improvement on the development of standards for services for older people with eating disorders.
Any older person who presents with altered eating behaviours and/or weight requires a holistic assessment that should include malnutrition screening (Elia 2003). It should also include an assessment of environmental and social factors, since social eating has been shown to be an important component of psychological well-being and healthy nutritional status in older people (Herman 2015, Tani et al 2018). When assessing the older person, nurses should be mindful of the possibility that they have an eating disorder.
To structure the assessment, the authors suggest using a formulation framework such as the ‘5 Ps’ – which stand for presenting problem, predisposing factors, precipitating factors, perpetuating factors and protective factors (Johnstone and Dallos 2013). Determining the presenting problem(s) may raise suspicion of an eating disorder, and exploring predisposing, precipitating, perpetuating and protective factors with the older person may reveal psychosocial factors that could confirm that suspicion.
The presenting problem(s) related to an eating disorder in older people may be subtly different than in younger people (Luca et al 2014). Signs and symptoms of an eating disorder in older people may include (Schaeffer 2021):
• Significant change in weight (increase or decrease) over a relatively short time.
• Change in behaviours, such as immediately using the bathroom after eating something.
• Presence of boxes of laxatives, diet pills and/or diuretics when there appears to be no clinical indication for them.
• Expressed desire to eat alone.
• Missing meals.
• Sensitivity to cold.
• Excessive hair loss, dental damage or cardiovascular or gastrointestinal issues (for example, constipation or bloating).
Many of these signs and symptoms are also associated with ageing and can be easily ascribed to something other than an eating disorder. Behavioural signs of eating disorders in older people who live alone, or whose routine is restricted because they live in a care setting, may not be immediately apparent.
Factors that may predispose older people to developing an eating disorder include a history of eating disorder, which may or may not be known to the healthcare professionals involved in their care; an over-emphasis on food in earlier life, for example through dieting (Haines and Neumark-Sztainer 2006); and experience of anxiety or depression (DeBoer and Smits 2013). In can be useful to incorporate questions about the older person’s past into the assessment. Historical trauma is a risk factor in eating disorders and an additional indicator that the person may require referral for further management.
Historical trauma has been linked to eating disorders in older people. In a study of 98 older adults with a diagnosed eating disorder, approximately 25% reported having experienced traumatic events in their personal life (Vanderlinden et al 1993). A longitudinal study investigating the 12-month prevalence and the lifetime prevalence of eating disorders in 5,658 women in midlife found that 15% of them met the criteria for a lifetime eating disorder. Childhood sexual abuse was prospectively associated with all binge and/or purge types of eating disorders and childhood life events and interpersonal sensitivity were associated with all eating disorders (Micali et al 2017).
The onset or re-emergence of an eating disorder in later life may be attributable to distressing life events such as the death of a spouse and may represent a return to a previous coping method (Maine and Kelly 2016, Schaeffer 2021). Life events that cause an older person to experience a loss of self-agency and independence, for example moving into a care home, can contribute to the development of an eating disorder. The person’s attempts to regain self-agency and independence by controlling their food intake can escalate into an eating disorder (Harris and Cummella 2006).
There are various psychological mechanisms that can contribute to perpetuate an eating disorder. For an older person, restricting what they eat may be, from their perspective, the only way they can have some control over their life. Similarly to younger people, older people can experience distorted body image (Marshall et al 2014), which can be a perpetuating factor. Thinking styles such as perfectionism or dysfunctional evaluation of self-worth are also likely to perpetuate an eating disorder (Cella et al 2020). Lampard et al (2013) identified several perpetuating factors in younger people with eating disorders, including low self-esteem, overevaluation of weight and shape, and issues with forming and maintaining relationships with others. Further research is needed to identify what perpetuating factors may be present in older people with eating disorders.
It is important to explore potential protective factors and positive coping mechanisms that may have assisted the older person in managing their eating disorder in the past or may assist them in their present situation. Protective factors include having close family members or friends in whom the older person can confide and having accessed support in the past.
If appropriate, nurses can complement the assessment by using a validated screening tool, thereby collecting further evidence in case the older person needs to be referred to their GP. The SCOFF questionnaire is a validated screening tool designed to raise suspicion of an eating disorder (Morgan et al 1999), which was tested by Solmi et al (2015) in a multi-ethnic population-based sample of adults up to the age of 90 years.
The SCOFF questionnaire includes the following questions (Morgan et al 1999):
• S: do you make yourself feel Sick because you feel uncomfortably full?
• C: do you worry you have lost Control over how much you eat?
• O: have you recently lost more than One stone in a three-month period?
• F: do you believe yourself to be Fat when others say you are too thin?
• F: would you say that Food dominates your life?
A positive response to each question yields one point. A total score of two or more points is considered to indicate a possible eating disorder.
If the assessment indicates that the older person is likely to have an eating disorder and/or if their change in weight is negatively affecting their physical or mental health regardless of cause, nurses need to contact the person’s GP. The GP will have access to the person’s past medical history and can use it to contextualise their presentation. Unless they are trained in psychological therapies or have relevant experience or training in working with people with eating disorders, nurses should not provide any intervention themselves but refer patients to their GP for further management. The GP can then initiate specialist psychological and/or medical intervention as needed, which may require further referral to specialist services and eating disorders nurses. It is best practice to discuss the referral with the older person before making it.
The National Institute for Health and Care Excellence (NICE) (2020) guideline on the recognition and treatment of eating disorders recommends that interventions include psychological therapy, psychoeducation about the disorder, and monitoring of mental and physical health with appropriate treatment if needed; that there should be coordinated multidisciplinary input; and that family members and carers should be involved and have their own support needs assessed.
Psychological treatment for an eating disorder needs to be provided in the context of older people’s understanding of mental health and their expectations of psychological treatment. A study of older people’s perceptions of the term ‘trauma’ showed that although they recognised the term, they did not believe their own experiences fitted into that category (Marsh et al 2021). Older people of a certain generation may ‘keep a stiff upper lip’ despite traumatic childhood experiences, notably in wartime, such as having to leave their home or experiencing the death of a parent or sibling (Marsh et al 2021). Another factor is that older people are often less digitally knowledgeable than younger generations and therefore less likely to access online information on how to maintain optimal mental health (Andrews et al 2019).
Eating disorders in older people can go undetected because their manifestations are incorrectly attributed to normal ageing, which can have negative and potentially serious consequences on people’s physical and mental health. Nurses need to be alert to the possibility that an older person presenting with altered eating behaviours, weight and/or mental health may have an eating disorder. The ‘5 Ps’ framework can assist nurses to conduct a holistic assessment of older people and explore with them their psychosocial risk factors for an eating disorder. Older people who appear likely to have an eating disorder and/or whose change in weight is negatively affecting their physical or mental health regardless of cause will need to be referred to their GP for further management.
Eating disorders training
www.e-lfh.org.uk/programmes/eating-disorders-training-for-health-and-care-staff
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