Anorexic or simply old?

Anorexia nervosa and bulimia are often thought of as teenage afflictions. But, in Eating Disorders Awareness Week this week, Natalie Valios reports that professionals often miss the symptoms in older people.

Hear the word “bulimic” and your automatic thought will probably be of a teenage girl. The picture that won’t spring to mind is of a woman in her eighties bingeing and making herself vomit. But in the past few years there has been a growing recognition by eating disorder specialists that anorexia nervosa and bulimia can affect anyone at any age.

Eating disorders are a serious mental illness affecting 1.1 million people in the UK. But the dearth of research or information on how they affect older people means many health and social care practitioners often miss the signs. While some may not even realise that older people can have eating disorders, others may confuse anorexia nervosa – where food is consciously restricted – with anorexia, where appetite loss is caused by cancer and other wasting illnesses. Symptoms can go further unnoticed because older people may stop eating for any number of reasons, including badly fitting dentures, a lack of taste or smell, bowel problems, difficulty in swallowing or chewing and depression. This leads to a belief that loss in appetite and weight is simply an integral part of growing old.

But there is a lethal cost to eating disorders going unnoticed, as research from the University of British Columbia in 1996 revealed. Two psychologists examined 10.5 million death records in the US from 1986 to 1990, which showed that the average age of death from anorexia nervosa for women was 69 and, for men, 80. It also emerged that, although the disorder was more common among young people, 78% of all deaths from anorexia nervosa were of older people.

Because starvation affects circulation, heart function, the liver and kidneys it is unsurprising that the risks are higher for an older person, whose organs may already be damaged.

Susan Ringwood, chief executive of Beat, the UK charity for people with eating disorders, says: “Very young people and very old people are at most risk because they don’t have the reserves in their body to cope.”

Dave Anderson, chair of the faculty of old age psychiatry at the Royal College of Psychiatrists, is aware of the existence of the disorder among older people, even though in 20 years as a consultant he has never seen a case. “It’s poorly understood and described, and part of the problem is that it’s going unnoticed because of this,” he says.

Anderson has a warning for the future: “There’s a feeling that eating disorders we see in such large numbers in young people are generationally linked. They are undoubtedly influenced by the culture that you grow up with which will fuel the problem. If there is a cultural effect of that sort, the younger generation who are affected by that now will become elderly so we may see more of it in 40 years.”

There are several factors that can trigger eating disorders: loss of self esteem; genetic predisposition; trauma; and personality traits such as perfectionism, an obsessive compulsive nature and needing to be in control.

“It’s a toxic mixture,” says Ringwood. “Then if your life takes a turn that makes you feel bereft or low it can become difficult to manage and food feels like the answer because the effect of starvation on the brain is to dull the emotional state.

“It could be that those who develop it later in life may have always been at risk but enough factors haven’t come together [and when they do] these are what push people over the edge.”

Alternatively, says Ringwood, it could be a recurrence of an earlier episode of an eating disorder that has been triggered by recent life changes such as loneliness, loss or moving into a care home, although this may be more difficult to verify because many eating disorders were undiagnosed 40 years ago.

Eating disorder specialist Vathani Navasothy has seen eight older people with eating disorders at her private practice. Two of her clients are women aged 83 and 78. Both are bulimic. “My 83-year-old client went from being morbidly obese to dropping weight and maintaining it for a number of years before becoming bulimic and doing the classic things – that you don’t imagine an older person doing – such as using laxatives, diuretics, purging. She’s now coming out of it,” says Navasothy.

“My other client had buried a traumatic background for many years. Her partner died the year before her 70th birthday, she was lonely and the birthday triggered bulimic tendencies.

“Both went to their GP but were disillusioned that they didn’t pick up on the bulimia. If someone is saying they have a problem with eating, people need to start to listen. There needs to be special training in the medical profession to notice these things and to look for the symptoms even if they come to you with a different problem.

“Anorexia nervosa changes your brain chemistry so much that someone with it is not going to want to get that help so it’s up to us to notice that something is wrong. Are they not eating for a medical reason or is there something else behind it?”

Signs to look for include consistent patterns of low appetite; BMI going below 18; missed or skipped meals; dull hair; facial hair growth; and grazing on knuckles and swollen face glands can be signs of bulimia.

The difficulty, says Navasothy, is that some clinical symptoms of eating disorders are similar to the signs of ageing and GPs don’t have the knowledge to distinguish between them. As Ringwood says, the biggest risk is that professionals simply don’t think of it.

CASE STUDY

Andrew’s story  – ‘In her seventies Mum dropped to 6st. She was 5ft 11in’

Mum was obsessive about ideals of body shape and weight. She was incredibly condemning of fat people. When I was a child I became aware that she spent a lot of time cooking for everybody, but would never sit down herself. She was always the last to eat and it was always small portions.

“I can clearly remember in the 1970s eating steak and kidney pie while she was eating Ryvita and cottage cheese. Then she became really tied up with the whole health food thing so she would only eat beans, pulses and lettuce.

“She had a very active lifestyle, walking, cycling and doing charity work and, as she got older, it became apparent that she wasn’t eating well enough to support her lifestyle.

“After my father’s death 10 years ago she lost all motivation to cook. In her late seventies, she dropped to 6st. She’s 5ft 11in tall.

“She’s 84 now and at the end of last year she had home care for a couple of months. I was worried that, unless the care workers understood the nature of her eccentric attitude towards food and eating, they wouldn’t be able to provide her with nourishing meals because she wouldn’t eat them.

“She had intermittent hospital trips after panic attacks, I think because of the onset of dementia and she was frail because she wasn’t eating.

“She’s now at an assessment centre to determine whether she has Alzheimer’s. Ironically, now she forgets to be neurotic about food so is eating again.”

* Name has been changed.

Useful Information

University of British Columbia research

Beat, including details of Eating Disorder Awareness Week

National Centre for Eating Disorders

British Dietetic Association