Course:SOWK551/2021/Eating Disorders and the Elderly
This literature review explores types and definitions of EDs, the root causes of EDs in the elderly, researches EDs in older men and women, and provides recommendations on approaches to treatment and social work practice with senior adults. Author: Anonymous
Date: December 11, 2022
"Things which are growing have the greatest natural warmth and, accordingly, need most nourishment. Old men have little warmth and they need little food which produces warmth; too much only extinguishes the warmth they have" as cited in .
Eating disorders (EDs) are serious psychiatric illnesses that can occur across the lifespan;  they are associated with significant functional impairment, high rates of psychiatric and medical comorbidities, and have the highest mortality rate among mental disorders.  Although long-time described only in the younger populations, now eating disorders are increasingly diagnosed in the elderly. 
Researching eating disorders (EDs) in the elderly population is critically important because EDs seriously affect older adults' physical, mental and social well-being. This literature review explores types and definitions of EDs, the root causes of EDs in the elderly, researches EDs in older men and women, and provides recommendations on approaches to treatment and social work practice with senior adults.
Defining types of Eating Disorders
There is no disagreement in defining EDs: clinicians and researchers rely on the Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR) of the American Psychiatric Association. The DSM-V-TR (2000) definitions of eating disorders are important for several reasons: they are used to define the goals of prevention programs and the measurement instruments commonly used to evaluate the long-term success of these interventions.  provide the following list of EDs: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED).  provide a broader list of EDs: pica, rumination disorder avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge eating disorder.
Anorexia nervosa (AN) is described by the DSM-5 as a restriction of energy intake requirements, leading to a significantly low body weight in the context of age, sex, and physical health, along with an intense fear of gaining weight or of becoming fat and a disturbance in the body image.
Binge eating disorder (BED) was recognized in DSM-5 as an autonomous disorder characterized as recurring episodes of eating a significant amount of food in a short period of time. These episodes are marked by .a sense of lack of control and are accompanied by marked distress, the absence of regular compensatory behaviors, and occur at least once a week over three months.
Bulimia nervosa is characterized, according to DSM-5, by recurrent episodes of binge eating and inappropriate compensatory behavior to prevent weight gain, appearing at least three times a month.
Pica, according to DSM-5, is characterized by persistent eating of nonnutritive, nonfood substances for at least one month that is inappropriate to the developmental level and not a part of a culturally supported or socially normative practice.
Rumination disorder is a "condition in which people repeatedly and unintentionally spit up (regurgitate) undigested or partially digested food from the stomach, rechew it, and then either reswallow it or spit it out".
Avoidant/restrictive food intake disorder is an eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional or energy needs associated with one (or more) of the following: significant weight loss, nutritional deficiency, dependence on enteral feeding or oral nutritional supplements, and marked interference with psychosocial functioning.
Eating Disorders and Older Adults
The literature analysis shows that EDs and disordered eating symptoms have become normative in the aging population worldwide. The "face of eating disorders" now appears across age, gender, ethnicity, race, class, culture, and place. According to , a community study found that the prevalence of EDs increased over the decade 1998 -2008 at a faster rate in older subjects with consecutive impairments in their quality of life (as cited in ).
Eating disorders in Elderly Women
The literature concerning EDs in older, postmenopausal women is minimal; however, researchers agree that the incidence of EDs in older women has been increasing in recent decades.  address a medical aspect of EDs in older women and states that menopause, like puberty, represents a window of vulnerability to EDs, likely because of changes in hormonal function, body composition, and conceptions of womanhood.  explore a psychosocial aspect and inform that "age does not immunize women from body image preoccupation, weight and shape concerns, restrictive dieting, and disordered eating" (p.3). While body image dissatisfaction may have begun in early life, societal influence appears to continue contributing to body image despair in older women, regardless of body size.
Eating Disorders in Elderly Men
The amount of research devoted to the issue of EDs in men is disproportionally insufficient, and knowledge regarding the extent and consequences of this problem is minimal. , historically, men have been neglected in the field of eating disorders owing to traditional and female-centric approaches to conceptualization and classification. Men aged midlife and beyond are vulnerable to stigma and stereotypes portraying eating disorders as afflictions of young people and the female gender. Factors precipitating EDs in senior men include stressors that disproportionately occur in later life, including loss due to death or divorce, changes in financial or housing situation, and medical issues. Rates of subthreshold eating disordered behavior are higher and appear to be increasing among older individuals and males in the community; however, "very little is known regarding the prevalence of eating disorders in older men, with initial population estimates ranging from 0.02% to 1.6%"  (p. 248).
Root Causes of Eating Disorders in the Elderly
Most researchers agree that the causality of EDs in the elderly is complex, and they provide multiple reasons why elderly adults develop EDs. Aging persons tend to be, on average, less hungry and eat smaller portions compared to younger adults.  Further,  informs that the reasons may be biological (e.g., a decline in taste sensitivity, loss of olfactory functions, oral and swallowing problems, poor dentition, decreased efficiency of the gastrointestinal system), but mainly they can be described as social or psychological. While most changes in nutrition patterns are reflected in the number of portions old persons eat or the quality of foods and nutrients they consume, they also reflect how they think about food. In addition,  provide detailed descriptions of the causalities of EDs in older adult populations and divides them into psychological and social categories. The psychological causalities of ED in the elderly are body dissatisfaction related to aging, internalization of ideal body images, depression, aging anxiety, self-objectification, negative affectivity, such as a sense of shame and helplessness, and low self-esteem, while social causalities include poverty, social isolation, change in social networks, institutionalization, limitations in daily activities, and elderly abuse. Similarly, provide the following root causes of EDs in older adults: psychological factors, such as comorbid psychiatric disorders, chronic depression, paranoia, indirect self-destructive behavior, dementia, stroke, and Parkinson's disease, acute and chronic illnesses, some medications that diminish appetite. Social and environmental factors include lack of social support and loneliness, spouse grief, and financial difficulties.
The analysis of recent articles devoted to EDs in seniors showed that the treatment and management of EDs in senior adults are very complex. Moreover, "up till now, there are no general guidelines for the treatment of EDs in the elderly, and there are no data about long-term recovery rates in older patients with eating disorders"  (p. 89).  concluded that "the management of disorders of eating in the elderly is a diagnostic and therapeutic challenge, requiring the combined skills of the medical and nursing staff"(p.87). The causes are often multifactorial and require careful assessment of the patient's social, psychological, and medical history, and approaches to treatment involve these factors, as well as ethical and cultural considerations. Furthermore, several challenges make the effectiveness of treatment more complicated because EDs in seniors are often associated with other diseases (e.g., hypertension, diabetes) or mental problems (e.g., dementia, depression, anxiety, food phobias, choking phobia, etc.), which require medical treatment  as cited in . According to , the best outcomes have been observed for combined interventions such as integrated behavioral, pharmacology, and psychotherapy interventions which need to be carefully planned by interdisciplinary teams of doctors, psychotherapists, psychiatrists, and nutritionists, as cited in .
Recommendations for Social work Practice
A majority of researchers in the field of EDs in senior adults provide a variety of practical recommendations applicable to professional social work practice in the area. According to , "the complete approach of the EDs in the elderly should be based on the concept of the biopsychosocial model and should always include the possible psychological and psychiatric disorders" as cited in . In addition,  stress the importance of social support and the involvement of family members in approaching professional practice with elders struggling with EDs. "The primary sources of social support for them are spouses or children, and they need to be trained in what concerns the treatment and engaged in the intervention itself".  Similarly,  informs that social networks can also be co-opted in the treatment since eating together with someone has been shown to enhance enjoyment and increase the quantity of food consumed in patients with anorexia.
 and  advise that group therapy and Cognitive Behavioral Therapy are beneficial approaches to practice with seniors struggling with EDs. "The aim of the therapy is to change the patient's beliefs and her conclusions"(p.150). Psychoeducation serves as a guide to the recovery process, helping women to challenge their self-defeating, distorted cognitions and their perfectionism, and teaching about the biopsychosocial and developmental nature of EDs"  (p.6). In addition, they comment that the treatment of eating disorders relies on a multidisciplinary approach, such as medical, nutritional, social and psychological components.
 explore best practices when working with elder women struggling with EDs and promote a feminist framework enabling a power of collaboration as the client and clinician move through the treatment experience with empathy as the primary therapeutic tool. "By giving the adult woman information to guide her decisions about her behavior and symptom reduction, she can become a more effective collaborator in her care"  (p.6).
The critical aspect highlighted by this literature review is that the number of EDs in senior adults has significantly grown in the last decade and presents a multidimensional medical, psychological, and socioeconomic issue affecting the health and well-being of elders. There is a significant lack of research in the field of EDs in elder populations. Therefore, education on approaches to treatment, prevention, and the creation of specific programs and services targeting seniors struggling with EDs, are the essential steps to be taken in this practice area. Social work practice in this field should be based on a bio-psycho-social model and address older adults' psychological, social, and economic needs.
- ↑ Hippocrates aphorisms 13 and 14
- ↑ Lloyd, G. E. R. (Ed.), (1986). Hippocratic writings. Middlesex, England: Penguin Books.
- ↑ Reas, D., & Stedal, K. (2015). Eating disorders in men aged midlife and beyond. Volume 81, Issue 2, 2015, Pages 248-255, ISSN 0378-5122, https://doi.org/10.1016/j.maturitas.2015.03.004.
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 Fadgyas Stanculete, M., Dumitrasku, D. L., Baban, A., & Dumitrasku, D. I. (2019). Eating disorders in elderly: Clinical implications. A.S.C.R. PRESS. doi:10.24193/jebp.2019.2.14
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. Washington, DC
- ↑ 6.0 6.1 Levine, M.P., & Smolak, L. (2005). The Prevention of Eating Problems and Eating Disorders: Theory, Research, and Practice (1st ed.). Psychology Press. https://doi.org/10.4324/9781410613189
- ↑ Mayo Clinic (2020). Rumination Syndrome. Retrieved from: https://www.mayoclinic.org/diseases-conditions/rumination-syndrome/symptoms-causes/syc-20377330#:~:text=Rumination%20syndrome%20is%20a%20condition,it%20or%20spit%20it%20out.
- ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 Samuels, K.L., Maine, M.M. & Tantillo, M. (2019). Disordered Eating, Eating Disorders, and Body Image in Midlife and Older Women. Curr Psychiatry Rep 21, 70 (2019). https://doi.org/10.1007/s11920-019-1057-5
- ↑ Mitchison, D., Hay, P., Slewa-Younan, S., & Mond, J. (2014). The changing demographic profile of eating disorder behaviors in the community. B.M.C. Public Health, 14(1), 943.
- ↑ 10.0 10.1 10.2 10.3 Podfigurna-Stopa, A., Adam Czyzyk, A., Katulski, K., Smolarczyk, R., Grymowicz, M., Maciejewska-Jeske, M., Blazej Meczekalski, B. (2015). Eating disorders in older women.Volume 82, Issue 2, 2015, Pages 146-152, ISSN 0378-5122, https://doi.org/10.1016/j.maturitas.2015.06.036.
- ↑ 11.0 11.1 Reas, D., & Stedal, K. (2015). Eating disorders in men aged midlife and beyond. Volume 81, Issue 2, 2015, Pages 248-255, ISSN 0378-5122, https://doi.org/10.1016/j.maturitas.2015.03.004.
- ↑ 12.0 12.1 Elsner, R. J. (2002). Changes in eating behavior during the aging process. Eating behaviors, 3(1), 15-43.
- ↑ 13.0 13.1 13.2 13.3 Berry, E. M., & Marcus, E. L. (2000). Disorders of eating in the elderly. Journal of Adult Development, 7(2), 87-99.
- ↑ Gadalla, T. M. (2008). Eating disorders and associated psychiatric comorbidity in elderly Canadian women. Archives of women's mental health, 11(5-6), 357-362.
- ↑ American Dietetic Association. (2006). Position of the American Dietetic Association: Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and other eating disorders. Journal of the American Dietetic Association, 106(12), 2073.
- ↑ Adler, R. H. (2009). Engel's biopsychosocial model is still relevant today. Journal of psychosomatic research, 67(6), 607-611.
- ↑ Katz, W. (2005). An examination of the relationship between physical appearance, personality, internalization of sociocultural norms, and anxiety about aging among middle-aged White women (Doctoral dissertation, Columbia University), 2826.