Death from anorexia nervosa: age span and sex differences

Treatment of eating disorders in older people: a systematic review

BACKGROUND

Historically, eating disorders were not identified in older populations and it is only in more recent times that there is greater recognition of the existence of eating disorders among the elderly. This is despite the high level of morbidity and mortality associated with these disorders. Current guidelines focus on treatment of eating disorders within the adolescent and general adult age groups, without apparent concessions made for the older age group. The aim of this study was to review existing literature on the demographics and treatment of eating disorders in older people.

METHODS/DESIGN

A systematic review of the literature was conducted using CINAHL, MEDLINE, EMBASE, PsycInfo, Scopus, and Web of Science to identify publications focusing on treatment of eating disorders in people over the age of 65 years, age of diagnosis, gender distribution, treatment setting, and treatment outcomes.

RESULTS

A total of 35 articles (reporting on 39 cases) were relevant to our study, with 33 of the 35 articles being either case studies or case series. The mean age of participants was 73.2 years (range 66-94 years) with the majority (84.6%) being female. Most cases (84.6%) were diagnosed with anorexia nervosa, and 56.4% of all cases were reported as late onset (i.e., after age 40 years). The vast majority (94.8%) received treatment, of which 51.5% was hospital-based treatment. In case descriptions where improvement was reported, the majority described a multidimensional approach that included a combination of hospital admission, therapy and pharmacotherapy. Overall, 79.5% of cases who underwent treatment for an eating disorder improved, while 20.5% relapsed or died as a result of the complications from their eating disorder. There were significant inconsistencies and omissions in the way cases were described, thereby impacting on the interpretation of the results and potential conclusions.

CONCLUSIONS

The information available on the treatment of eating disorders in people over the age of 65 years is limited. The quality of case reports to date makes it difficult to suggest specific assessment or treatment guidelines for this population.

Five-year mortality of severely malnourished patients with chronic anorexia nervosa admitted to a medical unit

OBJECTIVE

Anorexia nervosa (AN) is associated with one of the highest mortality rates of any psychiatric disorder but limited mortality data were reported for those with extremely severe malnutrition. This study aimed to estimate standardized mortality ratio (SMR), investigate predictive factors of mortality and causes of death among a sample of patients with AN admitted to a specialized clinical nutrition unit (CNU) because of extremely severe malnutrition.

METHODS

Between 11/27/1997 and 01/15/2014, vital status was determined for 384 patients admitted for AN at the first time in the CNU. Sociodemographic, anamnestic, and clinical data were collected. We calculated the SMR. Univariate and multivariate Cox regression analyses were performed to identify mortality predictors.

RESULTS

Crude mortality rate was 11.5%. (44 deaths) and SMR 15.9 [CI 95% (11.6-21.4)], 5.2 years post inpatient treatment. Mortality predictors at the time of hospitalization were as follows: older age, occurrence of an in-hospital suicide attempt, transfer to medical intensive care unit and the following somatic complications: frank anemia, dysnatremia, infectious and cardiac complications. Other predictors of mortality were: past or present history of discharge against medical advice, hematological comorbidities (not related to AN). A longer inpatient length of stay was a protective factor.

CONCLUSION

Very severely malnourished patients with AN hospitalized in a medical unit because of extremely severe somatic issues have a medium-term mortality rate higher than the general population and even higher than patients in tertiary specialized ED units. This study highlights predictive factors of mortality that will help clinicians in recognizing and managing patients at risk of death.

Which Comes First? An Examination of Associations and Shared Risk Factors for Eating Disorders and Suicidality

PURPOSE OF REVIEW

This narrative review evaluates recent literature on the associations between eating disorders and suicidality and discusses potential shared mechanisms that may account for these relationships. Additionally, the review highlights shortcomings with the literature to date and suggests avenues for future research.

RECENT FINDINGS

Individuals with anorexia nervosa, bulimia nervosa, and binge eating disorder experience elevated rates of suicidality compared to the general population. Suicide risk is higher when eating disorders occur with other psychological conditions. Additionally, genetic factors, emotion dysregulation, trauma, stressful life events, and lack of body regard may have roles in the development of both eating disorders and suicidality. Much of the risk for suicidality in eating disorders appears to be driven by comorbid psychopathology and genetic factors. However, the lack of longitudinal research makes it difficult to draw conclusions about the directionality or temporality of these relations; thus, novel methods are needed.

Disordered eating in older people: Some causes and treatments

This overview considers causes of disordered eating, including eating disorders, in older people. Eating disorders are becoming more common in older adults and research has shown a related mortality of 21%. The wide range of medical and pharmacological causes of weight loss in older people means that eating disorders may go undetected, occurring insidiously and surreptitiously.

Learning Objectives

• Be aware of the numerous causes of weight loss in older people, and understand that eating disorders are not about weight but about control

• Appreciate that physical and mental health problems and polypharmacy affect eating and weight

• Understand that successful management focuses on a combination of pharmacological and behavioural interventions

Eating disorders in midlife women: A perimenopausal eating disorder?

Eating disorders afflict women across the lifespan with peak onset during critical or sensitive developmental periods of reproductive hormone change, such as puberty. A growing body of research supports the role of reproductive hormones, specifically estrogen, in the risk for eating disorders and related symptomatology in adolescence and young adulthood. Like puberty, perimenopause is characterized by estrogen change and may also present a window of vulnerability to eating disorder development. Here, we discuss the evidence that suggests perimenopause indeed may be a vulnerable period for the development or redevelopment of an eating disorder for midlife women. Drawing from what is known about the influence of estrogen on eating disorders at younger ages and from other psychiatric disorders with similar risk trajectories (i.e., perimenopausal depression), we describe a potential mechanism of risk for a perimenopausal eating disorder and how this can be explored in future research. Investigating vulnerability to perimenopausal eating disorders will clarify eating disorder etiology, identify reproductive stage-specific risk profiles, and guide future treatment directions.

Sex differences in motivational responses to dietary fat in Syrian hamsters

Women are more likely than men to exhibit motivational disorders (e.g., anhedonia and anxiety) with limited treatment options, and to overconsume high-fat "comfort foods" to improve motivational disruptions. Unfortunately, neurobiological underpinnings for sex differences in motivational disruptions and their responses to dietary fat are poorly understood. To help bridge these fundamental knowledge gaps, we assessed behavioral and neurobiological responses to dietary fat in a hamster model of female-biased motivational lability. Relative to social housing, social separation reduced hedonic drive in a new behavioral assay, the reward investigational preference (RIP) test. Fluoxetine or desipramine treatment for 21, but not 7, days improved RIP test performance. Pharmacologic specificity in this test was shown by non-responsiveness to diazepam, tracazolate, propranolol, or naltrexone. In the anxiety-related feeding/exploration conflict (AFEC) test, social separation worsened latency to eat highly palatable food under anxiogenic conditions, but not in home cages. Social separation also reduced weight gain, food intake, and adiposity while elevating energy expenditure, assessed by caloric efficiency and indirect calorimetry. Furthermore, chronic high-fat feeding improved anhedonic and anxious responses to separation, particularly in females. In the motivation-influencing nucleus accumbens, females, but not males, exhibited a separation-induced anxiety-related decrease in Creb1 mRNA levels and an anhedonia-related decrease in ΔFosb mRNA levels. Consistent with its antidepressant- and anxiolytic-like effects on behavior, high-fat feeding elevated accumbal Creb1 and ΔFosb mRNA levels in females only. Another accumbal reward marker, Tlr4 mRNA, was elevated in females by high-fat feeding. These results show that social separation of hamsters provides a novel model of sex-dependent comorbid anhedonia, anxiety, and anorexia, and implicate accumbal CREB, ΔFosB, and TLR4. Moreover, the results validate a new assay for chronic antidepressant efficacy.

Unexplained weight loss in an 80-year-old woman

An 80-year-old woman presented with long-standing history of weight loss and malnutrition, which had caused her to become reliant on the use of a wheelchair. Her symptoms were initially attributed to her medical comorbidities, however, during admission it became apparent that she had been suffering from depression and had gone on to develop an eating disorder. Eating disorders are most common in young adults but can affect all age groups, including the elderly population. The diagnosis is rarely considered in such patients and easily overlooked, especially when in the presence of chronic conditions and cognitive decline. A pre-existing psychiatric issue, most often depression, may also be present in this age group. There are no current treatment methods targeting patients in this population, who may not respond as effectively to the available strategies directed at young adults. It is important to always consider an eating disorder as a contributor or direct cause of unexplained weight loss in elderly patients.

A case of anorexia nervosa in an elderly man

OBJECTIVE

To explore aspects of anorexia nervosa occurring in older populations, especially men, by reviewing the literature and presenting a case study of an elderly man with unexplained vomiting and weight loss.

METHOD

The literature is reviewed and an illustrative case study of an elderly man with unexplained vomiting and weight loss is described.

CONCLUSIONS

Anorexia nervosa is an uncommon cause of unexplained weight loss in the elderly, but may be under-recognized and associated with a high level of mortality.

Disordered Eating and Psychological Distress among Adults

The majority of our knowledge about eating disorders derives from adolescent and young adult samples; knowledge regarding disordered eating in middle and later adulthood is limited. We examined the associations among known predictors of eating disorders for younger adults in an age-diverse sample and within the context of psychological distress. Using data from 567 adults (ages 18 to 88 years), we tested a path model in which age, gender, eating-related cognitions, and satisfaction with appearance predicted eating disorders which, in turn, predicted psychological distress. The model fit the data well (χ2 (DF= 11, N = 567) = 30.58, p < .001; GFI = .987, NFI = .963; RMSEA = .056), explaining 20.1% of the variance in psychological distress.

Eating disorders in the elderly

BACKGROUND

Eating disorders in the elderly are often overlooked. When they occur, significant morbidity and mortality result. In this study we review all existing literature on eating disorders in the elderly and provide practical guidelines for clinicians in recognizing and managing eating disorders in the elderly.

METHODS

A literature search using Medline, PubMed, Web of Knowledge, and PsychINFO revealed 48 published cases of eating disorders in people over the age of 50 years.

RESULTS

The mean age was 68.6 years (range 50-94), and the majority (88%) of cases were females. The majority (81%) of cases had anorexia nervosa, and 10% had bulimia nervosa. Late onset eating disorders were more common (69%) than early onset. Comorbid psychiatric conditions existed in 60%, most commonly major depression. Management with a combination of behavioral and pharmacologic interventions was most successful, although only 42% were treated successfully. Mortality was high (21%) secondary to the eating disorder and its complications.

CONCLUSION

Eating disorders do occur in the elderly and should be included in the differential diagnosis of unexplained weight loss in the elderly.

Eating disorders across the life span

Clearly, eating disorders appear in both men and women across the entire life span. Nurses must be aware of eating disorder issues in populations such as children and adolescents, adult men, middle-aged women, and older adults so that proper screening and treatment can occur to reduce the consequences of these potentially life-threatening illnesses.

Characteristics of anorexia nervosa-related deaths in Norway (1992-2000): data from the National Patient Register and the Causes of Death Register

OBJECTIVE

This study investigated demographic and diagnostic characteristics of individuals whose medical record or death certificate indicated the presence of anorexia nervosa at the time of death.

METHOD

Two national registers, the National Patient Register (NPR) and the Causes of Death Register (CODR), were examined in Norway for anorexia nervosa-related deaths occurring across a 9-year period (1992-2000).

RESULTS

The medical record or death certificate listed anorexia nervosa as a diagnosis or cause of death for 66 individuals. Rates of death were 6.46 and 9.93 per 100,000 deaths for the NPR and the CODR, respectively. A substantial percentage of deaths (43.9%) in both registers occurred at or above the age of 65 years. For the NPR, the mean age at the time of death was 61 years and 31% of deaths occurred among men. For the CODR, the mean age at the time of death was 49 years and 18% of deaths occurred among men.

DISCUSSION

Potential merits and shortcomings of assessing mortality rates using register-based data without linkage to a previously identified clinical sample are discussed.

An audit of a British sample of death certificates in which anorexia nervosa is listed as a cause of death

OBJECTIVE

Anorexia nervosa is associated with an increased mortality rate. National mortality statistics based on statutory death certification are potentially an important source of information. However, there are reasons to believe that these statistics may be subject to significant errors. An audit of the quality of information and diagnosis was conducted on death certificates in which anorexia nervosa was mentioned.

METHOD

The current study examined data from death certificates of people who died in England and Wales between 1993 and 1999.

RESULTS

There were 230 such deaths, but only 128--just over one half--were rated as likely to be deaths associated with true anorexia nervosa.

DISCUSSION

National mortality statistics derived from death certificates are a flawed source of information on deaths from anorexia nervosa when taken at face value. There may be both underreporting and overreporting. Detailed examination may improve their usefulness by reducing the overerreporting. It seems likely that the association of deaths with anorexia nervosa is systematically underreported.

Long-term survival of patients with anorexia nervosa: a population-based study in Rochester, Minn

OBJECTIVE

To estimate long-term survival of unselected patients with anorexia nervosa from Rochester, Minn.

PATIENTS AND METHODS

In this population-based retrospective cohort study, all 208 Rochester residents who presented with anorexia nervosa (193 women and 15 men) for the first time from 1935 through 1989 were monitored for up to 63 years. Subsequent survival was compared with that expected for Minnesota white residents of similar age and sex, and standardized mortality ratios were determined on the basis of age- and sex-specific death rates for the US population in 1987.

RESULTS

Survival was not worse than expected in this cohort (P = .16). The estimated survival 30 years after the initial diagnosis of anorexia nervosa was 93% (95% confidence interval, 88%-97%) compared with an expected 94%. During 5646 person-years of follow-up (median, 22 years per patient), 17 deaths occurred (14 women and 3 men) compared with an expected 23.7 deaths (standardized mortality ratio, 0.71; 95% confidence interval, 0.42-1.09). One woman died of complications of anorexia nervosa, 2 women committed suicide, and 6 patients (5 women and 1 man) died of complications of alcoholism. Other causes of death were not increased.

CONCLUSIONS

Long-term survival of Rochester patients with anorexia nervosa did not differ from that expected. This finding suggests that overall mortality was not increased among the spectrum of cases representative of the community.