Eating Disorders in Old Age

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1 Eating Disorders in Old Age Dr. William Rhys Jones Consultant Psychiatrist & Clinical Lead CONNECT: The West Yorkshire and Harrogate Adult Eating Disorders Service

2 Eating Disorders in Old Age Eating disorders: an overview Eating disorders in old age

3 Eating Disorders Anorexia Nervosa BMI<17.5 Core psychopathology Amenorrhoea Bulimia Nervosa BMI>17.5 Core psychopathology Regular binge/purge 2x/week Eating Disorder Not Otherwise Specified Subclinical disorders Binge eating disorder

4 Eating Disorders Anorexia Nervosa 1 in 250 females 1 in 2000 males Bulimia Nervosa 1 in 50 females 1 in 500 males Eating Disorder Not Otherwise Specified More common still but rates uncertain

5 Eating Disorders Anorexia Nervosa BMI<18.5 Core psychopathology Bulimia Nervosa BMI>18.5 Core psychopathology Regular binge/purge 1x/week Other Specified Feeding and Eating Disorders (OSFED) Subclinical disorders Binge Eating Disorder

6 Clinical Features Core psychopathology Behaviours Physical complications

7 Core Psychopathology Morbid fear of weight gain Pursuit of thinness Body dissatisfaction Body image distortion Self evaluation based on weight and shape

8 Common Behaviours Dieting Fasting Calorie counting Excessive exercise Water loading Diet pills, thyroxine, diuretics, appetite suppressants Excessive weighing Body checking Culinary behaviours Avoidance Isolation Bingeing Purging Starve-binge-purge cycle Misuse of insulin Laxatives DSH Substance misuse

9 System Starvation Bingeing/purging CVS Renal GI Skeletal Endocrine Haem Neuro Metabolic Bradycardia Hypotension Sudden death Oedema Electrolyte abnormalities Renal calculi Renal failure Parotid swelling Delayed gastric emptying Nutritional hepatitis Constipation Osteoporosis Pathological fractures Short stature Amenorrhoea Infertility Hypothyroidism Anaemia Leukopenia Thrombocytopenia Generalised seizures Confusional states Impaired temperature regulation Hypoglycaemia Arrhythmias Cardiac failure Sudden death Severe oedema Electrolyte abnormalities Renal calculi Renal failure Parotid swelling Dental erosion Oesophageal erosion/perforation Constipation Osteoporosis Pathological fractures Oligomenorrhoea/amenorrhoea Leukopenia/lymphocytosis Generalised seizures Confusional states Impaired temperature regulation Hypoglycaemia Derm Lanugo, brittle hair and nails Calluses on dorsum of hands (Russell s sign)

10 High Mortality AN has highest mortality rate of any psychiatric disorder (Arcelus et al, 2011) with SMR of 6 Most deaths due to physical complications of dieting, bingeing and purging 20-40% of deaths in AN due to suicide

11 Physical Risk Assessment Clinical history and physical examination Body mass index (BMI) Electrocardiogram (ECG) Blood investigations

12 Physical Risk in Eating Disorders Index (PREDIX) SYSTEM TEST OR INVESTIGATION MODERATE RISK HIGH RISK Nutrition BMI Rate of weight loss <15 >0.5kg/week <13 kg/m 2 >1kg/week Cardiovascular Blood pressure Postural drop Pulse rate Peripheral cyanosis <90/60 mmhg >10 mmhg <50 bpm <80/50 mmhg >20 mmhg <40bpm Yes Musculo-skeletal Stand up or sit up test (proximal Grade 2 Grade 0-1 myopathy) Temperature <35 C <34.5 C Blood profile White cell count Neutrophils Haemoglobin Platelets Concern if outside normal limits <2.0 x 10 9 /l <1.0 x 10 9 /l <9.0 g/dl <110 x 10 9 /l Biochemistry Electrocardiogram Potassium Sodium Phosphate Pulse rate Corrected QT interval (QTc) Arrhythmias Concern if outside normal limits <2.5 mmol/l <130 mmol/l <0.5 mmol/l <50 bpm <40 bpm >450 msec

13 Principles of Treatment Early intervention is key Usually done as an outpatient Most AN require specialist Rx BN & EDNOS will mainly be treated either in primary care or secondary services NG feeding last resort Treatment on a medical unit relatively rare Consider rehabilitation model of care in severe and enduring cases Nutritional rehabilitation and psychological intervention MANTRA, CBT-ED, CAT, IPT, psychodynamic psychotherapy, family therapy, family interventions, DBT Fluoxetine 60mg daily in BN Best services offer eclectic mix of therapies not one size fits all CBT is not the panacea

14 Eating Disorders in Old Age Literature on ED after menopause is sparse ED do occur in the elderly (SEED, anorexia tardive) Similar presentation to younger population but with important differences Usually complicated by psychiatric and medical comorbidities which increase risk and have implications for treatment

15 Eating Disorders in Old Age Early onset - continues/recurs in old age Late onset - develops for the first time later in life Severe and enduring eating disorders (SEED) Implications for treatment, e.g. rehabilitation model of care Anorexia tardive (Dally, 1984) Recovery model of care but be mindful of specific needs of the elderly

16 Clinical Presentation and Risk Factors Similar clinical presentation to younger population Body dissatisfaction remains stable across the life span and does not diminish with age Higher psychiatric and medical comorbidity which can hamper diagnosis and treatment Aging appearance and body changes Familial relationships Feel devalued by society Unconscious control mechanism Bereavement, medical illness, marital difficulties

17 Treatment Combination of psychological and pharmacological treatment most effective with lower threshold for use of psychotropics due to high comorbidity Polypharmacy Therapy may need to target grief and loss Different approach to family interventions may be needed Impact of cognitive impairment on therapy Sensory deficits (e.g. impact on group therapy)

18 Jones WR, Schelhase M, Morgan JF (2012) Eating disorders: clinical features and the role of the generalist. Advances in Psychiatric Treatment, 18: National Collaborating Centre for Mental Health (2017) Eating Disorders: Recognition and Treatment. NG69. National Institute for Clinical Excellence Royal College of Psychiatrists (2014) MARSIPAN: Management of Really Sick Patients with Anorexia Nervosa (CR189). Royal College of Psychiatrists. Jones WR, Morgan JF (2014) Balancing risk requires a balanced approach. Commentary on severe and enduring eating disorders: recognition and management. Advances in Psychiatric Treatment,20: Jones WR, Morgan JF, Arcelus J (2013) Refreshment: Managing risk in anorexia nervosa. Advances in Psychiatric Treatment, 19: Lapid et al (2010) Eating disorders in the elderly. International Psychogeriatrics, 22: Useful Resources

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