Table 1 Characteristics of included studies
From: Treatment of eating disorders in older people: a systematic review
Study details (author, year) Study type [ref] Rated quality | Age (gender) | Diagnosisa | Clinical featuresa | Treatmenta | Outcome/mortality | Conclusions b |
|---|---|---|---|---|---|---|
(Bernstein, 1972) Case study [20] GQ | 94 (F) | AN | *Weight 36 kg *Refusal to eat *Symptoms: uncooperative/agitated, depressed, paranoid | *ECT, intravenous feedings | *Weight gain of 2.7 kg, improve oral intake, no paranoid thinking | |
(Launer, 1978) Case report [21] GQ | 70 (F) | AN (BP) | *BMI 10.3 *Fear of gaining weight despite being thin, *Caloric restriction, laxative abuse | *Medical inpatient admission *Chlorpromazine and clomipramine (for obsessional thoughts) *Structured behavioural regime observed during mealtimes, confined to bed and rewards (mobility) made contingent on an increase in weight | *Weight gain of 14 kg & more amenable. *Weight loss with less restrictive care. *Remained in hospital (6-month admission) | *AN can exist in the elderly, without a past diagnosis of AN |
(Price, 1985) Case study [22] GQ | 68 (F) | AN (PT) | *BMI 17.9 *Weight loss of 9.5 kg *Body image disturbance *Food restriction, laxative abuse, *Mild nutritional anaemia | *Behavioural plan which provides positive reinforcers for gaining weight & negative for either losing or failing to gain weight. | *Weight gain of 9.5 kg over the following 10-12 months *Loss to follow up after moving away | |
(Ronch, 1985) Case study [23] GQ | 75 (M) | AN | *BMI 13.7 *Distorted body image *Food restriction, self-induced vomiting, laxative abuse, secretive food disposing *No physiological abnormalities | *Admission to intermediate care facility *Dietician review but declined nutritional supplements. *Psychological therapy included CBT *Weight goals with medical transfer if falls below threshold weight. *Food and nutrition plan devised in conjunction with patient. Close supervision of food, nutritional supplement intake & food consumption in dining room with others. *Tranxene 3.75 mg every 2nd night for anxiety | *Weight gain of 5.5 kg & ceased disposing of food | *AN can survive and become a predominant feature of late-life adaptation patterns. *Treating AN in older population can be modestly successful with a coordinated interdisciplinary, institution-wide effort. *Putting AN into life context helps to better understand its aetiology and lifelong role as an adaptive attempt in the face of narcissistic injury, problems with control, anger and self-esteem, &possibly as a way to try to cope with some of the stresses of ageing. |
(Barry, 1987) Clinical comment [24] PQ | 78 (M) | IB | *Binging and purging | *CBT | *Cessation of purging, but relapse after termination of individual psychotherapy. *Social skills training | *Feasibility of psychologically based eating disturbances among the institutionalised aged. Proper diagnosis is essential for both targeting appropriate referrals and for effective treatment planning. |
(Ramell, 1988) Case study [25] GQ | 67 (F) | AN, | * BMI: 18.2 *Fear of gaining weight *Distorted body image *Caloric restriction *Purging | *Admitted to medical ward *Small doses of Chlorpromazine & insulin, *Free choice of diet *Daily monitoring *Laxative discouraged and replaced with stool bulking agents | *Rapid weight gain of 7 kg and stable at 6 months but preoccupied with caloric counting | *AN can develop in patients of any age |
(Fenley, 1990) Case study [26] GQ | 75 (F) | AN | * BMI 20.4 *Weight loss *Fear of being overweight * Body image disturbance *Chronic laxative abuse *Numerous serious medical complications from ED | *Medical stabilisation *Inpatient psychiatric admission *Behavioural management, individual psychotherapy, family therapy, group therapy, therapeutic milieu *Escalating oral *Alprazolam, poor tolerance of nortriptyline *After discharge, outpatient psychiatrist and physician follow-up | *Weight gain of 2 to 36 kg & maintenance of weight. | |
(White, 1990) Case report and literature review [27] GQ | 82 (F) | AN | *BMI 11.7 *Body image disturbance *Restriction of food intake, purging | *Medical admission *Started on isocarboxazid 15 mg daily | *Gained 6-kg weight with improvement in oral intake. *Discharged from hospital & doing well with out-patient supervision *Two months after discharge, died from pneumonia | *There is lack of guidance in literature as to the best treatment and anticipated outcome of AN in old age *Pharmacological treatment of AN has had limited success. *Antidepressants should be considered, starting at very low doses and slowly increased. *No epidemiological data about prognosis of AN in elderly exists. |
(Cosford,1991) Letter to editor [28] PQ | 73 (F) | AN | *Weight loss, *Fear of weight gain *Body image disturbance | *Inpatient psychiatry admission with strict dietary regime, outpatient follow-up | *Weight restoration and maintenance of weight | |
(Nottingham,1991) Case study [29] GQ | 66 (F) | AN (PT) | *BMI 11.9 *Body image disturbance *Purging and laxative abuse *Medical complications from AN | *Inpatient admission *Doxepin *Hyperalimentation | *Discharged after weight gain of 7 kg, but relapse with weight loss *Chronically remained unwell with AN and then death due to complications from AN | *Need to be aware of AN in elderly and that coordination and education is needed to provide adequate treatment. |
(Riemann, 1993) Case study [30] GQ | 72 (M) | AN (PT) | *BMI 16.5, weight loss of 31 kg *Fear of becoming fat *Low body weight *Body image disturbance *Purging, laxative abuse, excessive exercise, food restriction | *Declined inpatient admission & did not engage in community follow-up | ||
(Wiederman,1995) Clinical comment [31] PQ | 86 (F) | *Weight 57 kg, weight loss of 18 kg *Food restriction *No physiological abnormality identified | *Dietician and physician involvement *Soft food initially and then gradual introduction of normal diet *Reinforcement of recovery *Involvement in nursing home social support group | *Not known | *To consider eating disturbances in elderly from a mental health perspective | |
(Beck, 1996) Case series [32] GQ | 77 (F) | AN(RS) | * BMI 13.5 *Weight loss of 19 kg *Body image disturbance *No physiological abnormalities | *High caloric supplement diet, *Monthly psychiatry follow-up *Food diary | *Weight stabilised at 41–43 kg, *Working as volunteer | |
(Beck, 1996) Case series [32] GQ | 80 (F) | AN (BS) | * BMI 21.0 *Weight loss 27 kg *Refusal to maintain body weight *Food restriction *Binge behaviour with compensatory fasting | *Declined treatment | ||
(Pobee, 1996) Case study [33] GQ | 82 (F) | AN(PT) | *BMI 15.5 *Weight loss of 13 kg *Body image disturbance *Food restriction, *Purging and laxative | *Prescribed oral supplements as per dietician but refused and continued to lose weight *Failed trial of Ritalin *Conservative management with goal to increase weight. *Encouragement by staff at meal times | *“Remained a poor eater and continued to be very critical of food” | |
(Hsu,1988) Case 1 [34] GQ | 72 (F) | AN | *BMI 12.6 *Weight loss of 17.7 kg *Fear of gaining weight *Body image disturbance | *Admitted to psychogeriatric ward *Behaviour modification but difficult to engage | *Weight gain of 4.5 kg, but relapsed soon after discharge and admitted to another teaching hospital | *Outcome of ED in elderly just as varied as younger patients. AN seems to do badly whereas people with BN seem to do better with treatment *ADTs are worth the trial even in absence of concurrent depression. If one ADT is ineffective, trial of second or third should be made. *Treatment should be directed at all major areas of dysfunction, since improvement in one symptoms is not necessarily related to that of another |
(Hsu,1988) Case 2 [34] GQ | 67 (F) | BN (PT) | * BMI 18.7 *Weight loss of 5.5 kg *Trying to control weight *Fear of weight gain *Denial of illness *Binging and vomiting, laxative abuse | *CBT *Continuation of medications (trazadone, diazepam, dextroamphetamine) *Tranylcypromine dramatically improved dysthymic symptoms | *Improvement of binging and vomiting, unknown weight gain | *Outcome of ED in elderly just as varied as younger patients. AN seems to do badly whereas people with BN seem to do better with treatment *ADTs are worth the trial even in absence of concurrent depression. If one ADT is ineffective, trial of second or third should be made. *Treatment should be directed at all major areas of dysfunction, since improvement in one symptoms is not necessarily related to that of another |
(Nagaratanam, 1988) Case study [35] GQ | 70 (M) | AN | *Low body weight, 31 kg *Food restriction, *Medical complications from AN | *Nasogastric feeding | *Weight gain of 4.2 kg over 15 days, but then died suddenly of unknown cause | |
(Nicholson, 1998) Literature review with case study [36] PQ | 76 (F) | AN | *Weight 36 kg *Intense fear of gaining weight *Body image disturbance *Medical complications from AN. | *Psychiatric inpatient admission Psychoeducation *Small regular attractive meals and extra feeds | *Deterioration in physical state leading to medical admission. *Subsequently discharged to nursing home where she eventually died | *Treatment modalities similar to those of younger people: pharmacological and psychological, given general frailty of older people, best to admit to hospital for treatment of ED. *Around 2/3 of patients respond to treatment, which in line with younger people. |
(Russell, 1998) Case study [37] PQ | 69 (F) | AN (PT) | *BMI 11.3 *Weight loss of 17.5 kg *Fear of gaining weight *Food restriction and purging *Medical complications | *Inpatient medical admission *Nasogastric refeeding with supplements | *Weight gain to 39 kg, however died from complication related to metastatic lung carcinoma | *AN in postmenopausal patients is an unusual condition and be regarded cautiously as a diagnosis of exclusion. |
(Wills , 1998) Case series [38] GQ | 74 (F) | AN | *BMI 12.7 *Fear of gaining weight, *Body image disturbance *Restriction of food intake *No physiological abnormalities identified | *Managed in community-based old age psychiatry with “a programme” | *Weight gain of 7.8 kg. *Died aged 82 in nursing home | *AN is an attempt to take control when other aspects are out of control *Age should no longer appear as a diagnostic criteria for AN |
(Wills Case 2, 1998) Case series [38] GQ | 67 (F) | AN | *BMI 15.6 *Body image disturbance *Food faddiness | *Group psychotherapy *Community psychiatric follow-up | *Followed up for 7 years. *Weight remained below 40 kg but able to return to normal lifestyle | *AN is an attempt to take control when other aspects are out of control *Age should no longer appear as a diagnostic criteria for AN |
(Wills Case 6, 1998) Case series [38] GQ | 75 (F) | AN | *BMI 13.7 *Preoccupation with food, laxative abuse | *3 hospital admissions in 6 years *Non-compliant | *Lives with husband | *AN is an attempt to take control when other aspects are out of control *Age should no longer appear as a diagnostic criteria for AN |
(Hill, 2001) Case study [39] GQ | 77 (F) | AN | *BMI 16.5 *Weight loss of 21 kg *Restrictive food intake and exercise *Other symptoms: depressive symptoms *No physiological abnormalities | *Inpatient psychiatric admission *ECT (to treat depressive symptoms) | *Weight gain of 2 kg, eating regular and full meals *Euthymic mood | |
(Mermelstein, 2001) Case study [40] PQ | 92 (F) | AN | * BMI 14.7 *Body image disturbance *Restrictive intake, laxative abuse, excessive exercise *Medical complications from AN | *Inpatient admission *Treatment based on for younger anorectic patients. *Cognitive therapy focusing on body image, food- and weight-related constructs. *Privileges based on weight gain *Paroxetine 20 mg to lessen obsessional attention to eating *Dietician review and caloric supplementation | *After 3 months, gained enough weight to be discharged to a minimal assisted living facility. *Doing well 6 months post discharge | *The need to heighten diagnostic sensitivity for AN and other ED at any age |
(Parke, 2008) Case study [41] GQ | 72 (M) | EDNOS | *BMI 16.7 *Disturbed body image *Denial of seriousness of illness. *Dietary restriction, preoccupied with food, excessive exercise to control weight *Medical complications | *Inpatient psychiatric admission *Multivitamin, iron, and mineral therapy. *Fluoxetine *Weighed regularly and monitored closely after meals. *Physical activity restricted | *Gain of 10 kg *No improvement in cognition. *Discharged to nursing home | * Need for diagnostic awareness regarding ED in patients of all ages and both genders |
(Lapid, 2010) Review with case study [1] PQ | 73 (F) | AN | *Low body weight *Preoccupation with weight *Laxative abuse | *Inpatient psychogeriatric admission *ECT *Continuation of antidepressant *Behavioural intervention *Psychoeducation *Calorie counting *Meal observations and 1 h post prandial | *Weight gain, improved appetite, and caloric intake. | *ED occur in elderly, with AN being the most common. *Depression is most common comorbid psychiatric condition *Combination of pharmacological and behavioural interventions may be successful. |
(Cwikel, 2011) Case study [42] GQ | 67 (F) | AN | * Weight: 59 kg *Concerns about body image *No physiological abnormalities | *CBT and follow-up with nutritionist | *Currently stable. *Nil relapse. *Resumption of normal eating patterns | |
(Lozano, 2011) Case study [43] PQ | 79 (F) | AN | *BMI 12.7 *Food restriction *Purging *Other symptoms: low mood, delusions *Medical complications from AN | *Regular diet with monitoring of intake. *Initiation of fluoxetine and mirtazapine *Physical therapy *Occupational therapy | *Unknown | |
(Main, 2011) Letter to editor [44] PQ | 75 (F) | AN (RT) | *BMI 14.8 *Food restriction *No physiological abnormalities, | *Family therapy *Community dietician *Medical and psychiatric input from primary care and community psychiatry | Unknown | |
(Lehman, 2012) Case study [45] PQ | 77 (F) | AN | *BMI 16.4 *Refusal to maintain normal body weight *Fear of gaining weight *Denial of seriousness of illness *Laxative abuse *Other symptoms: mood symptoms | *Minimum weekly outpatient individual psychotherapy (including CBT and Knight’s Contextual, Cohort-Based, Maturity, Specific-Challenge (CCMSC) psychotherapy model) *2 days/week of partial hospitalization program *Clinician built relationship with all involved stakeholders *Maintenance treatment included asenapine, zolpidem, aripiprazole, mirtazapine, buproprion XR, lorazepam, benztropine. *Increase in dose of antidepressant. | *Eating 2 meals/day, increased functional independence, improved social engagement *Ongoing mood fluctuation (related to schizoaffective disorder) | |
(Lwin, 2014) Case study [46] GQ | 73 (F) | BN (PT) | *Weight loss of 11.3 kg *Binging and purging *Repetitive pacing, agitation *No physiological abnormalities | *Mirtazapine 30 mg started and within a week, self-induced vomiting and pacing abated. *Patient gained weight | *Bulimic symptoms were in remission 1 year follow-up | |
(Malik, 2014) Case study and literature review [47] GQ | 81 (M) | AN(PT) | *BMI 17 *Weight loss of 12 kg *Preoccupied with weight *Purging *Medical complications (hypophosphataemia, hypoalbuminaemic, hypoalbuminaemic), CT brain showed small vessel ischaemia in white matter | *Inpatient care *Advice from tertiary eating disorders service *Non-restrictive approach focusing upon dietary supplementation. *Follow-up with GP for monitoring of nutritional state. | *BMI improved to 17.5 | *AN is an uncommon cause of unexplained weight loss in the elderly, but may be under-recognised and associated with a high level of mortality |
(Taylor, 2015) Case study [48] PQ | 80 (F) | AN | *BMI 11.5. *Weight loss of 8 kg *Restricted food intake *Medical complications from AN | *Dietician review and started on dietary supplementation and intravenous fluids *Started on an antidepressant (name not provided) | *Started to gain weight but then developed hospital-acquired pneumonia and died shortly afterwards | *AN in elderly remains underdiagnosed *ED should be a differential diagnosis of unexplained weight loss in the elderly *Symptoms of AN are the same as younger age group *Greater awareness of ED amongst healthcare workers is needed to prevent significant morbidity and mortality *There is need for service provision for this population group *Controlled trial investigation is needed to understand best treatment approach for older patient with an ED |
(Aziz, 2017) Review [49] GQ | 73 (F) | ED | *BMI 13.75 *Restriction of food intake | *Mirtazapine *Supportive care through SMHSOP *CMHT, day hospital *Dietetic support | *Recovered over a 6-month period to BMI of 18 | *Treat both ED and comorbid psychiatric disorders *Pharmacological and behavioural interventions *Working on psychological problems (focus on psychotherapy) more effective than focussing on food choice and addressing weight loss *Supportive counselling *Psychoeducation on normal physical changes with ageing *Address physical health needs *Psychoeducation to families *Day programmes: dine with others, increase social interactions, physical health rehab. *Treat comorbid psychiatric disorders |
(Aziz, 2017) Review [49] GQ | 67 (F) | AN (AT) | *BMI 14 *Restriction of food intake *Other symptoms: felt full, not hungry, affect indifferent and lacked drive | *Psychotherapy *Support from local eating disorders services | *BMI reached 16.5 | As above |
(Aziz, 2017) Review [49] GQ | 89 (F) | AN | *BMI 14 *Restriction of food intake | *ADT antidepressant medication | *Responded to this | as above |
(Zayed, 2017) Report PQ [11] | 66(F) | AN | *BMI 17.5 *Fear of gaining weight *Body image disturbance *Restriction of food intake *Denial of seriousness of current low body weight *Physical complications: oedema, ECG changes, pathology changes (low haematocrits, glucose, calcium, protein, albumin) | *Enteral feeding | *Developed refeeding syndrome, with multi-organ failure resulting in death | *Combination of both behavioural and pharmacological treatment found to be most successful. |
(Hasan, 2017) Case report [50] PQ | 76 (F) | AN | *Restriction of food intake *Fear of gaining weight *Body image disturbance | *CBT (with exposure and response modification): 8 weeks *Group programming (experiential therapy, nutrition, nursing) *Psychoeducation (body image & nutrition education) *Dietitian and meal plan *Managing physical complications *Venlafaxine 187.5 mg daily | *Gained 17 lbs *Increased caloric intake *Home health nurse to help with managing medications | *Support for the use of exposure-based CBT, coupled with behavioural activation, medical consultation |
(Fahs, 2013) Book Chapter [51] | General comments made by author “An older adult generally presents with a greater severity of disordered eating but has fewer body image difficulties. Tend to deny symptoms. Use of over the counter meds, prescribed or illicit substances to produce weight loss, making difficult life transitions, inability to mourn major losses, fear of aging, feeling in competition with younger generations, setting unrealistic goals for oneself”. | *Before making an ED diagnosis, need to rule out other medical issues for symptoms and also medical consequences of ED. *Psychological interventions to understand how individual is coping with natural life transitions and one’s own mortality. *Nutritional counselling for meeting nutritional requirements *Stretching, aerobic, and strengthening exercises are recommended | ||||
(Blake, 1996) Proceedings [52] | *“Medical intervention” required. *“A MDT approach, focusing on medical, psychological, and dietary issues, with antidepressants and ECT being useful in some cases.” | |||||