When most people hear the word "anorexia" they picture a young, previously healthy woman who has starved herself into a skeletal state. Seldom, if ever, do people think about an eating disorder among the elderly population. But as new research is coming to light, it shows a definite and growing problem in this group.
A full quarter of nursing home residents refuse to eat and are malnourished. The figure is expected to rise in the near future as the homes become more crowded and staffing becomes even more inadequate. Of course there are a number of psychological reasons why nursing home residents refuse to eat, such as difficulty swallowing or various diseases including dementia that render patients disinterested in food and sometimes unable to eat, or they forget to eat. But there are also a number of people, previously healthy, who for no apparent reason refuse to eat and so they die. Having watched my own grandmother place herself into a state of dementia due to lack of eating when she was unhappily living far from her children and grandchildren, these statistics took on special meaning for me.
David Rissmiller, DO, is the chair of the Department of Psychiatry at the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine in Stratford, New Jersey. He has been working with this population of older adults who give up food to help them overcome their resistance in order to regain their health. When I spoke with him, he told me that these are rational people who had been previously enjoying a good life. Then suddenly something happens and they need to go into a nursing home. For sometimes unexplained reasons, they refuse to eat and this starts a horrible downward cycle. Dr. Rissmiller explained that "passive self-harm from not eating is one of the major risk factors for death in nursing home patients."
When a person rapidly loses 5% of his/her body weight, it begins to affect protein stores... a rapid loss of 10% of body weight can make a person lose the ability to fight infections or heal wounds. One reason the problem of starvation in the elderly has remained hidden is because death certificates do not list the cause as starvation but rather the event that was actually a result of malnutrition. Also malnourished individuals lack the ability to utilize, react appropriately to, and successfully metabolize medications, which makes treatment with conventional means even more difficult.
WHO BECOMES ANOREXIC?
While many elderly people stop eating because of depression, there is a sub-group of older anorexics that stop eating because of a traumatic event that has to do with food. This generally has three aspects to it, he says. It happens in people who tend toward anxiety problems... who are fastidious about their personal habits... and who had a bad reaction to something they ate. Sometimes it is that they choked on a piece of food... other times it was the humiliation they experienced by having an episode of unexpected, uncontrolled vomiting or a sudden onset of fecal incontinence and the resultant mess. At other times they fear a reoccurrence of severe constipation or impaction. Their fear of a repeat event grows and turns into a food phobia, known as sitophobia, that is stronger than their natural impetus to feed their body.
If this happens to a person in a nursing home or living on his own, his physical and mental health can deteriorate quickly. Of course this downward failure to thrive frightens family members, but most are frustrated by the fact that there is nothing they can do about it. Sometimes a psychiatrist will misdiagnose depression when the elderly person is really phobic of eating. In such cases, he urges family members to meet with the psychiatrist. He says that often the family can give the history of events that will bring the situation to light because the patient now is either too frightened to remember the incident or too embarrassed to talk about it. Inevitably, he says, once the catalyst event has been identified, the family will recognize that the anorexia started immediately afterward.
OVERCOMING THE FEARS
Food phobia is a difficult challenge, says Dr. Rissmiller. It requires reversing patients' nutritional patterns as well as their anxiety about what they perceived as a catastrophic event. In these patients, even the approach of food will be repugnant or cause panic, he adds. It is key at this point for family and staff to take a completely non-judgmental attitude, no tsk-tsking about how the patient "should" be eating. Instead, the patient and his/her doctors should explore the details of the event, including what the patient was eating at the time, where it took place, etc. Doctors should give reassurance that this kind of thing isn't uncommon and there is no need to feel humiliated so they can begin to build positive experiences with food. Working with a nutritionist, they begin to introduce foods that are safe -- the last thing a patient needs at this point is another bad experience -- and so they have him start with ice chips or perhaps a little yogurt (as well as nutritional supplements). Many patients also take low-dose medications that enhance appetite while decreasing anxiety.
Dr. Rissmiller has found that about one-third of the sitophobic elderly patients he has worked with resumed eating and recovered their health. Others are more recalcitrant and require further work, but he says that he and his staff continue to explore ways to resolve this problem. The first step, though, remains: to recognize anorexia in a formerly healthy person for what it is and treat it accordingly. This is true whether the patient is 25 or 75.
Reprinted with the permission of:
Bottom Line Daily Health News
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