A case of anorexia nervosa in an elderly man

Case study

We present the case of an 81 year old man, FJ, with unexplained vomiting and weight loss. Identifying features of FJ have been removed and FJ provided written consent for the publication of his case.

FJ was a widowed, retired ship steward living with his step-daughter (a child from his wife’s previous relationship) and her family in an outer suburban area.

He was admitted, under a medical physician’s care, with lumbar spine pain and problems mobilizing after a fall at home.

The fall appeared to be the consequence of a delirious state attributed to medications, namely amitriptyline 30mg/day combined with tramadol 200mg/day, precipitating a possible serotonin syndrome. His admission was to address these physical concerns but FJ was referred to the consultation-liaison psychiatry team by the dietician after his step-daughter expressed concern about his abnormal eating behaviour and self-induced vomiting. FJ was reported to experience nausea 10–15 minutes post-prandially and frequently vomit after meals. His step-daughter also described FJ’s attempts to disguise his poor eating, ‘playing with food for minutes’ and then trying to discreetly dispose of it. She described FJ as being preoccupied with weight, observing him frequently weighing himself.

FJ denied or minimized many of his step-daughter’s concerns. Although he admitted frequent vomiting, he denied it was self-induced. He denied ever using laxatives, purgatives or vigorously exercising to lose weight. Whilst nausea and vomiting had worsened over the preceding fortnight, FJ described 10–12 years of poor appetite, describing himself as ‘almost never hungry’. Without a discernable trigger, FJ reported weight loss of 12kg over the previous two years.

He had no formal history of mental illness. Poor appetite and weight loss were the only neurovegetative disturbances. There was no evidence of pervasively depressed mood or any problems with motivation and pleasure. FJ denied any problems with anxiety other than some obsessional concerns relating to order which did not meet criteria for obsessive compulsive disorder.

Although a heavy drinker in his youth, he reported that he had stopped drinking completely 25 years ago at his wife’s request. FJ denied any past/current illicit substance use.

He had a significant cardiac history with six myocardial infarctions, congestive cardiac failure and atrial fibrillation. He also suffered from chronic obstructive airways disease, cholelithiasis and a left renal cyst.

He was 1.76 m tall and his weight on admission was 52.8 kg (body mass index, BMI, 17).

His medications included atorvastatin 80mg, isosorbide mononitrate 120mg, perhexiline 100mg, ramipril 5mg, movicol two sachets, nicorandil 10mg (mane), carvedilol 12.5mg (b.d.), ipratropium 250µg, salbutamol 2.5mg nebulized (t.d.s.) and warfarin (variable dose).

The youngest of a sibship of eight, FJ has one surviving brother, who lives interstate. He was raised a Catholic in a household described as loving though strictly disciplined. FJ attributed to this his tendency to perfectionism and need for order. There was a strong family history of ischemic heart disease; his father died from a myocardial infarct in his late 40s. FJ left school at 15 and began a career at sea working as a ship’s steward. During his 20s FJ had a homosexual relationship with a close friend.

In the early 1960s, he renounced his Catholicism due to his non-agreement with the Pope’s views on same sex relationships. Aged 46, he returned home to live with his mother as her carer after she was diagnosed with breast cancer which resulted in her death two years later. He then married a woman with whom he lived for 20 years until her death 10 years before this admission. He denied being troubled by any contradictions or conflicts related to his sexuality or religious upbringing. He was closely supported by his step-daughter’s family.

FJ, despite a rather shy demeanour, was a sociable and popular elderly gentleman with a stream of visitors on the ward.

Relevant investigation findings included ECG and X-ray changes consistent with his respiratory and cardiac disease. He was hypophosphataemic (0.58mmol/l) (ref. range 0.81–1.45) and hypoalbuminaemic (27g/l) (ref. range 30–50). Other electrolytes were within normal ranges and cancer markers were not elevated. A computed tomography head scan showed evidence of small vessel ischaemia in the white matter.

His mental state examination revealed an alert, orientated elderly man of average height and thin build. He maintained good eye contact and rapport with the interviewer.

He was appropriately sad talking about his wife, and his affect was restricted.

He described his mood as low. There was no evidence of psychomotor change.

He had logical thinking with no evidence of perceptual disturbances, delusional thoughts or thoughts of self-harm.

FJ scored 28/30 on the MMSE.

He was accepting of inpatient care but appeared tominimize his problems in maintaining adequate nutrition. He did not accept that he had abnormal eating behaviour.

He was observed to continue to eat poorly on the ward. No self-induced vomiting was observed.

Advice was sought from a tertiary eating disorders service, which recommended a non-restrictive approach focusing upon dietary supplementation. His nutritional state improved with improvement in his BMI to 17.5. The implemented recommendation for outpatient care was GP liaison for monitoring of nutritional state.

Discussion

FJ’s symptoms meet the criteria for anorexia nervosa in the DSM V. ³ The DSM V criteria allow, in the absence of explanation for demonstrably low weight, ‘clinical inference from collateral sources’. In this case the history provided by the step-daughter was convincing.

His BMI of 17 probably puts his condition in the mild range, though the potential for his condition to further compromise his physical health makes it more serious.

The differential diagnosis of an elderly person with nausea, vomiting and substantial weight loss is broad with a high degree of suspicion for physical causes, particularly occult advanced malignancy. Anorexia and weight loss are also typical of Alzheimer’s disease and other degenerative brain diseases. ‘Anorexia of old age’ has also been described.

From a psychiatric perspective a major depressive episode with melancholia is commonly associated with signs very similar to FJ’s presentation. However, FJ lacked a history of anhedonia and more pervasive neurovegetative disturbances that would make the clinical picture more consistent with his presentation. The very clear history of longstanding abnormal eating behaviour strongly implicated an eating disorder as a likely diagnosis. As has been previously reported, depressive symptoms are more common in TA. AN in older people also frequently has a clearly identified precipitant, often a loss, with some authors seeing it as akin to a grieving reaction. Whilst it is unclear, it seems more likely that FJ had sub-threshold abnormal eating behaviour throughout much of his life, with a further deterioration over 10 years since his wife’s death.

Wills and Olivieri ⁸ note from their case series comment upon disenfranchisement of the elderly AN sufferer and issues of control similar to those of the adolescent. It is conceivable that FJ’s failing health and increased dependency on his step family could be contributing factors in his more recent weight loss.

Other features of FJ’s condition fit neatly into the clinical picture of anorexia nervosa in older populations. Case reports of other elderly sufferers also describe the highly covert nature of the condition and the reduced focus on body image disturbance. ¹¹ Whilst it can be only speculative, internal conflict regarding sexual orientation and discomfort with intimacy may be a relevant factor in the genesis of abnormal eating behaviour in this case, a common observation in AN generally.

There is evidence of particularly high mortality amongst FJ’s demographic group. Hewitt and Coren ¹² found two peaks of fatal forms of AN, one of early onset affecting 89% females and a late onset form affecting 24% men.

Conclusion

Whilst clearly an uncommon condition, this possibility in the differential diagnoses of elderly patients with unexplained weight loss warrants an open mind.