Issue 60 I Eating Disorders in Aged Care: What does this look like?

About this resource

NEDC e-Bulletin

Editor’s Note

Welcome to the 60th edition of the NEDC e-Bulletin.

In this edition of the NEDC e-Bulletin, we look at the effects of malnutrition in the aged care setting, and the link between poor nutrition (among other factors) and eating disorders in later life.

As we move with pace towards the end of another financial year and the marking of 10 years of the National Eating Disorders Collaboration (NEDC), we are pleased to announce the ongoing support of the Commonwealth Government in funding the work of the NEDC into 2022.

With the announcement of increased funding to support Australians living with an eating disorder and their carers, along with the incoming changes to the Medicare Benefits Scheme, we acknowledge now, more than ever, the importance of a united and collaborative sector.

Engaging with our membership, developing and growing our relationships within the health sector and primary health networks across Australia will always remain at the forefront of NEDC activities.

As we move forward into the next funding period, we will continue to drive the evolution of an evidence-based, best practice framework that will support and educate our workforce, in the creation of a nationally consistent approach to the prevention, treatment, and management of eating disorders.

We look forward to working with our key stakeholders who provide the supportive foundations required to extend our reach and partnership across new areas of primary and secondary care, and amongst diverse sectors.

We are grateful for the continued support of our membership, who unite in our vision to make eating disorders a priority mainstream health issue in Australia, with an effective continuum of prevention, care and ongoing recovery support for all Australians.

We look forward to what our collaboration brings to the sector in the future.

Contents

Anorexia of Aging – Eating Disorders within Aged Care

Significant mortality and morbidity are associated with eating disorders in the elderly (Lapid et al., 2010), where a small decline in body mass can cause death (Morley, 2003).

While the exact prevalence of eating disorders in aged care within Australia is unknown, an American research review reported that in the US, the majority of cases affected women between the ages of 50 – 94, with an average age of diagnosis of 68 years. What is more, the majority of diagnoses reported were for anorexia nervosa, which was present in 81% of cases and affected both female and male patients alike. Interestingly, comorbid depression was present in 69% of cases (Lapid et al., 2010).

Within Australia, Beyond Blue reports that 15-20% of older adults experience depression and approximately 10% experience anxiety. Additionally, the rates of depression among individuals living in residential care are much higher, at around 30% (Beyond Blue, 2009)

We know that it is common for eating disorders to be associated with comorbid mental health issues and that psychiatric disorders do cause weight loss through a reduction in appetite (Lapid et al., 2010). However, there are other age-related factors at play, making it difficult to diagnose an eating disorder in an elderly patient.

In November 2008, the Journal of Nutrition, Health and Aging published an Italian study that observed the prevalence of eating disorders among aged care patients in an acute and rehabilitation setting. This study demonstrated that malnutrition occurs in 20-60% of elderly patients admitted to hospital and in an estimated 30-50% of nursing home patients (Donini et al., 2008). The study also established that the most common pathological change in eating behaviour among older persons is anorexia nervosa, which accounted for a large percentage of undernutrition in adults.

What factors contribute to these changes in eating behaviour within our elderly population?

A research review undertaken by the Catholic University of the Sacred Heart, in Rome, Italy, 2016, highlighted that there exists a range of factors that contribute to the poor nutrition levels in the elderly that ultimately lead to adverse outcomes such as an eating disorder. Age-related changes in lifestyle, disease conditions, social and environmental factors have a direct impact on dietary behaviours and nutritional status (Landi, Calvani, Tosato, & Martone, 2016). Other common factors that occur before the onset of an eating disorder in an elderly patient include widowhood, bereavement, marriage related difficulties, medical illness, pharmacological treatment or another known age-related condition (Lapid et al., 2010). These age-related factors contribute to a decrease in appetite and reduced food intake, which then gives rise to the development of an eating disorder, in particular, anorexia nervosa (referred to as Anorexia Nervosa of Aging) (Landi et al., 2016).

The physical process of aging and the accumulation of health issues that come with it, leave an older person more vulnerable to the development of an eating disorder. Many medical conditions share related comorbidities and adverse outcomes, which create disability, a decrease in food intake and poor nutritional outcomes for the elderly (Landi et al., 2016). The process of aging changes the brain signals that aid and control food ingestion; it changes our sense of smell and taste along with our hormones and gastrointestinal function, and increases chronic inflammation within the body.

Additional factors that place the aged at risk of developing an eating disorder are:

Physical factors: functional impairment affecting the basic activities of daily living, eating by oneself, difficulty in getting foods, a lack of cooking skills, and chewing problems. These factors are associated with a lower intake of specific nutrients and higher fat and cholesterol intake.
Medical Factors: gastrointestinal disease, malabsorption syndromes, acute and chronic infections, hypermetabolism (hyperthyroidism), depression and cognitive impairment.
Medications: the consumption of multiple over the counter medications often causes malabsorption, gastro upset and loss of appetite.
Social Factors: poverty, social isolation and living alone; Ignorance of food preferences in an aged-care setting and failure provide a positive environment to eat.

A combination of these factors can lead to inappropriate food choices, the elimination of hard protein from the diet, a lack of motivation to eat and a poorer appetite, all of which contributes to lower nutrient intake and malnutrition (Donini et al., 2008). This decrease in food and nutrient intake gives rise to changes in the brain, caused by the effects of starvation and in turn, anorexia nervosa.

Additionally, the inadequate food intake associated with the development of anorexia nervosa results in reduced physical activity and declining muscle mass and strength. Patients present with poor lower extremity functioning and reduced hand grip strength, further suggesting that anorexia nervosa of aging is directly linked to the development of frailty in elderly patients (Landi et al., 2016). Research indicates that it is the combined factors of malnutrition, the development of frailty and increased adverse health outcomes associated with anorexia nervosa of aging that place an older person with anorexia nervosa at an almost two-fold risk of death for all causes when compared with those without anorexia nervosa (Donini et al., 2008; Landi et al., 2016).

How do we support older people and their carers in the prevention and treatment of an eating disorder, in particular, anorexia nervosa?

Successful treatment and recovery are complex processes requiring multiple steps, different treatment options and collaborative care from a multidisciplinary team (NEDC, 2018).

When considering treatment approaches for an eating disorder, it is essential to understand that different people respond to different types of treatment, even if they are experiencing the same eating disorder (NEDC, 2018). However, research suggests that due to age-related factors an integrated approach to prevention and treatment may involve the following aspects (Donini et al., 2008; Landi et al., 2016; Lapid et al., 2010; Morley, 2003):

Enhancing food texture, palatability, flavour, variety and providing additional assistance with feeding;
Preventing social isolation and creating a more friendly and sociable eating environment (particularly in the aged-care setting);
Evaluating personal medications to determine those that interfere with appetite and lead to weight loss; and
Assessing and addressing medical conditions that contribute to weight loss such as swallowing disorders, malabsorption, endocrine, psychiatric, respiratory and cardiac disorders.

Treatment and recovery from an eating disorder is always a personal journey. Not every individual will experience an eating disorder in the same way as another. Knowing the symptoms and owning the ability to recognise and assess the common physical, behavioural and psychological signs and symptoms is critical in early identification and management. It is particularly vital within the elderly and aged care environment, where the consequences of disordered eating behaviours result in rapidly developing and life-threatening health complications.

The National Eating Disorders Collaboration (NEDC) provide training and resources about the management, screening, identification and referral of eating disorders.

You will find online, the NEDC Screening, Identification and Referral tool that is available to download and print for use in the primary care setting.

NEDC provide information about collaboration with and access to state and territory based health services within your area, with the knowledge to provide support for referral and treatment of eating disorders in the aged care setting. You will find this information online through our Support & Services page.

If you or someone you know require support or guidance on treatment options and referral pathways contact The Butterfly Foundation’s National Helpline on 1800 33 4673.

Additional information about eating disorders is available on our website at https://www.nedc.com.au/eating-disorders/

References

Donini, L. M., Savina, C., Piredda, M., Cucinotta, D., Fiorito, A., Inelmen, E. M., … Cannella, C. (2008). Senile anorexia in acute-ward and rehabilitation settings. Journal of Nutrition, Health and Aging, 12(8), 511–517. https://doi.org/10.1007/BF02983203

Beyond Blue. (2009). Statistics. Retrieved March 22, 2019, from https://www.beyondblue.org.au/media/statistics

Landi, F., Calvani, R., Tosato, M., & Martone, A. M. (2016). Anorexia of Aging: Risk Factors, Consequences, and Potential Treatments, (January). https://doi.org/10.3390/nu8020069

Lapid, M. I., Prom, M. C., Burton, M. C., McAlpine, D. E., Sutor, B., & Rummans, T. A. (2010). Eating disorders in the elderly. International Psychogeriatrics, 22(4), 523–536. https://doi.org/10.1017/S1041610210000104

Morley, J. E. (2003). Anorexia and weight loss in older persons. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 58(2), 131–137. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12586850

NEDC. (2018). Eating Disorders Treatment & Recovery. Retrieved March 22, 2019, from https://www.nedc.com.au/eating-disorders/treatment-and-recovery/

Working with the aged: Q and A with the Queensland Eating Disorder Service

The National Eating Disorders Collaboration spoke with Amy Hannigan, Team Manager, Service Development and Amanda Davis, Senior Dietitian at the Queensland Eating Disorder Service (QuEDS) about Eating Disorders in the Aged Care setting. QuEDS have recently been undertaking work in this space and have taken time out to answer some of our questions on this topic. We thank them for their contribution.

Do you have any indication of the prevalence of Eating Disorders within the elderly and aged care setting?

Unfortunately, this information is not routinely collected and could be very hard to diagnose secondary to the interplay between depression, dementia, limited food access, and starvation syndrome. These secondary health problems can be difficult to distinguish as separate from eating disorder symptoms until adequate renourishment has occurred. Additionally, renourishment in the aged care sector can be difficult due to a range of issues such as assistance required with eating, personal food preferences that may not be catered for, and the impact of medications on appetite to name a few.

Do you agree that Anorexia is the most commonly developed eating disorder within this age group?

It is unclear how many would be reaching diagnostic criteria for Anorexia Nervosa, however food restriction and starvation syndrome are indeed more prevalent then Bulimia Nervosa or Binge Eating Disorder.

What do you see as the foundational causes of Eating Disorders in this age group?

It is hard to say. Individuals may have a history of a diagnosed or undiagnosed eating disorder when moving into care, however eating disorders may also be triggered, or relapses occur following significant life events. For example, moving into care or the loss of a partner may create a sense of loss of control over one’s life and fluctuations in mood, creating subsequent changes in food intake and behaviours.

Do you feel that carers are informed that this aged group are at risk within the aged care setting or in general?

I would say that there is a general acceptance within the community that the elderly, particularly elderly females, eat very little or “like birds”. Therefore intentional restriction may be hard to identify. I would concur with the Dietitians Association of Australia’s (DAA) submission to the Aged Care Royal Commission that mentions a “culture of acceptance by many service providers that weight loss is usual or even desirable… viewing unplanned weight loss and underweight as normal”. The DAA also add that “low levels of nutrition literacy across the aged care workforce contribute to these beliefs”.

Do you feel that the potential or increased risk factors of the elderly/aged in developing an eating disorder is well understood?

There has recently been increased interest in the negative functional sequelae of sarcopenia/malnutrition in the elderly, which helps highlight the significance of early intervention in this age group.

Do you have experience with working with the aged in treating eating disorders and managing recovery?

In my professional experience, I have treated elderly patients in the hospital setting that have demonstrated very restrictive eating behaviours, and although these cases have not received a clinical diagnosis of an eating disorder, this disordered eating behaviour has occurred in the absence of any other clear primary reason for restrictive eating.

In terms of recovery, the nutrition principles in the setting remain the same for caring for a younger person with an eating disorder. Support before, during and after meals is essential to begin the nutrition restoration process to allow psychological therapy to be effective.

What do you believe is the best possible pathway to recovery for an older adult experiencing disordered eating behaviours?

Quality of life should be the primary focus. Nutritional focus provides the correct amount of macro and micronutrients to maintain or improve physical function, improve starvation induced cognitive changes, and to address any nutritional deficiencies. Containment of the associated disordered eating behaviours is ideal, so progression is not delayed.

QuEDS has been working in this space. What has this involved?

QuEDS consultation services have provided support to nursing home staff with medical monitoring and training for nursing staff. Training has included meal support, documentation of oral intake, developing an understanding of the psychological issues associated with the undernourished brain and the appropriate communication styles that should midnight with the patient during this time.

What assessment techniques are suggested to be used within this age group as a nutritional/health assessment in identifying older adults at risk of developing an eating disorder?

In Queensland, the Malnutrition Screening Tool (MST) and Subjective Global Assessment (SGA) are screening and assessment tools routinely used in hospitals. These do not screen for disordered eating behaviours at all, but rather screen for nutritional risk and assess for nutritional status.

If you require additional information, referrals or support on caring for an elderly person experiencing disordered eating behaviours, please call The Butterfly National Helpline on1800 33 4673. Consultation Services, similar to those offered by QuEDS, can be accessed through most state-based eating disorder specialist services, which is available at www.nedc.com.au

A copy of the Dietitians Association of Australia’s (DAA) submission to the Royal Commission into Aged Care Quality and Safety can be accessed via the DAA website online.

Additional Reading

With limited resources and research available on the subject of eating disorders within the aged care setting, the NEDC has accessed a variety resources that may be beneficial to health professionals working within the aged care sector, or for individuals or loved ones caring for an elderly person.

The Sydney North Health Network has developed a Healthy Ageing & Frailty page, which is a good resource for professionals working with the elderly. The page provides links to clinical resources, referral information, and patient resources including the Eating Well Booklet: A Nutrition Resource for Older People and their Carers.
SANE Australia Growing Older, Staying Well report on Mental health care for older Australians. The report examines the lived experience of older adults with mental illness, their carers, family and friends. It describes some of the major concerns faced by this group and outlines the key areas in need of attention and change.

While not directly linked to the prevalence of eating disorders in this age group, the report provides recommendations suggesting that GPs understand the interplay between physical and mental health in older people and highlights the need for GPs and other primary health professionals to seek additional training and education in the treatment of coexisting physical and mental health problems.

The report also highlights the need for a collaborative workforce and the importance of communication across sectors, health, not for profit, and government in providing the support and care required by our elderly population.
Eating Disorders Victoria provide information about eating disorders in later life on their website at https://www.eatingdisorders.org.au/eating-disorders/eating-disorders-children-teens-and-older-adults/eating-disorders-in-midlife-and-onwards
You will find additional reading and information about working with the Aged and the Elderly on the Australian Government Department of Health's Head to Health website at https://headtohealth.gov.au/supporting-someone-else/supporting/aged-and-elderly

New NEDC Digital Training Package: Eating Disorders Professional Development Videos

It is our goal to create a workforce that is sufficiently trained and adequately equipped to identify, respond to and manage a patient with an eating disorder. With eating disorders affecting one million Australians, we know that this is a priority area for improvement.

This video series aims to support the professional development of the health workforce across Australia. Each of these modules can be claimed as half an hour of self-directed CPD with your professional body.

The series of videos include:

Introduction to Eating Disorders
Eating Disorders: Screening and Assessment
Medical Management
Nutritional Management
Recovery-focused Psychological Treatment

The NEDC is committed to an inclusive, collaborative approach to the development of knowledge and resources. The expertise of key stakeholders, clinicians, people with lived experience and evidence-based research has been used to create this video series.

The full series of the videos are available through the NEDC professional development, e-learning page at https://www.nedc.com.au/professional-development/e-learning/

Along with the videos you will find a handout that provides further information and links based on the content of the videos.

New Professional Resources: Eating Disorders and Oral Health – Fact Sheets for patients and practitioners added to the Australian Dental Association’s (ADA) CPD Portal.

Patient Fact Sheets 002 Page 4 Patient Fact Sheets 002 Page 3

The NEDC has collaborated with the Australian Dental Association (ADA) to produce a screening and assessment tool for oral health practitioners and two patient fact sheets on Eating Disorders and Oral Health. These are available online to print and provide to patients.

Last year, the NEDC collaborated with the Australian Dental Association (ADA) to produce the `Open Your Mouth’ video on eating disorders in oral health. This video was made available on the NEDC website, within our professional development page.

We are pleased to announce that this tool is now included in the ADA Continuing Professional Development (CPD) Portal, along with the three new resources.

All of the resources are available to ADA members to view on the site as part of the continuing professional development required of them as a registered dental practitioner.

The CPD portal, on the Australian Dental Association website, is a service provided to ADA members that allows them to maintain, improve and broaden their knowledge, and expertise to develop their personal and professional skills.

ADA Health Promotion Officer, Mikaela Chinotti commented that “these resources created with the NEDC will go a long way to educating and assisting dental practitioners in recognising, discussing and treating eating disorders in their clinical practice.”

The resources are also available on the ADA website at https://www.ada.org.au/Your-Dental-Health/Resources-for-Professionals On entering the ADA website, click YOUR DENTAL HEALTH, then RESOURCES FOR PROFESSIONALS to download and print.

The fact sheets are available across every age group category. You will find the three documents listed as: Protecting your Oral Health, Talking to your Dentist and A Guide for Dental Practitioners.

For additional information on this resource please see the online article on the ADA website https://www.ada.org.au/News-Media/News-and-Release/Latest-News/Open-Your-Mouth-Education-on-eating-disorders-for

Upcoming Training and Professional Development Opportunities

The NEDC website includes a dedicated space that enables access to current training, professional development and events taking place across the country, within the eating disorder sector.

We encourage our members and professional providers to use this space to promote training and professional development opportunities taking place throughout the year.

This month we would like to highlight the below GP training opportunity provided through Eating Disorders Victoria. Expressions of interest are currently being taken for this training. If you require further information please contact Eating Disorders Victoria through the Eating Disorders Victoria website, by email or phone. You will find the contact information below.

Eating Disorders Victoria GP Training – Eating Disorders: Early Intervention and Community Treatment

This RACGP accredited program aims to improve early detection by raising awareness of the signs and symptoms or eating disorders; help GPs understand how to communicate with their patients about eating behaviours; outline the GP’s role within the multidisciplinary care team and increase GP awareness of prevalence, morbidity and mortality related to eating disorders in order to encourage early diagnosis, appropriate community treatment and appropriate referral options.

The program includes presentations from specialist professional workers and consumers who have recovered from an eating disorder.

For more information and to join the wait list for upcoming training please contact Eating Disorders Victoria via Email: education@eatingdisorders.org.au, Phone on 1300 550 236 or via the website at https://www.eatingdisorders.org.au/education/for-health-and-other-professionals

If you have an event or training opportunity and would like to list this on the NEDC Professional Development, Training and Event page please visit our website to register and share your event information.

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Finding Support during the Easter Break

Face to face support may become limited over Easter. However, with celebrations involving food and socialising, a heightened sense of fear and anxiety may occur during this period for people experiencing or caring for someone with an eating disorder (Grilo et al., 2011).

Knowing what support services are available over Easter can help individuals manage their anxiety and assist in making this time as comfortable and enjoyable as possible.

If you wish to speak to someone, you can contact the below support services.

The Butterfly National Helpline 1800 334 673

Butterfly's National Helpline is Australia’s national eating disorders support service providing phone, email and web counselling for all those affected by eating disorders or body image concerns.

People with an eating disorder, families, carers, friends and professionals can contact the Helpline for information, support and referrals.

Additional contact is available by:

Online Chat: Open Chat Now or Email: https://butterfly.org.au/get-support/helpline-email/

Open Hours: Monday to Friday, 8 am-Midnight AEST, seven days a week (except national public holidays).

Closed Hours: Friday 19th April * Monday 22^nd April * Thursday, April 25^th

Eating Disorders Victoria Helpline

1300 550 236
Eating Disorders Victoria Helpline is a free and confidential service providing support and information about eating disorders and related issues.
e. help@eatingdisorders.org.au
Normal Operating Hours: Mon to Fri, 9.30am – 5:00 pm AEST (except national/ major public holidays).

Beyond Blue

1300 224 636
Beyond Blue provides support for people with anxiety and depression and their families and friends.
Support Service: Contact Now
Online Chat: Open Chat Now (7 days a week, 3pm-12am AEST)
24/7 Helpline (including public holidays).

SANE

1800 187 263
SANE help centre provides information, guidance and referral to help manage mental health concerns.
Email: helpline@sane.org and Online Counselling: Open Chat Now
SANE Web Forums: Open 24/7, fully moderated.

Closed: All Helpline, Online Counselling and Email services will be unavailable during the Easter period and will reopen on Tuesday 23^rd of April. However, you may leave a message with the SANE after-hours service for a return call on Tuesday.

Normal Operating Hours: Mon to Fri, 10:00 am – 10:00 pm AEST (except national/major public holidays).

MensLine

1300 789 978
MensLine Australia is the national telephone and online support, information and referral service for men with personal, family and relationship concerns.
Online Counselling: Open Chat Now
Operating Hours: 24/7 Helpline and Chat including public holidays.

Qlife

1800 184 527
Qlife is the national counselling and referral service for Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) people.
Online Counselling: Open Chat Now
Operating Hours: 7 days a week, 3:00 pm – 12:00 am AEST (including public holidays).

EMERGENCIES - If you or someone you know is in crisis, please call one of the following:

Emergency Services

000
If you are experiencing immediate danger and/ or require medical assistance, please contact emergency services.
Operating Hours: 24/7 including public holidays.

Lifeline

13 11 14
Lifeline provides all Australians experiencing a personal crisis with access to online and phone crisis support and suicide prevention services.
Online enquiries form
Crisis Support Chat: Open Chat Now (7 days a week, 7pm-4am AEST)
Operating Hours: 24/7 Helpline including public holidays.

Suicide Call Back Service

The Suicide Call Back Service is a free, professional, 24 hour seven days a week national counselling service that provides free telephone and online counselling.
You can call anywhere and anytime.-1300 659 467
Contact via online form
Online Counselling: Open Chat Now
Operating Hours: 24/7 Helpline and Chat including public holidays.

Kids Helpline

Kids Helpline provides confidential counselling for kids and young people (ages 5-25) regarding all topics.
1800 551 800
counsellor@kidshelpline.com.au
WebChat: Open Chat Now
Operating Hours: 24/7 Helpline and Chat including public holidays.

What to do with this information?

It may be useful to keep this information with you at all times and even print a copy to have at hand. Healthcare providers, practice managers and educators are encouraged to share or print a copy to keep in their office for referrals and professional support.

This information is useful for:
• People experiencing an eating disorder
• Families, friends and carers
• Health professionals
• Educators

This information may also be downloaded online from the NEDC website.