LAUSR

Dear Editor, Eating disorders occur in individuals of all ages. Prevalence rates for the very old (80+) are unknown, though estimates for those above age 65 range from 2% to 4%. Individuals 65+ face particular challenges in receiving care. They frequently do not seek treatment, are misdiagnosed or underdiagnosed, and no treatment guidelines exist for this age group. Current evidence‐based recommendations are derived from studies where mean age is typically <30. To our knowledge, no eating disorder research treatment trials included participants of very old age. Only a handful of studies have specifically studied eating disorder treatment in middle life or older individuals and to date no long‐term recovery data exists. Without sufficient data, it is unclear which treatments should be offered to older patients. We report on treating two very old age individuals with eating disorders. Patient A was 87 years old, and patient B was 86 years old. Both patients were female with a duration of illness over 55 years. Neither had ever received previous eating disorder treatment and nor did they did they receive or require psychotropic medication. Patient A recalled that her eating disorder started when she was 20 and she dieted to fit into her wedding gown. For the next 7 decades, she met current diagnostic criteria for anorexia nervosa or bulimia nervosa, alternating between the two. At time of presentation, she was diagnosed with bulimia nervosa. She reported an intense dislike of her body shape; both the areas she believed were “too fat” and those that were “too old.” Her eating pattern consisted of a small breakfast of yogurt and coffee, with restricted eating until dinnertime. After dinner, she would “nibble” on foods while cleaning, leading to a binge. As a result of binge eating, the next day she would restrict her eating and attempt to “walk it off”. Her walks were driven in nature, often lasting well over an hour despite inclement weather, pain, or illness. She sought treatment after her granddaughter had completed a successful course of eating disorder treatment. Patient B reported that concerns about her shape and weight began in her 30s after her gynecologist commented that she was gaining too much pregnancy weight. For the next 5 decades, she met current diagnostic criteria for anorexia nervosa restricting type. She reported experiencing amenorrhea after her last pregnancy and that she skipped a “traditional menopause.” She endorsed an intense dislike of her shape and aging. She reported that her family had been concerned about her low weight and restrictive eating patterns for years and had encouraged her to seek treatment many times. Her eating patterns consisted of restricting the amount of food eaten due to fear of becoming fat, avoiding fats and sugary foods, and occasional subjective binge episodes on her favorite sweets. Her primary care physician referred her for the treatment of anorexia nervosa. In each case, we offered enhanced cognitive behavior therapy for eating disorders (CBT‐E). CBT‐E is a leading evidence based treatment for eating disorders in adults. It is a time‐limited psychological therapy, typically lasting 20 sessions. It focuses on the disorders' main maintaining mechanisms, namely an over‐evaluation of eating, shape, and weight. The treatment consists of four stages. The first half emphasizes a regular pattern of eating and collaborative weekly weighing. The later stages focus on techniques to decrease unhelpful behaviors (i.e., body checking) and improve body image. We added an extra module focused on age related appearance changes to address these concerns present in both patients. At the end of treatment, eating disorder symptoms were greatly reduced in both patients A and B. Patient A stopped binge eating and reduced her daily walking, reporting that it was “just for enjoyment” now. Patient B regained weight, moving her from a BMI of 17.0–19.3. Both patients completed objective outcome measures including the Eating Disorder Examination Questionnaire and Clinical Impairment Assessment at baseline, mid‐treatment, post treatment, and 5‐month follow‐up. While patient A's outcome measure scores decreased throughout treatment and remained stable at follow‐up, scores for patient B were low and remained low throughout treatment. Patient B's scores may question the validity of these measures in the older adults or individuals with very long duration of illness. Our findings suggest that very old age individuals may respond favorably to CBT‐E. This work warrants further investigation and replication. In the meantime, we encourage our colleagues to routinely screen for eating disorders in patients of very old age and refer them to specialist eating disorder treatment when indicated.