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Ask the Mental Health Expert Archives 2001-2004

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Elderly with Anorexia

Q. My elderly mother suffered from anorexia 5 years ago and required ECT, which reversed her anorexia. However, she has become anorexic again and is presently being tube fed. She has received ECT again but so far it is ineffective. Could you let me know if there is anything that would benefit her treatment? Do you think she should be on antidepressants? I realize that her problem may be different from younger patients suffering from anorexia nervosa. Her phobia against food has really affected her ability to get better.

A. This sounds like a very difficult situation for you and your mother. While I can't offer a diagnosis or specific treatment recommendations, here are some issues to consider. First, let's distinguish (as you seem to realize already) between anorexia as a symptom and anorexia nervosa as a disorder. The latter is a disease involving distorted body image that ordinarily begins in the teens or twenties. In contrast, anorexia is just another term for poor appetite, and has no specific diagnostic meaning.

Loss of appetite is extremely common in patients with severe major depression, which ordinarily responds well to ECT. Your mention of your mother's phobia against food raises other questions, however. Could it be that she has a delusion regarding food--for example, that it is poisoned, or that she will choke if she eats it? If so, there may be a psychotic/delusional component to her problem that has not been fully treated--though I would have expected ECT to be of help, if your mother has a major depressive episode with psychotic features. But, keep in mind that it may take 9 or more ECT sessions before some patients fully respond. It is also important to make sure there are no medical reasons underlying your mother's avoidance of food--for example, some patients may have gastrointestinal problems that make it difficult to swallow or digest food.

If there is evidence of a major depressive disorder, antidepressants would ordinarily be a mainstay of treatment, even after ECT. For depressed, elderly patients with weight loss, the antidepressant mirtazepine [Remeron] is often quite useful, since it tends to promote weight gain. If there is a delusional component to your mother's illness, an antipsychotic medication such as olanzapine or risperidone could be of help (assuming there are no medical conditions that would prohibit their use).

Finally, while the elderly are sometimes (mistakenly) felt to be too old for psychotherapy, I would not rule this out as an option for someone in your mother's circumstances. It might help her talk about her fears, or perhaps learn some behavioral techniques to help her overcome them. I would certainly discuss both the diagnosis and the appropriate treatment with your mother's psychiatrist, and, if necessary, request a second opinion from an expert in geriatric psychiatry. I hope that your mother's situation improves.

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October 2001

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