Clinical Geriatrics

Case Presentation

A 68-year-old widowed woman was referred to a psychologist for counseling by her primary care physician. The physician was concerned that Mrs. R was dieting and exercising excessively. Mrs. R is a nurse who retired two years ago. She moved to an assisted living facility one year ago following the death of her husband. Mrs. R has two daughters who live nearby. She was referred to both a psychiatrist and psychologist many times, but refused to see them. Her daughter convinced her to see a psychologist and came with her to the appointment.

Mrs. R arrived early for her appointment and drank many glasses of water while she was waiting. She appeared thin, but was neatly dressed and groomed. Mrs. R was extremely verbal and relayed her history in great detail, often using medical terminology. She described being concerned about her weight since the age of 10, when she was teased in school after she began developing breasts. Mrs. R started restricting her intake of food to one meal per day. She recalled being admitted to the hospital at the age of 14 after fainting in school. She reported that she learned to drink large amounts of water before being weighed to give the illusion of gaining weight. At 5’ 1’’ tall, Mrs. R recalled that her typical weight throughout high school and nursing school was 84 lbs. She typically ate one meal per day, and if she exceeded this, she would exercise by riding a bicycle, running up stairs, or jogging. Mrs. R noted that while in nursing school she fainted several times and was often hypotensive and anemic. She learned to eat and drink enough to have the ability to work, while keeping her weight at 84 lbs. She spent large amounts of time planning her one daily meal, calculating the calories it would contain. Mrs. R was able to function as a nurse, and enjoyed working in the maternity ward of a university hospital. She married a sales representative from a baby formula company when she was 28. Mrs. R had two children, and was able to gain weight during her pregnancies with support from her husband. She reported that she hated being pregnant, and constantly thought of how she was going to lose the weight she gained, but realized that she needed to eat more to have healthy children.

Mrs. R stayed home to raise her daughters, and resumed her pattern of eating one meal daily. After her daughters left home to attend college, she tried to resume her nursing career, but found the work too physically demanding. Mrs. R saw a physician for lower back pain and was found to have severe osteoporosis at the age of 52. She suffered several spinal compression fractures, and was less able to exercise. She started feeling increasingly anxious that she would “become fat” after her weight increased to 92 lbs. Mrs. R recalled that she went on a “liquid fast” of fruit juice diluted with water. After several days, she fell down the stairs in her home and sustained fractures of her left hip and left arm. She was hospitalized, required several surgical procedures, and was given tube feedings. Mrs. R recalled that she was so anxious in the hospital that she was given sedatives. She left the hospital weighing 100 lbs, but was able to recover from her fractures. She had a period of stability for several years after this, in part because she was fearful of falling and sustaining more fractures. She and her husband traveled, spent time with their grandchildren, and Mrs. R was able to eat in restaurants for the first time in many years. She resumed working part-time as an employee health nurse. Her husband died following a series of heart problems, and she moved to the assisted living facility. While living alone she resumed her previous pattern of eating only one meal per day, and started using an exercise bicycle to reduce her weight back to a goal of no more than 84 lbs. The nurse and administrator of the facility grew concerned and referred her to the consulting physician.