Failure to Thrive in Elderly Adults

Failure to thrive in elderly persons is defined by The Institute of Medicine as weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction, and low cholesterol. Failure to thrive is not a single disease or medical condition; rather, it's a nonspecific manifestation of an underlying physical, mental, or psychosocial condition.

Malnutrition is the key pathophysiologic component of failure to thrive in elderly persons. This malnutrition manifests as weight loss and loss of functional skills and psychological decline.

Many different medical conditions lead to failure to thrive, including chronic infections, inflammatory conditions, psychiatric conditions, and medication use. Each of these conditions effect different organs and produce different types of physical, mental, nutritional and metabolic derangements leading to the manifestations of failure to thrive. A brief list of specific derangements caused by medical conditions and drugs that lead to failure to thrive are discussed below.

The following are common medical conditions associated with failure to thrive in elderly patients:[1]

• Cancer metastases: Malnutrition, cancer cachexia

• Chronic lung disease: Respiratory failure

• Chronic renal insufficiency: Renal failure

• Chronic steroid use: Steroid myopathy, diabetes, osteoporosis, vision loss

• Cirrhosis, history of hepatitis: Hepatic failure

• Depression, other psychiatric disorders: Major depression, psychosis, poor functional status

• Diabetes: Malabsorption, poor glucose homeostasis, end-organ damage

• Hip or other large-bone fracture: Functional impairment

• Inflammatory bowel disease: Malabsorption, malnutrition

• Myocardial infarction, congestive heart failure: Cardiac failure

• Previous gastrointestinal surgery: Malabsorption, malnutrition

• Recurrent urinary tract infections or pneumonia: Chronic infection, functional impairment

• Stroke: Dysphagia, depression, cognitive loss, functional impairment.

• Rheumatologic disease (eg, temporal arteritis, rheumatoid arthritis, lupus erythematosus): Chronic inflammation

• Tuberculosis, other systemic infection: Chronic infection

Medications commonly associated with failure to thrive in elderly patients include the following:[1]

• Anticholinergic drugs: May result in cognition changes, dysgeusia, dry mouth

• Antiepileptic drugs: May result in cognition changes, anorexia

• Benzodiazepines: May result in anorexia, depression, cognition changes

• Beta blockers: May result in cognition changes, depression

• Central alpha antagonists: May result in cognition changes, anorexia, depression

• Diuretics (high-potency combinations): May result in dehydration, electrolyte abnormalities

• Glucocorticoids: May result in steroid myopathy, diabetes, osteoporosis

• More than four prescription medications: May result in drug interactions, adverse effects

• Neuroleptics: May result in anorexia, parkinsonism

• Opioids: May result in anorexia, cognition changes

• SSRIs: May result in anorexia

Tricyclic antidepressants: May result in dysgeusia, dry mouth, cognition changes

Many different precipitants lead to failure to thrive. The precipitants can be categorized in the following 8 groups, discussed below. The following list provides a mnemonic (the 11 D’s of “The Dwindles,” a mnemonic for the precipitants of geriatric failure to thrive):[2]

1. Diseases (medical illness)

2. Dementia

3. Delirium

4. Drinking alcohol, other substance abuse

5. Drugs

6. Dysphagia

7. Deafness, blindness, other sensory deficits

8. Depression

9. Desertion by family, friends (social isolation)

10. Destitution (poverty)

11. Despair (giving up)

Diseases

Medical conditions that are either undiagnosed (eg, malignancy) or worsening of existing conditions (eg, congestive heart failure, chronic obstructive pulmonary disease, renal failure) can lead to failure to thrive.

Dementia

Dementia can lead to several factors that result in failure to thrive, such as poor food intake, social isolation, and depression.[3]

Alcohol and drugs

Elderly patients are limited in their ability to metabolize and excrete drugs and ethanol. Thus, it is critical to review the social history and list of medications to identify potential precipitants such as digoxin. Narcotics and benzodiazepines are another important class of medications that lead to failure to thrive by increasing somnolence or sedation.

Delirium

Dementia needs to be differentiated from delirium because the latter is an emergency situation that needs to be diagnosed and corrected immediately. Unlike dementia, delirium is acute in onset and has a fluctuating course. It is characterized by inattention and cognitive impairment.

Deafness, blindness, and other sensory deficits

Loss of vision, hearing, and taste and other sensory deficits are social barriers for patients and lead to isolation and depression.

Dysphagia

Another important consideration is the patient's ability to chew and swallow food without coughing, choking, or aspirating. Difficulty swallowing needs to be further investigated to identify mechanical or neurological causes.

Depression and despair

Elderly patients may have underlying mental conditions such as depression or anxiety that may result in poor intake of food and social isolation. Some elderly patients may feel that their life is not worth living, because of either their physical limitations or social circumstances, and not eating may be a manifestation of that emotion.

Destitution and desertion

An important aspect of social history in elderly persons is physical and financial access to food. Elderly persons who live alone may be physically limited in their ability to cook or shop for food or may not be able to afford food, predisposing to failure to thrive. In addition, those who lack social support from family and friends are more likely to have failure to thrive due to social isolation and possibly depression.

Incidence

The prevalence of failure to thrive in elderly adults varies depending on the setting in which it is measured. In the United States, failure to thrive is found in 5%-35% of community-dwelling older adults, 25%-40% of nursing home residents, and 50%-60% of hospitalized veterans.[4]

Fifteen percent of community-dwelling elderly persons in Europe were found to have failure to thrive.[5] Another study revealed that around 28% of elderly patients living in long-term-care facilities in Canada were found to suffer from failure to thrive.[5]

Age-based incidence

Failure to thrive is not part of normal aging, although its prevalence increases with age. Multiple risk factors place elderly individuals at risk for failure to thrive, such as dementia, multiple comorbidities, decreased or limited mobility, and a decreased ability to deal with physical stresses.[3]

Because failure to thrive does not result from a single condition, it is not possible to provide a general prognosis. The prognosis depends on the etiology.

Failure to thrive leads to an increased risk of morbidity and mortality via several different mechanisms.[6, 7]

Weight loss in elderly persons is often accompanied by physical, mental, and social consequences that lead to poor quality of life and mortality. Physical changes include loss of height, lower metabolic rate, and alterations in the gastrointestinal tract that further compromise food intake and decrease physical activity.[6] These changes then contribute to social isolation and depression, which leads to further compromise of nutritional and functional status.

Loss of dietary protein has also been found to lead to loss of muscle function and bone mass, infections due to compromised immunity, anemia, and impaired wound healing and ability to recover from physical stresses related to disease or surgery.[7]

Failure to thrive in elderly persons manifests as an inability to sustain weight due to poor nutrition, leading to progressive decline in physical and mental functioning. Many physical, mental, and social conditions can lead to failure to thrive.

It is important that the patient is seen and evaluated by a physician to evaluate the etiology. Once the underlying cause is identified, steps can be taken to address the problem, as well as to help the patient improve nutrition, physical activity, and mental health.

A detailed history is required to diagnose the underlying cause of failure to thrive in the elderly population. All systems should be reviewed to identify new symptoms indicative of a new diagnosis or a worsening existing condition.

A detailed nutrition history to review all aspects, including food shopping, cooking, frequency of meals, and type of food groups consumed, is taken into consideration. A validated tool to assess the nutritional status in elderly persons is the Mini Nutritional Assessment.

A review of medication lists, including over-the-counter medications and herbal products, is critically important.

A social history should include documentation and quantification of alcohol and substance intake. The health provider needs to inquire about social support available from family, friends, and community, as well as barriers such as falls and balance problems leading to social isolation and need for more supervision.

An important aspect of the history is cognitive evaluation to assess dementia. Many instruments can be used for this assessment, including the Mini-Cog Test, Mini-Mental State Examination, and General Practitioner Assessment of Cognition. Dementia needs to be differentiated from pseudodementia related to depression.

Another important aspect is the functional assessment in terms of ambulation and carrying out activities of daily living (ADL). Both the Katz ADL and Lawton IADL can be used to assess the performance of ADL.

Finally, the patient is evaluated for any underlying mental health conditions such as depression or anxiety. The Geriatric Depression Scale (GDS) has been specifically designed for elderly persons.[8] Alternatively, a single screening question, “Do you often feel sad or depressed?” may effectively screen for depression.[9]

A complete examination, including a vision and hearing test, is the first step to evaluate for deterioration of existing medical conditions or diagnosis of new diseases. In addition, the examination will help identify signs of malnutrition and vitamin deficiencies.

Timed Up and Go is a quick and reliable test to assess mobility. The patient is asked to get up from a chair and walk 3 meters before returning to the chair. The time taken by the patient to complete the task is used to grade the functional mobility.

Multiple coexisting precipitants can lead to malnutrition in persons with failure to thrive.[10] A comprehensive history and physical examination is key to identifying the underlying precipitants. Based on the initial assessment, further workup can be performed to confirm or rule out possible suspected etiologies.

Based on the history and physical examination, laboratory studies can be performed to further investigate the underlying etiology for failure to thrive. The following is a list of tests and conditions for which these tests may be helpful:[1]

• Blood culture: Infection

• Complete blood cell count: Anemia, infection

• Erythrocyte sedimentation rate (ESR), C-reactive protein levels: Inflammation

• Growth hormone, testosterone (men): Endocrine deficiency

• HIV, rapid plasma reagin (RPR) test: Infection

• Purified protein derivative (PPD) testing: Tuberculosis

• Serum albumin and cholesterol levels: Malnutrition

• Serum blood urea nitrogen (BUN) and creatinine levels: Dehydration, renal failure

• Serum electrolyte levels: Electrolyte imbalance

• Serum glucose level: Diabetes

• Thyroid-stimulating hormone level: Thyroid disease

• Urinalysis: Infection, renal failure, dehydration

Imaging studies such as radiography and CT scanning can be performed depending on suspected etiologies based on history and examination findings to further investigate and confirm the diagnosis.

Chest radiography can be used to evaluate for infection and/or malignancy.

CT scanning and MRI can be performed to assess for malignancy and/or abscesses.

After failure to thrive is diagnosed, appropriate interventions need to be directed toward removing or reducing the precipitant factor, as well as treating the symptoms. The image below provides a diagrammatic representation of the steps for managing failure to thrive.

If a new diagnosis has been established, appropriate treatment and follow-up is recommended. However, it is important to look at the side-effect profile of treatment in elderly patients. A discussion needs to take place to clarify treatment goals and available options to provide patient-centered care. If the precipitant is worsening of an underlying medical problem, management needs to be optimized and an end-of-life care discussion needs to take place.

There are multiple approaches to treating depression in elderly persons patients. In addition to pharmacotherapy, which may cause serious side effects in elderly persons, nonpharmacological interventions such as psychotherapy and light and music therapy need to be considered.[11]

Patients with cognitive impairment benefit from cognitive training in terms of improving their cognitive abilities and ability to carry out activities of daily living and decreasing long-term functional decline.[12, 13]

Nutritional and vitamin deficiencies diagnosed in patients with failure to thrive need to be treated and monitored. Dietary restrictions should be reduced to encourage a greater variety of food options. In addition, nutritional boosts or supplements with meals can prevent malnutrition in patients with decreased intake.

Another strategy is prescribing of appetite stimulants such as dronabinol (Marinol) or megestrol (Megace).[14] The evidence for megestrol efficacy is much stronger than for dronabinol in elderly persons. The side-effect profile of megestrol includes thromboembolism, adrenal insufficiency or suppression, catabolic effect on the muscles, hypoglycemia, and hyperglycemia, particularly when used for more than 12 weeks. The side-effect profile of dronabinol includes sedation, fatigue, euphoria, and hallucinations, so judicious prescription of these medications for a limited period with close follow-up is recommended.

Patients with functional impairment require physical therapy and occupational therapy to prevent falls through improvement of balance, muscle strength, and endurance.[15] In addition, the patient’s physical environment needs to be evaluated and modified to reduce fall risk. Another important aspect is provision of supportive aids such as a cane or wheelchair to improve balance and ambulation.

Failure to thrive can be multifactorial and can lead to physical and mental impairment. It is imperative that a team approach is used to address this complex and multidimensional problem. A coordinated effort involving a dietitian, social worker, psychiatrist, and physical and occupational therapist can provide the necessary support to help these patients. Additional consultation with specialists for management of the specific suspected etiologies underlying failure to thrive may be needed.