Failure to Thrive in the Elderly
Geriatric Failure to Thrive (FTT) is a serious issue that affects between 5% and 35% of community-dwelling seniors and between 25% and 40% of residents who are living in nursing homes. Certain elderly patients develop failure to thrive for reasons that are not clearly understood, but the prevalence of the problem seems to increase with age. Research has shown that failure to thrive is associated with low immunity and higher rates of infection as well an increase is the risk of hip fracture, and decubitus ulcers. For this reason, seniors who experience sudden weight loss, a decrease in appetite, depression, and inactivity should be evaluated by a doctor right away to prevent further progression of the issue.
What is the medical term failure to thrive (FTT)?
Failure to thrive is a term used to describe a general state of decline in elderly patients that’s characterized by profound weight loss, diminished appetite, poor nutrition, and a lack of physical activity. It is not a diagnosis and it is not a disease. Failure to Thrive is rather a set of indicators that can be used by caregivers to recognize that there has been a significant change in the patient’s normal health status. The underlying cause of failure to thrive is not always easy to discover and the syndrome may be caused by a variety of factors that vary from patient to patient.
The development of FTT is particularly serious among populations of people with malnutrition, depression, impaired physical function, and cognitive impairment, but FTT can also impact even the healthiest older adults. When an older adult patient suddenly develops the symptoms associated with failure to thrive, it is often challenging to determine the cause of the problem and for this reason, it’s vital that caregivers take action immediately to see a doctor and report the problem if an elderly patient appears depressed and is losing weight quickly. Caregivers who observe the hallmark signs should not just assume that a lack of appetite, profound weight loss, depression, and lack of physical activity are a natural consequence of the aging process, chronic disease, or even dementia. Even patients with a terminal disease who exhibit symptoms of FTT should be taken to see their doctor immediately should these symptoms arise.
What causes failure to thrive in the elderly?
There are a variety of possible causes that underlie the development of failure to thrive. Often the cause is multifactorial. In other words there are multiple contributing factors that work together to bring on the characteristic symptoms of this disorder. Common causes include chronic disease or functional impairments including cancer, chronic infection, stroke, or psychiatric disorders that include cognitive loss. But while some patients who have been diagnosed with cancer or chronic infection may go on to develop FTT, a number of them do not. The factors that ultimately lead to profound weight loss, depression, and lack of activity (the symptoms associated with FTT) may not be identifiable even by doctors who regularly work with patients who have been diagnosed with this disorder.
Health professionals who work closely with elderly populations often view failure to thrive as a syndrome caused by a mix of different issues. Each patient may experience a sudden and significant health decline due to issues unique to their situation, but malnutrition and a lack of exercise along with chronic health problems typically play an important role in the development of FTT. The most popular theory today is that poor physical or mental health sets off a chain reaction that causes the patient to have difficulty eating a proper diet. Malnutrition leads to deficiencies of certain vitamins and minerals which causes the patient’s health to decline even further. As the patient’s nutritional status deteriorates, their health gets worse and the patient eats less and moves around less which further exacerbates malnutrition and depression and so on and so forth.
What increases the risk for FTT in the elderly?
Caregivers who are working with elderly adults should be mindful of the signs of failure to thrive and the risk factors that are associated with this kind of decline in health. First and foremost, the patient’s medications should be evaluated to determine whether side effects caused by the medication could be at the root of the problem, or whether the patient may be experiencing negative drug interactions that are causing the problem.
Patients who have more than one chronic disease and patients who have physical or cognitive limitations are more likely to develop FTT. Patients who are home-bound or bed-bound may be more likely to develop Failure to Thrive due to limited social interaction, but additionally, limited income can also play a role, which seems to indicate that high-levels of frustration and the sense that the condition is insurmountable may play a role in the development of this disorder.
Some experts suggest that caregivers should remember these “D” words (or disease states) associated with Failure to Thrive:
● Drugs and substance misuse or abuse (including alcohol)
● Deafness, blindness, and other sensory-related deficits
● Dysphagia (difficulty or discomfort swallowing)
● Desertion by the family
The Diagnosis and Treatment of FTT
Because failure to thrive is not a disease or a diagnosis in and of itself, it can be challenging for doctors to put a label on the issue or identify a root cause that can be labeled. Indeed, it’s often exceedingly difficult to identify what is causing the deterioration in health status. Typically, patients with an acute illness or a severe and long-standing chronic disease will suddenly undergo a process of functional decline and then develop a progressively deepening sense of apathy and depression followed by an unwillingness to eat or to drink. This final phase culminates in death. One research study found that the mortality rate of patients in hospitals who developed failure to thrive was 15.9%.
Diagnosis of Geriatric FTT
There are four syndromes associated with failure to thrive that tend to predict negative outcomes for patients:
● Impaired physical function
● Cognitive decline or impairment
The patient’s doctor should assess the patient’s medical history, do a physical exam along with a thorough, comprehensive review of the patient’s current medications including prescription, non-prescription medications as well as herbal medications and vitamin and mineral supplements. Lab and diagnostic tests should be performed to rule out the possibility that the patient is afflicted with a similar, previously undiagnosed disease or disorder.
Below is a list of medical conditions that are commonly associated with the development of FTT:
● Chronic lung disease
● Chronic tuberculosis
● Recurrent pneumonia
● Cancer metastases
● Recurrent urinary tract infections
● Mental illness including depression or psychosis
● Cirrhosis of the liver
● Myocardial infarction (heart attack)
● Congestive heart failure
● Rheumatological diseases and infections
Below is a list of medications that are commonly associated with the development of FTT:
● Antiepileptic drugs
● Central alpha antagonists
● Anticholinergic drugs
The patient’s doctor should take the patient’s medical history and prescription drug list into consideration before diagnosing the illness. Assessment of the patient should be thorough to either rule out other possible diseases or disorders or to attempt to discover the root cause of the problem. Assessment of geriatric FTT should include a total work-up including the following:
● Physical evaluation of the patient
● Psychological evaluation of the patient to determine the mood and awareness as well as time and place orientation.
● The Geriatric Depression Scale or the Cornell Scale for Depression in Dementia
● Assessment of physical well-being using the Get Up and Go Test
● Assessment of the patient’s functional ability
● Assessment of the patient’s socioeconomic situation
● Comprehensive medication review including a search for possible drug interactions or possible adverse effects. Cross-checking of the patient’s prescription drug list using Beers criteria (which is a tool for identifying potentially inappropriate pharmaceuticals for the elderly).
● Assess the impact of pre-existing chronic disease states
● Assess the patient’s nutritional status using the Mini Nutritional Assessment (this is a special tool that’s easy to administer to assess the nutritional risk of elderly patients)
● Laboratory evaluation to determine complete blood count, thyroid-stimulating hormone levels, chemistry panel, and urinalysis to check for liver function and infection of the kidney as well as the patient’s overall health. Lab tests may also test for blood alcohol levels.
● Radiological tests including chest X-ray, CT, or MRI may be ordered depending on the patient’s unique needs to rule out the possibility of tumors or infection in the body.
● Assessment of the patient’s hearing
● Assessment of the patient’s vision
Without a thorough assessment of the patient, it will be hard to accurately diagnose FTT and therefore, nearly impossible to formulate a viable treatment plan for the patient. Any patient who has a pre-existing, chronic or acute medical condition should be thoroughly re-evaluated by the physician to determine its current level of severity. The laboratory screening will help the physician rule out the possibility of substance or alcohol abuse. And patients who are exhibiting signs of Failure to Thrive and who are also taking medications that may contribute to the problem, should be evaluated for prescription drug changes to rule out the possibility that the drug is at the root of the problem.
Treatment of Geriatric FTT
The goal of treating geriatric patients with failure to thrive is to improve their quality of life and functional abilities. The best treatment strategy takes a team approach and includes not only the patient’s doctor, but also a nurse, a dietitian, and a physical therapist along with a social worker, mental health professional, and when necessary, a speech pathologist. Depression and poor nutritional intake are issues that should be addressed as soon as possible.
An elderly patient’s nutritional status plays an important role in his or her ability to recover from any illness, injury, or surgery. Older adults who are malnourished lack muscle strength and this problem can lead to generalized weakness and diminishing levels of independence as a result. Patients who have weak muscles due to undernourishment may also be more prone to falls and they’re more likely to experience a slow recovery from illness. Further, patients who are weak will be less physically active which makes them susceptible to pressure ulcers, anemia, and fatigue. They also become more prone to developing infection and immune dysfunction. A well-developed nutritional plan for a patient with Failure to Thrive is one of the most important aspects of treatment.
Medical nutrition therapy is geared at stabilizing or reversing the patient’s weight loss and malnutrition while treating any underlying problems. It’s important to remember that even patients who are overweight may be suffering from malnutrition. There are certain common nutritional problems that all older adults face including an inability to eat the proper amount of calories or protein to meet their daily needs. Extremely restrictive diets can contribute to this problem and some dietitians may encourage patients to eat a more liberal diet if they’re struggling to meet their caloric needs. The most common medical nutrition intervention for geriatric Failure to Thrive patients is to increase their caloric and protein intake. Enhanced or fortified foods and nutritional supplements may also be used along with appetite stimulants or even enteral feeding, if appropriate.
Caregivers may be asked to give vitamin or mineral supplements to patients in the form of a daily multivitamin calibrated specifically for older adults. Appetite stimulants may be prescribed as well. Enteral feeding, however, is a last resort that is only recommended in certain situations.
In addition to nutritional therapy, patients with FTT are often encouraged to engage in a certain amount of physical activity. The combination of physical activity and good nutrition are a winning combination for patients with this disorder. Though physical activity is an essential part of the treatment equation for geriatric Failure to Thrive, only about 22% of patients over the age of 65 years participate in leisure-time physical activity. Caregivers who encourage their patients to engage in physical activity can help prevent the development of FTT.
One of the most common reasons why seniors go to the emergency room is due to fall-related injuries. According to the National Institutes of Health, among elderly populations in the U.S., falls are the primary cause of trauma, fractures, loss of independence, and death related to injury. The fear of falls may deter older adults from exercising which can, in turn, lead to the development of Failure to Thrive. But most older adults can benefit from resistance or strength training to improve muscle strength and general functional ability. Often, treatment of FTT includes a well-designed physical activity plan that includes the following components:
● Endurance exercises to improve cardiovascular and circulatory health. These exercises typically include low-impact aerobic activities.
● Strength-training to build muscle and prevent osteoporosis and also reduce sarcopenia (the loss of skeletal mass due to aging processes). Resistance training is typically prescribed to take place three times weekly along with a non-steroidal anti-inflammatory agent before exercise to reduce post-workout inflammation.
● Balancing exercises to prevent falls. Yoga or Tai Chi are excellent exercise options for building balance.
● Flexibility exercises to prevent or recover from injuries. Often balancing and flexibility exercises can be combined.
Nutritional therapy and exercise therapy combined together have a synergistic effect on the patient’s overall health and well-being. When a patient has shown signs of Failure to Thrive, combating malnutrition while increasing strength and stamina can promote well-being and turn the tide. For patients who have physical limitations, a physical therapist may be needed to address issues related to range-of-motion and to prescribe the use of assistive devices such as canes, grab bars, walkers, or shower chairs to further enhance the patient’s sense of independence.
How can a caregiver help their patient who is suffering from this condition?
Caregivers who are working with patients who are showing signs of failure to thrive should schedule a visit to a knowledgeable physician as soon as possible to rule out other possible causes and to begin a treatment plan to hopefully reverse the issue. Nutrition and physical exercise will likely play an important role in the treatment plan unless other underlying causes for FTT are identified such as substance abuse, diagnosis of another disease, or previously unidentified drug interactions.
After the initial assessment of the patient, caregivers should pay special attention to the patient’s nutrition and exercise plan. Nutritional supplements should be given as prescribed and exercises that address the patient’s strength, endurance, flexibility, and resistance should be performed regularly according to the doctor’s prescription. As part of the exercise routine, patients may also benefit from having time outdoors particularly with other people. Spending time outside can improve mood while socialization may also lift the patient’s depression. As strength and flexibility improves, patients may begin to feel more independent, though the risk of falls needs to continue to be considered and accounted for throughout the treatment process. By addressing the patient’s needs as part of a team that includes doctors, nurses, nutritionists, and other therapists, the caregiver is more likely to see successful outcomes.
On the other hand, patients who refuse to eat or do physical exercise will need to be provided with a different course of treatment that does not needlessly prolong his or her suffering. Aggressive, life-prolonging interventions are typically not recommended in situations like these, especially if the patient has been diagnosed with another terminal disease. If an elderly patient develops the symptoms of Failure to Thrive and refuses all efforts at treatment, caregivers should follow the doctor’s instruction and try to make the patient as comfortable as possible.