Failure to Thrive in Older Adults

Failure to thrive, a term historically used to portray children who don't grow at the expected rate, is increasingly being used to describe older adults who begin to decline for no clear reason. Most of us have known at least one of them - a neighbor or relative who seems to have "just given up" or lost the will to live, typically showing signs such as weight loss, decreased appetite, poor nutrition, and inactivity.

"Signs of failure to thrive in older adults can be very subtle, including things like depression or withdrawal, less engagement in the events around them, a change in mental status, or decreased pleasure in activities they used to enjoy," says Russell Robertson, MD.

Dr. Robertson, Medical College of Wisconsin Associate Dean for Faculty Affairs and Associate Professor of Family and Community Medicine at the Medical College of Wisconsin, along with Marcos Montagnini, MD, Assistant Professor of Medicine at the Medical College, authored the article "Geriatric Failure to Thrive," which appeared in American Family Physician in July. In the article the authors describe failure to thrive and discuss the ways in which medical staff can identify and help resolve the problems associated with the condition.

Although "there's a noticeable change" in those experiencing failure to thrive, says Dr. Robertson, "people who see them every day might not be able to see it. It's not like a switch turning to 'off,' it's more like a dimmer switch - the changes are often hard to notice because they are so gradual. Their life begins fraying around the edges, they become disengaged, and they experience emotional and mental drift."

"That's why it might not be the primary caregiver (usually the spouse or children) who make the decision to bring the patient in to the doctor. It often takes something noticeable and specific, like pneumonia, to get the patient in for medical care."

Thorough Assessment
Can anything be done to help people who show the marked decline typical of failure to thrive? Often, the answer is "yes."

The first step, says Dr. Robertson, is a comprehensive initial assessment that includes an evaluation of physical and psychological health, functional ability, and social and environmental factors. "It's like a 'medical tune-up'," says Dr. Robertson. "It's a thorough check of all the systems to make sure everything is functioning as it should."

After taking a detailed health history, the doctor will look at any existing chronic health conditions or medical problems and look for recent changes in disease management. For instance, diabetic patients might not be keeping their blood sugar under control, or patients with hypertension might be forgetting their blood pressure medications.

The next part of the process is to look for relatively simple problems - such as urinary tract or respiratory infections - that are having negative effects on the patient. A problem with teeth or oral health, for example, can cause eating or appetite changes.

The doctor will also want to assess the patient's emotional state and wellbeing, asking about any changes in sleep and eating habits or signs of depression - is the patient having any thoughts of suicide, or thoughts that make death seem appealing?

Finally, the doctor will perform a more in-depth evaluation of any problem areas, followed by a plan of action that might include physical or occupational therapy, nutritional supplementation, new medication, or fine-tuning the dosage and timing of current medications to minimize side effects.

Finding the root cause of failure to thrive might not be possible; the causes and effects are often intertwined. As the article notes, "depression can be a cause and a consequence of failure to thrive." The same could be said of virtually any of the symptoms of failure to thrive.

Syndromes Point to Adverse Outcome
Four syndromes are "prevalent and predictive of adverse outcomes in patients with failure to thrive," notes Dr. Robertson: impaired physical function, malnutrition, depression, and cognitive impairment. Physicians can evaluate patients in each of these areas.

• Impaired physical function. "Activities of daily living," or ADLs, consist of everyday tasks such as eating, bathing, moving around in one's environment, and dressing. Patients who have trouble with these activities will likely have a difficult time maintaining their independence. Physicians have a number of simple tests that they can ask the patient to perform in order to assess physical status.
• Malnutrition. Many medical conditions that are common among the elderly - and, unfortunately, the medications used to treat them - can result in poor nutrition among older adults. To discern the causes of malnutrition, physicians can discuss dietary habits with patients and run a number of laboratory tests to assess conditions such as dehydration, electrolyte imbalances or loss of muscle mass.
• Depression. Depression is "the most common psychiatric condition in older persons," says Dr. Robertson, "often in response to physical, mental or emotional issues that accompany aging. We don't use anti-depressants as effectively as we should in the geriatric population. A significant percentage of the time, there's a role depression is playing in their behavior." There are numerous tests and questionnaires that doctors can use to evaluate a patient's state of mind, and a number of highly effective medications to help alleviate the condition.
• Cognitive impairment. The article states that in addition to physical health problems, many situations can have an impact on the status of a patient's mental function: "Information on the patient's social network, relationships, family support, living situation, financial resources, abuse, neglect, and recent loss are important aspects of the assessment."

After considering reversible causes of failure to thrive, the doctor will want to look for more serious illnesses like cancer or thyroid disease.

Dr. Robertson notes that older individuals might not recognize the decline themselves, or dismiss the concerns of family members or friends. "If an individual has been relatively well functioning and something changes, you might have to point it out to them and they might deny it or disagree - 'No, I'm fine, I'm just not feeling well today…' The child or caregiver might have to be assertive, explaining that there's been a noticeable change and they want to help find the cause."

What can family members do in advance in case a parent or loved one begins to show signs of failure to thrive? It helps if families decide who is going to be the "lead person" in dealing with patient. "If you can't be near your parents, hopefully someone can," says Dr. Robertson, noting that patients might dismiss the concerns of family members who aren't present. "It's easy for someone to pretend to be fine for the duration of a 5- to 7-minute phone call."

In addition, make sure power of attorney and living will are in place so it's clear what the patient wants in a situation where they begin to decline.

Doctors can help by giving positive feedback to patients and reassuring them that it could be possible to help them feel better than their current state of health allows.

"I see the diagnosis of failure to thrive as a decision point," Dr. Robertson says. "We look for reversible causes. If there are none, it might be time to change your expectations about this patient, to move from therapeutic to palliative care. Besides treating the patient, you're often treating family members, too. I'd like family members to have peace of mind that they saw the change in their parent and made some really good decisions - that they did the right thing at the right time."

Eileen Early, RN, BSN
HealthLink Editor

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.