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Failure to Thrive

Failure to Thrive. Gail Wiley D.O. Candidate July 2012. Definition.

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Failure to Thrive

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  1. Failure to Thrive Gail Wiley D.O. Candidate July 2012

  2. Definition • National Instutitute of Aging- described FTT as “syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol”.

  3. diagnostic criteria • there is absence of a consensus on diagnositic criteria however FTT is a syndrome of global decline defined by: • physical frailty • functional disability • neurocognitive impairment

  4. Causes of FTT- in one retrospective chart study • Cancer 30% (n = 39) • Infection, particularly pneumonia and urinary tract infection, was found in 18% (n = 24), • Dehydration in 13% (n = 17) • Depression in 12% (n = 16). • Gastrointestinal disease (n = 15), dementia (n = 14), and substance abuse (n = 14) 11% each. • No underlying diagnoses in 5% (n = 7)

  5. Accelerated weight loss is associated with FTT • weight loss is normal in aging • decreased olfactory sensitivity • up to ~ ½ pound per year after age 70 accelerated rate of weight loss is a significant predictor of death in nursing home patients weight loss of more than 5% of body weight in a year suggests FTT optimal BMI in elderly is higher – BMI 24-29 had less functional decline “normal” (18.5-24.9)

  6. ADL dependency • FTT defined by loss of at least one ADL Basic ADL’s: • Personal hygiene and grooming • Dressing and undressing • Self feeding • Functional transfers (getting into and out of bed or wheelchair, getting onto or off toilet, etc.) • Bowel and bladder management • Ambulation (walking with or without use of an assistive device (walker, cane, or crutches) or using a wheelchair)

  7. Neurocognitive Impairment Depression and Dementia leading causes of FTT Depression is treatable incidence of depression in the elderly from anywhere from 5-25% (nursing homes) incidence of dementia shown to be as high as 42% in those over 85 years of age

  8. Laboratory Abnormalities in FTT • low cholesterol • total cholesterol less <90 is a sensitive marker for malnutrition • hypoalbuminemia • anemia • lymphopenia

  9. Vitamin deficiency • Vit D deficiency common in elderly and associated with falls, gait imbalance and nursing home admission

  10. Management • in order to be successful requires a multi-disciplinary approach, including • clinician • social worker • PT/OT/ speech therapy • dietician

  11. how to treat malnutrition • add supplements between meals (Ensure) • nutritional counseling • remove dietary restrictions and make favorite foods readily available • tube feeding did not affect survival at 24 months • appetite stimulants such as Megestrol and Dronabinol may be helpful but are not well-studied and have adverse side effects- use with caution

  12. Physical Frailty • benefit has been shown for resistance exercise- almost a two-fold increase in muscle mass • exercise and movement is imperative

  13. Dementia • when dementia is a leading factor in FTT, changing the living situation to a higher level of assistance and supervision may be helpful • in advanced dementia FTT is inevitable as patients lose the ability to chew and swallow

  14. Depression • a common and reversible cause of FTT in elderly • antidepressants are a mainstay of treatment, ECT is also helpful • when accompanied by psychosis, anxiety or mania- pt should be referred to a psychiatrist • Mirtazapine in particular has the added benefit of increasing appetite • low doses of Methylphenidate useful in those who are severely depressed

  15. Something to keep in mind- medication side effects • common in elderly (decreased Cr clearance/ metabolism, polypharmacy) • updated Beers criteria suggest many common medications should be avoided in the elderly, such as: • benzodiazepines • NSAIDS • estrogen • muscle relaxers

  16. End of Life Care • FTT is a final common pathway towards death • patients status may not be amenable to interventions and at that point it is appropriate to consider palliative care

  17. Palliative Care • following criteria used by hospice to determine when a pt has 6 months or less to live: • weight loss not due to reversible causes • recurrent/ intractable infections • progressing dementia • progressive pressure ulcers (stage 3 or 4) despite optimal care • progressive loss of ADL’s

  18. Summary • FTT is a nebulous diagnosis without clear diagnostic criteria or guidelines for treatment • it is an umbrella term used to describe a human’s de-evolution and regression towards death • recognizing and treating FTT is not delaying the inevitable- sometimes causes are treatable

  19. References: • Use of the diagnosis "failure to thrive" in older veterans.Hildebrand JK - J Am Geriatr Soc - 01-SEP-1997; 45(9): 1113-7 • Kathryn Agarwal, MD Failure to thrive in elderly adults: Evaluation. In: UpToDate, Basow, DS (Ed), UpToDate,Waltham, MA, 2012. • Kathryn Agarwal, MD Failure to thrive in elderly adults: Management. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2012. • Christine Aranson, Jan Busby-Whitehead, Kenneth Brummel-Smith, James O’Brien, Mary Palmer, William Reichel (2009) Reichel’s Care of the Elderly. 6th Cambridge Univeristy Press

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