FAILURE TO THRIVE
Gail Wiley
D.O. Candidate
July 2012
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”.
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

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)

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)
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)
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
LABORATORY ABNORMALITIES IN FTT

low cholesterol

total cholesterol less <90 is a sensitive marker for
malnutrition
hypoalbuminemia
 anemia
 lymphopenia

VITAMIN DEFICIENCY

Vit D deficiency common in elderly and
associated with falls, gait imbalance and nursing
home admission
MANAGEMENT

in order to be successful requires a multidisciplinary approach, including
clinician
 social worker
 PT/OT/ speech therapy
 dietician

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 wellstudied and have adverse side effects- use with
caution
PHYSICAL FRAILTY
benefit has been shown for resistance exercisealmost a two-fold increase in muscle mass
 exercise and movement is imperative

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

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

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

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

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
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
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