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Failure to thrive in older adults: Evaluation

Failure to thrive in older adults: Evaluation
Author:
Kathryn Agarwal, MD
Section Editors:
Kenneth E Schmader, MD
Eduardo Bruera, MD
Deputy Editor:
Jane Givens, MD, MSCE
Literature review current through: Dec 2022. | This topic last updated: Jun 29, 2021.

INTRODUCTION — The National Institute of Aging describes failure to thrive (FTT) as a "syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol" [1]. Many of these features of FTT are actually defined as features of frailty, including weight loss, malnutrition, and inactivity. In geriatric practice, FTT describes a syndrome of global decline that occurs in older adults as a worsening of physical frailty that is frequently compounded by cognitive impairment and/or functional disability. FTT describes a point further along a geriatric functional continuum that is closer to full dependence and death, with "frailty as a mid-point between independence and pre-death" [2].

The term FTT has long been used in pediatrics to describe infants who are unable to gain weight and have physical and cognitive developmental impairments and depressive symptoms [3]. Pediatric patients with FTT have not achieved their expected functional level, while older adults with FTT are unable to maintain their functional status [1]; the symptom complex is similar at both ends of the age spectrum.

Some authors cite concerns that the terminology "failure to thrive" impedes appropriate patient evaluation and management [1], and its use has fallen out of favor. In some regions, FTT is considered an equivalent diagnosis as failure to cope or acopia, which may imply more social issues than medical [4]. FTT should not be considered unimportant, as the components of FTT are associated with very poor prognoses if not addressed appropriately. It is critical that the appearance of an FTT syndrome be used as an alarm to look for unrecognized medical illness and to optimize the care of multimorbidity.

Due to the difficulty in precisely defining FTT as a syndrome in clinical practice, data are limited regarding its incidence, epidemiology, and outcomes. The individual components associated with FTT, however, are clearly predictive of mortality.

This topic will discuss an overview of the evaluation of patients with suspected FTT. Management of older patients with FTT is discussed separately (see "Failure to thrive in older adults: Management"), as are discussions cited below on individual components of FTT.

COMPONENTS OF FTT — Failure to thrive (FTT) may be considered to result from interaction of three components:

Physical frailty

Disability

Impaired neuropsychiatric function

Major contributors to decompensation are medication side effects, medical comorbidities, and psychosocial factors (figure 1). The key feature that must be present in FTT is frailty, which includes weight loss, malnutrition, and physical inactivity. The elements in this model are commonly seen in patients with FTT; however, all factors are not required to yield a state of functional and medical decline consistent with FTT. For example, an older patient with cancer, weight loss, frailty, and functional decline or disability may have FTT without any element of neuropsychiatric impairment. Another example may be a patient with advanced dementia with increasing disability, frailty, and weight loss due to consequences of the dementia process. By contrast, a patient with a chronic disability and dementia may not have FTT because they do not have physical frailty or weight loss and is at a stable functional level.

Frailty — Frailty, representing decreased physiologic reserve affecting multiple systems, is a vulnerable state for future adverse health outcomes [5]. Frailty is most often identified when aging and disease lead to a critical mass of deficits, resulting in impaired physical function and malnutrition or weight loss [6]. (See "Frailty", section on 'Concepts and definitions'.)

The frailty phenotype is defined by meeting three or more of these five criteria derived from the Cardiovascular Health Study (CHS) [7]. Some of these criteria, however, are not readily assessed in the non-research clinical setting.

Weight loss (≥5 percent of body weight in last year)

Exhaustion (positive response to questions regarding effort required for activity)

Weakness (decreased grip strength)

Slow walking speed (>6 to 7 seconds to walk 15 feet)

Decreased physical activity (Kcals spent per week: males expending <383 Kcals and females <270 Kcals)

A number of frailty screening tools are available. (See "Frailty", section on 'Instruments developed to identify frailty'.)

Epidemiology — The majority of older adults in nursing homes in the United States are believed to be frail [6], although this does not suggest that the majority of nursing home residents have FTT. One study showed that frailty is associated with subsequent disability and death, independent of comorbid diseases, health habits, and psychosocial characteristics [7].

Weight loss — A well-accepted definition of clinically significant weight loss is 5 percent of body weight over a period of 6 to 12 months. Optimal body mass index (BMI) in the older adult is considered to be 24 to 29 kg/m2 (calculator 1) [8]. This is higher than generally considered optimal for younger adults.

In a group of 983 community-dwelling older adults, those with a BMI between 25 and 29 had less functional decline compared with older adults in the “normal” or lower BMI range of 18.5 to 24.9 [9].

A BMI <22 kg/m2 in community-based older adults was associated with an increased one-year mortality risk and poorer functional status [10].

In men over 75 years of age, a BMI <20.5 was associated with a 20 percent greater mortality rate; for the same age group in women, a BMI <18.5 was associated with a 40 percent increase in mortality in a 14-year prospective study in the United States [11].

Unintentional weight loss is a significant predictor of death in nursing home patients [12]. It has also been associated with decline in activities of daily living (ADLs), increased hospital complications, admissions to nursing homes, and poorer quality of life [12,13]. Unintentional weight loss has been shown to have a negative effect on functional decline regardless of baseline BMI [9].

Normal aging is associated with small amounts of weight loss per year, approximately 0.1 to 0.2 kg per year after age 70 [8]. This slow weight loss is associated with an increased ratio of fat to lean body mass. Physiologic changes with aging, such as decreased olfactory sensitivity, are felt to increase anorexia and promote weight loss.

Although the frailty phenotype includes weight loss, obese older adults may also be considered frail by meeting the other criteria for the frailty phenotype [14]. Even if weight loss is not apparent, the patient should be evaluated for evidence of malnutrition.

Causes of weight loss may broadly be divided into two categories: inadequate intake and increased energy expenditure. Many older adults, especially those in nursing homes, lack adequate intake of calories and nutrients [15].

The differential diagnosis for the etiology of weight loss and malnutrition in older adults is extensive and includes medical conditions, medications, and socioeconomic factors (table 1). Poor oral health and dry mouth are risk factors for decreased oral intake due to changes in taste and difficulty with chewing and swallowing.

Medications that are most commonly associated with weight loss in older adults are shown in a table (table 2). The list of associated medical diagnoses is the same as for FTT, with malignancy the most common cause of involuntary weight loss and the most common medical diagnosis in case-series of patients admitted with FTT (table 3) [16-19].

Neuromuscular function — Several physiologic changes with age affect neuromuscular function, including decreases in skeletal muscle mass and strength (sarcopenia), aerobic capacity, and forced expiratory volume. These changes reduce the physiologic reserve and increase vulnerability to stressors.

A cycle of frailty has been described in which malnutrition associated with frailty adds to age-related loss of lean muscle mass or sarcopenia. This contributes to loss of strength, decreased aerobic capacity, decreased walking speed, and, ultimately, significant disability [5].

Vitamin D deficiency is common in both community-dwelling and institutionalized older adults and has been associated with falls and gait imbalance [20,21]. Additionally, low serum 25 (OH) vitamin D is associated with an increased risk for nursing home admission [22]. In a meta-analysis of seven studies, low vitamin D level was associated with risk of frailty in females [23]. (See "Falls in older persons: Risk factors and patient evaluation".)

Disability — Disability is defined as difficulty or dependency in completing tasks essential for self-care and independent living. Screening for disability involves asking about ADLs and instrumental ADLs (IADLs).

The Katz ADL scale assesses basic life skills: the patient's ability to bathe, dress, toilet themselves, transfer, feed themselves, and maintain continence (table 4). The Lawton IADL scale is intended for use in community-dwelling older adults to identify their current level of independent living skills and how those abilities change over time. It assesses activities required to live independently: using the telephone, shopping and using transportation, preparing meals, doing housework, and managing finances and medications (table 5).

Physical disability is common in older adults. In the 1996 National Health Interview Survey, approximately 20 to 30 percent of community-dwelling older adults reported disability in mobility, IADLs, and/or ADLs [6]. Many adults, however, can compensate for any disabilities and thrive. Additionally, disability is often reversible and/or recurrent [24]. Disability is not synonymous with frailty or with FTT.

Disability may develop slowly due to progressive comorbidities and frailty, or acutely due to catastrophic events (eg, stroke). Disability is an independent risk factor for mortality, hospitalization, and need for long-term care [6].

Neuropsychiatric impairment — Delirium, depression, and dementia are the most common conditions impairing cognitive status in older adults. The evaluation of any patient with FTT should include attention to the signs or symptoms of delirium, dementia, and depression. These conditions may result from medical comorbidities and medication effects; each may also contribute to the development of disability, malnutrition, and frailty.

Dementia and depression were among the five leading causes of FTT in a case series of inpatients admitted with FTT [19]. Another case series of FTT admissions found "nervous and mental disorders" to account for 13 percent of the discharge diagnoses, and 54 percent were found to have cognitive impairment [18].

Delirium — Delirium is defined as an acute disorder of attention and global cognitive function and is commonly seen in hospitalized patients with FTT, since delirium and FTT have overlapping risk factors. Dementia, sensory impairments, severe illness, depression, volume depletion, and medical comorbidities greatly increase the risk for delirium. The presence of delirium adds to the patient's in-hospital morbidity and mortality and complicates the evaluation of FTT by impairing the clinical team's ability to assess for dementia and depression. (See "Diagnosis of delirium and confusional states".)

Dementia — The incidence of dementia increases rapidly with age, doubling every decade between the seventh and ninth. Some studies have reported an incidence of dementia as high as 42 percent in adults ≥85 years of age [25]. Unintentional weight loss has been reported in up to 50 percent of nursing home older adults with dementia and approximately 30 percent of non-institutionalized patients with mild to moderate Alzheimer disease [26].

Patients with FTT and dementia may require additional workup for undetected disease due to the patient's inability to communicate well or lack of insight into their symptoms.

Depression — Depression can be a sole cause of, or one of many contributors to, FTT. Depression may lead to disability, malnutrition, and weight loss. Rates of all-cause mortality are higher among older adults with depression than their non-depressed counterparts. Depression is common in older adults, with incidence rates ranging from 5 percent in the community to 25 percent in the nursing home population [27]. All patients with the FTT syndrome should be assessed for depression. (See "Diagnosis and management of late-life unipolar depression".)

GENERAL EVALUATION — The approach to the patient perceived to have failure to thrive (FTT) includes a comprehensive history and physical examination with directed laboratory and radiologic tests.

History — The history, a critical component of the evaluation of FTT, should be obtained from both the patient and caregivers and should focus on timing and symptoms of frailty, disability, and neuropsychiatric impairment. An extensive history should include:

All identified medical and psychiatric comorbidities

Medications – Prescribed, over-the-counter medications, and herbal or vitamin supplements

Use of alcohol or illicit drugs

Comprehensive review of systems for new and or/changing symptoms

Potential contributors to disability, including vision and hearing loss

Factors related to poor mobility – Podiatric and arthritic problems, history of falls in last year

Factors related to difficulty feeding – Tremor, use of upper extremities, dental problems, xerostomia, odynophagia and dysphagia

Symptoms suggesting chronic infection (tuberculosis, bronchiectasis, endocarditis) or malignancy – Fever, sweats, pain, weight loss

Factors potentially underlying weight loss – Dysphagia, anorexia, nausea, vomiting, diarrhea, bloating, abdominal pain

Musculoskeletal pain symptoms – Shoulder/hip stiffness suggesting polymyalgia rheumatica; other sources of pain

A functional history is essential, documenting the patient's ability to perform activities of daily living (ADLs) and instrumental ADLs (IADLs). It is also important to try to determine the time of onset of functional deficits and the tempo of decline.

An assessment of weight loss and malnutrition involves verification of change in weight and body mass index (BMI). A dietary history should include the patient’s access to food, number of daily meals, amount of food eaten, need for assistance with eating, difficulty with chewing, and symptoms of anorexia, early satiety, and dysphagia. It is also extremely helpful to observe the patient eating or try to obtain observational reports.

The Simplified Nutritional Assessment Questionnaires (SNAQ) are a set of three simple tools intended for use in the hospital, nursing homes, and with community dwelling older adults to screen for anorexia, malnutrition, and to predict future weight loss. The tools and validation studies are available at the Dutch Malnutrition Steering Group website [28,29]. The Mini-Nutritional Assessment (MNA) is a validated nutrition screening and assessment tool used to identify patients age 65 and older who are malnourished or at risk of malnutrition. The original “full MNA” has 18 questions and the current MNA has only six questions while retaining its validity. Multiple versions of the MNA for clinical use are now available for clinicians, self-administration, and integration into electronic medical records [30].

Patients and their caregivers should be questioned about symptoms of depression and cognitive impairment. The Geriatric Depression Scale (GDS) can be administered quickly in the office and has been validated in patients with mild to moderate cognitive impairment (table 6) [31]. GDS scores correlate with depression symptoms and outcomes, including decreased pain tolerance, disability, and mortality [32]. It is important to ask about somatic complaints associated with depression, including loss of appetite, poor sleep, fatigue, and poor concentration. Somatic symptoms of depression may be difficult to separate from those of medical illness, and referral to a psychiatrist or geriatrician is often helpful [32]. (See "Diagnosis and management of late-life unipolar depression".)

Caregivers should be asked about patient problems with memory, including repetition of questions, difficulty with handling finances, getting lost in the community, car accidents, and participation in usual activities. The AD8 Dementia Screening Interview and the Short Form of the Informant Questionnaire on Cognitive

Decline in the Elderly (Short IQCODE) are both validated tools to screen for signs of dementia via short, informant-based questionnaires. These and other cognitive assessment tools are available in the Alzheimer’s Association Cognitive Assessment Toolkit [33].

A social history should include information about the patient's social network and family/other supports, living situation, financial resources, education, degree of isolation, and recent deaths or losses. Social isolation is a risk factor for institutionalization and death in older adults [1]. Social vulnerability was independently associated with increased mortality and increased levels of frailty in a study of two large cohorts of older adults in Canada [34].

Older adult mistreatment and neglect is common, and clinicians should be alert for signs of these conditions. A telephone survey of 2010 older adults in Boston revealed 3.2 percent had been victims of older adult mistreatment at least once since age 65 [35]. Red flags for possible older adult abuse include:

Substance abuse among caregivers

Limited social supports

Behavioral changes in the presence of the caregiver

Unexplained injuries

Failure to fill medication prescriptions

The patient should be questioned privately about mistreatment. Interviewing the suspected abuser is more difficult and may require help from providers with experience in this area [36].

Physical examination — The physical examination is used to determine and document the level of physical and cognitive impairment, as well as to look for signs of disease that might lead to impairment. Particular interest should be paid to the following components:

Vital signs – Including weight and height, and orthostatic blood pressure measurements (heart rate and blood pressure measured supine and standing at one and three minutes).

Head, eyes, ears, neck, and throat (HEENT) examination – Complete oral cavity examination for signs of dental abscess, dental caries, poorly fitting dentures, or thrush. Otologic examination for cerumen impaction or otitis. Palpation of temporal arteries and sinuses.

Neck examination – Palpation for lymphadenopathy and thyroid nodules.

Breast examination – Rule out masses and axillary lymphadenopathy.

Rectal examination – For perirectal abscess, fecal impaction, and occult blood in stool.

Functional evaluation – Observation of the patient dressing and undressing will give significant clues to range of motion of the shoulders and legs or to apraxia.

Office screening tests of vision and hearing.

Detailed neurologic examination – Deep tendon reflexes, muscle strength, tests of proprioception and sensation.

The "Get up and go test" provides performance information as well as many key components of a neurologic examination (table 7). The patient is asked to rise from a seated position not using their arms, walk 10 feet, turn, and return to the chair to sit. Normal time to complete the test is 7 to 10 seconds; those who require greater than 10 seconds may be at higher risk for falls [37]. Patients who can complete the test in 20 seconds or less are generally independent for basic transfers and able to leave the house unattended [38].

Mental status testing should start with an evaluation for attention. If attention is impaired, a workup for delirium should be initiated. The evaluation of cognitive impairment and dementia is discussed separately (algorithm 1). (See "Evaluation of cognitive impairment and dementia".)

Laboratory and other studies — The suspicion of specific disease states developed through the history and physical examination should guide the selection of tests to be ordered. Initial tests should screen for sources of infection, organ failure, and malignancy [39]. Basic laboratory studies to be drawn on all patients with FTT include:

Complete blood count (CBC) with differential

Basic metabolic panel (electrolytes, blood urea nitrogen [BUN], creatinine, glucose)

Liver function studies

Urinalysis

Calcium, phosphate

Thyroid-stimulating hormone (TSH)

Vitamin B12 and folate levels

Albumin and total cholesterol (the most definitive markers of malnutrition)

25-hydroxy vitamin D (if history of falls)

Additionally, a chest radiograph can assess for tuberculosis, other occult infections, or malignancy. An electrocardiogram may detect silent myocardial infarction or arrhythmia.

An erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) level may be considered looking for polymyalgia rheumatica, chronic infection, or malignancy. If risk factors are present, one should consider blood cultures and serologic testing for HIV and syphilis.

Consultants — Speech therapists and dietitians can help in the evaluation of unexplained weight loss or malnutrition. Speech therapy may distinguish whether poor oral intake relates to difficulty with swallowing coordination (dementia or stroke), difficulty with chewing (poor dentition or periodontal infection), or difficulty with aspiration. The speech therapy evaluation may lead to therapeutic interventions involving appropriate food textures, positioning, and swallowing techniques. A dietitian can perform a detailed analysis of the patient's current caloric intake and caloric needs for their activity level and illness, leading to therapeutic suggestions.

The patient with FTT should also be evaluated by physical and occupational therapy. Physical therapy can assess and advise regarding use of appropriate assistive devices, grab bars and other home safety tools, and rehabilitation therapy. Occupational therapy can evaluate the patient's ability to perform activities of daily living and assist in a cognitive evaluation, recommending appropriate therapy and safety interventions.

A skilled social worker can work with families and loved ones to address social isolation. Social work interventions may include family/loved ones and patient education regarding dementia and end-of-life issues, referral to community resources, and counseling for depression and bereavement.

SUMMARY AND RECOMMENDATIONS

Failure to thrive (FTT) in older adults is a syndrome of global decline, often associated with physical frailty, functional disability, and neuropsychiatric impairment. (See 'Introduction' above.)

Frailty is defined by the features of weight loss, exhaustion, weakness, slow gait, and decreased physical activity. Medications, medical comorbidities, and socioeconomic factors often play a role (table 2 and table 3). (See 'Frailty' above.)

Disability is difficulty in performing tasks necessary for self-care (activities of daily living [ADLs]) and independent living (instrumental ADLs [IADLs]). Many adults can compensate for their disability, which is not synonymous with frailty or with FTT. Neuropsychiatric impairment commonly relates to one of three conditions: delirium, dementia, or depression. (See 'Disability' above.)

The history should be obtained from the patient and their caregivers. In addition to a complete history and review of symptoms, the clinician should explore timing of symptom onset and progression, prescription and over-the-counter medication use, substance abuse, functional status, depression and cognitive issues, and social history. Signs of older adult mistreatment and neglect should be kept in mind. (See 'History' above.)

A comprehensive medical examination should be supplemented by the "Get up and go test," mental status testing, and office-based screening for hearing and vision. Laboratory investigations should be based on suspected underlying diseases. (See 'Laboratory and other studies' above.)

A multidisciplinary team approach is recommended for patient assessment and might include a speech therapist, dietitian, physical therapist, occupational therapist, and social worker. (See 'Consultants' above.)

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