Failure to thrive in elderly adults: Management
- Kathryn Agarwal, MD
Kathryn Agarwal, MD
- Assistant Professor of Medicine
- Baylor College of Medicine
- Section Editors
- Kenneth E Schmader, MD
Kenneth E Schmader, MD
- Editor in Chief — Geriatric Medicine
- Section Editor — Geriatrics
- Chief, Division of Geriatrics
- Duke University
- Director, Geriatric Research Education and Clinical Center
- Durham VA Medical Centers
- J Andrew Billings, MD
J Andrew Billings, MD
- Editor-in-Chief — Palliative Care
- Section Editor — Non Pain Symptoms: Assessment and Management
- Associate Professor of Medicine
- Harvard Medical School
- Cambridge Health Alliance
Failure to thrive (FTT) describes a syndrome of global decline that occurs in elders as an aggregate of physical frailty, cognitive impairment, and functional disability (figure 1). The United States National Institute of Aging described 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" . FTT describes the late stages of decline and may represent a final common pathway toward death unless interventions can reverse the course.
For some patients, FTT is caused by a single disease (eg, cancer) and the treatment of that disease drives the management plan. However, Occam's Razor (the concept that the simplest hypothesis is correct) may not be applicable to FTT. In many cases, multiple factors are present and contribute to impairment: medical comorbidities, medications, and psychological factors may interact. Identifying and treating multiple contributing factors can improve quality of life and function in this group of elders; such treatment should be instituted as appropriate and in keeping with the patient's goals of care. A diagnosis of FTT should be considered as a critical point for the clinician to initiate discussions with patients and caregivers about goals of care; considering aggressive interventions cautiously in the face of declining functional status and worsening prognosis.
An overview of the management of FTT will be presented here. Evaluation of older patients for suspected FTT and an overview of management of the elder resident in a long-term care facility are discussed separately. (See "Failure to thrive in elderly adults: Evaluation" and "Medical care of the nursing home patient in the United States".)
Optimal management of FTT requires a multidisciplinary and multi-faceted approach to treat those identifiable causes that are amenable to treatment. Significant improvements in quality of life can be achieved, even in the setting of a major disease state that cannot be cured, by treating contributing factors. As an example, progressive Alzheimer disease cannot be cured. However, simultaneous pharmacologic interventions for depression and memory, elimination of potentially harmful medications, aggressive social work interventions to increase safety and social interaction, and physical therapy to improve gait instability, may halt the downward spiral of FTT for months to years.
While enlisting the expertise of a multidisciplinary support team (social worker; dietitian; physical, occupational, and speech therapist), the clinician should address the role of medical illness and medications as factors. Oral hygiene should be addressed and referral to dentistry should not be overlooked. Reasonable efforts should be made to uncover new treatable medical problems (ie, reactivation tuberculosis, endocarditis, polymyalgia rheumatica, thyroid disease, or malignancy).
- Sarkisian CA, Lachs MS. "Failure to thrive" in older adults. Ann Intern Med 1996; 124:1072.
- Han L, Agostini JV, Allore HG. Cumulative anticholinergic exposure is associated with poor memory and executive function in older men. J Am Geriatr Soc 2008; 56:2203.
- Fabiny AR, Kiel DP. Assessing and treating weight loss in nursing home patients. Clin Geriatr Med 1997; 13:737.
- Alibhai SM, Greenwood C, Payette H. An approach to the management of unintentional weight loss in elderly people. CMAJ 2005; 172:773.
- Baldwin C, Parsons T, Logan S. Dietary advice for illness-related malnutrition in adults. Cochrane Database Syst Rev 2007; :CD002008.
- Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev 2009; :CD003288.
- Bauer J, Biolo G, Cederholm T, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc 2013; 14:542.
- Vellas BJ, Hunt WC, Romero LJ, et al. Changes in nutritional status and patterns of morbidity among free-living elderly persons: a 10-year longitudinal study. Nutrition 1997; 13:515.
- Morley JE, Silver AJ. Nutritional issues in nursing home care. Ann Intern Med 1995; 123:850.
- Mitchell SL, Kiely DK, Lipsitz LA. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Arch Intern Med 1997; 157:327.
- Simmons SF, Keeler E, Zhuo X, et al. Prevention of unintentional weight loss in nursing home residents: a controlled trial of feeding assistance. J Am Geriatr Soc 2008; 56:1466.
- Pascual López A, Roqué i Figuls M, Urrútia Cuchi G, et al. Systematic review of megestrol acetate in the treatment of anorexia-cachexia syndrome. J Pain Symptom Manage 2004; 27:360.
- Berenstein EG, Ortiz Z. Megestrol acetate for the treatment of anorexia-cachexia syndrome. Cochrane Database Syst Rev 2005; :CD004310.
- Reuben DB, Hirsch SH, Zhou K, Greendale GA. The effects of megestrol acetate suspension for elderly patients with reduced appetite after hospitalization: a phase II randomized clinical trial. J Am Geriatr Soc 2005; 53:970.
- Yeh SS, Wu SY, Lee TP, et al. Improvement in quality-of-life measures and stimulation of weight gain after treatment with megestrol acetate oral suspension in geriatric cachexia: results of a double-blind, placebo-controlled study. J Am Geriatr Soc 2000; 48:485.
- Bodenner D, Spencer T, Riggs AT, et al. A retrospective study of the association between megestrol acetate administration and mortality among nursing home residents with clinically significant weight loss. Am J Geriatr Pharmacother 2007; 5:137.
- Kropsky B, Shi Y, Cherniack EP. Incidence of deep-venous thrombosis in nursing home residents using megestrol acetate. J Am Med Dir Assoc 2003; 4:255.
- Beal JE, Olson R, Laubenstein L, et al. Dronabinol as a treatment for anorexia associated with weight loss in patients with AIDS. J Pain Symptom Manage 1995; 10:89.
- Volicer L, Stelly M, Morris J, et al. Effects of dronabinol on anorexia and disturbed behavior in patients with Alzheimer's disease. Int J Geriatr Psychiatry 1997; 12:913.
- Wilson MM, Philpot C, Morley JE. Anorexia of aging in long term care: is dronabinol an effective appetite stimulant?--a pilot study. J Nutr Health Aging 2007; 11:195.
- Fiatarone MA, O'Neill EF, Ryan ND, et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med 1994; 330:1769.
- Binder EF, Schechtman KB, Ehsani AA, et al. Effects of exercise training on frailty in community-dwelling older adults: results of a randomized, controlled trial. J Am Geriatr Soc 2002; 50:1921.
- LIFE Study Investigators, Pahor M, Blair SN, et al. Effects of a physical activity intervention on measures of physical performance: Results of the lifestyle interventions and independence for Elders Pilot (LIFE-P) study. J Gerontol A Biol Sci Med Sci 2006; 61:1157.
- Daniels R, van Rossum E, de Witte L, et al. Interventions to prevent disability in frail community-dwelling elderly: a systematic review. BMC Health Serv Res 2008; 8:278.
- Hubbard RE, Fallah N, Searle SD, et al. Impact of exercise in community-dwelling older adults. PLoS One 2009; 4:e6174.
- Liu H, Bravata DM, Olkin I, et al. Systematic review: the safety and efficacy of growth hormone in the healthy elderly. Ann Intern Med 2007; 146:104.
- Lundholm K, Gunnebo L, Körner U, et al. Effects by daily long term provision of ghrelin to unselected weight-losing cancer patients: a randomized double-blind study. Cancer 2010; 116:2044.
- Nass R, Pezzoli SS, Oliveri MC, et al. Effects of an oral ghrelin mimetic on body composition and clinical outcomes in healthy older adults: a randomized trial. Ann Intern Med 2008; 149:601.
- http://clinicaltrials.gov/ct2/show/NCT01898611 (Accessed on March 05, 2014).
- Emmelot-Vonk MH, Verhaar HJ, Nakhai Pour HR, et al. Effect of testosterone supplementation on functional mobility, cognition, and other parameters in older men: a randomized controlled trial. JAMA 2008; 299:39.
- Storer TW, Woodhouse L, Magliano L, et al. Changes in muscle mass, muscle strength, and power but not physical function are related to testosterone dose in healthy older men. J Am Geriatr Soc 2008; 56:1991.
- Vigen R, O'Donnell CI, Barón AE, et al. Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels. JAMA 2013; 310:1829.
- Vanina Y, Podolskaya A, Sedky K, et al. Body weight changes associated with psychopharmacology. Psychiatr Serv 2002; 53:842.
- Banerjee S, Hellier J, Romeo R, et al. Study of the use of antidepressants for depression in dementia: the HTA-SADD trial--a multicentre, randomised, double-blind, placebo-controlled trial of the clinical effectiveness and cost-effectiveness of sertraline and mirtazapine. Health Technol Assess 2013; 17:1.
- Goldberg RJ. Weight change in depressed nursing home patients on mirtazapine. J Am Geriatr Soc 2002; 50:1461.
- Mihara IQ, McCombs JS, Williams BR. The impact of mirtazapine compared with non-TCA antidepressants on weight change in nursing facility residents. Consult Pharm 2005; 20:217.
- Fox CB, Treadway AK, Blaszczyk AT, Sleeper RB. Megestrol acetate and mirtazapine for the treatment of unplanned weight loss in the elderly. Pharmacotherapy 2009; 29:383.
- Pickett P, Masand P, Murray GB. Psychostimulant treatment of geriatric depressive disorders secondary to medical illness. J Geriatr Psychiatry Neurol 1990; 3:146.
- Lavretsky H, Park S, Siddarth P, et al. Methylphenidate-enhanced antidepressant response to citalopram in the elderly: a double-blind, placebo-controlled pilot trial. Am J Geriatr Psychiatry 2006; 14:181.
- Padala PR, Burke WJ, Shostrom VK, et al. Methylphenidate for apathy and functional status in dementia of the Alzheimer type. Am J Geriatr Psychiatry 2010; 18:371.
- National Association for Home Care & Hospice. Hospice Claims and Use of Debility, Adult Failure to Thrive, and Dementia Diagnoses. Homecare & Hospice website, Mary 2013. Available at: http://www.nahc.org/NAHCReport/nr130509_1/ (Accessed on October 22, 2013).
- National Gerontological Nurses Association Website. http://www.ngna.org/resources/clinical-fast-facts/64-facilitating-the-transition-to-hospice-care.html (Accessed on April 29, 2011).