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).