Clinical Geriatrics

CASE PRESENTATION
Mrs. C is a 79-year-old widowed woman admitted to the hospital after suffering a syncopal episode. She was found to be thin and frail, with a blood pressure of 90/50 mm Hg. Mrs. C is 5’9” tall and weighs 112 lbs. Her protein and albumin levels were low, and she was mildly anemic. She underwent numerous diagnostic tests, including computed tomography studies of the head, chest, and abdomen; magnetic resonance imaging of the brain; transesophageal echocardiogram; and monitoring in the hospital telemetry unit. On the third hospital day, Mrs. C was scheduled for endoscopy, but refused the test, stating that she had had enough and wanted to go home. Mrs. C’s primary care physician was away, and the covering physician, Dr. W, knew very little about her except that her records indicated a diagnosis of failure to thrive for the past two years. The nursing staff told him that Mrs. C had been eating very little, complained a great deal, and had been wandering in the hallway. Dr. W ordered a psychiatry consultation to determine her decision-making capacity.

When the psychiatrist came to see Mrs. C, she appeared very upset. Her speech seemed somewhat dysarthric, but she explained that her dentures were lost in the emergency room. She had been given a puréed diet, which she described as “beyond disgusting,” and complained that there was no clothing to wear other than hospital gowns. Mrs. C was able to calm down, and reported that she has had a lot of problems since the death of her only son four years ago. Mrs. C is a retired fashion designer and former model, who continued to work with her son in a clothing business that she
started more than 50 years ago. Following her son’s death, she sold the business and moved to an assisted living facility. She reported that she never liked her new apartment, always feeling lonely and bored. Mrs. C described herself as always being thin, but lost weight after her son’s death, suffered several falls, and sustained vertebral compression fractures. She suffers from osteoporosis and takes calcium supplements. Mrs. C saw a psychiatrist two years previously, after her primary care physician thought she was depressed. Fluoxetine was prescribed, but Mrs. C refused to take it. She was angry when she was admitted to the hospital two years previously after a fall and learned that her diagnosis was failure to thrive, stating that it makes her sound like a failure. She admitted that she has “not been herself” since her son died and feels like she has nothing to do. She scored 30 out of 30 on the Mini-Mental State Examination (MMSE). She suffers from chronic back pain, but became sedated when pain medication was prescribed in the past. Mrs. C is lonely, bored, suffers from chronic pain, and displays symptoms of depression and bereavement. She is able to understand the risks and benefits of refusing procedures and leaving the hospital. She can clearly communicate a choice and shows evidence of reasoning and appreciation. She returned to her apartment, but agreed to see the psychiatrist again and follow up with her primary care physician.

DISCUSSION
Failure to thrive is a syndrome borrowed from the field of pediatrics, where it is used to describe children who do not grow within the expected rate.1 The syndrome refers to the physical and emotional deprivation that often accompanies poor growth. It is this deprivation that applies so often to the elderly. Mrs. C was once a totally independent business woman who was very active. She is now lonely, bored, and malnourished with no clearly identifiable cause.