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.
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. Older adults who suffer from failure to thrive are often experiencing a constellation of disorders that act in concert to create an insidious yet significant decline in physical, emotional, and functional status.2 Some important features of the failure-to-thrive syndrome include progressive functional decline, social withdrawal, weight loss, and nutritional deficiencies.1,2 This condition is recognized by ICD-9 with code 783.4.
Older adults with failure to thrive often present with an acute event or illness, such as pneumonia, chest pain, multiple falls, or a fracture.3 It is following this acute event that family members, caregivers, and physicians identify that there has been a decline in multiple areas of functioning, often accompanied by weight loss and loss of interest.1,2 This cluster of symptoms warrants further evaluation, which should include attention to chronic conditions as well as new, potentially treatable illnesses.
Four domains have been identified that play a significant role in the evaluation and possible treatment approaches to the failure-to-thrive syndrome. These include: impaired functional status, poor nutrition, depressive symptoms, and cognitive loss (Table).1-3 These domains form a means of approaching the assessment of failure to thrive, and help address factors that can be corrected or improved.
A thorough medical evaluation is vital, but, as in all geriatric patients, psychosocial, emotional, economic, and spiritual needs must also be assessed. Undiagnosed acute medical problems, such as urinary tract infection, respiratory illness, and peptic ulcer disease, may result in a rapid decline in functioning in a vulnerable older adult.1 Chronic conditions, including diabetes, congestive heart failure, hypertension, and pain, may be poorly controlled, resulting in a progressive loss of abilities. Polypharmacy, drug-drug interactions, and adverse drug events must be considered in every patient. Problems with hearing, vision, or dentition may lead to dramatic losses in function, socialization, and oral intake. Unfortunately, obtaining items such as hearing aids, eyeglasses, and dentures is often difficult for an older adult.2
The nutritional status of older persons is complicated by medical, functional, economic, emotional, and psychosocial factors. Everything from loss of dentures and lack of available food, to depression and neglect may contribute to weight loss.4 Often, it is difficult to assess if the weight loss is a cause or an effect of other symptoms such as depression, functional decline, or cognitive loss. Nutritional support through a change in diet, use of supplements, or access to home-delivered meals should be provided.4
Attention to the psychosocial and economic needs of the patient often provides significant clues to overall well-being. If a patient cannot afford to fill prescriptions, lives in an isolated setting with limited social contact, or is the victim of abuse or neglect, these issues must be addressed before any meaningful improvement in function can occur.1,2 Screening for depression is vital, as well as identifying recent losses, grief, and bereavement. Treatment for depression should be considered in every case in which the clinician believes that it may be beneficial.2
In older adults suffering from failure to thrive, some symptoms may be treatable or modified with resulting improvement in function. Some decline may be prevented through the use of physical activity and exercise. Regular physical exercise is associated with less weight loss and more stable mood in elderly patients.5 Other factors, such as dementia, have a chronic, progressive course that will lead to a further decline in all domains. All adults who present with failure to thrive should have a review of advance directives and wishes regarding their care.1,2 It is important to address issues of artificial feeding and hydration and cardiopulmonary resuscitation well in advance, and re-visit them as the patient’s condition changes over time.
OUTCOME OF THE CASE PATIENT
Mrs. C went back to the assisted living facility. She was found to have a urinary tract infection while in the hospital and was treated with a 5-day course of ciprofloxacin. She went back to see the psychiatrist, still angry that the hospital had lost her dentures (fortunately, Mrs. C had the means to obtain a new set). She continued to complain of boredom and was negativistic. She adamantly refused any trial of antidepressants. Her functional status was limited by chronic back pain, and she returned to her primary care physician. Mrs. C responded to a course of therapy that utilized a cognitive-behavioral approach. She was able to gain more awareness of her negative thinking, started keeping a journal, and read books about loss and bereavement. Mrs. C was able to gain a greater sense of control over her feelings and her body, and was more active in developing a treatment plan with her physician. Mrs. C was found to have both hypothyroidism and vitamin B12 deficiency, and received thyroxine and a course of vitamin B12 injections. She was referred for physical therapy and to a pain specialist to help with her vertebral compression fractures. She met with the dietician at her assisted living center and agreed to eat breakfast instead of only drinking coffee. Over the course of four months, Mrs. C became less withdrawn and appeared more comfortable. She gained 6 lbs and started going out to museums and art shows. Although she remains thin, and there is still a question of whether her mood will improve further with antidepressant medication, Mrs. C has improved in terms of functional status and nutrition and has found some social supports.