Failure to Thrive in the Elderly Population

Report
Failure to Thrive in the Elderly
Population
RYAN MULLINS MS-III
MERCER UNIVERSITY SCHOOL OF MEDICINE
DR. RAHIMI- RTR MEDICAL GROUP
SAVANNAH, GA
12/9/2011
Failure to Thrive (FTT)
 “The Institute of Medicine defined failure to thrive
late in life as a syndrome manifested by weight loss
greater than 5 percent of baseline, decreased
appetite, poor nutrition, and inactivity, often
accompanied by dehydration, depressive symptoms,
impaired immune function, and low cholesterol
levels.”1
 “Failure to thrive should not be considered a normal
consequence of aging, a synonym for dementia, the
inevitable result of a chronic disease, or a descriptor
of the later stages of a terminal disease.” 1
FTT- Pediatrics vs Geriatrics?
 When people hear the term FTT, most often they
think of its use in pediatrics to describe infants who
are unable to gain weight, height, or behavioral
milestones accepted as normal.
 What is the difference? Pediatric patients diagnosed
with FTT are unable to achieve their expected
functional level. Geriatric patients diagnosed with
FTT are unable to maintain their functional status.
Why Should We Care?
 The incidence of FTT increases with age and is
associated with increased medical care costs and
high morbidity/mortality rates.
 FTT is associated with increased rates of hip
fractures, decubitus ulcers, and infection;
diminished cell-mediated immunity; and increased
surgical mortality rates.
 FTT will ultimately result in death unless
interventions can reverse the course.
Components of FTT
Physical Frailty
2. Disability
3. Impaired Neuropsychiatric Function
1.
 FTT may result from the interaction of these three
components.
Physical Frailty
 Defined by meeting ≥3 of the following criteria2:
 Weight loss ≥ 5% of body weight in the last year
 Exhaustion
 Weakness (decreased grip strength)
 Slow Walking Speed (>6-7 seconds to walk 15 feet)
 Decreased Physical Activity (kcal expenditure/week: males
<383 kcal and females <270 kcal)
Physical Frailty
 Weight Loss
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Clinically significant when there is loss of ≥ 5% of body weight over a
period of 6-12 months.
24-29 kg/m2-> Optimal BMI in older adults
Unintentional weight loss is associated with decreased functional
status, increased complications in the hospital, and poorer quality of
life.
With normal aging, an increased ratio of fat:lean mass results in
small amounts of weight loss each year. This normal weight loss
must be distinguished from pathologic weight loss.
 Neuromuscular function
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Decreases in skeletal muscle mass and strength, aerobic capacity,
and forced expiratory volume are physiologic changes that occur with
aging.
Disability
 Defined as, “difficulty or dependency in completing
tasks essential for self-care and independent living.”2
 Screening involves asking patient about activities of
daily living (ADL) and instrumental activities of daily
living (IADL).
 ADLs: Bathing, dressing, toileting, transferring,
maintaining continence, and feeding.
 IADLs: Ability to use the telephone, shopping, food
preparation, housekeeping, laundry, mode of
transportation, responsibility for own medications,
ability to handle finances.
Neuropsychiatric Impairment
 Delirium
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“an acute disorder of attention and global cognitive function” 2
Prevalent in hospitalized patients with FTT
Hospitalization, sensory impairments, severe illness, dementia,
volume depletion, and depression greatly increase risk for delirium
 Dementia
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Incidence increases rapidly with age.
Commonly associated with unintentional weight loss.
 Depression
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Most common psychiatric condition in older persons. 1
Signs of depression in elderly patients often misdiagnosed as
dementia.
Evaluation of Possible FTT Patient
 An extensive history of the patient should be obtained, including but
not limited to:
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Medical and Psychiatric comorbidities
Medications
Alcohol/illicit drug use
ROS
Vision/hearing loss
Podiatric and arthritic problems, history of falls in the last year, and any other
factors related to poor mobility
Factors related to difficulty feeding: tremor, odynophagia, dysphagia, etc.
Symptoms of malignancy or chronic infection: fever, pain, sweats, weight loss
Factors associated with weight loss: nausea, vomiting, diarrhea, dysphagia,
anorexia, abdominal pain
Musculoskeletal pain symptoms
Social history: social network, family support, living situation, resources,
stressors, education, etc.
Questions about mistreatment/neglect should be asked without the caregiver in
the room.
Common Medical Conditions Associated with
Failure to Thrive in Elderly Patients
Medical condition
Cancer
Chronic lung disease
Chronic renal insufficiency
Chronic steroid use
Cirrhosis, history of hepatitis
Depression, other psychiatric disorders
Diabetes
Cause of failure to thrive
Metastases, malnutrition, cancer cachexia
Respiratory failure
Renal failure
Steroid myopathy, diabetes, osteoporosis,
vison loss
Hepatic failure
Major depression, psychosis, poor
functional status, cognitive loss
Malabsorption, poor glucose homeostasis,
end-organ damage
Functional impairment
Malabsorption, malnutrition
Cardiac failure
Hip or other large-bone fracture
Inflammatory bowel disease
Myocardial infarction, congestive heart
failure
Previous gastrointestinal surgery
Malabsorption, malnutrition
Recurrent urinary infections or pneumonia Chronic infection, functional impairment
Rheumatologic disease (e.g., temporal
arteritis, rheumatoid arthritis, lupus
erythematosus)
Stroke
Tuberculosis, other systemic infection
Chronic inflammation
Dysphagia, depression, cognitive loss,
functional impairment
Chronic infection
Medications Commonly Associated with Failure
to Thrive in Elderly Patients
Medication class
Anticholinergic drugs
Antiepileptic drugs
Benzodiazepines
Beta blockers
Central alpha antagonists
Diuretics (high-potency combinations)
Glucocorticoids
More than four prescription medications
Neuroleptics
Opioids
SSRIs
Tricyclic antidepressants
Possible effect
Cognition changes, dysgeusia, dry mouth
Cognition changes, anorexia
Anorexia, depression, cognition changes
Cognition changes, depression
Cognition changes, anorexia, depression
Dehydration, electrolyte abnormalities
Steroid myopathy, diabetes, osteoporosis
Drug interactions, adverse effects
Anorexia, parkinsonism
Anorexia, cognition changes
Anorexia
Dysgeusia, dry mouth, cognition changes
ADLs
http://www.uptodate.com/contents/failure-to-thrive-in-elderly-adults-evaluation
IADLs
MNA
• Must determine access to food as
well.
• Useful to observe patient eating if
possible.
Depression Screen
• Important to ask about somatic
complaints associated with
depression as well including:
fatigue, poor sleep, loss of appetite,
impaired concentration.
Physical Exam
 Important to do thorough PE, paying particular attention
to the following:
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Vitals: HR, BP (supine and standing), RR, T, Weight
HEENT: Do thorough examination of mouth looking for sores,
dental abscesses, proper fit of dentures etc. Vision/hearing loss
screen.
Neck Exam- lymphadenopathy, thyroid nodules
Breast Exam- masses, axillary lymphadenopathy
Rectal Exam- perirectal abscess, fecal impaction
Functional Evaluation- Observation of patient undressing/dressing
Neurological Exam- DTRs, strength, sensation, proprioception
“Get up and go test”
MMSE
Evaluating Elderly Patients for Failure to Thrive
Test
Target conditions
Blood culture
Infection
Chest radiography
Infection, malignancy
Complete blood count
Anemia, infection
Computed tomography, MRI
malignancy, abscess
ESR, C-reactive protein levels
Inflammation
Growth hormone, testosterone (men)
Endocrine deficiency
HIV, RPR test
Infection
PPD
Tuberculosis
Serum albumin and cholesterol levels
Malnutrition
Serum BUN and creatinine levels
Dehydration, renal failure
Serum electrolyte levels
Electrolyte imbalance
Serum glucose level
Diabetes
Thyroid-stimulating hormone level
Thyroid disease
Urinalysis
Infection, renal failure, dehydration
*EKG, Vit B12, Folate, LFT’s, and Vit D also useful, but not in table
http://www.aafp.org/afp/2004/0715/p343.html
Consults
 Speech Therapy: may distinguish difficulty with
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swallowing coordination, difficulty chewing, or
difficulty with aspiration.
Dietitian: analysis of patient’s caloric intake vs
caloric needs.
Physical Therapy
Occupational Therapy
Social Work
Treatment of FTT
 As one can see, FTT can be the result of one disease
or a multitude of factors.
 When a patient is diagnosed with FTT, the clinician
should have a discussion with the patient/caregiver
regarding patient’s goals of care.
 Treatment should focus on identifiable disease and
should be limited to interventions with few risks.
 Aggressive interventions should be avoided in these
frail patients. FTT typically occurs near the end of a
patient’s life, so risk:benefit should be assessed
before a treatment is undertaken.
Treatment of FTT
 A team approach may be helpful including a speech therapist,
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dietitian, physical therapist, mental health professional, and social
worker.
Resistance and strength exercises result in increased muscle
strength.
Nutritional supplementation- administration of dietary
supplementation between meals. Allow patients to eat what they
want.
Megace and Marinol may promote appetite. Drugs should be
closely monitored if given to a patient.
For depression, medications are chosen based on their side effect
profile. TCA’s increase appetite, but are limited by their many side
effects. SSRIs, with much fewer side effects, are as effective as TCAs
at treating depression, but may not be as effective at promoting
weight gain. If depression is refractory to treatment, may consider
ECT in severe cases.
It is very important to review medications and discontinue any that
are not necessary in these patients.
References
Robertson RG, Montagnini M. Geriatric Failure to
Thrive. American Family Physician. 2004; 70(2):
343-350.
2. Agarwal, K. Failure to thrive in elderly adults:
Evaluation.http://www.uptodate.com/contents/fai
lure-to-thrive-in-elderly-adults-evaluation. Topic
updated December 20, 2010.
3. Sarkisian CA and Lachs MS. "'Failure to Thrive' in
Older Adults." Annals of Internal Medicine 124(12):
1072-1078, 1996.
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