Sarah is 80 years old with chronic depression. She visits your office with her son, presenting with substantial and unintentional weight loss over the past three months. She spends her days confined to her home, engrossed in television. She displays signs of declining mobility, like unsteadiness and slowed movements. Her fragility, neglect of self-care, and malodor are apparent during assessment and her interaction with you is minimal.

Understanding failure to thrive

Failure to thrive (FTT) is a holistic decline in patients characterized by frailty, reduced appetite, weight loss, and cognitive and functional challenges. As age increases, so does the prevalence of FTT, leading to heightened health care costs and adverse health outcomes (Robertson RG and Montagnini M, Am Fam Physician 2004;70(2):343–350). Some older adults are labeled with FTT in hospitals when a primary cause isn’t evident, implying a “social admission” without medical acuity. But research indicates that most inpatients initially diagnosed with FTT eventually receive a medical diagnosis and often experience delays in receiving appropriate care (Tsui C et al, BMC Geriatr 2020;20(1):62; Kumeliauskas L et al, Can Geriatr J 2013;16(2):49–53).

Nonetheless, in community settings, FTT is a useful term to convey a patient’s general decline and rising acuity. In the absence of standardized diagnostic criteria, we recommend following the Institute of Medicine’s guidelines, focusing on the following characteristics:

• Weight loss >5% of baseline 
• Decreased appetite, poor nutrition, or dehydration
• Inactivity leading to muscle wasting
• Depressive symptoms or apathy
• Impaired immune function (eg, a cold that won’t resolve)
• Physiological abnormalities (eg, low albumin/cholesterol levels, anemia, ulcers)
• Cognitive impairment

FTT is primarily a clinical diagnosis, but we recommend your patient’s PCP conduct a thorough evaluation to confirm the diagnosis and exclude other potential causes for the symptoms. After the PCP’s evaluation, our role is to focus on the patient’s psychiatric issues and psychosocial stressors. Depression can be a cause or a result of FTT, significantly impacting physical, mental, and social functioning. (For more, visit www.thecarlatreport.com/FTTAssessments and see CGPR Oct/Nov/Dec 2022.)

Treat identifiable diseases

Upon diagnosis of FTT, the primary objective shifts toward enhancing functional status. FTT is frequently reversible with medical intervention, although it may also be the final common pathway toward death when interventions cannot reverse the progression of an illness. In patients with a limited lifespan, emphasize treating identifiable diseases while minimizing invasive diagnostic interventions. For example, physical therapy and strength training can counteract muscle weakness and stimulate appetite.

Address depression

If the patient experiences core symptoms of depression (eg, anhedonia), start with psychotherapy and consider antidepressants to improve quality of life. Selective serotonin reuptake inhibitors are as effective as tricyclic antidepressants but cause fewer side effects. Consider mirtazapine to promote weight gain. Regardless of the chosen antidepressant, monitor for side effects like hyponatremia, sleep disturbances, nausea, and anticholinergic effects (Katz IR and DiFilippo S, Clin Geriatr Med 1997;13(4):623–638; Blazer DG et al, Am J Psychiatry 2000;157(12):1915–1924). In severe cases, or when rapid response is required, consider electroconvulsive therapy. For apathy, consider a brief stimulant trial (eg, low-dose methylphenidate) as it may help with the patient’s energy to engage in activities.

Additional interventions

Nutritional deficiencies

For patients who have lost weight, emphasize increasing meal frequency, taking dietary supplements to ensure adequate caloric and protein intake, and tailoring meals to the individual. For example, many patients with Alzheimer’s disease have a larger appetite in the morning, making a substantial breakfast beneficial. Consulting with a dietician is often helpful.

Environmental changes

Patients can benefit from environmental changes (eg, participation in group activities, increased home-based services, moving to an assisted living facility or nursing home).

End-of-life care

Initiate end-of-life care discussions with patients and their families. Consider consultation with hospice or palliative care. Such discussions should include filling out the following forms:

• Medical Orders for Life-Sustaining Treatment (MOLST): a medical order form for patients with advanced illness based on the patient’s care goals
• Health Care Proxy (HCP): a document naming a health care decision maker for the patient when they are incapacitated or unable to make medical decisions
• Power of Attorney (POA): a legal authorization for a person to make decisions about the patient’s finances, property, or medical care

Sarah has lost 10% of her body weight in three months; scores 8 on the Geriatric Depression Scale, suggesting depression; and takes 40 seconds to complete the Timed Up & Go Test. You prescribe mirtazapine 15 mg nightly and recommend nutritional supplementation with breakfast. Her son enrolls her in a day program for older adults. Three months later, you help Sarah complete the MOLST, HCP, and POA forms.

Principal symptoms of FTT include weight loss, frailty, muscle wasting, depressive symptoms, and cognitive decline. Conduct a comprehensive assessment of the physical and mental needs of the patient, underpinned by interventions to improve functional status.

CARLAT VERDICT

Principal symptoms of FTT include weight loss, frailty, muscle wasting, depressive symptoms, and cognitive decline. Conduct a comprehensive assessment of the physical and mental needs of the patient, under- pinned by interventions to improve functional status.