Lesson 2 of 1
In Progress

FAILURE TO THRIVE FOR THE ELDERLY LESSON

January 15, 2017

INTRODUCTION

Failure to thrive for the elderly patients is not a failure to develop, but it is simply a progressive functional decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments. The Institute of Medicine defines FTT as, “Weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity” leading to functional decline. The prevalence of failure to thrive increases with age and is associated with increased costs of medical care and high morbidity and mortality rates.  Also called adult failure to thrive, it affects up to 35% of older adults in general and up to 40% of nursing home patients. It is important to note that FTT is not a part of the aging process and can often lead to death. In elderly patients, failure to thrive is associated with increased infection rates, diminished cell-mediated immunity, hip fractures, decubitus ulcers, and increased surgical mortality rates.

As mentioned above, Adult FTT is most commonly seen in the frail elderly who may not have one specific terminal illness, but may have one or more chronic illness. In the absence of a known terminal illness, patients with FTT often have manifestations of the condition which include decreased appetite, weight loss, increased fatigue and a progressive functional decline.

Adult Failure to thrive is commonly used as a nonspecific diagnosis when a patient loses weight due to an unknown etiology. The four chief characteristics of geriatric failure to thrive are impaired physical function, malnutrition, depression, and cognitive impairment. Undesired weight loss in the elderly causes a reduced quality of life and contributes to serious illness. Elderly residents of nursing facilities who lose 5% of their body weight in one month are 4.6 times more likely to die within a year. Malnutrition in the elderly can also result in pressure sores, functional decline, longer rehabilitation, and multiple medical complications. The importance of functional decline is the key to recognizing the AFTT syndrome when the patient is not functioning as well as would be expected.

As mentioned above, impaired physical function is one of the four characteristics of geriatric failure to thrive, and evaluation of physical functioning is an integral part of the geriatric evaluation. Healthcare workers should determine any changes in mobility and evaluate for signs of a functional decline. Functional decline may be rapid, in cases of hospitalization and severe illness, or gradual, with the patient experiencing decreased mobility and independence over a long period of time. Physical and occupational therapists can provide a complete assessment of a patient’s mobility and ability to perform activities of daily living (ADL) independently. The Katz Index of Independence in Activities of Daily Living, commonly referred to as the Katz ADL, is the most appropriate instrument to assess functional status as a measurement of the elder’s ability to perform activities of daily living independently. The Katz ADL scale assesses a patient’s ability to perform six related functions which includes, bathing, dressing, toileting, transferring, continence and eating.

 

ASSESSMENT OF PHYSICAL FUNCTION

Impaired physical function is one of the four chief characteristics of geriatric failure to thrive, and evaluation of physical functioning decline is an integral part of the geriatric evaluation. Any changes in mobility must be evaluated and determined if they are subtle signs of a functional decline. The patient’s current strength, mobility, balance, and safety awareness should all be evaluated. Based on this assessment, assistive devices, such as walkers, canes, wheelchairs, and splints, may be prescribed. For a patient who has declined in function, a physical therapist may create a plan of rehabilitation to return the patient to his or her prior level of function. Rehabilitation may include therapeutic exercises, resistance exercise training, pain management modalities, and gait and ambulation training.

For patients with failure to thrive, assessment of eating and ability to feed themselves is particularly important. For patients who are bedridden, repositioning every two hours will help prevent formation of contractures or deformities and prevent pressure ulcers. To curb the effects of functional decline and contracture management and prevention, need for splints, positioning in wheelchairs or specialty chairs, and the need for assistive devices to help with eating may be made. A rehabilitation plan to assist the patient to regain independence in daily activities can be helpful.

 

MENTAL HEALTH AND COGNITIVE STATUS

Cognitive impairment is another characteristic of geriatric failure to thrive. Cognitive impairment (also known as brain fog) is the loss of intellectual functions such as thinking, remembering, and reasoning of sufficient severity to interfere with daily functioning. Patients with cognitive impairment have trouble with verbal recall, basic arithmetic, and concentration. Cognitive impairment is a change, a noticeable change for the worse, in someone’s ability to think, reason, make judgments, remember, and plan. Everyone loses some degree of mental ability and memory as they age. But for the person who has geriatric failure to thrive, the cognitive deficits are greater than what is expected and they negatively affect functioning. There are many medical conditions that can cause cognitive impairment in the elderly which includes Alzheimer’s disease, Parkinson’s disease, stroke, infections, medication adverse effects and dehydration.

An assessment of psychological and sociological functioning is necessary to fully evaluate geriatric failure to thrive. The Mini-Mental State Examination (MMSE) or Folstein test may be used as an objective assessment of cognition, either to establish a baseline measurement of mental status or to track progress or decline. The Mini-Mental State Examination assesses important aspects of cognitive ability, including the individual’s orientation, attention, calculating ability, recall, and language skills. There are 30 questions: a correct answer scores one point and a score of less than 20 usually indicates cognitive impairment. The Mini-Mental State Examination questions are very simple and difficulty in answering them correctly clearly shows cognitive impairment. These questions includes;

 

Mini-Mental State Examination Questions

  1. Language skills…..Show the patient two simple objects, such as a wristwatch and a pencil, and ask the patient to name them.
  1. Recall….Ask the individual to repeat the following: “No if, ands, or buts”
  1. Attention and calculating ability…..Ask the patient to spell WORLD backwards. Also ask the patient to count backward from 100 by sevens. (93, 86, 79, 72, 65, …) Stop after five answers.
  1. Orientation…..What is the year? Season? Date? Day of the week? Month?

 

GERIATRIC DEPRESSION

The most common psychiatric condition in older persons is depression. Depression can both be a cause and a consequence of failure to thrive. It is widespread and frequently undiagnosed in older adults which is why screening for depression is necessary for all patients who exhibit characteristics of failure to thrive. Depression is a major cause of weight loss in the elderly, and geriatric depression is a significant health risk, affecting function and quality of life. Any patient who had had an unintentional weight loss should therefore be screened for depression. Geriatric patients have often experienced multiple losses, including the death of a spouse, peers, or children; loss of independence; loss of health or mobility; and loss of physical or financial independence. All these losses can induce depression.

The stigma of psychiatric illness may prevent elderly patients from seeking help for depression. To make matters worse, the early signs of depression which includes weight loss, fatigue, mood changes, and noticeable changes in memory, concentration, and attention span; can be misdiagnosed as dementia. Elderly patients who are depressed are more likely to complain of physical problems than to mention conventional depressive symptoms (such as mood changes) and may manifest depression as weight loss. Patients with geriatric depression often seem indifferent, socially withdrawn, lonely, bored, and may have little interest in activities they previously enjoyed and they don’t care to socialize. The good news is that geriatric depression can be treated successfully with medications. Nurse assistants can also encourage patients to engage in activities that will promote social interaction in the nursing facilities like playing BINGO.

 

MALNUTRITION

People suffer from hunger if they don’t get enough food. Hunger and this lack of nutrition eventually leads to malnutrition. Some diseases can also cause malnutrition. Malnutrition is therefore the result of a body not getting enough of the nutrients it needs. The consequences of malnutrition include muscle wasting, generalized weakness, fatigue, decreased activities, altered immunity, poorer surgical outcomes, and increased mortality. Weight loss is one of the most important signs of failure to thrive in adults. Weight loss may be a sign of a physical problem like chronic diarrhea, or it may be a result of poor appetite. In addition to weight loss, problems with nutrition almost always go hand-in-hand with dehydration. Malnutrition is often due to one or more of the following factors: inadequate food intake; food choices that lead to dietary deficiencies; and illness that causes increased nutrient requirements, increased nutrient loss, poor nutrient absorption, or a combination of these factors.

A complete nutritional assessment and treatment should be a routine part of care for all elderly persons, whether in the outpatient setting, acute care hospital, or long-term institutional care setting. Patients should also be assessed for oral pathology, ill-fitting dentures, problems with speech or swallowing, and medication use that might cause anorexia. A dietary history, including caloric intake and body weight, needs to be taken and monitored on an ongoing basis. Nutritional supplementation is one of the most important interventions in patients with failure to thrive. Caregivers can provide older adults nutritional supplements with high caloric booster meals. Because the goal of dietary supplements is to provide adequate energy and protein intake, almost anything the patient eats is suitable. In elderly patients, the administration of dietary supplements between meals rather than with meals may be more effective in increasing energy consumption.

How Nurse Assistants can help….

  • Monitor weight loss closely. A loss of 5% or more in body weight from the baseline should be documented in the patient’s chart and reported.
  • Monitor and report any chronic diarrhea. This may be a sign that food is not being absorbed properly and is usually a reversible cause which responds to treatment
  • Clients who receive chemotherapy or radiation for cancer treatment may experience nausea and vomiting. This is also treatable and reversible. Be sure to report to your supervisor if your client is unable to eat or drink because of nausea or vomiting.
  • Some medications and the normal aging process can leave clients unable to smell and taste food the way they used to. This can make eating a miserable experience. Talk to your supervisor. There are certain spices and herbs that can be safely added to most people’s food to make it easier to taste.
  • Patients with poor eyesight may find it hard to get excited about eating what they can’t see. Describe in detail what is on the plate and what it looks like. Explain where items are located. Use the face of a clock as a road map. For example, your roll is at two o’clock, your meat is at six o’clock and your green beans are at nine o’clock.
  • Constipation may be part of the problem as the digestive process slows and becomes less efficient. This can cause bloating, nausea, and abdominal pain, often making it too uncomfortable to eat. Be sure your patient eats plenty of whole grains and high fiber foods, and drinks 6-8 eight ounce glasses of water each day to avoid constipation.
  • A relaxed and positive setting with easy social interaction during meals helps improve nutritional intake and overall health.
  • If the patient becomes agitated during mealtimes, decrease noise and distractions.
  • If possible, serve 5 or 6 small meals and snacks throughout the day instead of 3 big ones

Unfortunately, certain geriatric failure to thrive patients will not respond to interventions and treatments. These patients will continue to lose weight and decline despite interventions. If the BMI is less than 22 and significant physical impairment is causing disability, the patient should be considered as a candidate for hospice care. When the patient has declined parenteral feeding or has not responded to nutritional support despite adequate caloric intake, a referral to hospice should be considered. These patients should be identified so that prompt discussion of end of life care options should be initiated to prevent needless interventions that may prolong suffering. For a patient in a nursing facility, the hospice services will be rendered in the facility; others may use a home hospice service. The patient and family members should be supported through the dying process.

ADVANCE DIRECTIVES

An advance healthcare directive, also known as living will, is a legal documents that allow a patient to spell out his or her decisions about end-of-life care. Advance healthcare directives allow the patient and family to determine what medical care is desired. State regulations vary regarding how and when advance directives can be used. In California, POLST (Physician Orders for Life-Sustaining Treatment), is a form that gives seriously-ill patients more control over their end-of-life care, including medical treatment, extraordinary measures (such as a ventilator or feeding tube) and CPR. Printed on bright pink paper, and signed by both a patient and physician, nurse practitioner or physician assistant, POLST can prevent unwanted or ineffective treatments, reduce patient and family suffering, and ensure that a patient’s wishes are honored. California law requires that a POLST form be followed by healthcare providers, and provides immunity to those who comply in good faith. In the hospital setting, a patient will be assessed by a physician who will issue appropriate orders that are consistent with the patient’s preferences

When caring for any patient with failure to thrive, it should first be determined if advance directives exist, and copies of any documents should be obtained. If no advance directives exist, it should be determined if the patient is capable of making his or her own healthcare decisions. This is called a determination of capacity and usually requires the signatures of two physicians. If the patient is deemed incapable of making medical decisions, the healthcare proxy will assume the role of medical decision maker. A healthcare proxy is a person that is chosen by the patient/family to make healthcare decisions for the patient. If there is not a surrogate designated, a close family member or personal friend may be appointed the proxy.

SUMMARY

Geriatric failure to thrive is a challenging condition for healthcare providers and is associated with high morbidity and mortality. The four characteristics of geriatric failure to thrive are impaired physical function, malnutrition, depression, and cognitive impairment. Malnutrition is a key aspect of FTT and its treatment is critical for reversing FTT. It is vital to remember that undesired weight loss in the elderly is generally not a normal part of aging. Weight loss occurs in up to 35% of elderly patients with no obvious cause.  A complete physical assessment is necessary for the elderly to assess changes that are not the result of normal aging.

There is a lack of data on the efficacy of primary prevention, as well as on an optimal treatment strategy. However, with early recognition and intervention, FTT is treatable. Because FTT commonly occurs near the end of a person’s life, potential benefits of treatment should be considered before evaluations and treatments are undertaken. Treatment of FTT should focus on treating identifiable causes and be limited to interventions that have fewer risks for the elderly patients

A team approach that includes a medical team, dietitian, a speech therapist, a social worker, nurses, nurse assistants, physical therapists, occupational therapist, and family members can contribute important components to the treatment of malnutrition.

Advance directives are important in determining the care plan and treatment modalities for the patients suffering from FTT. Conferences with the patient and family are crucial for clarifying the goals of care. For patients who do not respond to treatments, geriatric failure to thrive may progress to a terminal condition with poor prognosis. A hospice referral may be appropriate for end-stage care.

 

 

References

Ryan C, Bryant E, Eleazer P, Rhodes A, Guest K. Unintentional weight loss in long-term care: predictor of mortality in the elderly. South Med J. 1995;88(7):721-724.

http://www.gnjournal.com/article/S0197-4572(00)70015-2/abstract

National Association for Home Care and Hospice. Hospice Regulatory Issues. Available at http://www.nahc.org/advocacy-policy/hospice-regulatory-issues. Last accessed March 10, 2014.

Robertson RG, Montagnini M. Geriatric failure to thrive. Am Fam Physician. 2004;70(2):343-350.

http://familymed.uthscsa.edu/geriatrics/reading%20resources/virtual_library/PGY2_%20Articles/Geri%20FTT04.pdf

http://www.aafp.org/afp/2004/0715/p343.html