Nutrition and exercise play key roles in treating older adults with this condition.

The term failure to thrive (FTT) is used to describe infants and young children with failure to grow or gain weight at the expected rate. Possible causes include physical and emotional deprivation, poor appetite and diet, and medical problems.1 It is this type of syndrome of physical and emotional deprivation that so often applies to the older person who was once active and is now lonely, bored, and possibly depressed. This deprivation and depression can easily lead to social withdrawal and poor food intake, which can result in malnutrition and unintentional weight loss, followed by weakness, functional decline, and other complicating factors.

Geriatric FTT is a common enough term to have its own ICD code (783.4), yet it is a controversial term in practice. In 1991, the Institute of Medicine described FTT late in life as “a syndrome manifested by weight loss greater than 5% of baseline, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol levels.”2

FTT in the older adult may be the result of multiple issues, including chronic disease and functional decline. As clinicians, we first notice the symptoms of poor food and fluid intake, unintentional weight loss, malnutrition, and inactivity. The adverse outcomes of this syndrome follow and include malnutrition, depression, cognitive impairment, and impaired physical function.

Robertson notes, “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

Woolley notes that physicians should take caution when applying the geriatric FTT label. FTT should not be treated as a diagnosis or disease or equated with frailty, and it should not signal the withdrawal of efforts to find and treat underlying causes. Instead, it should be viewed as unexpected and significant change in normal health status and a decline in vigor, weight, and function that can affect even the healthiest of older people. For older individuals who exhibit unintentional reduction of food intake and weight loss, decline in ability to provide self care, decline in cognitive function, and a general decline in interest in daily life, the term failure to thrive should trigger a thorough evaluation to determine possible reversible underlying causes.3

Identification and Assessment
FTT affects anywhere from 5% to 35% of community-dwelling elders and 25% to 40% of nursing home residents.1 Prevalence of the syndrome appears to increase with age. Studies indicate that it is associated with decreased immunity and increased rates of infection, incidence of hip fractures, pressure ulcers, surgical mortality, mortality rates, and medical costs.1

Because the decline is so gradual, loved ones often do not notice the subtle changes in condition. If they do observe changes, the older adult often denies there is anything wrong and treatment may be delayed until there is an acute illness or event (eg, fall, fracture, pneumonia). At the time of the assessment for the acute event, healthcare professionals and caregivers realize there has been a decline in condition, which usually includes unintentional weight loss.

Initial assessment should include a total review of mental and physical health, functional ability, and social/environmental factors. This total assessment should include a review of chronic diseases, possible medication interactions, a nutritional assessment, and appropriate laboratory and radiological evaluations individualized to the patient’s specific needs. An alcohol and substance abuse screening is also recommended.1

Common medical conditions associated with FTT include cancer, congestive heart failure (CHF), chronic lung disease, chronic renal insufficiency, chronic steroid use, cirrhosis, cerebrovascular accident, depression or other mental disorders, diabetes, hepatitis, hip or large bone fracture, inflammatory bowel disease, history of gastrointestinal surgery, M. incognitus, recurrent urinary tract infections, recurrent pneumonia, rheumatologic disease (eg, rheumatoid arthritis, lupus), systemic infection, and tuberculosis.1

Common medications associated with FTT include anticholinergic drugs, antiepileptic drugs, benzodiazepines, beta blockers, central alpha antagonists, diuretics in high-potency combinations, glucocorticoids, neuroleptics, opioids, selective serotonin reuptake inhibitors, tricyclic antidepressants, and more than four prescription medications.1

Four main areas of assessment and treatment for FTT syndrome have been identified:

• impaired physical function or status;

• undernutrition or malnutrition (including unintentional or significant weight loss);

• depression or depressive symptoms; and

• cognitive impairment or decline.1,4

Impaired Physical Function or Status
It is important to assess the individual’s ability to perform activities of daily living. This can be achieved using the Katz ADL scale to assess ability in six areas: eating, dressing, toileting, transferring, continence, and bathing. A physician can administer a simple test called the “Up and Go.” The physician asks the patient to rise from a chair, walk 10 feet, turn, and return to the chair to sit down. If the patient can easily achieve this task in less than 20 seconds, he or she is generally competent to perform basic transfers. Those who take more than 30 seconds to complete the test generally need more assistance and have a higher risk for falls.1

Undernutrition or Malnutrition
One of the most common symptoms of FTT is unintentional weight loss. Malnutrition may result if the patient is not treated. In the nursing home setting, residents are assessed by the dietetics professional and appropriate interventions are determined and implemented. In the outpatient setting, The Mini Nutritional Assessment (MNA) is a validated nutrition assessment tool that may be used to identify malnutrition.5 However, a more commonly used tool in the outpatient and home care setting is the DETERMINE Your Health Checklist.6

Depression or Depressive Symptoms
Depression is common with FTT and may be either a cause or a result of the syndrome. Depression can be a major cause of unintentional weight loss, and if left untreated, it is associated with increased morbidity and mortality in FTT patients. It is imperative to screen for depression. The Geriatric Depression Scale is a commonly used tool for assessment of depression.7

Cognitive Impairment or Decline
The Mini-Mental State Examination is the most common and valid screening tool to assess cognitive disorders.8 Cognitive impairment may be the result of factors such as abuse or neglect, lack of support, recent personal loss, medications, chronic disease, malnutrition, electrolyte imbalances, and dehydration. Cognitive status should be evaluated frequently due to potential ongoing changes in overall health status and condition in an older adult with FTT.1

In addition to an in-depth evaluation of the above four factors, a thorough medical evaluation should determine any underlying medical problems. Undiagnosed health problems such as diabetes, hypertension, or acute issues such as urinary tract or upper respiratory infections can result in rapid declines in older adults. A review of medications is also pertinent. Drug nutrient interactions, drug-drug interactions, polypharmacy, and adverse reactions can all have devastating effects on an older person. Dentition, vision, hearing, continence, and gastrointestinal issues must also be addressed. Each patient should also be assessed for psychosocial, economic, spiritual, and emotional needs. Living situation, caregiver ability, potential abuse or neglect situations, isolation, and financial ability to purchase food and prescriptions can all have a dramatic effect on an older adult’s ability to thrive.4

Treatment
The goal of medical interventions is to improve overall quality of life and functional abilities. Interventions for easily treatable causes of FTT (eg, poor nutritional intake) should be implemented immediately. Treatment is best achieved through a team approach: physician, nurse, dietitian, physical therapist, social worker, mental health professional, and/or speech pathologist, as dictated by individual need.1

Malnutrition
Nutritional status has a significant impact on a person’s ability to resist infection; recover from illness, injury, or surgery; and have the strength and energy to rehabilitate. Malnourished older adults have diminished muscle strength, which can lead to weakness, decreased independence, and falls. They may also have slower recovery from illness or acute episodes, a tendency toward poor healing, increased risk of pressure ulcers, weight loss, infection, immune dysfunction, anemia, weakness, fatigue, and morbidity and mortality.

Low albumin and anemia are associated with lower survival rates, decreased ability for self care, depression, and cognitive impairment. Low albumin in FTT may be related to effects of chronic disease and inflammation or to “interactions between nutrition and illness.”9

Sarcopenia
In addition to malnutrition, sarcopenia may exacerbate the difficulties challenging the health of an older adult. Sarcopenia is the excessive loss of muscle associated with aging. Generally, people start losing muscle at roughly 45 years of age and tend to continue losing muscle at a rate of approximately 1% per year. This muscle loss leads to reduced strength and ability to perform everyday tasks. In addition, unsteadiness may result in falls.

There are several key factors that accelerate loss of muscle mass, including decreased physical activity, testosterone and growth hormone deficiency, decreased neuronal endplate input into muscles, and possibly mild cytokine excess (severe cytokine excess leads to cachexia).10 The stress response can create additional loss of lean body mass (LBM). The stress response can occur due to catabolic illness such as wounds, trauma, surgery, and infection. It is essentially a hormonal response to stress (a heightened “fight or flight” response) that increases energy needs, causes the body to break down proteins and LBM, and can lead to protein calorie malnutrition.

LBM makes up 75% of body weight, mostly in the form of muscle, bone, and tendon. This LBM provides the majority of the body’s protein. Unfortunately, the rate of recovery of LBM is much slower during the recovery stage than the rate of loss during the inflammatory stage. Loss of just 10% of LBM decreases immune response and increases the risk of infection. A loss of 15% or more reduces the rate of wound healing and increases weakness. At 30% loss of LBM, pressure ulcers may develop and healing response is nonexistent. A 40% LBM loss usually results in death (often due to pneumonia).11

Medical Nutrition Therapy (MNT)
It is important to quickly and accurately identify older adults at risk of malnutrition. There are various tools available, including the DETERMINE Your Health Checklist, the Subjective Global Assessment, the MNA (www.mna-elderly.com), and the Malnutrition Universal Screening Tool.12,13

In addition to these standardized tools, some simple screening questions may also be practical in certain settings:

• Have you lost weight recently? If so, how much and in what period of time?

• Do you eat three meals per day?

• What do you typically eat for breakfast, lunch, dinner, and snacks (24-hour recall)?

• Do you consume at least three servings of dairy products and 5 ounces of meat per day?

• Are you taking any vitamin/mineral supplements? If so, what are you taking?

• Are you having any difficulty chewing or swallowing?

The goal of MNT should be to improve quality of life, stabilize or reverse weight loss and malnutrition, and treat any identified problems. Even if an older person is overweight, he or she may have a low LBM. Common nutritional problems of older adults include an inability to consume adequate calories and protein to meet needs, overly restrictive diets (liberalized diets can help to improve food intake), dysphagia, and depression.14

One of the most important interventions is to ensure adequate calorie and protein intake. This can be achieved using enhanced foods and oral nutritional supplements, ensuring adequate access to foods and a pleasant dining experience, offering favorite foods, providing adequate assistance, and starting enteral feeding, if necessary. Every bite counts for these frail individuals, so it is important to liberalize diets as much as possible.14

Nutrient Needs
General recommendations for calorie needs of older adults are as follows:

• 25 calories per kilogram for normal weight/nonstressed patients;

• 30 to 35 calories per kilogram for underweight or for pressure ulcers or stressed patients; and

• 40 calories per kilogram for more severe cases (stage 3/4, multiple pressure ulcers, or severe unintentional weight loss).14-19

It is important to ensure adequate protein intake to slow sarcopenia, decrease the loss of LBM, and avoid protein-energy malnutrition by following these recommendations:

• 1 to 1.2 grams per kilogram of body weight for nonstressed patients;

• 1.2 to 1.5 grams per kilogram of body weight for patients at high risk of pressure ulcers, with pressure ulcers, or those who are stressed; and

• 0.8 grams per kilogram of body weight for chronic renal failure (predialysis).14,18,19

Fluid needs for older adults may be met by following these general guidelines:

• 30 milliliters per kilogram of body weight;

• 35 milliliters per kilogram of body weight for dehydration;

• 25 milliliters per kilogram of body weight for CHF and renal failure; and

• 1 milliliter per calorie for enteral feeding.14,18

Some older adults need vitamin and mineral supplementation with calcium, folate, vitamin B12, and vitamin B6. Most will need vitamins D and E. Magnesium and zinc intake are sometimes inadequate. In general, a daily multivitamin and mineral supplement is suggested for most older adults.10,19

Individuals who experience anorexia, food aversions, or loss of appetite may benefit from alternative interventions such as appetite stimulants and/or anabolic steroids.20

Physical Activity
Falls are the leading cause of injuries, hospital admissions for trauma, and deaths due to injury. Estimates indicate that there are 360,000 to 480,000 fall-related fractures per year.21 By age 65, 48% of all people in the United States do not participate in leisure time physical activity, and at 75-plus years of age, more than 61% do not participate. Inactivity contributes to an increase in body fat and a decrease in muscle mass, which in turn leads to reduced functional ability.

Nearly all older adults can benefit from resistive and strength training to increase muscle strength, improve functional ability, and prevent further decline.4

Four components of physical activity are important for a well-balanced exercise plan:

• endurance to improve cardiovascular and circulatory systems (low-impact exercises);

• strength to reduce sarcopenia, build muscles, and possibly prevent osteoporosis. (Strength training can include resistance training three times per week. Tylenol or a nonsteroidal anti-inflammatory agent may be needed prior to exercise to reduce postworkout pain from inflammation.10 Alone and in combination with nutritional supplementation, strength training increases strength and functional capacity.)19;

• balance to prevent falls (Balance exercises may include Tai Chi, which improves balance, or something as simple as standing on one leg with eyes closed. Older adults may need to hold on to something.); and

• flexibility to recover from or prevent injuries. (Flexibility exercises such as yoga or stretching may help prevent falls.)21

A Winning Combination
Nutrition and exercise together have a synergistic effect that helps combat malnutrition, increase strength, and promote well-being. Patients need adequate energy and protein to meet needs and support muscle synthesis and repair.19 Encourage physical activity to promote anabolism and suggest appropriate exercises (including strength training). Address protein losses if present and encourage adequate protein and caloric intake.10 Refer to a physical therapist to assess range of motion, strength, and endurance and determine need for assistive devices (eg, canes, walkers, grab bars, shower chairs). Offer early physical therapy, strength training, and occupational therapy, if necessary. Encourage walking, and refer to social services for home environment assessment if necessary.19

By being aware of each individual’s conditions, problems, and concerns in relation to nutrition and physical activity, you can provide the most appropriate interventions for each individual.

— Becky Dorner, RD, LD, is a speaker and an author who provides publications, presentations, and consulting services to enhance the quality of care for the nation’s older adults. Visit www.beckydorner.com for free articles, newsletters, and information.

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

2. Institute of Medicine. Committee on a National Research Agenda on Aging, Lonergan ET. Extending life, enhancing life: a national research agenda on aging. Washington, D.C.: National Academy Press, 1991.

3. Woolley D. How useful is the concept of ‘failure to thrive’ in care of the aged? Am Fam Physician. 2004;70:248,257.

4. Lantz MS. Psychiatry rounds: Failure to thrive. Clinical Geriatrics. 2005;13(3):20-23.

5. Guigoz Y, Vellas B, Garry PJ. Assessing the nutritional status of the elderly: The Mini Nutritional Assessment as part of the geriatric evaluation. Nutr Rev. 1996;54:S59-S65.

6. The Nutrition Screening Initiative. Available at: http://www.eatright.org/ada/files/Checklist.pdf. Accessed June 13, 2006.

7. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165-172.

8. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State Examination. Available at: http://www.minimental.com. Accessed June 22, 2006.

9. Katz IR, Beaston-Wimmer P, Parmelee P, et al. Failure to thrive in the elderly: Exploration of the concept and delineation of psychiatric components. J Geriatr Psychiatry Neurol. 1993;6(3):161-169.

10. Morley JE, DiMaria RA, Amella EJ. Frailty and the Older Adult: Features, Vulnerabilities and Feeding. Clinical Nutrition Week. January 30, 2005.

11. Demling R, DeSanti L. Involuntary weight loss and the nonhealing wound: The role of anabolic agents. Advances in Wound Care. 1999;12(Supp1):1-14.

12. Sacks GS, Dearman K, Replogle WH, et al. Use of subjective global assessment to identify nutrition-associated complications and death in geriatric long-term care facility residents. J Am Coll Nutr. 2000;19(5):570-577.

13. British Association for Parenteral and Enteral Nutrition, ‘Malnutrition Universal Screening Tool’ (The ‘MUST’). Available at: http://www.bapen.org.uk/the-must.htm. Accessed June 13, 2006.

14. Niedert KC, American Dietetic Association. Position of the American Dietetic Association: Liberalization of the diet prescription improves quality of life for older adults in long-term care. J Am Diet Assoc. 2005;105(12):1955-1965.

15. Mahan K, Escott-Stump S. Krause’s Food, Nutrition, & Diet Therapy. Saunders, Philadelphia, Pa., 2004.

16. Dorner B. Healthy Weights: Preventing and Treating Weight Loss. Becky Dorner & Associates, Inc., Akron, Ohio, 2005.

17. Niedert K, et al. Pocket Resource for Nutrition Assessment, Consultant Dietitians in Health Care Facilities, a dietetic practice group of the American Dietetic Association, Chicago, Ill., 2001.

18. Niedert K, Dorner B. Nutrition Care of the Older Adult, American Dietetic Association, Chicago, Ill., 2004.

19. Mead Johnson Advisory Board for Geriatric Health and Nutrition, Recuperative Powers of Nutrition: Resistance, Recovery, Rehabilitation Monograph. Mead Johnson Nutritionals, Mead Johnson & Company, 2003.

20. Smith-Edge MA, Morley JE, Gallager A. Charting the Future of Long-Term Care Nutritional Strategies, Council for Nutrition, Clinical Strategies In LTC, MultiMedia HealthCare/Freedom, LLC, USA, 2004.

21. National Institute on Aging. Exercise: A Guide from the National Institute on Aging.