1. F AILURE TO T HRIVE Gail Wiley D.O. Candidate July 2012

2. D EFINITION National Instutitute of Aging- described FTT as “syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol”.

3. DIAGNOSTIC CRITERIA there is absence of a consensus on diagnositic criteria however FTT is a syndrome of global decline defined by: physical frailty functional disability neurocognitive impairment

4. C AUSES OF FTT- IN ONE RETROSPECTIVE CHART STUDY Cancer 30% (n = 39) Infection, particularly pneumonia and urinary tract infection, was found in 18% (n = 24), Dehydration in 13% (n = 17) Depression in 12% (n = 16). Gastrointestinal disease (n = 15), dementia (n = 14), and substance abuse (n = 14) 11% each. No underlying diagnoses in 5% (n = 7)

5. A CCELERATED WEIGHT LOSS IS ASSOCIATED WITH FTT weight loss is normal in aging decreased olfactory sensitivity up to ~ ½ pound per year after age 70 accelerated rate of weight loss is a significant predictor of death in nursing home patients weight loss of more than 5% of body weight in a year suggests FTT optimal BMI in elderly is higher – BMI 24-29 had less functional decline “normal” (18.5-24.9)

6. ADL DEPENDENCY FTT defined by loss of at least one ADL Basic ADL’s: Personal hygiene and grooming Dressing and undressing Self feeding Functional transfers (getting into and out of bed or wheelchair, getting onto or off toilet, etc.) Bowel and bladder management Ambulation (walking with or without use of an assistive device (walker, cane, or crutches) or using a wheelchair)

7. N EUROCOGNITIVE I MPAIRMENT Depression and Dementia leading causes of FTT Depression is treatable incidence of depression in the elderly from anywhere from 5-25% (nursing homes) incidence of dementia shown to be as high as 42% in those over 85 years of age

8. L ABORATORY A BNORMALITIES IN FTT low cholesterol total cholesterol less <90 is a sensitive marker for malnutrition hypoalbuminemia anemia lymphopenia

9. V ITAMIN DEFICIENCY Vit D deficiency common in elderly and associated with falls, gait imbalance and nursing home admission

11. M ANAGEMENT in order to be successful requires a multi- disciplinary approach, including clinician social worker PT/OT/ speech therapy dietician

12. HOW TO TREAT MALNUTRITION add supplements between meals (Ensure) nutritional counseling remove dietary restrictions and make favorite foods readily available tube feeding did not affect survival at 24 months appetite stimulants such as Megestrol and Dronabinol may be helpful but are not well- studied and have adverse side effects- use with caution

13. P HYSICAL F RAILTY benefit has been shown for resistance exercise- almost a two-fold increase in muscle mass exercise and movement is imperative

14. D EMENTIA when dementia is a leading factor in FTT, changing the living situation to a higher level of assistance and supervision may be helpful in advanced dementia FTT is inevitable as patients lose the ability to chew and swallow

15. D EPRESSION a common and reversible cause of FTT in elderly antidepressants are a mainstay of treatment, ECT is also helpful when accompanied by psychosis, anxiety or mania- pt should be referred to a psychiatrist Mirtazapine in particular has the added benefit of increasing appetite low doses of Methylphenidate useful in those who are severely depressed

16. S OMETHING TO KEEP IN MIND - MEDICATION SIDE EFFECTS common in elderly (decreased Cr clearance/ metabolism, polypharmacy) updated Beers criteria suggest many common medications should be avoided in the elderly, such as: benzodiazepines NSAIDS estrogen muscle relaxers

17. E ND OF L IFE C ARE FTT is a final common pathway towards death patients status may not be amenable to interventions and at that point it is appropriate to consider palliative care

18. P ALLIATIVE C ARE following criteria used by hospice to determine when a pt has 6 months or less to live: weight loss not due to reversible causes recurrent/ intractable infections progressing dementia progressive pressure ulcers (stage 3 or 4) despite optimal care progressive loss of ADL’s

19. S UMMARY FTT is a nebulous diagnosis without clear diagnostic criteria or guidelines for treatment it is an umbrella term used to describe a human’s de-evolution and regression towards death recognizing and treating FTT is not delaying the inevitable- sometimes causes are treatable

20. R EFERENCES : Use of the diagnosis "failure to thrive" in older veterans. Hildebrand JK - J Am Geriatr Soc - 01-SEP-1997; 45(9): 1113-7 Kathryn Agarwal, MD Failure to thrive in elderly adults: Evaluation. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2012. Kathryn Agarwal, MD Failure to thrive in elderly adults: Management. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2012. Christine Aranson, Jan Busby-Whitehead, Kenneth Brummel-Smith, James O’Brien, Mary Palmer, William Reichel (2009) Reichel’s Care of the Elderly. 6 th Cambridge Univeristy Press