Frailty and Failure to Thrive
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Transcript Frailty and Failure to Thrive
FAILURE TO THRIVE
Gail Wiley
D.O. Candidate
July 2012
DEFINITION
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”.
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
CAUSES 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)
ACCELERATED 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)
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)
NEUROCOGNITIVE IMPAIRMENT
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
LABORATORY ABNORMALITIES IN FTT
low cholesterol
total cholesterol less <90 is a sensitive marker for
malnutrition
hypoalbuminemia
anemia
lymphopenia
VITAMIN DEFICIENCY
Vit D deficiency common in elderly and
associated with falls, gait imbalance and nursing
home admission
MANAGEMENT
in order to be successful requires a multidisciplinary approach, including
clinician
social worker
PT/OT/ speech therapy
dietician
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 wellstudied and have adverse side effects- use with
caution
PHYSICAL FRAILTY
benefit has been shown for resistance exercisealmost a two-fold increase in muscle mass
exercise and movement is imperative
DEMENTIA
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
DEPRESSION
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
SOMETHING 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
END OF LIFE CARE
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
PALLIATIVE CARE
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
SUMMARY
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
REFERENCES:
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.
6th Cambridge Univeristy Press