Failure to Thrive in the Elderly

NUTRITION, AGING, AND AGE-DEPENDENT DISEASES 0749-0690 /95 $0.00

+ .20

FAILURE TO THRIVE IN THE ELDERLY Roy B. Verdery, MD, PhD

Failure to thrive in the elderly is a syndrome that occurs near the end of life and is associated with morbidity and mortality. It is a syndrome rather than a diagnosis and encompasses a number of biologic and psychosocial problems associated with morbidity and mortality in older people. The failure to thrive synIn children, however, it drome in older people is similar to that seen in ~hildren.~ is easier to define failure to thrive because thriving children show regular growth rates, and childhood failure to thrive is easily defined as growth that is slower than expected. It is clear that the great majority of older people actually do "thrive" and are physiologically indistinguishable from younger people. Only near the end of life does the burden of chronic illness and acute disease cause people to develop functional deficits and fail to thrive. For those people who do not die of acute disease, the process of failing to thrive at the end of life is a slow one. This is well illustrated in literature as in Shakespeare's play, "As You Like It." The ages of man outlined in this play can be contrasted with the metaphor of the one hoss shay in Holmes' "The Deacon's Masterpiece," which suggests that people die suddenly "as bubbles do when they burst." Failure to thrive in the elderly, as in childhood, can occur for both organic and nonorganic causes. Cases depicted in Table 1 are examples of organic and nonorganic failure to thrive. One of the persons whose clinical condition is outlined in Table 1had pneumonia. She also had underlying Alzheimer's disease and concomitant functional disability. Because of the pneumonia and Alzheimer's disease, she developed weight loss, hypoalbuminemia, hypocholesterolemia, and anemia of chronic disease, the major metabolic concomittents of failure to thrive. The organic cause of her decline was the pneumonia. In contrast, the other person depicted in Table 1, while she also had Alzheimer's disease, did not have pneumonia but, rather, was kept locked in a room without adequate food or water by a granddaughter who expected to inherit her house. She, too, had low weight and developed anemia and hypoalbuminemia although not hypocholesterolemia. This woman is an example of nonorganic failure to thrive. In contrast to the first person From the Arizona Center on Aging, Tucson, Arizona CLINICS IN GERIATRIC MEDICINE

.

VOLUME 11 NUMBER 4 NOVEMBER 1995

653

654

VERDERY

Table 1. EXAMPLES O F FAILURE TO THRIVE

Age Gender Assessment: Medical Cognition Function Social Database: BMI

Hemoglobin Albumin

Cholesterol Outcome:

Organic etiology

Nonorganic etiology

Pneumonia Alzheimer's

Osteoarthritis Alzheimer's IADL dependent Abused by relative

ADL & IADL dependent

In long-term care 15 kg/m2 9.7 gldL 3.0 gldL 110 mg/dL Died

19 kglm2 1 1.3g1dL

3.9 gldL 250 mgldL Recovered (in long-term care)

who died of her pneumonia, the second person was admitted to a nursing home where she regained weight and survived. In order to develop a general model for failure to thrive in old age, one can take advantage of the extensive studies of age-associated changes in metabolic parameters in people. Most metabolic parameters that have age-associated changes show linear declines from age 30 until old age. Examples of such parameters include forced expiratory volume at 1 second, basal metabolic rate, gIomerular filtration rate, and other measurements of functional lean mass.ll Typically, an elderly person with failure to thrive comes to the attention of health care providers because one of these functions (e.g., weight) has decreased to a level significantly below that expected for an age-matched cohort. This model is illustrated in Figure 1.Many measurements are possible that could be used to identify failure to thrive in older people, but the one that is often most useful is weight, and failure to thrive is identified as unexplained weight loss. Figure 1shows a linear decline with age of an age-associated functional measurement. It also shows that the range of normality increases with advancing age (a property of most functional measurements). The large dot in Figure 1 depicts the properties of a hypothetical person with abnormally low function. Such people often come to the attention of a health care professional and may be thought of as "frail" or "failing to thrive." Often a review of medical history suggests that failure to thrive occurred as a consequence of an identifiable event such as a hip fracture or pneumonia. If such an event cannot be identified, it can often be inferred on a basis of history. This gives rise to the "trigger model" of failure to thrive depicted in Figure 1. The author has conducted several studies that can be identified using such a model. Figure 2 depicts three such studies: (1) a study of relatively healthy younger people undergoing elective knee replacementI2; (2) a study of people in a nursin.~home with manv different degrees of dysfunction, including some who are within the range of normality along with others who are failing to thrivel4; and (3) a study of people with decubitus ulcers who not only are failing to thrive, but may have reached a degree of dysfunction that is irreversible and will lead inevitably to death.15 Failure to thrive defined in this way is associated with a large number of metabolic abnormalities.Among the significant abnormalities that have been discussed recently in the literature are acquired hypocholesterolemia~hypoalbuminemia,8 weight loss,' and the associated loss of lean muscle mass called "sarco-

FAILURE TO THRIVE IN THE ELDERLY

655

Age (years) Figure 1. General model of failure to thrive within a gerontologicperspective. Lean body mass

along with many functional measurementsdecline with advancing age. These decreases are accompanied by increases in variability. A person with failure to thrive is usually recognized when his or her function is significantly lower than that of people of the same age cohort. The trajectory of decline, which is faster than normal, identifies failure to thrive. Often a trigger event initiating the "downhill"process can be identified by observation or inference.

~ e n i a , "physical ~ frailty; and the development of decubitus ulcers in old age.17 The exact relationship among these functional, structural, and metabolic abnormalities is known to be complex. The common pathway or pathways that cause these abnormalities to be interrelated are not known but are under active investigation by a number of research groups. Also being considered are declines in anabolic hormome levels (e.g., growth hormone or IGF-16,7)and increases in catabolic cytokine levels (e.g., IL-61Z). One model that serves to tie all of these phenomena together is shown in Figure 3. Trigger events occur in elderly people in the setting of declining functional reserve. Most often, healthy elderly people recover from such events without problem. However, in some elderly, those who fail to thrive, a vicious cycle may develop wherein one process (e.g., weight loss or loss of functional lean mass) is accelerated by the trigger event. This catabolic process then leads to multiple secondary problems including anorexia, negative and positive acute phase responses, anergy, additional loss of muscle, weakness, and functional decline. These secondary processes feed back making the initial catabolic process worse. Unless it is interrupted, this vicious cycle leads progressively to additional problems, culminating in death. In summary, it is possible to definefailure to thvive as an unexplained decrease in function, structure, or metabolic process in excess of that expected for an agematched cohort. When compared with childhood failure to thrive, the easiest measurement to define failure to thrive is unexplained weight loss. If failure to thrive is not arrested and the decrease in function reversed, these losses then cause secondary problems including hypocholesterolemia, l~ypoalbuminemia,anemia of chronic disease, glucose intolerance, muscle loss, and so forth. The goal of diagnosis and treatment in people with failure to thrive is to identify a cause that

656

VERDERY

I

Knee Replacement Study

I

Age (years) Figure 2. Representation of several studies by the authorwithin the general model describing failure to thrive shown in Figure 1. The study of efficacy of growth hormone in preventing

functional decline after elective knee replacement is an example of a study of prevention. The study of metabolic abnormalitiespredicting death in nursing home patients is a study of people at various places along the trajectory leading to death. Study of decubitus ulcers is a study of people near or beyond a hypothetical "irreversibilitythreshold beyond which recovery may be impossible.

can be treated and to stop a vicious cycle from developing or to break it if it has already been established: The evaluation of failure to thrive is best accomplished using a geriatric assessment paradigmJ3 In a geriatric assessment paradigm, global problems are evaluated with a multidisciplinary approach including consideration of medical, psychological, functional, and social problems. This is necessary because of the of both organic and nonorganic causes. For most health care practitioners, medical or metabolic causes of failure to thrive are self evident. The differential diagnosis includes cancer; failure of organs such as heart, liver, or kidneys; chronic infection; endocrine diseases such as diabetes and hypo- or hyperthyroidism; and inflammatory processes such as temporal arteritis. As with younger people, the standard approach of reviewing the medical history, conducting a physical examination, and obtaining appropriate laboratory tests is appropriate for older people with failure to thrive. If this approach leads to a diagnosis that explains the declining function, weight or muscle loss, or the worsening metabolic problems, then the appropriate course is specific trp.?tmnnt ~~ nf +hpiC!~n+ifi~c! d i c o ~ c eQften. . ~~:A.TPBPI. ~

m jdentifiahlp ~ l a ~ ~ d i ig p~a ~ a pl

is not present in elderly people with failure to thrive. Anecdotally, this is true even when the examining physician is a well-established, academic internist and the person with failure to thrive is a beloved family member. In these circumstances, it is necessary to look for nonorganic causes including psychologic, functional, and social problems. The differential diagnosis for failure to thrive due to psychologic problems includes depression, dementia, psychosis, grief, and suicidality.To rule out a psy-

FAILURE TO THRIVE IN THE ELDERLY

657

Trigger event

Acute phase response

/\y Chronic acute phase

t

Elevated cytokine levels

I

1

Normal cytokine levels

Negative energy balance Hypocholesterolemia Anemia of chronic disease Hypoalbuminemia

lm~rovina

Discharge

I

Worsenina

I

Death

Figure 3. Model tying together the metabolic abnormalitiesseen in the development of failure to thrive after a trigger event. The development of a "chronicacute phaseY'that is biochemically related to the acute phase response is a mechanism that is hypothesized to explain the chronically elevated cytokine levels seen in some elderly people with failure to thrive. The condition of people in the chronic acute phase continues to worsen, culminating in death unless an intervention occurs that leads to the usual pathway for recovery from an acute event.

chologic problem, it may be necessary to refer a patient to a geropsychiatrist. Often, however, simple screening tools including the Folstein Mini-Mental State Score: the Yesavge Depression Scale,17and careful history taking with focus on psychologic problems and antecedent stress events makes it possible for a diagnosis to be obtained without subspecialty referral. The occurrence of failure to thrive in someone with dementia, particularly end-stage dementia, is a vexing problem with no simple solution. However, failure to thrive in the setting of depression, psychosis, grief, or intention, is amenable to treatment. Treatment modalities include counseling and support groups along with drugs and other established methods for treating psychiatric disease such as electro-convulsive therapy. Although failure to thrive is commonly recognized as weight loss, loss of functional lean mass, or just loss of function, it is not a tautology to recognize that some functional deficits can actually cause failure to thrive. Functional problems that can cause failure to thrive include immobility (e.g., due to arthritis) limiting the ability of a person to get food or provide for other self-care activities. Deafness and blindness are potential causes of failure to thrive because they decrease the ability of a person to interact with his or her environment and obtain necessities such as food, or services such as nursing or medical attention. Dental problems

658

VERDERY

can cause overt starvation and. accompanying weight loss and other metabolic problems. It is well recognized that, especially in the elderly, repair of dentures or treatment of gum or tooth disease can reverse weight loss. People with suspected functional deficits that might be causing failure to thrive can be evaluated and treated by referral to physical and occupational therapists, audiologists, ophthalmologists, and dentists. The importance of social factors as causes or contributors to failure to thrive cannot be underestimated. Older people, especially in retirement communities, are frequently isolated from family and traditional support groups such as churches. Currently, it is common for couples to move thousands of miles at the time of retirement and to buy a house in a retirement community. Although new friends may be found, these new friends are usually also retired and may have functional deficits themselves. In such a community it is possible to thrive while in good health. However, the development of health problems in one or the other member of a couple can cause the beginning of a progressive, downward decline in the function of both. In addition to isolation, it is well established that the prevalence of poverty is high in elderly people, particularly in women over the age of 75. In addition, demented people have additional risks and potential for problems including "burnout" of their caregiver and consequent neglect. It must also be kept in mind that elder abuse is a major problem and can present as failure to thrive as described in the previous anecdote. Most practitioners, except for those directly involved in social services, have little experience of evaluating and treating social problems associated with failure to thrive. Often, these problems are efficiently evaluated by referral to a social worker or Adult Protective Services. Obtaining adequate social support including Meals-on-Wheels, referral to community nutrition centers, obtaining home health aides, moving to assisted living, or provision of respite care for a "burned out" caregiver is sufficient to reverse weight loss and metabolic problems associated with failure to thrive in such cases. Although it is almost never anybody's first choice, placement in a nursing home is an effective way to address both social and functional problems causing failure to thrive. In conclusion, failure to thrive is a syndrome and not a disease. It is a syndrome with multiple possible diagnoses including physiologic, psychologic, functional, and social causes. Often it can be associated with a "trigger event" that sets the stage for progressive decline. There is a strong age association of failure to thrive for unknown reasons, probably due to declining functional reserve that has been seen in almost all cross-sectional and longitudinal studies of aging people as depicted in the trigger model, Figure 1.The evaluation and diagnosis of causes of failure to thrive seems to be best accomplished in a comprehensive geriatric assessment with attention being paid to problems in various disciplines. Treatment requires attention to not just medical but also -psychologic, functional, and social . problems that can co-exist. Additional research into this syndrome is also necessary. The prevalence of failure to thrive in various groups of older people is not known, although it can be estimated to be higher than 20% in people over the age of 85. The causes have not been elucidated in a definitive fashion and, therefore, it is not clear how to prevent this problem in very old (over 75) or oldest old (over 85) people. Finally, it is not clear whether failure to thrive is reversible in all cases. This problem is important because if there is an irreversible stage for failure to thrive, this syndrome needs to be detected before that stage is reached. Conversely, in some patients with irreversible failure to thrive, treatment should perhaps be limited. Finally, the conceptual and investigational relationship among the related geriatric syndromes of frailty and sarcopenia need to be elucidated.

FAILURE TO THRIVE IN THE ELDERLY

659

References 1. Andres R: Mortality and obesity: The rationale for age-specific height-weight tables. In Andres R, Bierman EL, Hazzard WR (eds):Principles of Geriatric Medicine. New York, McGraw-Hill, p p 311-318,1984 2. Allman RM, Laprade CA, Noel LB, et al: Pressure sores among hospitalized patients. Ann Intern Med 105:337-342,1986 3. Ershler WB: Interleukin-6: A cytokine for gerontologists. J Am Geriatr Soc 41:176-181, 1993 4. Evans WJ, Campbell WW: Sarcopenia and age-related changes in body composition and functional capacity. J Nutr 123:465-846,1993 5. Folstein MF, Folstein SE, McHugh PR: Mini-mental state. J Psychiatr Res 12:189-198, 1975 6. Homer C, Ludwig S: Categorization of etiology of failure to thrive. Am J Dis Child 135:848-851,1981 7. Rudman D, Feller AG, Nagraj HS, et al: Effects of human growth hormone in men over 60 years old. N Engl J Med 323:l-6,1990 8. Rudman D, Feller AG, Nagraj HS, et al: Relation of serum albumin concentration to death rate in nursing home men. JPEN J Parenter Enter Nutr 11:360-363, 1987 9. Rudman D, Mattson DE, Feller AG, et al: A mortality risk index for men in a Veterans Administration extended care facility.JPEN J Parenter Enter Nutr 13:189-195, 1989 10. Rudman SD, Nagraj HS, Mattson DE, et al: Hyposomatomedinemia in the nursing home patient. J Am Geriatr Soc 34:427430,1986 11. Shock NW, Greulich RC, Andres R, et al: Normal human aging: The Baltimore longitudinal study of aging. Waslungton, DC, United States Government Printing Office, 1984 12. Verdery RB: Effects of growth hormone treatment on rehabilitation after elective knee replacement, investigator meeting: Anabolic indications of GH and/or IGF-1, San Francisco, 1994 13. Verdery RB: Geriatric assessment. In Greene HL (ed):Clinical Medicine. St. Louis, Mosby Yearbook, pp 713-716,1995 14. Verdery RB, Goldberg AP: Hypocholesterolemia as a predictor of death: A prospective study of 224 nursing home residents. J Geronto146:M8&90,1991 15. Verdery R, Kouba E. Hypocholesterolemia in older people: Roles of inflammation and energy malnutrition [abstract]. The Gerontologist 32:220, 1992 16. Weindruch R, Hadley EC, Ory MG (eds). Reducing Frailty and Falls in Older Persons. Springfield, IL, Thomas, 1991, pp 5-12 17. Yesavage JA, Brink TL, Rose TL, et al: J Psychiatr Res 17:3749,1983

Address reprint requests to Roy B. Verdery, MD, PhD Arizona Center on Aging 1821 East Elm Street Tucson, AZ 85719