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INTRODUCTION

The syndromes of failure to thrive, pressure ulcers, and falls share features that make them particularly challenging. Their etiologies are multifactorial; they require an interdisciplinary approach to maximize care; and they often herald disability, institutionalization, and death. Interventions in multiple domains can improve outcomes. However, in patients with low functional reserve the physician should be prepared to transition from cure to palliative care. Open and frank communication is vital and should employ the skills needed to address life-changing diagnoses while continuing to supply hope and support. Eliciting patient’s goals, what they want and what they want to avoid, is fundamental to crafting an end-of-life framework that is consistent with their values and preferences. The physician can and should maintain a therapeutic relationship with the patient and the family beyond the time when medical therapies are effective. Home visits enhance this relationship and often reveal opportunity for interventions and support.

FAILURE TO THRIVE

ESSENTIALS OF DIAGNOSIS

  • Weight loss of more than 5%.

  • Functional decline.

  • Depression.

  • Cognitive impairment.

General Considerations

The National Institute on Aging defined failure to thrive (FTT) as “a syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol.” The concepts, cachexia and sarcopenia, have enhanced our understanding of the pathophysiology of FTT and should be considered in the approach to the patient. Cachexia is the catabolic state seen in illnesses such as cancer, end-stage renal disease, lung disease, and heart failure. It is progressive and characterized by weight loss, anorexia, inflammation, and insulin resistance; nutrition therapy does not alter the course. Sarcopenia is loss of muscle mass that occurs with aging. It is associated with functional decline, disability, and falls; it is mitigated by exercise.

Clinical Findings

A. Symptoms and Signs

Weight loss is an essential feature. Functional decline contributes to falls, poor grooming, depression, and cognitive decline. As in infants, FTT can occur from organic and nonorganic causes, necessitating an approach that includes medical, psychological, functional, and social domains.

B. History and Physical Examination

The history provided by the patient and caregiver can help identify common acute triggers: change in medication, infection, constipation, pain, loss, or grief. Undiagnosed chronic diseases, such as endocrine disorders, tuberculosis, dementia, depression, substance abuse, and rarely, hypoactive delirium, may trigger FTT.

Assess, do not assume, medication compliance; have the patient demonstrate how he/she is taking all prescription and over-the-counter (OTC) medications. Drug effects and interactions should not be underestimated. Alendronate, antiarrhythmics, antihistamines (eg, H2-blockers, α-antagonists, benzodiazepines, β-blockers, calcium antagonists, colchicine, and digoxin, even within therapeutic range), diuretics, iron or zinc, metformin, metronidazole, neuroleptics, nonsteroid anti-inflammatory drugs (NSAIDs), narcotics, steroids, SSRIs, tricyclic antidepressants, and xanthines have been associated with FTT. Levels are nonspecific; normal therapeutic ...

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