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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. Small improvements in multiple domains can improve outcomes. Maintaining open communication with patients and/or caregivers is vital. Empower them to play a role in their care and keep expectations realistic. The physician can and should maintain a therapeutic relationship with the patient and the family beyond the time medical therapies are effective. Home visits enhance this relationship and often reveal opportunity for intervention.

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Essentials of Diagnosis

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  • Weight loss of more than 5%.
  • Functional decline.
  • Depression.
  • Cognitive impairment.

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General Considerations

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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." Two new 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.

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Clinical Findings

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Symptoms and Signs

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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.

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History and Physical Examination

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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: endocrine, tuberculosis, dementia, depression, substance abuse, and rarely, hypoactive delirium may trigger FTT.

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Assess, do not assume, medication compliance; have the patient demonstrate how he/she is taking all prescription and over-the-counter medications. Drug effects and interactions should not be underestimated. Alendronate, antiarrhythmics, antihistamines including H2 blockers, α-antagonists, benzodiazepines, β-blockers, calcium antagonists, colchicine, 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 levels can have adverse effects. Be aware of genetic and racial variation in drug metabolism.

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A comprehensive physical examination should focus on those items noted in Table 40-1. Laboratory evaluations should include complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid-stimulating hormone (TSH), erythrocyte sedimentation rate (ESR), total 25-OH vitamin D, B12 (if 200-400 pmol/L check a ...

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