Failure to thrive in older adults: Management

INTRODUCTION — Failure to thrive (FTT) describes a syndrome of global decline. The United States National Institute of Aging described 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" [1]. FTT in older adults may represent a final common pathway toward death unless interventions can reverse the course.

For some patients, FTT is caused by a single disease (eg, cancer) and the treatment of that disease drives the management plan. However, in many cases, multiple factors such as medical comorbidities, medications, and psychological factors contribute to impairment. Identifying and treating these contributing factors can change the course of illness, improve quality of life and function in this group of older adults; such treatment should be instituted as appropriate and in keeping with the patient's goals of care.

This topic will present an overview of the management of older adult patients with FTT. Evaluation of older patients with suspected FTT, including evaluation of potentially reversible causes, and an overview of management of the older adult resident in a long-term care facility are discussed separately. (See "Failure to thrive in older adults: Evaluation" and "Medical care in skilled nursing facilities (SNFs) in the United States".)

OUR APPROACH — Failure to thrive (FTT) is a somewhat confusing term that has been used to describe patients with varied clinical scenarios. In some circumstances, the diagnosis is given upon initial evaluation of a patient in decline who has subsequent identification of a treatable illness (eg, depression, grief, thyroid disorder). In this situation, the diagnosis of FTT is no longer useful and the underlying condition should be treated. It is important that all patients with a FTT diagnosis receive a thorough workup for treatable conditions, rather than a preemptive palliative approach. (See "Failure to thrive in older adults: Evaluation".)

Other patients with FTT include those in decline despite optimal management of a chronic or terminal illness (eg, congestive heart failure, chronic obstructive pulmonary disease, cancer, dementia), or those with symptoms of global decline but no causative illness despite appropriate workup. We suggest that both of these patients can benefit from continued management of underlying chronic conditions as well as management of FTT symptoms.

For patients in continued decline despite maximal medical management of treatable conditions, or no definable cause of decline, a diagnosis of FTT marks an appropriate time for the clinician to engage patients and families/other loved ones in discussions about goals of care. A frank evaluation of the relative benefits of life-prolonging versus comfort-oriented treatment is appropriate, as FTT is a condition associated with considerable debility.

However, all patients have the potential for significant improvements in quality of life, even in the setting of a major disease states, by treating symptoms contributing to FTT.

The following measures are appropriate for all patients:

●Enlist a multidisciplinary team (social worker; dietitian; dentist; physical, occupational, and speech therapists) to address symptom management as appropriate.

●Optimize chronic medical illness management, including any new conditions which may be contributing to FTT (eg, reactivation tuberculosis, polymyalgia rheumatica, malignancy). This may involve more aggressive intervention or de-escalating interventions in light of worsening prognosis.

●Evaluate and treat pain.

●Evaluate for potentially reversible causes of FTT (eg, medication side effect, depression, thyroid disease)

●Review medications with the following considerations (see "Drug prescribing for older adults"):

•Medications with the potential to cause drowsiness or lethargy may cause symptoms of FTT. For example, patients who are have previously tolerated stable doses of chronic narcotics may experience increased side effects as they decline, and they may exhibit symptoms of FTT due to oversedation. Reducing the dose or eliminating sedating medications can have a significant beneficial effect on functional status and nutrition.

•Identify and discontinue medications taken for long-term health benefits that are beyond the patient's life expectancy (eg, statins for cardiovascular disease prevention).

•Adjust medication doses to the lowest effective dose in order to lessen adverse side effects. Attention to dose adjustments is especially important for patients with FTT due to changes in pharmacokinetics secondary to progressive renal failure or hypoalbuminemia.

•Address polypharmacy in terms of overall number of medications, as well as the timing and the frequency of dosing.

•Identify and discontinue medications inappropriate for older adults, if possible. In particular, those with anticholinergic properties (table 1) should be discontinued due to their association with voiding difficulties and cognitive decline [2]. Several criteria sets, including Beers Criteria [3] and Assessing Care of Vulnerable Elderly (ACOVE) indicators, have identified potentially inappropriate medications for older individuals (table 2).

●Evaluate patients with end-stage FTT for recurrent infections and development of pressure-induced skin and soft tissue injuries. (See "Epidemiology, pathogenesis, and risk assessment of pressure-induced skin and soft tissue injury", section on 'Malnutrition'.)

SYMPTOM MANAGEMENT — Approaches to the key failure to thrive (FTT) symptoms of weight loss, physical frailty, and neuropsychological impairment are discussed below. For any given patient, the decision of whether to initiate specific treatments is largely based on the preferences of the patient and their family or other loved ones in consideration with the overall goals of care. For the majority of the approaches below, there is little evidence supporting their efficacy, although for some there is evidence of potential harm, and these should be avoided. Patient preference is also an important factor in the decision to discontinue treatments which are only marginally effective or have become burdensome.

Weight loss — Key features of FTT include weight loss and malnutrition, the causes of which are often multifactorial (table 3). Although weight loss may not be reversible, all patients can benefit from efforts to address decreased food intake, with the goal of improving quality of life and potentially increasing weight.

Approaches for increasing food intake — Efforts to improve food intake involve addressing mechanical, social, and dietary issues. Referral to a dietician for evaluation and treatment can help with nutrition management.

●Address dental issues such as oral pain and poor denture fit

●Assess dysphagia and provide an appropriate diet if present

●Provide assistance with feeding and optimize social support at mealtimes

●Eliminate unnecessary dietary restrictions such as low-salt or low-fat diets

●Provide appealing foods, vary texture and flavors, and use finger foods

●Offer frequent small meals and encourage the patient to eat when they choose to

●Decrease pill burden by reducing the number and frequency of medications

●Treat depression if appropriate

Interventions of no or marginal benefit — We suggest caution and limited use of the following interventions as they may have no or marginal benefits.

Caloric supplements — The decision to use caloric supplements should be considered only after removal of dietary restrictions and after other causes of anorexia or dysphagia have been addressed. Subsequently, since both the data and harms are limited, the decision to use of caloric supplements should be based on patient and family or other loved ones' preferences, with considerations of the financial burden and possible intolerance due to diarrhea or nausea. Although oral nutritional supplements (low-volume, high-calorie drinks or puddings) may add protein and calories, the overall benefit is not clear.

●The American Geriatrics Society's "Choosing Wisely" initiative advises to avoid the use of high-calorie supplements for treatment of cachexia in older adults because they do not improve quality of life, mood, functional status, or survival [4].

●In a meta-analysis of trials in older adults, protein and energy supplements yielded a 2.2 percent gain in weight and a small mortality benefit among those who were undernourished but no improvement in function or decrease in hospital length of stay [5].

Appetite stimulants — The best-studied appetite stimulants are megestrol acetate and dronabinol. The 2019 Updated Beers Criteria recommends avoiding megestrol acetate due to the unfavorable risk to benefit ratio [3]. The American Geriatrics Society (AGS) "Choosing Wisely" campaign recommends not using megestrol acetate due to lack of improvement in quality of life or survival and the increased risk of thrombotic events, fluid retention, and death [4]. (See "Geriatric nutrition: Nutritional issues in older adults", section on 'Appetite stimulants'.)

Cyproheptadine is also used as an appetite stimulant but is not recommended by the AGS "Choosing Wisely" campaign or the 2019 Beers Criteria.

Appetite stimulants in patients with anorexia or cachexia are discussed in detail elsewhere. (See "Assessment and management of anorexia and cachexia in palliative care", section on 'Treatment'.)

Physical frailty — Recommendations regarding treatments for physical frailty are mostly made in the context of patients who are frail but more robust than those with FTT. In frail older adults, four interventions (exercise [resistance and aerobic]), vitamin D supplementation, caloric and protein support, and reduction of polypharmacy are recommended [6]. Frailty is discussed in greater detail elsewhere. (See "Frailty".)

Exercise — Exercise, including strength and aerobic training, improves functional outcomes and prevents disability in older adults [7-9] and attenuates the impact of age on mortality [10]. Discussions of exercise for older adults can be found elsewhere. (See "Physical activity and exercise in older adults" and "Practical guidelines for implementing a strength training program for adults", section on 'Important considerations for strength training in older adult patients'.)

For patients with FTT, exercise may play a role, although clinicians should recognize that patients who are preterminal may not be able to exercise, and other patients may not wish to do so. Referral to physical therapy for evaluation and treatment is a key step in an exercise intervention.

Progressive resistance training (PRT) is the best-studied form of exercise for sarcopenia (age-related muscle loss). Resistance exercise among frail nursing home patients increases muscle mass, gait speed, and exercise tolerance [11]. Families and other loved ones should be counseled about ongoing strength and aerobic training or continued PRT after physical therapy treatment has finished.

Vitamin D — Patients with FTT are at risk for sarcopenia. For patients with sarcopenia and low vitamin D levels (<20 ng/mL measured by a 25-hydroxyvitamin D test), Vitamin D supplementation is not recommended to improve sarcopenia alone, but we would consider a trial of therapy on an individual basis for patients with FTT since there is no robust evidence of benefit or harm in this population [12]. For older patients without sarcopenia, the value of treating low vitamin D levels to prevent falls, or to improve physical function, is questionable and is discussed in detail elsewhere [13]. (See "Vitamin D and extraskeletal health".)

Interventions to avoid — We recommend not using growth hormone and anabolic agents in FTT due to lack of efficacy and detrimental side effects [14-17] (see "Frailty", section on 'Ineffective interventions'). The use of ghrelin, an amino-acid peptide which stimulates secretion of growth hormone, is not well studied in the population and is discussed elsewhere [18-20]. (See "Ghrelin".)

Special populations — FTT in patients with dementia, depression and those at the end of life have unique considerations.

Dementia — Patients with dementia and FTT may benefit from increased environmental support, to assist with feeding and self-care, and increased social interaction. Some patients with dementia may stabilize and even improve when their living situation is changed to a higher level of assistance and supervision, such as in an assisted living facility or nursing home. (See "Management of the patient with dementia".)

Patients with advanced dementia lose the ability to chew, swallow, and manage their oral secretions. Providing food for comfort at this stage may be an option, although the risk of aspiration should be evaluated and considered. A discussion of oral versus tube feeding for patients with advanced dementia can be found elsewhere. (See "Care of patients with advanced dementia", section on 'Oral versus tube feeding'.)

For patients with dementia who are depressed, the benefit of antidepressant therapy is discussed elsewhere. (See "Management of neuropsychiatric symptoms of dementia", section on 'Depression'.)

Depression — Treatment of depression may result in marked improvement in FTT and potential reversal of symptoms. The mainstay of therapy for depression is antidepressant medication supplemented by structured psychotherapy, when appropriate.

Electroconvulsive therapy may be appropriate for older patients with severe depression. (See "Diagnosis and management of late-life unipolar depression".)

Antidepressants — Antidepressant medications are chosen based on their desired side effect profile, as most agents are equally effective. In older patients with depressive symptoms, we would use mirtazapine or a selective serotonin reuptake inhibitor (SSRI)/serotonin–norepinephrine reuptake inhibitor (SNRI) not associated with anorexia (eg, citalopram, venlafaxine) to treat depression and possibly assist with weight gain. Bupropion and the SSRIs fluoxetine and sertraline are more likely to cause anorexia and weight loss than other antidepressants [21]. Although tricyclic antidepressants may improve appetite more than SSRIs, they have significant anticholinergic side effects.

Mirtazapine is known to have side effects of increased appetite and weight gain [22]. Although at least one case report has described efficacy in FTT [23], two studies comparing mirtazapine with other non-tricyclic antidepressants in depressed older nursing facility patients showed similar weight gain in both groups [24,25]. In general, the use of mirtazapine for treatment of unintended weight loss is not recommended in the absence of depression [26]. Depressed older adult patients who are wary of taking an antidepressant may be willing to try mirtazapine if it offered as an appetite stimulant rather than an antidepressant. (See "Atypical antidepressants: Pharmacology, administration, and side effects", section on 'Mirtazapine'.)

Psychostimulants — Severely depressed and medically ill older adults are sometimes treated with psychostimulants such as methylphenidate to rapidly improve the symptoms of depression. There is limited evidence to support use of psychostimulants to improve food intake. However, in patients with significant apathy symptoms it may be worthwhile to attempt a brief trial of low-dose methylphenidate with caution to monitor for side effects [27-29].

●In a case series of 129 medically ill geriatric patients given methylphenidate or dextroamphetamine for depression, 81 percent demonstrated some improvement, starting on the second day of treatment [30]. Only 8 percent had to stop the drug trial due to adverse side effects.

Although psychostimulants are not considered appetite stimulants, methylphenidate at low doses may improve apathy and give patients enough energy to eat and to participate in activities. However, methylphenidate at doses of 20 mg per day was associated with weight loss in patients with dementia [31].We suggest that if methylphenidate is used, it should be initiated cautiously at small doses, starting typically with 2.5 mg in the morning and titrating slowly.

HOSPICE — Failure to thrive (FTT) may represent a final common pathway toward death unless interventions can reverse the course. Even with the best of care, a patient's weight loss and functional decline may not be amenable to interventions or may not improve depending on the underlying disease state and comorbidities. As FTT in the older adult progresses, it is important to consider a focus on palliative care.

FTT and debility are no longer diagnoses used for enrollment in hospice; in April 2013, the Centers for Medicare and Medicaid Services (CMS) indicated that FTT or debility are not primary diagnoses for hospice admission; rather, hospices should bill for the primary disease state as the principal diagnosis [32]. However, the prognosis for any disease state will be worse if the patient meets criteria for clinical decline. Frequently used criteria for determining non-disease-specific decline in clinical status that correlate with a six-month prognosis may include [33]:

●Weight loss not due to reversible causes

●Recurrent or intractable infections

●Recurrent aspiration and/or inadequate oral intake due to intractable dysphagia

●Progressive decline in Karnofsky Performance status

●Progressing dementia by objective measures

●Progressive pressure ulcers (stage 3 or 4) despite optimal care

Since hospice can provide support and benefits for patients with FTT who are approaching the end of life, consultation with a local hospice organization or palliative care specialist may be helpful in determining eligibility. (See "Hospice: Philosophy of care and appropriate utilization in the United States".)

Other issues related to end-of-life care are discussed separately in multiple topics in UpToDate. (See "Ethical issues in palliative care" and "Legal aspects in palliative and end-of-life care in the United States" and "Approach to symptom assessment in palliative care" and "Stopping nutrition and hydration at the end of life" and "Overview of managing common non-pain symptoms in palliative care" and "Overview of comprehensive patient assessment in palliative care".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Malnutrition (The Basics)" and "Patient education: Malnutrition – Discharge instructions (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Patient selection – Management of failure to thrive (FTT) as outlined above is appropriate for patients in whom reversible causes of decline have been evaluated and treated. (See 'Introduction' above and 'Our approach' above.)

●Assessing goals of care – A diagnosis of FTT may be considered as a critical point for evaluation of the patient's overall goals of care. A frank discussion of the relative benefits of life-prolonging versus comfort-oriented treatment is appropriate. Aggressive interventions should be approached cautiously in the face of declining functional status and worsening prognosis. However, all patients have the potential to benefit from interventions to improve quality of life. (See 'Our approach' above.)

●Multidisciplinary approach – Treatment for FTT may involve enlisting a multidisciplinary team (eg, social worker, dietitian, dentist, physical, occupational, and speech therapists) as needed to address contributing factors. (See 'Our approach' above.)

●Approach to weight loss – For patients with weight loss, interventions to increase food intake include assistance with feeding, discontinuation of dietary restrictions, addressing oral and swallowing issues, and providing social support at mealtimes. Referral to a dietician for evaluation and treatment can help with nutrition management. (See 'Approaches for increasing food intake' above.)

•If diet interventions have failed to improve food intake, the use of caloric supplements can be considered be based on patient and family/other loved ones' preferences, in light of the financial burden and possible intolerance due to diarrhea or nausea. (See 'Caloric supplements' above.)

•We agree with guidelines for older adults that recommend avoiding appetite stimulants (megestrol acetate or dronabinol) since these drugs have marginal benefit and potential side effects. (See 'Appetite stimulants' above.)

●Management of physical frailty – For patients with physical frailty, progressive resistance training (PRT) or strength and aerobic training can improve functional outcomes, if they are able to exercise. (See 'Physical frailty' above.)

●Treating depression – For patients with depression, treatment can improve appetite. Antidepressants differ in their impact on appetite and weight and, when a trial of antidepressants is initiated, the choice of antidepressant should include consideration of their side effect profile. In older patients with both depressive symptoms and weight loss, we would prescribe mirtazapine or a selective serotonin reuptake inhibitor (SSRI)/serotonin–norepinephrine reuptake inhibitor (SNRI) not associated with anorexia (eg, citalopram, venlafaxine). (See 'Antidepressants' above.)

•For patients with severe depression, a psychiatry consultation is indicated for consideration of other therapies, hospitalization, and/or electroconvulsive therapy. (See 'Depression' above.)

●Patients with dementia – Patients with advanced dementia lose the ability to chew, swallow, and manage their oral secretions. Providing food for comfort at this stage may be an option, although the risk of aspiration should be evaluated and considered. (See 'Dementia' above.)

●Palliative approach for some patients – As FTT advances, a palliative care approach should be considered, including hospice evaluation. (See 'Hospice' above.)