Elderly Care Center: Failure to Thrive in Older Adults

by Eileen Early, RN, BSN

Failure to thrive, a term historically used to portray children who don’t grow at the expected rate, is increasingly being used in the elderly care center to describe older adults who begin to decline for no clear reason.

Most skilled nursing home workers have known at least one of them the resident who seems to have “just given up” or lost the will to live, typically showing signs such as weight loss, decreased appetite, poor nutrition, and inactivity.

Signs of failure to thrive in nursing home residents can be very subtle, including things like depression or withdrawal, less engagement in the events around them, a change in mental status, or decreased pleasure in activities they used to enjoy.

Although there are noticeable changes in those experiencing failure to thrive, people who see them every day might not be able to see them. The changes are often hard to notice because they are so gradual. Their life begins unraveling, they become disengaged, and they experience emotional and mental drift.

Thorough Assessment

What can be done to help people in the elderly care center who show the marked decline typical of failure to thrive?

The first step is a comprehensive initial assessment that includes an evaluation of physical and psychological health, functional ability, and social and environmental factors-a thorough check of all the systems to make sure everything is functioning as it should.

After taking a detailed health history, the doctor will look at any existing chronic health conditions or medical problems and look for recent changes in disease management.

For instance, diabetic patients might not be keeping their blood sugar under control, or patients with hypertension might be forgetting their blood pressure medications.

The next part of the process is to look for relatively simple problems – such as urinary tract or respiratory infections – that are having negative effects on the patient. A problem with teeth or oral health, for example, can cause eating or appetite changes.

The doctor will also want to assess the patient’s emotional state and wellbeing, asking about any changes in sleep and eating habits or signs of depression – is the patient having any thoughts of suicide, or thoughts that make death seem appealing?

Finally, the doctor will perform a more in-depth evaluation of any problem areas, followed by a plan of action that might include physical or occupational therapy, nutritional supplementation, new medication, or fine-tuning the dosage and timing of current medications to minimize side effects.

Finding the root cause of failure to thrive might not be possible; the causes and effects are often intertwined. Depression can be a cause and a consequence of failure to thrive and the same could be said of virtually any of the symptoms.

Syndromes Point to Adverse Outcome

Physicians should evaluate patients in each of these areas.

• Impaired physical function. “Activities of daily living,” or ADLs, consist of everyday tasks such as eating, bathing, moving around in one’s environment, and dressing.

  Patients who have trouble with these activities will likely have a difficult time maintaining their independence. Physicians have a number of simple tests that they can ask the patient to perform in order to assess physical status.

• Malnutrition. Many medical conditions that are common among the elderly – and, unfortunately, the medications used to treat them – can result in poor nutrition among older adults.

  To discern the causes of malnutrition, physicians can discuss dietary habits with patients and run a number of laboratory tests to assess conditions such as dehydration, electrolyte imbalances or loss of muscle mass.

• Depression. Depression is one of the more common psychiatric conditions of older persons in the elderly care center. It exists often in response to physical, mental or emotional issues that accompany aging. We don’t use psychotherapy or anti-depressants as effectively as we should in the geriatric population.

  A significant percentage of the time, there’s a role depression is playing in their behavior.” There are numerous tests and questionnaires that doctors can use to evaluate a patient’s state of mind, and a number of highly effective medications to help alleviate the condition.

• Cognitive impairment. In addition to physical health problems, many situations can have an impact on the status of a patient’s mental function: Information on the patient’s social network, relationships, family support, living situation, financial resources, abuse, neglect, and recent loss are important aspects of the assessment.

After considering reversible causes of failure to thrive, the doctor will want to look for more serious illnesses like cancer or thyroid disease.

Older residents might not recognize the decline themselves or dismiss the concerns of family members or staff. If an individual has been well functioning and something changes, the elderly care center worker might have to point it out to him/her and s/he might deny it or disagree. The caregiver might have to be assertive, explaining that there’s been a noticeable change and need to find the cause.

Doctors should give positive feedback to ailing elderly care center residents and reassure them that it might be possible to help them feel better.

Failure to thrive is often a decision point. One looks for reversible causes. If there are none, it might be time to change expectations about this patient and move from therapeutic to palliative care.