This course examines the complex, multidimensional nature of geriatric failure to thrive (FTT) and emphasizes the importance of a holistic, interdisciplinary approach to patient care. The course reviews explores strategies for developing comprehensive treatment plans for patients with geriatric FTT. Participants will learn evidence-based approaches to nutritional therapy, the management of common vitamin and mineral deficiencies, the role of family involvement in improving outcomes, and circumstances warranting referral to geriatric psychiatry. The course also evaluates commonly used pharmacologic interventions, including their potential benefits, limitations, and risks, enabling healthcare professionals to make informed treatment decisions that support the health, function, and quality of life of older adults.
This course is designed for nurses, nurse practitioners, and behavioral health professionals who work in or are interested in learning more about geriatrics.
The purpose of this course is to educate healthcare providers involved in care planning and provision for patients with geriatric failure to thrive.
Upon completion of this course, you should be able to:
- Discuss the approach to nutritional therapy in the treatment of geriatric failure to thrive.
- Evaluate cases in which referral to geriatric psychiatry would benefit the patient with geriatric failure to thrive.
- Compare and contrast medications used to manage geriatric failure to thrive.
Susan Waterbury, MSN, FNP-BC, ACHPN, entered the medical field in 1985 as a certified medical assistant and basic x-ray operator. She achieved her RN in 1990 and practiced in a variety of settings, including hospital, home health care, and hospice. Ms. Waterbury achieved her BSN in 1996 and her MSN as a Family Nurse Practitioner in 1999. She was board-certified as an FNP-BC in 2000 and has practiced in family practice, geriatrics, corporate leadership, hospice, and palliative care settings. She holds RN and NP licenses in Florida and Arizona.
In addition to her clinical roles, Ms. Waterbury continues to play an active role in educating and mentoring nurses and healthcare professionals. She has been a faculty member of the University of Phoenix since 2015, teaching in the nurse practitioner and MSN programs. She develops and presents educational programs for a variety of healthcare organizations and community groups.
Contributing faculty, Susan Waterbury, MSN, FNP-BC, ACHPN, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
Mary Franks, MSN, APRN, FNP-C
Alice Yick Flanagan, PhD, MSW
The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
Sarah Campbell
The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.
The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.
Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.
It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
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The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.
Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.
#99110: Treatment Planning for Geriatric Failure to Thrive
Failure to thrive is defined by the Institute of Medicine as "weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction, and low cholesterol" [1]. It is not a single disease or medical condition. Rather, it is a multidimensional problem that requires a multidisciplinary approach for its treatment. The four chief characteristics of geriatric failure to thrive are impaired physical function, malnutrition, depression, and cognitive impairment [2]. Failure to thrive is commonly used as a nonspecific diagnosis when a patient loses weight due to an unknown cause. After the diagnosis is made, it stimulates further assessment and interventions. Each of the domains of geriatric failure to thrive should be evaluated to determine areas in which the elder is having difficulty.
When developing a treatment plan for patients with geriatric failure to thrive, it is important to take a holistic and interdisciplinary approach in order to address all of the domains of geriatric failure to thrive [2]. Input from medical specialists, nursing staff, social workers, and physical, speech, and occupational therapists should be considered. Treatment efforts addressing only the physical effects of geriatric failure to thrive will most likely not achieve the desired results. For patients with both acute and chronic illnesses, acute infections and conditions should be resolved before a longer term plan is implemented.
During periods of acute illness, an elderly patient can experience a decline in function, and resolution of the acute condition may return the patient to his or her baseline. Common acute illnesses that cause physical and cognitive function deficits in older adults include urinary tract infection, pneumonia, dehydration, and exacerbation of congestive heart failure or COPD. Extended periods of bed rest also prove detrimental and can cause severe debility. Delirium can develop, requiring the use of physical or chemical restraints. Acute medical conditions also increase nutritional requirements at a time when nutritional intake is often reduced secondary to poor eating. After the acute issue is resolved, medical treatment may be provided for any other conditions present. Optimization of treatment of chronic illnesses is crucial in the care of patients with failure to thrive.
Family meetings may be difficult but are often productive interactions. These conferences provide an opportunity to present the results of the specialty consults and the tests and assessments that have been performed and for the patient and family to ask questions or request additional information. If further medical care and treatments would be futile or serve to prolong the dying process, this should be conveyed to the patient and family. Advance directives should be reviewed and updated. Any concerns expressed by the patient or family should be fully addressed. The healthcare provider, family members, and patient should leave the meeting with an agreement regarding the plan of care and treatment desired. When patients and family members have a good understanding of the options available, including potential benefits and risks, they are in a position to provide informed consent, and this can help to prevent misunderstandings later.
Correction of vitamin and nutritional deficits is necessary to reverse malnutrition. As such, collaboration with a dietician and a speech therapist is essential when caring for patients with failure to thrive. The speech therapist can determine the consistency of food best suited for the patient's needs and can recommend modifications to the established diet. The patient may require thickened liquids, puréed diet, mechanical soft diet, or other variation. Some patients will benefit from a restorative dining program, as supervision, encouragement, and socialization may increase food intake.
Discontinuation of restricted diets is an appropriate step for the patient with malnourishment. Therapeutic and restrictive diets do not promote adequate energy intake and should be thoroughly reviewed for each patient [3]. For example, the American Dietetic Association recommends a liberalized diet approach for nursing home residents [4]. A dietician should assess patients' food preferences and determine if oral nutritional supplements would be appropriate and accepted by the patient. The most common approach is to provide liquid nutritional supplements, shakes, and puddings between meals, with the goal of increasing calorie consumption. Geriatric patients may eat most of their calories at breakfast, which should be accommodated. It is important to provide high-calorie, fortified foods when the patient's appetite is greatest [2].
The first line of treatment for most patients living in nursing facilities is administration of oral liquid nutritional supplements. These are added to the plan of care and generally administered by nursing staff and dietary assistants. Compliance with the treatment plan can be an issue, and it is essential to evaluate whether the supplements are offered and taken as prescribed.
Fortified foods are prepared with extra protein and calories to provide a more calorie-dense food. The addition of one-third cup of instant, nonfat dry milk adds 80 calories, 8 g protein, and 12 g carbohydrates. The addition of butter, milk, and cream boosts calorie intake as well, and oral protein supplements are available to help reverse protein malnutrition. Making the supplements appealing to the patient is an ongoing challenge.
Families can play a large role in reversing malnutrition in a nursing facility. When the family is present for a meal or brings in the patient's favorite food, intake is improved [2]. Patients may complain that they do not like the food that is served, and family members are better equipped to cater to any ethnic preferences. Family members can often coax their loved one to eat their meal and take liquid nutritional supplements. Dedicated staff members and caregivers can promote positive outcomes by making sure supplements are offered and taken.
A number of common vitamin and mineral deficiencies may occur in patients with failure to thrive. Deficiencies may occur from not consuming enough fresh, nutrient-rich foods and/or from malabsorption disorders of the gastrointestinal tract. Common nutrient deficiencies include vitamin B12, vitamin D, iron, and zinc. In most cases, deficiencies will resolve with the administration of vitamins and supplements.
The consequences of vitamin D deficiency include muscle weakness, body sway, osteomalacia, and a tendency for falls and fractures [5]. Many elderly persons are not exposed to enough sunlight each day for adequate vitamin D synthesis. Supplementation with 800 IU of vitamin D daily is recommended and has been shown to reduce falls [6,7].
Vitamin B12 deficiency occurs due to inadequate dietary intake or impaired absorption. It may be associated with neurologic symptoms such as tingling of extremities, fatigue, irritability, depression, weakened concentration, and impaired memory [8]. It is fairly common in the elderly population due to decreased or absent intrinsic factor secondary to atrophic gastritis, achlorhydria, or previous gastric surgery. Deficiency may also be caused by medication side effects, such as those associated with the prolonged use of proton pump inhibitors. Vitamin B12 deficiency is traditionally treated by injectable cobalamin but is also effectively addressed with an oral supplement 1–2 grams daily.
Eldertonic is a vitamin B complex elixir with zinc, manganese, and magnesium in an alcohol base. The usual dose is 15 cc given three times daily, just before meals [8]. It is similar to a before meal alcoholic drink with a sherry base. Although some patients may find it distasteful and refuse to take it, no significant side effects have been noted [9]. It is associated with a mild anecdotal appetite improvement, which may be the result of correcting zinc and vitamin deficiencies.
Zinc deficiency is common in the institutionalized and homebound elderly patient. Zinc is needed for protein synthesis and is important in wound healing and skin repair and renewal. Zinc deficiency is caused by inadequate intake, gastrointestinal malabsorption, or increased zinc losses from the body (e.g., with diarrhea) and is associated with increased inflammation in older patients [10]. A diet lacking in zinc can lead to frequent infections, delayed wound healing, reduced appetite, decreased taste and smell, poor skin condition, and white flecks on the nails. A replacement dose of 50 mg elemental zinc per day is recommended.
Iron deficiency leading to anemia is a common finding in the elderly patient, affecting an estimated 3 million elderly Americans [11]. The most common causes include iron deficiency (with or without blood loss), chronic disease/inflammation, and chronic kidney disease [11,12]. Serum ferritin levels less than 45 mcg/L are suspicious for iron deficiency in the elderly [13]. Iron replacement therapy should be undertaken cautiously, as high iron stores can also be detrimental.
It is important to identify the cause of anemia and to treat accordingly. This often includes a gastroenterology evaluation [11]. Ferrous sulfate 200 mg three times a day is usually sufficient to replenish iron stores. It is important to consider ordering stool softeners at the same time, as constipation and fecal impaction are side effects. Supplementation should continue for three months past correction of the deficiency.
In addition to multiple medical comorbidities and psychiatric disorders associated with aging (e.g., dementia), the geriatric patient may have longstanding psychiatric illness, such as bipolar disorder or psychosis, requiring multiple medications [14]. This makes treating the geriatric psychiatric patient quite complex.
There are multiple long-term complications associated with typical and atypical antipsychotic medications, including pharmacokinetic and pharmacodynamic changes, limitations, and cardiovascular and other adverse effects (e.g., gastrointestinal, liver) [14]. A patient may develop a Parkinsonian syndrome secondary to long-term antipsychotic use, resulting in dysphagia, tremors, difficulty performing activities of daily living, and difficulty feeding, all of which can result in unintentional weight loss [14]. Prior to changing longstanding medication regimens, a geriatric psychiatrist should be consulted in order to help prevent exacerbation of the underlying psychiatric illness.
Psychiatric symptoms associated with dementia, such as anxiety or agitation, may cause an increased energy demand. Psychiatric symptoms such as pacing, hyperactivity, repetitive behaviors, insomnia, and mania all can lead to weight loss. These symptoms should be effectively managed. Referral to a psychiatrist or psychologist is recommended in cases of continued weight loss, treatment failures, and additional behavioral problems.
Potential underlying causes of unintentional weight loss should be fully assessed and treated prior to initiating pharmacotherapy for geriatric failure to thrive. Each patient should be evaluated on an individual basis prior to prescribing an appetite stimulant. The medications commonly used and discussed in the following section are not approved by the U.S. Food and Drug Administration (FDA) for appetite stimulation in patients with failure to thrive.
Mirtazapine is an atypical antidepressant with noradrenergic and specific serotonergic effects. It is indicated for major depressive disorder in the elderly; the starting geriatric dose is 7.5 mg at bedtime [15]. This can be increased to a maximum of 45 mg, if necessary. Mirtazapine's antihistamine-like effects are more pronounced at the 15 mg daily dosage. Mirtazapine has been studied for treatment of depression, anxiety, and anorexia nervosa with depression, with weight gain as a secondary endpoint. The weight gain usually occurs early in therapy. It has not been shown to be effective for weight gain in nondepressed individuals. Its sedating effects can be useful for patients with sleep disturbances or anxiety.
Dronabinol is a schedule III drug that contains delta-9-tetrahydrocannabinol (THC), the major active component of cannabis. It is FDA-approved to treat AIDS-related anorexia and refractory nausea and vomiting secondary to chemotherapy [15]. Dronabinol may also improve disturbed behavior in patients with Alzheimer disease [16]. Dronabinol is available in doses of 2.5 mg, 5 mg, and 10 mg in a gel cap that cannot be crushed and as an oral solution with a calibrated oral dosing syringe [15]. When used for geriatric failure to thrive, it is usually given one hour before meals (lunch and dinner). It has also been used as a single dose at bedtime due to central nervous system (CNS) side effects.
More research is needed regarding the use of dronabinol in the elderly population. Precautions should be used if this drug is prescribed to patients with liver disorders or seizure disorders [15]. There may be significant CNS side effects, including somnolence, emotional lability, and euphoria.
Megestrol acetate is a synthetic progestin and antineoplastic agent product, originally used for patients with cancer. Its use for weight loss in geriatric patients without cancer or AIDS is considered off label [15]. In small studies, megestrol has been effective at increasing appetite in certain geriatric patients at higher doses, although the actual impact on weight gain appears slight and side effects are common [17,18,19,20]. It has the potential to increase hypercoagulability, leading to thromboembolism. In addition, megestrol has glucocorticoid-like activity, which can potentially cause adrenal insufficiency and worsening of diabetes. New-onset diabetes and exacerbation of pre-existing diabetes have been reported with long-term use [15]. A case report associated megestrol acetate to two cases of osteoporosis; higher dosages of megestrol are associated with decreased bone density and may be associated with bone loss and fractures [21].
While megestrol has had some positive results for weight gain in the past, the potential drawbacks limit its use in practice. Patients with a history of thromboembolism should not receive megestrol. The Beers list includes megestrol acetate as a potentially harmful drug in the elderly, and its use should generally be avoided [22].
Anabolic steroids have been used in elderly patients with unintended weight loss with varying results. However, the side effects may prohibit their use in the geriatric population. Adverse reactions may include hyperglycemia, aggression, agitation, psychosis, and osteoporosis [23]. Anabolic steroids are possibly best known as the substance that athletes use to increase muscle volume and strength. The Anabolic Steroids Control Act classifies steroids as a controlled substance [24,25]. It is a criminal offense for providers to prescribe an anabolic steroid unless it is used to treat a disease or medical condition.
The anabolic steroid nandrolone decanoate was the subject of a study of hip fracture recovery in elderly women [26]. In this study, a small dose was administered to determine if it could preserve lean body mass. The authors suggest that nandrolone decanoate with vitamin D and calcium supplementation improved body composition, bone mineral density, and clinical function. However, a systematic review found insufficient evidence to support the use of anabolic steroids for rehabilitation after hip fracture in the elderly and recommended that future research focus on a combined intervention of anabolic steroids and nutritional supplements [27].
Administration of testosterone, growth hormone, and essential amino acids are other approaches to geriatric sarcopenia and cachexia that have had variable results [28,29]. Growth hormone was found to increase lean body mass and decrease fat mass. The side effects may prohibit its use, however, except for in controlled trials [28]. Growth hormone was found to cause insulin resistance, diabetes, and carpal tunnel syndrome. More clinical research is necessary before the use of anabolic steroids, amino acids, or growth hormones can be recommended for geriatric weight loss.
Geriatric failure to thrive is a multifactorial syndrome that requires comprehensive assessment and coordinated intervention across multiple domains of care. Successful treatment extends beyond addressing weight loss alone and involves identifying underlying medical, nutritional, psychological, functional, and social contributors to decline. Nutritional optimization, correction of vitamin and mineral deficiencies, family engagement, and appropriate psychiatric consultation are key components of an effective care plan. While pharmacologic therapies may be considered in select cases, they should be used cautiously and only after reversible causes have been evaluated and addressed. Through an interdisciplinary and patient-centered approach, healthcare professionals can improve functional outcomes, enhance quality of life, and better support older adults experiencing geriatric failure to thrive.
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Mention of commercial products does not indicate endorsement.