1 . Which of the following is considered one of the four chief characteristics of geriatric failure to thrive?
| A) | | Hypertension |
| B) | | Malnutrition |
| C) | | Osteoarthritis |
| D) | | Chronic kidney disease |
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.
2 . When developing a treatment plan for a patient with geriatric failure to thrive, the most effective approach is
| A) | | referring all patients for psychiatric evaluation. |
| B) | | limiting treatment to nutritional interventions. |
| C) | | utilizing a holistic, interdisciplinary care model. |
| D) | | focusing primarily on pharmacologic appetite stimulants. |
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.
3 . Which healthcare professional is particularly important for determining appropriate food consistency and swallowing-related dietary modifications?
| A) | | Dietitian |
| B) | | Social worker |
| C) | | Speech therapist |
| D) | | Occupational therapist |
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.
4 . According to recommended nutritional strategies, patients with malnourishment may benefit from
| A) | | reduced caloric intake. |
| B) | | increased dietary restrictions. |
| C) | | elimination of oral nutritional supplements. |
| D) | | iberalization of restrictive diets when appropriate. |
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].
5 . Vitamin D supplementation in older adults is recommended primarily because deficiency is associated with
| A) | | hearing loss. |
| B) | | liver dysfunction. |
| C) | | falls and fractures. |
| D) | | increased blood pressure. |
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].
6 . Which vitamin deficiency may contribute to depression, impaired memory, fatigue, and neurologic symptoms in older adults?
| A) | | Vitamin A |
| B) | | Vitamin B12 |
| C) | | Vitamin C |
| D) | | Vitamin K |
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.
7 . A referral to geriatric psychiatry is especially appropriate when a patient with geriatric failure to thrive experiences
| A) | | mild vitamin deficiency alone. |
| B) | | well-controlled chronic disease. |
| C) | | stable weight and improved function. |
| D) | | continued weight loss despite interventions and behavioral concerns. |
GERIATRIC PSYCHIATRY REFERRAL
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.
8 . Before initiating pharmacologic therapy for geriatric failure to thrive, clinicians should first
| A) | | prescribe an appetite stimulant immediately. |
| B) | | begin anabolic steroid therapy. |
| C) | | assess and address underlying causes of unintentional weight loss. |
| D) | | recommend growth hormone therapy. |
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.
9 . Which medication may be useful for a patient with depression, insomnia, and poor appetite, but has not been shown to promote weight gain in nondepressed individuals?
| A) | | Dronabinol |
| B) | | Mirtazapine |
| C) | | Testosterone |
| D) | | Megestrol acetate |
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.
10 . Which of the following statements regarding megestrol acetate is TRUE?
| A) | | It has no significant adverse effects. |
| B) | | It is recommended for all elderly patients with weight loss. |
| C) | | It is FDA-approved specifically for geriatric failure to thrive. |
| D) | | It may increase the risk of thromboembolism and should generally be avoided in many elderly patients. |
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].
