The Multidisciplinary Approach to Investigating Failure to Thrive
Failure to thrive (FTT) in older adults is not a single disease but a complex syndrome often characterized by unintentional weight loss, decreased appetite, malnutrition, and impaired physical function. Its causes are multifactorial, spanning physical, psychological, and socioeconomic domains. For this reason, a single test is rarely sufficient, and a comprehensive, multidisciplinary assessment is crucial for accurate diagnosis and effective intervention.
The Foundational Assessment: History and Physical Examination
The investigative process begins with a meticulous and detailed geriatric assessment. This goes beyond a standard physical exam to gather a holistic view of the senior’s health and living situation. A healthcare provider will collect information on:
- Medical History: Reviewing existing chronic conditions (e.g., heart failure, COPD, diabetes), recent illnesses, and past hospitalizations that could contribute to decline.
- Dietary History: Documenting food intake, appetite changes, swallowing difficulties (dysphagia), and any issues with chewing or dental health.
- Psychosocial Factors: Exploring social isolation, recent life events (loss of a loved one), living situation, financial constraints, and access to food.
- Functional Status: Assessing the ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) like meal preparation, shopping, and managing finances.
The physical examination will look for obvious signs of malnutrition, dehydration, muscle wasting (sarcopenia), and any physical indicators of underlying disease. Observation of the patient during a meal can also provide critical insights into feeding issues.
Laboratory and Imaging Investigations
Based on the history and physical exam, a healthcare provider will order a series of tests to screen for common issues associated with FTT. Indiscriminate testing is often unhelpful, so the selection of tests is guided by clinical suspicion.
Standard Laboratory Tests
- Complete Blood Count (CBC): Checks for anemia, infection, and other blood disorders.
- Complete Metabolic Panel (CMP): Measures electrolytes, kidney function (BUN, creatinine), liver function, and blood glucose, which can indicate dehydration, organ failure, or diabetes.
- Thyroid-Stimulating Hormone (TSH): Evaluates thyroid function, as both hyperthyroidism and hypothyroidism can affect weight and energy levels.
- Urinalysis: Screens for urinary tract infections or kidney problems.
Advanced Nutritional and Inflammatory Markers
- Serum Albumin and Prealbumin: While not always a definitive measure of nutrition due to influences from infection and inflammation, low levels can indicate malnutrition.
- C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR): High levels suggest an inflammatory process, which can be linked to chronic illness, infection, or cancer.
Imaging Studies
- Chest X-ray: A basic imaging study to check for signs of infection (pneumonia) or malignancy in the lungs.
- Abdominal Ultrasound: May be considered to investigate gastrointestinal or abdominal issues suggested by symptoms.
- CT or MRI Scan: Reserved for cases where specific symptoms or initial lab results point toward a more serious issue, such as a tumor or systemic infection.
Psychological and Cognitive Assessments
Mental health issues like depression and cognitive impairment are major contributors to FTT and must be evaluated. Formal screening tools are commonly used.
- Geriatric Depression Scale (GDS): This simple questionnaire is an effective tool for screening for depression, which can significantly impact appetite and motivation.
- Mini-Mental State Examination (MMSE): A standard test to assess cognitive function, memory, and awareness, helping to detect dementia or other cognitive issues that might interfere with eating or self-care.
Medication and Substance Review
Polypharmacy and adverse drug reactions are often overlooked causes of FTT. A thorough review of all medications, including prescription drugs, over-the-counter supplements, and alcohol or substance use, is a critical step. Many medications can cause dry mouth, altered taste, nausea, or appetite suppression.
Comparison of Assessment Types
| Assessment Type | What It Uncovers | When It is Used |
|---|---|---|
| History & Physical | Overall health, specific symptoms, functional capacity, social context, environmental factors | Initial, foundational evaluation for all patients |
| Laboratory Tests | Infections, organ function, electrolyte imbalances, some nutritional deficiencies | Routine screening; tailored to specific symptoms |
| Imaging Studies | Malignancy, internal infections, organ abnormalities | Directed by specific symptoms or abnormal lab findings |
| Nutritional Screening | Inadequate caloric intake, specific nutrient deficiencies, swallowing issues | Initial evaluation and ongoing monitoring |
| Psychological Screen | Depression, anxiety, cognitive decline | Initial screening for all patients, especially with mood or memory changes |
| Medication Review | Side effects, drug interactions impacting appetite or energy | Initial evaluation and whenever there is a change in status |
Putting It All Together for a Diagnosis
Once the comprehensive data is gathered, the healthcare team can synthesize the information to determine the root cause or causes of the failure to thrive syndrome. It is common for multiple factors to be at play simultaneously. For instance, a senior with heart failure may experience increased fatigue (impaired physical function), leading to less interest in cooking (poor nutrition), which is compounded by a new medication's side effect (medication issues), resulting in the overall FTT presentation.
Conclusion
Investigating failure to thrive in older adults is a complex but necessary process that demands a holistic and patient-centered approach. By moving beyond a simple diagnostic label and undertaking a full geriatric assessment, healthcare providers can uncover the reversible medical, psychological, or social issues contributing to decline. Early detection and intervention, guided by these thorough investigations, are essential for improving the patient's quality of life and prognosis.
For more detailed guidance on geriatric assessment, visit the American Academy of Family Physicians at https://www.aafp.org/pubs/afp/issues/2011/0101/p48.html.
