Detecting "Failure to Thrive".

A new assessment tool to help identify and manage this often mystifying syndrome in elderly patients

Chronically ill older adults who enter or reside in long-term care facilities often complain of general malaise-"just not feeling well." Family members and the healthcare team might note that they are "going downhill." This condition of progressive decline is sometimes referred to as "failure to thrive" (FTT), a syndrome of nonspecific symptoms.

There are ways to manage this, and indicators of FTT are needed so that early assessment and treatment can be initiated. The Episcopal Church Home, a 180-bed, not-for-profit long-term care facility in Rochester, New York, developed a program designed to address this issue. Its major objective was to learn ways in which a Multidisciplinary Care Plan Team (MDCPT) could more effectively identify' residents in the early stages of declining health status.

No commonly accepted definitions have been developed for the "failure to thrive" syndrome, which makes it difficult to compare study results and understand the causes of these syndromes.'

The prevalence of FTT is difficult to estimate because the syndrome is multidimensional and nonspecific in nature. It is typically under-reported, and the diagnosis has not been formally accepted in many healthcare disciplines. Adding to the difficulty in understanding FTT is the fact that there are numerous overlapping symptoms and clinically complex problems in the average elderly resident. Nevertheless, studies at one nursing home revealed that an estimated 50 to 60% of newly admitted individuals had evidence of the syndrome.2

Organic and nonorganic causes, as well as psychological factors, play a critical

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role. The causes of FTT include occult organic illness, polypharmacy, malnutrition, depression, dementing illnesses, age-related changes in the presence of decreased homeostatic reserves and an inadequate psychological support system. As mentioned, the label FTT is often used to describe a complex of nonspecific and generalized symptoms that frequently lead to increased disability and premature death. These nonspecific symptoms of decline include:

* Unexplained/unintentional weightloss with development or worsening of anemia, renal insufficiency, anorexia and malnutrition;

* Deterioration in mental status and cognitive ability with social isolation, clinical depression, agitation, withdrawal or decreased will to live;

* Functional ability changes with resulting complications (e.g., skin breakdown, falls and pain);

* Episodic changes or disease exacerbations (e.g., angina, congestive heart failure); and

* Complications (e.g., fever and infection).

After conducting a comprehensive pilot study at The Episcopal Church Home using many of the above criteria, I developed the Multidisciplinary Decline Rounding Audit tool (Figure) to assist the MDCPT in early detection of failure to thrive.

Decline Program

Believing that all residents of longterm care facilities should be routinely assessed for changes in their ongoing health status, the MDCPT used the Decline Rounding Audit to identify residents who were declining early in the course of their disease progression. This proactive stance was intended not only to aid in early diagnosis of FTT, but also to facilitate therapeutic intervention. It was also hoped that in cases involving irreversible deterioration and hospice referrals, earlier detection would enable residents and their families to receive the fullest benefit of services. This program has been found to provide a means whereby all residents are continually assessed for changes in health status that might indicate FTT.

The major components and objectives of the Early Detection of Failure to Thrive program include:

* Assessment and early identification by the MDCPT of the seven "markers" for decline/FTT for all residents. Any member of the team may request that a resident be reviewed if he or she suspects changes. The audit can easily be completed in 5 to 15 minutes, using the resident record.

* Planning and mobilization of the MDCPT with the resident and family, when appropriate, to modify the plan of care as needed. This often involves a medical workup, psychological consultation, nutritional evaluation, physical therapy and occupational therapy consultation.

* Mobilization, communication and involvement of the MDCPT with the resident/family in the care-planning process, and this is documented. Advance Directives are often reviewed and altered to accommodate resident/family wishes.

* Increased autonomy for residents and families in healthcare decision making and Advance Directives.

* Clinical evaluation and follow-up as indicated.

Follow-up evaluations and documentation of stabilization and/or hospice referral are scheduled and completed. The audits, which are kept on record, are often the basis for MDS/care-plan review. The Audit Tool is more user-friendly than the MDS, is a predictor of FTT, and is more holistic and comprehensive. It is similar in some respects to the outlined clinical approach and standardized outpatient evaluation method used at the Arizona Center on Aging to identify common problems causing failure to thrive. [3]

Tool Evaluation

A retrospective, noncontrolled and nonexperimental study was undertaken to evaluate the original Audit Tool. For one year all residents who died were retrospectively evaluated to see if they had shown evidence of FTT prior to death. Incidental information relevant to diagnosis, hospice utilization, presence of the audit criteria and length of stay at facility were also recorded.

Given the high association of mortality with FTT in the elderly, it was anticipated that there would have been at least three of the seven decline indicators prior to death and, in fact, study data revealed that most residents who died had exhibited symptoms of decline in the three months prior to death. The data also revealed that several indicators, specifically weight loss/ weight gain, worsening renal function or anemia (with or without GI bleeding), along with presence of pain, were the chief indicators of a poor outcome.

Early identification and assessment, utilizing the Decline Rounding Audit, assisted the team in providing consistent, improved care for residents experiencing declining health status. This in-depth geriatric assessment provided the team with directions to reverse or halt failure to thrive similar to those outlined by others, such as Boston University Medical Center, which recognized organic etiologies of failure, as well as psychosocial factors and their interactions. [4]

Improved communication between the MDCPT and residents and their families in the care-planning process was realized. Outcomes, ranging from health stabilization to hospice referral, were provided in a more timely manner. It is felt that the MDCPT has become better prepared to meet the needs of residents and their families, and that this holistic and focused approach to resident care has ultimately improved the residents' quality of life.

Summary and Conclusions

The need to improve assessment of and decision making for the frail elderly in long-term care becomes more apparent each day. Manylong-term care facilities are grappling with challenging issues, such as providing timely resident care while ensuring the individual's rights and dignity. The Early Detection of Failure to Thrive program has proven to help meet these challenges.

The Decline Rounding Audit, which is an effective multidisciplinary tool, may be modified for implementation in any setting with diverse populations-acute, subacute or long-term care. Future studies to evaluate failure to thrive in the elderly are needed to improve even further the quality of life of the geriatric resident.

Acknowledgments

The author wishes to acknowledge Erane Allen, vice-president of operations of The Episcopal Church Home, for her support and encouragement; Elaine Gallup for her editorial assistance and manuscript preparation; and Nancy Watson, PhD, for her mentorship and assistance with research and design.

Karen S. Roth, MS, RN, CS-ANP, is a nurse practitioner with the Medical Department of The Episcopal Church Home, Rochester, New York.

References

(1.) Roubenoff R, Harris TB. Failure to thrive, sarcopenia and functional decline in the elderly. Clin Geriatr Med 1997;13(4):613-22.

(2.) Morley, Kraenzle D. Causes of weight loss in a community nursing home [see comments]. J Am Geriatr Soc 1994;42(6):583-5.

(3.) Verdery RB. Clinical evaluation of failure to thrive in older people. Clin Geriatr Med 1997;13(4):769-78.

(4.) Markson EW. Functional, social, and psychological disability as causes of loss of weight and independence in older community-living people. Clin Geriatr Med 1997;13(4):639-52.

Additional Reading

Berkman B, Foster LW, Campion E. Failure to thrive: Paradigm for the frail elder. Gerontologist 1989;29(5):654-9.

Braun JV, Wykle MH, Cowling WR III. Failure to thrive in older persons: A concept derived. Gerontologist 1989;28(6):809-12.

Brink S. The American way of dying. U.S. News & World Report, Dec. 4, 1995, pp. 70-5.

Chriskis AN, Escsrce JJ. Survival of medicare patients after enrollment in hospice programs. J Am Geriatr Soc 1997;45:259-61.

Cranmer K. Hospice defined: benefits, problems, and regulatory conflicts. Nursing Home Medicine 1997;5(7):230-7.

Cutchins CH. Making room for hospice. Geriatr Nurs 1991;12(3):144-6.

Dimant J. An algorithm and guidelines for assessment and care planning of weight loss in nursing home residents. Nursing Home Medicine 1997;5(9):308- 14.

Duthrie EH, Gambert SK. Geriatrics consultation: Implication for teaching and clinical care. Geriatrics and Geriatrics Education 1983;4(2):59-66.

Hoffman C, Rice D, Sung HY. Persons with chronic conditions. Their prevalence and costs [see comments]. JAMA 1996;276:1473-9.

Keller H. Malnutrition in institutionalized elderly: How and why? Am Geriatr Soc l993;41:1212-18.

Kimball MJ, Williams-Burgess C. Failure to thrive: The silent epidemic of the elderly. Arch Psychiatr Nurs 1995;9(2):99-105.

Newbern VB, Krowchuk HV. Failure to thrive in elderly people: A conceptual analysis. J Adv Nurs 1994;19(5):840-9.

Rymes J. Hospice care in the nursing home. Nursing Home Medicine 1993;1(6):14-24.

Sahayoun NR, Otradovec CL, Hartz SC, et al. Dietary intakes and biochemical indicators of nutritional status in the elderly institutional population. Am Clin Nutr 1988;47(3):524-33.

Wallace JI, Schwartz RS, La Croix AZ, et al. Involuntary weight loss in older outpatients: Incidence and clinical significance [see comments] J Am Geriatr Soc 1995;43(4):329-37.