Failure to Thrive (Adult) and Nursing Care

Nursing Care and Failure to Thrive

Failure to Thrive (Adult),Clinical Categorization, Level In Disease Classification, Verdery Propositions About Etiology, Nursing Home Care and FTT.

Failure to Thrive (Adult)

    Adult failure to thrive (FTT) syndrome is defined as a lower-than-expected level of functioning associated with nutritional deficits, depressed mood state, and social isolation. This definition is derived from numerous theoretical, clinical, and research sources (Newbern & Krowchuk , 1994; Verdery , 1996). 

Clinical Categorization

    Clinically, FTT has been used interchangeably with the term's cachexia, frailty, dwindling, nonspecific presentation of illness, and decompensation. 

    Although it has been discussed primarily in relation to the elderly (Egbert , 1996), based on the above definition, it is likely that the syndrome crosses age boundaries and exists in other chronically ill patient populations, for example, adults with multiple sclerosis , AIDS, or diabetes.

Level In Disease Classification

    In the International Classification of Diseases, 10th revision (ICD-10), FTT is most frequently classified as a pediatric diagnosis. In children, FTT is very broadly defined as deviation from an expected growth pattern in terms of norms for age and sex (Frank & Zeisel, 1988). 

    Pediatric FTT is generally classified as organic, in which there is a known underlying medical condition; nonorganic, in which the causes are psychosocial; or mixed. 

    Advances in pediatric research also have produced a theoretical framework in which mal-nutrition is of fundamental importance, either as a primary cause of failure to thrive or a secondary symptom of a chronic illness.

Verdery Propositions About Etiology

    Based on several years of clinical and research experience with the elderly, Verdery (1996) proposed two interesting ideas about the etiology of adult FTT. 

    The first is that the syndrome may occur in response to an event that triggers a more rapid than normal rate of decline. 

    The idea that a trigger event may be a precursor to FTT needs further investigation but it is intuitively believable from both a clinical and research perspective: an event could be physiological in nature (for example, a hip fracture), environmental (for example, a change in residence), psychological (for example, death of a spouse), or a combination of all three. 

    Verderer's second proposition is that there are two categories of adult FTT. This first is primary adult FTT, where the reasons for the patient's decline are ambiguous or obscure. In secondary adult FTT, the reasons are diagnosable and potentially treatable and there is a wide range of possible underlying factors: 

(a) medical history and treatment, for example, immune function or polypharmacy.

(b) psychological problems, primarily depression.

(c) nutritional factors, including eating disorders.

(d) social and/or environmental factors such as isolation or alcohol intake. 

    Although many of the factors in the secondary category of adult FTT have been investigated in relation to health behaviors and outcomes, few have been examined from within a theoretical framework of adult FTT. 

    The framework is in its early stages, and unlike pediatric FTT, there is no consensus on the critical concepts and their relationships, nor are there objective criteria that can be used to evaluate deviation from the norm. There is also relatively little published research on adult FTT, particularly in the last 5-7 years. 

    Methodological approaches have varied and, without a dominant model of adult FTT, studies have used different definitions of the syndrome, as well as various defining criteria. The following brief summaries of four articles illustrate this feature of our current state of knowledge about adult FIT. 

    In one of the earliest reported studies, Messert , Kurlanzik , and Thorning (1976) identified adult FIT through documentation of a cluster of symptoms in five adult patients diagnosed with neurological disorders (age range 24-67, mean = 49 years). 

    All of the patients had irreversible weight loss despite high caloric intake, wide variations in body temperature, decreased level of consciousness, unexplained rapid development of decubitus ulcers, and sudden death. A second study examined characteristics of 62 male patients admitted with a medical diagnosis of FIT ( Osato , Stone, Phillips, & Winne, 1993), using retrospective chart review. 

    The patients had a wide age range (37-104 years), an average of seven medical diagnoses, required an average of five medications, and 62% had low levels of serum albumin (< 3.5 g/dL). 

    A third study retrospectively examined the medical records of 82 elders admitted with a diagnosis of FTT (Berkman et al., 1986) and used factor analysis to group FTT factors into three categories: patient care management problems, functional problems, and patient coping problems. 

    A fourth study followed 252 subjects for 2 years after new hip fracture (Fox, Hawkes, Magaziner , Zimmerman, & Hebe, 1996). Subjects were generally older (mean = 77 years) and FIT was defined as a decline in walking 6-12 months post-fracture after subjects had achieved an initial gain in mobility.     

Results were mixed: those classified as FTT (n = 26) were significantly worse off than the "no decline" group (n = 226) in their cognitive decline, number of hospitalizations at 12 months, and self-reported health at 24 months. No statistically significant differences were found between the two groups on the variables of social interaction or depression scores, mortality, physician visits, or

Nursing Home Care and FTT

    Nursing home stays. Although the literature has yet to produce a universally accepted definition, it appears that adult FTT is a multidimensional concept more accurately defined as a syndrome rather than a medical diagnosis ( Verdery , 1997). 

    And although it is frequently thought of as a precursor to death, there is also support for the idea that adult failure to thrive is not normal aging, the unavoidable result of chronic disease, or a synonym for the terminal stages of dying (Egbert, 1996 ).