Detecting "Failure to Thrive"

Nursing Homes, Oct, 2001 by Karen S. Roth

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

60 * October 2001

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]