Geriatric Failure to Thrive



FREE PREVIEW Log in or buy this issue to read the full article. AAFP members and paid subscribers get free access to all articles. Subscribe now.


FREE PREVIEW Subscribe or buy this issue. AAFP members and paid subscribers get free access to all articles.

Am Fam Physician. 2004 Jul 15;70(2):343-350.

  Related Editorial

ACF  This article exemplifies the AAFP 2004 Annual Clinical Focus on caring for America’s aging population.

In elderly patients, failure to thrive describes a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments. Manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity. Four syndromes are prevalent and predictive of adverse outcomes in patients with failure to thrive: impaired physical function, malnutrition, depression, and cognitive impairment. Initial assessments should include information on physical and psychologic health, functional ability, socioenvironmental factors, and nutrition. Laboratory and radiologic evaluations initially are limited to a complete blood count, chemistry panel, thyroid-stimulating hormone level, urinalysis, and other studies that are appropriate for an individual patient. A medication review should ensure that side effects or drug interactions are not a contributing factor to failure to thrive. The impact of existing chronic diseases should be assessed. Interventions should be directed toward easily treatable causes of failure to thrive, with the goal of maintaining or improving overall functional status. Physicians should recognize the diagnosis of failure to thrive as a key decision point in the care of an elderly person. The diagnosis should prompt discussion of end-of-life care options to prevent needless interventions that may prolong suffering.

The elderly patient with declining health poses significant challenges for attending physicians. Often, the cause or causes of the deterioration are not identifiable or are irreversible. Some elderly patients, including those who do not have acute illness or severe chronic disease, eventually undergo a process of functional decline, progressive apathy, and a loss of willingness to eat and drink that culminates in death.1

Strength of Recommendations

Key clinical recommendation SOR labels References

The Geriatric Depression Scale and the Cornell Scale for Depression in Dementia are useful tools for assessing this dynamic in patients with failure to thrive.

B

1820

High-intensity resistance exercise training counteracts muscle weakness and physical frailty in very elderly people.

A

25

The goal of dietary supplements is to provide adequate energy and protein intake, so almost anything the patient eats is suitable.

B

5, 27

Strength of Recommendations

View Table

Strength of Recommendations

Key clinical recommendation SOR labels References

The Geriatric Depression Scale and the Cornell Scale for Depression in Dementia are useful tools for assessing this dynamic in patients with failure to thrive.

B

1820

High-intensity resistance exercise training counteracts muscle weakness and physical frailty in very elderly people.

A

25

The goal of dietary supplements is to provide adequate energy and protein intake, so almost anything the patient eats is suitable.

B

5, 27

Various terms have been used to describe this decline in vitality, the most encompassing of which is failure to thrive. The Institute of Medicine defined failure to thrive late in life as a syndrome manifested by weight loss greater than 5 percent of baseline, decreased appetite, poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol levels.2 The prevalence of failure to thrive increases with age and is associated with increased costs of medical care and high morbidity and mortality rates.3,4 In elderly patients, failure to thrive is associated with increased infection rates, diminished cell-mediated immunity, hip fractures, decubitus ulcers, and increased surgical mortality rates.25

The condition affects 5 to 35 percent of community-dwelling older adults, 25 to 40 percent of nursing home residents, and 50 to 60 percent of hospitalized veterans.6,7,8 One study found that the in-hospital mortality rate in patients with failure to thrive was 15.9 percent.9 Failure to thrive should not be considered a normal consequence of aging, a synonym for dementia, the inevitable result of a chronic disease, or a descriptor of the later stages of a terminal disease.3

Initial Evaluation

Four syndromes are prevalent and predictive of adverse outcomes in persons who may have failure to thrive: (1) impaired physical function, (2) malnutrition, (3) depression, (4) and cognitive impairment.10 A comprehensive initial assessment should include information about physical and psychologic health, functional ability, and socioenvironmental factors.

The medical assessment includes a thorough history and physical examination, a comprehensive review of medications (prescription and nonprescription), and laboratory and diagnostic testing (Table 1).5  This assessment should assist the physician in identifying common medical conditions associated with failure to thrive (Table 2).5  Any medical condition present in a patient with failure to thrive merits an assessment of its severity and susceptibility to remediation. Table 35 outlines medications that can contribute to the development of failure to thrive. Patients also should be screened for alcohol and substance abuse. A nutritional assessment is mandatory.11

TABLE 1

Evaluating Elderly Patients for Failure to Thrive

Test Target conditions

Blood culture

Infection

Chest radiography

Infection, malignancy

Complete blood count

Anemia, infection

Computed tomography, MRI

malignancy, abscess

ESR, C-reactive protein levels

Inflammation

Growth hormone, testosterone (men)

Endocrine deficiency

HIV, RPR test

Infection

PPD

Tuberculosis

Serum albumin and cholesterol levels

Malnutrition

Serum BUN and creatinine levels

Dehydration, renal failure

Serum electrolyte levels

Electrolyte imbalance

Serum glucose level

Diabetes

Thyroid-stimulating hormone level

Thyroid disease

Urinalysis

Infection, renal failure, dehydration


MRI = magnetic resonance imaging; ESR = erythrocyte sedimentation rate; HIV = human immunodeficiency virus; RPR = reactive plasma reagin; PPD = purified protein derivative; BUN = blood urea nitrogen.

Adapted with permission from Verdery RB. Clinical evaluation of failure to thrive in older people. Clin Geriatr Med 1997;13:769–78.

TABLE 1   Evaluating Elderly Patients for Failure to Thrive

View Table

TABLE 1

Evaluating Elderly Patients for Failure to Thrive

Test Target conditions

Blood culture

Infection

Chest radiography

Infection, malignancy

Complete blood count

Anemia, infection

Computed tomography, MRI

malignancy, abscess

ESR, C-reactive protein levels

Inflammation

Growth hormone, testosterone (men)

Endocrine deficiency

HIV, RPR test

Infection

PPD

Tuberculosis

Serum albumin and cholesterol levels

Malnutrition

Serum BUN and creatinine levels

Dehydration, renal failure

Serum electrolyte levels

Electrolyte imbalance

Serum glucose level

Diabetes

Thyroid-stimulating hormone level

Thyroid disease

Urinalysis

Infection, renal failure, dehydration


MRI = magnetic resonance imaging; ESR = erythrocyte sedimentation rate; HIV = human immunodeficiency virus; RPR = reactive plasma reagin; PPD = purified protein derivative; BUN = blood urea nitrogen.

Adapted with permission from Verdery RB. Clinical evaluation of failure to thrive in older people. Clin Geriatr Med 1997;13:769–78.

TABLE 2

Common Medical Conditions Associated with Failure to Thrive in Elderly Patients

Medical condition Cause of failure to thrive

Cancer

Metastases, malnutrition, cancer cachexia

Chronic lung disease

Respiratory failure

Chronic renal insufficiency

Renal failure

Chronic steroid use

Steroid myopathy, diabetes, osteoporosis, vison loss

Cirrhosis, history of hepatitis

Hepatic failure

Depression, other psychiatric disorders

Major depression, psychosis, poor functional status, cognitive loss

Diabetes

Malabsorption, poor glucose homeostasis, end-organ damage

Hip or other large-bone fracture

Functional impairment

Inflammatory bowel disease

Malabsorption, malnutrition

Myocardial infarction, congestive heart failure

Cardiac failure

Previous gastrointestinal surgery

Malabsorption, malnutrition

Recurrent urinary infections or pneumonia

Chronic infection, functional impairment

Rheumatologic disease (e.g., temporal arteritis, rheumatoid arthritis, lupus erythematosus)

Chronic inflammation

Stroke

Dysphagia, depression, cognitive loss, functional impairment

Tuberculosis, other systemic infection

Chronic infection


Adapted with permission from Verdery RB. Clinical evaluation of failure to thrive in older people. Clin Geriatr Med 1997;13:769–78.

TABLE 2   Common Medical Conditions Associated with Failure to Thrive in Elderly Patients

View Table

TABLE 2

Common Medical Conditions Associated with Failure to Thrive in Elderly Patients

Medical condition Cause of failure to thrive

Cancer

Metastases, malnutrition, cancer cachexia

Chronic lung disease

Respiratory failure

Chronic renal insufficiency

Renal failure

Chronic steroid use

Steroid myopathy, diabetes, osteoporosis, vison loss

Cirrhosis, history of hepatitis

Hepatic failure

Depression, other psychiatric disorders

Major depression, psychosis, poor functional status, cognitive loss

Diabetes

Malabsorption, poor glucose homeostasis, end-organ damage

Hip or other large-bone fracture

Functional impairment

Inflammatory bowel disease

Malabsorption, malnutrition

Myocardial infarction, congestive heart failure

Cardiac failure

Previous gastrointestinal surgery

Malabsorption, malnutrition

Recurrent urinary infections or pneumonia

Chronic infection, functional impairment

Rheumatologic disease (e.g., temporal arteritis, rheumatoid arthritis, lupus erythematosus)

Chronic inflammation

Stroke

Dysphagia, depression, cognitive loss, functional impairment

Tuberculosis, other systemic infection

Chronic infection


Adapted with permission from Verdery RB. Clinical evaluation of failure to thrive in older people. Clin Geriatr Med 1997;13:769–78.

TABLE 3

Medications Commonly Associated with Failure to Thrive in Elderly Patients

Medication class Possible effect

Anticholinergic drugs

Cognition changes, dysgeusia, dry mouth

Antiepileptic drugs

Cognition changes, anorexia

Benzodiazepines

Anorexia, depression, cognition changes

Beta blockers

Cognition changes, depression

Central alpha antagonists

Cognition changes, anorexia, depression

Diuretics (high-potency combinations)

Dehydration, electrolyte abnormalities

Glucocorticoids

Steroid myopathy, diabetes, osteoporosis

More than four prescription medications

Drug interactions, adverse effects

Neuroleptics

Anorexia, parkinsonism

Opioids

Anorexia, cognition changes

SSRIs

Anorexia

Tricyclic antidepressants

Dysgeusia, dry mouth, cognition changes


SSRI = selective serotonin reuptake inhibitors.

Adapted with permission from Verdery RB. Clinical evaluation of failure to thrive in older people. Clin Geriatr Med 1997;13:773.

TABLE 3   Medications Commonly Associated with Failure to Thrive in Elderly Patients

View Table

TABLE 3

Medications Commonly Associated with Failure to Thrive in Elderly Patients

Medication class Possible effect

Anticholinergic drugs

Cognition changes, dysgeusia, dry mouth

Antiepileptic drugs

Cognition changes, anorexia

Benzodiazepines

Anorexia, depression, cognition changes

Beta blockers

Cognition changes, depression

Central alpha antagonists

Cognition changes, anorexia, depression

Diuretics (high-potency combinations)

Dehydration, electrolyte abnormalities

Glucocorticoids

Steroid myopathy, diabetes, osteoporosis

More than four prescription medications

Drug interactions, adverse effects

Neuroleptics

Anorexia, parkinsonism

Opioids

Anorexia, cognition changes

SSRIs

Anorexia

Tricyclic antidepressants

Dysgeusia, dry mouth, cognition changes


SSRI = selective serotonin reuptake inhibitors.

Adapted with permission from Verdery RB. Clinical evaluation of failure to thrive in older people. Clin Geriatr Med 1997;13:773.

FUNCTIONAL ASSESSMENT

The assessment of physical function should include documentation of a patient’s ability to perform activities of daily living (ADL) and instrumental activities of daily living (IADL). The Katz ADL scale12 assesses a patient’s ability to perform six related functions: bathing, dressing, toileting, transferring, continence, and eating. The Lawton IADL scale13 examines a patient’s ability in such tasks as telephone use, shopping, transportation, budget management, adhering to medication regimens, cooking, housekeeping, and laundry. Approximately 23 percent of older community-dwelling people have health-related difficulties with at least one element of the ADL, while as many as 28 percent have difficulty with at least one element of the IADL.11

The “Up & Go” test14 is a performance-based measure that can be administered easily in the office setting. The patient is asked to rise from a sitting position, walk 10 feet, turn, and return to the chair to sit.5,15 Performance on this test correlates with the patient’s functional mobility skills and ability to safely leave the house unattended. Patients who complete the test in less than 20 seconds are generally independent for basic transfers. Patients who take more than 30 seconds to complete the test tend to be more dependent and at a higher risk for falls.15 Patients also should be screened for contributors to functional disability such as specific neurologic disorders, visual conditions, musculoskeletal disorders, podiatric problems, and environmental obstacles.10

COGNITIVE STATUS

Evaluation of psychosocial function should include an assessment of the patient’s cognitive status, mood, and social setting. The Mini-Mental State Examination is a valid screening tool for cognitive disorders in community and hospital settings.15 Information on the patient’s social network, relationships, family support, living situation, financial resources, abuse, neglect, and recent loss are important aspects of the assessment of failure to thrive.5 In some patients with failure to thrive, cognitive status changes because of delirium-induced effects of chronic illnesses. Various medications can trigger depression, functional incapacity, and nutritional deficiency. A patient’s cognitive status can change because of overall health and in response to interventions and, therefore, requires frequent reassessment.5

DEPRESSION

The most common psychiatric condition in older persons is depression.16 Depression can be a cause and a consequence of failure to thrive. Therefore, screening for depression is necessary for all patients who exhibit characteristics of failure to thrive.13 Elderly patients who are depressed are more likely to complain of physical problems than to mention conventional depressive symptoms (such as mood changes) and may manifest depression as weight loss. Traditional signs of depression in young persons, such as changes in attention span, concentration, and memory, are often misdiagnosed in elderly persons as dementia.16

Depression that occurs for the first time late in life is frequent in patients with significant chronic disease; the impact of these medical conditions is increased by depression.17 A delay in the diagnosis and treatment of depression in elderly patients may accelerate the decline associated with failure to thrive and increase morbidity and mortality. The Geriatric Depression Scale (Figure 1)18 and the Cornell Scale for Depression in Dementia19 are useful tools for assessing this dynamic in patients with failure to thrive.20

Geriatric Depression Scale (Short Form)

Figure 1

Geriatric depression scale (short form)

Adapted with permission from Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol 1986;5:165–73.

View Large

Geriatric Depression Scale (Short Form)


Figure 1

Geriatric depression scale (short form)

Adapted with permission from Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol 1986;5:165–73.

Geriatric Depression Scale (Short Form)


Figure 1

Geriatric depression scale (short form)

Adapted with permission from Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol 1986;5:165–73.

MALNUTRITION

Malnutrition is an independent predictor of mortality in older adults. The most accurate evidence of malnutrition in an elderly patient is hypocholesterolemia and hypo-albuminemia.9,21 Assessment of malnutrition involves a dietary history that includes daily caloric intake, the availability of food, the use of nutritional or herbal supplements, and the adequacy of the patient’s diet as quantified through the amount of food intake, the number of meals, and the balance of nutrients. Body weight, weight trend, and muscle wasting that is found on physical examination and confirmed by laboratory data (such as serum albumin and total cholesterol levels, and lymphocyte count) should be included.22 The Mini Nutritional Assessment, a validated tool for measuring nutritional risk in elderly persons that combines anthropometric measures and dietary history, is easy to use in the office setting.23 Patients also should be assessed for oral pathology, ill-fitting dentures, problems with speech or swallowing, medication use that might cause anorexia or dysgeusia, and financial and social problems that may be contributors to malnutrition.22

Treatment

Treatment of failure to thrive should focus on identifiable diseases and be limited to interventions that have few risks for these frail patients. Failure to thrive commonly occurs near the end of a person’s life, so the potential benefits of treatment should be considered before evaluations and treatments are undertaken.5 Initially, treatment involves efforts to modify possible causes. A team approach that includes a dietitian, a speech therapist, a social worker, a mental health professional, and a physical therapist may be helpful.3 Figure 224 offers an algorithmic approach to the diagnosis and management of elderly patients with failure to thrive.

Failure to Trive in Elderly Patients

Figure 2

Algorithm for the diagnosis and management of elderly patients with failure to thrive. (MMSE = Mini-Mental State Examination; ADL = activities of daily living; IADL = instrumental activities of daily living)

*-A positive response is defined as achievement of set pretreatment goals, as determined by the patient, the patient's family, and participating caregivers.33

Information from reference 24.

View Large

Failure to Trive in Elderly Patients


Figure 2

Algorithm for the diagnosis and management of elderly patients with failure to thrive. (MMSE = Mini-Mental State Examination; ADL = activities of daily living; IADL = instrumental activities of daily living)

*-A positive response is defined as achievement of set pretreatment goals, as determined by the patient, the patient's family, and participating caregivers.33

Information from reference 24.

Failure to Trive in Elderly Patients


Figure 2

Algorithm for the diagnosis and management of elderly patients with failure to thrive. (MMSE = Mini-Mental State Examination; ADL = activities of daily living; IADL = instrumental activities of daily living)

*-A positive response is defined as achievement of set pretreatment goals, as determined by the patient, the patient's family, and participating caregivers.33

Information from reference 24.

Resistive and strength testing have shown promise in patients with nearly all physical conditions and resulted in increased muscle strength even in elderly, deconditioned patients living in nursing homes. High-intensity resistance exercise training counteracts muscle weakness and physical frailty in very elderly people.25 In patients with confirmed cognitive impairment, treating the underlying conditions and optimizing the patient’s living conditions may improve functional ability. The diagnosis of Alzheimer’s-type dementia requires treatment consistent with current guidelines.

Nutritional supplementation is one of the most important interventions in patients with failure to thrive.26 Because the goal of dietary supplements is to provide adequate energy and protein intake, almost anything the patient eats is suitable.5,27 In elderly patients, the administration of dietary supplements between meals rather than with meals may be more effective in increasing energy consumption.28

Insufficient food intake in elderly patients may be corrected or ameliorated by manipulation of nonphysiologic factors, such as the number of people present at meals, the palatability of meals, and the time of day and location of meals.29 Because elderly persons with Alzheimer’s disease tend to eat more food in the morning, it is recommended that they be given more food at breakfast.30 Increasing the palatability of meals also improves food intake and body weight in elderly nursing home residents.31 There is some evidence that megestrol (Megace) and dronabinol (Marinol) are helpful in prompting appetite, but they are associated with significant side effects; patients should be monitored closely while receiving these medications.32,33

The mainstay of treatment of major depression in patients with failure to thrive should be antidepressants, supplemented with structured approaches to psychotherapy, if appropriate. In cases where depression and deterioration are severe enough that the time required for response to antidepressants may endanger the patient, hospitalization and use of electroconvulsive therapy may be considered.34

In standard, controlled clinical trials, the selective serotonin reuptake inhibitors (SSRIs) fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) appear to be equivalent in efficacy to tricyclic antidepressants (TCAs), with response rates in elderly patients of 60 to 80 percent.34 Evidence suggests that mirtazapine (Remeron) may be more effective than SSRIs but not as effective as TCAs in promoting weight gain.3436 Newer antidepressants are as effective as older TCAs in the treatment of depression, with the caveat that side effects of the older medications are more prominent, and the newer agents are better tolerated.16 The benefits of antidepressant therapy can be maximized by ensuring proper dosing and compliance.37

The Authors

RUSSELL G. ROBERTSON, M.D., is associate dean for faculty affairs and a faculty member in the Department of Family and Community Medicine at the Medical College of Wisconsin, Milwaukee. Dr. Robertson is also the medical director of Mequon Healthcare Center, Mequon, Wisc. He received his medical degree from Wayne State University School of Medicine, Detroit, and completed a family practice residency at Grand Rapids Family Practice Residency Program, Grand Rapids, Mich. Dr. Robertson holds a certificate of added qualification in geriatrics.

MARCOS MONTAGNINI, M.D., is assistant professor of medicine at the Medical College of Wisconsin. He is also a staff geriatrician and director of the palliative care program at the Zablocki Veterans Affairs Medical Center, Milwaukee. Dr. Montagnini received his medical degree at the Faculdade de Ciências Médicas da Santa Casa de São Paulo, Brazil, and completed an internal medicine residency at Boston University and a geriatrics fellowship at the University of Michigan Medical School, Ann Arbor. He is board-certified in internal medicine, geriatric medicine, and hospice and palliative medicine.

Address correspondence to Russell G. Robertson, M.D., Department of Family and Community Medicine, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226 (e-mail: rrdoc@mcw.edu). Reprints are not available from the authors.

The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.

References

1. McCue JD. The naturalness of dying. JAMA. 1995;273:1039–43.

2. Institute of Medicine (U.S.), Committee on a National Research Agenda on Aging, Lonergan ET. Extending life, enhancing life: a national research agenda on aging. Washington, D.C.: National Academy Press, 1991.

3. Egbert AM. The dwindles: failure to thrive in older patients. Nutr Rev. 1996;54:S25–S30.

4. Fischer J, Johnson MA. Low body weight and weight loss in the aged. J Am Diet Assoc. 1990;90:1697–706.

5. Verdery RB. Clinical evaluation of failure to thrive in older people. Clin Geriatr Med. 1997;13:769–78.

6. Verdery RB. Failure to thrive in old age: follow-up on a workshop. J Gerontol A Biol Sci Med Sci. 1997;52: M333–M6.

7. Silver AJ, Morley JE, Strome LS, Jones D, Vickers L. Nutritional status in an academic nursing home. J Am Geriatr Soc. 1988;36:487–91.

8. Berkman B, Foster LW, Campion E. Failure to thrive: paradigm for the frail elder. Gerontologist. 1989;29:654–9.

9. Sullivan DH, Wall RC, Lipschitz DA. Protein-energy under-nutrition and the risk of mortality within 1 y of hospital discharge in a select population of geriatric rehabilitation patients. Am J Clin Nutr. 1991;53:599–605.

10. Sarkisian CA, Lachs MS. “Failure to thrive” in older adults [published correction appears in Ann Intern Med 1996;125:701]”. Ann Intern Med. 1996;124:1072–8.

11. American Association of Retired Persons, United States, Administration on Aging. A profile of older Americans, 1996. Washington, D.C.: AARP, 1996.

12. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963;185:914–9.

13. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9:179–86.

14. Posiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–8.

15. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician”. J Psychiatr Res. 1975;12:189–98.

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

17. Katz IR, Streim J, Parmelee P. Prevention of depression, recurrences, and complications in late life. Prev med. 1994;23:743–50.

18. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol. 1986;5:165–73.

19. Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell scale for depression in dementia. Biol Psychiatry. 1988;23:271–84.

20. Watson LC, Pignone MP. Screening accuracy for late-life depression in primary care: a systematic review. J Fam Pract. 2003;52;956–64.

21. Verdery RB, Goldberg AP. Hypocholesterolemia as a predictor of death: a prospective study of 224 nursing home residents. J Gerontol. 1991;46:M84–90.

22. Huffman GB. Evaluating and treating unintentional weight loss in the elderly. Am Fam Physician. 2002;65:640–50.

23. Guigoz Y, Vellas B, Garry PJ. Assessing the nutritional status of the elderly: The Mini Nutritional Assessment as part of the geriatric evaluation. Nutr Rev. 1996;54: S59–S65.

24. Bogardus ST, Bradley EH, Williams CS, Maciejewski PK, van Doorn C, Inouye SK. Goals for the care of frail older adults: do caregivers and clinicians agree? Am J Med. 2001;110:97–102.

25. Fiatarone MA, O’Neill EF, Ryan ND, Clements KM, Solares GR, Nelson ME, et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med. 1994;330:1769–75.

26. Lipschitz DA. Approaches to the nutritional support of the older patient. Clin Geriatr Med. 1995;11:715–24.

27. Milne AC, Potter J, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev 2004;1:CD003288.

28. Wilson MM, Purushothaman R, Morley JE. Effect of liquid dietary supplements on energy intake in the elderly. Am J Clin Nutr. 2002;75:944–7.

29. De Castro JM. Age-related changes in the social, psychological, and temporal influences on food intake in free-living, healthy, adult humans. J Gerontol A Biol Sci Med Sci. 2002;57:M368–M77.

30. Young KW, Greenwood CE. Shift in diurnal feeding patterns in nursing home residents with Alzheimer’s disease. J Gerontol A Biol Sci Med Sci. 2001;56:M700–M6.

31. Mathey MF, Siebelink E, de Graaf C, Van Staveren WA. Flavor enhancement of food improves dietary intake and nutritional status of elderly nursing home residents. J Gerontol Med A Biol Sci Med Sci. 2001;56:M200–M5.

32. Yeh SS, Wu SY, Lee TP, Olson JS, Stevens MR, Dixon T, et al. Improvement in quality-of-life measures and stimulation of weight gain after treatment with megestrol acetate oral suspension in geriatric cachexia: results of a double-blind, placebo-controlled study. J Am Geriatr Soc. 2000;48:485–92.

33. Volicer L, Stelly M, Morris J, McLaughlin J, Volicer BJ. Effects of dronabinol on anorexia and disturbed behavior in patients with Alzheimer’s disease. Int J Geriatr Psychiatry. 1997;12:913–9.

34. Katz IR, DiFilippo S. Neuropsychiatric aspects of failure to thrive in late life. Clin Geriatr Med. 1997;13:623–38.

35. Fava M. Weight gain and antidepressants. J Clin Psychiatry. 2000;61:37–41.

36. Raji MA, Brady SR. Mirtazapine for treatment of depression and comorbidities in Alzheimer disease. Ann Pharmacother. 2001;35:1024–7.

37. Anderson DN. Treating depression in old age: the reasons to be positive. Age Ageing. 2001;30:13–7.



Copyright © 2004 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Article Tools

  • Download PDF
  • Print page
  • Share this page
  • AFP CME Quiz

Information From Industry

More in Pubmed

Navigate this Article