Am Fam Physician. 2004;70(2):248-257
In this issue of American Family Physician, Robertson and Montagnini1 review the challenges of caring for an aged patient with multiple problems whose health and vitality are rapidly declining. The term “failure to thrive,” which was borrowed from health care for children to describe this accelerated decline, began appearing in the geriatric literature more than 30 years ago to denote a range of circumstances including physical and mental deterioration, abuse and neglect, and rapidly progressing frailty.
In a study2 of physicians who used the term “geriatric failure to thrive,” the authors noted that it “is a term irregularly used and poorly defined.” They questioned whether the concept should be used in reference to geriatric patients, fearing that it “can reinforce the stereotype of elderly people as demented and decrepit” and “may actually hinder the urgent search for treatable, reversible causes of an elder’s deterioration.”2 Other authors3 concluded that “the label ‘failure to thrive’ promotes an intellectual laziness—accompanied by a certain resignation, passivity, or fatalism.” These authors3 responded with a recommendation for “the abandonment of the term ‘failure to thrive’ and the adoption of a more measurement-oriented approach” that explicitly assesses impaired physical function, malnutrition, depression, and dementia.
A review of MEDLINE citations and geriatric textbooks shows that, although “failure to thrive” is still a fairly common focus of authors in nutrition and nursing, it has become less prominent in the medical literature in the past six years as a central conceptualizing theme.
Contributing to concern about the use of the term “geriatric failure to thrive” are the generally vague or broad definitions, the huge clinical territory to which the term has been applied, and the difficulties of formulating a coherent research agenda. Family physicians should be wary of the application and implications of this label. First, geriatric failure to thrive should not be treated as a diagnosis or a specific disease.3 Second, it should not be equated with frailty.4 Decreased function, strength, and stamina are hallmarks of the frail aged person; however, frailty is primarily a state of increased risk and low reserve to stress, a state which all people who live into their ninth decade manifest at varying levels.4,5
Failure to thrive should be seen as an unexpected and significant falling away from the normal curve of declining vigor, weight, function, and reserve that affects even the healthiest aged persons.5 Finally, failure to thrive should not be a summary concept of a patient’s situation that prompts resignation and withdrawal of efforts to find underlying causes,2 and it should not be the final clinical thought.
If the term “geriatric failure to thrive” is of any use, it is as a brief reminder to the clinician that there is major work ahead in carefully reviewing potentially reversible underlying processes in aged patients who are manifesting unexpected and unexplained declines in nutritional intake and weight, self-care, cognitive function, and interest in life. It is true that a single major problem may not be identified or, if identified, may not be reversible. However, multiple contributors often can be found, and some of them can be ameliorated; some, when thoughtfully addressed, can serve to leverage improvement in other issues that had seemed refractory.6
Encountering the unexpected and unexplained acceleration of decline in a frail aged patient gives family physicians a wonderful opportunity to do what they do best: serve as human ecologists, as expert observers and investigators, and as healers of dysfunction in a complex hierarchy comprising a biological system and an individual with a mind, feelings, and personality, who is living within a family, community, and environment.