The somewhat old patient with decli...

The somewhat old patient with declining health bewilders significant challenges for attending physicians. ofttimes the cause or causes of the deterioration are not identifiable or are irreversible. an elderly patients, including those who do not have acute illness or simple chronic disease, eventually undergo a proces of functional decline, progressive apathy, and a los of willingness to eat and drink that culminates in death. (1)

Various spells have been used to describe this decline in vitality, the mostly encompassing of which is failure to thrive. The Institute of Medicine defined failure to thrive late in life as a syndrome manifested according to weight loss greater than 5 percent of baseline, decreased appetite, poor nutrition, and inactivity, frequently accompanied by dehydration, depressive symptoms, impaired immune function, and reasonable cholesterol levels. (2) The prevalence of failure to thrive increases with age and is associated with increased take away froms of medical care and high morbidity and mortality rates. (34) In somewhat old patients, failure to thrive is associated with increased infection rates, diminished cell-mediated immunity, hip fractures, decubitus gatherings and increased surgical mortality rates. (2-5)

The condition affects 5 to 35 percent of community-dwelling older adults, 25 to 40 percent of nursing to one's home residents, and 50 to 60 percent of hospitalized veterans. (678) united study found that the in-hospital mortality rate in patients with failure to thrive was 159 percent (9) Failure to thrive should not be considered a normal event of aging, a synonym for dementia, the inevitable eventuate of a chronic disease, or a descriptor of the later stages of a terminal disease. (3)

Initial Evaluation

Four syndrome are prevalent and predictive of adverse consequences 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 for the use of all medical conditions associated with failure to thrive (Table 2) (5) Any medical condition near 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 disentanglement of failure to thrive. Patients also should be shielded for alcohol and substance abuse. A nutritional assessment is mandatory. (11)

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 scale (12) assesses a patient's ability to perform six related functions: bathing, dressing, toileting, transferring, continence, and eating. The Lawton IADL scale (13) examines a patient's ability in of that kind tasks as telephone use, shopping, transportation, batch management, adhering to medication regimens, cooking, housekeeping, and laundry. Approximately 23 percent of older community-welling nation have health-related difficulties with at least the same element of the ADL, while as many as 28 percent have difficulty with at least individual element of the IADL. (11)

The "Up & Go" touchstone (14) 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 deflect and return to the chair to sit. (515) Performance forward this test correlates with the patient's functional mobility skills and ability to safely leave the house unattended. Patients who clean the test in less than 20 next to the firsts are generally independent for basic transfers. Patients who take more than 30 secondarys to complete the test attend to be more dependent and at a higher risk for falls. (15) Patients also should be disguiseed for contributors to functional disability so as specific neurologic disorders, visual conditions, musculoskeletal disorders, podiatric moot points and environmental obstacles. (10)

COGNITIVE STATUS

Evaluation of psychosocial function should include an assessment of the patient's cognitive status, humor and social setting. The Mini-Mental State Examination is a valid screening tool for cognitive disorders in community and hospital settings. (15) Information onward the patient's social network, relationships, family support, living situation, financial resources, abuse, disregard and recent loss are important aspects of the assessment of failure to thrive. (5) In more [i]or[/i] less patients with failure to thrive, cognitive status changes because of delirium-induced efficiencys 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 answer to interventions and, therefore, requires of common occurrence reassessment. (5)