What is the treatment for adult failure to thrive?

Treatment of Adult Failure to Thrive

Adult failure to thrive requires a systematic approach targeting four core syndromes—impaired physical function, malnutrition, depression, and cognitive impairment—with interventions directed at easily modifiable contributors first, followed by aggressive nutritional support and multidisciplinary coordination. 1, 2

Initial Management Framework

The treatment strategy must address the syndrome's defining features: weight loss, decreased appetite, poor nutrition, and functional decline occurring in the context of multiple chronic diseases 3, 2. Begin by identifying and quantifying impairments across all four prevalent syndromes, as these interact and compound each other 1, 2.

Address Easily Modifiable Contributors First

Medication Optimization

• Conduct a comprehensive medication review to eliminate drugs causing anorexia, nausea, or functional impairment 2
• Reduce polypharmacy by stopping medications without immediate effect on symptom relief or quality of life (such as statins) 4
• Adjust timing and dosing of diuretics to prevent incontinence and maintain adequate hydration 4

Treat Underlying Medical Conditions

• Optimize management of gastroesophageal reflux with proton pump inhibitors, particularly when feeding difficulties are present 5
• Implement appropriate bowel regimens for constipation and intestinal dysmotility, as these significantly impact nutritional intake 5
• Correct specific micronutrient deficiencies (trace elements, vitamins) through targeted supplementation 5

Aggressive Nutritional Intervention

Caloric Enhancement Strategy

Increase caloric density of the existing diet by fortifying foods with extra oil or fat rather than simply increasing volume 5. This approach is more effective than attempting to increase meal size, which often fails in patients with poor appetite 5.

Oral Nutritional Supplements

• Add oral nutritional supplements (ONS) to normal food intake, as nutritional counseling alone is insufficient to improve nutritional status 5
• This is a critical point: multiple studies demonstrate that counseling without supplementation fails to reverse malnutrition 5

Hyperphagia Encouragement

• Encourage unrestricted oral intake with no futile food restriction, as increased intake promotes physiologic adaptive processes 4
• In patients with functioning gut, macronutrient absorption increases substantially with increased oral intake, potentially up to 3-fold the resting energy expenditure 4

Manage Depression and Cognitive Impairment

Depression Treatment

• Screen for and aggressively treat depression, as it is both a contributor to and consequence of failure to thrive 1, 2
• Depression directly impacts appetite, functional status, and engagement with treatment 1, 2

Cognitive Support

• Provide medication compliance aids and tailored self-care advice for patients with cognitive impairment 4
• Involve family and caregivers in medication management and nutritional support 4

Functional Rehabilitation

Physical Function Restoration

• Address impaired physical functioning through targeted interventions, as this syndrome independently predicts adverse outcomes 1, 2
• Monitor frailty scores and seek reversible causes (both cardiovascular and non-cardiovascular) of functional deterioration 4

Multidisciplinary Team Coordination

Essential Referrals

• Refer to gastroenterology for persistent feeding difficulties, reflux, or poor growth despite initial interventions 5
• Consider specialized referrals to endocrinology, genetics, or neurology when initial evaluation does not identify a cause 5
• Engage social workers for addressing social isolation and environmental factors 6, 2

Team Collaboration

• Coordinate care between primary care physician, specialists, dietitians, and social workers 6, 2
• This common-sense approach by primary care providers with appropriate support is more effective than extensive referral patterns 6

Monitoring Strategy

Monitor growth and functional status at regular intervals: every clinic visit initially, then every 3 months for ongoing assessment 5. Serial measurements over time are more valuable than single evaluations for detecting treatment failure 5.

Critical Pitfalls to Avoid

Do Not Rely on Counseling Alone

The most critical error is relying on nutritional counseling alone without oral nutritional supplements, as multiple studies demonstrate this approach is insufficient 5. Always add ONS to the treatment plan 5.

Avoid Therapeutic Nihilism

• Do not allow the diagnosis of "failure to thrive" to reinforce fatalism or intellectual laziness 1
• Each component syndrome requires specific identification and targeted intervention 1, 2

Do Not Delay Intervention

• Intervene early enough to prevent progression, as delayed treatment makes reversal increasingly difficult 6
• Early identification of all precipitants is key to effective management 6

End-of-Life Care Considerations

When to Transition Goals

Recognize failure to thrive as a key decision point requiring discussion of end-of-life care options 2. Consider palliative care when patients demonstrate:

• Progressive functional decline with dependence in most activities of daily living 4
• Poor quality of life despite optimal treatment 4
• Cardiac cachexia or clinically judged to be close to end of life 4

Palliative Interventions

• Focus on symptom management, emotional support, and communication with patient and family 4
• Use morphine (with antiemetic) to reduce breathlessness, pain, and anxiety when appropriate 4
• Coordinate shared care approach between palliative care services and primary care physician 4