What is the recommended workup for an elderly patient with failure to thrive (FTT)?

Workup for Elderly Patients with Failure to Thrive

Begin with a structured assessment targeting the four core syndromes that predict adverse outcomes: impaired physical function, malnutrition, depression, and cognitive impairment—these are the foundation of your evaluation. 1, 2

Initial Clinical Assessment

Functional Status Evaluation

• Assess activities of daily living (ADL) and instrumental activities of daily living (IADL) using standardized instruments to quantify functional impairment and establish baseline independence 3, 4
• Evaluate mobility, falls history, and gait stability, as falls affect 6% with fractures and 10-30% develop polytrauma 5
• Screen for frailty using validated tools, recognizing it affects approximately 25% of persons aged ≥85 years and independently predicts mortality 5, 1

Nutritional Assessment

• Document weight history with specific attention to unintended weight loss >5% in 6 months or >10% beyond 6 months, which defines malnutrition in older adults 5, 1
• Calculate BMI and assess for sarcopenia through muscle mass evaluation and grip strength testing 1
• Evaluate dietary intake patterns, appetite changes, and barriers to adequate nutrition including chewing/swallowing problems, dental issues, and gastrointestinal symptoms 3

Cognitive and Psychological Evaluation

• Screen for dementia using standardized cognitive assessment tools, as cognitive impairment affects treatment decisions and medication adherence 5, 2
• Assess for depression using validated screening instruments (e.g., Geriatric Depression Scale), as depression commonly co-occurs with cognitive decline and affects treatment adherence 5, 1
• Distinguish between delirium (acute) and dementia (chronic), as delirium is often precipitated by illness or medications and requires immediate intervention 5, 4

Laboratory and Diagnostic Studies

Essential Initial Laboratory Tests

• Complete blood count (CBC) with differential to assess for anemia, infection, and bone marrow function 2, 6
• Comprehensive metabolic panel including electrolytes, renal function, liver function, calcium, and albumin 2, 6
• Thyroid-stimulating hormone (TSH) to exclude thyroid dysfunction as a reversible cause 2, 6
• Urinalysis to screen for infection or renal disease 2
• Vitamin D level, as deficiency increases osteoporosis and fracture risk 5

Additional Studies Based on Clinical Findings

• Order additional targeted studies only when history and physical examination suggest specific diagnoses—avoid shotgun approaches 2, 6
• Consider chest radiography if respiratory symptoms or signs of infection are present 6
• Obtain additional imaging or specialized testing only when clinically indicated by specific findings, not routinely 6

Medication Review

Conduct a comprehensive medication review to identify drugs causing anorexia, xerostomia, dysgeusia, gastrointestinal disturbances, or somnolence 3, 1

• Systematically review all medications for appropriateness and deprescribing opportunities, as polypharmacy accounts for >700,000 emergency visits annually in older adults 5, 1
• Eliminate or adjust medications that impair appetite, cognition, or physical function 3, 1
• Assess for drug-drug interactions and adverse effects, particularly with insulin, warfarin, diuretics, β-blockers, and phenothiazines 5

Comorbidity Assessment

Evaluate the impact of existing chronic diseases on functional status and life expectancy, as comorbidities determine whether more immediate medical problems could end the patient's life before other conditions become life-threatening 3, 2

• Assess cardiovascular disease, heart failure, diabetes, chronic kidney disease, and pulmonary conditions for their contribution to functional decline 3
• Identify geriatric syndromes including dementia, delirium, depression, falls, neglect/abuse, spontaneous fractures, and failure to thrive itself 3
• Document presence and severity of pain, as chronic pain contributes to functional impairment and poor nutrition 3

Social and Environmental Evaluation

Assess social support, living conditions, caregiver presence, and financial status, as social isolation is a significant predictor of mortality and absence of adequate social support predicts mortality in elderly populations 3, 5

• Evaluate for elder abuse, neglect, or self-neglect 3, 4
• Determine access to food, meal preparation capabilities, and transportation 3, 7
• Assess financial resources and insurance coverage that impact treatment feasibility 5

Specialized Assessments When Indicated

Comprehensive Geriatric Assessment (CGA)

Consider formal CGA when initial evaluation reveals multiple complex problems, as it estimates functional status, comorbidities, mental status, emotional conditions, nutritional status, polypharmacy, and geriatric syndromes 3, 1

• Recognize that full CGA is time and manpower consuming, so use abbreviated screening tools in routine practice with referral for complete CGA when needed 3
• Use CGA results to identify potentially treatable problems such as depression or malnutrition that may otherwise decrease tolerability and increase toxicity 3

Swallowing and Dental Evaluation

Obtain professional swallowing evaluation if dysphagia is suspected, as swallowing problems are widespread in institutionalized older people 3

• Arrange dental examination for chewing problems or oral pain 3
• Implement appropriate texture-modified diets only after professional evaluation 3

Common Pitfalls to Avoid

• Never attribute symptoms solely to "old age" without thorough investigation 5
• Do not miss atypical presentations, as elderly patients often lack typical symptoms of serious conditions 5
• Avoid overlooking medication burden—systematically review all medications 5
• Do not ignore cognitive status, as it affects informed consent, medication adherence, and self-care abilities 5
• Never fail to assess frailty, as it predicts outcomes better than chronological age alone 5
• Avoid extensive referrals and testing when a common-sense approach by primary care with targeted interventions is more appropriate 7

Integration and Next Steps

After completing the workup, identify all precipitants and intervene early enough to prevent progression, directing initial interventions toward easily remediable contributors with the goal of improving overall functional status 1, 7, 6

Recognize failure to thrive as a critical decision point requiring goals of care discussion, and consider palliative care options and hospice referral for patients with severe, progressive decline despite interventions 1, 2