Management of Failure to Thrive in Early 70s Patient
Begin with systematic screening for geriatric syndromes using validated assessment tools, as these conditions directly impact functional status and are often reversible when identified early. 1
Initial Comprehensive Assessment
Evaluate across five critical domains within the first 48 hours:
Medical Domain
- Screen for diabetes complications if present, particularly visual impairment and lower-extremity problems that develop rapidly and impair function 1
- Assess cardiovascular risk factors: hypertension, coronary disease, and stroke history are major drivers of mortality in this age group 1, 2
- Review all medications for polypharmacy - a primary geriatric syndrome causing functional decline 1
Cognitive Assessment
- Administer Montreal Cognitive Assessment (MoCA) or Mini-Mental State Examination at the initial visit 1
- Cognitive impairment affects self-management abilities and increases hypoglycemia risk if diabetic 1
- Annual screening is indicated for all patients ≥65 years 1
Functional Status
- Evaluate both basic and instrumental Activities of Daily Living (ADLs) 1
- Pre-existing functional limitations and falls are the strongest predictors of further decline 3
- Use the FRAIL mnemonic: Falls/functional decline, Reactions (medications), Altered mental status, Illnesses, Living situation 4
Psychological Screening
- Screen for depression using validated tools - depression is highly prevalent and treatable in older adults with chronic disease 1
- Depression screening should occur at initial visit and annually 1
Social/Environmental Factors
- Assess living situation, caregiver support, and financial resources - these external factors determine severity of disability as much as medical conditions 5
- Inadequate social support predicts poor outcomes 1
Specific Interventions Based on Findings
For Patients with Diabetes
- Set individualized glycemic targets based on health complexity 1:
- Healthy with intact function: A1C <7.5%
- Multiple comorbidities: A1C 8.0-8.5%
- Very complex/poor health: avoid hypoglycemia and symptomatic hyperglycemia (glucose 100-200 mg/dL)
- Avoid hypoglycemia aggressively - it accelerates cognitive decline and increases mortality 1
- Consider metformin as first-line if eGFR ≥30 mL/min/1.73 m² 1
For Functional Decline and Sarcopenia
- Prescribe structured exercise program including aerobic, weight-bearing, and resistance training 1
- Ensure adequate protein intake - inadequate nutrition increases sarcopenia and frailty risk 1
- Goal is enhanced functional status, not weight loss, unless patient is non-frail with obesity 1
For Cardiovascular Risk
- Treat hypertension to <140/90 mmHg in complex patients, <130/80 mmHg in healthier patients 1
- Initiate statin therapy unless life expectancy <2.5 years (the time-to-benefit for statins) 1
- These interventions reduce morbidity and mortality more than tight glycemic control alone 1
Medication Optimization
- Eliminate anticholinergic medications (diphenhydramine, cyclobenzaprine, oxybutynin, scopolamine) - these worsen cognition and increase fall risk 6, 7
- Review and deprescribe medications that don't match life expectancy or treatment goals 1
- Involve clinical pharmacist if available to reduce medication errors 1
Common Pitfalls to Avoid
Do not set overly aggressive glycemic targets - this increases hypoglycemia risk without mortality benefit in older adults 1. The Look AHEAD trial showed intensive lifestyle intervention improved quality of life metrics but not cardiovascular mortality 1.
Do not overlook cognitive screening - subtle executive dysfunction often goes unrecognized but profoundly affects self-management capacity 1.
Do not prescribe therapeutic diets that reduce food intake in long-term care settings - this contributes to malnutrition and functional decline 1.
Do not assume all decline is irreversible - many geriatric syndromes (depression, polypharmacy effects, nutritional deficits) are treatable when identified 1, 8.