Can a 60-year-old woman with severe major depressive disorder, medication non‑compliance, total dependence for activities of daily living, probable weight loss, dehydration, and malnutrition be diagnosed with failure‑to‑thrive?

Can This Be Diagnosed as Failure to Thrive?

Yes, this 60-year-old woman with severe major depressive disorder, medication non-compliance, total dependence for activities of daily living, probable weight loss, dehydration, and malnutrition meets diagnostic criteria for failure to thrive (adult/geriatric failure to thrive). 1, 2

Diagnostic Criteria Met

This patient fulfills the core diagnostic elements of geriatric failure to thrive as defined in the medical literature:

• Functional decline with dependence in activities of daily living – She has total dependence for ADLs, representing severe impairment in physical function 2, 3
• Weight loss and malnutrition – Probable weight loss with documented malnutrition 2, 4, 3
• Dehydration – Present as a manifestation of inadequate self-care and nutritional compromise 1
• Multifactorial decline – The combination of severe psychiatric illness (major depressive disorder), medication non-compliance, and resulting functional deterioration represents the multifactorial nature characteristic of failure to thrive 2, 4, 3

Understanding the Diagnosis

Failure to thrive in adults is characterized by a gradual decline in physical and/or cognitive function, usually accompanied by weight loss and social withdrawal, occurring without immediate single explanation 4. The term has had its own ICD-9 code since 1979 and describes a clinical condition of insufficient weight gain or decline 1.

Four syndromes are consistently identified as prevalent and predictive of adverse outcomes in failure to thrive patients: 2, 3

• Impaired physical functioning (present – total ADL dependence)
• Malnutrition (present – documented)
• Depression (present – severe major depressive disorder)
• Cognitive impairment (may be present secondary to depression or as independent contributor)

These syndromes interact with and exacerbate each other, creating a vicious cycle where depression reduces food intake, malnutrition worsens functional status, and functional decline deepens depression 2, 3.

Critical Diagnostic Considerations

The most common etiologies of failure to thrive are dementia, depression, delirium, drug reactions, and chronic diseases – this patient has severe depression and medication non-compliance, both recognized primary contributors 4, 3.

Medication non-compliance itself is both a symptom and a cause of failure to thrive, as untreated depression perpetuates the syndrome while adverse drug effects or inappropriate polypharmacy can contribute to functional decline and decreased nutrient intake 5.

Age Consideration

While failure to thrive terminology is most commonly applied to elderly patients (typically ≥65 years), this 60-year-old woman's presentation with severe functional decline, malnutrition, dehydration, and psychiatric illness creating a state of progressive deterioration fits the diagnostic framework 2, 4, 3. The syndrome represents a state of decline that is multifactorial and caused by concurrent diseases and functional impairments, regardless of whether the patient meets an arbitrary age cutoff 3.

Clinical Implications of This Diagnosis

Making the diagnosis of failure to thrive should serve as a key decision point prompting comprehensive intervention: 3

• Immediate assessment and treatment of depression (within 2 weeks or sooner if danger to self) 1
• Nutritional support with target of approximately 30 kcal/kg body weight daily 1
• Hydration management addressing the documented dehydration 1
• Medication review and reconciliation to address non-compliance and identify potentially contributing agents 3, 5
• Evaluation for reversible contributors including thyroid dysfunction, B12 deficiency, and other metabolic derangements 1, 3

Common pitfall to avoid: Do not use the diagnosis of failure to thrive as an endpoint that reinforces fatalism or intellectual laziness 2. Instead, use it as a framework to systematically identify and address each modifiable contributor – depression, malnutrition, dehydration, and medication issues – recognizing that improving one syndrome often improves the others 2, 3.

The diagnosis should also prompt discussion of goals of care and advance care planning, as failure to thrive is associated with increased mortality risk and may represent a trajectory requiring palliative approaches if interventions fail 3.