What evaluation should be performed in an adult presenting with failure to thrive?

Evaluation of Failure to Thrive in Adults

The evaluation of adult failure to thrive should begin with a targeted assessment of four key syndromes—impaired physical function, malnutrition, depression, and cognitive impairment—followed by focused laboratory testing only when clinically indicated, as extensive laboratory workups rarely yield diagnostic value without specific clinical suspicion. 1, 2

Initial Clinical Assessment

History Taking

• Functional status: Document the patient's ability to perform routine and desired activities of daily living, including both basic (bathing, dressing, toileting) and instrumental activities (cooking, shopping, managing medications) 3, 2
• Weight trajectory: Quantify weight loss over time, decreased appetite, and nutritional intake patterns 2, 4
• Medication review: Obtain a careful history of current and past use of prescription medications, alcohol, illicit drugs, and alternative therapies that could contribute to decline 3, 5
• Chronic disease burden: Assess the impact of existing chronic diseases on functional status 2, 4
• Psychosocial factors: Evaluate for social isolation, caregiver availability, financial constraints, and access to food 4

Physical Examination

• Anthropometric measurements: Measure weight, height, and calculate body mass index; assess for signs of malnutrition including muscle wasting and subcutaneous fat loss 3, 2
• Volume status assessment: Check for orthostatic blood pressure changes, which may indicate volume depletion or autonomic dysfunction 3, 5
• Functional capacity: Observe gait, balance, and ability to perform basic movements 5

Screening for the Four Core Syndromes

1. Impaired Physical Function

• Assess mobility, strength, and endurance through direct observation 1, 2
• Document specific functional limitations that impact independence 1

2. Malnutrition

• Evaluate dietary intake patterns and barriers to adequate nutrition 2, 4
• Assess for dysphagia, dental problems, or gastrointestinal symptoms 4

3. Depression

• Screen systematically for depressive symptoms, as depression is highly prevalent and often overlooked in this population 1, 2, 4

4. Cognitive Impairment

• Perform mental status examination to identify dementia or delirium 1, 2, 4

Laboratory and Diagnostic Testing

Critical principle: Laboratory investigations are rarely helpful without specific clinical indications from the history and physical examination. 6

Initial Laboratory Panel (Only if Clinically Indicated)

• Complete blood count 3, 5, 2
• Comprehensive metabolic panel including serum electrolytes, blood urea nitrogen, and serum creatinine 3, 5, 2
• Fasting blood glucose or glycohemoglobin 3, 5
• Thyroid-stimulating hormone 3, 5, 2
• Urinalysis 3, 5
• Liver function tests 3, 5

Additional Testing Based on Clinical Suspicion

• Lipid profile: If cardiovascular risk assessment is needed 3, 5
• Inflammatory markers (ESR, CRP): Only if inflammatory or rheumatologic conditions are suspected 5
• Creatine kinase: Only if myopathy is suspected 5

Imaging Studies

• Chest radiograph and 12-lead ECG: Consider if cardiopulmonary disease is suspected based on clinical findings 3, 5
• Echocardiography: Only if heart failure is specifically suspected to assess left ventricular function 3, 7, 5

Common Pitfalls to Avoid

• Avoid shotgun laboratory testing: Only 1.4% of laboratory studies performed without clinical indication provide diagnostic value 6
• Don't overlook medication side effects: Drug interactions and adverse effects are frequently reversible contributors 2, 4
• Recognize that multiple syndromes interact: A single contributor (e.g., depression) may simultaneously influence malnutrition, cognitive function, and physical decline 1, 4
• Don't assume irreversibility: Many contributors are easily modifiable if identified early, particularly medication effects, depression, and nutritional deficits 1, 2

Management Approach

Initial interventions should target easily remediable contributors first, as addressing one syndrome often improves others due to their interconnected nature 1, 2. This includes:

• Optimizing medication regimens 2, 4
• Treating depression 1, 2, 4
• Implementing nutritional interventions 2, 4
• Addressing social isolation and environmental factors 4

The diagnosis of failure to thrive should prompt discussion of goals of care and end-of-life preferences to prevent needless interventions that may prolong suffering 2.