FAILURE TO THRIVE

Progressive functional decline in elderly: weight loss, poor appetite, malnutrition, dehydration, and loss of independence — a geriatric syndrome

SYMPTOMS / ASSOCIATED SX

  • Unintentional weight loss ≥5% in 1 month or ≥10% in 6 months; cachexia; muscle wasting

  • Decreased appetite, poor PO intake, early satiety, dysphagia

  • Functional decline: ADL/IADL dependence, recurrent falls, reduced mobility

  • Social isolation, caregiver burden, cognitive decline, depression

  • Pressure ulcers, recurrent infections, dehydration

DENIES

  • Hemoptysis/hematochezia (occult malignancy)

  • Night sweats/fever (malignancy, TB, HIV)

  • Dysphagia/odynophagia (esophageal/oropharyngeal pathology)

  • Symptoms of depression (PHQ-9 — treatable and reversible)

  • Pain limiting appetite or mobility

SOCIAL HISTORY

  • Lives alone vs. family support; food insecurity, financial constraints, inability to cook or shop

  • Caregiver assessment; recent loss of spouse/partner; social isolation

MAIN ETIOLOGY

  • 9 D's of Geriatric FTT: Dementia, Depression, Delirium, Disease (occult malignancy/thyroid/GI), Drugs (polypharmacy), Dysphagia, Dysfunction (disability), Destitution, Dentition

  • Malignancy (>40% of unintentional weight loss ≥10% in patients ≥65 — GI, lung, lymphoma most common)

  • Hyperthyroidism (unexpectedly common; weight loss with maintained or increased appetite)

MOST COMMON DDX

  • Occult malignancy (CT CAP + age-appropriate cancer screening)

  • Depression (PHQ-9 ≥10; anhedonia, sleep disruption — highly treatable)

  • Hyperthyroidism (TSH suppressed, weight loss with preserved appetite, tremor, tachycardia)

  • Dementia (impaired self-care, forgetting to eat)

  • Dysphagia (speech therapy, modified barium swallow)

  • GI pathology (malabsorption, IBD, celiac — stool studies, endoscopy)

  • Medication side effects (metformin, SSRIs, digoxin)

DATA

  • BMP, CBC, LFTs, TSH, HbA1c, ESR/CRP, LDH, albumin, prealbumin

  • SPEP; PSA (men); stool occult blood; colonoscopy if not recent

  • HIV, RPR if risk factors; IGRA/CXR if TB suspected

  • CT chest/abdomen/pelvis with contrast (malignancy screen — high yield if >10% weight loss)

  • PHQ-9 or GDS (depression); MMSE or MoCA (cognitive); speech therapy if dysphagia

  • Dentition assessment; anti-tTG IgA (celiac); fecal elastase if EPI suspected

HOME MEDS

  • Digoxin, metformin — appetite suppressing; reassess necessity

  • SSRIs — may suppress appetite early; switch to mirtazapine if depression + anorexia

  • Polypharmacy review — remove non-essential medications (Beers Criteria)

PLAN

  • Nutritional support:

    • Dietitian consultation — goal 30–35 kcal/kg/day; protein 1.2–1.5 g/kg/day

    • High-calorie, high-protein supplements (Ensure Plus, Boost) between meals

    • Soft/pureed diet if dysphagia; oral care before meals to improve taste/appetite

  • Enteral nutrition (PEG/NGT): only if safe swallow impossible AND meaningful prognosis AND GOC aligned — avoid in advanced dementia (Teno et al., JAMA 2012)

  • Appetite stimulants (limited evidence — use cautiously):

    • Mirtazapine 7.5–15 mg PO qhs — preferred (appetite + depression + sleep; best choice)

    • Megestrol acetate 400–800 mg PO daily (VTE, adrenal suppression, edema risk)

    • Dronabinol 2.5 mg PO BID (malignancy-related cachexia; limited evidence)

  • Supplements: MVI daily; vitamin D 800–1000 IU; B12 if deficient; thiamine 100 mg daily if malnutrition/alcoholism

  • PT/OT: resistance exercise (sarcopenia); ADL training; assistive device assessment

  • Social work: Meals on Wheels, food assistance, caregiver support, financial assistance

  • Palliative care: involve early if advanced illness or GOC discussions needed

  • DISCHARGE:

    • Home health PT/OT; dietitian outpatient; Meals on Wheels enrollment

    • Malignancy workup completion if initiated inpatient; oncology referral

    • SNF or assisted living if functional decline severe; geriatrics follow-up

    • GOC documentation (POLST/MOLST) if advanced illness

RED FLAGS

  • Rapid weight loss >10% in 6 months → malignancy screen urgently; CT CAP

  • Night sweats + weight loss + lymphadenopathy → lymphoma; CT CAP + hematology

  • Dysphagia with aspiration → NPO; speech therapy urgently; aspiration pneumonia risk

  • Severe protein-calorie malnutrition (albumin <2.5) → refeeding syndrome risk; monitor Phos/K/Mg closely for 72h

  • Suspected elder abuse or neglect → mandatory reporting; social work + APS

SENIOR IM RESIDENT PEARLS

  • Malignancy accounts for >40% of significant unintentional weight loss (>10%) in elderly — CT CAP is high yield

  • Refeeding syndrome: hypophosphatemia + hypokalemia + hypoMg after nutrition in starved patient → cardiac arrhythmia; start at 20 kcal/kg/day; replace electrolytes prophylactically; thiamine FIRST

  • Teno et al. (JAMA 2012): PEG tube in advanced dementia does NOT improve survival, QOL, or wound healing — discuss GOC before placing

  • Mirtazapine is the preferred pharmacologic agent — simultaneously treats depression, improves appetite, sedates for sleep; start 7.5 mg qhs in elderly

  • Common mistake: placing PEG tube in advanced dementia without GOC discussion

  • MNA score <17 = malnourished; 17–23.5 = at risk

  • Sarcopenia requires resistance exercise + protein supplementation — not just caloric loading