July 9, 2005
Adult Failure to Thrive in the Older Rehabilitation Patient
Increasing numbers of older adults require rehabilitation therapy upon discharge from a hospital. This pilot study tested a tool developed to assess failure to thrive syndrome (FTT) in patients admitted to a long-term rehabilitation unit (N=34), examined the association among commonly recognized FTT factors (persistent, unexpected impairment in physical function, cognitive impairment, and poor nutrition and mood state), and investigated relationships between FTT factors and discharge disposition. Patients with a high level of physical function differed from those with a low level of function in terms of age, mood state, and discharge disposition. Patients discharged home differed from patients who were unable to return home in mood state, physical function score, and admission serum albumin. Suggestions for practice and further research are offered.
KEY WORDS adult failure to thrive assessment tools measurement toolsPatients with chronic health problems, a growing population in the United States, accounted for 76% of direct medical costs in 1987 (Huffman, Rice, & Song, 1996). In 2001, chronic diseases were the leading cause of death in persons age 65 and older (Centers for Disease Control and Prevention & Merck Institute of Aging & Health, 2004). In addition, the incidence of chronic disease increases with age, and comorbidities often complicate recovery from acute illnesses. As increasing numbers of hospitalized patients require therapy at rehabilitation facilities following earlier discharge, rehabilitation nurses face the challenge of identifying those patients who are most at risk of persistent disability. Adult failure to thrive (FTT) is a syndrome characterized by lower-than- expected physical function that may predict difficulty or failure to achieve rehabilitation goals. Documentation of FIT factors may assist clinicians in identifying patients at risk and facilitate early implementation of aggressive preventive measures, as well as assisting nurses, patients, and families to prepare for postrehabilitation care and for making decisions about whether to continue various medical interventions. Currently, however, research that describes FTT factors and their impact on patient outcomes is lacking, especially in patients who receive long-term rehabilitation therapy. The purpose of this paper is to describe a pilot study that provides preliminary data about FTT factors, as well as an approach for measuring these factors on admission to an adult rehabilitation facility.
FTT syndrome usually is considered a pediatric diagnosis and is broadly defined as deviation from a growth pattern based on norms for age and sex (Frank & Zeisel, 1988). For adults, the diagnosis of FTT does not conform to a prevailing model (Sarkisian & Lachs, 1996), but there is general consensus that adult FTT is a multidimensional syndrome of nonspecific symptoms (Robertson & Montagnini, 2004). There also is agreement that it is not normal aging, the unavoidable result of chronic disease, or a synonym for the terminal stages of dying (Egbert, 1996).
Adult FTT is defined as a low level of physical functioning associated with nutritional deficits, decreased cognitive functioning, and poor mood state. This definition was derived from numerous theoretical, clinical, and research sources (Berkman, Foster, & Campion, 1989; Braun, Wykle, & Cowling, 1988; Newbern & Krowchuk, 1994; Sarkisian & Lachs, 1996; Verdery, 1994). Although adult FTT has been discussed primarily in relation to the elderly (Egbert; Hollinger-Smith & Buschman, 1999; Newbern, 1992; Palmer, 1990; Verdery), it is likely that the syndrome exists in other adult populations, particularly those who are chronically ill or have experienced an illness serious enough to require inpatient rehabilitation. Most literature related to adult FTT also reflects clinical, rather than research, perspectives (Egbert; Newbern; Palmer, 1990; Robertson & Montagnini; Verdery; Wooley, 2004). Four research studies documented FTT symptoms in adult hospitalized patients; one case report described FTT in three rehabilitation patients. Methodological approaches have varied, and because there is no prevailing theoretical model of adult FTT, there are different definitions of the syndrome and defining criteria.
In the earliest known research, Messert, Kurlanzik, and Thorning (1976) identified adult FTT through documentation of a cluster of symptoms in five adult patients aged 24-67 years who were diagnosed with neurological disorders. All of the patients had irreversible weight loss despite high caloric intake, wide variations in body temperature, decreased level of consciousness, unexplained rapid development of decubitus ulcers, and sudden death. Berkman et al. (1989) retrospectively examined the medical records of 82 elders admitted with a diagnosis of FTT and used factor analysis to identify three categories of FTT factors: patient care management problems, functional problems, and patient coping problems. Osato, Stone, Phillips, and Winne (1993) examined characteristics in 62 male patients, aged 37-104 years, admitted with a medical diagnosis of FTT. These patients had an average of 7 medical diagnoses, required an average of 5 medications, and 62% had low levels of serum albumin (
In the only known prospective study, Fox, Hawkes, Magaziner, Zimmerman, and Rebel (1996) followed 252 subjects, with a mean age of 77 years, for 2 years after hip fracture. FTT was defined in this study as functional decline or a decline in walking 6-12 months postfracture after achievement of an initial gain in mobility. Those classified as FTT (n = 26) were significantly worse off than the "no decline" group (n = 226) in their cognitive impairment and number of hospitalizations at 12 months (p = .05) and self-reported health at 24 months (p = .0001). There were no statistically significant differences between the two groups, however, in social interaction or depression scores, mortality, physician visits, or nursing home stays.
One additional case report of three older adults linked metoclopramide therapy with impaired functional capacity, which, in turn, compromised rehabilitation therapy efforts. The writers suggest that this sequence of events could then lead to failure to thrive (Gorelick, Williams, & Steward, 2003).
Although adult FTT syndrome has received little research attention, investigators have studied the relationship between individual adult FTT factors and patient outcomes in hospitalized and nursing home patients. In the description that follows, there is some evidence that supports the theoretical model of FTT as diminished or lower-than-expected functional status, nutritional status, psychological status, and cognitive status, but findings have not been consistent.
In a study of hospitalized elderly (N = 396), Narain et al. (1988) found significant inverse relationships between functional status and the outcomes of mortality, length of stay, and nursing home admission. Increasing age also has been associated with lower functional capabilities postrehabilitation in older adults (N = 61) with chronic obstructive pulmonary disease (Emery, 1994), but Resnick and Daly (1998) found no relationship between age and functional status on admission to a rehabilitation program and only a small relationship between the two variables on discharge (N = 200).
A number of studies documented relationships between the indicators of nutritional status and patient outcomes. Herrmann, Safran, Levkoff, and Minaker (1992) found that a low serum albumin ( 25% of meals left uneaten, psychiatric/mood diagnoses, and decline in ability to participate in activities of daily living [ADL]) identified protein calorie malnutrition as measured by the Nutrition Screening Initiative Guidelines. Conversely, three indicators (antidepressant use, diuretic use, therapeutic diet) were considered "protective," because they were associated with a more normal body mass index.
There are numerous articles documenting the relationship between quality of life and overall functioning. For example, in a study of nursing home patients (N = 130), Hollinger-Smith and Buschman (1999) reported a 34.6% prevalence rate of depression, as measured by the Geriatric Depression Scale, and reported several statistically significant findings: depressed patients were more likely to be older, less likely to be comfortable with touch, had poorer appetites, more feelings of dejection and hopelessness, greater preferences for privacy, lower levels of self-esteem, and fewer available social resources. Mossey, Knott, and Craik (1990) reported that a sample of women (N = 196) who reported few depressive symptoms following hip fracture achieved higher levels of physical functioning than those who reported more depressive symptom\s. Depression also has been shown to affect the recovery of poststroke patients; 2 years after experiencing a stroke, depressed patients had significantly lower levels of language functioning and independence in performing ADL (Parikh et al., 1990). And finally, older persons who reported falling in the previous 12 months (N = 77, 92% male) had significantly improved scores on psychosocial variables following a 6-week moderate exercise program (Means, O'Sullivan, & Rodell, 2003).
Early studies suggested that impaired cognitive function is related to increased mortality in hospitalized adults (Hodkinson & Hodkinson, 1980; Narain et al., 1988). In addition to being predictive of mortality, cognitive impairment has been associated with lack of recovery of functional abilities in community-dwelling women following surgical repair for a hip fracture (N = 211, mean age = 78.5 years) (Mossey, Mutran, Knott, & Craik, 1989). Rubenstein et al. (1984) also reported that impaired cognitive status limited functional gains during rehabilitation, but more recently, Diamond, Felsenthal, Macciocchi, Butler, and Lally-Cassady (1996) found that cognitive status had little effect on functional gains for adults admitted to a geriatric rehabilitation unit. Although the relationship between cognitive status and physical functioning remains unclear, Berg et al. (1997), in a six-country international study, reported that longterm residents of nursing homes were more likely to receive therapy if their MDS scores indicated poor functioning on ADL, but good cognitive function.
In summary, the research on FTT syndrome lacks a unifying definition; most investigations have used retrospective, cross- sectional designs; and there is no known research of adult FTT in nursing home patients receiving rehabilitation therapy. Using a prospective, longitudinal design with a sample of older adults admitted to a long-term rehabilitation unit, the investigators of the study described here specifically aimed to:
1. Describe the relationship among factors associated with adult FTT.
2. Examine the relationship between FTT factors and discharge disposition.
3. Pilot-test a tool developed to measure FTT factors on admission.
Sample and Setting
The study was conducted in a 291-bed skilled nursing facility with a total of 90 subacute beds. The rehabilitation facility is associated with two academic medical centers. After approval by the human subjects review board, the convenience sample of 34 patients was recruited over a 12-month period. All subjects were admitted to a subacute unit for long-term rehabilitation therapy. Preliminary information indicated that length of stay on the three subacute units was 30-60 days, and approximately 50% of the patients are discharged home (L. Tighe, Director of Nurses, MHCSN, personal communication, April, 1998).
Inclusion criteria included: (a) > 50 years old at time of enrollment, (b) able to comprehend the English language, and (c) sufficient communication abilities to enable the patient to be understood. Patients requiring continuous mechanical ventilation were excluded, but patients with speech impediments were included if they could communicate with body language (head and/or body gestures). Subjects assessed on the admission MDS 2.0 as lacking "independent decision making that is reasonable and consistent," were excluded from the study. The MDS 2.0, required for all patients admitted for more than 15 days to all Medicare-certified nursing facilities in the United States, is a clinical data set of more than 100 items used to assess cognition and memory, physical functioning, diseases, nutrition, relationships, special problems, and medications (Fredericksen, Tariot, & De Jonghe, 1996).
Design and Measurement
This pilot study was a prospective, descriptive investigation. A tool to collect FTT data was developed from previous work (Higgins, 1996, 1997), a review of the literature (Berkman et al., 1989; DaIy, Rudy, Thompson & Harp, 1991; Howard & Reilly, 1994; Mayer-Oakes, Oye, & Leake, 1991; Narain et al., 1988) and the MDS. The data collection tool was reviewed by staff nurses responsible for completing the MDS in the rehabilitation institution that served as the site for data collection, and revised after initial trials. This tool was used to collect data related to functional status, nutrition, psychological status, and cognition at the time of admission to the rehabilitation facility. Data abstraction from the MDS was completed with reasonable consistency and the research team's interrater reliability was maintained at 96%. Data pertaining to mood state also were collected on admission and once a week during hospitalization using the Profile of Mood States Short Form (McNair, Lorr, & Droppleman, 1971). Measurement of each FTT concept is discussed in the next section.
Functional status was measured using the ADL self-performance index developed from the MDS. Fredericksen et al. (1996) reported a correlation coefficient of .92 between the MDS-ADL functional status measure (N = 8 items) and the Physical Signs and Symptoms Scale. This study used the updated version, the MDS 2.0, which has two additional items. Each item, rated 0-8, ranks the subject's ability to perform common ADL, such as walking in one's room, dressing, eating, and toileting. Scores range from 0 to 80, with higher scores indicating greater disability.
Because there is no single, global indicator of nutrition, data were obtained for three variables: body mass index (BMI), serum albumin, and hemoglobin. BMI, calculated from height and weight, is known to be a valid and reliable indicator of relative weight that is applicable to all populations at all ages and useful for the diagnosis of malnutrition and obesity (Bailey & Ferro-Luzzi, 1995; National Institutes of Health, 1998). In a study of nutritional status in nursing home residents, Blaum, O'Neill, Clements, Fries, and fiatarone (1997) reported significant correlations between the MDS height and weight measures and bioelectrical and anthropomtrie measures of nutrition. BMI also has been used to measure mortality risk in underweight older persons (Harris et al., 1988).
Because MDS mood scores have not correlated consistently with research profiles (Fredericksen et al., 1996), the Profile of Mood States (POMS) short form, a measure of a patient's psychological and emotional mood states (Shacham, 1983) was used rather than the MDS subscale. Both the original POMS scale and its short form measure six independent mood states: confusion, anger, depression, fatigue, tensionanxiety, and vigor (McNair et al. 1971). Each 5-item Likert- type subscale has a possible range of scores of 0-20. The total score has a possible range of -20-100, obtained by subtracting the "vigor" score (a positive/pleasant mood) from the summative scores of the five negative/unpleasant moods. Higher scores indicate more mood distress. Construct validity of the six subscales has been suggested by strong correlations between the short and the original subscales and internal consistencies were maintained for all six shortened subscales (Cronbach's alpha = 0.80-0.91) (Shacham, 1983). POMS data were collected on admission to the study and weekly thereafter. On average, the POMS form required approximately 10 minutes to complete.
Cognitive status was measured with the MDS Cognition Scale (MDS- COGS), a 0-10 point scale developed from eight MDS items. Higher scores indicate decreased cognitive function. The MDS-COGS score is produced directly from MDS data and has been validated using the Mini Mental State Exam and the Global Deterioration Scale (Hartmaier, Sloane, Guess, & Koch, 1994).
Table 1 summarizes demographic information for the study subject. The mean age of the subjects was 68.5 years (SD = 11.4); 94% were admitted from an acute care institution; prior to this illness, 49% lived alone, and 43% lived with others in the community. Only one patient lived permanently in a long-term care (LTC) institution; however, 20% had been admitted to a nursing home in the previous 5 years. Almost half of the subjects had a medical diagnosis of diabetes mellitus. All of the subjects were in occupational therapy, 93% were in physical therapy, and 21% were receiving speech therapy. None of the subjects were receiving psychological therapy, but 10% were undergoing reorientation (cueing) therapy. One received passive range of motion exercises, and 7% were receiving respiratory therapy.
The Cronbach's alpha for this study's functional status subscale (N = 10 items) was 0.87. The subjects' scores ranged from 0 to 53, with a mean of 31.8 (SD = 13.5) and a median of 33.5. All subjects had been clinically evaluated as having potential to benefit from rehabilitation therapy, so, as expected, none of their scores (61- 80) indicated severe physical incapacity.
Table 1. Demographic Characteristics of Sample
Using the study's definition of FTT ("a lower-thanexpected level of function"), the median score was used to categorize subjects into "lower" or "higher" functional levels, and the two groups were compared on the other measures (Table 2). Subjects with lower levels of function on admission were significantly older, with a more negative mood state and a lower BMI. These subjects also had lower cognitive status scores, serum albumin levels, and hemoglobin levels, though these differences were not statistically significant.
Nutritional status was evaluated through data from the MDS, BMI, and chart abstraction of laboratory data (serum albumin and hemoglobin). A BMI of 24-29 is recommended for those > 65 years (Committee on Diet and Health, 1989). For this study, using a range of 25-30 as normal, 7% of the subjects were underweight, 45% were normal, and 48\% were overweight (National Institutes of Health, 1998; Thomas, McKay, & Cutlip, 1976). One subject, who was grossly obese (BMI = 50.0), was on a weight-loss program, and three of the subjects (BMI = 15.6-21.3) were on weight-gain programs.
There were limited laboratory data recorded either at admission or for any time during the patients' stays. Of the 19 subjects with at least one serum albumin recorded in their chart, six were at or above normal (> 3.5 g/dL), and nine were less than normal. Hemoglobin values were available on six men, and all were below normal (
Table 2. FTT Factors and Outcomes by Level of Physical Function (N = 34)
On admission, the mean total POMS score was 20.0 (SD =14.5, range = 0-57), indicating a moderategood mood score. As indicated by the range and standard deviation, subject scores varied considerably. Fatigue had the highest mean score of the six subscales on admission (M = 7.5, SD = 5.2, range 0-20), and its mean scores remained the highest throughout the hospitalization. The other subscales' scores were as follows: confusion (M = 4.3, SD = 3.2, range = 0-11); anger (M = 3.9, SD = 3.8, range = 0-12); depression (M = 4.5, SD = 4.1, range = 0-14); tension (M = 6.0, SD = 3.8, range = 0-14); vigor (M = 5.7, SD = 4.8, range = 0-18). Cronbach's alpha for the POMS total score was 0.67.
There were 18 subjects who had at least three weekly data points, which allowed for assessment of the potential change in mood state over time. The mean number of data points for this subset of the sample was 6 (range = 3-16). These weekly data were divided into tertiles, with time point 1 (TPl) representing the first third of the subject's stay in the facility, TP2 representing the second third of the stay, and TP3 the final third. The data showed little change over time for any of the mood subscales, and therefore, only the admission POMS score was used in analyses.
Because this was a pilot study that was aimed, in part, at evaluating methods to assess FTT, we also examined the subjects' data from the nine MDS items that are closely associated with mood state. Using the MDS items, subjects' scores indicated little distress. None of the subjects exhibited distress through expressions of negative statements, repetitive questions, self- deprecation, unrealistic fears, or premonitions that something terrible would happen. Only three subjects were evaluated as distressed in a least one category. One subject expressed distress in four ways: through repetitive verbalizations, persistent anger with self or others, repetitive health complaints, and nonhealth- related anxiety complaints; this subject was evaluated as having persistent depressed, sad, or anxious moods that were not easily altered. A second subject was evaluated as expressing repetitive health complaints, and a third subject had episodes of crying and tearfulness.
The MDS-COGS evaluates short- and long-term memory, decision- making skills, orientation to place, ability to express information content, and dressing self-performance. Cronbach's alpha for these subjects' data was 0.76. According to the composite score, 70% (n = 21) of the subjects were intact or had only slight impairment; 17% (n = 5) were mild-moderately impaired; and only 13% (n = 4) were moderate-severely impaired. The lack of a significant difference between the lower and higher physical-functioning groups may, in part, reflect the relative lack of variability in cognition among the sample.
As noted in Table 2, lower physical-function scores were associated with a transfer to a long-term care facility or back to an acute care hospital, while higher functional levels were associated with discharge home. Table 3 provides further evidence that other FTT factors contributed to discharge disposition in this sample. In addition to physical functional ability, older patients who were more distressed and had lower levels of serum albumin were less likely to be discharged home. One goal of rehabilitation is to enable the patient to regain independence, or at least improve in ability to function outside of inpatient settings; thus, discharge disposition provides an important outcome for evaluating the effect of FTT factors.
This pilot study had three aims: to explore the association among FTT factors, examine the association of these factors with discharge disposition, and test a method that could be used readily to measure these factors early in a patient's stay in rehabilitation. The data from this study lend support to the theoretical model of adult FTT as a syndrome of diminished physical function associated with impaired cognitive status, poor mood state, and poor nutrition.
There are two limitations to this study. The first was the small convenience sample, which prohibits generalizations from the findings. A second limitation concerns the MDS 2.0, which was the source of data for much of the study. Other researchers (Hawes et al, 1995; Phillips & Morris, 1997) have reported that the MDS 2.0 is a valid and reliable data set. While the investigators agree with these findings, some limitations with the tool also were encountered. During data collection, comments made by the nurses responsible for completing the MDS indicated that completion varies greatly according to several factors, such as patient acuity, nurse staffing patterns, patients' cognitive status, and availability of family members. They also reported differences based on the type of MDS item; for example, documenting medication use and progress in ADL is more straightforward than evaluating personal relationships. Thus, the nurses were more likely to complete the more objective items, and further, they had a greater degree of confidence in their evaluation of the more objective items. In this study, the more subjective MDS items had more missing data. In rehabilitation or long-term care units where there is a coordinator who completes all MDS forms, consistency of completion might be improved, but the hurdles with construct validity would remain. Accordingly, a larger study would have to remedy this limitation to overcome concerns with interrater reliability and construct validity.
Table 3. Comparison of FTT Factors by Discharge Disposition (N = 28)
Finally, while the MDS is an incredibly rich and comprehensive source of data for research, in its current form, it does not readily yield simple, predictive classifications that rehabilitation staff can use for ready identification of patients at risk for FTT. However, items from a simplified tool, such as the one developed for this study, might easily be used to individualize a patient's plan of care. For example, assessing psychological status remains a challenge for clinicians. Although additional research is required to investigate the effectiveness of POMS as a clinical tool in the inpatient rehabilitation setting, it could potentially be used as a first screen for assessment of mood state. Patients with higher fatigue and depressed mood scores may have poor sleep patterns and/ or need for further evaluation for clinical depression. Depression is underrecognized and undertreated in older adults (Mulsant Sz Ganguli, 1999), and it is related to physical functioning. Consequently, assessment of the rehabilitation patient's psychological status should be a priority for nurses.
Early discharge from acute care is an accepted practice in today's healthcare system; consequently, the importance of posthospital rehabilitation care has increased dramatically. Given these preliminary findings of a significant relationship between physical function and achieving the goal of eventual discharge home, addressing factors that contribute to FTT should be a priority for rehabilitation staff. Treatment of delirium that is not due to organic, nonmodifiable factors should be initiated. Because improving factors associated with FTT syndrome is likely to require considerable time, it is important that they be assessed early in the patient's stay and appropriate interventions initiated.
This preliminary study was intended to provide pilot data using information readily available. The small sample size and missing data for some variables preclude definitive conclusions about relationships among factors and incidence of FTT. However, the findings do establish that FTT factors can be measured with minimal additional data-collection efforts and that there is reason to further investigate FTT factors to determine which are modifiable and which are not. For example, do FTT factors make a difference in how older patients respond to physical and/or occupational therapy? To what extent do impaired physical function, malnutrition, impaired cognition, and poor mood state contribute to other patient outcomes, such as disability and/or healthrelated quality of life? These and other questions can form the basis for additional study.
This study was funded by the American Nurses Foundation.
Although adult FTT syndrome has received little research attention, investigators have studied the relationship between individual adult FTT factors and patient outcomes in hospitalized and nursing home patients.
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Patricia A. Higgins, PhD RN * Barbara J. Daly, PhD RN FAAN
About the Authors
Patricia A. Higgins, PhD RN, is an assistant professor at Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, OH.
Barbara J. Daly, PhD RN FAAN, is an associate professor at Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, OH.
Direct correspondence to Patricia Higgins, PhD RN, Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH44106-4904, or via e-mail to [email protected]
Copyright Association of Rehabilitation Nurses Jul/Aug 2005