"Failure To Thrive" in Older Adults
Catherine A. Sarkisian, MD, and Mark S. Lachs, MD, MPH
The term "failure to thrive" is frequently used to describe older adults whose independence is declining. The term was exported from pediatrics in the 1970s and is used to describe otder adults with various concurrent chronic diseases, functional impairments, or both. Despite this heterogeneity, failure to thrive has had its own International Classification of Diseases, Ninth Revision (ICD-9) code since 1979 and has been approached as a clinically meaningful diagnosis in many review articles. This conceptual framework, however, can create barriers to proper evaluation and management. The most worrisome of these barriers is the reinforcement of both fatalism and intellectual laziness, which need to be balanced with a deconstructionist approach, wherein the major areas of impairment are identified and quantified and have their interactions considered. Four syndromes known to be individually predictive of adverse outcomes in older adults are repeatedly cited as prevalent in patients with failure to thrive: impaired physical functioning, malnutrition, depression, and cognitive impairment. The differential diagnosis of contributors to each of these syndromes includes the other three syndromes, and multiple contributors often exist concurrently. Some of these contributors are unmodifiable, some are easily modifiable, and some are potentially modifiable but only with the use of resource-intensive strategies. Initial interventions should be directed at easily remediable contributors in the hope of improving overall functional status, because a single contributor may simultaneously influence several other syndromes that conspire to create the phenotype of failure to thrive. How aggressively should more resource-intensive strategies for less easily modifiable contributors be pursued? This is a central clinical, ethical, and policy issue in geriatric medicine that cannot be settled without better process and outcome data. This paper examines the medical etymology of failure to thrive and proposes a rational approach to evaluation and management that is based on the limited medical literature.
t is a scenario familiar to physicians who provide primary care to older adults. A once functionally independent patient is no longer flourishing in the community. Sometimes the office visit is patient initiated, but more often a family member, frustrated by a decline that might escape the notice of more casual observers, serves as the impetus for consultation. The physician also may become frustrated when a traditional history and physical examination fail to elicit telltale signs or symptoms leading to welltraveled algorithms of differential diagnosis. Discrete temporal landmarks as to the onset of symptoms are unelicitable. The examinations may show little other than the stigmata of malnutrition. Psychomotor retardation may be present, but it is unclear whether this represents a dementing syndrome, depression, or simply an appropriate response to the overall situation. Out of exasperation, the family may insist on hospitalization. Alternatively, the patient and family may present to the emergency department and become the dreaded "social admission," whereupon an often poorly tolerated search for cancer and other occult illness begins, usually without satisfying diagnostic resolution. Subsequently, pressure from the family is replaced by pressure from insurers to hasten discharge, bringing pragmatic social issues such as patient safety, nursing home placement, and decision-making capacity to the fore. We became interested in this topic after encountering many older patients who had received a diagnosis of "failure to thrive." Reviewing the medical literature, we discovered that failure to thrive is a complex construct derived from many overlapping bodies of literature. It also possesses a complicated medical etymology that will be of interest to physicians and medical sociologists. In this paper, we review the origins of failure to thrive as a diagnostic construct and propose a rational approach to the problem based on the limited medical literature. Finally, we suggest important areas for research into this understudied problem.
Review of the Literature: An Intellectual Tension
Ann Intern Med. 1996;124:1072-1078. From The New York Hospital-Cornell Medical College and the Amsterdam Nursing Home Corporation, New York, New York. For current author addresses, see end of text. 1072 © 1996 American College of Physicians
A review of the complicated failure to thrive literature shows many synonyms and colloquialisms
several subsequent review articles in the medical (2. and often exhibits signs of hopelessness and helplessness. The older person loses weight. loss of appetite. weight loss. Isaacs and colleagues (1) reported on the functional status of residents of Glasgow toward the end of life:
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. 45% of patients were incontinent. All of these problems are familiar geriatric syndromes in their own right. apathy. .
The juxtaposition of these two papers from the early 1970s emphasizes the balance between the thorough medical evaluations typical of the geriatrician and failure to thrive as a prelude to "natural" death. Clearly. .
. Synonyms Encountered in Reviewing the Medical Literature on Failure to Thrive in Older Adults*
Pre-death (1) The dwindles (2) Failure to maintain (2) Physical and psychosocial failure (2) Biopsychosocial failure (2) Asthenia/cachexia syndrome (3) Wasting away (3) End-stage frailty (4) Taking to bed (5)
* Numbers given in parentheses are reference citations. increasing frailty.8% had decubiti. it is certainly not a desirable one.
The verbs "lose" and "decline" in the above statement underscore the primary intellectual obstacle to a tidy transposition of the term "failure to thrive" from infant to octogenarian: The pediatrician uses the term to describe the patient who has not attained functional status. If we were to take a cue from our pediatric colleagues and construct nomograms with "activities of daily living dependence" rather than height or weight as the measure of scrutiny. Pediatricians use the term "failure to thrive" when their patients fail to achieve height. This general failure of the old person is all too often accepted as due to "old age" or senility or is regarded as a dementing process and the physical basis is overlooked." Despite the heterogeneity of the patients studied (and the subsequent admonition  that the diagnosis "failure to thrive" should perhaps be abandoned).familiar to physicians (1-5) (Table 1). very elderly patients will eventually undergo a process of progressive functional decline. for which the paediatric term "failure to thrive" is appropriate. anorexia. There are many diagnostic possibilities.
Seeking occult and treatable illnesses as the basis for decline resonates with modern geriatric practice. Braun (7) was the first to provide a justification for exporting the concept to geriatrics:
The clinical picture or symptom complex in the elderly failure-to-thrive person presents as a mirror image of the infant failure-to-thrive. or behavioral milestones as determined from large populations that have generated normative data (6). Two systematic studies (13. and dementia are prevalent. and loss of willingness to eat and drink that culminates in death (12). depression. and drive. in such a situation. weight. . Could the symptom complex described as failure to thrive sometimes be simply the manifestations of "pre-death"? It has been proposed that in the absence of disease. But which is the more appropriate vantage point from which to approach such patients? No published work addresses this question directly. in which older adults are often denied optimal care (10). the geriatrician uses it for the patient who has not maintained functional status. Although 13% to 15% of patients died during hospitalization and more than 30% were discharged to nursing homes. have examined how failure to thrive is used as a diagnosis in adults. we would discover that the prevalence of at least one impairment increases with each decade of life and approaches 40% in nonagenarians (9). declines in physical and cognitive function. The distinction is crucial because it forces the internist to reconfront a central challenge of geriatric medicine—distinguishing disease states prevalent in older adults from "normal aging" (for example. 15. Comorbid conditions. and diminishing initiative. In contrast. 14). should we express surprise or acceptance when our patients reach it? Given the pervasive ageism in our society. incontinence. In the larger study (13). 35% were fallers. 16) and nursing (17-19) literature have conceptually approached failure to thrive as a
Table 1. Typically the patient's decline comprises deteriorating social competence. and 9. a high proportion of all deaths in old age were preceded by a period of "pre-death" during which the patient was unable to care for himself in consequence of loss of mobility. an aggressive diagnostic approach would not only be futile but could contribute to suffering. . or mental abnormality . If some degree of impairment is a "normative" milestone. both retrospective and done in inpatient settings. These studies show that the term is applied to a heterogeneous. functional impairment. distinguishing dementing illness from "physiologic changes" in the aging brain ). It is with these same noble ideals that failure to thrive was first described by Hodkinson (11) in 1973:
Illness [in the elderly] often presents as insidious and progressive physical deterioration. neither study addressed the extent and cost of the diagnostic procedures done with the hope of finding something "curable. geriatricians teach that it is a mistake to reflexively ascribe decline to "old age" and accept it as inevitable. concentration. incapacitated group of patients who are no longer able to function independently. It seems that many of those who survive into old age enter a phase of "pre-death" in which they outlive the vigour of their bodies and the wisdom of their brains.
including nursing home placement and death (23. memory loss from depression. the symptom complex inconsistently described as failure to thrive does not conform to any accepted model of disease (such as that of the New York Heart Association). numerous studies have shown the prognostic power of functional status: Impaired patients are at high risk for many poor outcomes. wherein the areas of impairment would be carefully identified. often accompanied by dehydration. Alternatively. because undernutrition is an independent predictor of death in older adults (34). because pathologically low weight in an older person may be confused with lifelong low weight (3). It has had its own International Classification of Diseases. or a combination of these? Does the patient who cannot use a telephone have visual disturbance from cataracts. A recent evaluation of a geriatric inpatient unit showed that failure to thrive was a common admitting diagnosis. In our view. scrutinized for potential interactions. depression. and disabilities resulting in a variety of physiologic changes. alongside more tangible entities. comorbid conditions. the weight at which a person has the lowest mortality increases
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. Unlike diabetes and gastrointestinal bleeding. Careful measurement with standard assessment tools precisely defines the nature of impairments and forces the clinician to adopt a problem-solving approach. 24). Ninth Revision (ICD-9) code since 1979 and is used increasingly in the geriatric population as well as in patients positive for the human immunodeficiency virus (HIV). by anyone's definition. pathophysiology. whereas insidious decline suggests the natural history of chronic processes such as dementing syndromes. and functional effect (21). quantified. we believe that the rather disorderly literature on failure to thrive—by the very nature of its disorganization—says something about the conceptual framework required to care for these patients. although there is no consensus on which tests should be selected for office-based practices or how they should be integrated. This is alarming. should one proceed when confronted with a patient who.
Even though 55% of geriatric inpatients have protein-calorie undernutrition. impaired immune function. pathologic conditions. decreased appetite and poor nutrition. apraxia from dementia. most importantly. the National Institute on Aging in 1991 described failure to thrive as "a syndrome of weight loss. Determining the acuity of any deficit is crucial. or fatalism—that needs to be balanced by a considered and thoughtful deconstructionist approach. hemi-neglect from stroke. depressive symptoms. conditions. then. such as diabetes and gastrointestinal bleeding (20). We therefore advocate the abandonment of the term "failure to thrive" and the adoption of a more measurement-oriented approach with particular attention to four major contributor domains that recur in this literature and are known to be morbid and mortal entities in older adults: impaired physical functioning. these have since been supplemented by performance-based methods that might detect functional dependence in a "subclinical state" (26-28).clinically meaningful diagnosis. Whether intervening in incipient impairment will avert illness and death is one of the most actively pursued questions in geriatric research. and. one might conceptualize failure to thrive as a geriatric syndrome (such as falling and immobility) that may be defined as "a cluster of symptoms. and low cholesterol" (22). or impaired manual dexterity from arthritis? Physical and occupational therapy consultations are invaluable in sorting out these contributors. however. wherein the patient is observed in typical real world maneuvers (29). Early measures focused on self-reported ability to perform activities of daily living (25). to screen for malnutrition? Body weight alone may be unreliable.
Impaired Physical Functioning
A Rational Approach to Management Abandoning Failure To Thrive as a Disease Construct
How. patients may benefit from several interventions. The use of performance-based measures. is failing? Ironically. anatomy. and inactivity. How best. malnutrition. and dementia (Figure 1). in which a fully specified disease must include a clear definition of its cause. If all treatable contributors have been addressed and impaired physical functioning still persists. such as high-intensity strength training to increase functional mobility (30) or multiple risk-factor reduction to decrease the risk for falling (31. most cases of this condition are never diagnosed or treated (33). Does the patient who is unable to dress himself have a frozen shoulder from previous injuries.
Beyond the obvious relevance of functional impairment to quality of life. the label "failure to thrive" promotes an intellectual laziness—accompanied by a certain resignation. 32). With this approach. Using many data sources (including the patient and family) helps to determine the trajectory of decline. and environmental challenges" (22). passivity. then. Furthermore. Rapid decline suggests new illness or acutely decompensating chronic disease. may be especially useful.
Of course. when the underlying causes of malnutrition are be1075
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. A rational approach is to consider abnormal laboratory values in the context of body weight. Although not diagnostic by themselves. Hypocholesterolemia is a predictor of death in patients
in nursing homes (38). Evaluation of the older adult who is failing in the community. Anthropometric measurements derived from midarm circumference and triceps skinfold thickness (36) are time-consuming and lack interobserver reliability (3). and the presence of other stigmata of malnutrition.
with age (35).Figure 1 . such as muscle wasting. low serum cholesterol and albumin levels may be indicators of undernutrition (37). weight trend. and hypoalbuminemia is an independent risk factor for death in older persons (39).
Patients who are declining in any of the four contributor domains should be screened for depression. Clearly. when the octogenarian was the exception rather than the rule in medical practice. changes in food preference.
The notion that all signs and symptoms in a patient's presentation are referable to a single pathophysiologic process served internists well at the turn of the century. attempts to determine which deficits than 65 years of age (50) have dementing synare primary and which are secondary may be an dromes. including poorly fitting dentures. A Mental Status Examination (54) are useful for both more rational approach is to quantify the nature screening and diagnosis and should be administered and level of the patient's impairments. such as myocardial infarction (46). FreThus. including those in the Diagnostic and Statistical Manual of Mental Disorders risk factors that many geriatric syndromes share. Both depression (59) and dementia (60) may initially present with weight loss. several instruments such as the Geriatric Depression Scale (47) and the Center for Epidemiologic Studies Depression Scale (48) are available for this purpose. recognize to all older adults. dramatically with each successive decade (51). Although comprehensive management of the patient with dementia is also beyond the purview of our discussion. 67). it may be possible to restore compensatory ability and (DSM-IV). The rates of major or minor depression among elderly persons range from 5% in primary care clinics to 15% to 25% in nursing homes. the linear or vectorial reasoning that is quently overlooked by clinicians (52).
Depression and Decreasing Socialization
for reversible or treatable causes of cognitive impairment. it is important to take into account not only the exacerbation of more serious chronic illness (the patient with chronic obstructive pulmonary disease who is so dyspneic that he cannot eat) but also easily remedied causes. although only a few dementias are reversible and even fewer reverse completely (55). Similarly. the 85-year-old patient is more likely to have a combination of decompensated congestive heart failure and osteoporotic compression fractures. a higher level of depressive symptoms in Cognitive Impairment patients with dementia (63. and treat the easily remrequires additional criteria for which several algoedied contributors. Physically impaired patients are at greater risk for becoming malnourished (37) and are more likely to have decubitus ulcers (62).ing considered. Although a detailed discussion of the pharmacotherapy of depression in older adults is beyond the scope of this discussion. 41). By modifying the predisposing rithms have been established. establishing a diagnosis of dementia create further impairment. clinicians are referred to other articles on medical management of the demented patient (56-58). readers are referred to recently published expert guidelines on the topic (49). dementia applicable to the care of the younger patient may leads to progressive impairment. Similarly. After cognitive impairment is that deficits interact in mutual and complex ways to documented. and dysgeusia-causing medications. a single chief symptom in the elderly patient is more likely to have several contributing causes. and all-cause mortality rates are higher among elderly persons with depression than among their nondepressed counterparts (42). which may lead to infection and worsening nutritional status and thus perpetuate a vicious cycle of functional decline. and attempts to find a unifying diagnosis may be futile. If depression persists despite treatment of all potentially contributing factors. and the prevalence of dementia increases academic exercise that is not clinically useful. including institutionalization (43) and death (44). The evaluation should include a search
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Failure to diagnose depression in elderly patients is a well-documented phenomenon (40. pharmacologic treatment should be started. By 75 years of age. In contrast. most adults have two to three chronic medical conditions. however. Geriatric psychiatry consultation can be useful in establishing a diagnosis and assisting with management. Furthermore. actually be an intellectual obstacle in the evaluation and death (53). with substantial implications for the clinician. New depression may be the first sign of impending cognitive dysfunction (61). social isolation in itself is a risk factor for poor outcomes. Berkman and Syme (45) showed that persons who lacked social and community ties were more likely to die during the follow-up period than were those with more extensive contacts. deficits frequently coexist in more than one of the contributor domains cited above. Standardized tests such as the Miniof the older patient who is declining (66. institutionalization.
Abandoning Parsimony of Diagnosis
. Whereas the 55-year-old patient with dyspnea and back pain may have bronchoalveolar carcinoma metastatic to the spine. An increasing body of research has shown that emotional support is predictive of recovery from specific illnesses. 64) and chronic medical conditions (65) correlates with poorer functional About 11% of adults in the United States older status.
9th ed. the recipi-
1. Gerety MB. Lonergan ET.273:1039-43. Taking to bed. N Engl J Med. 1990. 1992. J Am Geriatr Soc. Beaston-Wimmer P. Siu AL. McMillan I. Barker W H . 38:1105-12. a patient who is dying should not be forced to endure a battery of multiple assessment scales when palliation would be more appropriate. 2. Rudolph CD. Norwalk. Studies identifying the patients who are more likely to benefit from interventions at presentation. common areas of impairment have similar predisposing factors. Failure to thrive in older patients.18:21-5. Katz IR. Goodwin JS. malnutrition. Kresevic D M . eds. Campion E. J Gerontol Nurs. MD. and cognitive impairment. Levin Rl. Stephen Paget and Thomas Gill for reviewing early drafts of the manuscript. painful. Failure to thrive in the elderly: exploration of the concept and delineation of psychiatric components. Kowal J.258:516. Failure to thrive: paradigm for the frail elder. Functional reach: a marker of physical frailty. Braun JV.4:94-6. 1992. Postgrad Med. "Failure to thrive" in the elderly: diagnosis and management. Ferrucci L. J Gerontol Nurs. 1991:60.29:654-9. Lachs: New York Hospital-Cornell University Medical Center. Dominguez F Jr. 6. Ford AB. Newbern VB. Kimpau S. Phillips SL. Katz S. Frailty. this crucial question has profound ethical and policy implications and cannot be answered without better data. Studenski S. Isaacs B. 515 East 17th Street #912. 7. "The dwindles". Requests for Reprints: Mark Lachs. CT: Appleton & Lange. Bierman EL. Lachs is a Paul Beeson Physician Faculty Scholar (American Federation For Aging Research). Landesfeld CS. 1988. Boston: Little. Halter JB. 1991:844. Extending Life. A diagnostic model for failure to thrive. eds. Fox AC. but few experienced clinicians would advocate routine computed tomographic scans as part of the initial workup. Rudolph's Pediatrics. Jaffe MW. J Geriatr Psychiatry Neurol. Non-specific presentation of illness. 18. Age as a risk factor for inadequate treatment [Editorial]. Strawbridge WJ. 12.19:840-9. Failure to thrive in elderly people: a conceptual analysis. Gerontologist. Hoffman Jl. Gorlin R. New York. Although some geriatricians who are committed to the comprehensive care of older adults may find it objectionable to identify a group of older adults who should not receive aggressive diagnostic evaluations. depression. Newbern VB. Dion M. This stigmatizing label distracts the clinician from a systematic evaluation of the combination of interacting deficits known to be prevalent in patients who are said to have failure to thrive: impaired physical functioning. Brown.38:967-72. The naturalness of dying.
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. Osato EE. 19th ed. the treatment for others can be resourceintensive and may be poorly tolerated by the patient. Lawton MP. Camucho T. 21. Salive ME. 1973. McGaghie WC. 25. Br Med J. 3.39:778-84. 204-6. Foster LW. The predictive validity of self-report and performance-based measures of function and health. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 23.
Acknowledgments: The authors thank Drs. 17. 22. 24. Washington. 1994:1149-56. 29. 3d ed. 14. An objective measurement of physical function of elderly outpatients. and the therapeutic approaches that improve the outcomes that really matter to patients and families should help clinicians and patients make these difficult decisions. and an American College of Physicians Teaching and Research Scholarship. Palmer RM. 1993. Screening for frailty: criteria and predictors of outcomes. Krowchuk HV. 5. 1994. 11. Egbert A M . Wykle M H . Kaplan GA. Failure to thrive in the elderly. Moskowitz RW. 8. 20. Timed manual performance in a community elderly population. the clinician must rely on the limited information that is available and. 1996. Geriatrics.
Conclusions and Areas for Future Study
Failure to thrive should be abandoned as a diagnostic entity. J Am Geriatr Soc. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. Blass JP. 1971. 13. JAMA. Chung M. Verdery RB. Neville Y. Siu AL. ed. 210-2. Vallone R. Principles of Geriatric Medicine and Gerontology. Winne D M . Although many predisposing factors are easily corrected. Groom DD. 16. 1989. eds. 1990. Clinical manifestations. J Am Geriatr Soc. Similarly. Fried LP. Dolgin M. 1993. Dr. J Adv Nurs.45:47-50.28:809-12. Fortinsky RH. Geriatric ideology: the myth of the myth of senility. Ettinger WH. 515 East 17th Street #912. Gaylord SA. Gunn J. Cohen RD. J Am Geriatr Soc. Chandler J. The index of ADL: a standardized measure of biological and psychosocial function. 1994. some treatable and some not.47: M106-10. Elder care. 1987. Guralnik JM. NY 10021. Parmelee P. Duncan PW. In: Hazzard WR. Grant Support: Dr. Goldstein MK. 505 East 70th Street. McKechan A. NY 10021. and ineffective therapies is an important goal of modern geriatric medicine. Enhancing Life: A National Research Agenda on Aging. Hodkinson H M .39:627-31.
ent of Academic Award K00800580 from the National Institute on Aging. We have deliberately avoided making specific recommendations about how aggressively to pursue underlying occult illness as a factor contributing to a patient's decline. Gerontologist.45:26-31.delay the progression of functional dependence (68). McCue JD. 10. 1963. 1991. The Physical Performance Test. N Engl J Med.40:799-806. New York Hospital-Cornell Medical College. The concept of pre-death. 1990. Weiner DK. 26. Reuben DB. Reubin A. Jackson BA. 28. JAMA. Palmer RM. Lowerextremity function in persons over the age of 70 years as a predictor of subsequent disability. J Gerontol Nurs. Wallace RB. Sarkisian: Cornell Internal Medicine Associates. Berkman B. 53-5. 4. "Wasting away" of the old old: can it—and should it—be treated? Geriatrics. 15. Friedman E. HT-4. the diagnostic maneuvers that are the most effective and the most tolerable.709:1115-8. 9.94:199-201. 1992. Thus. 1990. Winograd CH.332:556-61. Wetle T. At this point. 1993. Reuben DB. sparing patients from undignified. Like many problems in geriatric medicine. 19. 1995. 1995. Cowling WR 3d. J Gerontol. The dynamics of disability and functional change in an elderly cohort: results from the Alameda County study.19:12-6. Lancet. At the same time. 1991. JAMA. DC: National Academy Pr. Current Author Addresses: Dr.185:914-9. failure to thrive is more clinically approachable when broken down into measurable domains. 1992. Williams ME.6:161-9. Clark LP. J Am Geriatr Soc. Failure to thrive: a growing concern in the elderly. Failure to thrive in older persons: a concept derived.332:1338-44. respect the personal preferences of the patient. Takano Stone J.38:1120-6. J Am Geriatr Soc. Rapid functional decline in an independently mobile older population living in an intermediate-care facility.40:203-7. Studies of illness in the aged. New York. New York. New depression may indicate underlying pancreatic cancer. 1993. Simonsick EM. most importantly. NY 10021. 27. Sagan P. New York: McGraw-Hill. MPH.19:28-34. J Am Geriatr Soc. Rudolph A M . good geriatric practice requires careful balance and a broad perspective. 1990.
Ann Intern Med.1:385-401. Unifying the approach to geriatric syndromes.50:643-50. 1994. 1992. N Engl J Med. Sullivan DH. 67. Province MA. Holthausen BA. 1994.262:914-9. Feller AG. Evans DA. 43. 55. 1993. Berkman LF.42:583-5. The reversible dementias: do they reverse? Ann Intern Med. Horwitz Rl. J Am Diet Assoc. Chown MJ. J Am Geriatr Soc. J Gerontol. Radloff LS. Pilgrim D M . Emotional support and survival after myocardial infarction. 54. Caradoc-Davies TH. 32.115:122-32. Berkman LF. Rose TL. Garrett P. Med J Aust. 49. Corti MC. Sorkin JD. 1994.47:S183-90. 1990. Elahi D. Tinetti ME. Schechtman KB. NIH consensus conference. 1993. Syme SL Social networks. Prospective trial of a new diagnostic criterion for severe wasting malnutrition in the elderly.273:1354-9. 65. Beers M. Depression. Walls RC. Sweden. 1992.34:295-308. 48. Am J Epidemiol. Leirer VO. A study of physician behavior. 39. McGilchrist C. Burnam A.17:37-49. 38. JAMA. The prevalence of undiagnosed protein-calorie undernutrition in a population of hospitalized elderly patients.29:87-100. 45. Role of caregiver training and risk factors. Medical assessment of the elderly patient. Alexopoulos GS. 63. Du W. Fitz AG. McAvay G. J Am Geriatr Soc. Tinetti ME. Ory MG. and mortality among elderly people in the United States. Ann Intern Med. Pond DC. Verdery RB. 1991. 58. et al. Teri L. M o w e M. Jorm AF.1:34-8. Storer DJ. J Psychiatr Res. Chancellor AH. Rudman D. 34. Malnutrition in the institutionalized older adult. Lipschitz DA. Fiatarone MA. Huang V. Palmateer LM. 1988. Muller DC. Development and validation of a geriatric depression screening scale: a pre-
liminary report. J Am Geriatr Soc. 272:1036-42. 41. Eyland EA. Clin Geriatr Med. 59. Andres R. The functioning and well-being of depressed patients. Mini-mental state. 52. 64. Leo-Summers L. Beckett LA. 1991. Am J Epidemiol. Psychopharmacol Bull. Scherr PA. Arch Neurol. Age-specific incidence of Alzheimer's disease in a community population. O'Neill EF. J Geriatr Psychiatry Neurol. Teri L. Protein-energy undernutrition and the risk of mortality within 1 y of hospital discharge in a select population of geriatric rehabilitation patients. Salive ME. Brodaty H. 66. Peters KE. institutionalization. Folstein SE. 1984.39:1089-92. The CES-D scale: a self report depression scale for research in the general population. 68. JAMA. Janzon L.41:283-96.331:821-7. Malmo. 61. Growdon JH. J Gerontol. Mant A. 1988. Screening for dementia and investigating its causes. Social network and social support influence mortality in elderly men. and mortality: a nine-year follow-up study of Alameda County residents. Claus EB. Age Ageing. Inouye SK. Fam Pract. Chown MJ. Time until institutionalization and death in patients with dementia. 44. Campbell AJ. Lindell SE. Applied Psychological Measurement. Raskind MA. Ann Intern Med. Watts DT. Abrams RC. Stewart A. cognition. Albert MS. population-based study of the elderly. Rogers W. Lum O. Diagnosis and treatment of depression in late life.330:1769-75. Funkenstein HH. Social networks. Solares GR. and functional ability in patients with Alzheimer's disease. J Am Geriatr Soc. Exercise training and nutritional supplementation for physical frailty in very elderly people.14:149-54. 1990. 1985. Albert MS. J Am Geriatr Soc.5:431-7.37:173-83. 1994. 1992. 50. J Psychiatr Res. Fried LP. Physician management of the demented patient. 153: 192-6. incontinence. Garfield A M .42:186-91. A multifactorial intervention to reduce the risk of falling among elderly people living in the community.
15 June 1996 • Annals of Internal Medicine • Volume 124 • Number 12
.117:1003-9. N Engl J Med. 1989. Folstein MF. 46. et al. et al. Goldberg AP. 1994. 35. 60. Tobin JD. Bohmer T. Hypocholesterolemia as a predictor of death: a prospective study of 224 nursing home residents.5:184-8. Fiatarone MA. Daniels M. Morley JE. Wells KB. 56. 36. Diagnosis of illness presentation in the elderly. Winograd CH. 1975. Frailty and injuries in later life: the FICSIT trials. 1979. 1991. Howell T.92:1109-16.3:17-27. 1992. Reifler BV. JAMA. 1991. 1989:262:2551-6.14:327-40. A prospective. Cook NR. Harris P. 47. Gill T M . Brant L Impact of age on weight goals. Brink TL. Saunders NA.12:189-98. DiLuca C. Behavioral complications of dementia: a clinical approach for the general internist. Henderson AS. Depression in Alzheimer's disease. Bowers J. Serum albumin level and physical disability as predictors of mortality in older persons. Hanson BS. 1987.30. 1977. JAMA. Miller JP. J Am Geriatr Soc. 42. host resistance. JAMA. 57. 51. 37. 1995. McCartney JR. Harris L. Higher than previously reported. 1982. Protein-calorie undernutrition in the nursing home. Assessment of cognitive deficit in geriatric patients. JAMA. 1991. Nelson ME.46:M8490. Psychiatr Clin North Am. Guralnik JM.33:467-71. Functional status and cognitive impairment in Alzheimer's patients with and without depression. Recognition of dementia in general practice: comparison of general practitioners' opinions with assessments using the mini-mental state examination and the Blessed dementia rating scale. A practical method for grading the cognitive state of patients for the clinician. Clements KM. Steinbach U. 62. 1991. 31. J Am Geriatr Soc. Jarvik LF. Hays RD.103:1030-3.109:476-86. King DE. Weight loss in Alzheimer's disease. Hebert LE.53:599-605.130:100-1. J Am Geriatr Soc. Results from the Medical Outcomes Study. Adey M. 1986. 1989.268:1018-24. Hadley EC. Besdine R.109:186-204. 1985. General practitioners' detection of depression and dementia in elderly patients. et al. et al. Gottschalk M. J Am Geriatr Soc. Isacsson SO. Scherr PA. Siu AL. and functional dependence. The prospective population study of men born in 1914. 33. Am J Clin Nutr. Diagnosis and treatment of depression in late life: the NIH Consensus Development Conference Statement. Shared risk factors for falls. Kraenzle D. Lodder F. Causes of weight loss in a community nursing home. Ryan ND. Prevalence of Alzheimer's disease in a community population of older persons. et al. Fitz PA. Doucette JT. 1989. Pearson JL. 1993. Baker Dl. Friedman PJ. 1993. 1989. 1995.273:1348-53. 53. McHugh PR. Yesavage JA. Kerstetter JE.39:117-23. J Gen Intern Med. 40.37:1117-21.