An 85-year-old man is sent to the hospital by his primary care physician because he has been experiencing generalized weakness, unintentional weight loss, and functional decline over the past 6 months. The patient reports poor appetite, fatigue, and difficulty performing daily activities. He has no living family or regular caregiver. His neighbor, who is his primary social support, reports that the patient has had reduced interest in activities he previously enjoyed, low mood, and social withdrawal. On examination, the patient appears frail, with a body mass index of 19 kg/m2. He has mild orthostatic hypotension, reduced muscle mass, and temporal wasting. His hair and nails are poorly groomed. Laboratory test results are unremarkable except for mild anemia and hypoalbuminemia. He is admitted to the hospital for failure to thrive.
Although this patient’s story may be familiar to many hospitalists, “failure to thrive” is not in fact a diagnosis. It has no consensus definition or approved treatments. Moreover, while failure to thrive is costly1 and frequently seen in medically complex patients,2 it is often trivialized as a “social admission.”3 The medical literature provides limited guidance on how to approach failure to thrive.4
Here, we describe a practical framework for caring for older adults hospitalized for failure to thrive based on the comprehensive geriatric assessment, a multidomain assessment used in geriatrics, streamlined and adapted for hospitalists.5
FAILURE TO THRIVE IS A FAILURE TO DESCRIBE
The term failure to thrive first appeared in the pediatric literature, where it described babies or children who fail to meet growth and behavioral milestones.6 In the 1980s, Braun et al7 posited that this pediatric syndrome mirrors a syndrome of weight loss accompanied by cognitive and functional decline commonly seen in older adults. Although subsequent definitions have been proposed, encompassing a wide range of variables that include weight loss, malnutrition, cognitive decline, functional decline, depressive symptoms, impaired immune function, and low cholesterol,4,8 no consensus definition exists. While adult failure to thrive has had an associated International Classification of Diseases code since 1979, this term has been criticized for creating barriers to appropriate evaluation and management, and some have argued against its use.1,4
Lack of a consensus definition has led to a paucity of data describing failure to thrive’s prevalence, risk factors, outcomes, and recommended management.
FRAILTY AND FAILURE TO THRIVE: A COMPLEX INTERPLAY
Proposing a definition of failure to thrive based on measurable clinical parameters is complicated by the fact that 2 patients with identical biomedical profiles may not both experience failure to thrive. A patient who is struggling to meet daily needs, losing weight, and generally declining at home may thrive with additional home support, a live-in caregiver, or transition to a long-term care facility. Therefore, we propose that failure to thrive in older adults is best understood as an imbalance between patient frailty and environmental support.
Frailty is a syndrome seen in older adults that is characterized by impaired ability to respond to physiologic stress due to the accumulation of deficits across multiple domains of health over time.9 Frailty is associated with many adverse clinical outcomes, including lower quality of life and increased risk of hospitalization, institutionalization, and death.9–11 Because frail older adults are vulnerable to adverse outcomes, patients living with a high burden of frailty need robust environmental supports. When the degree of frailty outweighs those supports, patients fail to thrive.
COMPONENTS OF A MODIFIED COMPREHENSIVE GERIATRIC ASSESSMENT
The comprehensive geriatric assessment is a structured evaluation of a range of health domains including cognition, function, medication management, social context, and patient care goals, in addition to the traditional biomedical domain. It is frequently performed by an interdisciplinary team. Because the comprehensive geriatric assessment takes a long time to complete, we propose a modified assessment tailored to hospitalized older adults with failure to thrive and streamlined for practicality. This assessment includes focused evaluations of the following health domains: biomedical, cognitive, functional, medications, and social context. It is based on the patient’s baseline health as of about 2 weeks before admission, which may be compared with the patient’s in-hospital baseline. The modified comprehensive geriatric assessment relies on history from the patient as well as collateral information from family, caregivers, or both.
Below, we describe how to systematically and efficiently assess these domains for a patient presenting with failure to thrive.
Assess for biomedical causes
Many biomedical pathologies may cause or contribute to failure to thrive12; listing them is beyond the scope of this commentary. We suggest the use of advanced organizers such as broad categories of disease (eg, infectious, inflammatory, metabolic, toxic, malignant, and idiopathic) or organ system–based pathologies. Clinicians should consider whether a new disease (eg, undiagnosed malignancy) or a decompensated chronic disease (eg, poorly controlled heart failure) may be driving the presentation. We recommend a stepwise approach, beginning with a basic laboratory workup, including a complete blood count, comprehensive metabolic panel, and thyroid-stimulating hormone, and allowing history and a physical examination to guide further diagnostics.
Assess cognition
Impaired cognition may present as failure to thrive in many ways. Patients with impaired memory or executive function may forget to eat or not recognize signs of hunger or thirst. They may struggle with routine tasks involved in purchasing, transporting, and preparing food. They may experience comorbid mood symptoms, including apathy and depression, which can affect appetite. These cognitive changes drive a positive feedback loop wherein loss of ability to acquire and prepare food leads to weight loss, generalized weakness, and worsening difficulty acquiring and preparing food.
Daily delirium screening using a validated tool such as the Confusion Assessment Method is warranted for all hospitalized older adults.13 Inpatient geriatrics consultation, although not available at all institutions, may be considered for support managing delirium, especially in cases where chemical or mechanical restraints are needed to maintain safety. If a patient is not delirious, we recommend administering the Mini-Cog,14 a 3- to 5-minute dementia screening tool that provides an objective measure of a patient’s cognitive baseline and has been validated for use in the inpatient setting.15 Additionally, the Patient Health Questionnaire-2, which also has been validated for use in the inpatient setting,16 may be helpful in screening for a mood disorder, which is often comorbid with cognitive impairment. Collateral history from family or caregivers is critical to obtaining a complete history. We recommend asking about difficulty completing daily tasks because of memory loss, daily problems with thinking and memory, and repetition of the same questions and or stories. Deficits in hearing and vision can compromise cognition; these can be assessed at the bedside.
If cognitive impairment is identified, a targeted workup for reversible etiologies may include a complete blood count, comprehensive metabolic panel, and measurement of thyroid-stimulating hormone and vitamin B12 levels. One-time brain imaging may be considered, with the choice of imaging modality dependent on clinical context, a consideration that is beyond the scope of this article. More comprehensive cognitive evaluations such as a Mini-Mental State Examination, Montreal Cognitive Assessment, or neuropsychiatric testing are best deferred to the outpatient setting, where the care team has the advantage of longitudinal follow-up. Hospital social workers can help optimize community support. Because most neurodegenerative diseases worsen over time, care goals should be explored and documented early.
Assess function
A focused functional assessment includes a brief overview of the basic and instrumental activities of daily living. Asking patients to describe their typical day can be an effective strategy for learning about their functional baseline. If mobility is a concern, we suggest observing the patient rise from a seated position, walk a few steps, and sit back down. This simple maneuver can give insight into strength, balance, mobility, and the ability to follow multistep instructions. If nutrition is a concern, we suggest directly observing a patient eat and drink small amounts of food and water to identify barriers to adequate nutrition, including visual or proprioceptive difficulties that make eating difficult, poor dental health, badly fitting dentures, impaired swallow, or lack of interest in food.
Key elements of the physical examination may also yield information about function. Intact skin indicates a basic degree of mobility or care is being met; pressure ulcers are often a sign of significant mobility impairment. Hair that is recently cut, styled, or colored indicates that either the patient or a caregiver is providing routine care. Toenails that are clean and well-maintained may indicate that the patient either has the memory, mobility, and manual dexterity to maintain nail care, or adequate support to regularly receive care.17 These examination findings are easily accessible and take seconds to observe.
Once barriers to independent function are identified, the care team can take steps to rectify them. Collaboration with physical and occupational therapists may optimize mobility and function. Speech and language pathologists may support safe and effective swallowing, while dentists can help treat oral disease that may be impairing eating. Independent functioning may be supported by appropriate medical equipment and technology, including mobility devices (canes, walkers), safety devices (fall alert systems), and cognitive aids (alarmed pill boxes).
Review medications
Medications are common and reversible contributors to functional, cognitive, and nutritional declines in older adults that may cause patients to present with failure to thrive. Medications may contribute to failure to thrive by impairing nutrition either directly or indirectly, or by increasing the risk of adverse cognitive side effects, functional impairment, and falls (Figure 1).
Medications contributing to failure to thrive in older adults.
A structured approach can help optimize management of pharmacotherapy. First, we suggest compiling a comprehensive list of the patient’s prescription and over-the-counter drugs, supplements, and herbal remedies. Next, explore patient interest in deprescribing. Ask patients if they want to take fewer medications and if they have noticed any unwanted side effects from any of their medications. This can guide a deprescribing plan, prioritizing18 potentially inappropriate medications for older adults such as those with anticholinergic properties and sedative-hypnotics; validated tools such as the Beers criteria19 may identify such medications. A consultation with pharmacy or geriatrics can guide a medication review and deprescribing plan.
Assess social context
The social context a patient lives in and the interplay between it and biomedical pathology is a key feature of failure to thrive. Social isolation and loneliness are well-known risk factors for adverse health outcomes in older adults.20 Furthermore, inadequate support at home in conjunction with even mild cognitive changes and comorbidities can precipitate failure to thrive. Moreover, a significant life change such as the loss of a spouse, arrival of a new caregiver, or a recent move can set the course for failure to thrive or intensify an existing decline. Two simple questions may help clinicians understand contributing social factors:
Who helps you at home?
What activities does your caregiver help with?
Asking caregivers directly about caregiver burden may also identify areas of vulnerability. Once social vulnerabilities have been identified, clinicians can partner with social workers to mobilize resources such as meal delivery services, transportation services, patient and caregiver support groups, religious and social networks, local Councils on Aging, and skilled services provided in the patient’s home.
Figure 2 presents a summary of the assessments and corresponding interventions in the modified comprehensive geriatric assessment.
Assessment and management of failure to thrive that will inform comprehensive discharge planning.
UNDERSTAND GOALS AND VALUES
A targeted assessment in the care domains of cognition, function, medication management, and social context, layered on top of a standard biomedical evaluation, will almost always identify deficits contributing to failure to thrive. Whatever these deficits may be, it is impossible to effectively manage them without understanding the patient’s health priorities and reviewing and updating advance directives. Open-ended questions such as “What is important to you?” or “What do you value with regard to your health care?” often lead to general answers touching on universal themes21 that may help start a conversation but not yield actionable guidance for specific decisions. Other questions that may help guide practical decision-making include asking what the patient’s preferred site of care is and whether significant time spent in a healthcare setting is acceptable. If comorbid conditions such as cardiac, pulmonary, renal, or malignant diseases are contributing to failure to thrive, disease-based therapies aimed at extending length of life often entail increased time in a healthcare setting; we recommend clearly articulating and exploring this tradeoff.
CONCLUSION AND NEXT STEPS
Many hospitalists have cared for patients with an admitted diagnosis documented as failure to thrive. They will likely care for many more. Seeing failure to thrive documented as an admitting diagnosis presents an opportunity for clinicians to identify, articulate, and begin to ameliorate the true underlying diagnoses that have caused the patient’s health deficits and care needs to exceed their home supports. A systematic, holistic, domain-based approach to care may help such patients thrive.
DISCLOSURES
The authors report no relevant financial relationships which, in the context of their contributions, could be perceived as a potential conflict of interest.
- Copyright © 2025 The Cleveland Clinic Foundation. All Rights Reserved.
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