The diagnosis “failure to thrive” and its impact on the care of hospitalized older adults: a matched case-control study

Abstract

Background: "Failure to thrive" and associated diagnoses are non-specific terms applied to older adults when there is lack of diagnostic clarity and imply an absence of medical acuity. We investigated the effect of such admission diagnoses on delivery of patient care in a cohort of older adults admitted to a tertiary care teaching hospital. Methods: Retrospective matched cohort study conducted at a tertiary care hospital in Vancouver, BC. Cases identified were adults aged ≥65 years admitted to acute medical wards with an admission diagnosis of "failure to thrive", "FTT", "failure to cope", or "FTC", between January 1, 2016 and November 1, 2017 (n = 60, median age 80 years). Age-matched controls met the same inclusion criteria with admission diagnoses other than those of interest (n = 60, median age 79 years). Results: The primary outcome was time to admission, measured from time points in the emergency room that spanned from triage to completion of admission orders. Secondary outcomes were concordance of admission and discharge diagnoses and length of stay in hospital. The total time from triage to admission for older adults admitted with FTT and associated diagnoses was 10 h 40 min, compared to 6 h 58 min for controls (p = .02). Concordance of admission and discharge diagnoses was only 12% for the "failure to thrive" cohort, and 95% for controls. Notably, 88% of the "failure to thrive" cohort had an acute medical diagnosis at the time of discharge. Patients in this cohort stayed 18.3 days in hospital compared to 10.2 days (p = .001). Conclusions: Patients with an admission diagnosis of FTT or other associated diagnoses had significant delays in care when presenting to the emergency room, despite often having acute medical conditions on presentation. The use of this non-specific label can lead to premature diagnostic closure and should be avoided in clinical practice.

Factors Associated with a Label of Failure to Cope in Older Medical Inpatients: a Case-Control Study*

“…We advocate, as others have before us, ( 6 , 10 , 26 ) that more descriptive and precise language be used to describe patients with complex social situations presenting to hospital. Continued use of labels such as FTC to air frustrations and lay blame on the patient only perpetuates ageism in the system and in the hidden curriculum of medical students and residents.…”

“…( 9 ) Those labelled with FTC also experience delays in care and have longer lengths of stay in hospital compared to controls. ( 10 ) FTC has been associated with significant morbidity and mortality, with 15–54% of patients being discharged to a long-term care home at the time of discharge, and a mortality rate of 22.2%. ( 4 , 9 , 11 ) These data suggest that many patients with FTC do have active medical conditions, legitimizing their need for treatment in an acute care hospital and suggesting that more appropriate language is required.…”

The combined effects of physical frailty and cognitive impairment on emergency department- versus direct-admission hospitalizations

“…For instance, increased involvement of caregivers among frail and/or CI patients could mean more opportunities for recognition of hospitalization-requiring disease [ 35 ], and communication challenges in CI could lead to more opportunities for admission for vague diagnoses (e.g. “failure to thrive”) [ 36 ]. Communication challenges could also delay access to emergency care for those without involved caregivers.…”

Occupational Therapy in the Emergency Department: Patient Frailty and Unscheduled Return Visits

“…The ED physician diagnosed her with "failure to thrive" and referred her for admission to hospital. The use of a non-descriptive label rather than a more specific diagnosis found through exploration of an individual's functional, cognitive, or complicated medical issues (Tsui et al, 2020) is one example of how the ED fails to provide high quality care to frail older adults. The complexity of the frail individual is not well managed in an ED setting, which promotes a medical model (Dawood et al, 2011), frequently focusing on a single episode rather than the individual's history and context (Fernández-Alonso & Martín-Sánchez, 2013).…”