Spitz (1945) found similar deterioration in foundling home babies who, although their physical needs were addressed, were isolated in a gray world with little human contact or stimulation. After 2 years, the babies who remained institutionalized displayed severely retarded motor and intellectual development.
Reviewing all the earlier studies on maternal deprivation and failure to thrive, Bowlby (1969) theorized that people must attach, or bond, with one another to move from globalness to social relatedness and, thus, thrive as separate, competent beings. Although Bowlby's early work pointed to the necessity for attachment in early life, he has since characterized attachment behavior as a necessity throughout the life span (Bowlby, 1982).
FH AND THE ELDERLY
The term "failure to thrive" has recently been applied to the elderly (Braun, 1988), with particular reference to weight loss and malnutrition (Hazzard, 1990), to what is considered a downward course (Palmer, 1990), and to vague clusters of symptoms on admission (Campion, 1986). That is, failure to thrive is used as a convenient blanket admission diagnosis.
Only two reports, however, have considered failure to thrive in the elderly in the conceptual context in which it is used with children. Burnside (1988) wonders if "caring behaviors influence the survival of older people" and asks, "Is there possibly a 'marasmus' among the elderly?" Berkman, Foster, and Campion (1989), in a retrospective study, attempted to define the term "failure to thrive" as used by physicians treating elders. Their findings suggest that patients hospitalized with FTT have multiple problems: physical, mental, social, and environmental. Their functional capacities and coping abilities are severely diminished. The authors note that the diagnosis of FTT does not reflect the normal changes related to aging, nor does every older person with a chronic condition develop FTT. Like others (Braun, 1988; Hazzard, 1990), Berkman and colleagues call for rigorous research to clarify the dynamics of FTT in older adults.
No one would quarrel with the need for such studies, but in the meantime, those of us working with the elderly should take a lesson from the old miasma theory of epidemiology. Early on, miasma (bad air) was thought to be the causal agent for yellow fever, malaria, and other diseases common in low-lying swampy areas during the hot, humid summer months. The "proof" was that those who could afford to flee to the mountains or more northern latitudes escaped the pestilences. Similarly, because the concept of FTT seems to fit well with the picture presented by some older adults, it seems expethent to use the notion of interaction with the environment as a causative factor while waiting for more definitive word on the causes of these problems among the elderly.
Whether or not they have been diagnosed as having FTT, many older persons fit the picture with decline in cognitive and physical function, consistent unplanned weight loss, inadequate nutritional intake, signs of depression, giving up or taking to bed, and helplessness.
Precipitating factors are multiple. Some may always have been present but were masked or mediated by roles, work, or others (Austin, 1989; Newgarten, 1964). Losses, small and large, numerous and irreplaceable, may snowball and thus overwhelm the individual. Loss of relationships may result in loneliness, feelings of being excluded from life, and dependence on strangers. Functional losses can create feelings of dependency and shame, which are often reinforced by caregivers so that elderly patients' feelings of exclusion - of "being stupid, insignificant, a 'nobody/ 'out of place and out of line' " (Drew, 1986) - are confirmed. Loss of place within society as social space constricts, within the family as role reversal begins, and within the self as buffers fall away and coping skills diminish can drain life of joy and reason for being. All meaning may be lost.
Older adults at risk for FTT are likely to present with symptoms similar to those seen in infants and young children with FTT. Differences are age-related; for example, infants fail to gain weight, older adults lose it; infants are apathetic and fail to develop social bonds, older adults become apathetic and fail to maintain social relatedness skills; infants fail to develop cognitive and perceptual-motor skills, older adults exhibit cognitive/intellectual and perceptualmotor losses. The changes in the elderly may be attributed to many causes. It is, therefore, imperative that an in-depth assessment, including a developmental assessment, be done. There are a number of tools that gerontological nurses will find helpful in developing a true picture of FTT in the elderly. Several are described below.
Gerontological nurses should always be suspicious of unexplained weight loss, particularly when the loss is involuntary. Robbins (1989) has listed common causes of weight loss in the elderly (Figure 1), and Collingsworth and Boyle (1989) provide a comprehensive list of nutritional indicators that nurses should explore if they are to identify vulnerable elders and intervene early (Figure 2). The results of their study emphasize the need for nurses to rely on more than visual indicators to get a true picture of the patient's condition.
There is a great deal of research that links nutritional deficits with cognitive and physical functioning (Goodwin, 1983; Newman, 1987), although the direction of the association is not always clear. Because this chicken or egg state is current reality, the presence of either should trigger concern and immediate intervention.
Older adults with FTT may be depressed; in fact, FTT has been called a disguise for depression (Anderson, 1989). They may present with some or all of the usual diagnostic criteria for depression. In addition, they may take to bed (Clark, 1990), turn to face the wall, or exhibit helplessness and hopelessness (Hansson, 1986-87). They may have a diminished sense of time in contrast to the expansion of subjective time experienced by elderly who are content with their quality of life (Newman, 1987).
Therefore, mental status should be assessed for these behaviors as well as those covered in one of the popular tools, such as the Beck Depression Inventory (Beck, 1961) or the Zung Self-Rating Depression Scale (Zung, 1965).
Assessment of Attachment
A reliable and valid tool for assessing attachment in the elderly is the 24-item Adult Attachment Scale developed by Lipson-Parra (1989). This tool uses self-report to identify the special person to whom the adult is attached and measures characteristics of the attachment, residential proximity, and contact frequency. Typical items include:
* I feel safe when I am with this person.
* This person listens to my problems and worries.
* I frequently think about this person.
Demographic data obtained when the instrument was tested indicated that the old-old led in scores, raising the question of whether their attachments contribute to their longevity. Both this question and its correlate (Are the attachments reported by the old-old longstanding or are they serial?) need answers. In other words, do long-lived people have a greater capacity for social relatedness?
This instrument provides a valuable tool for approaching FTT through the back door. It is a screening instrument that, when used with other tools such as genograms, should provide early detection and thus early intervention.
Herth (1989) described the process of using genograms to explore the cultural, behavioral, and social development of a family. Information explaining how to use genograms is beyond the scope of this article; however, the use of genograms has been reported to increase the amount of medical and family data fourfold over an average history.
The Nine D's of Weight loss in the Elderly*
Moreover, a major advantage of the genogram is that it identifies the impact of critical events and changes as perceived by the client that may threaten to rob life of meaning (Putnam, 1987). Also, the use of genograms tends to encourage reminiscence. The importance of reminiscence to a developmental assessment cannot be underestimated, and its therapeutic value has been documented extensively (Burnside, 1984; Newbern, 1992). If the interviewer has the requisite skills, reminiscence may lead to a structured life review, a chance to work through and summarize life events (Goodwin, 1983; Haight, 1988).
Assessment is one form of intervention. Based on the findings of the assessment, many interventions may be appropriate; for example, diet, traditional treatments for depression and physical problems, or reminiscence therapy. Based on "tried and true" remedies used with FTT infants and young children, two other interventions hold promise.
Montague (1 971 ) said that the rhythmic contractions of childbirth were critical to the health of the newborn and also noted the hunger for touch evidenced by the elderly. The touch of another is an innate human need. We cuddle our infants and our lovers. We touch each other with our eyes when we listen. We rock our children, holding them close to soothe and comfort them; we swing them, dance with them, and play games with them. We stimulate their minds as we introduce them to the touch of sand, soil, a puppy's tongue, and ice cream. We are, in fact, stimulating them to integrate themselves into a whole, trusting being.
As older people sustain inevitable losses, that hard-won integrated self may begin to unravel. Touching may now be limited to hurtful contacts: injections, emotional distancing, or condescending or infantalizing behaviors. The elderly need the stimulation we provide for children, not to build, but simply to maintain. They need caring touch. They need to listen and be listened to. They need touch through eye contact, holding hands, hugs, back rubs, massages, dancing. They can learn again the comfort, joy, and stimulation of rocking and swinging, and exercise and play. With help and encouragement, they can remain integrated.
One of the major tasks that children face in becoming integrated is building a sense of social relatedness, coming to know and trust themselves so that they can reach out to others and bond with them.
In the case of the elderly, bonds may have been broken or badly frayed by death, disabilities, or physical or emotional distancing. Some seem able to forge new bonds throughout life; others do well until they are overwhelmed by life.
Gerontological nurses can facilitate the maintenance or renewal of bonds in many ways: by encouraging family visits; setting up conference calls between the elderly and family members and significant others; helping to produce audio and video tapes as well as letters, computer discs, and fax sheets. They can encourage working through old quarrels so that relationships can be mended. They can facilitate network building by sparking old interests and concerns of the elders so that they become involved in conservation efforts, gardening, historical societies, formal learning, or whatever their interests happen to be.
They can encourage older persons to set up or become involved in a Dolphin type plan, where elders living in the community become buddies with institutionalized elders (Thomas, 1982). They can encourage elders living alone to consider sharing their home with another person, perhaps another older person, a single mother, or a developmentally disabled person who is working and coping but needs a home and mutual caring (Newbern, in press).
In essence, gerontological nurses can find the concept of failure to thrive useful in identifying elders at risk and in working with those elders in creative ways to nurture and maintain their potential in this last stage of life. They can help to maintain or build attachments. As Drew noted, "Cultivation of this primordial relationship is necessary so that the care does not diminish but rather nourishes the humanness of both giver and receiver" (Drew, 1986).
- Anderson, E., Feverly, C, LaChance, R., Trygtad, C, Vogel, L. Coping with the care of the elderly. Geriatrics 1989; 44(1)3344.
- Austin, A.G. Becoming immune to loneliness: Helping the elderly fill a void. Journal of Gerontological Nursing 1989; 15(9):25-28.
- Beck, A.T., Beck, R.W. Screening depressed patients in family practice: A rapid technique. Arch Gen Psychiatry. 1961; 4(1):6163.
- Berkman, B., Foster, L., Campion, E. Failure to thrive: Paradigm for the frail elderly. Gerontologist 1989; 29(5):654~659.
- Bowlby, J. Attachment and loss. New York: Basic Books, 1969.
- Bowlby, J. Attachment and loss: Retrospect and prospect. Am J Orthopsychiatry 1982; 52:644-678.
- Braun, J.V., Wycle, M.N., Cowling, W.R. Failure to thrive in older persons: A concept derived. Gerontologist 1988; 28:809-812.
- Burnside, I.M. Working with the elderly: Group process and techniques. Monterey, CA: Wadsworth, 1984.
- Burnside, LM. Nursing and the aged. New York: McGraw-Hill, 1988.
- Campion, E., Berkman, B., Fulmer, T. Failure to thrive for older adults. Gerontologist 1986; 26:192-197.
- Clark, L.P., Dion, D.M., Barker, W.H. Taking to bed: Rapid functional decline in an independently mobile older population living in an intermediate-care facility. J Am Geriatr Soc 1 990; 38(9>:967-972.
- Collingsworth, R., Boyle, K. Nutritional assessment of the elderly. Journal of Gerontological Nursing 1989; 15(12):11-21.
- Drew, N. Exclusion and confirmation: A phenomenology of patients' experiences with caregivers. Image 1986; 18(2):39-43.
- Durand, B. Failure to thrive in a child with Down's syndrome- Nurs Res 1978; 24:275285.
- Fischoff, J., Whitten, C, Petit, M.G. A psychiatric study of mothers of infants with growth failure secondary to maternal deprivation. / Pediatr 1971; 79(4):200-215.
- Goodwin, J.S., Goodwin, M.D., Garry, P- Association between nutritional status and cognitive functioning in a healthy elder population. JAMA 1983; 249(21 ):291 7-2920.
- Haight, B. The therapeutic role of a structured life review process in homebound elderly subjects. / Gerontol 1988; 43(l):40-44.
- Hansson, R.G., Jones, W.H., Carpenter, B.N., Remondet, J.H. Loneliness and adjustment in old age. Journal of Aging and Human Development. 1986-87; 24(l):41-52.
- Harlow, H., Harlow, M. Effects of various mother-infant relationships on Rhesus monkey behaviors. In: B.M. Foss (Ed.), Determinants of infant behavior, IV. London: Methuen, 1969.
- Hazzard, W., Andras, R., Bierman, E., Blass, J. Fatigue, failure to thrive, weight loss and cachexia. In: R. Verdery (Ed.), Principles of geriatric medicine and gerontology, 2nd ed. New York: McGraw-Hill, 1990.
- Herth, K.A. The root of it all: Genograms as a nursing assessment tool. Journal of Gerontological Nursing 1989; 15(12):32-37.
- Holt, J.E. The care and feeding of children. New York: Appleton, 1894.
- Hopwood, N. Investigating the inorganic causes. Consultant 1984; 24(l):45-56.
- Lipson-Parra, H.B. Development and validation of the adult attachment scale: Assessing attachment in older adults. Presented at the 3rd Annual Conference of the Southern Nursing Research Society, February 1989, Austin, Texas.
- Montague, A. Touching. New York: Columbia University Press, 1971.
- Newbern, V.B. Sharing the memories: The value of reminiscence as a research tool. journal of Gerontological Nursing 1992; 18(5):13-18.
- Newbern, V.B., Hargett, M.V. The aged developmentally disabled. Holistic Nursing Practice In press.
- Newgarten, B. (Ed.). Personality in middle and late life. New York: Atherton Press, 1964.
- Newman, M. Aging as increasing complexity. Journal of Gerontological Nursing 1987; 13(9).16-18.
- Palmer, M. H. "Failure to thrive" in the elderly: Diagnosis and management. Geriatrics 1990; 45(9):47-55.
- Pout, E., Eichler, A. Behavioral disturbances among failure to thrive children. Am ) Dis Child 1976; 130(l):24-29.
- Putnam, P.A. Coping in later years: The reconciliation of opposites. image 1987; 19(2):6769.
- Rhymes, J.P. Working with mothers and babies who fail to thrive. Am f Nurs 1966; 66:1971-1976.
- Ribble, M. The rights of infants. New York: Columbia University Press, 1943.
- Robbins, L. Evaluation of weight loss in the elderly. Geriatrics 1989; 44(4):31-37.
- Spitz, R. Hospitalization: An inquiry into the genesis of psychiatric conditions in early childhood. Psychoanal Study Child 1945; l(l):53-74.
- Suran, B.G., Hatcher, R.F. The psychological treatment of hospitalized children with failure to thrive. Pediatric Nursing 1975; 1(1):1017.
- Thomas, V. You're a what? What's a dolphin? Geriatr Nurs 1982; 3:118-121.
- Zung, W.K. A self-rating depression scale. Arch Gen Psychol 1965; 72(5):63-70.
The Nine D's of Weight loss in the Elderly*