Sarkisian C A, Lachs M S
New York Hospital-Cornell Medical College, New York, USA.
Ann Intern Med. 1996 Jun 15;124(12):1072-8. doi: 10.7326/0003-4819-124-12-199606150-00008.
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 older 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.
“发育迟缓”一词常被用于描述独立性逐渐下降的老年人。该术语于20世纪70年代从儿科学引入，用于描述患有各种并发慢性疾病、功能障碍或两者皆有的老年人。尽管存在这种异质性，但自1979年以来，“发育迟缓”就有了自己的国际疾病分类第九版（ICD - 9）编码，并且在许多综述文章中都被视为具有临床意义的诊断。然而，这种概念框架可能会给正确的评估和管理带来障碍。其中最令人担忧的障碍是宿命论和思维惰性的强化，需要用解构主义方法加以平衡，即在这种方法中要识别和量化主要的损伤领域，并考虑它们之间的相互作用。已知在老年人中可单独预测不良后果的四种综合征在发育迟缓患者中经常被反复提及：身体功能受损、营养不良、抑郁和认知障碍。对这些综合征中每一种的促成因素进行鉴别诊断时会涉及其他三种综合征，而且多种促成因素常常同时存在。其中一些促成因素不可改变，一些容易改变，还有一些可能可以改变但仅需采用资源密集型策略，初始干预应针对易于纠正的促成因素，以期改善整体功能状态，因为单一促成因素可能同时影响其他几种综合征，这些综合征共同导致了发育迟缓的表现型。对于较难改变的促成因素，应多积极地采用资源密集型策略呢？这是老年医学中一个核心的临床、伦理和政策问题，没有更好的过程和结果数据就无法解决。本文研究了“发育迟缓”的医学词源，并基于有限的医学文献提出了一种合理的评估和管理方法。
