Analysis of the validity and reliability of the failure to thrive scale in older adults

Abstract

Objective  To estimate the psychometric properties (factor structure, validity and internal consistency) of an instrument developed to measure failure to thrive in the geriatric population.

Method  The sample consisted of 200 older adults, with an age range between 60 and 105 years, from three medical-geriatric care units in Morelia, Celaya and San Miguel de Allende (Mexico). The psychometric analyses used were factor analysis for validity and Cronbach's alpha for reliability.

Results  The reliability analysis showed an index of 0.913 (CI95% = 0.86-0.89) in the total score. In addition, the results indicate the factorial validity of the proposed instrument in seven dimensions: cognitive performance, depression, multimorbidity, functionality, social risk, primary caregiver and nutrition.

Conclusions  The validity and reliability of a failure to thrive scale in diagnosing this geriatric syndrome were obtained, and they suggest implications for development in the clinical and research field.

Keywords
Frailty; Palliative Care; Elderly Nutrition; Multimorbidity; Dementia; Social Vulnerability

Resumen

Objetivo  estimar las propiedades psicométricas (estructura factorial, validez y consistencia interna) de un instrumento desarrollado para medir falla para progresar en la población geriátrica.

Método  La muestra estuvo conformada por 200 adulto mayores, con un rango de edad entre 60 y 105 años de tres unidades de atención médico-geriátrica de Morelia, Celaya y San Miguel de Allende (México). Los análisis psicométricos utilizados fueron análisis factorial para la validez y alfa de Cronbach para la confiabilidad.

Resultados  El análisis de confiabilidad mostró un índice de 0.913 (IC95% = 0.86-0.89) en el puntaje total. Además, los resultados indican la validez factorial del instrumento propuesto con siete dimensiones: rendimiento cognitivo, depresión, multimorbilidad, funcionalidad, riesgo social, cuidador principal y nutrición.

Conclusiones  Se obtuvo la validez y confiabilidad una escala de falla para progresar en el diagnóstico de este síndrome geriátrico, y sugieren implicaciones de desarrollo en el ámbito clínico y de investigación.

Palabras Clave:
Fragilidad; Cuidados Paliativos; Nutrición del Anciano; Multimorbilidad; Demencia; Vulnerabilidad Social.

INTRODUCTION

Failure to thrive in older adults is a geriatric syndrome that describes the irreversible and severe decline in the physiological reserve that predicts the end of life in a short period with a multicausal origin¹, associated with the presence of acute illnesses, severe chronic illnesses or even without an identifiable cause of deterioration that generates problems at a biological and psychosocial level².

The National Institute on Ageing, in the United States, described this geriatric syndrome as a constellation formed by weight loss, decreased appetite, deficient nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, deterioration of immune function and low cholesterol levels³. Other authors describe failure to thrive as a syndrome that involves physiological and social problems that lead to functional and cognitive deterioration that results in death⁴,⁵.

Hodkinson first described the failure to thrive syndrome in the geriatric population⁶. Several studies have been carried out that take as criteria for this syndrome those described by Hodkinson, and their results show their overall impact on the patient's evolution⁷,⁸. They reflect a significant reduction in the physiological reserve with a greater probability of hospital readmissions, longer stays in different hospital services and death⁹.

From the above, we can infer that identifying failure to thrive has a social, economic, and health impact¹⁰. This allows us to guide medical decisions in geriatric patients with poor recovery possibilities¹¹ or promote specific therapies that improve the quality of life of a recoverable patient without stigmatizing the patient's geriatric conditions or offering futile measures¹².

A standardized and validated diagnostic evaluation of failure to thrive has not been established yet, and this generates an erroneous diagnosis of a geriatric patient with this syndrome¹³,¹⁴. Therefore, the measurement of events described by several authors as integrative elements of failure to thrive is the starting point for the construction and development of a specific instrument that allows more objective decision-making in geriatric patients concerned with a state of a significant decline in physiological reserve¹⁵.

Currently, some instruments measure geriatric frailty¹⁶. However, there is no evidence of a validated scale that measures the degree of extreme homeorhesis in frail patients with a significant loss of physiological reserve compromising their short-term life prognosis¹⁷,¹⁸. Some studies examine risk factors highly related to the mortality of geriatric patients¹⁹,²⁰. Still, they do not pinpoint or quantify the impact of each of these in conjunction with other biopsychosocial variables in the geriatric population²¹,²². In Mexico, an instrument was designed to evaluate failure to thrive, accounting for a content validity obtained using an Aiken validity index of 0.94; however, obtaining different evidence of validity and reliability²³ would be advisable.

A scale to approach failure to thrive could be used for diagnostic, research or clinical purposes, allowing the establishment of the level of homeorhesis in geriatric patients undergoing an acute and/or chronic condition with severe deterioration of the global physiological reserve²⁴,²⁵. Medical decisions must always be oriented toward the quality of life or quality of death of the older adult²⁶,²⁷. Aware of the existence of failure to thrive in a geriatric patient, we can infer the degree of response to medical therapy with a return to the patient's baseline state or no response to the treatment, culminating in death²⁸.

Thus, this study aims to estimate an instrument’s psychometric properties (factor structure and internal consistency) that assess failure to thrive in older adults.

METHOD

The present study deals with an instrument validation design carried out in 2021, including patients over 60 years old living in three medical-geriatric care units representative of the cities of Morelia, Celaya and San Miguel de Allende in Mexico. Their participation was voluntary, and the anonymity of the information provided was guaranteed. Patients who did not wish to participate were excluded if they did not have a complete clinical schedule. A non-probabilistic sampling method of intentional type was used. To calculate the sample size, a total population of 435 registered patients was considered, estimating a prevalence of 50% of the risk, with a confidence interval of 95% and a margin of error of 5%, resulting in a sample of 205 participants, with 200 eligible patients.

An instrument initially made up of eight dimensions was used, integrated by functionality, nutrition, multimorbidity, polypharmacy, cognitive performance, delirium, social risk and depression. Each dimension contains 6 items, with a total of 48 items of the initial instrument; each item counts with graduated response options to which it assigns a score that goes from 0 to 3, where 0 represents the absence of complications and 3 existence of some problem (e.g. the nutrition dimension counts with an item that values absolute lymphocytes where 0 represents values >1500, y 3 values smaller than 900)¹⁷.

Regarding functionality, items such as mobility capacity, sphincter control for defecation and urination and comparison of current functional status compared to previous months² are addressed. In the nutrition dimension, anthropometric variations such as body mass index are addressed, as well as biochemical changes in cholesterol, lymphocytes and albumin¹. In the multimorbidity dimension, items such as acute illness and admission to hospital in the last 6 months, fluctuations in mental state in the last month, presence of delirium, and invasions such as probes, catheters, etc.³ were established. In cognitive performance, items include questions associated with higher mental functions such as changes in episodic memory, changes in orientation in time, place and space, problems in reasoning, language and naming objects, and calculation². In the dimension of economic-social risk, points such as the economic capacity of the adult to cover their basic needs, access to health care units and housing features are studied. In contrast, the dimension of the main caregiver assesses the person who lives with the elderly, his/her daily care capabilities and in case of illness¹. The dimension of depression is made up of items that look for sleep disorders, states of apathy and fatigue in the last month, and recurrent death thoughts³.

The proposed scale was complemented with clinical information from the medical record and through the interrogation carried out by each of the participants or participants’ caregivers who integrated the study. This was completed through the participation of health professionals qualified to apply for this scale. The information was obtained throughout the six months of investigation. Participants and caregivers were informed that their participation was voluntary, their responses and information were anonymous, and their responses would be used for research purposes, with prior informed consent.

The application of the scale adheres to what was established by the Helsinki Declaration and the Nüremberg Code, as well as the provision in the General Health Law in matters of health investigation. It was submitted to the Autonomous University of Querétaro Research Ethics Committee, with approval number SAFM/302/22. To allow the collection of data on different sites where participants were located, we designed software that complied with data security criteria, highlighting encrypted information and control of accounts for each program user to protect the confidentiality of participant information.

An exploratory factor analysis of the main components with orthogonal rotation was carried out to group items, obtain construct validity, and measure the dimensionality of the proposed scale. Before factor analysis, correlation matrices were evaluated using the Kaiser-Meyer-Olkin (KMO) test adequacy index.

The exploratory factor analysis revealed 36 factors, of which the first 7 were selected. The criterion for selecting a factor was that its eigenvalue was greater than 1.0.

For the interpretation of factors, the criterion for including an item within each dimension was that it presented a factor weight greater than 0.35. The conceptual clarity of each dimension was also considered.

Using the Student t-test, differences in each dimension of the scale between healthy participants (patients with chronic non-decompensated pathology, absence of acute pathology) and sick participants (patients with acute decompensation of a chronic pathology, presence of an acute pathology not associated with chronic illnesses) were analyzed.

The internal consistency index (Cronbach's alpha coefficient) was calculated for each actor to obtain the scale's reliability.

The complete data supporting this study's results is available upon request to the corresponding author.

RESULTS

The study included 200 patients (67 men and 133 women), aged between 60 and 105 years, with an average age of 78.46 (DE=9.12). Table 1 shows the demographic characteristics of the participants.

Table 1
Demographic characteristics of older adult patients studied. (N=200). Guanajuato, Mexico; Michoacán, Mexico, 2022.

Variables	N (%)*
Sex
Men	67 (33.5)
Women	133 (66.5)
Age	78.4 ± 9.1
Schooling	9.7 ± 6.1
Marital status
Married	71 (35.5)
Single	22 (11)
Widow(er)	91 (45.5)
Divorced	9 (4.5)
Separated	4 (2)
Common-law	3 (1.5)
Clinical Frailty Scale	4.4 ± 1.8
Charlson Comorbidity Index
Severe	132 (66)
Moderate	45 (22.5)
Mild	23 (11.5)
Lawton and Brody Scale	2 (0-4)
Katz Index	4 (4-6)
MNA Scale
Malnutrition risk	90 (45)
Normal nutrition status	25 (12.5)
Malnutrition	85 (42.5)

• *N= 200; Source: Research data, 2022.

The Kaiser-Meyer-Olkin (KMO) sample adequacy index obtained a value of 0.895, considered excellent. The Bartlett's Sphericity Index was significant (X² =6169.12; df=630; p<.000), indicating the presence of significant correlations and that multidimensionality is adequate, as well as the relevance of carrying out the factor analysis.

The factor solution obtained explains 74.97% of the total variance. Table 2 shows the items grouped by factors and their respective saturations. The contents of the items that belong to the same factor presented theoretical coherence among themselves. According to the factor analysis, the exploratory analysis showed seven dimensions and 34 items, eliminating 14 items and one dimension in the proposed failure-to-thrive scale in older adults. To obtain criterion-referenced validity, Student's t-test analysis was performed.

Table 2
Factor analysis of the Failure to Thrive scale in older adults. Guanajuato, Mexico; Michoacán, Mexico, 2022.

ITEMS	Cronbach’s alpha	Total variance explained
Cognitive performance
Nomination ability	0.955	34.82
Remembering recent events	0.933
Calculation	0.925
Decision-making	0.927
Orientation	0.928
Ability to form sentences	0.892
Depression
Loss of energy	0.885	13.84
Death thoughts	0.759
Apathy	0.862
Daytime hypersomnia	0.836
Depression diagnosis	0.676
Weight changes	0.785
Sleep disorders	0.654
Food intake	0.805
Multimorbidity
Invasions	0.720	8.57
Acute illness	0.787
Mental state fluctuations	0.896
Delirium	0.890
Level of consciousness	0.847
Hospital admissions	0.709
Functionality
Urinary control	0.898	6.74
Bowel control	0.890
Ability to feed oneself	0.882
Daily activities	0.809
Social risk
Access to healthcare	0.888	4.52
Housing features	0.871
Economic income	0.856
Main caregiver
Daily patient’s caregiver	0.925	3.36
People the patient lives with	0.812
Patient’s caregiver in case of illness	0.887
Nutrition
Cholesterol	0.797	3.12
Serum lymphocytes	0.718
Body mass index	0.712
Serum albumin	0.809

• Source: Research data, 2022.

The internal consistency index (Cronbach's alpha coefficient) obtained from the instrument was 0.913 (95% CI = 0.86-0.89) for the total score. The results suggest satisfactory levels of reliability, indicating homogeneity in the items that make up each factor. Table 3 shows the reliability obtained and the number of items for each dimension.

Table 3
Cronbach's alpha coefficient and number of items by dimensions. Guanajuato, Mexico; Michoacán, Mexico, 2022.

DIMENSIONS	α	CI 95%	Items
Cognitive performance	0.967	0.959-0.974	6
Depression	0.898	0.876-0.918	8
Multimorbidity	0.891	0.866-0.913	6
Functionality	0.915	0.894-0.933	4
Social risk	0.839	0.796-0.874	3
Main caregiver	0.829	0.783-0.866	3
Nutrition	0.745	0.682-0.798	4

• α: alpha coefficient. Source: Research data, 2022.

Table 4 shows the mean score, standard deviation, and range for each factor. The mean values are close to the theoretical mean, indicating no problems with floor or ceiling effects in the responses. Standard deviations are relatively consistent across the factors.

Table 4
Descriptive statistics of the Failure to Thrive scale interval. Guanajuato, Mexico; Michoacán, Mexico, 2022.

DIMENSIONS	M	SD	Range
Cognitive performance	3.98	4.89	0-12
Depression	6.15	5.39	0-16
Multimorbidity	2.61	3.59	0-12
Functionality	2.97	3.4	0-10
Social risk	0.66	1.28	0-6
Main caregiver	1.05	1.78	0-6
Nutrition	2.48	2.59	0-10

• M = average values of the scores by dimension. SD = standard deviation of the scores obtained by dimension. Range = range of possible results obtained. Source: Research data, 2022.

Table 5 shows statistically significant differences. Patients have higher scores in all dimensions compared to healthy individuals.

Table 5
Descriptive statistics of the Failure to Thrive scale interval. Guanajuato, Mexico; Michoacán, Mexico, 2022.

DIMENSIONS	Healthy		Ill		t	P	Cohen’s D
	M	SD	M	SD
Cognitive performance	3.26	4.81	5.09	4.83	-2.62	0.009	0.37
Depression	4.06	4.13	9.37	5.54	-7.29	0.000	1.21
Multimorbidity	0.53	0.958	5.78	3.83	-11.94	0.000	2.08
Functionality	1.82	2.37	4.73	3.95	-5.89	0.000	0.94
Social risk	0.44	1.08	0.99	1.48	-2.83	0.003	0.43
Main caregiver	0.79	1.57	1.47	1.88	-2.67	0.006	0.40
Nutrition	1.53	1.81	3.94	2.93	-6.52	0.000	1.03

• M = average values of scores by dimensions of healthy and sick participants. SD = standard deviation of the scores obtained by dimension of healthy and ill participants. T = Student's t between healthy and sick participants. P = p value of the two groups studied. Cohen's D = effect size between healthy and ill participants. Source: Research data, 2022.

DISCUSSION

The Failure to Thrive scale is an instrument designed to measure the prognosis of geriatric patients with low physiological reserve suffering from an acute illness or worsening of a chronic problem. It assesses survival based on the gradual and progressive reduction of components such as nutritional status, function, social risk, characteristics of their primary caregiver, cognitive status, the existence of depression and multimorbidity¹³.

The factor structure obtained retains some of the dimensions of the original scale such as functionality, nutrition, multimorbidity, cognitive performance, depression and social risk¹⁷. Additionally, the instrument incorporates the primary caregiver as a subscale, eliminating polypharmacy and delirium as dimensions²⁹. With these adjustments, its conceptual and factor structure is corroborated, evidencing the factorial validity of the scale in a consistent manner.

The reliability based on the internal consistency of the results shows indices between 0.74 and 0.96, considered adequate and indicating that the study group evaluated is coherent through the different items that make up each subscale of this instrument, and compared with the existing frailty scales, they present a similar statistical behavior³⁰. Regarding the construct validity obtained through the factor structure, there is conceptual congruence between the factors obtained, presenting a Cronbach's alpha of 0.913, which means satisfactory reliability. The evidence of factor validity reaffirms the conceptual approach and the construct validity of the items as they have been evaluated in the present research¹⁶.

The analysis carried out between the differences of the dimensions, the category of cognitive performance, depression and functionality show higher scores as compared with the other dimensions. This confirms what is described in the literature regarding the great association between the cognitive state and disability, the fragile depressive syndrome and its impact on adverse outcomes such as death³¹,³².

Based on the results, it can be observed that an instrument was obtained with has adequate psychometric properties of construct validity, factor validity, reliability and explained variance that allows measuring failure to thrive in older adults³³.

The relevance of this study is based on obtaining a scale with adequate psychometric properties to measure failure to thrive in older adults in a valid and reliable way, through an adequate grouping of variables obtained through an exploratory factor analysis and through the calculation of reliability by Cronbach's alpha, being acceptable in this study. This allows this instrument to measure patients according to the degree of presenting poor therapeutic response to an acute or chronic health problem, and to be guidelines in making health decisions¹⁸.

The study has some weaknesses, the first being the sample size, since it is small considering the geriatric population that lives in the cities studied. In addition, since it is a non-probability sample, the information obtained can only be considered for the sample studied, which does not allow the results to be generalized to the entire geriatric population. However, different authors describe that to estimate the reliability of an instrument, as is the objective of this study, the sample size between 200 and 300 participants does not generate statistical fluctuations for its validation and reliability calculation³⁴.

CONCLUSION

The findings show that this instrument can measure the construct in a multidimensional way, obtaining adequate psychometric properties, preserving the principles of the geriatric patient where his/her health and illness status depend on biological aspects (level of independence according to his/her functional status, nutritional status and acute illnesses or chronic diseases), social aspects (integrating aspects related to the support network in the community group where he/she lives and access to health services), and psychological aspects (associated with cognitive behavioral changes and depression).

Finally, the scale obtained in this study can give rise to another line of research focused on the geriatric sliding syndrome, in which, knowing the scores of the proposed scale and diagnosing the patient, the degree of reversibility of each of the deficits of the dimensions can be studied and its impact on the patient's survival and quality of life can be seen.

• There was no funding for the execution of this work.
• DATA AVAILABILITY
  The complete data set supporting the results of this study is available at Mendeley Data and can be accessed at DOI: 10.17632/fcjcw2689h.1

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Edited by

• Edited by: Isac Davidson S. F. Pimenta

Data availability

The complete data set supporting the results of this study is available at Mendeley Data and can be accessed at DOI: 10.17632/fcjcw2689h.1

Publication Dates

• Publication in this collection
  24 Feb 2025
• Date of issue
  2025

History

• Received
  06 May 2024
• Accepted
  11 Dec 2024