Journal of Gerontology 1975, Vol. 30, No. 6, 655-660
Unrecognized Psychiatric Illness in Elderly Medical-Surgical Patients1 Marc A. Schuckit, MD, 2 Patricia L. Miller,2 and Dewey Hahlbohm2
estimated that 15% of the elderI Tlyhasin been the community are impaired with
nervous disorders, an additional 5% are psychotic but not hospitalized, and another 2 to 3% are institutionalized because of psychiatric problems (Busse & Pfeiffer, 1969; Kay, Beamish, & Roth, 1964; Larsson, 1968). Many of these elderly patients have concomitant medical and psychiatric illness. The mental problem is overlooked in up to 50% of any group of medical and surgical patients (Burville, 1971), but the interactions are especially strong in geriatric patients (Mechanic, 1972) where an underlying mental disorder may be masked by the somatic complaint. For example, depression, a frequent illness in the elderly, may be missed when too much emphasis is placed on the presenting symptoms of lethargy or pain with neglect of the underlying affective disorder (Kidd, 1962a). Many health professionals do not like to work with elderly patients, viewing them as hopeless and repugnant (Carmichael & Linn, 1974). As part of a cursory evaluation, the physician tends to respond to the patient's age (Carmichael & Linn, 1974), viewing confusion as a disease rather than as a symptom 'Complete background references and specific diagnostic criteria are available from the authors. The authors wish to thank Penny Fovall and Judy Schuckit for their help. 'Univ. of Washington, Alcoholism and Drug Abuse Institute, 3937 15th Ave., NE.NL 15, Seattle 98195.
of any of a wide range of maladies (Kidd, 1962a). Global impressions or imprecise diagnostic criteria are used (Goldfarb, 1961; Kidd, 1962b), which make it difficult for one health worker to understand the shorthand of another (Kendell, 1974). Older patients may display unique symptoms and unusual responses to treatment (Salzman, Kochansky, & Shader, 1972). Because the physician may not recognize the important differences between his older and younger patients, the elderly are often not treated until florid symptoms have developed and the case is incorrectly felt to be hopeless. The result is inadequate care and avoidably long hospitalization (Goldfarb, 1961). These problems are far from academic. Kidd (1962a) studied a group of elderly patients receiving inpatient medical or psychiatric care and discovered a 30% rate of improper diagnosis and placement with a resultant doubling of the expected mortality for misplaced patients. Improper actions were especially common for single or widowed, lower socioeconomic class patients over age 75 who had incontinence, confusion, restlessness or impaired mobility (Kidd, 1962b). The chance for error was also higher for patients transferred from community hospitals or chronic care facilities, rather than from home. 655
Downloaded from http://geronj.oxfordjournals.org/ at University of Winnipeg on August 17, 2015
Research diagnostic criteria were used in a structured interview to evaluate the presence of unrecognized psychiatric illness in 50 acute medical and surgical patients over the age of 65 at the La Jolla Veterans Administration Hospital; 24% of the subjects had unrecognized major mental disorders — predominantly depression or alcoholism. The geriatric patients most likely to have unrecognized illness were older, widowed or divorced, had past jail and/or psychiatric hospital experiences, and gave histories of vascular disorders. The results are consistent with past literature on the elderly.
656
SCHUCKIT, MILLER, AND HAHLBOHM
METHODS
The subjects were 50 consecutive male patients aged 65 and over who were admitted to acute medical and surgical wards at the La Jolla Veterans Administration Hospital over 6 weeks beginning September 18, 1974. In order to study the prevalence of unrecognized psychiatric illness, only those patients whose admitting evaluation did not note a specific psychiatric illness (including alcoholism) were eligible. Also excluded from the study were those patients whose physicians considered them too medically ill to be interviewed. Whenever possible, subjects were seen within 72 hours of hospital admission. Interview Each eligible patient was given a structured interview. The interview form was modified for a geriatric population from a series of interviews used in psychiatric investigations carried out on younger populations over the last 10 years (Schuckit, Halikas, Schuckit, McClure, & Rimmer, 1973). The interview was divided as follows: (1) introduction and request for cooperation; (2) demography and social functioning; (3) smoking, drug, and alcohol history; (4) personal history of psychiatric syndromes both over the prior 6 mo. and the person's lifetime; (5) family history of psychiatric illness; and (6) organicity tests. The organicity measures were used to establish the presence of obvious organic impairment rather than for finding subtle
organicity changes. We used three tests: (1) the Memory-For-Designs Test (MFD) (Graham & Kendall, 1960; May, Urguhart, & Watts, 1970); (2) the Face-Hand Test (Fink, Green, & Bender, 1952); and (3) the Orientation Tests also known as the Mental Status Questionnaire (MSQ) (Arie, 1973; Withers & Hinton, 1971). The patient interview took approximately 60 min., which included 15 min. of organicity testing. The series of questions was easily adapted into two 30-min. sessions for those patients who found the protocol too strenuous. Chart Review Each patient's present medical chart was reviewed for the following data: identifying and demographic information, past and present physical status, medications, chief complaint, medical review of symptoms, mental status information, alcohol — smoking — drug history, and the patient's condition on admission. Diagnostic Criteria The paradigm of diagnoses presented by Feighner et al. (1972) was followed in this study. The diagnostic label is meant to give more than a description of the patient at one point in time — it indicates the probable future course and treatment response for the individual. The basic Feighner criteria were used for schizophrenia, primary affective disorder, anxiety neurosis, and obsessive compulsive or phobic neurosis. Where appropriate, additional symptoms for the elderly were added. The diagnoses of alcoholism and drug abuse parallel those of Feighner et al. (1972), and the National Council on Alcoholism (Criteria Committee, NCA, 1972). Several diagnostic entities were not covered by Feighner et al. They are: Late onset paranoia (late paraphrenia). — This refers to paranoid delusions beginning at age 50 or older in the absence of an organic brain syndrome and in the absence of other diagnoses (Post, 1965). Senile dementia and atherosclerotic dementia. — The disgnosis of an Organic Brain Syndrome (OBS) is made in the presence of memory impairment, intellectual deterioration, confusion, disorientation and impaired judgment along with possible hallucinations and/or delusions (Busse, 1973; Carmichael & Linn, 1974). The presence of obvious drug,
Downloaded from http://geronj.oxfordjournals.org/ at University of Winnipeg on August 17, 2015
The inaccurate diagnostic practices in elderly medical and surgical patients result in much needless human suffering and wasted monies. Relatively crisp diagnostic criteria have been set forth for younger psychiatric patients (Feighner, Robins, Guze, Woodruff, Winokur, & Munoz, 1972) but their relevance to the elderly is not known. In addition, there are a number of psychiatric syndromes of the elderly which are either ignored or inadequately covered in the standard criteria. There is a need for the establishment of accurate diagnostic criteria applicable to older populations. This investigation uses personal interviews and chart reviews to establish the prevalence of unrecognized psychiatric disorders in elderly medical and surgical patients at a Veterans Administration Hospital.
UNRECOGNIZED PSYCHIATRIC ILLNESS
Senile dementia. — This OBS has a gradual onset of a continually progressive picture of the usual OBS symptoms plus failure in common activities and disorganization of the usual personality (Kay et al., 1964). The patient shows a bland affect and deterioration in personal habits (Berkett, 1972).
RESULTS
The admission charts of 105 patients were reviewed. Excluded from the study were all men who received a psychiatric diagnosis on admission (N = 26) and all patients who were too physically ill to be interviewed (i.e., they were so weak they could not talk to us) (N= 12). Twelve men were discharged too soon after admission to be seen and 5 subjects refused to participate in the study. Thus, 50 of the 55 (91%) finally eligible patients were successfully interviewed. Patients were
consecutive admissions to acute surgical (N = 19) and medical (N = 31) services. Of the original 105 chart review subjects 75 were on the medical wards — of these 31 (41 °/o) were psychiatrically ill. The 31 mentally ill men included 24 patients whose physicians noted the presence of mental disorders (77 % of the ill men) and 7 patients whose diagnoses were only picked up by the interview. Seven of the 30 surgical patients were psychiatrically ill (23 °/o). These 7 mentally ill subjects included 2 patients whose physicians noticed the presence of mental disorder (29% of the ill men) and 5 whose diagnoses were only noted by interview. The final study sample of 50 men had a mean and mode age of 74 years and all but one were Caucasian. The mean elapsed time from admission to interview was 51 hours. This did not differ significantly between psychiatrically ill and well groups. Twelve patients met the research criteria for psychiatric illness which had not been noted or treated in the hospital. The diagnoses included 8% with alcoholism, 6°7o with affective disorder, 6% with atherosclerotic dementia, and 2% each with anxiety neuroses or undiagnosed psychiatric illness. All affective patients were unipolar depressives. Six of the 12 ill patients had past histories of psychiatric illness — none of which were noted in their clinical charts. The patients included 3 alcoholics who had prior alcoholic difficulties; 1 depressive with a prior depression along with alcohol problems; 1 anxiety neurotic patient with prior serious depression; and 1 patient who was undiagnosed both now and in the past. Two patients who were not diagnosed as psychiatrically ill had alcoholic histories ending 3 and 14 years previously. Most patients were on some medication at home and entered the hospital taking an average of 2 drugs (range 0-7, mean 1.8, mode 2). This increased to between 4 and 5 medications when they were admitted to their ward (range 2-10, mode 4). Psychotropic drugs given in the hospital were limited to diazepam and hypnotics; two-thirds of the patients received these drugs. Table 1 compares the backgrounds of men diagnosed psychiatrically ill with those of men felt to be well. To give a standard for comparison, the chi-square results are indicated but the small number of patients makes statistical analysis tenuous.
Downloaded from http://geronj.oxfordjournals.org/ at University of Winnipeg on August 17, 2015
metabolic, neoplastic, or traumatic causes of the syndrome was evaluated by the chart review. In addition, patients with signs of serious depression prior to or concomitant with the OBS were considered to be primarily depressed with OBS a secondary phenomenon (Kendall, 1974). Two specific organic syndromes were diagnosed in this study and preset criteria for each have been established: Atherosclerotic Dementia (or Psychosis) and Senile Dementia (or Psychosis). Acute Confusional States (i.e., the evolution of an OBS over hours or days) were noted, but this syndrome is presumed to be secondary to other major psychiatric (e.g., depression) or organic (e.g., circulatory or traumatic insults or drug reaction) causes (Alexander, 1972; Foley, 1971). Atherosclerotic dementia. — This OBS begins with a fluctuating course — periods of OBS (especially at night) alternating with normality (Arie, 1973; Slater, Roth, 1969). The clinical picture consists of the typical OBS signs listed above plus emotional lability and restlessness; the patient has some insight into the fact that he is impaired and has preservation of his normal personality pattern (Alexander, 1972). The onset can be quite sudden (Roth, 1959)and hallucinations and/or delusions (especially paranoid) might be present (Arie, 1973). The patient will almost always give a past history consistent with circulatory insufficiency, e.g., strokes or myocardial infraction (Goldfarb, 1961).
657
SCHUCKIT, MILLER,
658
Table 1. Demographic Comparison of Psychiatrically 111 and Well Samples Within the SO Interviewed Patients.
III (N) Age (years) Range Education % attending college Mean grade of those without college
Well
Sig (N)
(N)
76.6 68-87
73.6 65-87
17
24
7.7
9.1
Religion (%) Catholic Protestant Other None
8 50 33 8
32 45 8 16
Marital status (%) Single Married Separated or divorced Widowed
8 33 33 25
5 66 8 21
Living with (%) Spouse Other relative or friend Alone Nursing Home
33 25 17 225
66 5 27 2
Place of residence (%) House Apartment Trailer Nursing home Other
33 17 17 25 8
45 21 26 2 5
% with past psychiatric hospitalization % ever in jail % with vascular disease MSQ score MFD score over 6CV0)
33 60 58 1.1 67
5 24 26
XJ-=4.4O63,/K.O5 XJ=4.39O0,p
Unrecognized Psychiatric Illness in Elderly Medical-Surgical Patients1 Marc A. Schuckit, MD, 2 Patricia L. Miller,2 and Dewey Hahlbohm2
estimated that 15% of the elderI Tlyhasin been the community are impaired with
nervous disorders, an additional 5% are psychotic but not hospitalized, and another 2 to 3% are institutionalized because of psychiatric problems (Busse & Pfeiffer, 1969; Kay, Beamish, & Roth, 1964; Larsson, 1968). Many of these elderly patients have concomitant medical and psychiatric illness. The mental problem is overlooked in up to 50% of any group of medical and surgical patients (Burville, 1971), but the interactions are especially strong in geriatric patients (Mechanic, 1972) where an underlying mental disorder may be masked by the somatic complaint. For example, depression, a frequent illness in the elderly, may be missed when too much emphasis is placed on the presenting symptoms of lethargy or pain with neglect of the underlying affective disorder (Kidd, 1962a). Many health professionals do not like to work with elderly patients, viewing them as hopeless and repugnant (Carmichael & Linn, 1974). As part of a cursory evaluation, the physician tends to respond to the patient's age (Carmichael & Linn, 1974), viewing confusion as a disease rather than as a symptom 'Complete background references and specific diagnostic criteria are available from the authors. The authors wish to thank Penny Fovall and Judy Schuckit for their help. 'Univ. of Washington, Alcoholism and Drug Abuse Institute, 3937 15th Ave., NE.NL 15, Seattle 98195.
of any of a wide range of maladies (Kidd, 1962a). Global impressions or imprecise diagnostic criteria are used (Goldfarb, 1961; Kidd, 1962b), which make it difficult for one health worker to understand the shorthand of another (Kendell, 1974). Older patients may display unique symptoms and unusual responses to treatment (Salzman, Kochansky, & Shader, 1972). Because the physician may not recognize the important differences between his older and younger patients, the elderly are often not treated until florid symptoms have developed and the case is incorrectly felt to be hopeless. The result is inadequate care and avoidably long hospitalization (Goldfarb, 1961). These problems are far from academic. Kidd (1962a) studied a group of elderly patients receiving inpatient medical or psychiatric care and discovered a 30% rate of improper diagnosis and placement with a resultant doubling of the expected mortality for misplaced patients. Improper actions were especially common for single or widowed, lower socioeconomic class patients over age 75 who had incontinence, confusion, restlessness or impaired mobility (Kidd, 1962b). The chance for error was also higher for patients transferred from community hospitals or chronic care facilities, rather than from home. 655
Downloaded from http://geronj.oxfordjournals.org/ at University of Winnipeg on August 17, 2015
Research diagnostic criteria were used in a structured interview to evaluate the presence of unrecognized psychiatric illness in 50 acute medical and surgical patients over the age of 65 at the La Jolla Veterans Administration Hospital; 24% of the subjects had unrecognized major mental disorders — predominantly depression or alcoholism. The geriatric patients most likely to have unrecognized illness were older, widowed or divorced, had past jail and/or psychiatric hospital experiences, and gave histories of vascular disorders. The results are consistent with past literature on the elderly.
656
SCHUCKIT, MILLER, AND HAHLBOHM
METHODS
The subjects were 50 consecutive male patients aged 65 and over who were admitted to acute medical and surgical wards at the La Jolla Veterans Administration Hospital over 6 weeks beginning September 18, 1974. In order to study the prevalence of unrecognized psychiatric illness, only those patients whose admitting evaluation did not note a specific psychiatric illness (including alcoholism) were eligible. Also excluded from the study were those patients whose physicians considered them too medically ill to be interviewed. Whenever possible, subjects were seen within 72 hours of hospital admission. Interview Each eligible patient was given a structured interview. The interview form was modified for a geriatric population from a series of interviews used in psychiatric investigations carried out on younger populations over the last 10 years (Schuckit, Halikas, Schuckit, McClure, & Rimmer, 1973). The interview was divided as follows: (1) introduction and request for cooperation; (2) demography and social functioning; (3) smoking, drug, and alcohol history; (4) personal history of psychiatric syndromes both over the prior 6 mo. and the person's lifetime; (5) family history of psychiatric illness; and (6) organicity tests. The organicity measures were used to establish the presence of obvious organic impairment rather than for finding subtle
organicity changes. We used three tests: (1) the Memory-For-Designs Test (MFD) (Graham & Kendall, 1960; May, Urguhart, & Watts, 1970); (2) the Face-Hand Test (Fink, Green, & Bender, 1952); and (3) the Orientation Tests also known as the Mental Status Questionnaire (MSQ) (Arie, 1973; Withers & Hinton, 1971). The patient interview took approximately 60 min., which included 15 min. of organicity testing. The series of questions was easily adapted into two 30-min. sessions for those patients who found the protocol too strenuous. Chart Review Each patient's present medical chart was reviewed for the following data: identifying and demographic information, past and present physical status, medications, chief complaint, medical review of symptoms, mental status information, alcohol — smoking — drug history, and the patient's condition on admission. Diagnostic Criteria The paradigm of diagnoses presented by Feighner et al. (1972) was followed in this study. The diagnostic label is meant to give more than a description of the patient at one point in time — it indicates the probable future course and treatment response for the individual. The basic Feighner criteria were used for schizophrenia, primary affective disorder, anxiety neurosis, and obsessive compulsive or phobic neurosis. Where appropriate, additional symptoms for the elderly were added. The diagnoses of alcoholism and drug abuse parallel those of Feighner et al. (1972), and the National Council on Alcoholism (Criteria Committee, NCA, 1972). Several diagnostic entities were not covered by Feighner et al. They are: Late onset paranoia (late paraphrenia). — This refers to paranoid delusions beginning at age 50 or older in the absence of an organic brain syndrome and in the absence of other diagnoses (Post, 1965). Senile dementia and atherosclerotic dementia. — The disgnosis of an Organic Brain Syndrome (OBS) is made in the presence of memory impairment, intellectual deterioration, confusion, disorientation and impaired judgment along with possible hallucinations and/or delusions (Busse, 1973; Carmichael & Linn, 1974). The presence of obvious drug,
Downloaded from http://geronj.oxfordjournals.org/ at University of Winnipeg on August 17, 2015
The inaccurate diagnostic practices in elderly medical and surgical patients result in much needless human suffering and wasted monies. Relatively crisp diagnostic criteria have been set forth for younger psychiatric patients (Feighner, Robins, Guze, Woodruff, Winokur, & Munoz, 1972) but their relevance to the elderly is not known. In addition, there are a number of psychiatric syndromes of the elderly which are either ignored or inadequately covered in the standard criteria. There is a need for the establishment of accurate diagnostic criteria applicable to older populations. This investigation uses personal interviews and chart reviews to establish the prevalence of unrecognized psychiatric disorders in elderly medical and surgical patients at a Veterans Administration Hospital.
UNRECOGNIZED PSYCHIATRIC ILLNESS
Senile dementia. — This OBS has a gradual onset of a continually progressive picture of the usual OBS symptoms plus failure in common activities and disorganization of the usual personality (Kay et al., 1964). The patient shows a bland affect and deterioration in personal habits (Berkett, 1972).
RESULTS
The admission charts of 105 patients were reviewed. Excluded from the study were all men who received a psychiatric diagnosis on admission (N = 26) and all patients who were too physically ill to be interviewed (i.e., they were so weak they could not talk to us) (N= 12). Twelve men were discharged too soon after admission to be seen and 5 subjects refused to participate in the study. Thus, 50 of the 55 (91%) finally eligible patients were successfully interviewed. Patients were
consecutive admissions to acute surgical (N = 19) and medical (N = 31) services. Of the original 105 chart review subjects 75 were on the medical wards — of these 31 (41 °/o) were psychiatrically ill. The 31 mentally ill men included 24 patients whose physicians noted the presence of mental disorders (77 % of the ill men) and 7 patients whose diagnoses were only picked up by the interview. Seven of the 30 surgical patients were psychiatrically ill (23 °/o). These 7 mentally ill subjects included 2 patients whose physicians noticed the presence of mental disorder (29% of the ill men) and 5 whose diagnoses were only noted by interview. The final study sample of 50 men had a mean and mode age of 74 years and all but one were Caucasian. The mean elapsed time from admission to interview was 51 hours. This did not differ significantly between psychiatrically ill and well groups. Twelve patients met the research criteria for psychiatric illness which had not been noted or treated in the hospital. The diagnoses included 8% with alcoholism, 6°7o with affective disorder, 6% with atherosclerotic dementia, and 2% each with anxiety neuroses or undiagnosed psychiatric illness. All affective patients were unipolar depressives. Six of the 12 ill patients had past histories of psychiatric illness — none of which were noted in their clinical charts. The patients included 3 alcoholics who had prior alcoholic difficulties; 1 depressive with a prior depression along with alcohol problems; 1 anxiety neurotic patient with prior serious depression; and 1 patient who was undiagnosed both now and in the past. Two patients who were not diagnosed as psychiatrically ill had alcoholic histories ending 3 and 14 years previously. Most patients were on some medication at home and entered the hospital taking an average of 2 drugs (range 0-7, mean 1.8, mode 2). This increased to between 4 and 5 medications when they were admitted to their ward (range 2-10, mode 4). Psychotropic drugs given in the hospital were limited to diazepam and hypnotics; two-thirds of the patients received these drugs. Table 1 compares the backgrounds of men diagnosed psychiatrically ill with those of men felt to be well. To give a standard for comparison, the chi-square results are indicated but the small number of patients makes statistical analysis tenuous.
Downloaded from http://geronj.oxfordjournals.org/ at University of Winnipeg on August 17, 2015
metabolic, neoplastic, or traumatic causes of the syndrome was evaluated by the chart review. In addition, patients with signs of serious depression prior to or concomitant with the OBS were considered to be primarily depressed with OBS a secondary phenomenon (Kendall, 1974). Two specific organic syndromes were diagnosed in this study and preset criteria for each have been established: Atherosclerotic Dementia (or Psychosis) and Senile Dementia (or Psychosis). Acute Confusional States (i.e., the evolution of an OBS over hours or days) were noted, but this syndrome is presumed to be secondary to other major psychiatric (e.g., depression) or organic (e.g., circulatory or traumatic insults or drug reaction) causes (Alexander, 1972; Foley, 1971). Atherosclerotic dementia. — This OBS begins with a fluctuating course — periods of OBS (especially at night) alternating with normality (Arie, 1973; Slater, Roth, 1969). The clinical picture consists of the typical OBS signs listed above plus emotional lability and restlessness; the patient has some insight into the fact that he is impaired and has preservation of his normal personality pattern (Alexander, 1972). The onset can be quite sudden (Roth, 1959)and hallucinations and/or delusions (especially paranoid) might be present (Arie, 1973). The patient will almost always give a past history consistent with circulatory insufficiency, e.g., strokes or myocardial infraction (Goldfarb, 1961).
657
SCHUCKIT, MILLER,
658
Table 1. Demographic Comparison of Psychiatrically 111 and Well Samples Within the SO Interviewed Patients.
III (N) Age (years) Range Education % attending college Mean grade of those without college
Well
Sig (N)
(N)
76.6 68-87
73.6 65-87
17
24
7.7
9.1
Religion (%) Catholic Protestant Other None
8 50 33 8
32 45 8 16
Marital status (%) Single Married Separated or divorced Widowed
8 33 33 25
5 66 8 21
Living with (%) Spouse Other relative or friend Alone Nursing Home
33 25 17 225
66 5 27 2
Place of residence (%) House Apartment Trailer Nursing home Other
33 17 17 25 8
45 21 26 2 5
% with past psychiatric hospitalization % ever in jail % with vascular disease MSQ score MFD score over 6CV0)
33 60 58 1.1 67
5 24 26
XJ-=4.4O63,/K.O5 XJ=4.39O0,p
