Older patients referred to a consultation-liaison psychiatry clinic

OLDER PATIENTS REFERRED TO ACONSULTATION-LIAISON PSYCHIATRY CLINIC

PHILIP WILKINSON1*, JONATHAN BOLTON

2AND CHRISTOPHER BASS

3

1Department of Psychiatry of Old Age, Fulbrook Centre, Churchill Hospital, Oxford OX3 7JU, UK2Department of Psychiatry, The Cambridge Hospital, Cambridge, MA 02193, USA

3Department of Psychological Medicine, John Radcli�e Hospital, Oxford OX3 9DU, UK

ABSTRACT

Background. Little is known about the psychiatric disorders which are associated with somatic presentations ofpsychological distress in older people.Method. A study of patients aged 65 years and over referred to an adult consultation-liaison psychiatry clinic in a

general hospital.Results. Of 900 patients referred over a 7-year period, 45 (5%) were aged 65 years and over. The most frequent ICD-

10 diagnostic category was somatoform disorder (N�30) followed by depressive disorder (N�6). The age of onset ofthe physical symptoms was signi®cantly earlier in those with somatoform disorders (mean 49 years; SD 3.1 years)compared with patients with depressive disorders (mean 74 years; SD 3.1 years) (p50.05). All diagnoses were equallyassociated with moderate functional impairment.Conclusion. Medically unexplained physical symptoms may occur as part of a range of psychiatric disorders in older

people and diagnostic groups are distinct in a number of ways. The usefulness of the ICD-10 classi®cation of disordersin relation to these patients is considered. Implications for the delivery of old age psychiatry services are discussed.Copyright # 2001 John Wiley & Sons, Ltd.

KEY WORDSÐsomatisation; elderly; somatoform disorder

INTRODUCTION

Old age psychiatrists are accustomed to workingwith patients who present with both physical andpsychiatric symptoms. Frequently, these symptomsare attributed to particular physical disorders or topsychiatric illnesses such as anxiety disorders. Onoccasions, however, the cause of the physicalsymptoms may be unclear, although psychologicalfactors may be aetiologically relevant.Understandably, psychiatrists and physicians areoften reluctant to attribute unexplained physicalsymptoms to psychiatric disorder in a populationin whom physical illness is so prevalent andatypical presentations so common. Nonetheless, itis evident that the process of somatisation (physicalsymptoms occurring in the absence of relevantphysical disorder which have a presumed psycho-logical basis) does occur in older patients.

Despite evidence that somatisation is no lessfrequent with ageing (Lloyd, 1985), there has beenlittle interest in identifying and classifying dis-orders associated with somatisation in olderpatients. Studies in younger adults indicate thata�ective and anxiety disorders account for a largeproportion of somatic presentations of psychiatricillness (Simon and von Kor�, 1991), althoughfrequently presentations do not fall convenientlywithin these categories. With the trend towards amore categorical classi®cation of the neuroticdisorders (Lindesay, 1993), some of these patientswith medically unexplained symptoms have beensubsumed within the category of somatoformdisorders (International Classi®cation of Diseases10; WHO, 1992). The validity and usefulness ofthis category remain unclear, however, especially inrelation to older patients.

A clear research agenda has now emerged whichhas addressed the prevalence and phenomenologyof these disorders, the need to include them inmedical education and the need for e�ectiveinterventions (Barsky, 1993). This has been accom-

Copyright # 2001 John Wiley & Sons, Ltd. Received 24 August 1999Accepted 28 April 2000

INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int. J. Geriatr. Psychiatry 16, 100±105 (2001)

* Correspondence to: Dr P. Wilkinson, Department of Psychia-try of Old Age, Fulbrook Centre, Churchill Hospital, OxfordOX3 7JU, UK. Tel: 01865 223821. Fax: 01865 223829. E-mail:[email protected]

panied by the establishment of psychiatric consul-tation-liaison outpatient services within or along-side general hospital clinics, where patients withmedically unexplained symptoms often present.Published accounts of these services includepatients from a range of ages including olderpeople with somatoform disorders (Creed et al.,1993). The provision and evaluation of liaisonservices for older people has, however, tended tore¯ect the disorders typically seen amongst inpa-tients in general hospitals, namely severe depressiveillness, dementia and delirium (Anderson andPhilpott, 1991; Bowler et al., 1994).

This study is concerned with patients aged 65years and over referred to an adult consultation-liaison psychiatry outpatient clinic in a generalhospital. The nature and duration of the psychia-tric disorders seen are reported, together with ratesof current physical comorbidity, associated func-tional impairment and putative precipitants ofillness. Finally, we consider the usefulness of adiagnosis of somatoform disorder when applied toolder adults.

METHODS

Setting

The study took place at a consultation-liaisonpsychiatry clinic in an Oxford teaching generalhospital serving a population of 0.5 million people.[Details of the whole group of patients attendingover a 7-year period from 1991 are describedelsewhere (Bass et al., submitted)]. The clinic issta�ed by a consultant liaison psychiatrist andtrainee psychiatrists under his supervision.Referrals of patients aged 17 upwards are receivedfrom hospital specialists and for most of the studyperiod referrals were also received direct formgeneral practitioners. Other parts of the consul-tation-liaison service in the hospital o�er inpatientliaison psychiatry and assessment of patients withdeliberate self-harm. A range of interventions iso�ered, although it is outside the scope of thispaper to describe these. Referrers have also theoption to refer directly to the local old agepsychiatry service.

Assessment

A routine semi-structured psychiatric interviewwas conducted which, in most cases, also involvedan informant. Most assessments were completed

with one interview but in some cases two interviewswere necessary. An ICD-10 diagnosis was allocatedby the consultant who had received training andhad reached a satisfactory level of reliability in aprevious study using ICD-10 criteria (Malt et al.,1996). Precedence was given to the diagnosis mostrelevant to the reason for referral, according to thesuggested hierarchy of ICD-10. A standard pro-forma was completed which included informationon referral source, sociodemographic status, pre-senting problems, concurrent physical illness, levelof functional impairment, psychiatric history andinterventions o�ered. Functional disability wasmeasured according to the patient's account ofhis or her activities in the previous month, backedup by the informant where possible. This was ratedon a 5-point scale on which 1�no interference withlifestyle; 2�some restriction of lifestyle/lives in-dependently; 3�severe restriction of lifestyle orincapable of complete independence; 4�dependentbut not needing constant attention; 5�totaldependence/in need of almost constant attention.Finally, the following information was also re-trieved from the relevant medical and psychiatricpast records: apparent precipitants to currentpresentation, onset and duration of current psy-chiatric disorder, and frequency and nature ofpsychiatric presentations in earlier life.

RESULTS

Over the 7-year period, a total of 900 patients of allages were referred to the clinic. Forty-®ve (5%) ofthe 900 patients referred were aged 65 or over whenreferred and all attended for assessment. Theresults presented below concern this group of 45older patients.

Referral source

Twenty-seven patients (60%) were referred fromother hospital specialists (eight from physicians,seven from anaesthetists in a pain clinic, three fromsurgeons, two from other psychiatrists and sevenfrom miscellaneous specialists). The remainder (18;40%) were referred by general practitioners.

Demographic characteristics

The mean age of patients referred was 71 years(range 65±88 years; SD 5 years). Thirty-one werewomen and 14 were men; 25 were married, nine

CONSULTATION-LIAISON PSYCHIATRY CLINIC 101

Copyright # 2001 John Wiley & Sons, Ltd. Int. J. Geriatr. Psychiatry 16, 100±105 (2001)

widowed, six divorced and ®ve were single. All wereWhite Europeans, except for one Afro-Caribbean.

Reasons for referral

Referrers gave a number of reasons for referral,the most frequent being problems with somaticsymptoms or pain (32; 71%); the next mostfrequent being confusion and disordered mood.

Diagnoses

Tables 1 and 2 show primary psychiatricdiagnoses with mean ages of onset, duration andassociated disability. In three patients no psychia-tric diagnosis was made. Two of these weresu�ering with cardiac disease and one had anarthritic disorder. Few patients were given sub-sidiary diagnoses. Three patients with persistentsomatoform pain disorder had subsidiary diag-noses of depressive disorder, and one with depress-ive disorder had a subsidiary diagnosis of persistentsomatoform pain disorder.

Functional impairment

Mean functional impairment scores were similarfor all disorders, most patients scoring either 2 or 3on the 5-point scale (Tables 1 and 2).

Previous psychiatric history

Twenty two patients (49%) had at least oneprevious episode of documented psychiatric illness.The mean age at which the previous illnessoccurred was 36.7 years (SD 15.2 years; range18±71 years).

Concurrent physical illness

Over half of the group (24; 53%) had aconcurrent physical illness at the assessment. Themost frequent category was cardiovascular disease(9; 20%) followed by gastrointestinal (4; 9%),neurological (2; 4%), respiratory (1; 2%) andothers (8; 18%).

Putative precipitants of current psychiatric disorder

In approximately half of the cases (28; 62%) theassessor recorded physical illness as having beenthe trigger to the current psychiatric illness. In farfewer cases (7; 15%) psychosocial events wererecorded as being the main causal factors. In those18 patients whose psychiatric illness began at age65 years or over, more were precipitated by physicalillness (14; 78%) than by psychosocial stressors (4;22%).

Physical investigations and complaint behaviour

Seventeen patients (38%) had undergonephysical investigations for their physical symptoms

Table 1. Primary psychiatric diagnoses (ICD-10), durations and ages of onset of disorders, and mean disabilityscores

Diagnosis ICD-10

Code

Number of

cases

Mean age of onset in

years (range)

Mean duration in years

(range)

Mean functional

impairment scores

Somatoform

disorders

F45 30 49 (18±75)� 19 (1±50) 2.3

Depressive disorders F32/33 6 74 (66±87)� 2 (1±5) 2.2

Conversion disorder F44.4 1 44 23 3.0

Neurasthenia F48.4 1 72 11 3.0

Agoraphobia F40.0 1 60 8 3.0

Adjustment disorder F43.2 1 67 1 2.0

Benzodiazepine

withdrawal

F13.3 1 71 1 2.0

Delusional disorder F22.0 1 58 7 2.0

No psychiatric

diagnosis

3

�p50.05.

102 P. WILKINSON ET AL.


before referral. Twenty patients (44%) had beenseen by at least one other hospital specialist inaddition to the doctor making the referral to thisclinic. Six patients (13%) had seen ®ve or morespecialists for the presenting complaint; all of thesepatients had diagnoses of somatoform disorders.

DISCUSSION

This study has a number of limitations. The sampledoes not represent all cases of psychiatric disorderreferred by hospital specialists for psychiatricassessment, as no comparison is made with patientsreferred directly to old age psychiatrists. Thesample size is small and some data such as onsetof symptoms may have been subject to recall biaswhen previous psychiatric records were not avail-able for con®rmation.

In this study we attempted to address a numberof questions about the nature and course ofsomatisation in older patients. In this generalhospital outpatient clinic three quarters of thepatients had somatoform disorders. This is notsurprising, given that over half were referred fromother hospital specialists who had investigated thepatients initially because of their physical symp-toms. Patients presenting with more obviousanxiety or depressive disorders are more likely tohave been treated by general practitioners orreferred to the old age psychiatry service.

We were surprised by the long duration ofphysical symptoms in our patients with somato-form disorders. It is consistent with other accounts,however, which have demonstrated that somaticsymptoms may persist for up to 40 years (Goodwin

and Guze, 1989). Similarly, ®eld trials of diagnosticsystems have shown no decline in rates ofsomatisation disorder (the most chronic form ofsomatoform disorder) with advancing age (Priboret al., 1993). Our ®ndings shed further light on this.In the majority of cases the somatoform disorderhad begun earlier in life, and in some hadcommenced as early as the patients' twenties orthirties. In contrast, most cases of depressivedisorder were of recent onset; only two wererecurrent with onset before the age of sixty-®ve.This ®nding is consistent with the observations ofPearce and Morris (1995) who found that medi-cally unexplained physical symptoms of a shorterduration were associated with depressive illness.Rief et al. (1992) also found that somatoformdisorders ran a more chronic course than depress-ive disorders, especially in women.

These observations on the duration of thepsychiatric disorders support the notion thatsomatoform disorders are diagnostically distinctfrom depressive disorders. There is, however,some overlap in symptomatology: although fewpatients with somatoform disorders were givensubsidiary diagnoses of depressive disordermany reported prominent anxiety and depressivesymptoms. Rief et al. (1992) suggest thatalthough diagnostically distinct, somatoformand depressive disorders may have a sharedaetiology which would account for high rates ofconcurrence. In our study diagnostic overlapwas also apparent between the di�erent subtypesof somatoform disorder. For instance, inpatients attracting the main diagnosis of `per-sistent somatoform pain disorder' (F45.4), hypo-

Table 2. Breakdown of somatoform disorder diagnoses (ICD-10) with mean age of onset and duration of dis-orders

Diagnosis ICD-10

code

Number

of cases

Mean age of onset in

years (range)

Mean duration in

years (range)

Mean functional

impairment scores

Persistent somatoform pain disorder F45.4 14 47 (18±75) 22 (1±48) 2.4

Somatoform autonomic dysfucntion

(heart and cardiovascular system)

F45.30 3 66 (65±69) 2 (1±3) 2.3

Somatoform autonomic dysfunction

(lower gastrointestinal)

F45.32 3 37 (25±60) 35 (8±50) 2.0

Somatoform autonomic dysfunction

(respiratory system)

F45.33 2 68 (65±71) 1 2.0

Hypochondriacal disorder F45.2 3 33 (28±75) 19 (2±40) 2.6

Undi�erentiated somatoform disorder F45.1 3 38 (26±50) 28 (15±40) 2.6

Somatisation disorder F45.0 2 35 (22±47) 35 (20±50) 2.0



chondriacal beliefs were often also noted.Conversely, in those with `hypochondriasis'(F45.2) a number of physical symptoms werealso recorded.

In terms of the precipitants of episodes ofsomatisation, it has long been recognised thatepisodes of neurotic illness in the elderly can beprecipitated by physical illness (Lindesay, 1998).Our ®ndings support this observation. In con-trast, social stressors have been shown to beimportant precipitants of new onset casespresenting in primary care (Gilleard, 1998). Itis likely that physical illness, mood and somaticsymptoms have an important interaction, especi-ally in the elderly (Waxman et al., 1985) a®nding which suggests that a multi-dimensionalformulation of problems is appropriate (Mayouet al., 1995).

A simple ®ve-point scale of functional impair-ment was used in this study. Most patients scored 2or 3 on this scale, consistent with moderatedisability. These scores correspond to the range31±70 on the Global Assessment of Functioningscale (Jones et al., 1995). It is surprising, given theduration of some of these disorders, that evengreater impairment was not recorded. This mayre¯ect the semi-quantitative nature of the instru-ment used and the outpatient setting. It is possiblethat patients with greater functional impairmentmight be referred for domiciliary assessment by oldage psychiatrists.

Patients with acute somatisation resulting fromdepressive and anxiety disorders are frequentlyassessed and managed in primary care or referredto old age psychiatrists. Conventional psychiatricinterventions, which aim to reattribute physicalsymptoms to psychosocial problems and events,are often e�ective (Goldberg et al., 1989). Patientswith chronic somatisation, however `are skilled atavoiding psychiatrists' (Lindesay, 1993) and wheresuch services exist they are frequently referreddirect to specialist liaison psychiatrists. This hascertain advantages, such as acceptability topatients, improved communication with and accessto physician colleagues and pain clinics, and theopportunity to develop skills and knowledge ofthese disorders (Epstein and Gonzales, 1993). Theyrequire speci®c management skills, including recog-nition of the problem, containment of the patient'sdemands and avoidance of unnecessary investi-gation (Bass, 1996). The latter, of course, is moredi�cult in elderly patients given the high rates ofco-morbid physical illness, and appropriate

physical assessment will have an important placein management.

What are the implications for old age psychia-trists and the services they o�er? Certainly, thesepatients can `represent a formidable challenge tothe skills of both the general practitioner and thespecialist psychogeriatric service' (Lindesay, 1993).Severe somatoform disorders occur less frequentlythan other psychiatric disorders among olderpatients, and in the absence of specialist liaisonpsychiatry clinics these patients are rarely seen byold age psychiatry services, as surveys of old agepsychiatry liaison services would indicate(Anderson and Philpott, 1991; Bowler et al.,1994). Referrers may not consider old age psychia-try services as suitable for these patients, orpatients may refuse to be referred. Old agepsychiatry teams may have di�culty identifyingthese disorders and lack speci®c management skillssuch as using psychological formulations, contain-ing help-seeking behaviour and supporting col-leagues in other specialities. If, however, it does fallto old age psychiatry teams to manage thesepatients, then traditional patterns of working maybe of use, especially liaison with general prac-titioners and social services.

KEY POINTS

. Somatisation in older patients is associatedwith a range of psychiatric diagnoses.

. Cases of somatoform disorder in olderpatients may be of many years' duration.

. Somatisation in older patients is associatedwith signi®cant functional impairment anduse of specialist medical services.

. Although, overall, somatoform disorders arerare amongst older patients, they do requireappropriate specialist assessment. Thesepatients might only be reached throughlinks with other specialists and old agepsychiatrists may need to develop additionalskills to work with them.

ACKNOWLEDGEMENTS

We are grateful to Professor Robin Jacoby for hiscomments on an earlier version of this paper.

104 P. WILKINSON ET AL.


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