Geropsychiatric consultation in a general hospital in Taiwan
Dr Yeong-Yuh Juang, Department of Psychiatry, Chang Gung Memorial Hospital, 5 Fu-Hsin Road, Kweishan, Taoyuan 333, Taiwan. Email: firstname.lastname@example.org
Abstract The aim of this study was to characterize clinically significant issues in a psychiatric consultation service for geriatric inpatients in a general hospital in Taiwan. This was a case-control study. During a 5-month period, 100 geriatric (age ≥65 years) inpatients consecutively referred for consultation-liaison psychiatric service from non-psychiatric departments formed the study group. Another 100 medical inpatients, also referred for consultation-liaison to the psychiatric service, but aged 17–50, formed the control (non-geriatric) group. The diagnosis, demography, reason for referral, symptomatology, and other clinical characteristics were determined by consensus between two psychiatrists. Psychiatric diagnosis was made according to criteria in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders. The geropsychiatric consultation rate was 0.9%. Geriatric patients constituted 20.1% of all psychiatric referrals. Common reasons for referral of geriatric inpatients were confusion (32%), depression (17%), disturbing behaviors (14%), and psychosis (14%). The most common psychiatric disorder among geriatric patients was an organic mental disorder (79%), followed by a depressive disorder (13%). More geriatric patients suffered from cancers and cerebrovascular diseases than non-geriatric patients. The geriatric group was more likely to have multiple physical illnesses. Organic mental disorder and depressive disorders are the most common psychiatric diagnoses in the geropsychiatric consultation service of the authors. In the authors’ experience, both psychotropic medication treatment and psychosocial intervention are important in geropsychiatric consultation.
The geriatric population in Taiwan has increased rapidly in the past two decades. The percentage of people aged 65 years and above was 6.2% in 1980 and 8.4% in 1999. With the rapid growth of the geriatric population, geriatric psychiatry has come to play a more important role in recent years.1 There have been several studies related to the mental illnesses among the elderly populations in the community in Taiwan, yet only a few articles have referred to the issues of geriatric psychiatry in non-psychiatric inpatients.2,3
Many factors complicate the hospitalization of geriatric patients, such as multisystem disease, poor nutritional status, diminished overall strength, and impaired mental functioning.4,5 These factors are more common in elderly than in younger patients, and may contribute to longer hospital stays.6 Hospitalization is a difficult, stressful event in the life of an elderly person. It frequently creates emotional problems or exacerbates existing psychiatric disorders. The combination of a serious medical illness, removal from the familiar home setting to the hospital, and separation from family and friends produces a difficult situation for elderly patients.7 Furthermore, psychiatric symptoms are common in geriatric inpatients.8 However, these symptoms are often underdiagnosed and undertreated and this may contribute to their longer hospital stays, higher mortality, and higher medical costs.9,10 So, geropsychiatric consultation is important in a general hospital. Data suggest positive effects of psychiatric referral in geriatric inpatients, which may help in making accurate diagnoses, selecting appropriate treatments, and shortening hospital stays.11–13
Several articles have described referrals to geriatric psychiatric consultation services in other countries.7,11,14–17 However, for Asia, there is a paucity of literature on this issue. The aim of the current study was to investigate the clinical characteristics of psychiatric consultations of geriatric inpatients in a medical center in Taiwan. Reasons for referral, medical diagnoses, psychiatric diagnoses, and treatments were surveyed and comparisons were made between geriatric and non-geriatric inpatients.
MATERIALS AND METHODS
Non-psychiatric geriatric inpatients aged 65 years or above who were referred to the consultation-liaison psychiatric service between March and August 1999 in Chang Gung Memorial Hospital, formed the geriatric group. Consecutive inpatients referred to the consultation-liaison psychiatric service who were between ages 17 and 50 formed the non-geriatric (control) group.
All patients were interviewed and evaluated by a psychiatrist. Information was gathered from the patient, family, caregiver, physician and nursing staff. Medical records were scrutinized. Demographic data, gender, age, marital status, date of admission, date of psychiatric referral, department of referral, physical illnesses, and reasons for referral were included in the data forms. Data were collected and a special chart was filled out by the psychiatrist and reviewed by a senior professor in the consultation-liaison service meeting to confirm the diagnosis and treatment recommendations. Psychiatric diagnoses were based on recommendations found in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.18
For data in the special chart, the differences between the two groups, including gender, department of referral, reasons for referral, physical illnesses, psychiatric diagnoses, and treatment recommendations, were analyzed and compared. Continuous variables were analyzed by Student's t-test, and categorical variables were analyzed by the χ2 test.
Of all patients admitted to the hospital from March to August 1999, geriatric patients constituted 21% of all hospitalized patients during this period. A total of 100 geriatric subjects (0.9% of all geriatric inpatients) referred to the consultation-liaison psychiatric service were enrolled. Each inpatient referred to the consultation-liaison psychiatric service aged between 17 and 50 years was enrolled in the control (non-geriatric) group. Geropsychiatric consultation constituted 20.1% of all consultation cases during that period.
The mean age of the geriatric group was 75.3 ± 6.1 years and for the non-geriatric group was 34.1 ± 9.2 years (t = 37.3, P < 0.05). There were 52 men and 48 women in the geriatric group, and 54 men and 46 women in the non-geriatric group. No statistical difference was noted between the two groups by gender. Most patients were referred from the Department of Internal Medicine, followed by Surgery and others (Table 1).
Table 1. . General information
|Age (years)||34.1 ± 9.2||75.3 ± 6.1|| t = 37.3 |
d.f. = 1
P < 0.05
| Men||54||52|| χ2 = 0.080|
| Women||46||48||d.f. = 1 |
P = 0.777
|Department of referral|
| Medicine||53||57|| χ2 = 0.330|
| Surgery||31||28||d.f. = 2|
| Others||16||15|| P = 0.848|
Reason for referral
The most common reason for referral in the geriatric group was confusion (32%), followed by depression (17%), disturbing behaviors (including irritability, agitation, aggressive behaviors, and unusual behaviors, 14%), psychotic symptoms (delusion and/or hallucination, 14%), and sleep disturbance (8%). The most common reason for referral in the non-geriatric group was evaluation of suicidal risk (28%), followed by substance-related problems (13%), confusion (11%), and depression (10%). Some reasons for referral, such as confusion, psychotic symptoms, disturbing behaviors, and depression, were more common in the geriatric group. Differences between groups for confusion and depression were statistically significant. Suicidal risk, differential diagnosis, substance-related problems, and anxiety were more common in the non-geriatric group (Table 2).
Table 2. . Reasons for referral for psychiatric consultation
|Confusion||11 (11%)||32 (32%)||0.001*|
|Depression||10 (10%)||17 (17%)||0.147|
|Disturbing behaviors|| 7 (7%)||14 (14%)||0.106|
|Psychotic symptoms (delusions or hallucinations)|| 5 (5%)||14 (14%)||0.030*|
|Sleep disturbance|| 4 (4%)|| 8 (8%)||0.352|
|Suicide attempt or risk||28 (28%)|| 5 (5%)||0.000*|
|Differential diagnosis of physical symptoms||11 (11%)|| 3 (3%)||0.027*|
|Past psychiatric illness history|| 4 (4%)|| 3 (3%)||0.700|
|Substance-related problems (abuse or dependence)||13 (13%)|| 2 (2%)||0.030*|
|Anxiety|| 6 (6%)|| 0 (0%)||0.013*|
|Others (disposition, preoperation evaluation etc.)|| 1 (1%)|| 2 (2%)|| |
The main physical diseases that contributed to hospitalization of subjects are shown in Table 3. Cancers and cerebrovascular diseases were more common in the geriatric group, while trauma and other neurological diseases were less common. More geriatric patients suffered from two or more physical diseases at the time of hospitalization.
Table 3. . The main physical diseases contributing to hospitalization
|Cancer|| 9 (9%)||17 (17%)||0.093**|
|Cerebrovascular|| 7 (7%)||15 (15%)||0.071**|
|Infections|| 5 (5%)||10 (10%)||0.179|
|Metabolic||18 (18%)||10 (10%)||0.103|
|Trauma or Orthopedic||21 (21%)|| 9 (9%)||0.017*|
|Renal|| 5 (5%)|| 9 (9%)||0.171|
|Cardiovascular|| 3 (3%)|| 8 (8%)||0.121|
|Gastrointestinal||10 (10%)|| 7 (7%)||0.447|
|Hepato-biliary|| 9 (9%)|| 6 (6%)||0.421|
|Pulmonary|| 3 (3%)|| 5 (5%)||0.470|
|Neurological|| 7 (7%)|| 2 (2%)||0.088**|
|Others|| 3 (3%)|| 2 (2%)|| |
|Multiple physical illnesses||30 (30%)||62 (62%)||0.000*|
Psychiatric diagnoses among the geriatric referrals are shown in Table 4. Of these diagnoses, organic mental disorder (including dementia, delirium and others) was most common, occurring in 79% of geriatric patients. Depressive disorders, the next most common diagnosis, were diagnosed in 13%. In the non-geriatric group, the most common diagnosis was organic mental disorder (29%), followed by adjustment disorders (22%), and others. Organic mental disorders were significantly higher in the geriatric group, while adjustment disorders, substance related disorders, and psychotic disorders were more common in the non-geriatric group.
Table 4. . Psychiatric diagnosis
|Organic mental disorder||29 (29%)||79 (79%)||0.000*|
| Dementia|| 0 (0%)|| 5 (5%)||0.024*|
| Delirium||19 (19%)||61 (61%)||0.000*|
| Others||10 (10%)||13 (13%)||0.506|
|Depressive disorders||15 (15%)||13 (13%)||0.684|
| Major depressive disorder|| 6 (6%)|| 4 (4%)||0.516|
| Dysthymic disorder|| 2 (2%)|| 5 (5%)||0.248|
| Not otherwise specified|| 7 (7%)|| 4 (4%)||0.352|
|Bipolar I disorder|| 0 (0%)|| 1 (1%)|| |
|Psychotic disorder|| 8 (8%)|| 1 (1%)||0.017*|
| Schizophrenia|| 5 (5%)|| 0 (0%)||0.024*|
| Delusional disorder|| 0 (0%)|| 1 (1%)|| |
| Not otherwise specified|| 3 (3%)|| 0 (0%)||0.081|
|Adjustment disorder||22 (22%)|| 4 (4%)||0.000*|
| With depressed mood||16 (16%)|| 4 (4%)||0.005*|
| With anxiety|| 3 (3%)|| 0 (0%)||0.081|
| With mixed mood|| 3 (3%)|| 0 (0%)||0.081|
|Substance-related disorder (abuse or dependence)||10 (10%)|| 1 (1%)||0.05**|
|Anxiety disorder|| 3 (3%)|| 0 (0%)||0.081|
|Others (pain disorder, sleep disorder etc.)|| 3 (3%)|| 1 (1%)|| |
|No psychiatric diagnosis||10 (10%)|| 0 (0%)||0.01*|
Treatment recommendations, which included a broad range of biological, psychological and/or social approaches, are listed in Table 5. The most common recommendation was the use of psychotropic medication and was more common in the geriatric (98%) than the non-geriatric group (86%; P < 0.05). However, suggestions to combine pharmacotherapy and psychosocial approaches were also common (29% in the geriatric, and 22% in the non-geriatric group). One-third of patients in both groups were recommended for follow up at the outpatient clinic. Eight patients in the geriatric group and 12 patients in the non-geriatric group were recommended to have further surveys in terms of differential diagnosis of unexplained physical symptoms or to determine the etiology of delirium.
Table 5. . Suggestions of psychiatric consultation†
|Psychotropic medication||86 (86%)||98 (98%)||0.002*|
| Psychotropic medication only||47 (47%)||50 (50%)||0.671|
|Psychosocial intervention||23 (23%)||29 (29%)||0.333|
| Psychosocial intervention only|| 1 (1%)||0 (0%)|| |
| Combined psychotropic medication and psychosocial intervention||22 (22%)||29 (29%)||0.256|
|Psychiatric OPD f/u||38 (38%)||35 (35%)||0.659|
|Further survey‡||12 (12%)||8 (8%)||0.346|
There was no gender difference between groups with regard to the following variables: the referring department, reason for referral, physical illness, and psychiatric diagnoses.
The data presented in this study, which showed that geriatric patients constituted one-fifth of all psychiatric referrals, is similar to data from related reports for other countries.7 However, the psychiatric consultation rate in geriatric inpatients was lower in our study than in studies from western countries.7,8
The most common reason for referral was symptoms related to organic mental disorders in the geriatric group, such as confusion and disturbing behaviors. This was compatible with the result that organic mental disorders were the most common psychiatric diagnoses in the geriatric group. In this study, the rate of diagnosis of organic mental disorder (79%) was higher than in other reports. Several articles reported that of all psychiatric referrals, organic mental disorders was the diagnosis in 37–51% of all geriatric patients.7,14–16 This might reflect the fact that organic mental disorders are indeed more prevalent in our sample, or that diagnoses other than organic mental disorders were neglected by the doctors in charge. Other than confusion and disturbing behaviors, about one-third of subjects with organic mental disorders were referred by their physicians because they were regarded as having psychotic symptoms (i.e. delusions and/or hallucinations; 17%), depression (9%), or sleep disturbance (6%). Also, more patients in the geriatric group (14%) were referred to the consultation psychiatric service because of psychotic symptoms than in the non-geriatric group (5%). Yet none of these patients in the geriatric group received a psychiatric diagnosis of ‘functional psychosis’. All these geriatric patients turned out to have organic mental disorders. This may mean that physicians in charge did not consider their patients to be suffering from organic mental disorders. This finding might indicate that organic mental disorder in geriatric inpatients may be misdiagnosed or undiagnosed. Missing the possibility of organic mental disorder might further delay appropriate referral and work-up for organic factors, therefore, potentially treatable conditions could go undetected.16,19 Our results showed that misdiagnosis of organic mental disorder still existed in general medial hospitalization in Taiwan.
Although depression was the second most common diagnosis in the geriatric group, the rate (13%) was lower than in studies in western countries which reported between 17–25%.14–16 Comparing our data to data from a community study on geriatric depression in Taiwan,2,3 the lower rate of depressive disorders in our study should be noted. In comparison with the relatively higher referral rate of organic mental disorder, depressive symptoms might be overlooked by physicians in charge. In a previous study, we also found a low detection rate by general medical physicians in primary care in Taiwan.20 Though the two studies were from different settings, their results were quite compatible. It suggests that physicians’ alertness to detect organic mental disorder and depression should be improved by education and psychiatric liaison.
Competency evaluations are an important part of the diagnostic work with elderly patients. In several studies in western countries, it was the most common reason for referral.7,14,16 But none of the geriatric patients were referred for competency evaluations in our study. This may reflect the greater attention to medico-legal issues in western countries than in Taiwan.
A recommendation concerning the use of psychotropic medication was made for 98 (98%) geriatric patients in our study. Treatment with psychotropic medication in geriatric patients is complicated by underlying medical or surgical illness and the large number of non-psychiatric medications that are often being taken currently.7 Thus, in-depth knowledge about the use of psychotropic medication in the elderly is a vital component of geropsychiatric consultation.11,21 Of our geriatric patients, 29 (29%) were recommended to receive both psychopharmacological and psychosocial treatment. Psychosocial intervention is also important in helping the elderly adjust to the hospital environment and to physical illness.
In conclusion, organic mental disorders are prevalent in geriatric inpatients, yet various clinical manifestations may confuse the clinician. The differentiation of psychiatric from medical problems is often more subtle in older than in younger patients. Thus, the geropsychiatrist must constantly be on the lookout for symptoms that seem to have a psychiatric basis but actually have a medical cause. In contrast, depressive symptoms may be overlooked because they are less likely to attract the attention of the medical team. The psychiatrist also should have expertise in the psychopharmacologic treatment of the aged and in behavioral and psychosocial approaches, in order to provide adequate service to geriatric patients.22,23
A limitation of this study was that it was not a multicenter study. A result from a single hospital might not be generalized. However, Chang Gung Memorial Hospital is the largest medical center in Taiwan, and the consultation psychiatry program is one of the leading programs in this country. Somehow, the results can reflect the general condition in Taiwan.
This study was partly supported by grants from the National Science Counsel (NSC89-2314-B-182-140, NSC89-2314-B-182-027).