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Screening for Somatic Disease in Elderly Psychiatric Patients
Screening for Somatic Disease in Elderly Psychiatric Patients Evert J. Mookhoek, M.D., and Ineke M. Sterrenburg-v.d.Nieuwegiessen, M.D. Abstract: An inventory of the indications for laboratory tests, electrocardiography (EKG), and chest x-ray films was compiled in 194 elderly patients admitted to a general psychiatric hospital. Indications were obtained from data on medical history, physical complaints, chronically used medication, and findings of physical examination. The therapeutic benefit of tests was also evaluated. When the therapeutic value of nonindicated tests was assessed, only routine testing for glucose, folic acid, vitamin B12, and testing for urinary tract infection in women seemed useful. Furthermore, routine determination of full blood counts, certain liver enzymes, creatinine or urea, electrolytes, and thyroid-stimulating hormone seemed useful because of the frequency of indications. There were no arguments for performing the other evaluated laboratory tests, EKG, and x-ray films of the chest on a routine basis in these patients. © 1998 Elsevier Science Inc.
Introduction Somatic illness is encountered frequently in psychiatric patients [1–3]. Depending on the type of population, between 13% and 75% of all psychiatric patients suffer from a prior unknown somatic disorder at the time of first admission. The incidence and the prevalence of somatic disorders also increase with age. All authors agree on the necessity of a thorough somatic anamnesis and physical examination at the time elderly psychiatric patients are admitted [1,2]. Some authors also favor a large number of screening tests in all psychiatric patients [4]; this may include extensive laboratory tests, electrocardiography (EKG), electroencephalography, chest x-ray film and computer tomography Delta Psychiatrisch Ziekenhuis, P.O. Box 800, 3170 DZ Poortugaal Address reprint requests to: E. J. Mookhoek, Delta Psychiatrisch Ziekenhuis, P.O. Box 800, 3170 DZ Poortugaal, The Netherlands
102 ISSN 0163-8343/98/$19.00 PII S0163-8343(98)00005-X
scan of the brain. Other authors [5,6] plead for a more limited number of tests and recommend that more extended tests be undertaken only when indicated. Those in favor of extensive testing [4] point to the frequency of somatic illness, but fail to look into the necessity of each test for uncovering disorders. Sometimes, even the relevance of discrepant test results is not taken into account. Authors [5,6] pleading for a limited number of screening tests often arrived at this conclusion after scrutinizing a selective group of patients. In these surveys, the outcome of many tests was compared with that of somatic anamnesis and physical examination by an experienced physician. One should consider the differences between one’s own patient population and the survey populations before implementing such recommendations on a routine basis. The indications that should warrant further testing and therefore exclusion of the patient from the survey population are not mentioned by most authors. In a few cases, the indications for further testing were mentioned, but included relatively gross criteria such as age, encountered abnormalities upon physical examination, substance abuse, psychoorganic disease, and low level of self-care [7]. This makes translation of all recommendations to everyday practice difficult. It is also essential to remember that most of the surveys were undertaken retrospectively. To date, each patient older than 65 years is thoroughly examined at our hospital. Besides the somatic anamnesis and physical examination, extensive laboratory tests, EKG, and chest x-ray studies are also conducted. Recommendations in the literature for a more limited number of tests and the mentioned difficulties in implementing such recommendations at our hospital were our reasons for
General Hospital Psychiatry 20, 102–107, 1998 © 1998 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
Screening for somatic disease in elderly psychiatric patients
evaluating the benefits of somatic screening at admission. In the present study, the nature and number of indications warranting testing were investigated. Establishing the indications becomes more important in view of the possible limitations for routine testing. The eventual therapeutic benefit as a result of testing was also evaluated.
Methods Psychiatric patients older than 65 years are admitted to the geronto-psychiatric wards of the hospital. All patients live in the nearby region and are from both partly rural and partly urban communities. Patients are referred to the hospital by the organization for acute mental health, a consultant psychiatrist, or by a psychiatrist at a general hospital. All patients have a general psychiatric disorder. A small section of the ward is reserved for patients with a suspected and/or undefined organic brain disease. Apart from age, no selection is made prior to admission. The only selection criterion for examining organic brain disease is the presence of a diagnostic or a therapeutic difficulty. Somatic anamnesis and physical examination of each patient is undertaken upon admission. The following laboratory tests are routinely conducted in each patient: ESR, hemoglobin, hematocrit, red cell count, leucocytes, trombocytes, blood smear, thiamine, pyridoxine, vitamin B12, folic acid, creatinine, urea, bilirubin, alkaline phosphatase, ASAT, ALAT, LDH, GGT, CPK, albumin, uric acid, sodium, potassium, calcium, phosphate, TSH, glucose, cholesterol, triglycerides, cortisol, normotest, TPHA, and general examination of urine. Laboratory tests were requested on the first day after admission. An EKG and chest film were obtained in each patient in the first or second week of admission. Data concerning the use of medication, medical history, anamnesis, and physical examination were collected upon admission of each patient. This was the basis for establishing indications for the various laboratory tests, EKG, and chest film. Other general information on sex, age, (tentative) psychiatric diagnosis (DSM-III-R axis 1 and 2) was also collected. Patients who had been admitted to a psychiatric hospital or a psychiatric ward of a general hospital during the 6 months prior to the current admission were excluded from this study. The indications were extensively elaborated upon prior to collecting data. The recommendations provided for registration by the manufacturer of the particular drug on its long-term use were used as a
source of information [8]. Indications for tests according to general criteria mentioned by Krupp [9] were used for chronic illness, complaints, and findings upon physical examination. Each patient’s physician carefully evaluated the therapeutic consequences of each discrepant test result. We used the normal values from the laboratory to evaluate the test results; however, these were not validated specifically for elderly patients. The results will be presented using the descriptive statistics. The differences between subgroups was examined with Student’s-t and X2 tests.
Results A total of 230 patients were admitted during a period of 12 months between 1994 and 1995. Thirtyone patients had already been admitted for a psychiatric complaint during the 6 months prior to the current admission. Three patients were directly transferred to a general hospital because of a hip fracture, septic shock in pneumonia, and acute heart failure. One patient was discharged within a few hours and one patient refused all examinations. These 36 patients were excluded. Thus the survey population consisted of 194 patients (121 females and 73 males) with a mean age of 75.7 years (range 55–95 years). The psychiatric diagnosis of these patients are shown in Table 1. The survey population covers a wide variety in psychiatric diagnosis. A total of 5954 laboratory tests were done. From
Table 1. General particulars of the survey population
Number Mean age (years) Standard deviation DSM-III-r axis 1 diagnosisa Organic psycho-syndromes Psychotic disorders Affective disorders Other No diagnosis axis 1 DSM-III-r axis 2 diagnosisa Personality disorders Disturbed intellectual functioning No diagnosis axis 2 a
Males Females
Total
73 75.1 7.99
194 75.7 7.88
121 76.2 7.81
23 12 31 2 8
34 20 52 3 13
57 32 83 5 21
6
15
21
5 64
5 101
10 165
In some patients, 2 diagnoses were made.
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E.J. Mookhoek et al.
these, 1341 tests (23%) had values outside the normal range. Fifty-five tests (0.9%) were repeated without further consequences. Twenty laboratory tests (0.3%) had a discrepant test result and this discrepancy was the reason for further examination without therapeutic consequences. Eighty-three
laboratory tests (1.4%) had therapeutic consequences that affected 72 patients (Table 2). All of the seven patients whose hemoglobin (Hb) test had therapeutic consequences had an iron deficiency anemia and a Hb test was indicated. Five patients received oral iron preparations, one patient
Table 2. The number (N) of patients, N of executed tests, N of test results outside the normal range (discrepant) and those tests connected to the therapeutic consequences Nonindicated Test
N
Tests
Discrepant
Hemoglobin Hematocryt Red cell count Leukocytes Thrombocytes ESR Blood smear Creatinine Urea Sodium Potassium Bilirubin Alk. phosphatase ASAT (SGOT) ALAT (SGPT) LDH GGT CPK Protein Albumin Uric acid Calcium Phosphate Cholesterol Triglycerides Cortisol Normotest Glucose(sober) TSH TPHA Thiamine Pyridoxine Folic acid Vitamin B12 Urinary sediment Other urinalyses Total lab. tests EKG Chest x-ray film
44 179 190 46 50 170 171 68 76 78 82 84 79 84 79 84 84 171 177 177 192 153 180 165 165 160 194 89 70 192 172 180 178 173
43 177 187 45 49 165 166 68 69 77 80 55 78 83 57 56 83 119 122 56 131 105 120 113 113 104 134 79 63 182 165 172 172 168
3 36 29 1 6 141 110 10 10 6 2 12 3 1 1 9 8 20 5 50 37 18 16 29 31 6 22 20 4 2 80 25 38 26
123 113
112 102 3870 84 72
60 21 898 61 50
95 81
Indicated Consequences
1
1
40 9 7 2
N
Tests
Discrepant
— — — — — — 1% — — — — — — — — — — — — — — — — — — — — 1% — — 24% — 5% 4%
150 15 4 148 144 24 23 126 118 116 112 110 115 110 109 110 110 23 17 17 2 41 14 29 29 34 0 105 124 2 22 14 16 21
148 14 4 146 142 23 22 125 110 115 111 80 111 106 79 80 105 17 14 3 1 31 10 23 23 25 0 100 117 1 18 11 14 19
32 6 3 20 22 23 12 29 39 14 11 14 6 6 0 21 14 4 0 1 0 6 1 9 9 1 0 45 22 1 6 1 3 5
2% — 60 — —
71 81
63 73 2084 85 98
39 18 443 69 87
The figures are shown separately for indicated and nonindicated tests.
104
99 113
Consequences 7
2 2 1
3 1 3 1 1 2
5% — — — — — — 2% 2% 1% — — — — — — — — — — — — — — — — — 3% 1% — 17% — 7% 5%
3% — 23 4 5% 1 1%
Screening for somatic disease in elderly psychiatric patients
received blood transfusion, and one had gastric carcinoma and was treated surgically. In the group of patients with an indication for an Hb test, the mean Hb was lower than in the group without indication (9.23 mmol/L vs 9.64 mmol/L, Student’s-t test p , 0.05). There was a negative correlation between the ESR and the Hb (20.59) and a positive correlation between Hb and albumin (10.60). All medication was stopped in one patient because of eosinophilia without leucocytosis. Shortly after receiving the test results this patient developed an exanthema, the time gained was less than 24 hours. In two patients, the dose of medication had to be adjusted because of high creatinine and urea levels. The mean urea level in the group of patients with such an indication was higher than that in the group without an indication (7.96 mmol/L vs 6.16 mmol/L, Student’s-t test p , 0.05). In one patient, a high sodium value was one of the reasons to commence tube feeding. In one patient, diabetes mellitus was confirmed; in three patients, medication for diabetes mellitus was adjusted. In one patient, a hyperthyroidism was discovered. Supplements were prescribed 61 times for low levels of serum thiamine, folic acid, or vitamin B12. An antibiotic treatment was started in four females because of urinary tract infections. There was an indication for 2084 (35%) out of the 5954 laboratory tests. There was more than one indication in 703 (34%) out of the 2084 indicated laboratory tests. From the 2084 tests, 224 (11%) were indicated only because of medical history; 231 (11%) were indicated only because of chronic use of medication; 358 (17%) were indicated only because of physical complaints; 568 (27%) were indicated only because of abnormalities upon physical examination. Tests with more than one indication or indicated by abnormalities upon physical examination had more therapeutic consequences than the other indicated tests (1.4% vs 0.6%, Student’s-t test p , 0.05). The EKG had therapeutic consequences in four patients. New medication was prescribed or the dose was adjusted. In one of the patients, a chest x-ray film was followed by a course of antibiotics. There was no relationship among psychiatric diagnosis, age or gender, and indications, test results, or consequences.
Discussion It was noteworthy that so many tests were indicated. On the one hand we compiled a very thor-
ough inventory of all indications. We probably failed to notice only a few. On the other hand, sometimes detailed information on the patients from relatives or family doctors only became available at a later stage of the admission and was not available at the time of this survey. This information may have contributed to additional indications. Probably, the abundance of somatic illness in psychiatric patients is also an important cause for the large number of indicated tests. The many test results outside the normal range that did not have therapeutic consequences was also noteworthy. As mentioned before, the normal values we used were not validated specifically for elderly patients. However, there are more explanations. First, we only looked at the direct therapeutical consequences. Disease diagnosed by excluding other illness was not included in our survey. EKG findings have an influence on the choice of psychiatric medication. Such findings were neither considered as a therapeutical consequence nor as an indication for a specific test in our survey. Many of the discrepant test results were within close range to the normal values. Finally, some test results were followed by further diagnostic tests or the test was repeated. However, these did not have therapeutic consequences. The decision-making process of the physicians was not a subject in our survey. Why more discrepant thiamine test results were followed by treatment than discrepant TSH test results is a question we cannot answer; possibly, the disadvantages of therapy play a role. It is simple to prescribe a vitamin tablet with no side effects for a limited period. Treatment of thyroid dysfunction necessitates taking tablets for prolonged periods. Regular laboratory tests are also necessary to evaluate the effectiveness of therapy. Especially in cases of marginal discrepancy in the test results, it is logical for the physicians to wait and see if the therapy also has disadvantages. Findings of physical examination frequently gave indications for laboratory tests, and 27% of these tests were indicated only because of such findings. Looking at the tests for hemoglobin, glucose, urea, and the EKG, there was a clear relationship between indications and the test results and/or the therapeutic consequences. Sheleine and Kehr [10] also observed a relationship between indications and clinical consequences in psychiatric inpatients. Deficiencies of thiamine, folic acid, and vitamin B12 were noted in a number of cases although they were often marginal and were not accompanied by
105
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the classical clinical symptoms in any of the patients. Effects of supplements on marginal folic acid deficiency reported in the literature advocated the testing for folic acid on a routine basis [11]. Since there is a possible relationship between psychical function and marginal vitamin B12 deficiencies, testing for this deficiency on a routine basis was noted to be valuable [12,13]. The effect of supplementing marginal thiamine deficiency is not clear; some surveys reported a negative influence on physical and psychical functioning [14]. The influence of a thiamine deficiency in combination with deficiencies of other vitamins is more probable [15,16]. The effect of a marginal thiamine deficiency only is unclear. As a consequence, the value of testing for a possible thiamine deficiency on a routine basis is questionable. When the therapeutic consequences of the other tests without indications are taken into account, only testing for glucose seems relevant in elderly psychiatric patients. In females, a test for a urinary tract infection is recommended. There is a logical argument that all other tests should only be done on an indication basis. However, we compiled a thorough inventory of all indications; this is probably not undertaken as thoroughly for each patient in clinical practice. Therefore, we would advise taking into account the frequency of existing indications in considering which tests should be included for routine testing. As our study was not designed for investigating a detailed cost-benefit analysis, the cutoff percentage at which one should draw a line is not clear. Should we set the cutoff at 50%; then a full blood count, urea or creatinine, electrolytes, thyroid-stimulating hormone, and some liver enzymes should be included in routine testing. The extra inconvenience for the patient for providing a little extra blood is negligible. Obtaining an EKG or a chest film is more inconvenient for patients. Setting the cutoff at 50% for an EKG and chest film is less obvious in our view. Therefore, EKGs and x-ray films should not be done on a routine basis. Other authors came to the same conclusion [17]. In our 1994 survey, we recommended routine laboratory tests in elderly psychiatric patients admitted to our long-stay wards [18]. The admission screening battery that is recommended now is somewhat more extensive; this list is also more extensive than that recommended by Harms and Hermans in 1994 [5]. However, their survey population consisted only of patients without a suspected organic psycho-syndrome and was retro-
106
spective. Colgan and Philpot [19] studied 167 records of elderly psychiatric patients and concluded that a full blood count, folic acid, urea, electrolytes, and urine cultures were meaningful routine tests. Finally, we would like to point out that tests for discovering specific contraindications prior to treatment was not a part of our survey; for example, an EKG prior to treatment with tricyclic antidepressants or testing kidney function prior to treatment with lithium. This may also be an additional argument for enlarging a routine screening battery.
Conclusions Looking at the frequency of indications and the therapeutic consequences, routine testing for full blood count, glucose, some liver enzymes, creatinine or urea, electrolytes, thyroid-stimulating hormone, folic acid, vitamin B12, and urinary tract infection in women is valuable in elderly patients admitted to a general psychiatric hospital. The other evaluated tests—ESR, CPK, albumin, uric acid, calcium, phosphate, cholesterol, triglycerides, cortisol, normotest, thiamin, pyridoxine, EKG, and chest x-ray films should not be done on a routine basis. Physical examination appeared to be an important source of information for determining the appropriate supplementary tests.
References 1. Maguire GP, Granville-Grossman KL: Psychical illness in psychiatric patients. Br J Psychiatry 115:1365– 1369, 1968 2. Koranyi EK: Undiagnosed physical illness in psychiatric patients. Ann Rev Med 33:309–316, 1982 3. Sheline YI: High prevalence of physical illness in a geriatric psychiatric inpatient population. Gen Hosp Psychiatry 12:396–400, 1990 4. Hall RCW, Gardner ER, Popkin MK, Lecann AF, Stickney SK: Unrecognized physical illness prompting psychiatric admission—a prospective study. Am J Psychiatry 138–5:629–635, 1981 5. Harms HH, Hermans P: Admission laboratory testing in elderly psychiatric patients without organic mental syndromes—Should it be routine? Int J Geriatr Psychiatry 9:133–140, 1994 6. Anfinson TJ, Kathol RG: Screening laboratory evaluation in psychiatric patients: a review. Gen Hosp Psychiatry 14:248–257, 1992 7. Ferguson B, Dudleston K: Detection of physical disorder in newly admitted psychiatric patients. Acta Psychiatr Scand 74:485–489, 1986 8. Ziekenfonds Raad: Farmaco-therapeutisch Kompas. Amstelveen/NL: Ziekenfondsraad, 1994
Screening for somatic disease in elderly psychiatric patients 9. Krupp MA: Current Medical Diagnosis & Treatment. Los Altos California: Lange Medical Publications, 1988 10. Sheline Y, Kehr C: Cost and utility of routine admission laboratory testing for psychiatric inpatients. Gen Hosp Psychiatry 12:329–334, 1990 11. Godfrey PSA, Toone BK, Carney MWP, et al: Enhancement of recovery from psychiatric illness by methylfolate. Lancet 336:392–395, 1990 12. de Rooy S, R van Brugge, Thijssen C, Hooijer C: Een lage serum vitamine B12 spiegel en vitamine B12 deficie¨ntie bij ouderen. Wanneer suppleren? Tijdschr Gerontol Geriatr 25:3–10, 1994 13. Bell IR, Edman JS, Marby DW, et al: Vitamin B12 and folate status in acute geropsychiatric inpatients: affective and cognitive characteristics of a vitamin nondeficient population. Biol Psychiatry 27:125–137, 1990 14. Smidt LJ, Cremin FM, Grivetti LE, Clifford AJ: Influence of thiamine supplementation on the health and general well-being of an elderly Irish population with
15.
16. 17. 18.
19.
marginal thiamine deficiency. J Gerontol 46:M16–22, 1991 van de Beek EJ, van Dokkum W, Wedel M, et al: Combination of low thiamine, riboflavin, vitamin B6 and vitamin C intake among Dutch adults (Dutch nutrition surveillance system). J Am Coll Nutr 13: 383–391, 1994 Chandra RK: Effect of vitamin and trace-element supplementation on immune responses and infection in elderly subjects. Lancet 340:1124–1127, 1992 Brown M: An audit of the use of chest radiography in the elderly mentally ill. Int J Ger Psychiatry 10:155– 158, 1995 Mookhoek EJ, Sterrenburg CM: Annual laboratory screening for chronic hospitalized elderly psychiatric patients—habit or necessity. Int J Geriatric Psychiatry 11:477–481, 1996 Colgan J, Philpot M: The routine use of investigations in elderly psychiatric patients. Age Ageing 14:163– 167, 1985
107
Introduction Somatic illness is encountered frequently in psychiatric patients [1–3]. Depending on the type of population, between 13% and 75% of all psychiatric patients suffer from a prior unknown somatic disorder at the time of first admission. The incidence and the prevalence of somatic disorders also increase with age. All authors agree on the necessity of a thorough somatic anamnesis and physical examination at the time elderly psychiatric patients are admitted [1,2]. Some authors also favor a large number of screening tests in all psychiatric patients [4]; this may include extensive laboratory tests, electrocardiography (EKG), electroencephalography, chest x-ray film and computer tomography Delta Psychiatrisch Ziekenhuis, P.O. Box 800, 3170 DZ Poortugaal Address reprint requests to: E. J. Mookhoek, Delta Psychiatrisch Ziekenhuis, P.O. Box 800, 3170 DZ Poortugaal, The Netherlands
102 ISSN 0163-8343/98/$19.00 PII S0163-8343(98)00005-X
scan of the brain. Other authors [5,6] plead for a more limited number of tests and recommend that more extended tests be undertaken only when indicated. Those in favor of extensive testing [4] point to the frequency of somatic illness, but fail to look into the necessity of each test for uncovering disorders. Sometimes, even the relevance of discrepant test results is not taken into account. Authors [5,6] pleading for a limited number of screening tests often arrived at this conclusion after scrutinizing a selective group of patients. In these surveys, the outcome of many tests was compared with that of somatic anamnesis and physical examination by an experienced physician. One should consider the differences between one’s own patient population and the survey populations before implementing such recommendations on a routine basis. The indications that should warrant further testing and therefore exclusion of the patient from the survey population are not mentioned by most authors. In a few cases, the indications for further testing were mentioned, but included relatively gross criteria such as age, encountered abnormalities upon physical examination, substance abuse, psychoorganic disease, and low level of self-care [7]. This makes translation of all recommendations to everyday practice difficult. It is also essential to remember that most of the surveys were undertaken retrospectively. To date, each patient older than 65 years is thoroughly examined at our hospital. Besides the somatic anamnesis and physical examination, extensive laboratory tests, EKG, and chest x-ray studies are also conducted. Recommendations in the literature for a more limited number of tests and the mentioned difficulties in implementing such recommendations at our hospital were our reasons for
General Hospital Psychiatry 20, 102–107, 1998 © 1998 Elsevier Science Inc. All rights reserved. 655 Avenue of the Americas, New York, NY 10010
Screening for somatic disease in elderly psychiatric patients
evaluating the benefits of somatic screening at admission. In the present study, the nature and number of indications warranting testing were investigated. Establishing the indications becomes more important in view of the possible limitations for routine testing. The eventual therapeutic benefit as a result of testing was also evaluated.
Methods Psychiatric patients older than 65 years are admitted to the geronto-psychiatric wards of the hospital. All patients live in the nearby region and are from both partly rural and partly urban communities. Patients are referred to the hospital by the organization for acute mental health, a consultant psychiatrist, or by a psychiatrist at a general hospital. All patients have a general psychiatric disorder. A small section of the ward is reserved for patients with a suspected and/or undefined organic brain disease. Apart from age, no selection is made prior to admission. The only selection criterion for examining organic brain disease is the presence of a diagnostic or a therapeutic difficulty. Somatic anamnesis and physical examination of each patient is undertaken upon admission. The following laboratory tests are routinely conducted in each patient: ESR, hemoglobin, hematocrit, red cell count, leucocytes, trombocytes, blood smear, thiamine, pyridoxine, vitamin B12, folic acid, creatinine, urea, bilirubin, alkaline phosphatase, ASAT, ALAT, LDH, GGT, CPK, albumin, uric acid, sodium, potassium, calcium, phosphate, TSH, glucose, cholesterol, triglycerides, cortisol, normotest, TPHA, and general examination of urine. Laboratory tests were requested on the first day after admission. An EKG and chest film were obtained in each patient in the first or second week of admission. Data concerning the use of medication, medical history, anamnesis, and physical examination were collected upon admission of each patient. This was the basis for establishing indications for the various laboratory tests, EKG, and chest film. Other general information on sex, age, (tentative) psychiatric diagnosis (DSM-III-R axis 1 and 2) was also collected. Patients who had been admitted to a psychiatric hospital or a psychiatric ward of a general hospital during the 6 months prior to the current admission were excluded from this study. The indications were extensively elaborated upon prior to collecting data. The recommendations provided for registration by the manufacturer of the particular drug on its long-term use were used as a
source of information [8]. Indications for tests according to general criteria mentioned by Krupp [9] were used for chronic illness, complaints, and findings upon physical examination. Each patient’s physician carefully evaluated the therapeutic consequences of each discrepant test result. We used the normal values from the laboratory to evaluate the test results; however, these were not validated specifically for elderly patients. The results will be presented using the descriptive statistics. The differences between subgroups was examined with Student’s-t and X2 tests.
Results A total of 230 patients were admitted during a period of 12 months between 1994 and 1995. Thirtyone patients had already been admitted for a psychiatric complaint during the 6 months prior to the current admission. Three patients were directly transferred to a general hospital because of a hip fracture, septic shock in pneumonia, and acute heart failure. One patient was discharged within a few hours and one patient refused all examinations. These 36 patients were excluded. Thus the survey population consisted of 194 patients (121 females and 73 males) with a mean age of 75.7 years (range 55–95 years). The psychiatric diagnosis of these patients are shown in Table 1. The survey population covers a wide variety in psychiatric diagnosis. A total of 5954 laboratory tests were done. From
Table 1. General particulars of the survey population
Number Mean age (years) Standard deviation DSM-III-r axis 1 diagnosisa Organic psycho-syndromes Psychotic disorders Affective disorders Other No diagnosis axis 1 DSM-III-r axis 2 diagnosisa Personality disorders Disturbed intellectual functioning No diagnosis axis 2 a
Males Females
Total
73 75.1 7.99
194 75.7 7.88
121 76.2 7.81
23 12 31 2 8
34 20 52 3 13
57 32 83 5 21
6
15
21
5 64
5 101
10 165
In some patients, 2 diagnoses were made.
103
E.J. Mookhoek et al.
these, 1341 tests (23%) had values outside the normal range. Fifty-five tests (0.9%) were repeated without further consequences. Twenty laboratory tests (0.3%) had a discrepant test result and this discrepancy was the reason for further examination without therapeutic consequences. Eighty-three
laboratory tests (1.4%) had therapeutic consequences that affected 72 patients (Table 2). All of the seven patients whose hemoglobin (Hb) test had therapeutic consequences had an iron deficiency anemia and a Hb test was indicated. Five patients received oral iron preparations, one patient
Table 2. The number (N) of patients, N of executed tests, N of test results outside the normal range (discrepant) and those tests connected to the therapeutic consequences Nonindicated Test
N
Tests
Discrepant
Hemoglobin Hematocryt Red cell count Leukocytes Thrombocytes ESR Blood smear Creatinine Urea Sodium Potassium Bilirubin Alk. phosphatase ASAT (SGOT) ALAT (SGPT) LDH GGT CPK Protein Albumin Uric acid Calcium Phosphate Cholesterol Triglycerides Cortisol Normotest Glucose(sober) TSH TPHA Thiamine Pyridoxine Folic acid Vitamin B12 Urinary sediment Other urinalyses Total lab. tests EKG Chest x-ray film
44 179 190 46 50 170 171 68 76 78 82 84 79 84 79 84 84 171 177 177 192 153 180 165 165 160 194 89 70 192 172 180 178 173
43 177 187 45 49 165 166 68 69 77 80 55 78 83 57 56 83 119 122 56 131 105 120 113 113 104 134 79 63 182 165 172 172 168
3 36 29 1 6 141 110 10 10 6 2 12 3 1 1 9 8 20 5 50 37 18 16 29 31 6 22 20 4 2 80 25 38 26
123 113
112 102 3870 84 72
60 21 898 61 50
95 81
Indicated Consequences
1
1
40 9 7 2
N
Tests
Discrepant
— — — — — — 1% — — — — — — — — — — — — — — — — — — — — 1% — — 24% — 5% 4%
150 15 4 148 144 24 23 126 118 116 112 110 115 110 109 110 110 23 17 17 2 41 14 29 29 34 0 105 124 2 22 14 16 21
148 14 4 146 142 23 22 125 110 115 111 80 111 106 79 80 105 17 14 3 1 31 10 23 23 25 0 100 117 1 18 11 14 19
32 6 3 20 22 23 12 29 39 14 11 14 6 6 0 21 14 4 0 1 0 6 1 9 9 1 0 45 22 1 6 1 3 5
2% — 60 — —
71 81
63 73 2084 85 98
39 18 443 69 87
The figures are shown separately for indicated and nonindicated tests.
104
99 113
Consequences 7
2 2 1
3 1 3 1 1 2
5% — — — — — — 2% 2% 1% — — — — — — — — — — — — — — — — — 3% 1% — 17% — 7% 5%
3% — 23 4 5% 1 1%
Screening for somatic disease in elderly psychiatric patients
received blood transfusion, and one had gastric carcinoma and was treated surgically. In the group of patients with an indication for an Hb test, the mean Hb was lower than in the group without indication (9.23 mmol/L vs 9.64 mmol/L, Student’s-t test p , 0.05). There was a negative correlation between the ESR and the Hb (20.59) and a positive correlation between Hb and albumin (10.60). All medication was stopped in one patient because of eosinophilia without leucocytosis. Shortly after receiving the test results this patient developed an exanthema, the time gained was less than 24 hours. In two patients, the dose of medication had to be adjusted because of high creatinine and urea levels. The mean urea level in the group of patients with such an indication was higher than that in the group without an indication (7.96 mmol/L vs 6.16 mmol/L, Student’s-t test p , 0.05). In one patient, a high sodium value was one of the reasons to commence tube feeding. In one patient, diabetes mellitus was confirmed; in three patients, medication for diabetes mellitus was adjusted. In one patient, a hyperthyroidism was discovered. Supplements were prescribed 61 times for low levels of serum thiamine, folic acid, or vitamin B12. An antibiotic treatment was started in four females because of urinary tract infections. There was an indication for 2084 (35%) out of the 5954 laboratory tests. There was more than one indication in 703 (34%) out of the 2084 indicated laboratory tests. From the 2084 tests, 224 (11%) were indicated only because of medical history; 231 (11%) were indicated only because of chronic use of medication; 358 (17%) were indicated only because of physical complaints; 568 (27%) were indicated only because of abnormalities upon physical examination. Tests with more than one indication or indicated by abnormalities upon physical examination had more therapeutic consequences than the other indicated tests (1.4% vs 0.6%, Student’s-t test p , 0.05). The EKG had therapeutic consequences in four patients. New medication was prescribed or the dose was adjusted. In one of the patients, a chest x-ray film was followed by a course of antibiotics. There was no relationship among psychiatric diagnosis, age or gender, and indications, test results, or consequences.
Discussion It was noteworthy that so many tests were indicated. On the one hand we compiled a very thor-
ough inventory of all indications. We probably failed to notice only a few. On the other hand, sometimes detailed information on the patients from relatives or family doctors only became available at a later stage of the admission and was not available at the time of this survey. This information may have contributed to additional indications. Probably, the abundance of somatic illness in psychiatric patients is also an important cause for the large number of indicated tests. The many test results outside the normal range that did not have therapeutic consequences was also noteworthy. As mentioned before, the normal values we used were not validated specifically for elderly patients. However, there are more explanations. First, we only looked at the direct therapeutical consequences. Disease diagnosed by excluding other illness was not included in our survey. EKG findings have an influence on the choice of psychiatric medication. Such findings were neither considered as a therapeutical consequence nor as an indication for a specific test in our survey. Many of the discrepant test results were within close range to the normal values. Finally, some test results were followed by further diagnostic tests or the test was repeated. However, these did not have therapeutic consequences. The decision-making process of the physicians was not a subject in our survey. Why more discrepant thiamine test results were followed by treatment than discrepant TSH test results is a question we cannot answer; possibly, the disadvantages of therapy play a role. It is simple to prescribe a vitamin tablet with no side effects for a limited period. Treatment of thyroid dysfunction necessitates taking tablets for prolonged periods. Regular laboratory tests are also necessary to evaluate the effectiveness of therapy. Especially in cases of marginal discrepancy in the test results, it is logical for the physicians to wait and see if the therapy also has disadvantages. Findings of physical examination frequently gave indications for laboratory tests, and 27% of these tests were indicated only because of such findings. Looking at the tests for hemoglobin, glucose, urea, and the EKG, there was a clear relationship between indications and the test results and/or the therapeutic consequences. Sheleine and Kehr [10] also observed a relationship between indications and clinical consequences in psychiatric inpatients. Deficiencies of thiamine, folic acid, and vitamin B12 were noted in a number of cases although they were often marginal and were not accompanied by
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the classical clinical symptoms in any of the patients. Effects of supplements on marginal folic acid deficiency reported in the literature advocated the testing for folic acid on a routine basis [11]. Since there is a possible relationship between psychical function and marginal vitamin B12 deficiencies, testing for this deficiency on a routine basis was noted to be valuable [12,13]. The effect of supplementing marginal thiamine deficiency is not clear; some surveys reported a negative influence on physical and psychical functioning [14]. The influence of a thiamine deficiency in combination with deficiencies of other vitamins is more probable [15,16]. The effect of a marginal thiamine deficiency only is unclear. As a consequence, the value of testing for a possible thiamine deficiency on a routine basis is questionable. When the therapeutic consequences of the other tests without indications are taken into account, only testing for glucose seems relevant in elderly psychiatric patients. In females, a test for a urinary tract infection is recommended. There is a logical argument that all other tests should only be done on an indication basis. However, we compiled a thorough inventory of all indications; this is probably not undertaken as thoroughly for each patient in clinical practice. Therefore, we would advise taking into account the frequency of existing indications in considering which tests should be included for routine testing. As our study was not designed for investigating a detailed cost-benefit analysis, the cutoff percentage at which one should draw a line is not clear. Should we set the cutoff at 50%; then a full blood count, urea or creatinine, electrolytes, thyroid-stimulating hormone, and some liver enzymes should be included in routine testing. The extra inconvenience for the patient for providing a little extra blood is negligible. Obtaining an EKG or a chest film is more inconvenient for patients. Setting the cutoff at 50% for an EKG and chest film is less obvious in our view. Therefore, EKGs and x-ray films should not be done on a routine basis. Other authors came to the same conclusion [17]. In our 1994 survey, we recommended routine laboratory tests in elderly psychiatric patients admitted to our long-stay wards [18]. The admission screening battery that is recommended now is somewhat more extensive; this list is also more extensive than that recommended by Harms and Hermans in 1994 [5]. However, their survey population consisted only of patients without a suspected organic psycho-syndrome and was retro-
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spective. Colgan and Philpot [19] studied 167 records of elderly psychiatric patients and concluded that a full blood count, folic acid, urea, electrolytes, and urine cultures were meaningful routine tests. Finally, we would like to point out that tests for discovering specific contraindications prior to treatment was not a part of our survey; for example, an EKG prior to treatment with tricyclic antidepressants or testing kidney function prior to treatment with lithium. This may also be an additional argument for enlarging a routine screening battery.
Conclusions Looking at the frequency of indications and the therapeutic consequences, routine testing for full blood count, glucose, some liver enzymes, creatinine or urea, electrolytes, thyroid-stimulating hormone, folic acid, vitamin B12, and urinary tract infection in women is valuable in elderly patients admitted to a general psychiatric hospital. The other evaluated tests—ESR, CPK, albumin, uric acid, calcium, phosphate, cholesterol, triglycerides, cortisol, normotest, thiamin, pyridoxine, EKG, and chest x-ray films should not be done on a routine basis. Physical examination appeared to be an important source of information for determining the appropriate supplementary tests.
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