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Low prevalence of age disorientation in Dutch long-stay patients
SCHIZOPHRENIA RESEARCH ELSEVIER
SchizophreniaResearch 14 (1995) 141-143
Low prevalence of age disorientation in Dutch long-stay patients Jean-Paul C.J. Selten a,,, Dani~lle C. Cath
b
a Rosenburg Psychiatric Hospital," P.O. Box 53019, 2505 AA The Hague, The Netherlands, b Endegeest Psychiatric Hospital, Oegstgeest, The Netherlands
(Received 15 March 1994; accepted 12 July 1994
Abstract
Studies in Great-Britain and the USA have established the prevalence of 'age disorientation', defined as a discrepancy between true and subjective age of five years or more, as approximately 25% in the population of long-stay patients with a diagnosis of schizophrenia. We examined all schizophrenic patients in long-stay wards of three mental hospitals and found a prevalence of 6% (95% CI: 0.9-10.6%). We have no definitive explanation for this finding. 'Age disorientation' may be the result of an interaction between a serious form of the illness and poor psychosocial treatment. Keywords: Age disorientation; Inpatient; Duration of illness; Duration of schizophrenia; Psychosocial treatment
1. Introduction
Large studies in Great-Britain have revealed that only 35-46% of long-stay patients with a diagnosis of schizophrenia were able to answer correctly the question about their age. Moreover, it was found that about 25% of all patients estimated their age incorrectly by a margin of five years or more and this phenomenon was called 'age disorientation' (Crow and Mitchell, 1975; Crow and Stevens, 1978; Stevens et al., 1978). The finding has been replicated in the USA (Smith and Oswald, 1976), Japan (Nakagawa et al., 1987), and Spain (Pulido et al., 1992). Furthermore, 'age disorientation' has been reported to be highly prevalent in severely disabled patients with a relatively short duration of stay. T a p p e t al. (1992) examined 39 patients with 'Kraepelinian schizophrenia' (defined by Keefe * Corresponding author. 0920-9964/95/$9.50 © 1995ElsevierScienceB.V. All rights reserved SSDI 0920-9964(94)00049-2
et al. (1991) as completely dependent on others for necessities such as food, shelter and clothing for the last five years or continuously hospitalized for five years) and found a prevalence of age disorientation of 36%. Crow and colleagues reported that age disorientated patients almost always underestimated their age. For these patients 'time stood still', often for several decades. Age disorientation was found to be associated with global intellectual impairment (Liddle and Crow, 1984) and to be unexplained by premorbid intellectual impairment or past physical treatment (Buhrich et al., 1988). Stevens et al. (1978) reported that age disorientated patients were older, had a longer current admission and had been younger at first admission than age-orientated patients. Therefore Stevens et al. suggested that age disorientation was a feature of a type of schizophrenic illness of early onset and poor prognosis. We and our colleagues have received the impres-
142
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sion that age disorientation is relatively rare in The Netherlands. According to a retired Dutch psychiatrist the phenomenon was common before the introduction of neuroleptics. The symptom subsided if the patient was provided with chlorpromazine and a mirror (P.J. Stolk, personal communication). We decided to ask our patients about their age.
2. Materials and methods
We interviewed all schizophrenic patients (D.S.M.III-R diagnosis) in the long-stay wards of three mental hospitals (Rosenburg, Endegeest and Joris). To facilitate comparison with the British and American studies we examined patients who had stayed for five years or more. Exclusion criteria were (i) age above 65 years (to avoid inclusion of patients with a comorbid dementing illness) (ii) brain lesions or neurological dysfunctions that may interfere with cognition and (iii) mental subnormality. Mental subnormality was defined as failure to finish primary school or having repeated more than one class at primary school.
3. Results
The final sample included 87 patients, 55 men and 32 women. The mean age was 47.5 years (sd = 9.9, range = 23-65). The mean age at first admission was 22.7 years (sd = 7.1, range = 11-49). The mean length of current admission was 13.5 years (sd = 8.8, range = 5-41 ). When questioned about their age seventyfour patients (85%; 95% confidence interval: 77.6%-92.6%) gave a correct answer. One patient was mute and two patients refused to answer the question. One patient replied he did not know. Five patients (6%; 95% confidence interval 0.9%-10.6%) fulfilled the criteria for age disorientation. Four of them overestimated their age and only one patient believed himself to be younger than he really was (33 years instead of 38 years). The mean age of the five patients with age disorien-
tation (46.2 years) was almost the same as that of the entire group (47.5 years).
4. Discussion
How is this finding to be interpreted? First, we must consider the possibility that our finding is explained by sample differences with regard to variables such as age and duration of current admission. For this purpose we compared the Dutch sample to the largest British sample (Stevens et al., 1975). At the time of the investigation the Dutch patients were younger (mean: 47.5 years) than the patients in Great-Britain (mean: 56 years) and had a shorter current admission (mean: 13.5 years) than patients in Great-Britain (mean: 24.1 years). It is unlikely, however, that these differences explain our findings entirely. The mean age of British patients with age disorientation was 59 years and patients of this age were also present in the Dutch sample. Twenty-six patients from the Dutch sample were in the 56-65 age group and only one of them exhibited age disorientation. Furthermore, we should like to point out that T a p p e t al. (1992) found a high prevalence of age disorientation in relatively young patients, who had been hospitalized for a relatively short period of time. The mean age of the age disorientated Kraepelinian patients described by T a p p e t al. was 49 years and the total duration of hospitalization an average of 7 years. These data suggest that the level of psychiatric disability is a more significant predictor of age disorientation than age or length of stay. Indeed, the more sophisticated studies on the relationship between length of hospitalization and cognitive deficits showed no detrimental hospitalization effect (Johnstone et al., 1981; Goldstein et al., 1991). Our finding is not a result of a higher age of onset in the Dutch sample. At first admission the Dutch patients were actually younger (mean: 22.7 years) than their British counterparts (mean: 30.0 years). It is uncertain whether our finding can be accounted for by selection bias, as a result of differential admission and discharge policies with
J.-P. Selten, D. C. Cath/Schizophrenia Research 14 (1995) 141-143
r e g a r d to p a t i e n t s with the m o r e serious f o r m o f the illness. W e s h o u l d like to p o i n t out, however, t h a t C r o w a n d colleagues p e r f o r m e d their studies l o n g b e f o r e a massive r e d u c t i o n o f h o s p i t a l beds c o u l d l e a d to a c o n c e n t r a t i o n o f the severest cases in British l o n g - s t a y wards. T h e r e is a possibility t h a t the D u t c h age d i s o r i e n t a t e d p a t i e n t s w a n d e r the streets. N o t h i n g is k n o w n , however, a b o u t the severity o f cognitive deficits in D u t c h homeless p a t i e n t s a n d a b o u t possible differences with their British o r A m e r i c a n p a r t n e r s in m i s f o r t u n e . O t h e r p o s s i b l e e x p l a n a t i o n s include: (i) differences b e t w e e n the s a m p l e s in the d u r a t i o n o f u n t r e a t e d psychosis. Several studies have f o u n d t h a t u n t r e a t e d psychosis h a d a d e b i l i t a t i n g effect on l o n g - t e r m o u t c o m e (reviewed b y W y a t t , 1991); (ii) a t i m e - t r e n d t o w a r d s i m p r o v e m e n t in the p r o g n o s i s o f s c h i z o p h r e n i a (e.g., Z u b i n et al., 1983); a n d (iii) a c o m b i n a t i o n o f these factors. O n e p o s s i b l e e x p l a n a t i o n m u s t n o t go u n m e n tioned. D u t c h p s y c h i a t r i s t s w h o visited the U K o r the U S were s u r p r i s e d b y the c i r c u m s t a n c e s they f o u n d in s o m e l o n g - s t a y w a r d s (e.g. d e s o l a t e b u i l d ings, u n d e r s t a f f e d wards). T h e possibility s h o u l d be c o n s i d e r e d , therefore, t h a t age d i s o r i e n t a t i o n is the result o f an i n t e r a c t i o n b e t w e e n a severe f o r m o f the illness a n d p o o r p s y c h o s o c i a l t r e a t m e n t . A s m o r e objective d a t a o n the q u a l i t y o f p s y c h o s o c i a l t r e a t m e n t in l o n g - s t a y w a r d s are n o t available, this e x p l a n a t i o n r e m a i n s tentative. I n conclusion, we believe it is p r e m a t u r e to view age d i s o r i e n t a t i o n as a c o m m o n m a n i f e s t a t i o n o f an intellectual i m p a i r m e n t intrinsic to schizophrenic illness.
Acknowledments T h e a u t h o r s t h a n k Drs. J. Reichgelt a n d M. R i j k e b o e r for their help in collecting d a t a a n d Dr. J.P.J. Slaets for his c o m m e n t s on the m a n u s c r i p t .
143
References Buhrich, N. Crow, T.J. Johnstone, E.C. and Owens, D.G.C. (1988) Age disorientation in schizophrenia is not associated with premorbid intellectual impairment or past physical treatment. Br. J. Psychiatry 152, 462-469. Crow, T.J. and Mitchell, W.S. (1975) Subjective age in chronic schizophrenia: evidence for a sub-group of patients with defective learning-capacity? Br. J. Psychiatry 126, 360 363. Crow, T.J. and Stevens, M. (1978) Age disorientation in chronic schizophrenia: the nature of the cognitive deficit. Br. J. Psychiatry 133, 137-142. Goldstein, G., Zubin, J. and Pogue-Geile, M.F. (1991) Hospitalization and the cognitive deficits of schizophrenia. The influences of age and education. J. Nerv. Ment. Dis. 179, 202 206. Johnstone, E.C., Cunningham Owens, D.G., Gold, A., Crow, T.J. and MacMillan, J.F. (1981 ) Institutionalization and the defects of schizophrenia. Br. J. Psychiatry 139, 195-203. Keefe, R.S.E., Lobel, D.S., Mohs, R.C., Silverman, J.M., Harvey, P.D., Davidson, M., Losonczy, M.F. and Davis, K.L. (1991) Diagnostic issues in chronic schizophrenia: Kraepelinian schizophrenia, undifferentiated schizophrenia, and state-independent negative symptoms. Schizophr. Res. 24, 56-61. Liddle, P.F. and Crow, T.J. (1984) Age disorientation in chronic schizophrenia is associated with global intellectual impairment. Br. J. Psychiatry 144, 193-199. Nakagawa, A., Taguchi, M., Tamai, A., Hiraguchi, M., Enokido, H., Torii, H. (1987) Age disorientation in chronic schizophrenics. In: R.Takahashi, P.Flor-Henry, J.H.Gruzelier (eds.), Cerebral Dynamics, Laterality and Psychopathology. Elsevier, Amsterdam, pp. 351-352. Pulido, S.A., Marrognin, H., Obiols, J.E. (1992) Alteracion en la persepcion de la edad en la esquizofrenia cronica. Rev. Psiquiatria. Fac. Med. Barna. 19, 3-8. Smith, J.M. and Oswald, W.T. (1976) Subjective age in chronic schizophrenia (letter). Br. J. Psychiatry 128, 100. Stevens, M., Crow, T.J., Bowman, M.J. and Coles, E.C. (1978) Age disorientation in schizophrenia: a constant prevalence of 25 per cent in a chronic mental hospital population? Br. J. Psychiatry 133, 130 136. Tapp, A., Tandon, R., Scholten R. and Dudley, E. (1993) Age disorientation in Kraepelinian schizophrenia: frequency and clinical correlates. Psychopathology 26, 225 228. Wyatt, R.J. (1991) Neuroleptics and the natural course of schizophrenia. Schizophr. Bull. 17, 325 351. Zubin, J., Magaziner, J. and Steinhauer, J. (1983) The metamorphosis of schizophrenia: from chronicity to vulnerability. Psychol. Med. 13, 551 571.
SchizophreniaResearch 14 (1995) 141-143
Low prevalence of age disorientation in Dutch long-stay patients Jean-Paul C.J. Selten a,,, Dani~lle C. Cath
b
a Rosenburg Psychiatric Hospital," P.O. Box 53019, 2505 AA The Hague, The Netherlands, b Endegeest Psychiatric Hospital, Oegstgeest, The Netherlands
(Received 15 March 1994; accepted 12 July 1994
Abstract
Studies in Great-Britain and the USA have established the prevalence of 'age disorientation', defined as a discrepancy between true and subjective age of five years or more, as approximately 25% in the population of long-stay patients with a diagnosis of schizophrenia. We examined all schizophrenic patients in long-stay wards of three mental hospitals and found a prevalence of 6% (95% CI: 0.9-10.6%). We have no definitive explanation for this finding. 'Age disorientation' may be the result of an interaction between a serious form of the illness and poor psychosocial treatment. Keywords: Age disorientation; Inpatient; Duration of illness; Duration of schizophrenia; Psychosocial treatment
1. Introduction
Large studies in Great-Britain have revealed that only 35-46% of long-stay patients with a diagnosis of schizophrenia were able to answer correctly the question about their age. Moreover, it was found that about 25% of all patients estimated their age incorrectly by a margin of five years or more and this phenomenon was called 'age disorientation' (Crow and Mitchell, 1975; Crow and Stevens, 1978; Stevens et al., 1978). The finding has been replicated in the USA (Smith and Oswald, 1976), Japan (Nakagawa et al., 1987), and Spain (Pulido et al., 1992). Furthermore, 'age disorientation' has been reported to be highly prevalent in severely disabled patients with a relatively short duration of stay. T a p p e t al. (1992) examined 39 patients with 'Kraepelinian schizophrenia' (defined by Keefe * Corresponding author. 0920-9964/95/$9.50 © 1995ElsevierScienceB.V. All rights reserved SSDI 0920-9964(94)00049-2
et al. (1991) as completely dependent on others for necessities such as food, shelter and clothing for the last five years or continuously hospitalized for five years) and found a prevalence of age disorientation of 36%. Crow and colleagues reported that age disorientated patients almost always underestimated their age. For these patients 'time stood still', often for several decades. Age disorientation was found to be associated with global intellectual impairment (Liddle and Crow, 1984) and to be unexplained by premorbid intellectual impairment or past physical treatment (Buhrich et al., 1988). Stevens et al. (1978) reported that age disorientated patients were older, had a longer current admission and had been younger at first admission than age-orientated patients. Therefore Stevens et al. suggested that age disorientation was a feature of a type of schizophrenic illness of early onset and poor prognosis. We and our colleagues have received the impres-
142
J.-P. Selten, D.C. Cath/Schizophrenia Research 14 (1995) 141 143
sion that age disorientation is relatively rare in The Netherlands. According to a retired Dutch psychiatrist the phenomenon was common before the introduction of neuroleptics. The symptom subsided if the patient was provided with chlorpromazine and a mirror (P.J. Stolk, personal communication). We decided to ask our patients about their age.
2. Materials and methods
We interviewed all schizophrenic patients (D.S.M.III-R diagnosis) in the long-stay wards of three mental hospitals (Rosenburg, Endegeest and Joris). To facilitate comparison with the British and American studies we examined patients who had stayed for five years or more. Exclusion criteria were (i) age above 65 years (to avoid inclusion of patients with a comorbid dementing illness) (ii) brain lesions or neurological dysfunctions that may interfere with cognition and (iii) mental subnormality. Mental subnormality was defined as failure to finish primary school or having repeated more than one class at primary school.
3. Results
The final sample included 87 patients, 55 men and 32 women. The mean age was 47.5 years (sd = 9.9, range = 23-65). The mean age at first admission was 22.7 years (sd = 7.1, range = 11-49). The mean length of current admission was 13.5 years (sd = 8.8, range = 5-41 ). When questioned about their age seventyfour patients (85%; 95% confidence interval: 77.6%-92.6%) gave a correct answer. One patient was mute and two patients refused to answer the question. One patient replied he did not know. Five patients (6%; 95% confidence interval 0.9%-10.6%) fulfilled the criteria for age disorientation. Four of them overestimated their age and only one patient believed himself to be younger than he really was (33 years instead of 38 years). The mean age of the five patients with age disorien-
tation (46.2 years) was almost the same as that of the entire group (47.5 years).
4. Discussion
How is this finding to be interpreted? First, we must consider the possibility that our finding is explained by sample differences with regard to variables such as age and duration of current admission. For this purpose we compared the Dutch sample to the largest British sample (Stevens et al., 1975). At the time of the investigation the Dutch patients were younger (mean: 47.5 years) than the patients in Great-Britain (mean: 56 years) and had a shorter current admission (mean: 13.5 years) than patients in Great-Britain (mean: 24.1 years). It is unlikely, however, that these differences explain our findings entirely. The mean age of British patients with age disorientation was 59 years and patients of this age were also present in the Dutch sample. Twenty-six patients from the Dutch sample were in the 56-65 age group and only one of them exhibited age disorientation. Furthermore, we should like to point out that T a p p e t al. (1992) found a high prevalence of age disorientation in relatively young patients, who had been hospitalized for a relatively short period of time. The mean age of the age disorientated Kraepelinian patients described by T a p p e t al. was 49 years and the total duration of hospitalization an average of 7 years. These data suggest that the level of psychiatric disability is a more significant predictor of age disorientation than age or length of stay. Indeed, the more sophisticated studies on the relationship between length of hospitalization and cognitive deficits showed no detrimental hospitalization effect (Johnstone et al., 1981; Goldstein et al., 1991). Our finding is not a result of a higher age of onset in the Dutch sample. At first admission the Dutch patients were actually younger (mean: 22.7 years) than their British counterparts (mean: 30.0 years). It is uncertain whether our finding can be accounted for by selection bias, as a result of differential admission and discharge policies with
J.-P. Selten, D. C. Cath/Schizophrenia Research 14 (1995) 141-143
r e g a r d to p a t i e n t s with the m o r e serious f o r m o f the illness. W e s h o u l d like to p o i n t out, however, t h a t C r o w a n d colleagues p e r f o r m e d their studies l o n g b e f o r e a massive r e d u c t i o n o f h o s p i t a l beds c o u l d l e a d to a c o n c e n t r a t i o n o f the severest cases in British l o n g - s t a y wards. T h e r e is a possibility t h a t the D u t c h age d i s o r i e n t a t e d p a t i e n t s w a n d e r the streets. N o t h i n g is k n o w n , however, a b o u t the severity o f cognitive deficits in D u t c h homeless p a t i e n t s a n d a b o u t possible differences with their British o r A m e r i c a n p a r t n e r s in m i s f o r t u n e . O t h e r p o s s i b l e e x p l a n a t i o n s include: (i) differences b e t w e e n the s a m p l e s in the d u r a t i o n o f u n t r e a t e d psychosis. Several studies have f o u n d t h a t u n t r e a t e d psychosis h a d a d e b i l i t a t i n g effect on l o n g - t e r m o u t c o m e (reviewed b y W y a t t , 1991); (ii) a t i m e - t r e n d t o w a r d s i m p r o v e m e n t in the p r o g n o s i s o f s c h i z o p h r e n i a (e.g., Z u b i n et al., 1983); a n d (iii) a c o m b i n a t i o n o f these factors. O n e p o s s i b l e e x p l a n a t i o n m u s t n o t go u n m e n tioned. D u t c h p s y c h i a t r i s t s w h o visited the U K o r the U S were s u r p r i s e d b y the c i r c u m s t a n c e s they f o u n d in s o m e l o n g - s t a y w a r d s (e.g. d e s o l a t e b u i l d ings, u n d e r s t a f f e d wards). T h e possibility s h o u l d be c o n s i d e r e d , therefore, t h a t age d i s o r i e n t a t i o n is the result o f an i n t e r a c t i o n b e t w e e n a severe f o r m o f the illness a n d p o o r p s y c h o s o c i a l t r e a t m e n t . A s m o r e objective d a t a o n the q u a l i t y o f p s y c h o s o c i a l t r e a t m e n t in l o n g - s t a y w a r d s are n o t available, this e x p l a n a t i o n r e m a i n s tentative. I n conclusion, we believe it is p r e m a t u r e to view age d i s o r i e n t a t i o n as a c o m m o n m a n i f e s t a t i o n o f an intellectual i m p a i r m e n t intrinsic to schizophrenic illness.
Acknowledments T h e a u t h o r s t h a n k Drs. J. Reichgelt a n d M. R i j k e b o e r for their help in collecting d a t a a n d Dr. J.P.J. Slaets for his c o m m e n t s on the m a n u s c r i p t .
143
References Buhrich, N. Crow, T.J. Johnstone, E.C. and Owens, D.G.C. (1988) Age disorientation in schizophrenia is not associated with premorbid intellectual impairment or past physical treatment. Br. J. Psychiatry 152, 462-469. Crow, T.J. and Mitchell, W.S. (1975) Subjective age in chronic schizophrenia: evidence for a sub-group of patients with defective learning-capacity? Br. J. Psychiatry 126, 360 363. Crow, T.J. and Stevens, M. (1978) Age disorientation in chronic schizophrenia: the nature of the cognitive deficit. Br. J. Psychiatry 133, 137-142. Goldstein, G., Zubin, J. and Pogue-Geile, M.F. (1991) Hospitalization and the cognitive deficits of schizophrenia. The influences of age and education. J. Nerv. Ment. Dis. 179, 202 206. Johnstone, E.C., Cunningham Owens, D.G., Gold, A., Crow, T.J. and MacMillan, J.F. (1981 ) Institutionalization and the defects of schizophrenia. Br. J. Psychiatry 139, 195-203. Keefe, R.S.E., Lobel, D.S., Mohs, R.C., Silverman, J.M., Harvey, P.D., Davidson, M., Losonczy, M.F. and Davis, K.L. (1991) Diagnostic issues in chronic schizophrenia: Kraepelinian schizophrenia, undifferentiated schizophrenia, and state-independent negative symptoms. Schizophr. Res. 24, 56-61. Liddle, P.F. and Crow, T.J. (1984) Age disorientation in chronic schizophrenia is associated with global intellectual impairment. Br. J. Psychiatry 144, 193-199. Nakagawa, A., Taguchi, M., Tamai, A., Hiraguchi, M., Enokido, H., Torii, H. (1987) Age disorientation in chronic schizophrenics. In: R.Takahashi, P.Flor-Henry, J.H.Gruzelier (eds.), Cerebral Dynamics, Laterality and Psychopathology. Elsevier, Amsterdam, pp. 351-352. Pulido, S.A., Marrognin, H., Obiols, J.E. (1992) Alteracion en la persepcion de la edad en la esquizofrenia cronica. Rev. Psiquiatria. Fac. Med. Barna. 19, 3-8. Smith, J.M. and Oswald, W.T. (1976) Subjective age in chronic schizophrenia (letter). Br. J. Psychiatry 128, 100. Stevens, M., Crow, T.J., Bowman, M.J. and Coles, E.C. (1978) Age disorientation in schizophrenia: a constant prevalence of 25 per cent in a chronic mental hospital population? Br. J. Psychiatry 133, 130 136. Tapp, A., Tandon, R., Scholten R. and Dudley, E. (1993) Age disorientation in Kraepelinian schizophrenia: frequency and clinical correlates. Psychopathology 26, 225 228. Wyatt, R.J. (1991) Neuroleptics and the natural course of schizophrenia. Schizophr. Bull. 17, 325 351. Zubin, J., Magaziner, J. and Steinhauer, J. (1983) The metamorphosis of schizophrenia: from chronicity to vulnerability. Psychol. Med. 13, 551 571.