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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 19
| Issue : 1 | Page : 47-53 |
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Psychiatric presentations and factors associated with suspected organicity in elderly attending a tertiary care facility in South India
B Srisudha1, Munaf Babajan Nandyal2, Naveen Kolloju3, Rachna George Joseph4, Reka Karuppusami5, Suja Kurian1
1 Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
2 Adult Mental Health Rehabilitation Unit, Sunshine Hospital, Midwest Mental Health Area Services, Melbourne, Victoria, Australia
3 Broadmeadows Hospital, Northwest Mental Health Area Services, Melbourne, Victoria, Australia
4 Department of Child and Adolescent Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India
5 Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| Date of Submission | 21-Jan-2023 |
| Date of Acceptance | 23-Feb-2023 |
| Date of Web Publication | 17-Mar-2023 |
Correspondence Address:
Munaf Babajan Nandyal
Adult Mental Health Rehabilitation Unit, Sunshine Hospital, Midwest Mental Health Area Services, St. Albans, Melbourne, Victoria
Australia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jiag.jiag_5_23
Objectives: The objectives were to determine the proportion of elderly among the new psychiatry outpatient attendees, identify their sociodemographic profile and clinical presentations, and determine risk factors associated with suspected organic conditions in patients presenting with acute onset and chronic presentations. Methodology: This retrospective cross-sectional study focused on the elderly presenting with psychiatric symptoms to a psychiatric setting. The onset of symptoms at presentation was divided into acute and chronic conditions. Clinical symptom clusters and the risk factors associated with organic conditions were identified. The Chi-square and Fisher's exact test were used to find an association between factors and outcome (organic/functional). Results: Elderly seeking consultation constituted < 10% of total new case registration. Acute onset was seen in one-third and chronic presentation constituted nearly two-thirds of the group. The common clinical presentations with acute onset were acute psychosis, altered sensorium, and psychosis due to an organic etiology. The most common clinical presentation with chronic course was chronic psychosis. Nearly 40% had suspected organicity. Increasing age, structural abnormality in brain imaging, and the presence of stressors were risk factors for the onset of psychiatric presentation in the elderly (P = 0.001). Conclusion: Early detection of the clinical syndrome, identification of organic conditions, and appropriate and prompt referral to the general physician should be the rule for the care of the elderly presenting to a psychiatric facility.
Keywords: Elderly, organicity, psychiatric presentation, risk factors
How to cite this article:
Srisudha B, Nandyal MB, Kolloju N, Joseph RG, Karuppusami R, Kurian S. Psychiatric presentations and factors associated with suspected organicity in elderly attending a tertiary care facility in South India. J Indian Acad Geriatr 2023;19:47-53 |
How to cite this URL:
Srisudha B, Nandyal MB, Kolloju N, Joseph RG, Karuppusami R, Kurian S. Psychiatric presentations and factors associated with suspected organicity in elderly attending a tertiary care facility in South India. J Indian Acad Geriatr [serial online] 2023 [cited 2023 Mar 22];19:47-53. Available from: http://www.jiag.com/text.asp?2023/19/1/47/371903 |
| Introduction | |  |
Psychological needs of the elderly rise when they face economic dependence or social isolation. Presentation to psychiatric facilities can be due to multiple causes such as dementia causing changes in behavior or others such as psychological, physical, and unexplained somatic symptoms. Unexplained medical symptoms could be due to the lack of knowledge and inability to appreciate the condition as requiring assessment for a psychiatric disorder and intervention or the perceived stigma associated with help seeking for a mental illness.[1]
Coexisting medical conditions and increased vulnerability for side effects of medication make the care for the elderly with medical, psychological, and psychiatric needs complex. A comprehensive geropsychiatric assessment toward identification and early intervention of a psychiatric disorder would go a long way in their care improving the quality of life of the elderly.
The objectives of the study were to determine the proportion of elderly presenting to the center against the total outpatient registrations, to identify common clinical (syndrome) presentations among them, and to determine the sociodemographic profile of these patients and factors associated with suspected organic conditions.
| Methodology | | |
Study design
This retrospective cross-sectional study was conducted in a tertiary care psychiatric facility in South India.
Patients aged 65 and above who had registered for assessment in this center over 2 years from 2017 to 2019 were included in the study.
Data collection
The details of all patients aged 65 years and above registered for the first time during the specified time period were collected from their medical records after obtaining clearance from the Institutional Review Board (IRB Min. No. 13422) of the institution. The sociodemographic, clinical, and economic details were collected using a semistructured Proforma. The onset of clinical symptoms at presentation was divided into acute (1 month or less) and chronic (more than a month) based on the duration criteria in the International Classification of Mental and Behavioural Disorders-10. The clinical syndrome was identified and symptom clusters were noted and recorded using the pro forma. Among both groups of acute and chronic presentations of elderly patient's symptom clusters of suspected organic etiology were identified and risk factors for these cases were determined.
Statistical analysis
The number of patients and percentage was reported for categorical data. The Chi-square and Fisher's exact test (less cell count) were used to find an association between factors and outcome (organic/functional). All tests were two-sided at α =0.05 level of significance. All analyses were done using Statistical Package for the Social Sciences (SPSS) software version 21.0 (IBM Corp, Armonk, NY: USA).
| Results | | |
Elderly presenting to the facility and the clinical syndrome at the initial visit
People aged 65 years and above seeking consultation constituted <10% (453/5204; 8.7%) of patients attending the facility for the first time during the study period. The flowchart of patient numbers is as follows.
This study group had a male predominance, more than half of the group were (245/453; 54%) men. Majority (307/453; 68%) belonged to the age group between 65 and 75 years. One-third (146/453; 32.2%) of the group were illiterate and less than a quarter (90/453; 19.9%) had completed secondary school education. Those from rural habitats (52/453; 11.5%) continued to be employed in agricultural work whereas others had retired from work. More than half (265/453; 58.5%) of the study population lived in an extended family with spouse and married children.
This group of elderly who were brought by their family members to the facility had a variety of clinical presentations. The various clinical presentations across three age groups among the elderly are given in [Table 1]. The most common clinical presentation was memory impairment, and the second most common was acute-onset psychosis followed by chronic psychosis.
Sociodemographic and clinical details of elderly with acute onset of symptoms (129/453; 28.5%)
The sociodemographic and clinical profile of the elderly with acute onset of symptoms is given in [Table 2]. | Table 2: Sociodemographic and clinical profile of patients with acute and chronic presentation (n=453)
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Nearly one-third of the elderly (129/453; 28.5%) had an acute onset of their symptoms and it was more common in the young old belonging to 65–75 years (71/129; 55%). There was no difference in the gender distribution of acute-onset conditions and there were 66 men in the group (66/129; 51.2%). Majority of the group (74/129; 57.4%) were married and living with the spouse at the time of assessment and the remaining had widowed.
There was a positive family history of psychiatric illness in one-third of the group with acute onset of symptoms. The majority (114/129; 88.4%) had a well-adjusted premorbid personality. Stressors were identified in less than one-fourth of this group. A continuous pattern of substance use was noted in less than a quarter of the group of patients (22/129; 17.1%) and the substance of abuse was alcohol or tobacco.
Sensory deficits were identified in a few (21/129; 16%) in this group, the most common being hearing loss among 13 patients. More than a third (50/129; 38.8%) of the group were ordered neuroimaging after their initial visit and 26 patients (26/50; 52%) among them had a structural abnormality of the brain. A small group (25/129; 19.4%) had to be referred to the accident and emergency services for evaluation as they had presented with acute onset of confusional state.
Clinical syndromes identified in the order of their frequency are as follows. (i) Acute psychosis: (74/129; 57.3%), (ii) altered sensorium in (27/129; 20.9%), and (iii) psychosis due to organic etiology was detected in a small group (13/129; 10%).
Seventy percent (89/129; 69%) of this group were diagnosed with physical comorbidity, some with multiple comorbidities, the most common being the combination of diseases contributing to metabolic syndrome. Nearly half of the patients with the acute presentation were referred to other specialties for regular follow-up care for physical comorbidity, and 23% of the patients needed a referral to an emergency setup.
Sociodemographic and clinical profile of elderly with chronic symptoms (324/453; 71.5%)
The sociodemographic and clinical profile of the elderly with chronic symptoms is given in [Table 2].
Majority of the study group had chronic symptoms (324/453; 71.5%). Like the acute onset group, most of the patients belonged to the young old age group between 65 and 75 years (236/324; 72.8%). There were more men in the group (179/324; 55.2%) and majority (221/324; 68.2%) were married and living with a spouse.
Most of the group (250/324; 77.4%) with chronic presentation had well-adjusted premorbid personality. About a third (106/324; 32.7%) of this group had reported stressors and stressors were loss of loved ones and interpersonal problems among family members. Substance abuse in the dependence pattern was found in a small group (59/324; 18.2%) of patients. A small proportion of them had early onset of abuse of alcohol and very few had abuse of multiple agents such as alcohol, nicotine, and benzodiazepine.
Twelve percent (38/324; 12%) of the patients presented with sensory deficits, the most common being the loss of hearing capacity (23/38; 60%). More than a third (111/324; 34.3%) of the group of patients with chronic conditions were ordered neuroimaging after their initial visit and 92 patients (92/324; 28.4%) among them had a structural abnormality of the brain. Altered sensorium was noted in eight patients (2.5%) with a history of chronic symptoms in the background and a similar number had deranged blood parameters in need of a referral to the accident and emergency department.
The most common clinical presentation with the chronic course was memory impairment (97/324; 29.6) followed by chronic psychosis (67/324; 20.7) and followed by depressive symptoms (61/324; 18.8%).
Physical comorbidity was diagnosed in (215/324; 66.4%) at the time of index presentation.
One-third of the patients (106/324; 32.71) were diagnosed to have neurological disorders. Eight patients (2%) were diagnosed to have hypothyroidism and a majority (206/324; 63.6%) were referred for the management of their medical condition.
Risk factors associated with suspected organicity in elderly with acute onset and chronic conditions
Details of the assessment of risk factors for suspected organicity among the elderly with acute presentation are given in [Table 3]. Among those 129 elderlies who had presented with acute onset conditions, 41 (32%) had suspected organicity, and the increase in age (0.621), gender (0.253), and associated physical comorbidity (0.054) were not significant risk factors. The presence of family history of neuropsychiatric condition (0.974), presence of stress at the onset of the condition (0.163), abnormal neuroimaging finding (0.333), and deviant premorbid personality (0.297) were also not found to be significantly associated with suspected organicity in elderly with the acute presentation. | Table 3: Risk factors associated with organicity in acute presentation (n=129)
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Among the 324 elderlies with chronic presentations, 131 had organic presentations (40%). Details of the assessment for risk factors for suspected organic presentation are given in [Table 4]. All the variables except family history were found to be associated with suspected organicity among elderly with chronic conditions. | Table 4: Risk factors associated with organicity in chronic presentation (n=324)
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Age was found to be a risk factor for organicity among the elderly with chronic presentations (P = 0.001), about half of the elderly with organic presentations were aged 75 years and above (44%). Majority of the elderly with organic presentations were males (63%), so gender is associated with organicity (P = 0.028) in this group. Physical comorbidity was found to be associated with organicity (P = 0.030). Family history was not associated with suspected organicity in the elderly with chronic presentation. Structural abnormality was found to be associated with organicity in chronic presentations (P = 0.001), vast majority of the elderly with organic presentation had structural abnormality (93%). The presence of stressors was more among those with organic presentations (86%) (P = 0.001). Premorbid personality was found to be associated with suspected organicity (P = 0.001), i.e. majority of the elderly with organic presentations were found to be well adjusted (91%).
| Discussion | | |
More than 20% of older people aged above 60 years suffer from a neurological or mental disorder.[2] The elderly presenting to this tertiary care center with psychiatric symptoms accounted for 8.7% of the population seeking help here. Community-based studies on psychiatric disorders among the geriatric population showed a prevalence ranging from 8.9% to 61.2%[3] and a lower prevalence of 5% in studies done by Rao et al.[4] In hospital-based studies, a high rate of 60%[5] and a low prevalence of 4.17%[6] were noted. Factors such as poor realization or identification of symptoms and the felt need for treatment, low financial status, and acceptance of the symptoms as a part of normal aging can lead to a lower estimation of prevalence in the hospital setting.[7]
The older adult population is classified into three life-stage subgroups: the young-old (ages 65–74), the old (ages 75–84), and the oldest old (over age 85). Our group of elderly patients consisted of 307 young-old, 115 old, and 31 old old patient categories, and two thirds belonged to the young-old group, a finding noted in other studies.[7]
Historically, older men have shown lesser preponderance to mental health issues. Emotional-social financial insecurity is much more commonly seen in women than in men with mental health issues.[8] However, in some studies done in the community[7] and in the hospital setting[9] men outnumbered women across all age groups. The study population had shown a male preponderance. This could be due to the influence of cultural factors in more males seeking treatment in a hospital than women.[9]
Acute clinical presentation
Acute onset of altered sensorium can present in an agitated confused state or in an obtunded mental state.[10] The cause for the altered sensorium is multifactorial.[11] It can be the first indicator of underlying dementia, which could worsen the patient's functioning resulting in a further deterioration in the direction of health. Hence, it should be identified early and treated appropriately.[10]
In our study, most of the patients belonged to the young-old group, predominantly male, and 47 patients (36.4%) had multiple comorbidities. Older people who are at increased risk for medical conditions. They can present with atypical psychiatric symptoms which could be a hallmark feature of underlying organic pathology.[12] Overlap of certain symptoms secondary to normal aging, physical comorbidity, and psychiatric symptoms complicates the scenario, resulting in underdiagnosis or overdiagnosis. This indicates the need for utmost care in the assessment of the elderly for the organic causes before labeling and diagnosing it as “functional disorder.”[6]
This also warrants a liaison with multidisciplinary teams for providing good quality care, prescribing medications, and avoiding drug interactions.
The spectrum of psychiatric symptoms or the full range of syndrome contributing to a psychiatric disorder can arise due to an organic pathology, which could be an infection or a cerebrovascular disease, degenerative or due to traumatic brain injury,[13] and 10% of the population with acute-onset psychiatric symptoms were reported to have an underlying organic pathology.[13]
Acute onset of psychotic symptoms in the elderly can follow the trajectory of schizophrenia or a primary mood disorder with psychotic symptoms.[11] A careful diagnosis is required paying greater attention in assessing the risk of self-harm. Acute onset of psychotic symptoms was noted in 74 (57.3%) patients in this study.
Chronic presentation
Overall, seventy percent of this study population had presented with symptoms for more than a month duration. This could be due to multiple factors. Among this group of elderly individuals, less than a quarter had a diagnosis of chronic psychosis and had presented either with an exacerbation of the condition or for follow-up care. Although the usual onset is in young adulthood[14] symptoms of chronic psychotic conditions continue to manifest during adulthood and the course of the illness can remain unchanged.[15]
Depressive symptoms are common presentations and are four times more seen than a depressive syndrome in the elderly.[16] The depressive symptom is considered one of the risk factors for a decline in daily living activities.[17] This study showed (61 patients) 18% of the population had presented with depressive symptoms and 21 patients (34%) in this group were partly dependent on caregivers for their activities of daily living. This raises the necessity for the early detection and management of depressive symptoms which could in turn improve the quality of life. The onset of depressive symptoms in some was secondary to stressors. Some of the stressors identified were the loss of loved one, financial difficulties, and changes in culture and value patterns. These stressors have isolated the elderly psychologically rendering them vulnerable to develop psychiatric symptoms.[18] This not only raises the need for pharmacotherapy but also reinforces the need for psychological therapy to address coping skills. However, social isolation which was reported earlier as one of the causes of a psychiatric disorder was not replicated in this study. This study noticed that people in joint families or loose joint families were more likely to develop psychiatric disorders in the elderly population.
Behavioral disturbances are commonly seen in elderly patients with medical and neurological conditions. Some of the above conditions and medications can also precipitate behavioral disturbances in elderly patients.[14] Twenty-eight patients (8.6%) of the population with chronic presentation had presented with behavioral problems and psychotic symptoms secondary to organic pathology. This indicates the need for early identification of these symptoms and the underlying cause and early initiation of the treatment.
Risk factors associated with suspected organicity in elderly with acute- and chronic-onset condition
About a quarter of the elderly population had presented with an acute onset of symptoms, with an altered sensorium (21%) and another small proportion with acute onset of behavioral and psychotic symptoms due to an organic etiology (10.1%) together forming a third of the group. This indicates the need for a detailed geropsychiatric assessment for organic causes in this subset of patients and effective treatment in the context of comorbid medical conditions.[9]
It is well recognized that coexisting multiple medical conditions and increased vulnerability to side effects of medication make the treatment and care for the elderly with medical, psychological, and psychiatric needs complicated. Lack of resources such as poor access to health-care facilities causing delay in presentation or detection of illness, minimal availability of consultation‒liaison services involving geriatric and psychiatric teams adds to the burden.
This warrants the need for adequate training of doctors in general medicine and in primary care regarding common psychiatric disorders and their presentation among the elderly presenting with acute onset of behavioral symptoms.
Strength of the study
- The study was done among a large sample of elderly individuals attending a general hospital psychiatric care facility
- Most of the information about the patient was documented in the chart as they were accompanied by reliable informants who could give relevant history about patient's symptoms.
Limitation
There was a huge dropout rate, and details on structural abnormality and other physical comorbidity and response and remission to treatment could not be commented upon.
This could be attributed to various reasons:
- Acute onset of illness due to organic etiology can revert to normal with complete resolution of symptoms when the underlying pathology is treated[19]
- Dropout could also be due to poor relief of symptoms, poor support system, need for traveling a long distance, side effects of medication, etc.[20]
- A belief in the supernatural cause of illness and the trust and easy availability of the same, which is reinforced by significant others, can also be a cause for dropout.[21]
| Conclusion | | |
Psychiatric presentations among the elderly are heterogeneous in nature ranging from acute confusional state to chronic psychosis. A third of patients with acute onset of symptoms had presented with features suggestive of an underlying organic cause for their psychiatric presentation. Those with chronic symptoms had multiple risk factors toward their suspected organic presentations. Assessment for an organic cause is mandatory in this age group. Utmost care should be taken to identify the organic cause before attempting to make a psychiatric diagnosis.
Acknowledgments
We would like to acknowledge the work of the team members, patients, and their caregivers.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Lodha P, Sousa AD. Geriatric mental health: The challenges for India. J Geriatr Ment Health 2018;5:16.  [Full text] |
| 2. | |
| 3. | Shaji KS, Jithu VP, Jyothi KS. Indian research on aging and dementia. Indian J Psychiatry 2010;52:S148-52. |
| 4. | Rao VA, Virudhagirinathan BS, Malathi R. Mental illness in patients aged fifty and over. Indian J Psychiatry 1972;14:319. |
| 5. | Bhogale GS, Sudarshan CY. Geriatric patients attending a general hospital psychiatry clinic. Indian J Psychiatry 1993;35:203-5. [ PUBMED] [Full text] |
| 6. | Prasad KM, Sreenivas KN, Ashok MV, Bagchi D. Psychogeriatric patients – A sociodemographic and clinical profile. Indian J Psychiatry 1996;38:178-81. [ PUBMED] [Full text] |
| 7. | Rao AV, Madhavan T. Gerospsychiatric morbidity survey in a semi-urban area near Madurai. Indian J Psychiatry 1982;24:258-67. [ PUBMED] [Full text] |
| 8. | Skoog I. Psychiatric disorders in the elderly. Can J Psychiatry 2011;56:387-97. |
| 9. | Mukku SS, Hara SH, Sivakumar PT, Muliyala KP, Reddi VS, Varghese M. Clinical profile of older adults presenting to psychiatric emergency services: A retrospective study from South India. J Geriatr Ment Health 2020;7:51. |
| 10. | O'Connor D. Psychotic symptoms in the elderly – Assessment and management. Aust Fam Physician 2006;35:106-8. |
| 11. | Wass S, Webster PJ, Nair BR. Delirium in the elderly: A review. Oman Med J 2008;23:150-7. |
| 12. | McKee J, Brahm N. Medical mimics: Differential diagnostic considerations for psychiatric symptoms. Ment Health Clin 2016;6:289-96. |
| 13. | |
| 14. | Targum SD. Treating psychotic symptoms in elderly patients. Prim Care Companion J Clin Psychiatry 2001;3:156-63. |
| 15. | Nebhinani N, Pareek V, Grover S. Late-life psychosis: An overview. J Geriatr Ment Health 2014;1. |
| 16. | Urbina Torija JR, Flores Mayor JM, García Salazar MP, Torres Buisán L, Torrubias Fernández RM. Depressive symptoms in the elderly. Prevalence and associated factors. Gac Sanit 2007;21:37-42. |
| 17. | Kiyoshige E, Kabayama M, Gondo Y, Masui Y, Inagaki H, Ogawa M, et al. Age group differences in association between IADL decline and depressive symptoms in community-dwelling elderly. BMC Geriatr 2019;19:309. |
| 18. | Ghosh AB. Psychiatry in India: Need to focus on geriatric psychiatry. Indian J Psychiatry 2006;48:4-9. [ PUBMED] [Full text] |
| 19. | Fellner KD, Reddon JR. Organic disorders. In: Thomas JC, Hersen M, editors. Handbook of Clinical Psychology Competencies. New York, NY: Springer; 2010. p. 1009-38. Available from: https://doi.org/10.1007/978-0-387-09757-2_36. [Last accessed on 2020 Oct 20]. |
| 20. | Grover S, Mehra A, Chakrabarti S, Avasthi A. Dropout rates and reasons for dropout from treatment among elderly patients with depression. J Geriatr Ment Health 2018;5:121. [Full text] |
| 21. | |
[Table 1], [Table 2], [Table 3], [Table 4]
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