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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 49-54

Psychiatric morbidity among elderly presenting to emergency medical department: A study from tertiary hospital in North India


1 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication27-Jun-2018

Correspondence Address:
Sandeep Grover
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_28_17

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  Abstract 


Background: Geriatric population is on a steady rise since the past decade especially in densely populated countries like India. Elderly form a significant proportion of patients presenting to the medical emergency department and they warrant more attention in terms of mental health conditions as they are more predisposed to conditions such as delirium and cognitive impairment. Aim of this Study: This study aimed to evaluate the prevalence of psychiatric morbidity including substance use disorders among elderly (age ≥60 years) presenting to emergency medical outpatient services. Methodology: A total of 300 patients aged 60 years and above attending the medical emergency department of tertiary care hospital were approached, out of which, 232 participated. All the patients were assessed by Confusion Assessment Method, Modified Mini Screen and Alcohol, Smoking, and Substance Involvement Screening Test. Those found positive on any of the screening instrument were further evaluated on International Classification of Diseases-10 criteria, by a semi-structured interview to confirm the psychiatric diagnosis. Results: At least, one psychiatric diagnosis, i.e., either axis-I psychiatric disorder or substance dependence disorder was seen in 62% of cases. Nearly, half of the patients (47.4%) fulfilled at least one axis-I psychiatric diagnosis other than the substance dependence disorder at the time of assessment, with delirium being the most common, seen in about one-third (34.1%) of the participants. Other psychiatric diagnoses in the study sample included dementia (9.5%), depressive disorders (8.2%), adjustment disorder (3%), and anxiety (not otherwise specified) disorder in 3.4% of participants. About one-third (31%) of the participants had tobacco dependence, currently, using and one-fifth (19.8%) of patients had alcohol dependence syndrome currently using. Higher prevalence of delirium and dementia was noted among patients who were aged ≥70 years. Conclusion: The present study shows that elderly patients presenting to medical emergency department have a high prevalence of psychiatry morbidity. Accordingly, there is a need to reorganize psychiatric services and training to improve the identification and management of mental disorders among elderly patients presenting to emergency.

Keywords: Delirium, dementia, depression, geriatric, psychiatric morbidity, substance use


How to cite this article:
Grover S, Natarajan V, Rani S, Reddy SC, Bhalla A, Avasthi A. Psychiatric morbidity among elderly presenting to emergency medical department: A study from tertiary hospital in North India. J Geriatr Ment Health 2018;5:49-54

How to cite this URL:
Grover S, Natarajan V, Rani S, Reddy SC, Bhalla A, Avasthi A. Psychiatric morbidity among elderly presenting to emergency medical department: A study from tertiary hospital in North India. J Geriatr Ment Health [serial online] 2018 [cited 2018 Dec 18];5:49-54. Available from: http://www.jgmh.org/text.asp?2018/5/1/49/235370




  Introduction Top


Over the past 70 years, the life expectancy of an average Indian has improved significantly and this has resulted in rise in elderly population. Compared to 5.5% of the total population in the year 1951, elderly population (aged ≥60 years) increased to 8.5% in the year 2011, and it is projected that by 2050, elderly will form 19% of the total Indian.[1],[2],[3],[4] Available data from community-based studies also suggest that compared to nonelderly patients, psychiatric morbidity is higher among elderly patients.[5],[6],[7],[8],[9],[10],[11],[12] All this suggest that there is a need to reorient the health services to cater to the needs of ever-increasing elderly population. Among the various health-care facilities, emergency services form an integral and important facilities, as these provide care to patients presenting with critical illnesses. Elderly form a significant proportion of patients seeking medical help in emergency setup. Elderly patients also have higher rates of emergency department visits compared to young adults, and they account for 12%–24% of all emergency department visits.[13],[14],[15]

However, data are limited from developing countries in terms of psychiatric morbidity among patients attending the emergency departments. Studies which have reported information about psychiatric aspects of patients coming to emergency have mainly reported data of rate of referrals to psychiatry consultation liaison services and the referral rates have varied from 1.5% to 5.4% with 0.9–2.8 referrals received per day.[16],[17],[18],[19],[20],[21],[22] Occasional retrospective study has reported the prevalence of psychiatry morbidity among patients attending the emergency department to be 2.9%. A recent study which evaluated different consultation liaison models in the emergency setup reported that shifting from consultation model to a hybrid model led to increase in the proportion of patients referred to psychiatry services. This study also showed that about 10% of the psychiatric referrals from emergency department pertain to elderly patients.[23]

Studies from psychiatry consultation-liaison setup also suggest that compared to other age groups, elderly form a major proportion of patients, for whom psychiatry consultation is sought.[24] Studies in consultation-liaison setup, in general, suggest that when all the medically ill patients in a setup are screened, psychiatric morbidity is much higher, compared to relying only on referral method.[17],[19],[20],[25],[26],[27],[28],[29],[30],[31] A study from India, which screened all the elderly patients admitted to various medical wards for psychiatric diagnosis reported psychiatric morbidity in nearly half (49%) of cases as per the International Classification of Diseases-10 (ICD-10) criteria, with depression being the most common psychiatric diagnosis, seen in one-fourth (25.94%) of cases, followed by diagnosis of adjustment disorder (11%), anxiety disorders (4.54%), dementias (3.6%), delirium (3%), bipolar disorder (0.8%), and substance us related disorders (0.4%).[25]

Few studies have reported about psychiatric morbidity among elderly patients coming to the emergency, and these suggest that the most common psychiatric diagnosis in these patients is delirium. A systematic review which included data from 12 studies reported delirium in 7%–20% of patients at the time of admission to the emergency department.[32] Some of the studies which have focused on cognitive impairment have estimated the same to be present in 26% and 40% of patients.[33],[34],[35] Studies which have looked at the substance use disorders among elderly patients presenting to emergency have reported the prevalence of alcohol misuse to be 14%.[36] However, data are not available in terms of all the possible psychiatric morbidities among the same cohort attending the emergency department. Due to this exact burden of psychiatric morbidity among patients attending the emergency department is not known. Accordingly, the present study aimed to evaluate the prevalence of psychiatric morbidity including substance use disorders among elderly (age ≥60 years) presenting to emergency medical outpatient services.


  Methodology Top


This cross-sectional prospective study was carried out in the Emergency Medical Outpatient Department (EMOPD) of a tertiary care teaching hospital in North India. For this study, patients aged 60 years or more attending the EMOPD services for 2-month period were screened for the presence of psychiatric disorders.

To be included in the study, the patients were required to be aged 60 years or more. Patients who refused to provide informed consent or were comatose were not included in the study. Informed consent was obtained from either the patients themselves or their family caregivers. Informed consent was obtained from the family caregivers in case-patient was considered incapable of understanding the purpose of the study, due to cognitive disturbances and altered sensorium.

Each patient meeting the selection criteria were initially screened using modified MINI-Screen (MMS), confusion assessment method (CAM), and Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). MINI-Screen was used to screen for the presence of any psychiatric disorder, ASSIST was used to screen problems or risky use of various substances and CAM was used for screening patients for delirium.

MMS comprises of a set of 22 items derived from a structured psychiatric interview. It is designed to identify people who should have a mental health assessment. It covers three categories, i.e., mood disorders, anxiety disorders, and psychotic disorders. Some questions ask about problems over a specified time period (the period varies from 2 weeks to 2 years), while others ask questions about lifetime occurrences of problems. It is usually completed in about 15 min, and a score of ≥ 6 is considered as an indicator of the presence of a psychiatric disorder.[37]

The ASSIST was developed for the World Health Organization (WHO) by an international group of substance abuse researchers to screen for problem or risky use of tobacco, alcohol, cannabis, cocaine, amphetamine-type stimulants, sedatives, hallucinogens, inhalants, opioids, and “other drugs” that do not fall into the previous 9 categories. The ASSIST is an interviewer-administered questionnaire and screens for all levels of problem or risky substance use. It has good reliability for all substance use (alpha = 0.65–0.86).[38]

CAM was developed to screen for delirium. It is a 4-item instrument, which includes: (1) an acute change in mental status or fluctuating changes in mental status, (2) inattention and either (3) disorganized thinking, or (4) an altered level of consciousness. CAM takes only 1–2 min. CAM has been validated against the reference standard ratings of psychiatrists working with elderly based on Diagnostic and Statistical Manual for Mental Disorders Third Edition Revised (DSM-IIIR) criteria. It has a minimum of 93% sensitivity and 89% specificity for detecting delirium in comparison to full DSM-IV assessment. It has also been shown to have sensitivities from 94% to 100%, specificities from 90% to 95%, positive predictive accuracy of 91%–94%, negative predictive accuracy of 90%–100%, and interrater reliability ranging from 81 to 1.00.[39]

Those patients who screened positive on any of these scales were further evaluated as per the ICD-10 criteria by using a semistructured interview for making the psychiatric diagnosis.

Any patient, rated as unresponsive at the first assessment, was reassessed on the next day and every subsequent day throughout the stay, and effort was made to include these patients when they become cooperative and responsive.

The information for the study was collected from the patient, caregivers, treating physician, and nurses to reach the conclusion.

Data were analyzed using SPSS-version 14 (SPSS for Windows, Version 14.0, SPSS Inc., Chicago). The data were analyzed in the form of frequencies, percentage, mean, and standard deviation (SD). Comparisons were done by using Chi-square test and t-test.

Demographic and clinical profiles

For this study, during the study, 300 patients were approached by convenient sampling, of whom consent was given by 232 patients/caregivers. The sociodemographic profile of the study sample is given in [Table 1]. The mean age of the study sample was 68.18 (SD-7.1) with a range of 60–96 years. The mean duration of formal school education was 6.16 (SD-4.9) years. More than half of the participants were aged 60–69 years. Males formed about two-third of the study sample and females formed about one-third of the study sample. Majority of the participants were from urban locality, nonnuclear families and were currently married. There were nearly equal proportions of patients who were employed and who were not on paid employment at the time of assessment. When the sociodemographic profiles of patients who participated in the study and who refused to participate were compared, no significant difference was noted in any of the sociodemographic variables.
Table 1: Sociodemographic profile of the study sample

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More than three-fifth (62%) of the patients were found to have at least one psychiatric diagnosis, i.e., either axis-I psychiatric disorder or substance dependence disorder [Table 2]. Nearly, half of the patients (47.4%) fulfilled at least one axis-I psychiatric diagnosis other than the substance dependence disorder at the time of assessment, with delirium being the most common, seen in about one-third (34.1%) of the study sample. In few cases, delirium was superimposed on dementia or depressive disorder. One-tenth of the study sample (9.5%) had diagnosis of dementia. In terms of other diagnosis, depressive disorders (mild/moderate/severe depressive episode or dysthymia) were seen in 8.2% of cases. Adjustment disorder and anxiety (not otherwise specified) disorder were seen in a small proportion of cases.
Table 2: Psychiatric morbidity as per the various scales

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In terms of substance dependence disorder, about one-third (31%) of the participants had tobacco dependence, currently using and one-fifth (19.8%) of patients had alcohol dependence syndrome currently using. In addition, small proportion of patients had a history of harmful use of tobacco and alcohol. In terms of use, a small proportion of patients reported the use of tobacco, alcohol, cannabis, opioids, and benzodiazepines in their lifetime, but this use never amounted to harmful use or dependence.

Factors associated with psychiatric morbidity

There was no significant difference in the prevalence of psychiatric morbidity among patients of either gender. Substance dependence was significantly higher among males (51.3% vs. 5%; χ2 = 49.20; P < 0.001). There was no significant difference between the 2 genders in terms of the prevalence of delirium, dementia, or other axis-I disorder. Any psychiatric morbidity (i.e., axis-I diagnosis and/or substance dependence) was significantly higher among males (67.8% vs. 51.25%; χ2 = 6.07; P = 0.014*).

Compared to patients aged 60–69 years, those aged ≥70 years, had significantly higher prevalence of delirium (41.4% vs. 28.6%; χ2 = 4.16; P = 0.041), dementia (19.2% vs. 2.25%; χ2 = 18.96; P < 0.001), any axis-I psychiatric morbidity (56.6% vs. 40.6%; χ2 = 4.16; P = 0.016) and any psychiatric diagnosis including substance dependence disorder (72.7% vs. 54.1%; χ2 = 4.16; P = 0.041).

Compared to those currently married, patients who were single had higher prevalence of delirium (46.7% vs. 31%; χ2 = 3.95; P = 0.047), dementia (22.2% vs. 6.4%; χ2 = 10.55; P = 0.001), axis-I psychiatry diagnosis (64.4% vs. 43.3%; χ2 = 6.49; P = 0.011), and any psychiatric diagnosis including substance dependence disorder (75.5% vs. 58.8%; χ2 = 4.31; P = 0.038).

There was no significant difference between those on paid employment and those not on paid employment in terms of psychiatric morbidity. Similarly, family type did not have any influence on the prevalence of psychiatric morbidity.

There was no significant difference between those from urban and rural locality in terms of psychiatric morbidity, except for the fact that delirium was more prevalent among people from rural locality (37.7% vs. 20.4%; χ2 = 5.14; P = 0.023).


  Discussion Top


This study aimed to evaluate the psychiatry morbidity among elderly patients presenting to the emergency department of a tertiary care hospital. The present study involved screening of elderly patients presenting to the emergency department using standard screening instruments and those who screened positive were further evaluated for the presence of psychiatry morbidity as per the ICD-10 criteria. The present study shows that more than three-fifth of the elderly patients presenting to emergency have psychiatric disorders requiring psychiatry care and nearly half of the patients have at least one psychiatric diagnosis other than the substance use disorders, and about one-third of the elderly patients presenting to emergency have substance dependence.

There is lack of data on comprehensive psychiatric morbidity among elderly patients presenting to emergency as earlier studies have focused on only specific disorders such as delirium, cognitive disturbances, and substance use.[32],[33],[34],[35],[36] When the findings of the present study are compared with these studies, certain similarities are noted. In the present study, delirium was the most common psychiatric disorder, noted in about one-third of the study sample. Earlier studies which have evaluated the prevalence of delirium among elderly patients presenting to emergency have reported prevalence rates to vary from 7% to 20%.[32]

When we compare the findings of the present study with these studies, it can be said that the prevalence of delirium is higher in the present study. However, the higher prevalence can be understood in the light of the fact that previous studies which have evaluated the prevalence of delirium in consultation-liaison setup, intensive care unit setup suggest that compared to patients in the adult age group, the prevalence of delirium is significantly higher among elderly patients.[24],[40],[41],[42] Accordingly, it can be said that prevalence of delirium is much higher among the elderly patients irrespective of the treatment setting. Delirium has been shown to be associated with various negative consequences such as longer hospital stay, high mortality, need for institutional care, higher health-care cost, higher rates of mortality, subjective distress to the patient and the caregivers.[43],[44],[45],[46] Data also suggest that physicians often do not document the cognitive impairment and refer the patients presenting to emergency for the same to a psychiatrist.[33],[34],[35],[47],[48] Considering the high prevalence of delirium in elderly patients presenting to emergency and its negative consequences, it can be said that it is very important to screen all elderly patients presenting to emergency for delirium.

In the present study, about one-tenth of the patients had dementia. Earlier studies which have focused on estimation of the prevalence of cognitive impairment in patients presenting to emergency, have reported that 26% and 40% of patients have cognitive impairment.[33],[34],[35] Findings of the present study, at the first glance may appear to be lower. However, it is important to note that these studies have included the diagnosis of delirium in the broad category of cognitive impairment and have reported cognitive impairments without delirium, which not necessarily implies dementia.

Previous studies which have evaluated the factors associated with delirium and cognitive impairment in the emergency department have reported these to be associated with age and severity of illness.[33],[34],[35] In the present study too higher age was associated with higher prevalence of delirium and dementia. Accordingly, it can be said in case, if the resources are limited than mental health services should be directed toward old-old patients rather than young-old patients.

Studies which have reported about psychiatry referrals from emergency suggest that only 1.5%–5.4% of patients are referred to the psychiatrist.[16],[17],[18],[19],[20],[21],[22] Further, occasional study suggests that shifting from the consultation model to the hybrid model leads to increase in the psychiatry referral rates.[23] Findings of the present study, further emphasizes the fact that mental health professionals should not rely just on referrals to evaluate elderly patients presenting to emergency, but must attempt to screen all the elderly patients for psychiatric morbidity.

In the present study, about one-third of the patients had a diagnosis of a substance use disorder, currently using the substance. Among the various substances, tobacco was the most common, followed by alcohol. Studies which have looked at the substance use disorders among elderly patients presenting to emergency have reported the prevalence of alcohol misuse to be 14%.[36] Findings of the present study support the existing literature. Studies which have evaluated the prevalence of tobacco use pattern among patients presenting to emergency, have reported prevalence to current smokers to vary from 33% to 36%.[49],[50],[51] Finding of 31% patients having current tobacco dependence is comparable to these studies from other parts of the world and suggest that there is a need to address this issue.

Among the other axis-I psychiatric diagnosis, in the present study, depressive disorders (mild/moderate/severe depressive episode or dysthymia) were seen in 8.2% of cases, 3% of patients had adjustment disorder, and 3.4% of patients had anxiety (not otherwise specified). As there is lack of data on the prevalence of these disorders in the emergency department, it is not possible to compare the findings of the present study directly with the existing literature. Studies which have reported the prevalence of depressive disorders among psychiatry referrals from the emergency department have estimated the same to be about 8% and that of anxiety disorders to be about 5%.[23] Findings of the present study are comparable with the reported rates in these studies.


  Conclusion Top


It can be said that psychiatric morbidity is highly prevalent among elderly patients presenting to the emergency. However, on many occasions, the psychiatric morbidity is not picked up by the attending physicians.[52] This is understandable, considering the fact that major attention in the emergency setup is on attending to the life-threatening conditions. Considering these facts, findings of the present study have important implications. First, rather than just relying on the consultation model of consultation-liaison psychiatry, for emergency setup a true liaison model with screening of all elderly patients must be considered. Second, considering the fact that about one-third of the patients have delirium and substance dependence disorder, the physicians working in the emergency set-up need to be sensitized about these facts. The trainees, who are the first-line physicians attending these patients must be trained to screen all patients for delirium and evaluate substance use disorders in these patients. Improving the skills of the trainees in internal medicine can improve the referral rates to the psychiatry services. Third, these findings also suggest that the trainees in psychiatry must be adequately exposed to the emergency department during their training so that they are able to recognise the psychiatric disorders in the emergency setup and manage the same.

The present study has certain limitations. The study sample was recruited by convenient sampling among the patients attending the emergency medical department during the daytime. The study was done in the emergency medical department, and the findings cannot be generalized to surgical or trauma emergency or pediatric emergency department. The present study also involved evaluation of psychiatric morbidity among elderly patients only. Hence, the findings cannot be generalized to the adult patients attending the emergency medical department. The present study did not evaluate the impact of psychiatric morbidity on the outcome of the patients. Similarly, the present study did not evaluate the association of psychiatric morbidity with severity and type of physical morbidity. Future studies must evaluate these aspects to improve our understanding about elderly patients presenting to the emergency department.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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