Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0134Liaison with Medical andSurgical TeamsSheila A. MannClacton and District Hospital, Clacton-on-Sea, UKIn one of the early textbooks of geriatric medicine, Agate 1 wrote,‘‘As a sign of acute physical illness in old age, mental change ismore significant than a rise in temperature or pulse rate . . .’’. Notonly is delirium (acute organic brain syndrome) more frequentlyfound in old age than in earlier life, but the incidence of dementiarises sharply and affective disorders, particularly depression,remain common. Thus, someone presenting with medical orsurgical problems may well have coincidental, as well as causal orresultant, psychiatric symptoms. It is hard, therefore, forphysicians and surgeons to ignore the psychiatric problems oftheir patients.PREVALENCE OF PSYCHIATRIC DISORDER INNON-PSYCHIATRIC INPATIENTSA number of investigators have surveyed psychiatric disorderpresent in patients in non-psychiatric beds. Lipowski 2 estimatedthat psychiatric disorder or distress of significant degree waspresent in 30% of the patients he studied. Bergmann andEastham 3 published a series of 100 elderly patients admitted toan acute medical unit in the UK, whom they screened forpsychiatric disorder. They found that 7% had a diagnosis ofdementia, 16% delirium and 19% functional illness. Mezey andKellett 4 summarized a series of UK studies and found prevalenceof 5–51%.Nowhere are such numbers of patients referred for a psychiatricopinion. Other studies have investigated consultation rates.CONSULTATION RATESWallen 5 and her co-workers looked at consultation rates in shorttermgeneral hospitals in the USA, using a national sample of 327hospitals. This was retrospective and adequate information wasnot recorded in 25% of the hospitals. Patients admittedspecifically for a psychiatric illness were excluded. Less than 1%of those admitted were referred for psychiatric opinion. Thehighest rates were in hospitals attached to medical schools, thosein urban areas and those in the north-eastern USA. Notsurprisingly, these characteristics were highly correlated witheach other.Wallen and co-workers found that, in general, female patientsand younger patients were more likely to be referred. Thosereferred were sicker, i.e. had been given more ‘‘medical’’diagnoses, and had more complex problems. They thereforetended to use more resources. Ethnic origin was not asignificant variable, but payment system was. Patients onMedicaid (government financed medical care for low-incomepersons) were more likely to be referred than those admittedunder private insurance schemes.In this, as in many earlier studies, all ages were consideredtogether; in subsequent work, consultation rates for elderlypatients were compared with those for younger patients. Forinstance, Popkin et al. 6 compared a series of 266 psychiatricconsultations to patients aged 60+ with consultations to ayounger group. They found that the consultation rate forpatients under 60 was 2.85% and for those aged 60+ 1.99%, ahighly significant difference. In no specialty service did the ratefor those aged 60+ exceed that for younger patients. Thediagnoses given by psychiatrists differed between older andyounger patient groups: 46% of the older group were diagnosedas having organic mental disorder compared with 14% of theyounger inpatients. The psychiatrists also recommended morepsychotropic medication for the older patients, which could beexplained by the high percentage of organic diagnoses, andmore diagnostic tests, which could not. The psychiatristsassessing the elderly patients were not described as specialistsin geriatric psychiatry.In the UK, consultation rates were also studied. At Guy’sHospital, Anstee 7 looked at the pattern of referrals in 1968–1969—10 years after Fleminger and Mallett 8 had done so. Hefound that the referral rate had doubled from 0.7% to 1.4%. Ofthe 254 patients referred, 49 were elderly; 35 had been referredfrom medical and 13 from surgical wards. Also at Guy’s Hospital,Poynton 9 compared referrals from August 1982 to November1983, when there was no specialist psychogeriatric consultationservice, with those from December 1983 to January 1985, whensuch a service had been introduced. The rate of referral rose from0.64% to 1.40%, there being a greater rise in male referrals(0.34% to 0.96%) than in females (0.97% to 1.17%). In bothperiods, depression was the commonest single reason for referral.Anderson 10 reported a similar rise in referral rate following thesetting up of a specialist consultation service in Liverpool. Therate rose from 0.7% to 1.96%; proportionately more referralswere for depression in the second period (p. 142).WHY SUCH LOW REFERRAL RATES?Goldberg 11 suggests that medical and surgical patients are referredfor psychiatric opinion either because some cue alerts their doctorPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd