[Medically unexplained or not? Be aware of a somatic cause of Medically Unexplained Symptoms]. / Onverklaard of toch niet?

In 2 cases of men aged 26 and 55 respectively we illustrate the complexity of MUS patients since in both cases a somatic diagnosis was missed. The first patient presented with an inability to walk and persistent pain. Because of his symptoms he lost his job, had depressive moods and used alcohol and cannabis. His physical complaints were considered as a functional neurological disorder. Examination however revealed an avascular necrosis of the femoral head on both sides. After surgical treatment he is now slowly recovering. The second patient had developed sexual and bladder dysfunction 10 years ago. More recently he developed problems walking, speaking and swallowing. No neurological explanation had been found and the urologist prescribed self-catheterisation 6 times daily. Examination showed signs of multiple system atrophy. Patient was referred to a specialized neurologist who confirmed this diagnosis and now he can better accept his burden.

Frailty, multimorbidity and functional status as predictors for health outcomes of acute psychiatric hospitalisation in older adults.

Objectives: Frailty, multimorbidity and functional decline predict adverse health outcomes in community dwelling older people and older patients in general hospitals. This study investigates whether these characteristics separately are independent predictors of health outcomes of acute psychiatric hospitalization.Methods: Observational study in a prospectively sampled cohort of older patients, consecutively admitted to a psychiatric hospital. On admission we assessed frailty (Frailty Index and walking speed); multimorbidity (Cumulative Index Rating Scale Geriatrics (CIRS-G)) and functional status (Barthel Index). We used the Clinical Global Impressions of Improvement scale (CGI-I) as the psychiatric outcome measure, and dichotomized discharge destination as overall outcome measure: favourable (able to return home or previous care level) or adverse (death, or move to higher level of residential care).Results: We included 120 patients, 74.6 years (±7.8). 52.5% of the patients was frail (FI ≥0.25). The mean level of the CIRS-G was 13.5 (5.4). Mean CGI-I at discharge was 2.8 (± 1.0), indicating moderate improvement in the psychiatric outcome. Neither FI, CIRS-G, nor Barthel scores were, independent of age, sex and diagnosis, associated with the CGI-I. FI was predictive for adverse discharge destination (OR 1.91, 95%CI 1.09-3.37 per 0.1), as were higher CIRS-G (OR 1.19 95%CI 1.06-1.34, per point) and lower walking speed (OR 1.35 95%CI 1.06-1.72 per 0.1 m/s).Conclusions: Half of our patients were frail and had a high level of multimorbidity. The FI, walking speed and multimorbidity did not predict improvement of psychiatric symptoms at discharge, but independently helped to predict adverse discharge destination.

Health-Related Quality of Life in Older Persons with Medically Unexplained Symptoms.

OBJECTIVE: Research on health-related quality of life (HRQoL) in older persons with medically unexplained symptoms (MUS) is scarce, and, in contrast with younger patients, interactions with chronic somatic diseases are more complex. DESIGN: In the current study we compared HRQoL between older persons with MUS and older persons with medically explained symptoms (MES). Our study sample consisted of 118 older MUS-patients and 154 older MES-patients. SETTING/MEASUREMENTS: The diagnosis of MUS was ascertained by the general practitioner and confirmed by a geriatrician within a multidisciplinary diagnostic assessment. Additional characteristics, including the HRQoL (Short Form-36), were assessed during a home visit. MES-patients received two home visits to assess all measures. Multiple linear regression analyses, adjusted for age, sex, education, cognitive functioning, and psychiatric diagnoses, were performed to assess the relationship between group (MUS/MES) and HRQoL. Analyses were repeated with additional adjustments for somatization and hypochondriacal cognitions. RESULTS: Older patients with MUS had a significantly lower level of HRQoL compared with older patients with MES. Even after adjustments, the presence of MUS was still associated with both a lower physical and mental HRQoL. These associations disappeared, however, after additional adjustments for somatization and hypochondriacal cognitions. Within the subgroup of MUS-patients, higher levels of hypochondriac anxiety and of somatization were significantly associated with both lower physical and mental HRQoL. CONCLUSIONS: Associations between HRQoL and late-life MUS disappear when corrected for somatization and hypochondriacal cognitions, which is in line with the DSM-5 classification of somatic symptom disorder. Appropriate psychological treatment seems needed to improve HRQoL in older MUS-patients.

How does ageing affect the impact of medically unexplained symptoms and medically explained symptoms on health-related quality of life?

BACKGROUND: Physical symptoms significantly impair health-related quality of life (HRQoL), but age effects and differential effects of medically unexplained symptoms (MUS) and medically explained symptoms (MES) have hardly been examined. Our objective was to determine the effect of age on the impact of MUS and MES on HRQoL. METHODS: In a population-based cohort (n = 946, aged 28-75 years), MUS and MES were measured using the Composite International Diagnostic Interview and HRQoL using the EuroQol-5 dimensions (EQ-5D). Using multiple linear regression, we regressed MUS, MES and their interaction with age on HRQoL, adjusted for socio-demographic variables and the presence of depressive and anxiety disorders. In case of significant interaction terms, age-stratified results will be presented. RESULTS: In the whole study population, the association between MUS and HRQoL was stronger (ß = -0.35; p < 0.001) than between MES and HRQoL (ß = -0.26; p < 0.001). Adjusted for depressive and anxiety disorders, differences between these associations decline (MUS: ß = -0.28, p < 0.001; MES: ß = -0.25, p < 0.001). Age significantly interacted with number of MUS in explaining variance in HRQoL but not with the number of MES. The impact of MUS on HRQoL is much larger in people aged below 65 years (ß = -0.39, p < 0.001) versus those aged 65 years and over (ß = -0.21, p = 0.002). In the older group, the association between MUS and HRQoL lost significance when adjusted for depressive and anxiety disorders (ß = -0.12 p = 0.062). CONCLUSION: Our results show that age affects the association between MUS and HRQoL, which suggest that older persons cope better with MUS than younger persons.

Physical functioning in older persons with somatoform disorders: a pilot study.

OBJECTIVES: The primary objective of this study was to systematically examine the physical functioning of older persons with somatoform disorders, as this has never been carried out before. Second, we wanted to test our hypothesis that higher somatic disease burden in patients with somatoform disorders is associated with a higher level of somatisation. DESIGN AND SETTING: Observational study of patients referred for medically unexplained symptoms (MUS) to our outpatient mental health center for older adults. The patients were offered a standardized, multidisciplinary diagnostic procedure, including a comprehensive geriatric assessment. Inter-rater reliability between two geriatricians assessing the contribution of somatic pathology to the main somatic symptom was assessed. PARTICIPANTS: A total of 37 patients referred for MUS (mean age 75 ± 6 years). MEASUREMENTS: Timed up and go test (TUG) and hand grip strength were used as measures for frailty; the Cumulative Index Rating Scale for Geriatrics (CIRS-G) sum score and severity index measured the burden of cumulative somatic morbidity. The Groningen Activity Rating Scale (GARS) measured functional status. The Whitely Index was used as measure for somatisation. RESULTS: Patients' main symptom could be completely explained by a somatic disease in 3/37 (8%) patients (kappa between geriatricians = 0.72). A total of 32 patients met the criterion for a Somatoform Disorder according to DSM-IV-TR criteria, but somatic comorbidity partially explained the main symptom in 15/32 patients. These patients were older (P = .049), had more somatic comorbidity (P = .049), a slower gait speed (TUG, P = .035), a lower hand grip strength (P = .050), and a lower functional status (P = .30) compared with the 17 patients without any explanation for their main somatic symptom. In contrast to our hypothesis, a higher level of somatisation was associated with less somatic disease burden. CONCLUSION: Geriatric assessment has an important added value in older patients referred with medically unexplained symptoms because in half of these patients, symptoms can be partially or fully explicable following careful assessment of comorbidity and frailty.

The temporal relation between pain and depression: results from the longitudinal aging study Amsterdam.

OBJECTIVE: Pain and depression are both common in old age, but their (long-term) temporal relationship remains unknown. This study is designed to determine whether pain predicts the onset of depression and vice versa. METHODS: This is a prospective, population-based cohort study with 12-year follow-up and 3-year intervals in the Netherlands (Longitudinal Aging Study Amsterdam). At baseline, participants were aged 55 to 85 years (n = 2028). Main measurements outcomes were incident depression defined as crossing the cutoff of 16 and showing a relevant change (≥ 5 points) on the Center for Epidemiological Studies-Depression Scale among nondepressed participants and incident pain defined as a score of 2 or higher on the pain scale of the 5-item Nottingham Health Profile in pain-free participants. Multiple imputations were adopted to estimate missing values. RESULTS: In nondepressed participants (n = 1769), a higher level of pain was predictive of incident depression in multiple extended Cox regression analyses (hazard rate [HR] = 1.13 [95% confidence interval {CI}: 1.05-1.22], p = .001), which all remained significant after correction for sociodemographic characteristics, life-style characteristics, functional limitations, and chronic diseases (HR = 1.09 [95% CI = 1.01-1.18], p = .035). In the pain-free participants (n = 1420), depressive symptoms at baseline predicted incident pain (HR = 1.02 [95% CI: 1.01-1.04], p = .006). This depression measure did not independently predicted the onset of pain in the fully adjusted models. CONCLUSIONS: As pain precedes the onset of depression, strategies to prevent depression in chronic pain patients are warranted. In contrast, no effects of depression on the development of subsequent pain were found when adjusting for covariates.

Medically unexplained physical symptoms in elderly people: a pilot study of psychiatric geriatric characteristics.

OBJECTIVE: To examine the somatic complaints, functional impairment, and psychiatric comorbidity in elderly patients with medically unexplained symptoms (MUSs). METHOD: A consecutive case series of 37 patients referred for MUS to a multidisciplinary, outpatient clinic at a secondary care mental health center in the Netherlands. All patients underwent a standardized examination by a geriatrician, psychiatrist, and psychologist. RESULTS: For three patients, a somatic explanation was found, and in two, their symptoms spontaneously resolved before a diagnosis could be made. Of the remaining 32 patients with MUS, depressive disorders were present in 18 (56%), anxiety disorders in 10 (31%), and substance use disorders in 6 patients (19%). Compared with nondepressed patients with MUS, depressed patients had more severe somatic symptoms, more psychological symptoms, and more functional impairment. CONCLUSIONS: As the authors found a high comorbidity with other psychiatric disorders in elderly patients with MUSs, a systematic psychiatric examination should be part of their multidisciplinary assessment.