University of Groningen Factors associated with the persistence of medically unexplained symptoms in later life van Driel-de Jong, Dorine

(1)

University of Groningen

Factors associated with the persistence of medically unexplained symptoms in later life

van Driel-de Jong, Dorine

DOI:

10.33612/diss.136429372

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2020

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van Driel-de Jong, D. (2020). Factors associated with the persistence of medically unexplained symptoms

in later life. University of Groningen. https://doi.org/10.33612/diss.136429372

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(2)

Assessment of somatization and medically

unexplained symptoms in later life

van Driel, T. J. W., Hilderink,

_{P. H., Hanssen, D. J. C.,}

de Boer, P., Rosmalen, J. G. M., & Oude Voshaar, R. C. (2018)

Assessment, 25, 3, 374-393

(3)

Abstract

The assessment of medically unexplained symptoms and ‘somatic-symptom disorders’ in older

adults is challenging due to somatic multimorbidity, which threatens the validity of somatization

questionnaires. In a systematic review study, the Patient Health Questionnaire (PHQ-15)

and the somatization subscale of the Symptom Checklist 90-item version (SCL-90 SOM) are

measure physical symptoms which in younger persons often refer to unexplained symptoms,

in older persons these symptoms may originate from somatic diseases. Using empirical data,

we show that PHQ-15 and SCL-90 SOM among older patients correlate with proxies of

somatization as with somatic disease burden. Updating the previous systematic review,

revealed six additional questionnaires. Cross-validation studies are needed as none of 46

identified scales met the criteria of suitability for an older population. Nonetheless, specific

recommendations can be made for studying older persons, namely the SCL-90 SOM and

PHQ-15 for population-based studies, the Freiburg Complaint list and somatization subscale

of the Brief Symptom Inventory 53-item version for studies in primary care, and finally the

Schedule for Evaluating Persistent Symptoms and Somatic Symptom Experiences Questionnaire

for monitoring treatment studies.

(4)

Introduction

Somatization is the tendency to experience and communicate somatic distress in response

to psychosocial stress and to seek medical help for it

1

_{. The severity of somatization, however,}

is difficult to measure. In younger people, it is often assessed by a physical symptom count,

especially by counting symptoms that often remain medically unexplained in clinical practice,

like fatigue or dizziness. Medically unexplained physical symptoms (MUS) might thus be the

result of a process of somatization and are a core criterion of somatoform disorders in the

Diagnostic and Statistical manual of Mental disorders, version IV, text revised (DSM-IV-TR).

With the introduction of the DSM-5, the DSM-IV-TR section of somatoform disorders has

been replaced by the new section of somatic symptom and related disorders

2

_{. The most}

important change was the focus on so-called positive criteria for establishing a diagnosis, i.e.

the prominence of a physical symptom associated with significant distress and impairment.

The major diagnosis in this section, somatic symptom disorder, emphasizes diagnosis made

on the basis of positive symptoms and signs, i.e. distressing somatic symptoms plus abnormal

thoughts, feelings, and behaviors in response to these symptoms. This contrasts with somatoform

disorders in the DSM-IV-TR that poses the absence of a medical explanation for the somatic

symptoms a key feature. Although somatic symptom disorders might be more useful for

diagnosis in both primary and specialized (somatic) health care, the criteria for these disorders

do not necessarily apply to all patients burdened by MUS. MUS, irrespective of the DSM

classification rules, have consistently been associated with a lower quality of life, psychological

distress, and increased medical consumption

3,4

A systematic review has identified 40 scales to assess self-report somatic symptoms

5

_{. The}

Patient Health Questionnaire-15 (PHQ-15) and the somatization subscale of the Symptom

Checklist 90-item version (SCL-90 SOM) were considered the best options to be used

in large-scale population based studies, based on several criteria among which type of

symptoms, time frame, response scale, psychometric characteristics and patient burden

5

_.

Since older persons often suffer from physical symptoms due to one or more chronic somatic

diseases (multimorbidity)

6

_{, somatic symptom questionnaires may easily overestimate the}

severity of somatization in an older sample. Nonetheless, accumulating data emerge that

somatization, MUS, and somatoform disorders are highly relevant in older persons, posing

a significant burden on health-related quality of life, increased level of health care usage and

potentially iatrogenic damage

3

_{. Nonetheless, actual prevalence rates are somewhat lower}

among persons aged above 65 years compared to younger persons

7

_{. In a systematic review}

of six cohort studies including both younger and older people, prevalence rates for DSM-IV

defined somatoform disorders ranged from 1.5% through 13.0% (median 5.4%) among people

aged 65 years and older, and from 10.7% through 26.8% (median 15.3%) in younger people

7

_.

Whether these lower prevalence rates in later life are simply artefacts due to falsely attributing

physical symptoms to (comorbid) chronic somatic diseases, or reflect real differences due to better

coping with chronic illnesses and/or less disease benefits in later life have to be established.

(5)

The main objective of the present paper is to explore which assessment instrument is optimal

for assessing somatization in older adults. In our research program on MUS in later life, we

have applied both the PHQ-15 as well as the SCL-90 SOM among older patients with MUS

and medically explained symptoms (MES). Therefore, we first test empirically how the PHQ-15

and the SCL-90 SOM relate to other measures of somatization, namely the presence of a

somatoform disorder determined by a semi-structured psychiatric interview

8

_{, and health}

anxiety measured with the Whitley Index

9

_{, as well as to medically explained somatic disease}

burden. Since these results were rather disappointing, we decided to update and extend the

previously conducted systematic review of Zijlema

5

_{to examine which of the assessments of}

somatic symptoms might be most relevant for assessing somatization in older persons.

Method

Empirical tests of the PHQ-15 and SCL-90 SOM

For the empirical tests, we used our dataset of a pilot study on MUS in older patients as well as a

dataset on a larger case-control study. Both samples have been described elsewhere in detail

3,10

but can be summarized as follows.

The pilot study was a consecutive case-series of 37 older patients referred to our outpatient

mental health clinic for a diagnostic procedure and treatment for MUS

10

_{. In this pilot study,}

we administered the SCL-90 as well as the Patient Health Questionnaire-15

11

_{, whereby the}

item on menstrual cycle was omitted (being not relevant in later life). The case-control study,

acronym OPUS study (Older Persons with medically Unexplained Symptoms study) included

118 older persons suffering from MUS (cases) and 154 older patients suffering from MES for

which they frequently attended their general practitioner

3

_{. In this study, the Brief Symptom}

Inventory 53-items

12

_{, an abbreviated version of the SCL-90 with similar psychometric properties,}

has been administered as a measure for psychopathological distress

13

_.

In both studies, the same two indicators of somatization were administered. First, the Mini

International Neuropsychiatric Interview (MINI)

8

_{, a semi-structured psychiatric interview}

administered by an old age psychiatrist, to diagnose psychiatric morbidity according to

DSM-IV-TR criteria. Therefore, the presence of a somatoform disorder is the first indicator

of somatization. Secondly, health anxiety was in both studies assessed with the Whitely Index

(WI)

9

_{and used as the second indicator of somatization in the present study. The somatic}

disease burden was assessed differently in both studies. In the pilot study, the Cumulative

Illness Rating Scale for Geriatrics (CIRS-G)

14

_{was administered by a geriatrician after a full}

geriatric assessment. In the OPUS study, the self-report version of the Charlson Index was

applied

15,16

_{. As a measure of construct validity, Pearson’ s correlations coefficient of both the SCL-90/}

BSI-53 SOM subscale as well as the PHQ-15 sum score were calculated with both proxies of

somatization (WI, somatoform disorder) expecting a high correlation, and with both measures

of somatic disease burden (CIRS-G, Charlson Index) expecting a low correlation. The Pearson’s

r correlation can be interpreted as a no or minimal (0.00 < r < 0.30), low (0.30 < r < 0.50),

moderate (0.50 < r < 0.70), high (0.70 < r < 0.90) or extremely high (0.90 < r < 1.00) correlation.

(6)

Update and extension of the systematic review by Zijlema

5

The systematic review by Zijlema

5

_{has been conducted to systematically search and judge all}

self-report questionnaires for common somatic symptoms, generally used to assess somatic

symptom burden and/or level of somatization. After an update of the literature search, in this

paper all questionnaires will be evaluated on their suitability for use in an older population

(see ‘instrument evaluation’ below).

Search strategy

Since the literature search of the previous systematic review was conducted until October

2012, we repeated exactly the same literature search in the databases Medline, EMBASE, and

PsycINFO from October 2012 until 1 October 2016 to select additional questionnaires. The

search term contained a combination of somatoform disorder or synonyms and questionnaire

or synonyms and symptoms. For Medline, the following search term was used: (“somatoform

disorders/classification” [MeSH Major Topic] OR “somatoform disorders/diagnosis” [MeSH

Major Topic] OR “somatoform disorders/epidemiology” [MeSH Major Topic] OR “functional

somatic symptoms” [Title/Abstract]) AND (questionnaire [Title/Abstract] OR screen* [Title/

Abstract] OR “self report” [Title/Abstract] OR “index” [Title/Abstract]) AND symptoms.

For EMBASE and PsycINFO, comparable search terms were used. The search was conducted

without language restrictions.

Screening and selection procedures

The first two authors independently screened the retrieved articles. The articles were included if

they described the development, evaluation, or review of self-report somatization questionnaires.

The questionnaires selected had to include symptoms from more than one symptom cluster;

not just symptoms of the gastrointestinal tract or cardiopulmonary system. When the symptom

questionnaire was a subscale derived from a larger questionnaire, the symptom subscale had

to have been separately validated and used. There were no criteria for the target population

of the questionnaire. Discrepancies between the two researchers were resolved by consensus.

Full articles were then obtained for all potentially eligible studies. Based on the full text, articles

that still fulfilled the inclusion criteria were included in the review.

Data extraction

Name of questionnaire, number of items, domains assessed, answering scale, time frame and

target population, were extracted for every questionnaire. Table 2 shows an overview of the

questionnaires before and after October 2012.

Instrument evaluation

The evaluation on the suitability of the identified questionnaires for an older population

included 1) the number of items not applicable in older adults (e.g. items on menstrual cycle)

and the number of somatic symptoms included that in older persons usually reflect somatic

disease burden, 2) the presence of standardized scores (normative data) for older persons,

and 3) finally whether or not the instrument has been applied in an older sample previously.

(7)

Although each somatic symptom or sign can be due to somatic disease, some symptoms can

be assumed typically for old age and/or common geriatric syndromes. In order to assess the

most common geriatric syndromes we used the Brief Assessment Tool (BAT), a geriatric

assessment tool specifically developed for General Practitioners

119

_{. The BAT aims to identify}

the following geriatric syndromes: cognitive impairment, mood disorder, gait and balance

impairment/falls, visual impairment, hearing impairment, urinary incontinence, malnutrition/

loss of weight, and osteoporosis. The first and fourth author, being a clinical psychologist and

old age psychiatrist, respectively, assessed which items of each somatization scale corresponded

with a geriatric symptom or syndrome as defined by the Brief Assessment Tool. In case of

disagreement, the last author, an old age psychiatrist, made a decision.

For the third criterion, systematic literature searches were additionally conducted in Medline,

EMBASE, and PsycINFO for each questionnaire separately. This was done by search strings

combining the name of the questionnaire with the words indicative for a research sample

consisting of older persons defined as an age above 60 years, e.g. “older”, “aged” or “elderly”

and in Medline also the MeSH-terms “aged” and “aged, 80 years and over”.

Results

Empirical tests of the PHQ-15 and SCL-90 SOM

Pearson correlation coefficients of the PHQ-15 sum score and the SCL-90 SOM with the

proxies for somatization as well as somatic disease burden are presented in table 1. Collectively,

these results showed that the presence of a somatoform disorder, as proxy for somatization,

was neither significantly associated with the sum score of the SCL-90/BSI-53 SOM, nor with

the PHQ-15 sum score. Furthermore, the second proxy for somatization, health anxiety, was

moderately associated with both measures of somatization (SCL-90/BSI-53 SOM and PHQ-15)

as well as moderately associated with the measures of somatic disease burden (CIRS-G and

Charlson Index).

Update and extension of the systematic review

The literature research of Zijlema

5

_{until October 2012 had resulted in 40 symptom question-}

naires. In contrast to Zijlema

5

_{, however, we considered the two abbreviated versions of the}

somatization scale of the SCL-90 (SCL-90 SOM), i.e. the BSI-18 SOM (6 items) and the BSI-53

SOM (7 items), as separate questionnaires. Therefore, 41 symptom questionnaires were

available based on Zijlema

5

_{. The extended literature search from October 2012 until 1 October}

2016, retrieved a total of 631 hits (Medline, n= 187, EMBASE, n=157, PsycINFO, n=287),

including 75 duplicates. We excluded 436 studies identified on tittle and abstract. After full

text screening we excluded 96 studies because they were not about somatization (n=34), were

not a self-report questionnaire (n=3), or were about questionnaires already included (n=77).

A total of 6 articles were additionally included in the review, describing 5 new questionnaires.

This resulted in a final number of 46 questionnaires for the present review (table 2).

(8)

Table 1

Construct validity of the Patient Health Questionnaire (PHQ) sum score and Symptom Checklist (SCL-90) / Brief Symptom Inventory (BSI-53) somatization scale as measures of somatization

Number of SCL-90 / PHQ-15

patients BSI-53 SOM

Proxies for somatization:

Whitely Index (health anxiety)

• MUS patients (pilot study) n=33 r=0.45, p=.009 r=0.38, p=.019

• MUS patients OPUS study n=89 r=0.43, p<.001 n.a.

• MES patients OPUS study n=151 r=0.49, p<.001 n.a.

Presence of a somatoform disorder

• MUS patients (pilot study) n=33 r=0.12, p=.506 r=0.12, p=.495

• MUS patients OPUS study n=94 r=0.16, p=.133 n.a.

Somatic disease burden:

• CIRS-G* (Pilot study) n=29 r=0.33, p=.083 r=0.28, p=.125

• Charlson Index (OPUS study) MUS patients n=87 r=0.44, p<.001 n.a.

• Charlson Index (OPUS study) MES patients n=152 r=0.34, p<.001 n.a. * CIRS-G total score calculated without psychiatric disease

Note. Abbreviations: PHQ-15, Patient Health Questionnaire 15-item version; SCL-90 SOM, Somatisation subscale

of the Symptom Checklist 90-item version; BSI-53 SOM, somatisation subscale of the Brief Symptom Inventory 53-item version; MUS, Medically Unexplained physical Symptoms; MES= Medically Explained Symptoms; OPUS= Older Persons with medically Unexplained Symptoms (acronym for a study); CIRS-G, Cumulative Illness Rating Scale for Geriatrics.

Evaluation of questionnaires

Table 3 shows all questionnaires identified. While 8 out of 46 (17%) questionnaires have normative

data for older persons, only the Brief Symptom Screen (BSS) was specifically validated in an older

sample. The additional questionnaire-specific searches in Pubmed, EMBASE and PsycINFO

revealed that only 20 out of 46 (43%) questionnaires were ever used in an older population.

The identification of items overlapping with common geriatric syndromes revealed that

all items identified by rater 1 (first author) were also identified by rater 2 (fourth author).

Discrepancies could be clustered in three groups. The first group of items included fatigue,

tiredness, loss of energy and feeling weak, the second group of items loss of appetite and

weight loss, and finally the third group (an individual item) was insomnia (sleep onset). The

third rater (last author) concluded that these symptoms could all be classified as somatic

symptoms of depression and therefore overlap with depression. Taken this decision into

account, the median proportion of items overlapping with common geriatric syndromes, plus

the number of items not applicable for old age, was 25%. The variability between questionnaire

was large, with a range from 0% for the Schedule for Evaluating Persistent Symptoms (SEPS)

through as high as 83% for the NNS. For the PHQ-15, SCL-90 SOM, and BSI-53 SOM, these

percentages were 33%, 25%, and 14%, respectively.

(9)

Table 2 Overview of the 46 somatization questionnair

es and their pr

operties (abbr

eviations and r

efer

ences in the footnote).

Questionnair e items Domain assessed Scale Time frame Target population 4 DSQ 16 Somatization

5 categories: no to very often or constantly

Past week Primary car e patients ASR 11 Somatic complaints

3 categories: not true to very true or often

Past six Adults true months BDS Checklist 25 BDS; patter n of symptoms rather

5 categories not at all to a lot

Past month

Patients

than a simple symptom count (based on SCAN interview)

BSI-18 SOM

6

Somatization

5 categories: not at all to a lot

Past week

Adolescents and adults

BSI-53 SOM

a

7

Somatization

5 categories: not at all to a lot

Past week

Adolescents and adults

BSI (Bradfor

d

44

Somatic symptoms associated

3 categories: symptoms absent to pr

esent

Past month

Patients

Somatic

with anxiety and depr

ession

on mor

e than 15 days during the last

Inventory) month BSS a 10 Somatic complaints Yes/no Past 4 Community dwelling weeks older adults Cambodian 23

Somatic symptoms and cultural

5 categories: not at all to extr

emely

Past month

Traumatized Cambodian

SSI

syndr

omes: with a 12- item

Refugees

somatic subscale and an 11-item syndr

ome subscale

C-PSC

12

Psychosomatic symptoms

Fr

equency: 5 categories: not a pr

oblem to Childr en every day

. Severity ; 5 categories: not a

pr oblem to very , very bad CSI 36

Intensity of somatic complaints

4 categories: not at all to a whole lot

Past two Childr en weeks FBL 78 Somatic complaints Fr

equency: 5 categories: almost every day

(10)

to almost never . Intensity; 5 categories;

very str ongly to insensitive GBB-24 24 Physical complaints

5 categories never to sever

e

Patients and general population

GSL

37

Psychosomatic str

ess symptoms

4 categories never to constantly

Health-49

7

Somatoform complaints

5 categories: not at all to very much

ICD -10 14 Somatization disor der Yes/no Past two patients symptom list years Kellner’ s SQ 17 Somatic symptoms Yes/no or true/false Past week

Patients and general population

to day Malaise 8 Psychiatric morbidity Yes/no No specific Inventory timeframe, focus on recent state Manu 5 Somatization disor der Yes/no MSPQ 13

Heightened somatic and

4 categories; not at all to extr

emely , could Past week Specially for chr onic backache autonomic awar eness

not have been worse

patients

NSS

6

Non specific symptoms for

Pr esent/not pr esent At least Patients nonpsychotic morbidity thr ee month Othmer& 7 Somatization disor der Yes/no Lifetime General population DeSouza PHQ 14 Somatic symptoms

Items 1-11, 7 categories: not at all to all of the

Staf

f members of a hospital

time; items 12-13, 7 categories; 0 times to 7 +

times; items 14, 7 categories; 1 day to 7+ days

PHQ 15

15

Pr

obable somatoform disor

ders

3 categories; not at all to bother

ed a lot Past month Primary car e patients PILL 54

Common physical symptoms

5 categories; never or almost never to mor

e

Lifetime

and sensations

than once every week

PSC-17

17

Psychosomatic symptoms

Fr

equency 5 categories; daily to not a pr

oblem;

Past week

Primary car

e patients

intensity; 5 categories; extr

emely bothersome

to not a pr

(11)

PSC-51

51

Somatization

4 categories; not at all to most of the time

Past week Primary car e patients PSS 35 Psychosomatic symptoms Fr

equency; 4 categories; never to almost every

Past thr

ee

Childr

en and adolescents

day; disturbance; 3 categories none to str

ong

months

PVPS

14

Somatization

3 categories; never occurr

ed to fr equently Past month People of V ietnamese origin occurr ed RPSQ 26

Somatization in irritable bowel

4 categories; not at all to most of the time.

Past month IBS patients syndr ome patients R-SOMS-2 29 Somatization Yes/no Past two Primary car e patients years QUISS-P a 41

Severity of somatoform disor

ders

5 categories;mixed categories

usually

In- and outpatients form

psychiatric and psychosomatic

hospitals

SCI

22

Various physical symptoms

Fr

equency

, 5 categories: never to daily;

Past month General population intensity , 5 categories: no pr oblems to extr emely tr oublesome SCL-11 11

Common somatic complaints

5 categories: almost never to quite often

Past month Childr en SCL-90 SOM 12 Somatization

5 categories: not at all to extr

emely Psychiatric Past week medical out-patients/general population SEPS a Sectie 2:

Medically unexplained symptoms

4 mixed categories lifetime Medical patients 9 items SHC 29

Subjective health complaints

Severity

, 4 categories: not at all to serious;

Past month

General population

duration: number of days

SOMS-7

53

Intervention ef

fects in somatoform

5 categories: not at all to very sever

e Past week Primary car e patients disor ders SSEQ a 15 Psychological pr ocesses in 6 categories fr om never to always usually Psychosomatic inpatients somatoform disor der SSI 35 Somatization Yes/no Lifetime Primary car e patients SSS-8 a 8 Pr

esence and severity of somatic

5 categories fr

om not at all to very much

Past 7 days

General population

(12)

SQ-48

7

Somatization

5 categories; never to very often

Past week

Clinical and non-clinical

population

Swartz

11

Symptoms that potentially pr

edict

Yes/no

Lifetime

General population

a diagnosis of DID/DSM-3 somatization disor

der

Syrian

19

Psychosomatic symptoms; diagnose

4 categories; never to always

Past few Symptom individuals, follow up tr eatment, weeks checklist evaluate tr eatment intervention WHO-SSD 12 Somatoform disor der Yes/no Past six General population month YSR 9 Somatic complaints

3 categories; not true to very true or often

Past six 11-18 year olds true month Von Zerssen 24 Somatic complaints

4 categories; not at all to str

ong

Note.

Abbr

eviations and r

efer

ences of the 46 questionnair

es: 4 DSQ: Four

-Dimensional Symptom questionnair

e

17

, ASR: Adult Self r

eport

18, BDS

Checklist: Bodily Distr

ess Syndr ome Checklist 19; BSI: Bradfor d Somatic Inventory 20, 21

; BSI-18 SOM: Brief Symptom Inventory-18 item v

er si on s om at iz at io n sc al e

22; BSI-53 SOM: Brief Symptom Inventory 53-item version somatization scale 12; BSS: Brief

Symptom

Scr

een

23; Cambodian SSI: Cambodian Somatic Symptom and Syndr

ome Inventory 24 ; C-PSC: Childr en’ s Psychosomatic Symptom Checklist 25; CSI: Childr en’ s Somatization Inventory 26; FBL: Fr eiburger Beschwer den Liste (Fr

eiburg Complaint List)

27; GBB-24: Giessener Beschwer

debogen (Giessen Subjective Complaints List)

28

; GSL: Goldberg Symptom List

29

; Health-49: Hamburger

Module zur Erfassung allgemeiner Aspekte psychosocialer Gesundheit fur die therpeutische Praxis (Hamburger modules to measur

e general aspects of psychosocial health for therapeutic

praxis) 30 ; ICD-10 Symptom List: Inter national Classification of Diseases-10 Symptom List 31,32 ; Kellner’ s SQ: Kellner’ s Symptom Questionnair e 33; Malaise Inventory 34 ; Manu 35 ; MSPQ: Modified Somatic Per ception Questionnair e 36 ; NSS: Nonspecific Symptom Scr een 37

; PHQ: Physical Health Questionnair

e

38, 39

; PHQ-15: Patient Health Questionnair

e

40,41

; PILL: Pennebaker Inventory of

Limbic Languidness

42

; PSC-17: Psychosomatic Symptom Checklist

43; PSC-51: Physical Symptom Checklist

44

; PSS: Upitnika Psihosomatskih Simptoma (Psychosomatic Symptoms questionnair

e)

45; PVPS: Phan V

ietnamese Psychiatric Scale

46; Quiss: the Quantification Inventory for Somatoform Syndr

omes

47

; RPSQ; Recent Physical Symptoms Questionnair

e 48 ; R-SOMS-2: Revised Scr eening for Somatoform Symptoms 49 ; SCI: Somatic Symptom Checklist Instrument 50 ; SCL: Somatic Complaint List 51 ; SCL-90 SOM: Symptom Checklist 90-item version somatization scale

13; SEPS: Schedule for Evaluating Persistent Symptoms

52 ; S SE Q : S o m at ic

Symptoms Experiences Questionnair

e

53

; SSS-8: the Somatic Symptom Scale-8

54

; SHC: Subjective Health

Complaints Inventory

55

; SOMS-7; Scr

eening for Somatoform Symptoms

56, 57

; SSC: Syrian Symptom Checklist

58; SSI: Somatic Symptom Index 59; SQ-48: Symptom Questionnair

e 48

60; WHO-SSD:

W

orld Health Organization –Scr

eener for Somatoform Disor

ders

61; YSR: Y

outh Self Report

62; V

on Zerssen

63.

aLists derived form literatur

e sear

ch after October 2012 ar

(13)

Table 3 The 46 somatic scr

eening lists and their pr

operties for the old aged

Questionnair

e

4 DSQ ASR BDS Checklist BSI-18 SOM

Pr

oportion

(n/N, %) of items overlapping with commonly geriatric syndr

omes

or

items that ar

e

not applicable for the old aged 5/16 (31%) 2/11 (18%) 6/25 (24%) 1/6 (17%)

Overlapping items between symptom questionnair

e and geriatric syndr

ome

Items not adjusted for the old age

a

-

Dizziness or light-headed (gait and balance)

-

Painful muscles (osteopor

osis)

-

Neck pain (osteopor

osis)

-

Back pain (osteopor

osis)

-

Blurr

ed vision (visual impairment)

-

I feel dizzy or light headed (gait and balance)

-

Pr

oblems with eyes (visual impairment)

-

Pain in arms or legs (osteopor

osis)

-

Muscular aches or pain (osteopor

osis)

-

Pain in the joints (osteopor

osis)

-

Excessive fatigue (malnutrition/mood disor

der)

-

Impairment of memory (cognitive impairment)

-

Dizziness (gait and balance)

-

Faintness or dizziness (gait and balance)

Normative data for older persons - - -

-Older adults included in the study

. - Koor evaar et al (2016) 64 : n= 200;

age 15-85, shoulder patients

- - Budtz-Lilly et al (2015)

19

: n=1356;

age 18-95, primary car

e patients

-

Budtz-Lilly et al (2015)

19

: n=2480;

age 26-71, primary car

e patients

-

Asner

-Self et al (2006)

65: n=100,

age 18-80, American volunteers

-

Tanji et al (2008)

66

: n=96; age 57-75,

patients with morbus Parkinson and their spouses

-

Petkus et al (2009)

67: n=136,

(14)

BSI-53 SOM BSI (Bradfor

d

Somatic inventory)

-

Have you had pain or tension in your neck and shoulder? (osteopor

osis)

-

Has ther

e been darkness or mist in fr

ont

of your eyes (visual impairment)

-

Have you felt aches or pains all over the body? (osteopor

osis)

-

Have you been feeling tir

ed, even if you

ar

e not working? (mood disor

der)

1/7 (14%) 6/44 (14%)

- Hale et al (1984)

72: n=498, mean

age 74, comparison between

adults and older adults.

- Hale et al (1992)

73: n=220; age >65,

comparison between four age cohorts

- Chester et al (2001)

74: n= 498,

age >65, raw scor

e means for

independent living older adults.

-- W ether ell et al (2010) 68: n=54, age 70-78,

patients with generalized anxiety disor

der

-

Campo et al (2014)

69: n=40,

age 58-93, pr

ostate cancer survivors.

-

Cohen et al (2014)

70

: n=321,

aged > 60, cancer patients.

-

Russell et al (2015)

71: n=152,

mean age 64, color

ectal cancer survivors

-

Ritsner et al (2000)

75: n= 996,

age 18-87, Jewish immigrants.

-

Pietrzak et al (2005)

76: n=48, age 60+,

patients with pathological gambling.

-

Pietrzak, (2006)

77

: (n= 21; age 60+,

patients with pathological gambling

-

Zweig et al (2007)

78: n=129; age 63-87,

community dwelling elderly

-

Klein et al (2011)

79: n=737, age 55+,

patient with brain injury

. - V an Noor den et al (2012) 80 : n= 892; MUS patients r eferr ed to geriatric outpatient psychiatry . - V ideler et al ( 2014) 81: n=3 1, age 60 -78,

patients with personality disor

der . - Per eira et al (2014) 82: n=185, aged 50+, HIV - infected patients. - Dijk et al (2015) 83: n=153, age 60+,

patients with MUS.

-

Anderson et al (2015)

84: n= 1000, age

60+,

patients with alcohol use disor

der . - Saeed, 2001 85 (n=664, age 18-80).

Rurl community in Pakistan.

-

Kahn, 2011

86

(N=200; age 18-80).

(15)

-

Pain in your legs (osteopor

osis)

-

Dizzy (gait and balance)

-

Feeling tir

ed (mood disor

der)

-

Balance dizziness (gait and balance)

-

Daily pain (osteopor

osis)

-

Poor appetite (mood disor

der)

-

Anhedonia (mood disor

der)

-

Standing up and feeling dizzy (gait and balance)

-

Blurr

-

Tinnitus (hearing impairment)

- Neck sor eness (osteopor osis) - Sor

e arms and legs (osteopor

osis)

-

der)

-

Back ashes (osteopor

osis)

-

Sad (mood disor

der)

-

Feel stif

f all over (osteopor

osis)

-

Feel dizzy (gait and balance)

-

Eye pain when r

eading (visual impairment)

-

Blindness (visual impairment)

-

Fainting (gait and balance)

-

Memory loss (cognitive impairment)

-

Blurr

-

Deafness (hearing impairment

-

Pain in arms and legs (osteopor

osis)

-

Pain in joints (osteopor

osis) - Backpain (osteopor osis) - Tr

ouble walking (gait and balance

-

Low energy (malnutrition, mood disor

der)

-

Ermuden Sie schnell (mood disor

der)

-

Haben Sie appetitmangel (mood disor

der

,

malnutrition)

BSS- Cambodian SSI C-PSC CSI FBL

5/10 (50%) 7/23 (30%) 5/12 (42%) 11/36 (31%) 9/78 (12%)

-

Ritchie et al (2013)

23: n=1000,

age 65+, community dwelling older adults in Alabama.

- - - - Fahr

enberg (1995)

27

: n= 2070;

age >70, general population

- - Friborg et al (2007)

87

: n= 61.320,

age 45-74, patients with orapharyngael

car

cinomas.

(16)

-- Schachegefuhl (malnutrition) - Mattigkeit (malnutrition) - Nackenschmerzen (osteopor osis) - Schulterschmerzen (osteopor osis) - Kr euzschmerzen (osteopor osis) -

Schmerzenin den Armen (osteopor

osis)

-

Schmerzen in den Beinen (osteopor

osis) - Gliederschmerzen (osteopor osis) - Ruckenschmerzen (osteopor osis) - Nackenschmerzen (osteopor osis) -

Mudigkeit (mood disor

der)

-

Lower back pain (osteopor

osis)

-

Fatigue (mood disor

der)

-

Angry feelings (mood disor

der)

-

Sleep onset insomnia (mood disor

der)

-

W

orrisome thoughts (mood disor

der)

-

Early mor

ning awakenings (mood disor

der)

-

Loss of appetite (mood disor

der)

-

Neck, shoulder muscle aches (osteopor

osis)

-

Periods of depr

ession (mood disor

der)

-

Sadness (mood disor

der)

-

Backpain (osteopor

osis)

-

Thoughts that you would rather be dead (mood disor

der)

GBB-24 GSL Health-49

4/24 (17%) 9/37 (24%) 2/7 (29%)

Gunzelmann et al (1996)

88: n= 764,

age >60, general population -

--

89: n=593;

age >60, general population

-

90: n=630,

age 61-95, GBB24 used as construct validity instrument with Nottingham Health Pr

ofile.

-

Stankuniene et al (2012)

91: n=624,

age 60-84, general population

-

Csof

f et al (2010)

92

: n= 593,

age 60-84, immigrants Germany

- V aldear enas et al (2012) 93 : n= 562;

age 60-84, non demented community- dwelling elderly

- Stankunas et al (2013) 94: n=4467. age 60 -84, asoc iati on between somati c

complaints and educational level.

- - Rabung et al (2009)

30: n= 1548, clinical

samples; n= 5630 primary car

e

(17)

-

Lack of inter

est (mood disor

der)

-

Pain in muscles or joints (osteopor

osis)

-

Feeling of hopelessness (mood disor

der)

-

Pain in the limbs, extr

emities or joints

(osteopor

osis)

-

der)

-

Muscle pain (osteopor

osis)

-

Back ache (osteopor

osis) - Tir ed (mood disor der) - Depr

essed (mood disor

der)

-

Early waking (mood disor

der)

-

Poor appetite (mood/ malnutrition)

-

Blurr

-

Blurr

-

Muscles in neck aching (osteopor

osis)

-

Forgetfulness (cognitive impairment)

-

Giddiness/dizziness (gait and balance)

-

General aches and pain (osteopor

osis)

-

Fatigability (malnutrition)

-

Feeling weak (malnutrition)

-

Amnesia (cognitive impairment)

-

Painful extr

emities (osteopor

osis)

ICD-10 Symptom list Kellner’

s SQ

Malaise inventory Manu MSPQ NSS Othmer& DeSouza

1/14 (7%) 2/17 (12%) 5/8 (63%) 1/5 (20%) 3/13 (23%) 5/6 (83%) 4/7 (58%)

- - -

--

Schafer et al (2012)

95: n=50786,

age >70, primary car

e - Callixte et al (2015) 96 : n=187, age >60, neur ological patients. - Ricceri,et al (2014) 97: n=70; all ages, psoriasis patients - Quine et al (1987) 98: n=226;

age unknown, but car

ers for elderly >65

(often elderly themselves)

- Grant et al (1990)

99: n=125;

age unknown, spouses caring of partner aging 65 or mor

e

- - Staerkle et al (2004)

100

: n=388,

age 18-87, Low back pain patients

-

Roh et al (2008)

101

: n=111,

age 45-83, Parkinson patients.

- Donaldson et al (2011)

102

: n=unknown,

age 55-75, patients with neck and low back pain.

- Havakeshian et al (2013)

103

: n= 159;

mean age 65, spinal surgery patients

(18)

--

-

Dysmenorrhea

-

Difficulty getting to sleep (mood disor

der)

-

W

oken up during the night (mood disor

der)

-

How often has your sleep been peaceful and disturbed (mood disor

der)

-

Back pain (osteopor

osis)

-

Pain in your arms, legs or joints (osteopor

osis)

-

Feeling tir

ed or having low energy

(mood disor

der/ malnutrition)

-

Menstrual cramps or other pr

oblems

with your periods

-

Ringing in ears (hearing impairment)

-

Backpains (osteopor

osis)

-

Stif

f joints (osteopor

osis)

-

Fatigue (malnutrition, mood disor

der) - Backaches (osteopor osis) - Depr

ession (mood disor

der) - General stif fness (osteopor osis) -

-

Feeling tir

ed or having low energy

(malnutrition/ mood disor

der)

-

Easily fatigued without exertion) (mood disor

der)

-

Forgetfulness (cognitive impairment)

-

Muscle aches or sor

eness osteopor osis) PHQ PHQ-15 PILL PSC-17 PSC-51 3/14 (21%) 5/15 (33%) 4/54 (7%) 5/17 (29%) 12/51 (24%) - - Nor din et al (2013) 104 : Swedish

population apart norms for age 70-79;

- - -- - Sloane et al (1994) 105 :.n=65; age >60, patients with chr onic dizziness - Sha et al (2005) 106 : n=3498, age >60, validity of symptoms in pr edicting

hospitalization and mortality

-

Montalban et al (2010)

107

: n=3362;

age 18-90, outpatient psychiatric patients.

- Jeong et al (2014) 108 : n= 2100, aged >60, r elationship somatic symptoms - depr ession - Qian et al (2014) 109 :.n= 1329,

age 37-71, general hospital.

-

Graham et al (1997)

110

: n=109; 52%

aged >65, informal car

ers for

dementia patients.

(19)

--

Deafness (hearing impairment)

-

Double vision or blurr

ed vision

(visual impairment)

-

der)

-

W

eight loss (malnutrition)

-

Joint pain (osteopor

osis)

-

Back pain (osteopor

osis)

-

Pain in the back (osteopor

osis)

-

Lack of energy (mood disor

der)

-

Pain in joints (osteopor

osis)

-

osis)

-

Loss of balance (gait and balance)

-

Double vision (visual impairment)

-

Blurr

-

Sudden loss of vision (visual impairment)

-

Sudden loss of hearing (hearing impairment)

-

Sudden loss of memory (cognitive impairment)

-

der/malnutrition)

-

Dizzy spells (gait and balance)

-

Tir

ed eyes, sor

e eyes or flashy lights

(visual impairment)

-

W

or

n out or low in energy

(mood disor

der/ malnutrition)

-

Painful joints (osteopor

osis)

-

Incr

easingly tir

ed day after day

(mood disor der) - Backpain (osteopor osis) -

Pain in arms or leggs (osteopor

osis)

-

Pain in the joints (osteopor

osis)

-

Loss of memory (cognitive impairment)

-

Disturbance in balance and coor

dination

(gait and balance)

-

PSS PVPS QUISS-P 12/35 (34%) 5/14 (36%) 9/41 (22%) - - -- - Phan et al (2014) 111 : n=180, age 16-75, primary car e - W edekind et al (2007) 47: n= 96, age 18-75,

In- and outpatients fr

om psychiatric

(20)

-

Tir

edness (mood disor

der)

-

der)

-

Backpain (osteopor

osis)

-

Muscles aches (osteopor

osis)

-

ders)

-

Constant tir

edness (mood disor

der)

-

osis)

-

Pain in the arms /legs (osteopor

osis)

-

Impair

ed coor

dination in balance

(gait and balance)

-

Excessive tir

edness (mood disor

der)

-

Pain in arms and legs (gait and balance)

-

der)

-

Dizzy (gait and balance)

-

Tir

ed (mood disor

der/malnutrition)

-

osis)

-

Pain in lower back (osteopor

osis)

-

Sor

eness of your muscle (osteopor

osis)

-

geen

-

Shoulder pain (osteopor

osis)

-

Neck pain (osteopor

osis)

-

Upper back pain (osteopor

osis)

-

Arm pain (osteopor

osis)

-

Low back pain (osteopor

osis)

-

Sadness/depr

ession (mood disor

der)

-

Tir

edness (mood disor

der)

-

RPSQ R-SOMS-2 SCI SCL-11 SCL-90 SOM SEPS SHC

5/26 (19%) 5/29 (17%) 3/22 (14%) 3/11 (27%) 3/12 (25%) 0/9 (0%) 8/29 (28%)

- - - Agbayewa (1990)

112

: n=44;

age 66-96, geriatric adult population.

- - Thygesen et al (2009)

114

: n-242,

age >75>, older adults, community dwelling and r

eceiving in home car e. - - - Hassel, (2007) 113 : (n=125; age 60+) the corr

elation between OHRQoL and

somatization older patients fr

om

primary geriatric medical hospital.

- - Lhiebaek et al (2002)

115

: n= 1240;

(21)

SOMS- SSEQ SSI SSS-8 SQ-48

-

Backpain (osteopor

osis)

-

osis)

-

Pain in the legs and arms (osteopor

osis)

-

der/malnutrition

-

mpair

ed coor

dination of balance

(gait and balance)

-

Painful menstruation

-

Irregular menstruation

-

Excessive menstrual bleeding

-

Frequent vomiting during pregnancy

- - Pain in the extr

emities (osteopor

osis)

-

Back pain (osteopor

osis)

-

osis)

-

Blurr

-

Fainting of loss of consciousness (gait and balance)

-

Painful menstruation

-

Irregular menstrual periods

-

Vomiting throughout pregnancy

-

Backpain, (osteopor

osis)

-

Pain in arms/legs or joints (osteopor

osis)

-

Feeling tir

ed (mood disor

der) or low energy

(malnutrition loss of weight)

-

I felt dizzy or lightheaded (gait and balance)

13/53 (25%) 0/15 (0%) 13/35 (37%) 4/8 (50%) 1/7 (14%) - - - - Gierk et al (2014) 54 : n= 190, age 14-91 (normgr oep >79). General population. -- Sack et al (2010) 116 : n=240; age 18-74,

outpatients of the department for psychosomatic medicine and psychotherapy in Germany

. - Kliem et al (2014) 117 : n=2434; age 14-84, general population. - - -

(22)

-Swartz Syrian Symptom checklist WHO-SSD YSR Von Zerssen

-

Pain in extr

emities (osteopor

osis)

-

I feel dizzy (gait and balance)

-

I suf

fer tir

edness (mood disor

der)

-

I feel fatigued (mood disor

der)

-

I feel exhausted (mood disor

der)

-

I feel lethargic (mood disor

der)

-

Back pain (osteopor

osis)

-

Feelings of muscles and aches (osteopor

osis)

-

Persistent fatigue after minor mental or physical ef

fort (mood disor

der)

-

Irregular menstrual periods

-

I feel dizzy (gait and balance)

-

I feel tir

ed (mood disor

der)

-

Aches or pain (osteopor

osis)

-

Pr

oblems with eyes (visual impairment)

-

Kr

euz oder Ruckenschmerzen (osteopor

osis)

-

Swindelgefuhl (gait and balance)

-

Nacken oder Schulterschmerzen (osteopor

osis) - Gewichtsafnehme (malnutrition) 2/11 (20%) 5/19 (26%) 6/12 (50%) 4/9 (44%) 4/24 (17%) - - - - -- Swartz et al (1986) 118 : n=900; age >60, general population. - - - -Note.

aitems in the symptom list who ar

e not applicable for the old age;.

bLists derived form literatur

e sear ch after October 2012 ar e bold. Note. Abbr eviations: 4 DSQ: Four -Dimensional Symptom questionnair

e; ASR: Adult Self r

eport; BDS

Checklist: Bodily Distr

ess

Syndr

ome Checklist; BSI: Bradfor

d Somatic Inventory; BSI-18

SOM: Brief Symptom Inventory-18 item version somatization scale; BSI-53 SOM: Brief Symptom Inventory 53-item version somatizat

ion scale;

BSS: Brief Symptom Scr

een;

Cambodian SSI:

Cambodian Somatic Symptom and Syndr

ome Inventory; C-PSC: Childr

en’

s Psychosomatic Symptom Checklist; CSI: Childr

en’ s Somatization Inventory; FBL: Fr eiburger Beschwer den Liste (Fr eiburg Complaint List); GBB-24: Giessener Beschwer debogen (Giessen Subjective Complaints List); GSL: Goldberg Symptom List; Health-49: Hamburger Module zur Erfassung allgemeiner A sp ek te

psychosocialer Gesundheit fur die therpeutische Praxis (Hamburger modules to measur

e general aspects of psychosocial health for therapeutic praxis); ICD-10 Symptom List: Inter

national Classification

of Diseases-10 Symptom List; Kellner’

s SQ: Kellner’

s Symptom Questionnair

e; MSPQ: Modified Somatic Per

ception Questionnair

e; NSS: Nonspecific Symptom Scr

een; PHQ: Physical Health

Questionnair e; PHQ-15: Patient Health Questionnair e; PILL: Pennebaker Inventory of Limbic Languidness; PSC-17: Psychosomatic Symptom Checklist; PSC-51: Physical Symptom Checklist; PSS:

Upitnika Psihosomatskih Simptoma (Psychosomatic Symptoms questionnair

e); PVPS: Phan V

ietnamese Psychiatric Scale;

Quiss: the Quantification Inventory for Somatoform Syndr

omes;

RPSQ; Recent Physical Symptoms Questionnair

e; R-SOMS-2: Revised Scr

eening for Somatoform Symptoms; SCI: Somatic Symptom Checklist Instrument; SCL: Somatic Complaint List; SCL-90

SOM: Symptom Checklist 90-item version somatization scale;

SEPS: Schedule for Evaluating Persistent Symptoms; SSEQ: Somatic Symptoms Experiences Questionnair

e; SSS-8: the

Somatic Symptom Scale-8;

SHC: Subjective Health Complaints Inventory; SOMS-7; Scr eening for Somatoform Symptoms; SSC: Syrian Symptom Checklist; SSI: Somatic Symptom Index; SQ-48: Symptom Questionnair e 48; WHO-SSD: W

orld Health Organization –Scr

eener for Somatoform Disor

ders; YSR: Y

(23)

Discussion

The PHQ-15 and the SCL-90/BSI-53 SOM both had low correlations with the severity of

health anxiety among MUS patients, while neither the PHQ-15 nor the SCL-90/BSI-53 SOM

correlated with the presence of a somatoform disorder according to DSM-IV-TR criteria.

These findings did not match with our expectations of a moderate to high correlation between

both symptom scales and both proxies of somatization. Even more important to note, the

PHQ-15 and the SCL-90/BSI-53 SOM were both correlated with measures of somatic disease

burden with an effect-size comparably to their association with health anxiety. Although the

findings with respect to the PHQ-15 need replication in a larger sample, collectively, these

findings indicate that both scales do not perform well as indices of somatization in older persons.

An update of the literature search conducted by Zijlema

5

_{resulted in five additional self-report}

somatic screenings lists, namely the Brief Symptom Screen (BSS)

23

_{, the Quantification Inventory}

for Somatoform Syndromes (Quiss)

47

_{, the Schedule for Evaluating Persistent Symptoms (SEPS)}

52

_,

the Somatic Symptoms Experiences Questionnaire (SSEQ)

53

_{, and the Somatic Symptom Scale-8}

(SSS-8)

54

_.

Less than half (20 out of 46, 43%) of these 46 scales have been administered in studies with

exclusively or a substantial number of older adults. Of these studies, the BSI-18 SOM

22

_{, the}

BSI-53 SOM

12

_{, the Giessener Beschwerdebogen (GBB-24)}

28

_{; the Modified Somatic Perception}

Questionnaire (MSPQ)

36

_{, and the Patient Health Questionnaire 15-item version (PHQ-15)}

11

have been applied in more than two studies (see table 3). As pointed out below, these

questionnaires, however, do not have the most optimal characteristics for an older population.

Of the 46 questionnaires, only the BSS has been validated for older adults

23

_{. Nonetheless,}

the aim of the BSS was to evaluate overall symptom load in older adult populations in order

to estimate illness burden and distress, so not necessarily somatization. Since especially

symptoms related to common chronic conditions are included, it may more or less result

in a symptom count relevant for the A-criterion of somatic symptom disorder in DSM-5

2

_.

As 50% of the items overlap with common geriatric syndromes, the BSS is not a good (severity)

indicator of possible MUS or somatization in later life.

For eight questionnaires (8 out of 46, 17%) normative data for older persons are available, i.e.

the BSI-53 SOM, BSS, Freiburg complaint List, GBB-24, PHQ-15, SCL-90 SOM, Subjective

Health Complaints Inventory, and the Somatic Symptom Scale-8 (SSS-8). Therefore, future

results based on any of these scales can be interpreted in the context of scores derived from

another geriatric population.

With respect to overlap with common geriatric syndromes, we cannot give a cut-off value

above which a specific list should be discouraged to use in geriatric population. The findings

of objective 1 suggests that even a low proportion of overlap may already be too much (i.e.

14%, 25% and 33% for respectively the BSI-53 SOM, SCL-90 SOM, and PHQ-15). Of the

eight scales with normative data of a geriatric population, only one scale, the FBL has less

than 14% of their items overlapping with symptoms of common geriatric syndromes. Since

all questionnaires that use symptom counts to measure the level of somatization, we advise to

(24)

only use these questionnaires in older population when adjustment for the common geriatric

syndromes is possible.

Our review identified two scales without any overlap with common geriatric syndromes, i.e. the

SEPS and the SSEQ. Both scales focus on subjective experiences related to somatic symptoms

instead of the symptoms themselves. Unfortunately, none of these scales have normative data

for older age groups.

Previously, the PHQ-15 and SCL-90 SOM have been identified as most suitable self-report

somatic symptom questionnaires to be used in large-scale studies, because they have been

extensively validated, are relatively short, easy to use and of little burden to participants

5

_{. Our}

findings, however, show that the PHQ-15 and the SCL-90 SOM considerably overlap with

common geriatric symptoms and probably overestimate the level of somatization in older

persons. Recently, somatic symptom count (based on the PHQ-15, added with 10 items on

specific neurological symptoms and 5 on mental state) hardly differentiated between patients

with (n=1144) and without (n=2637) medically unexplained symptoms referred to an outpatient

neurology clinic

120

_{. Therefore, these questionnaires should only be used when adjustment for}

medically explained symptoms or common geriatric syndromes is possible.

Some methodological comments, however, need to be made. First of all, many recommendations

have been given to increase validity and reliability when designing self-report questionnaires

for older adults. Examples of these recommendations include the avoidance of reverse-scored

items, a short questionnaire with preferably short, easy to understand items (to avoid fatigue

of the participant), a dichotomized response scale (e.g. yes/no), and short reference period

(time-window) to avoid recall bias

121-124

_{.To our knowledge, none of these recommendations}

have been empirically tested in order to show that adapting a questionnaire will indeed

increase the validity of reliability when applied in older samples. Moreover, many studies,

even among frail elderly, generally use several scales together without (reporting) any

problems e.g. Collard

125

_{and Hanssen}

3

_{. Also, in clinical practice, older patients often have}

difficulty in making a dichotomous, often black or white choice. And finally, a short reference

period seems less applicable for the often, chronic somatic symptoms related to somatization.

Nonetheless, although the scientific merits of these criteria have to be established, they may

be relevant when choosing a list for a specific study (e.g. as short as possible being a secondary

outcome measure). Therefore, these characteristics have been summarized in table 2.

Secondly, we focused on self-report questionnaires being most relevant to apply in research

studies, acknowledging limited resources being at odds with sample size needs. Moreover,

self-report questionnaires are also relevant in later life in order to get unbiased information

about the complaints by minimizing the influence of formal and informal caregivers, often

involved with older adults with physical complaints. On the other hand, older persons are

more inclined than their younger counterparts to give socially desirable answers

126

_.

Thirdly, the validity of all questionnaires can be questioned as no gold standard exists for

the measurement of explained and unexplained physical symptoms (especially not in later

life). As the agreement between geriatricians whether a physical symptom is explained, partly

(25)

explained or fully explained is quite high

127

_{, this could be considered as gold standard in}

future cross-validation studies in old-age samples.

To conclude, our review does not allow to give a simple advice which scale is most optimal

to administer in studies in old age. This implies that the field is served by more studies cross-

validating these questionnaires in an older population. Depending on the exact research question,

however, specific choices can be made. In case overestimation of somatization should be

excluded, the SEPS or SSEQ can be used (although both questionnaires are not validated in

an older sample yet). These questionnaires however do not simply count symptoms, but rely

on subjective experiences about physical symptoms. When symptom counts are needed as

indication for possible somatization, the FBL emerges as the most optimal questionnaire

when simply based on our criteria of the presence of normative data and a low percentage of

overlap with common geriatric syndromes. Nonetheless, to our knowledge this questionnaire

is only available in the German language and has as much as 78 items. For pragmatic reasons,

therefore, one has to rely on less optimal alternatives, which are all provided by the present

review. Enclosed in a frame, we present our recommendations for most optimal choices below,

given the research objective.

Recommended for population-based cohort studies, especially when a broad age-range

is included (i.e. younger and older persons):

1. Somatization subscale Symptom Checklist 90-item version (SCL-90 SOM)*

2. Patient Health Questionnaire (PHQ-15)*

Recommended for screening in primary care (based on lowest level of overlap with

somatic diseases and availability for older patients):

1. Freiburger Beschwerden liste (FBL) / Freiburg Complaint List

2. Somatization subscale Brief Symptom Inventory 53- item version (BSI-53 SOM)

Recommended for treatment monitoring (emphasis on subjective experiences):

1. Schedule for Evaluating Persistent Symptoms (SEPS)

2. Somatic Symptoms Experiences Questionnaire (SSEQ)

* Please note that adjustment for the common geriatric syndromes is necessary to make age-related comparisons.

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University of Groningen Factors associated with the persistence of medically unexplained symptoms in later life van Driel-de Jong, Dorine