Ulysses syndrome: unnecessary investigation in older people

Ulysses syndrome is a term coined nearly 25 years ago on the basis of the legend of Ulysses. Ulysses was the legendary king of Ithaca, one of the main leaders of the Trojan war, and hero of Homer’s legendary epic poem the Odyssey. He left the Trojan war but returned home after 20 years, indulging in a series of needless adventures during that time, without achieving anything.¹ Similar to Ulysses, patients who are healthy may be subjected to a long journey through a maze of needless investigations, which is named Ulysses syndrome.² The medical dictionary defines it as “the ill-effects of extensive diagnostic investigations conducted because of a false-positive result in the course of routine laboratory screening.”³

Pathogenesis of Ulysses syndrome

The pathogenesis of Ulysses syndrome lies in unnecessary investigations resulting from mass screening, insurance tests or similar programmes. Considering that all the laboratory investigations with the defined limits cover 95% of the normal population, there is a chance of 5% of the normal population being labelled abnormal. Hypothetically then if each person has 20 tests, then at least two-thirds will have abnormal findings.⁴ As, Charles Essex put it, “The two hardest things to do in medicine—to say nothing and to do nothing.”⁵ Thus, abnormal results are hard to dismiss for a conscientious physician, who then sends the patient on a wild goose chase of further unfruitful investigations before the abnormality is dismissed as a normal variant or an aberration. This is also associated with mental and physical effects that accompany the discovery of a false-positive result.

Secondly, uncritical examination may identify a trivial variant, leading to cascade of further tests. Despite the operational advances in pathology, there is a potential for the tests to be false positive due to either testing errors, specificity and sensitivity or due to patients’ factors, and caution needs to be exercised in “trusting numbers.”⁶ However, critical examination and proper interpretation of the test results may prevent further needless investigations.

Enthusiasm of junior doctors to complete a routine battery of tests may be prompted by pressures on the bed and to discharge or otherwise reduce the length of stay. Thus, a junior doctor with limited knowledge finds liver function test results outside the normal limits, misinterprets a normal variant of the test and draws from his experience of a previous ward round, and then moves to imaging of the abdomen promptly resulting in increasingly unnecessary investigations. Our modern tick-box forms also prompt unnecessary investigations due to the ease of filling in the form or ticking the wrong box.

Finally, defensive medicine in neurotic patients, or a chance discovery may prompt further unnecessary investigations. This conforms to the “no-lose philosophy”⁷ or investigations undertaken “just in case”, the justification being that an investigation might pick up something abnormal.

Ulysses syndrome in elderly people

Older people are recognised as a medical subgroup and they may have subtle and atypical presentations of illness. For instance, presentation as a fall may indicate several predisposing underlying factors. Different theories of ageing have been proposed, but it is widely accepted that the physiological reserve decreases secondary to accumulating changes over the years. Furthermore, elderly patients have multiple comorbidities and bodily changes as a result of physiological factors.⁸ Thus, the normal limits for biochemical tests may not apply to older people.

The VITA study enrolled 600 adults older than 75 years and reported results from 120 apparently healthy older adults. It indicates that the ranges of biochemical test results and hormone levels may vary with age.⁹ More specifically, some test values can be expected to be abnormal more frequently if compared with normal adult ranges—serum alkaline phosphatase (elevations to about 2·5 times the normal), fasting or postprandial blood glucose, serum creatinine and creatinine clearance (which falls with ageing), higher erythrocyte sedimentation rate, haemoglobin and blood urea.¹⁰ Laboratory values may appear abnormal in 10% or more of healthy elderly people without necessarily representing a pathological process.¹¹

To ensure proper assessment of geriatic patients, clinicians need to interpret lab data in the elderly cautiously, taking into account the normal physiological processes in the older people.¹² Interpretation of test results in older people is further confounded by multiple disease states, polypharmacy, and atypical disease presentations, causing confusion in the clinical correlation of laboratory results.¹³ Thus, in elderly people, results should be interpreted by an experienced clinician to prevent further needless investigations or Ulysses syndrome.

Consequences of Ulysses syndrome

Ulysses syndrome does not serve any purpose for the patient. In fact, the disadvantage is that morbidity or angst caused from an unnecessary investigation outweighs the benefit of discovery of a rare disease. False positive results from tests and further investigations generated as a result cause more distress.¹⁴ This is a paramount factor in the quality of patients’ care. A dis-service may be done to the patient if following the lead of a so-called abnormal test, the patient is treated unnecessarily.

Further, Ulysses syndrome or the needless investigations result in waste of human and financial resources.¹⁵ As resources remain finite, needless overuse for one patient may deprive others. It may, however, produce a false sense of security for the physician and propagates the no lose philosophy when really the patients and the resources remain at a loss.

Conclusion

Ulysses syndrome or futile unnecessary investigations are common, especially in older people due to misinterpretation of results, over-enthusiastic investigation, use of general adult values for interpretation of results. It is potentially harmful to patients and results in abuse of resources. It may be avoided easily by cautious interpretation and by taking a detailed history and detailed medical examination.

The authors declare no conflict of interest.

Dr Preeti Gupta, Specialist Registrar, Geriatric Medicine, Intermediate Care, Torfaen, Block B, 2nd floor, Mamhilad House, Mamhilad Park Estate, Torfaen, Pontypool NP4 0YP, UK.

Professor Bimal Bhowmick, Consultant Physician, Intermediate Care, Torfaen, Block B, 2nd floor, Mamhilad House, Mamhilad Park Estate, Torfaen, Pontypool NP4 0YP, UK.

References

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14. Aro AR, Absetz SP, van Elderen TM, et al. False-positive findings in mammography screening induces short term distress— breast cancer-specific concern prevails longer. Eur J Cancer 2000;36:1089–97
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Professor Bimal Bhowmick

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