Isaac's Sign: Handkerchief Holding by Older Inpatients

Field: Medicine (Health Sciences)

“Beware a handkerchief in the hand, a handbag on the arm, food in the mouth, teeth in the jar, the hearing aid in the drawer and the artificial limb under the bed; all betoken a poor prognosis.” To the Editor: The persistent holding of a handkerchief or other object by older people is a common sight on hospital wards and in geriatric medicine outpatient clinics. Despite it apparently being a common observation, little has been documented about this phenomenon. The late Bernard Isaacs's observation that such behavior was associated with poor rehabilitative outcome1 is not proven but could, if true, point to physical or cognitive frailties as the underlying etiologies. Why many older people clutch handkerchiefs and other items is unclear. It may simply be due to physical symptoms such as rhinorrhea, drooling, or cough. There may be a psychological component—an association with insecurity, anxiety, or acute or chronic cognitive impairment. Handkerchief holding has a “mirror behavior” in childhood and could be considered regressive behavior in an older adult, analogous to a child with a security blanket or other attachment agent. One patient told us “I've always done it since I was a child. I had a rag then.” Local use of the term “andrexia nervosa” illustrates the possible association with anxiety or other emotional distress. (Andrex is a popular brand of toilet tissue in the United Kingdom. The late Independent UK newspaper witticist Miles Kington may have originally coined the term “andrexia nervosa.”) The prevalence and patient explanations of this behavior were studied. A point prevalence survey and single-question interview was conducted on all inpatient geriatric medical wards in the Leeds Teaching Hospitals National Health Services Trust (LTHT). The number of patients holding a handkerchief or other object and their age, sex, and handedness were recorded. Patients holding an object were asked one question: “May I ask why you hold a handkerchief [or tissue, etc.]?” Objective evidence of patients' physical explanations was sought from direct observation and case notes. Data are presented descriptively and analyzed using chi-square tests. Three hundred seventy-five of 420 beds in four hospital sites were occupied at the time of the survey. Thirty-three patients were excluded as unable to hold an item because of disability or severe illness; 332 patients were eligible to participate, of whom 11% were observed to be clutching a handkerchief or tissue (in 79% cases) or other object (mainly paper or toy). Patients ages ranged from 66 to 104; 84% were female. There was no difference between patients in beds or chairs; equal numbers were holding the item in their dominant and nondominant hand. More patients were found holding a tissue in acute wards (18%) than rehabilitation wards (7%). Of the explanations given by patients, 50% related to physical symptoms, objective evidence of which existed in only 28% cases (Table 1). Several patients gave a physical and a nonphysical explanation. Nonphysical explanations included “habit” or “for comfort.” Some patients were unable to explain their behavior. Most replies indicated that this behavior was long-standing; 55% using words such as “a long time,”“years,” or “always.” Fewer (2%) indicated that his behavior was recent, since being in the hospital. Some suggested that onset of handkerchief-holding behavior started in later life. We have often observed older patients holding handkerchiefs. This study, the first to explore this observation, found that it is common, with a prevalence of 11% of older inpatients, 84% of whom were female. Isaacs hypothesized that handkerchief holding may be associated with a poor rehabilitative outcome. Functional outcomes were not studied in this study, although patients gave several explanations for this behavior. Half of these were nonphysical, raising the possibility of a psychological association with handkerchief holding. In addition, objective evidence of physical explanations was found in only 28%, suggesting that some patients might be rationalizing the behavior. Tissue holding was more common on acute wards than postacute or rehabilitation wards (18% vs 7%). Greater anxiety in patients who are sicker or in a rapidly changing acute hospital environment may explain this. Use of attachment agents by children is associated with separation anxiety and is also frequently observed as a coping strategy in unfamiliar circumstances irrespective of children's maternal attachment status.2 There are obvious limitations to point prevalence studies; Isaac's sign may be intermittent and therefore underestimated, and short-term observation may inappropriately invalidate patient explanations. Further study is planned to investigate potential psychological and functional associations with handkerchief holding. Isaacs's original observation may prove a useful clinical eponymous sign. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Author Contributions: All authors listed were involved in inception of concept, study design, performance of study, analysis, and writing the letter. Sponsor's Role: None.