Diagnostic errors in older patients: a systematic review of incidence and potential causes in seven prevalent diseases

Abstract

Background

Misdiagnosis, either over- or underdiagnosis, exposes older patients to increased risk of inappropriate or omitted investigations and treatments, psychological distress, and financial burden.

Objective

To evaluate the frequency and nature of diagnostic errors in 16 conditions prevalent in older patients by undertaking a systematic literature review.

Data sources and study selection

Cohort studies, cross-sectional studies, or systematic reviews of such studies published in Medline between September 1993 and May 2014 were searched using key search terms of “diagnostic error”, “misdiagnosis”, “accuracy”, “validity”, or “diagnosis” and terms relating to each disease.

Data synthesis

A total of 938 articles were retrieved. Diagnostic error rates of >10% for both over- and underdiagnosis were seen in chronic obstructive pulmonary disease, dementia, Parkinson’s disease, heart failure, stroke/transient ischemic attack, and acute myocardial infarction. Diabetes was overdiagnosed in <5% of cases.

Conclusion

Over- and underdiagnosis are common in older patients. Explanations for over-diagnosis include subjective diagnostic criteria and the use of criteria not validated in older patients. Underdiagnosis was associated with long preclinical phases of disease or lack of sensitive diagnostic criteria. Factors that predispose to misdiagnosis in older patients must be emphasized in education and clinical guidelines.

Keywords:

• older patient
• elderly
• overdiagnosis
• underdiagnosis
• misdiagnosis

Acknowledgments

The authors thank Justin Scott, biostatistician from the Queensland Facility for Advanced Bioinformatics, and Christine Dalais, University of Queensland Library. The authors also wish to thank Dr Jonathon Belsey, Dr Simon Lusignan, Dr Alfredo J Mansur, Dr Rafael Saad, Assistant Professor Shyam Prabhakaran, Dr Min Joo, and Dr Julia Walters for assisting in this review by providing additional data from their studies.

Author contributions

All authors meet the International Committee of Medical Journal Editors criteria for authorship: substantial contributions to the conception or design of the work or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Disclosure

The authors report no conflicts of interest in this work.