Isaac's Sign: Handkerchief Holding by Older Inpatients

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 outcome 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 componentFan 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.