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CLINICAL SYNTHESIS   |    
Patient Management Exercise: Late-Life Psychiatry
Ian A. Cook, M.D.
FOCUS 2013;11:57-61. doi:10.1176/appi.focus.11.1.57
View Author and Article Information

Author Information and CME Disclosure

Ian A. Cook, M.D., Professor of Psychiatry and Biobehavioral Sciences and of Bioengineering, David Geffen School of Medicine and Semel Institute for Neuroscience and Human Behavior at UCLA.

Over his professional career, Dr. Cook's projects have been supported by grants from Aspect Medical Systems/Covidien, Cyberonics, Eli Lilly and Company, High Q Foundation, John E. Fetzer Foundation, John A. Hartford Foundation, MedAvante, Merck, NARSAD, NIH, Neuronetics, Novartis, Pfizer, Sepracor/Sunovion, Seaside Therapeutics, and the West Coast College of Biological Psychiatry, as Principal Investigator or Co-Investigator. At times he has served as an advisor or consultant to Allergan, Ascend Media, Bristol-Myers Squibb, Cyberonics, Eli Lilly and Company, Forest Laboratories, Janssen, Neuronetics, NeuroSigma, Pfizer, Scale Venture Partners, and the U.S. Departments of Defense and Justice. He has spoken on behalf of Bristol-Myers Squibb, CME LLC, Eli Lilly & Company, Medical Education Speakers Network, Pfizer, Neuronetics, NeuroSigma, and Wyeth. Dr. Cook’s biomedical device patents are assigned to the University of California. He has been granted stock options in NeuroSigma, the licensee of some of his inventions. From 1994-2008 he served on the Steering Committee on Practice Guidelines of the APA, and its Executive Committee from 2002-2008.

Abstract

This exercise is designed to test your comprehension of material presented in this issue of FOCUS as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below, to the best of your ability, on the information provided, making your decisions as you would with a real-life patient.

Questions are presented at “consideration points” that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections. You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. At the end of the exercise, you will add up your points to obtain a total score.

Abstract Teaser
Figures in this Article

Robert is a 64-year-old Caucasian male who came to see you with concerns about depression for many months that had persisted despite treatment by his primary care physician.

He reported that he first became clinically depressed around age 18–20, when he was “stressed out” about college matters. He saw a physician at that time in the 1960s, who prescribed an unknown antidepressant that “didn’t really help, but I took the pills anyway, and eventually I recovered.” His depression returned later in his 40s, when his youngest daughter was diagnosed with leukemia around age 4 (she is now alive and well). He was treated with fluoxetine, and then fluoxetine combined with lithium. Eventually he received and then recovered after a course of electroconvulsive therapy (ECT) that was employed because he had become completely disabled, with an inability even to shower, brush his teeth, or put on his clothes without assistance. In response to your questions, he denied to you that he had experienced any hallucinations, delusions, or thought disorganization at that time: “I was just completely unable to function; it was like I was living in slow motion.” After ECT he was put onto another SSRI antidepressant (he did not recall which one) and after a year the medication was tapered and eliminated. He had another bout of depression at age 52, soon after his wife died after being hit by a drunk driver, and that episode responded well to treatment with venlafaxine.

He did well until 9 or 10 months ago, when he had the onset of insomnia, with an inability to fall asleep “because my mind was racing with thoughts about what I should be doing with my life.” He reported to you that he had relatively low job satisfaction, but also believed that the economic climate was not conducive to “a 63-year-old finding a new job” and thus felt “boxed in” with his current position. He reported that he also had prominent loss of motivation: “my get-up-and-go had gotten up and left.” He saw his primary care physician, who prescribed a nonbenzodiazepine GABA-A agonist for sleep. While this intervention did help him fall asleep, he began waking up at 5 a.m. each day, an hour earlier than his alarm clock, and began to have more daytime fatigue, agitation, anxiety, and irritability. He also reported that he felt “overwhelmed” at times by simple tasks, like writing checks to pay his bills or keeping track of what food he needed to get at the market. Some of his coworkers urged him to “chill out” and not react with harsh, sarcastic comments whenever things did not go smoothly at the company where they worked.

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Consideration Point A

At this point in the patient’s history, the diagnosis which seems most appropriate for this patient would be

A.1_____Major depressive disorder, recurrent
A.2_____Adjustment disorder, related to job stress at midlife
A.3_____Substance-induced mood disorder

The patient described that, after 3 months of persistent symptoms despite the sleeping agent, his primary care physician had added mirtazapine, which had little impact on mood over an 8-week trial but which added 25 pounds in weight. That agent was discontinued, and monotherapy with sertraline was begun, with dose titration culminating in 150 mg/day for 12 weeks, with some mild improvement. At that point, about 4 weeks ago, bupropion was added at 150 mg/day.

As you inquired more about the patient’s history, he denied any prior times with experiences of manic or hypomanic symptoms, obsessive thoughts or compulsive behaviors, hallucinatory experiences, or delusional thoughts.

As you inquired about his early life history, you learn that the patient’s childhood was marked by maltreatment by an alcoholic father and a detached and absent mother who has had recurrent bouts of depression. His family history is also notable for depression in a nephew (did well with ECT), an older brother who reportedly did well with ECT at times but who committed suicide in his 40s, the death of his father from the effects of cirrhosis, and that his mother had been placed in a nursing home for dementia in her 70s. Socially, he was married once and widowed; two daughters live in the area and he reported they have good relationships.

The patient reported never using drugs of abuse and having smoked tobacco from age 18 to 40, then quitting to avoid exposing his children to “second hand smoke.” He reported occasional consumption of wine, estimated as two glasses of wine over dinner, roughly 5 nights out of the week.

In reviewing his medical history, the patient denied having any drug allergies, and any major medical conditions other than mild elevations on his liver panel. When you evaluated him, he reported that his current medication regimen was sertraline, 150 mg at bedtime, and bupropion, 150 mg each morning.

On examination, he was pleasant and cooperative with the interview, casually attired in sweatpants and a sweatshirt, with inattention to grooming. There was marked psychomotor slowing noted. Eye contact was adequate. Speech was of slowed rate, hypophonic volume, but normal prosody. He almost became tearful on a few occasions. Affect was constricted and unhappy. Mood was endorsed as sad, depressed, and unmotivated. Thought process was slowed but generally linear and coherent. Thought content was without hallucinations, delusions, or current suicidal or homicidal intent. Cognitively he was awake, alert, and oriented to self, place, date, and circumstances. Memory registration was intact with 3/3 stimuli, and recall after delay was 2/3 items but after a painfully slow delay. Recalling recent U.S. Presidents was problematic; he could name Obama but could not recall Bush even with clues. Some similarities were concrete (apple/orange = “grow on trees;” chair/table = “things you find in an office”), while others were more abstract (watch/ruler = “for measurement”). Insight was adequate, in that he recognized he had a recurrent illness and was seeking treatment. Judgment currently was adequate, in that he was pursuing treatments for his mood condition, and was open to considering all options for treatment. Neurologically, gait stride length was normal, as were arm swing and turning, and rapidly-alternating movements. His score on the self-rated IDS-30 instrument was 40, consistent with severe level of symptom severity (equivalent to HDRS-17 score of approximately 21, per www.ids-qids.org).

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Consideration Point B

At this point, the treatment options you consider with this patient include all of the following

B.1_____Increase sertraline to 200 mg total each day and have him return in 2 weeks
B.2_____Increase bupropion to 300 mg each morning and have him return in 2 weeks
B.3_____Continue to monitor the patient for another 4 weeks at the current doses
B.4_____Add an atypical antipsychotic agent and have him return in 2 weeks.

After discussion of the options for treatment for his depressive episode, the patient accepted your recommendation to increase the dose of bupropion to 300 mg as the next step. He returned after 2 weeks, reporting that his energy was better, he was better able to take care of his activities of daily living, and that sometimes his depression “wasn’t as dark as before.” You elected to increase the dose of sertraline to 200 mg and had him return in another 2 weeks. At that point his symptom burden had decreased to an IDS-30 score of 11, at the high cusp of remission.

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Consideration Point C

Given the patient’s history, the likelihood that he will have another depressive episode at some point is

C.1_____about 30%
C.2_____about 50%
C.3_____at least 80%

The patient continued under your care and comes to a more complete remission over the next 3 months (IDS-30 score of 4) while staying on the same regimen of medications. He continued on those medications for another 12 months, and although you and he had a long discussion about the merits of maintenance pharmacotherapy as a way to reduce the risk of a symptomatic relapse, he decided to discontinue both agents; he was willing to employ a slow taper over 6 months time. He then stopped seeing you regularly. You read in the local newspaper that he retired from his job and had begun some volunteering work.

After another 5 years time, you received a call from the patient’s daughter, who described worry about her father who had sounded “vacant and confused” on the phone when she called him. When she went over to his home, he was found staring at the stove, where a pair of pots sat with the carbonized remnants of dinner in them. She reported that he was crying but could not tell her about what; he was willing to stay at her house that night and see you the next day.

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Consideration Point D

Given that patient’s history, your differential includes

D.1_____Major depressive disorder, recurrent
D.2_____Dementia, rule-out Alzheimer’s disease
D.3_____Substance-induced mood disorder
D.4_____Bipolar disorder, depressed phase

When you saw Robert, you were impressed that he appeared to have aged significantly. He recognized you but was unable to recall your name. He reported that he had not been feeling well, but that he was hard pressed to say what the problem was. He denied feeling depressed or anhedonic, and reported that he enjoyed seeing his daughters and grandchildren. When you examined him, he was oriented to his name, to the city where you were, and to the year; he could register three of three items but recall zero of them, even with prompts. His affect was more blank than distressed, and his thought process was slowed and not well organized.

An MRI study confirmed marked sulcal widening over much of the cortex, most pronounced over the parietal regions bilaterally, along with rare scattered deep white matter hyperintensities. You suspected that he has developed a degenerative form of dementia, and proceeded to develop a biopsychosocial treatment plan to help Robert and his family.

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Consideration Point A

A.1_____+3 Major depressive disorder, recurrent. The patient has endorsed symptoms consistent with the DSM criteria for major depressive disorder and has a past history of prior episodes (1).
A.2_____+1 Adjustment disorder, related to job stress at midlife. This patient, like many, has experienced a set of stressful circumstances related to work-related stress and to existential questions in his middle years. Given the range of symptoms and impairments, major depression is probably a more parsimonious characterization (1).
A.3_____+1 Substance-induced mood disorder. Overt or covert substance use can lead to mood problems, either in intoxicated or withdrawal states (e.g., psychostimulants, alcohol) (1). This can take place covertly in older adults (2). Collecting more history will be important to help rule this out.

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Consideration Point B

B.1_____+3 Increase sertraline to 200 mg and return in 2 weeks. The dose of sertraline could be optimized, consistent with evidence-based practice guidelines (3, 4).
B.2_____+3 Increase bupropion to 300 mg each morning and return in 2 weeks. The dose of bupropion could be optimized, consistent with evidence-based practice guidelines (3, 4).
B.3_____−2 Continue to monitor and return in 4 weeks. In a patient with severe symptom burden and many months of failed pharmacotherapy, more active management and more frequent follow-up would be consonant with evidence-based practice (3)
B.4_____+1 Add an atypical antipsychotic agent. While augmentation with atypical antipsychotic agents can be effective in achieving better symptom improvement (3), before adding another drug to his complex cocktail, optimizing the dose of the other agent(s) would be more consonant with evidence-based practices and algorithms (3, 4).

+

Consideration Point C

C.1_____−2 about 30%.
C.2_____−2 about 50%
C.3_____+3 at least 80%

The number of prior episodes is a key risk factor for the development of a recurrence of a depressive episode (5, 6). This gentleman has had three prior episodes, placing him at high risk for yet another episode.

+

Consideration Point D

D.1_____+1 Major depressive disorder, recurrent
D.2_____+3 Dementia, rule-out Alzheimer’s disease
D.3_____+1 Substance-induced mood disorder
D.4_____−2 Bipolar disorder, depressed phase

Certainly in an individual with a lifelong pattern of recurrent depressive episodes, yet another recurrence is a high-probability event to consider, and substance-related mood disorders can occur in older patients (2). Without a history of manic or hypomanic symptoms at some point in his life, a diagnosis of bipolar disorder would not be fitting, but it is important to be aware that onset of mania in late-life can and does occur (7), although not in this patient.

Most critically to the present case, the patient appears to have developed symptoms consistent with dementia (1), and the presence of depression appears to be a risk factor for developing dementia (8, 9). Being alert for the development of cognitive decrements in patients with mood disorders will allow clinicians to be able to intervene as early as possible, while making sure that mood symptoms are also treated.

American Psychiatric Association:  Diagnostic and Statistical Manual of Mental Disorders , 4th ed., text revision.  Washington, DC,  American Psychiatric Publishing, 2000
 
Moore  AA;  Karno  MP;  Grella  CE;  Lin  JC;  Warda  U;  Liao  DH;  Hu  P:  Alcohol, tobacco, and nonmedical drug use in older U.S. Adults: data from the 2001/02 national epidemiologic survey of alcohol and related conditions.  J Am Geriatr Soc 2009; 57:2275–2281
[CrossRef] | [PubMed]
 
American Psychiatric Association:  Practice Guideline for the Treatment of Patients With Major Depressive Disorder , 3rd ed.  Washington, DC,  American Psychiatric Publishing, 2010
 
Lam  RW;  Kennedy  SH;  Grigoriadis  S;  McIntyre  RS;  Milev  R;  Ramasubbu  R;  Parikh  SV;  Patten  SB;  Ravindran  AV; Canadian Network for Mood and Anxiety Treatments (CANMAT):  Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. III. Pharmacotherapy.  J Affect Disord 2009; 117(Suppl 1):S26–S43
[CrossRef] | [PubMed]
 
Solomon  DA;  Keller  MB;  Leon  AC;  Mueller  TI;  Lavori  PW;  Shea  MT;  Coryell  W;  Warshaw  M;  Turvey  C;  Maser  JD;  Endicott  J:  Multiple recurrences of major depressive disorder.  Am J Psychiatry 2000; 157:229–233
[CrossRef] | [PubMed]
 
Burcusa  SL;  Iacono  WG:  Risk for recurrence in depression.  Clin Psychol Rev 2007; 27:959–985
[CrossRef] | [PubMed]
 
Depp  CA;  Jeste  DV:  Bipolar disorder in older adults: a critical review.  Bipolar Disord 2004; 6:343–367
[CrossRef] | [PubMed]
 
Jorm  AF:  History of depression as a risk factor for dementia: an updated review.  Aust N Z J Psychiatry 2001; 35:776–781
[CrossRef] | [PubMed]
 
Modrego  PJ;  Ferrández  J:  Depression in patients with mild cognitive impairment increases the risk of developing dementia of Alzheimer type: a prospective cohort study.  Arch Neurol 2004; 61:1290–1293
[CrossRef] | [PubMed]
 
References Container
+

References

American Psychiatric Association:  Diagnostic and Statistical Manual of Mental Disorders , 4th ed., text revision.  Washington, DC,  American Psychiatric Publishing, 2000
 
Moore  AA;  Karno  MP;  Grella  CE;  Lin  JC;  Warda  U;  Liao  DH;  Hu  P:  Alcohol, tobacco, and nonmedical drug use in older U.S. Adults: data from the 2001/02 national epidemiologic survey of alcohol and related conditions.  J Am Geriatr Soc 2009; 57:2275–2281
[CrossRef] | [PubMed]
 
American Psychiatric Association:  Practice Guideline for the Treatment of Patients With Major Depressive Disorder , 3rd ed.  Washington, DC,  American Psychiatric Publishing, 2010
 
Lam  RW;  Kennedy  SH;  Grigoriadis  S;  McIntyre  RS;  Milev  R;  Ramasubbu  R;  Parikh  SV;  Patten  SB;  Ravindran  AV; Canadian Network for Mood and Anxiety Treatments (CANMAT):  Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. III. Pharmacotherapy.  J Affect Disord 2009; 117(Suppl 1):S26–S43
[CrossRef] | [PubMed]
 
Solomon  DA;  Keller  MB;  Leon  AC;  Mueller  TI;  Lavori  PW;  Shea  MT;  Coryell  W;  Warshaw  M;  Turvey  C;  Maser  JD;  Endicott  J:  Multiple recurrences of major depressive disorder.  Am J Psychiatry 2000; 157:229–233
[CrossRef] | [PubMed]
 
Burcusa  SL;  Iacono  WG:  Risk for recurrence in depression.  Clin Psychol Rev 2007; 27:959–985
[CrossRef] | [PubMed]
 
Depp  CA;  Jeste  DV:  Bipolar disorder in older adults: a critical review.  Bipolar Disord 2004; 6:343–367
[CrossRef] | [PubMed]
 
Jorm  AF:  History of depression as a risk factor for dementia: an updated review.  Aust N Z J Psychiatry 2001; 35:776–781
[CrossRef] | [PubMed]
 
Modrego  PJ;  Ferrández  J:  Depression in patients with mild cognitive impairment increases the risk of developing dementia of Alzheimer type: a prospective cohort study.  Arch Neurol 2004; 61:1290–1293
[CrossRef] | [PubMed]
 
References Container
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