Patient Management Exercise: Late-Life Psychiatry

Case vignette

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.

Consideration Point A

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

Vignette continues

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).

Consideration Point B

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

Vignette continues

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.

Consideration Point C

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

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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.

Consideration Point D

Given that patient’s history, your differential includes

Vignette concludes

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.

Answers: scoring, relative weights, and comments

Consideration Point A

Consideration Point B

Consideration Point C

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

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.