Case Presentation

Mr. Y is a 68-year-old widowed man brought to the Emergency Department (ED) by his daughter, Ms. S. Ms. S came to see her father while on a business trip and found him to be weak and lethargic. She found very little food in the house and was concerned by the excessive number of bottles of whiskey in the kitchen and living room. Ms. S tells the ED staff that her father had a myocardial infarction 5 years ago and has hypertension. He is supposed to be taking medication for hypertension and heart disease, but Ms. S does not know the names of the medication. Mr. Y has been living alone since his wife died 2 years ago from cancer. Ms. S and her sister both live in other states but try to call and visit their father on a regular basis. Ms. S reports that Mr. Y always tells them that everything is fine. Mr. Y was functioning independently, even working part-time as a security guard until his position was eliminated in budget cuts 6 months ago. Ms. S reports that her mother always took care of everything in the household, including making medical appointments, filling prescriptions, and taking care of her father. She feels that he has been lost without her.

Mr. Y is found to be arousable to verbal stimuli but lethargic. He has alcohol on his breath. He appears thin, frail, and older than his age. His pulse is irregular, and an electrocardiogram reveals atrial flutter. He is found to be hyponatremic, with a sodium level of 128 mEq/L (normal range 134-149 mEq/L). His blood alcohol level is 80 mg/dL (close to the legally intoxicated limit of 100 mg/dL) and the staff is concerned about the possibility of withdrawal. His blood pressure is elevated at 160/100 mm Hg, and his pulse rate is 90-100 beats per minute. Mr. Y is admitted to the Telemetry unit to monitor his atrial flutter and is placed on alcohol withdrawal precautions.

Mr. Y is treated with lisinopril 20 mg daily, metoprolol 100 mg twice daily, and aspirin 81 mg daily for his hypertension and cardiac disease. A computed tomography scan of the head is performed, which reveals mild cortical atrophy but no signs of any acute stroke or head trauma. He becomes more alert and does not show any signs of alcohol withdrawal. His heart rhythm returns to normal by the third hospital day. The patient’s sodium level also returns to normal after oral and intravenous hydration is given. He is transferred to a general medical floor. Physical therapy is consulted due to Mr. Y’s generalized weakness. He is evaluated but shows poor effort. His appetite is also poor, and nutritional supplements are ordered. Mr. Y tells the unit staff that he has not seen his doctors since the death of his wife 2 years ago. He has not filled any prescriptions and does not know the names of his medications. He reports that he has never made a doctor’s appointment for himself in his life, as his wife used to do it for him. Mr. Y has a high school education and worked as a carpenter and building contractor in addition to his security job. He managed the finances for his family, used to attend church regularly, and belonged to a local social club. After his wife died, he reports that he stopped going out, except to weekly church services, but after a few months gave this up as well.

The unit social worker talks to Mr. Y about discharge planning and home care. He appears rather perplexed and states that he does not know what to do. His daughter visits him before she has to return home from her business trip and wants to have her father placed in a nursing home. The social worker consults with the medical staff, who feel that Mr. Y is capable of functioning independently. They note that he has had many visitors outside of his family who may be a source of support. However, the care team has concerns regarding possible depression, noncompliance with medical care prior to admission, and his alcohol use. A psychiatry evaluation is requested.

Discussion

All older adults face challenges associated with aging. Older men who suffer the loss of a spouse are presented with one of the more difficult issues of coping, loss, and bereavement that is typically unanticipated.1

The life expectancy of older women is 7-9 years greater than that of older men. Most older men expect to be outlived by their spouses.1,2 This is particularly true of the cohort of older males who are above the age of 65 years and have witnessed the death of their male relatives and friends.3 The overall health status of married males is better than that of unmarried and widowed men.1 A significant aspect of this difference is related to the nurturing and caregiving role assumed by older wives.4 Women make more visits to physicians throughout their lives and are often responsible for maintaining the health promotion of their mates. Males who have lost their wives often have difficulty taking over this role.2,4

This case illustrates the many typical losses that occur in later life that may lead to isolation, stress, withdrawal, poor compliance with healthcare, and the abuse of substances.5 Mr. Y suffered the loss of his wife, and later the loss of a job and the role associated with this. He began to withdraw, isolate himself, and no longer used any of the life skills that he had used in the past.6 This is a common pathway to depression, substance abuse, poor health status, and even premature death.3,4

Older men often link their feelings of self-worth with occupational roles, social status, physical health, and, to some degree, appearance.7 They are more likely to engage in activities that involve perceived action rather than talking. Men are less likely than women to seek help for emotional problems, and are far less likely to describe feelings of depression and anxiety to a physician or other healthcare provider.7,8 Men may utilize community supports if they have a prior association to a group or system but are less likely to establish a new linkage for assistance. This makes older men a more difficult group to reach when problems such as depression, substance abuse, anxiety, or isolation become significant. Older males are at the highest risk for suicide, yet present the greatest challenge for community outreach services. It is very important to identify men at risk when they present to any healthcare setting.3-5

The concept of health literacy is an important factor in the care of older males.9 Health literacy has been defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services. This has been linked to educational status and reading ability.9,10 Of more practical value is the concept of functional health literacy, which indicates the ability to read and comprehend prescription bottles, appointment slips, and the essential healthcare materials required to function as a patient. This includes the practical skills of making healthcare appointments, following recommendations, and practicing health maintenance.10 While men such as Mr. Y may have the educational and reading skills needed for health literacy, they often have never taken an active role in their healthcare. An important aspect for the clinician to appreciate is the need for health education and support that men may have to become more active participants in their care3-8 (Table). This may range from such issues as basic as reminder calls before appointments to literature geared toward the independence and activities of interest to men. Referrals to group programs that emphasize tasks and activity often appeal more to men than the traditional term therapy.6-8

The mental health needs of older widowers should never be underestimated. Men often have difficulties communicating their distress related to bereavement, loss, and depression but are relieved when the clinician identifies these issues.1,6 Referral to individual or group programs that focus on the bereavement issues of men are often very helpful. This may be a process that the clinician should offer over time, as the patient may be reluctant to accept mental health services.7 Signs of significant depressed mood, prolonged sadness, and loss of functioning indicate consideration of antidepressant medications and referral to a psychiatrist. Screening for suicidal thoughts is vital in this population.6

Older widowers are in the highest risk group for suicide.1 Identifying those at risk and providing linkage to routine healthcare, social supports, and treatment of mental health issues will not only improve quality of life, but may save one.

Information on improving health literacy may be downloaded from the website devoted to Improving Communication from the Federal Government to the Public: www.plainlanguage.gov.

Outcome of the Case Patient

Mr. Y was evaluated by the psychiatrist on his fifth hospital day. He was alert, verbal, and cooperative. He initially denied any symptoms or problems but later was able to discuss both the loss of his wife and the more recent loss of his job. He described being able to cope with his wife’s death by finding a job and socializing with men at work. When he lost his job, Mr. Y felt demoralized and spent most of his time alone in his apartment. His friends came to visit at times, but their main activity was watching television and drinking. After Mr. Y stopped going to church, he felt guilty, as he promised his wife that he would continue to attend services. He denied suicidal thoughts, had no access to guns, and was willing to accept home care services and see the psychiatrist as an outpatient.

Mr. Y was discharged home with home care and follow-up appointments with his primary care physician and psychiatrist. He received outpatient physical therapy and rapidly improved his strength and energy. He was willing to attend a men’s support group that included other widowers and also returned to his social club. He started attending church again with the assistance of a program that offered transportation to weekly services. Mr. Y missed a few appointments with his doctors but was able to call and reschedule appointments. He started using a mail order prescription plan to receive 90 days of medication, and his compliance improved. His mood improved after discharge from the hospital, and he did not require antidepressant treatment. Mr. Y started to volunteer at a program for high school students at risk of dropping out. At a 9-month follow-up visit with the psychiatrist, Mr. Y appeared neatly groomed, in good spirits, and was proud of his volunteer work. He was planning a trip to visit one of his daughters. He had no signs of depression and was limiting his alcohol intake to one night per week at his social club.

The author reports no relevant financial relationships.

Dr. Lantz is Chief of Geriatric Psychiatry, Beth Israel Medical Center, First Ave @ 16th Street #6K40, New York, NY 10003; (212) 420-2457; fax: (212) 844-7659; e-mail: mlantz@chpnet.org.