Clinical Geriatrics

This issue of Clinical Geriatrics features two articles on topics that are very important in the treatment of the older patient—depression and hyponatremia.

I was recently asked to see Mrs. S, a 65-year-old woman who was thought to be “depressed.” The medical team wanted a recommendation regarding the “right” antidepressant to give her in light of her coexisting medical condition. A few months earlier, she had extensive bowel surgery that left her with what is known as “short bowel syndrome,” and so had less than 30 cm of intestine remaining. Questions surfaced regarding what medication would be best given her limited ability to absorb anything. She was also having difficulty maintaining her fluid balance and was receiving total parenteral nutrition. One initial concern of mine upon hearing about this patient was the potential for cardiac side effects in light of her likely frequent metabolic imbalances.

Upon questioning, I learned that Mrs. S had recently lost her husband in the same car accident that was also responsible for her abdominal injury that led up to her current situation. She was too ill to attend her husband’s funeral 3 months earlier and despite an attempt at returning to the community, she had not been successful in managing her current needs at her daughter’s home. She became severely dehydrated putting out excessive fluid from her ostomy and had to be re-admitted to the hospital.

Prior to the accident, she was a very active person who played golf several times a week with her husband and loved the outdoors, hiking, and her freedom. She had no other hobbies, and while she claimed she had friends, she spoke with tears in her eyes about the loss of “my best friend,” her husband. She appeared to have great insight into her current situation and said she was concerned over how she could manage “all of the tubes and fluids” she needed to remain healthy and independent. She said that going to her daughter’s home was her only option at this time, though she had just “failed” an attempt to manage there and had no more insight into what she needed to do this time around. She expressed concern over what lay ahead. She smiled at times as we spoke and seemed to take my suggestion about a need to find new hobbies and activities. She had not been referred to a mental healthcare professional at any time since the accident.

Physicians all too often reach for a “pill” as a way of treating a specific problem. While it did not take an expert in Psychiatry in my opinion to see that Mrs. S was “depressed,” I could not help but feel sorry for this woman’s many losses, all coming within such a short period of time. Her state of mind was quite expected given all that she had gone through; a simple pill was not going to do much in the absence of counseling and “tincture of time.”

She expressed a feeling of sorrow at not attending her husband’s funeral and her inability to have “closure,” despite her viewing a home video made of the event. In just a few short months, Mrs. S had lost her husband and best friend, her ability to live in the way she had been accustomed to, her “dignity,” and her good health. She needed to mourn these losses, and it would take time. I believed that she would benefit from the help of a mental healthcare professional and needed to work through her medical issues that were not insurmountable but were nevertheless life-changing and potentially life-ending. I referred her to a program that treats individuals with similar bowel problems with the hope that they would also be able to provide the necessary counseling that I believed she needed. I encouraged her to talk to a mental healthcare professional and hope that she will follow through. I expect that she will continue to mourn her losses over the next year or two; hopefully, she will have the support, both medical and psychological, to be successful in regaining quality life.

Not every case is so clear-cut as the one I described above.