Clinical Geriatrics

Case Presentation

Mrs. P is a 72-year-old widowed African-American woman who is admitted to the medical service of a hospital due to dehydration, weight loss, and lethargy. She has a history of breast cancer treated with surgery and radiation 5 years ago. Her primary care physician is concerned that she may be suffering from a recurrence of cancer. Mrs. P undergoes a full medical evaluation with multiple consultations with an oncologist, gastroenterologist, and neurologist. Her lethargy improves with intravenous hydration, but her oral intake is poor. She complains that food doesn’t taste good and is reluctant to get out of bed to sit in a chair. A physical therapy evaluation finds that she is capable of standing and walking, but displays poor motivation. A psychiatric consultation is requested after all of Mrs. P’s medical tests are negative for malignancy. The patient has lost almost 40 pounds in the past year. She suffers from osteoarthritis and was functioning independently until she became increasingly depressed over the past 6-8 months.

The psychiatrist finds that Mrs. P displays feelings of hopelessness and helplessness with delusional beliefs that she cannot eat due to her food being stuck inside her stomach. She displays a tearful affect and ruminates about being a burden on her son and daughter-in-law. Mrs. P reports that she was treated in the past for depression after she was diagnosed with breast cancer and took a medication for several months. She cannot recall any details of her psychiatric treatment but is able to give the psychiatrist the telephone number of her son. Mrs. P requires a great deal of encouragement, but is able to give the correct date and to recall recent events. She agrees to take psychiatric medication but refuses admission to the inpatient psychiatry unit, requesting instead to go home.

Mrs. P is unable to care for herself, refusing meals due to her delusional beliefs, and displays depression with severe hopelessness and helplessness. She is admitted involuntarily to the hospital inpatient psychiatric unit for treatment of major depressive disorder with psychotic features. Her son is an Army medic who is home on leave but will return to Iraq in two weeks. Mr. P reports to the psychiatrist that he recalls his mother being treated with venlafaxine in the past. He requests that his mother be given any medications needed to stabilize her condition, but reports that the does not want her to receive “electric shock or any other type of memory-altering treatment.” The psychiatrist explains to him that his mother is willing to take medication and discusses options for treatment. Given the severity of her depression and presence of psychotic symptoms, she is a candidate for electroconvulsive therapy (ECT) but may respond well to a trial of medication.

Mrs. P is started on venlafaxine 75 mg daily for depression and olanzapine 5 mg for psychotic symptoms. Over the next 2 weeks the venlafaxine dose is titrated to 225 mg daily and olanzapine to 15 mg at bedtime. While Mrs. P becomes more ambulatory, she continues to appear depressed and focused on delusions of being unable to eat solid food. She drinks liquid nutritional supplements and gains 2 pounds. Her self-care remains poor, and she continues to require assistance in order to bathe or dress. A family meeting is held with Mrs. P and her son before he returns to Iraq. Due to the patient’s severe depression with psychotic symptoms, ECT is again discussed as a treatment option. Mr. P remains adamant that he would rather see his mother in a nursing home than “have her brain fried.”