Case: An Elderly Widow Who Just Lost Her Spouse ✓ Solved

Case An Elderly Widow Who Just Lost Her Spouse

An elderly widow who just lost her spouse presents to your primary care office today with chief complaint of insomnia. The patient is a 75-year-old female with a past medical history of diabetes mellitus (DM), hypertension (HTN), and major depressive disorder (MDD). Her husband of 41 years passed away 10 months ago, after which her depression and sleep habits worsened. The patient has no previous history of depression prior to her husband’s death and denies any suicidal ideations. She currently has a medication regimen that includes Metformin, Januvia, Losartan, HCTZ, and Sertraline. Current clinical data shows her weight at 88 kg, height at 64 inches, temperature at 98.6 degrees Fahrenheit, and blood pressure at 132/86.

Questions for the Patient

1. How have your sleeping patterns changed since your husband's passing?

This question can help understand the severity of her insomnia, as changes in sleep patterns can both indicate worsening depression and impact quality of life.

2. Have you experienced any changes in your appetite or energy levels?

Changes in appetite or energy can be indicative of depression severity and can also impact treatment choices.

3. How are you coping with the loss of your husband on a daily basis?

This question provides insight into her emotional state and coping mechanisms, which are crucial for managing her mental health.

Feedback from Loved Ones

To further assess the patient's situation, it would be essential to speak with her family members or close friends. The following questions could be asked:

1. How have you seen her change since her husband's death?

This can reveal behavioral changes and emotional responses that the patient may not fully disclose during her appointment.

2. What support systems does she currently have in place?

This question aims to assess her social support network, which is crucial for recovery from depression.

3. Have there been any incidents of concerning behavior or statements made by her?

This will help to consider any risks of suicidal ideation that she may not have expressed directly.

Physical Exams and Diagnostic Tests

Appropriate physical exams include a comprehensive psychiatric evaluation to assess depression severity using standardized scales such as the PHQ-9. Additionally, a physical exam may include checking for any signs of physical illness that could contribute to the patient's depressive symptoms, like thyroid dysfunction. Laboratory tests to assess thyroid function, complete blood count, and metabolic panel would be beneficial in ruling out any contributing medical conditions.

Differential Diagnosis

1. Major Depressive Disorder

2. Adjustment Disorder with Depressed Mood

3. Hypothyroidism

4. Anemia

5. Generalized Anxiety Disorder

The most likely diagnosis is Major Depressive Disorder, given the patient's lack of prior history of depression and the clear temporal relationship with her husband's passing.

Pharmacologic Agents

Two appropriate pharmacologic agents for antidepressant therapy would be:

1. Sertraline 100 mg daily (already prescribed, consider dose adjustment)

2. Escitalopram 10 mg daily

Sertraline, a selective serotonin reuptake inhibitor (SSRI), works by increasing serotonin levels in the brain. Escitalopram also raises serotonin levels but with a slightly different mechanism which may result in fewer side effects for some patients. Choosing Sertraline over Escitalopram could be based on the patient's previous response to the medication, if any, and considering the side effects she has experienced.

Contraindications and Ethnicity Considerations

Potential contraindications for Sertraline may include a history of bleeding disorders, as SSRIs can affect platelet aggregation. Given the patient’s advanced age, care must be taken not to initiate therapy without considering her comprehensive medical history and potential drug interactions.

Ethnic differences in drug metabolism can also affect dosing. For example, some individuals of Asian descent metabolize SSRIs differently, potentially leading to increased serum levels and side effects. Therefore, careful monitoring and possible dose adjustments are warranted.

Checkpoints and Follow-ups

Regular follow-up is essential, with checkpoints occurring at Weeks 4, 8, and 12 after treatment initiation. During these follow-up visits, the clinician should assess for symptom improvement, side effects, and overall treatment adherence. Adjustments to the treatment plan may include changing medications or dosages depending on the patient's therapeutic response.

Conclusion

In summary, treating elderly patients experiencing grief-related psychological symptoms requires a comprehensive and empathetic approach. Thorough assessments, involvement of family members, careful consideration of pharmacological treatments, and patient-specific monitoring plans are essential for successful outcomes.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
• Hankin, B. L., & Abela, J. R. (2005). Development of psychopathology: An ecological-systems perspective. Annual Review of Clinical Psychology, 1, 185-211.
• National Institutes of Health. (2020). Treatment of depression in older adults. Retrieved from https://www.nimh.nih.gov.
• Gonzalez, J. S., et al. (2013). Depression and diabetes treatment: A systematic review and meta-analysis. Diabetes Care, 36(5), 1098-1107.
• Schaffer, J. R., et al. (2015). Antidepressants for the treatment of depression in adults. American Family Physician, 92(9), 781-788.
• Singh, A. B., & Sharma, R. K. (2021). Ethnic diversity in the pharmacogenetics of antidepressant response. Pharmacogenetics and Genomics, 31(5), 129-140.
• The American Journal of Geriatric Psychiatry. (2014). Depression in older adults. Retrieved from https://www.ajgp.com.
• Canadian Mental Health Association. (2019). Depression: Information for adults. Retrieved from https://cmha.ca.
• Druss, B. G., et al. (2011). Medical illnesses and depression: A global perspective. The American Journal of Psychiatry, 168(12), 1349-1355.
• Katon, W., & Ciechanowski, P. (2010). Depression and diabetes: A cooperative perspective. Journal of Clinical Psychology, 66(9), 1098-1107.