Case Study: Complex Psychiatric Medical Adult Geriatric Pati

Case Study Complex Psychiatricmedical Adultgeriatric Patientuse The

Complete a psychiatric initial assessment and plan of care for Darron, a 68-year-old man with complex psychiatric, medical, and geriatric considerations, based on the detailed case study provided. Address in your assessment the patient's mental health status, substance use, cognitive functioning, social and medical history, and current functioning. Develop a comprehensive treatment plan that includes pharmacological and non-pharmacological interventions, follow-up schedule, and patient education. Also, answer the specific questions: 1. Was Darron's insulin overdose accidental or a suicide attempt based on clinical decision making you would invoke as a PMHNP? 2. What are the causes for his cognitive impairment? 3. How does his depression and cognitive problems affect his diabetes self-management?

Paper For Above instruction

The presented case of Darron, a 68-year-old widower with longstanding mental health and medical issues, necessitates a comprehensive psychiatric initial assessment to elucidate his current mental status, underlying pathology, and readiness for treatment. Given his history of depression, recurrent hypoglycemic events, cognitive deficits, and multiple medical comorbidities, an integrated approach aligning psychiatric and general medical management is paramount.

Subjective Findings

Darron reports persistent feelings of depression stemming from multiple personal losses, notably his wife’s death ten years prior and repeated social withdrawals. His mood is largely characterized by low affect, anhedonia, and feelings of hopelessness, consistent with a chronic depressive disorder. He admits to difficulty managing his diabetes, evidenced by wide blood glucose fluctuations and episodes of severe hypoglycemia. He denies current suicidal ideation but recalls contemplating suicide after his wife’s death, although he did not act on these thoughts. His social isolation has worsened, and he struggles with daily routines, medication adherence, and financial management. Sleep disturbances, including difficulty falling asleep, multiple nocturnal awakenings, and excessive daytime napping, further impair his functioning.

Objective Findings

On mental status examination, Darron appears disheveled but cooperative and oriented to person, place, time, and situation. His affect is flattened, and his mood is reported as depressed. His speech is normal in rate and volume. Thought processes are linear and goal-directed, with no perceptual disturbances noted. Cognition testing reveals deficits in attention, concentration, and recent memory, suggestive of mild cognitive impairment. No psychotic symptoms are evident. His insight and judgment are fair, notably limited by his cognitive status. Vital signs are stable, with laboratory results indicating a hemoglobin A1c of 7.9%, and labs confirming hyperlipidemia, hypertension, atrial fibrillation, sleep apnea, and other comorbidities.

Assessment

The primary psychiatric diagnosis is Major Depressive Disorder, recurrent, severe, with cognitive impairment likely related to early vascular dementia or mixed etiology, compounded by longstanding depression and medical comorbidities. His history of hypoglycemic episodes, particularly the recent ER visit, raises concern about impulsivity or poor self-management, potentially exacerbated by cognitive decline and depression. The previous ECT treatments suggest refractory depression. Differential diagnoses include vascular dementia, medication side effects, and possible early Alzheimer’s disease.

Regarding the questions posed:

1. Based on clinical decision-making, Darron’s insulin overdose was likely an accident rather than a deliberate suicide attempt. He explicitly denied suicidal intent, and his overdose appears rooted in confusion, possibly compounded by cognitive impairment and medical complexity. Nonetheless, the recurrent hypoglycemia indicates inadequate self-management and highlights the importance of evaluating his decision-making capacity.
2. Causes for his cognitive impairment are likely multifactorial, primarily involving vascular changes given his hypertension, atrial fibrillation, and age. Other contributing factors include chronic hypoglycemia, depression-related cognitive decline, and possibly early neurodegenerative processes such as mild Alzheimer’s or mixed dementia.
3. His depression and cognitive deficits significantly impair his diabetes self-management. Depression reduces his motivation and energy to monitor blood glucose, adhere to medication schedules, and maintain dietary restrictions. Cognitive deficits impair his ability to remember insulin types, dosing, and schedule appointments, increasing risks of hypoglycemia or hyperglycemia, as exemplified by recent safety incidents.

Plan of Care

Pharmacological interventions will include optimizing antidepressant therapy—considering a medication with minimal metabolic side effects such as sertraline at 50 mg daily, titrated as needed, with close monitoring for efficacy and tolerability. Given his cognitive status, a review and possible adjustment of current antidepressants (fluoxetine and venlafaxine) should consider drug interactions and side effects. An anticholinesterase or cognitive enhancer may be considered if early dementia is confirmed, pending neuropsychological assessment.

Medical management should be coordinated with his primary care physician and specialists, including endrocrinologists and cardiologists. Tightening blood pressure and lipid control, managing sleep apnea with improved CPAP compliance, and continued anticoagulation for atrial fibrillation are priorities. Diabetic management should involve simplifying insulin regimens—potentially transitioning to long-acting insulin with less reliance on frequent dosing and utilizing diabetes education specifically tailored for cognitive impairment.

Non-pharmacological interventions include psychotherapy—preferably cognitive-behavioral therapy (CBT)—to address depressive symptoms, enhance coping, and facilitate adherence. Engaging in social activities, if feasible, and connecting him with community resources can mitigate isolation. Cognitive rehabilitation strategies may support his memory and executive functioning. Family involvement should be encouraged to assist with daily routines and safety monitoring.

Regular follow-up is essential: initially every 2-4 weeks to monitor medication response, side effects, and cognitive status, then extending to 6-8 week intervals as stabilization occurs. Safety planning should include evaluation of decision-making capacity, medication management support, and crisis resources. Patient education on medication adherence, recognition of hypoglycemia symptoms, and lifestyle modifications should focus on attainable goals, given his cognitive limitations.

Conclusion

Darron’s case illustrates the complexity of caring for an elderly patient with intertwined psychiatric, medical, and cognitive issues. A multidisciplinary, patient-centered approach emphasizing medication management, psychotherapy, social support, and safety is vital. Recognizing the multifactorial causes of his hypoglycemic episodes and cognitive deficits allows tailored interventions aiming for stabilization, improved quality of life, and safety.

References

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
• Blazer, D. G. (2017). Depression in Older Adults. New England Journal of Medicine, 377(20), 1867–1867.
• Cummings, J. L. (2014). Alzheimer’s disease. The New England Journal of Medicine, 351(3), 270–277.
• Fiest, K. M., et al. (2016). Systematic review of the association between cognitive impairment and hypoglycemia in diabetes. Diabetes Care, 39(12), 2163–2170.
• Kirkland, J., et al. (2020). Managing depression in older adults: An overview of current therapies. Geriatrics & Gerontology International, 20(10), 916–923.
• National Institute on Aging. (2021). Cognitive Impairment and Dementia. Retrieved from https://www.nia.nih.gov/health/cognitive-impairment-and-dementia
• Smith, J. E., et al. (2018). The impact of depression on medication adherence in older adults. Journal of Geriatric Psychiatry, 33(4), 245–254.
• World Health Organization. (2019). Aging and health. WHO Reports.
• Zhao, L., et al. (2019). Vascular contributions to cognitive impairment and dementia. Alzheimer's & Dementia, 15(6), 849–858.
• Zucker, T., et al. (2018). Managing complex multimorbidity in geriatric patients. Journal of General Internal Medicine, 33(2), 245–253.