Past Case 4: Depression with melancholia

Question 1

You undertake a GP home visit to see Mr Fred Blake, an 80 year old recently widowed retired plumber living at Sunnyvale Gardens Nursing home. Fred has been a resident for two months following his discharge from hospital after a complicated neck of femur fracture. He had previously lived independently, enjoying an active retirement. Since his fall he has been frail and has required a walking frame because of his painful hip and loss of strength and has needed assistance with several ADLs including managing medication, preparing meals and some prompting/supervision for self-care including showers. The staff has noted that Fred has been increasingly miserable, withdrawn and anxious, particularly in the mornings. He appears slowed in his movements and speech. His appetite is poor with 10kg weight loss since admission. He only rarely comes out of his room, sleeps poorly and wakes regularly at 3am. His only pleasure is the weekly visits by his daughter and grandchildren. He still misses his wife but accepts her loss. He is frustrated at the loss of his previous fitness and independence and feels hopeless about the future. He often wishes he would just not wake up in the morning.

Answer 1

Impression
- summary: significant symptoms of depression in elderly male since onset of physical ailments preventing normal activities, features of melancholia with morning sx and psychomotor retardation, late insomnia, >2 weeks.

Given these symptoms, am concerned about melancholic depression as my provisional diagnosis. Important differentials and diagnostic considerations include;

• Other mood: MDD, PD, BD, dysthymia, adjustment disorder. Consider whether normal bereavement (however unlikely given significant impact on function)
• Consider organic causes: Dementia, hypoactive delirium (unlikely given consciousness intact), cancer (given weight loss), medication alteration/interaction
• Rule out psychosis, has implications for treatment

Would want to conduct complete psychiatric assessment, in particular a rigorous risk assessment for acute risk for TOSH/SI

Question 2

Melancholic depression - History

Answer 2

History

• Sx: investigate depression symptoms; worthlessness, hopelessness, anhedonia, withdrawal, sleep (early morning), appetite, weight, movement, mood, time duration, guilt
• risk assessment; TOSH, SI, concrete plans, previous attempts, fam hx of suicide
• screen for: psychotic features, mania, violence
• ask about; causes of dementia, causes of delirium
• ask about substance use
• medications
• PMHX, FamHx, Developmental, forensic, social

Atypical presentations in the elderly should indicate the need for further investigation, as may represent an organic cause rather than psychiatric.

Question 3

Melancholic depression - Examination

Answer 3

Examination
MSE
- A/B: psychomotor slowed, stooped posture, downcast gaze, no eye contact
- M/A: depressed, blunted
- S: reduced rate, single words, slowed, low volume
- TC: TOSH, SI, negative/depressed
- P: normal
- I/J: variable
- C: may have impairment, would require formal assessment

Would conduct assessment using MMSE or MOCA to formally assess patients cognition at this point

Other examination:

• general obs + vitals + anthropometric for baseline
• systems review

Question 4

Melancholic depression - Investigations

Answer 4

Investigations
Are mainly geared around ruling out organic causes of the presentation in this elderly patient.

• bedside: urinalysis + drug screen, ECG, vitals
• bloods: FBC, UEC, LFT, CRP/ESR, B12/Folate, TSH, lipid panel, iron studies?
• Imaging: CT/MRI-brain

Question 5

Melancholic depression - Management

Answer 5

Management
Would want the involvement of older person mental healthcare team including psychiatrist/pschogeriatrician, GP, psychologist, social worker, nursing home staff etc

Safety/Risk assessment

• Assess cognition + capacity
• Risk of suicide/self harm - management setting would depend on the degree of risk of this occurring.

Setting/location

• Given significant sx and impairment with considerable risk of suicide, would want to schedule and manage the patient on an inpatient basis. Would of course try to have patient on voluntary basis, but would schedule if not in agreeable
• would consider treating whilst on nursing home, depending on their available resources

Biological
Melancholic depression requires pharmacological treatment
1) SSRIs or SNRIs in elderly (sertraline, citalopram; have best evidence in the elderly), avoid fluoxetine in elderly due to longest half-life. Would want to consider lower doses depending on liver/kidney function
A/E to consider;
- SIADH/hypontraemia in elderly
- GIT: N/V/D
- increased risk of BLEEDING
- sexual dysfunction
- increased suicidality
- serotonergic syndrome
- CNS: restlessness, tremor, insomnia, headache
2) NaSSA (mirtazapine)
3) ECT/TMS if no response to antidepressants, is safe in elderly

• would ensure other medical issues are also addressed appropriately; particularly regarding physical health given it is major trigger for illness.

Psychological

• therapeutic alliance + rapport
• psychoedication
• CBT (12-20 sessions); de-arousal, cognitive challenging, graded exposure
• grievance counselling
• psychology referral

Social

• social supports, nursing home activities?
• GP review/
• guardianship/enduring power of attorney
• level of care in nursing home ?escalation
• optimise the sleeping environment