Case presentation geriatric depression

CASE PRESENTATION

Presenter : Kapil S. KulkarniModerator : Dr. C. Pinto, Dr. J.P. RawatDept of PsychiatryJRH, BCT.

History•A 57 yr old, Known diabetic & hypertensive, Right handed, Marathi speaking, Married, Hindu male, Working as Sr. Khalasi, Residing in Bhayandar•Complaints- Self- Loss of interest in work Ghabrahat

•Objective Data- Son & wife (Adequate, Reliable)•H/o- Sadness of mood. Minimal communication. Disturbed sleep (Excess for few weeks &

d decreased for few weeks)

Irritability Muttering & gesticulating to self •Total duration- 2-3 yrs

ODP•Patient was alright 3 yrs back.•Symptoms started gradually without any stressor and

progressed over period of time.•He started saying that he has lost interest in work. He was planning to take VRS and sit at home.•Sleep was becoming irregular and appetite was

increased.

•There was occasional forgetfulness.•He was feeling that people were talking about him.•Patient was gesticulating to himself sometimes.

(praying to god, counting finger)•He was never treated for the illness.

Negative History

•No h/o Hearing of voices, loss of self care.•No h/o Elated mood or big talk.•No h/o Suicidal attempt.•No h/o Seizure or any neurological disorder.•No h/o Cognitive decline. •No h/o Repeated checking or hand washing.•Pt has h/o occasional social drinking of alcohol in

past. But no consumption since last 8 yrs.

Past & Family History

•No h/o similar complaints in past.•But there is positive h/o mental illness in family. His

father developed abnormal behavior at the age of 70 yrs i/f/o suspiciousness, bizarre behavior, running away from home.

Personal History

•Birth details not available.•Studied up to 8th (failed in 9th)•Married in 1987.• Joined Railway in 1982 as Khalasi. Promoted to Sr.

Khalasi in 2009. No awards or charge sheet given. •His social behavior was normal but having minimal

social interactions. He was anxious & avoidant. He always preferred to be alone. He had minimal

communication.

Physical Examination

•General Examination- Conscious, co operative & well oriented. Built is average. Pulse- 84/min BP-140/90 mmHg RR- 16/min

•Neurological Examination- Higher function Motor system Sensory system All within normal limits.

•Systemic Examination- No abnormality was detected in systemic clinical

examination.

Mental Status Examination•General Appearance Conscious, co operative but had limited

communication. He was restless. Fidgedity was present. His dressing and grooming was proper.•Eye to eye contact Initiated but could not be maintained.•Rapport Established & maintained.

•Attention Arousable & sustained.•Mood Sad & anxious•Affect Appropriate to mood.•Speech Continuous, coherent & relevant. Speech decreased in amount.

•Thought Patient had ideas of hopelessness, helplessness &

worthlessness. He was feeling that life is not worth. Delusions were absent. But ideas of reference were present. Concepts Both simple and abstract thinking were intact.•Perception No perceptual abnormality was present.

•Memory Registration 3/3 Recall 1/3 Recent & remote memory intact.•Orientation To time, place and person was present.• Intelligence Average

• Judgment Both social & test judgment intact.• Insight 3/6 (Claims disease as a physical illness)

Differential Diagnosis

•D/D can be- 1) Agitated depression. 2) Double depression. 3) Major depressive disorder with psychotic

features. 4) Early features of dementia. 5) Malingering.

Investigations

•All routine blood & urine investigations- Normal •Dementia work up- VDRL, HIV ELISA, Sr. Homocystine Sr. Folate, Sr.

Vit B12 – All WNL.•Fundus examination- Normal.•MRI Brain- Normal.•ECG, X-ray chest- Normal.

•PSYCHOMETRIC ASSESSMENT- •ROR- Thought productivity- Below average. Reality ties good. Current psychopathology s/o depression.•BPRS- 38 (Significant psychopathology) •HDRS- 27 (Moderate to severe depression)•SAPS- 12 (Positive symptoms of schizophrenia)•SANS- 14 (Negative symptoms of schizophrenia)•MMSE- 26/30

Diagnosis•DSM IV TR•AXIS I- Agitated Depression.•AXIS II- Cluster C traits present.•AXIS III- DM, HTN (well controlled)•AXIS IV- No stressors.•AXIS V-GAF 61-70 at present & 71-80 before 1yr.

Treatment

•Patient was treated on OPD basis.•PHARMACOTHERAPY- He was started on Tab. Escitalopram 10mg (1-0-0) It was increased to 20 mg after 3 weeks. Tab. Lorazepam 2mg (0-0-1) was added for sleep.

•FAMILY PSYCHOEDUCATION- Family members were educated regarding illness,

their role in treatment & correct approach to interact with patient.

• INDIVIDUAL APPROACH- Patient was made aware of his illness. He was taught

relaxation techniques to cope up the stress. In next sessions he is planed for cognitive & behavior

therapy.

Treatment Response

•Patient was 50% improved in 3 weeks.•He was >80% better in 6 weeks.•Currently he has finished 2 months treatment &

follows up in OPD regularly.

Depression: A global crisis