NUR 7633 Module 1 Late-Life Depression Case: GDS Screening, Collaborative Care and Safe Prescribing Example

Nine Pills and an Empty Chair: Screening, Treating and Following a 74-Year-Old Widower's Depression Through Collaborative Care

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7633: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Geriatric Population, Part A

Mentor Name

Month Day, Year

Nine Pills and an Empty Chair: Screening, Treating and Following a 74-Year-Old Widower's Depression Through Collaborative Care

A Year Since the Funeral

Walter is an invented patient, 74, who spent forty years as a machinist at a plant in Paterson. His wife, Irene, died fourteen months ago; he nursed her at home through two years of decline. His daughter brought him to his primary care visit because he has stopped going to the senior center where he played cards, eats one meal a day, sleeps most of the afternoon and has said more than once that he is "just waiting." He has lost fifteen pounds. He answers questions slowly and says he is not sad so much as empty.

His conditions include systolic heart failure, type 2 diabetes, hypertension, chronic kidney disease at stage 3 and osteoarthritis of both knees. He takes nine medicines, including metoprolol, lisinopril, furosemide, metformin, a statin, aspirin, a nightly diphenhydramine for sleep that he buys at the pharmacy, and acetaminophen. Since the funeral he has lived by himself, up a flight of stairs. He keeps his late wife's pain medicines in a kitchen drawer and has a hunting rifle in the closet from years ago.

Screening and Diagnosis

Yesavage et al. (1982) designed the Geriatric Depression Scale for older people, starting with 100 yes-or-no items given to older adults who were or were not depressed and keeping the 30 that tracked most closely with total scores. In new groups of older subjects classified by research criteria, the scale's scores matched the number of depressive symptoms as well as a clinician-rated Hamilton scale and better than a widely used self-rating scale. Its yes-or-no format avoids somatic items, such as fatigue or poor appetite, that often reflect medical illness in older patients.

On the 15-item short form Walter scores 11, well above the usual cut point of 5. The interview confirms major depression: low mood, loss of interest, weight loss, slowed movement, poor concentration, guilt about his wife's last months and recurring thoughts of death for most of the past year. His grief has not followed the softening course most grief takes, and the depressive symptoms now stand apart from missing her. A Montreal Cognitive Assessment score of 25 shows mild slowing but no clear dementia, which will be retested when his mood improves.

Suicide Risk

Older men who are widowed, live alone, have chronic illness and own firearms carry some of the highest suicide rates in the country, and Walter has every one of those features. He is asked directly. He admits he has wished he might simply not wake some mornings, has no plan and says his grandchildren keep him from acting. The risk is judged moderate. With his consent, his daughter removes the rifle to her home and returns his wife's old pain medicines to a pharmacy take-back box that week. A safety plan names his daughter, his pastor and the crisis line.

Medicines and Medical Illness

Kok and Reynolds (2017) reviewed the management of depression in older adults and found antidepressants effective, but with more adverse events in this age group because of medical illness and drug interactions. They advised screening each drug against lists of medicines that carry extra risk after 65, starting low and going slowly, and keeping psychotherapy, exercise and electroconvulsive therapy in view for people who prefer them or cannot tolerate drugs.

Walter's review finds the nightly diphenhydramine, a strongly anticholinergic drug that can cloud thinking, cause constipation and urinary retention and raise the risk of falls in older people. It is tapered over a week and replaced with a sleep plan. Sertraline is chosen as the antidepressant because it has few interactions with his heart medicines, a good record in people with heart disease and no need for dose changes in moderate kidney disease. It starts at half the usual adult dose and rises after two weeks. Sodium is checked at two and four weeks because older adults on furosemide and an antidepressant of this class can develop low sodium, and he is asked about bleeding because he also takes aspirin.

Collaborative Care

Unützer et al. (2002) randomized 1,801 primary care patients over 60, whose diagnoses were major depression, dysthymia or both, across 18 clinics in five states. For up to twelve months, each IMPACT patient had a depression care manager, backed by a consulting psychiatrist and a primary care lead, who taught, tracked scores, helped the family doctor adjust medicine and delivered short courses of problem-solving therapy. A year in, 45 percent of the care-managed group had seen their symptom scores halve or better, against 19 percent of those in usual care, with better function, quality of life and satisfaction with care.

Walter's plan follows that model. A care manager in his primary care practice calls him weekly for the first month, repeats the PHQ-9 every two weeks and enters each score in a shared registry that the psychiatric nurse practitioner reviews each week. If his score does not fall by half within ten to twelve weeks, the dose is raised or the plan changes. Six sessions of problem-solving therapy help him choose one small goal each week, starting with a single afternoon at the senior center with his daughter driving.

Grief and Daily Life

His grief is honored rather than treated as a symptom. His pastor, with Walter's permission, arranges a visit from a widowers' group. Meals on Wheels is started for weekday lunches while his appetite returns, and his daughter arranges a weekly call with his grandchildren. Gentle walking, starting with five minutes after lunch, is encouraged within his heart failure plan, and a physical therapy referral addresses his knees.

Conclusion

Walter has major depression late in life after his wife's death, found with the Geriatric Depression Scale and confirmed at interview, with moderate suicide risk that is lowered at once by removing the rifle and old medicines. A review of his nine medicines removes the diphenhydramine, and sertraline is chosen for its safety with his heart and kidneys, started low with sodium checks. Care follows the IMPACT model with a care manager, a registry and problem-solving therapy, and his grief, meals and movement are part of the plan. For the first quarter year, each visit rechecks his GDS, PHQ-9, sodium and safety plan.

References

Kok, R. M., & Reynolds, C. F. (2017). Management of depression in older adults: A review. JAMA, 317(20), 2114-2122. https://doi.org/10.1001/jama.2017.5706

Unützer, J., Katon, W., Callahan, C. M., Williams, J. W., Hunkeler, E., Harpole, L., Hoffing, M., Della Penna, R. D., Noël, P. H., Lin, E. H. B., Areán, P. A., Hegel, M. T., Tang, L., Belin, T. R., Oishi, S., & Langston, C. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. JAMA, 288(22), 2836-2845. https://doi.org/10.1001/jama.288.22.2836

Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M., & Leirer, V. O. (1982). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17(1), 37-49. https://doi.org/10.1016/0022-3956(82)90033-4