case presentation geriatric depression

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CASE PRESENTATION Presenter : Kapil S. Kulkarni Moderator : Dr. C. Pinto, Dr. J.P. Rawat Dept of Psychiatry JRH, BCT.

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Its case of depression in old age. Its case o agitated depression in old age.

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Page 1: Case presentation geriatric depression

CASE PRESENTATION

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

Page 2: Case presentation geriatric depression

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

Page 3: Case presentation geriatric depression

•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

Page 4: Case presentation geriatric depression

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.

Page 5: Case presentation geriatric depression

•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.

Page 6: Case presentation geriatric depression

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.

Page 7: Case presentation geriatric depression

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.

Page 8: Case presentation geriatric depression

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.

Page 9: Case presentation geriatric depression

Physical Examination

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

Page 10: Case presentation geriatric depression

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

•Systemic Examination- No abnormality was detected in systemic clinical

examination.

Page 11: Case presentation geriatric depression

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.

Page 12: Case presentation geriatric depression

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

Page 13: Case presentation geriatric depression

•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.

Page 14: Case presentation geriatric depression

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

Page 15: Case presentation geriatric depression

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

Page 16: Case presentation geriatric depression

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.

Page 17: Case presentation geriatric depression

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.

Page 18: Case presentation geriatric depression

•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

Page 19: Case presentation geriatric depression

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.

Page 20: Case presentation geriatric depression

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.

Page 21: Case presentation geriatric depression

•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.

Page 22: Case presentation geriatric depression

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.

Page 23: Case presentation geriatric depression

Depression: A global crisis