Transcript Depression and ECT in the Elderly final

Case Presentation
Dr Andrew Hill
GPST2
Dr Jackson/Routh team
Leverndale Hospital, Glasgow
76 yr old female
‘xx’
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PC: Initially presented to GP with anxiety and
panic attacks
HPC: Reviewed by GP on Day 0. Gave history
of several months. More rapid deterioration in
2/52 prior to presentation.
Problems multifactorial in origin
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Main concerns: anxiety, overvalued idea regarding
argument with neighbour. Suffering from panic attacks.
Also concern over mood. Appetite poor, weight loss
noted by family. Feelings of worthlessness. Sleep very
poor. Concentration poor. Loss of function and
behavioural change.
Started on mirtazepine 15mg nocte for ‘agitated
depression’. Further consultation prompted urgent
referral to CMHT
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Reached crisis. Was staying with daughter.
Wandered from house. Found in nearby field
near a river. Hypothermic. Intent unclear but
thoughts of wanting to die.
Assessed by Psychiatry. Discharged with local
follow-up.
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Reviewed by Dr xx and CPN (xx). Impression:
Severe depression with distress
Deterioration in mental state. Increasingly
withdrawn. Mood deterioration. Delusional
quality to beliefs re. neighbours.
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Day prior to admission family described as mute,
unresponsive. Eyes closed. Had to be lifted from
chair to bed. Sleepy.
Following day, increased agitation. For fixated
on delusions. Then 15:00 withdrawn and
unresponsive again. Mute with no interaction at
all.
Admitted as emergency to xx Hospital ~Day30
Past Psychiatric History
 Nil
Past Medical History
 Hypertension
 Retinal Vein Occlusion
 Varicose veins
Drug History
(Prior to admission)
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On repeat:
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Aspirin 75mg od
Simvastatin 20mg nocte
Losartan 50mg od
Acutes:
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Diazepam 2mg PRN
Mirtazepine 15mg nocte
NKDA
Family History
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Youngest of 4 siblings
All 3 brothers suffered from depression (all deceased
now)
Eldest brother committed suicide in 1984 by drowning.
Has also had ECT.
Mother: Suffered from mental health problems. No
known diagnosis. Died when xx was 13 years old in
Psychiatric Hospital ‘of starvation’
Father died of cancer
2 children with no mental health problems
Personal History
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Born and brought up in xxyy place, Ireland
Lived in isolated location
Mother died at young age. Little contact in 2 years prior
to this.
Good relationship with father. Happy childhood
despite difficulties. No abuse
Got on well at School. Left aged 14 and went to work
in local bakery.
Moved to Scotland when around 20 years old for ‘a
better life’. Worked in hotel as telephonist. Met
husband in 1962 in Scotland.
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Married 1965. 2 daughters (1965, 1967). Sadly, one
stillbirth (girl) 1969 and one son born 1970 (died at age
of 1 during operation).
Worked in various jobs. Latterly as Home help
organiser in Social Work department. Retired in 1996
Recently, declining health of husband. Main carer
following recent hip operation
Premorbid personality: ‘Solid’, ‘great organiser’. Private
person but good at making friends.
Social History
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Lives with husband in their own home
Independent
Retired but looks after husband
No financial concerns and no dependents
Non smoker. No alcohol. No drugs
No forensic history
Ongoing legal dispute with neighbours
Protective factors: important role in family. Strong
Catholic faith.
On examination (on admission to xx
Hospital)
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A&B: Casually dressed lady, moderate build.
Looks her age. In wheelchair. Eyes closed.
Showing no emotion. No interaction.
Obeying commands, then resumes previous
posture. Looks tense/rigid. Held arms in
position placed in during examination.
MSE Cont’d
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Speech: Mute. Prior to deterioration had been
slow and monotonous
Mood: Appears sad. Flattened affect.
Thought: Unable to assess. Delusional according
to history (persecutory, guilt)
MSE cont’d
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Perception: Not obviously responding to any
hallucinations
Cognition: Unable to assess. No concern from family.
Insight: Unable to assess. Prior to presentation had
shown some insight ‘this is what mental illness is like’
Risk: Risk regarding nutrition. No immediate risk of
DSH. However, previous act
Impression
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Differential diagnosis
Initial management plan
Ongoing assessment
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Physical examination unremarkable
Bloods reveal hyponatraemia (129), otherwise
normal. Normal urine and serum osmolalities.
?iatrogenic
Mirtazepine stopped (in part due to concern
from family re. psychosis)
PRN diazepam
Progress following admission
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Initial catatonic presentation seemed to resolve. Asking if she
had been in coma. Replaced by severe psychomotor retardation.
Flattened and restricted affect. Aware unwell but limited insight.
Attributed all problems to lack of sleep.
Next few days, deteriorating mental state. Delusions of guilt and
nihilistic delusions ‘I’m not real’, ‘You’re not real’. Sleep poor.
Started on diazepam and zopiclone
Fluctuating consciousness over next few days. One episode of
decreased responsiveness associated with urinary incontinence
Further Action
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13/8/12. Observed over weekend. Psychotic
Depression. Started on Sertraline.
EEG to exclude seizure activity
CT Brain
15/8/12. Deterioration. Refusing medications at
times. Refusing food. Detained on STC. Started
on olanzapine.
Ongoing treatment
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20/8/12. Decreased oral intake. No progress despite
good medication compliance. Decision made for course
of ECT (T4 then T3). ‘ECT doesn’t exist’ ‘My family
don’t exist’
24/8/12. Received first ECT. Patient has now had 7
treatments and has shown signs of improvement
4/9/12. CTO application made (granted 18/9/12).
10/9/12. Improvement noted. Improving sleep. Less
delusional. Better compliance. Sertraline increased.
Points of interest
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Unusual age of first presentation given family
history and significant stressors in life
Unusual presentation
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Catatonia