Psychiatry

76 yo woman with inpatient psych consult for depression

Carrie Tamarelli on Jul 11, 2018 - University of Michigan
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A 76-year-old woman with history of hypertension, hyperlipidemia, and mitral valve replacement is diagnosed with endocarditis and admitted for extended treatment with IV antibiotics. After several days, her daughter talks with the medicine team after rounds because she is worried that her mother is becoming depressed about the long hospital stay and is no longer her cheerful, conversational self. She has napped much of the last two days with poor sleep at night and no longer seems to enjoy her daughter’s visits. Per nursing records, her oral nutritional intake has dropped sharply, and she requires significant encouragement to complete even 25-50% of her meals.

She has no personal history of psychiatric diagnoses or treatments. Her family history is significant for dementia in her father and older sister.

Psychiatry has been consulted for evaluation and management of depression. On exam, she is a frail appearing woman in no acute distress. She is cooperative with interview, though speech is sparse. Affect is flat with mood reported as “fine.” Thought process is tangential. She denies thoughts of suicide. She is alert and oriented to self, but she is unable to tell you the date or where she is. 

What diagnosis do you suspect?

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Dementia – what bedside screening tool would support this diagnosis?
Not necessarily. MOCA is a screening tool for dementia, but it may not be valid in this setting. Although she may have underlying cognitive impairment, more information about her baseline BEFORE entering the hospital would be needed to make this diagnosis and another answer choice is more appropriate.

Major depressive episode – what bedside screening tool would support this diagnosis?
Probably not (more information below), though it would be appropriate to administer the PHQ-2, PHQ-9, or the Geriatric Depression Scale. Although you were consulted for management of depression, another diagnosis is more appropriate at this time.

None, this is a normal reaction to hospitalization
No. Although everyone reacts to hospitalization differently, her symptoms are not normal. Beware minimizing these symptoms and missing this diagnosis.

Delirium, hypoactive type – what bedside screening tool would support this diagnosis?
Yes. Several screening tools are available for delirium, including CAM (which has multiple forms for various settings, including the ICU) and the Delirium Rating Scale. Attention may also be tested on mental status exam using serial sevens, spelling world backwards, or giving days of the week backwards. Of note, positive frontal release signs, such as the palmomental reflex, can support a diagnosis of delirium (see an example in the youtube video below)

In one study, over 40% of patients over 60 years of age who received inpatient referrals for depression were more appropriately diagnosed with delirium [1]. Delirium is on of the “3 D’s of geriatric psychiatry” (delirium, depression, and dementia) [2]. Table 1 by Downing et al. (reproduced below) shows some of the key distinguishing features among these three diagnoses [2]. Patients with dementia do have increased risk of developing delirium [3], so using a MOCA on admission to screen for dementia can be helpful to predict risk. Delirium has long been associated with worse outcomes and longer hospital stays, so prevention and early identification is important [4]. Hypoactive delirium is more common than hyperactive delirium, but hyperactive delirium is more likely to be recognized and diagnosed due to behavioral disturbances noticed by staff [5].

Of note, positive frontal release signs, such as the palmomental reflex, can support a diagnosis of delirium (see an example in the youtube video below).

[1] Farell KR, Ganzini L. Misdiagnosing delirium as depression in medically ill elderly patients. Arch Intern Med. 1995. 155(22):2459-2464.

[2] Downing LJ, Caprio TV, and Lyness JM. Geriatric psychiatry review: Differential diagnosis and treatment of the 3 D’s – Delirium, Dementia, and Depression. Curr Psych Rep. 2013. 15:365.

[3] Inouye SK, Westendorp RG, and Saczynski JS. Delirium in elderly people. Lancet. 2014. 383(9920): 911-922.

[4] Lipowski ZJ. Delirium in the elderly patient. N Engl J Med. 1989. 320:578-582.

[5] Hosker C and Ward D. Hypoactive delirium. Brit Med J. 2017. 357:online.

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A 76-year-old woman with history of hypertension, hyperlipidemia, and mitral valve replacement is diagnosed with endocarditis and admitted for extended treatment with IV antibiotics. After several days, her daughter talks with the medicine team after rounds because she is worried that her mother is becoming depressed about the long hospital stay and is no longer her cheerful, conversational self. She has napped much of the last two days with poor sleep at night and no longer seems to enjoy her daughter’s visits. Per nursing records, her oral nutritional intake has dropped sharply, and she requires significant encouragement to complete even 25-50% of her meals.

She has no personal history of psychiatric diagnoses or treatments. Her family history is significant for dementia in her father and older sister.

Psychiatry has been consulted for evaluation and management of depression. On exam, she is a frail appearing woman in no acute distress. She is cooperative with interview, though speech is sparse. Affect is flat with mood reported as “fine.” Thought process is tangential. She denies thoughts of suicide. She is alert and oriented to self, but she is unable to tell you the date or where she is. 

What diagnosis do you suspect?

Expand all answers
Dementia – what bedside screening tool would support this diagnosis?
Not necessarily. MOCA is a screening tool for dementia, but it may not be valid in this setting. Although she may have underlying cognitive impairment, more information about her baseline BEFORE entering the hospital would be needed to make this diagnosis and another answer choice is more appropriate.

Major depressive episode – what bedside screening tool would support this diagnosis?
Probably not (more information below), though it would be appropriate to administer the PHQ-2, PHQ-9, or the Geriatric Depression Scale. Although you were consulted for management of depression, another diagnosis is more appropriate at this time.

None, this is a normal reaction to hospitalization
No. Although everyone reacts to hospitalization differently, her symptoms are not normal. Beware minimizing these symptoms and missing this diagnosis.

Delirium, hypoactive type – what bedside screening tool would support this diagnosis?
Yes. Several screening tools are available for delirium, including CAM (which has multiple forms for various settings, including the ICU) and the Delirium Rating Scale. Attention may also be tested on mental status exam using serial sevens, spelling world backwards, or giving days of the week backwards. Of note, positive frontal release signs, such as the palmomental reflex, can support a diagnosis of delirium (see an example in the youtube video below)

In one study, over 40% of patients over 60 years of age who received inpatient referrals for depression were more appropriately diagnosed with delirium [1]. Delirium is on of the “3 D’s of geriatric psychiatry” (delirium, depression, and dementia) [2]. Table 1 by Downing et al. (reproduced below) shows some of the key distinguishing features among these three diagnoses [2]. Patients with dementia do have increased risk of developing delirium [3], so using a MOCA on admission to screen for dementia can be helpful to predict risk. Delirium has long been associated with worse outcomes and longer hospital stays, so prevention and early identification is important [4]. Hypoactive delirium is more common than hyperactive delirium, but hyperactive delirium is more likely to be recognized and diagnosed due to behavioral disturbances noticed by staff [5].

Of note, positive frontal release signs, such as the palmomental reflex, can support a diagnosis of delirium (see an example in the youtube video below).

[1] Farell KR, Ganzini L. Misdiagnosing delirium as depression in medically ill elderly patients. Arch Intern Med. 1995. 155(22):2459-2464.

[2] Downing LJ, Caprio TV, and Lyness JM. Geriatric psychiatry review: Differential diagnosis and treatment of the 3 D’s – Delirium, Dementia, and Depression. Curr Psych Rep. 2013. 15:365.

[3] Inouye SK, Westendorp RG, and Saczynski JS. Delirium in elderly people. Lancet. 2014. 383(9920): 911-922.

[4] Lipowski ZJ. Delirium in the elderly patient. N Engl J Med. 1989. 320:578-582.

[5] Hosker C and Ward D. Hypoactive delirium. Brit Med J. 2017. 357:online.

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