Geriatric Patient With Fatigue
MS3: Mrs S is a 65-year-old woman. Until 2 months ago, she hadn’t visited the clinic for over a year due to lapsed insurance. She couldn’t afford to pay out of pocket. This is her third visit in 2 months, since her health insurance was re-established.
Dr F: Unfortunately, finances can be a barrier to care for many patients. How is her health?
MS3: She is fairly healthy. She does have both hypertension and hyperlipidemia, but these are currently controlled with medications (hydrochlorothiazide, lisinopril, and simvastatin). Since getting insurance again, she has been taking medications well. She doesn’t need refills today. She did have one concern, but I wasn’t sure what to make of it.
Dr F: What was the concern?
MS3: Well, she said she has persistent fatigue that just wouldn’t go away. When I probed for possibly related symptoms, I didn’t come up with anything that made much sense to me.
Dr F: Tell me some more.
MS3: Okay. She doesn’t have systemic symptoms like fever, chills, or weight loss. No headaches or other neurologic complaints. No nausea, vomiting, or other digestive issues. No palpitations. No respiratory issues. No urinary tract complaints. Other than minor aches and pains (knees stiff in the morning), limited musculoskeletal complaints. I’m not sure why she’s fatigued, but she said it’s a big issue and has been going on at least for 6 months, if not a year.
Dr F: With middle aged and older patients, it’s helpful to think about the most likely reason for symptoms like fatigue. Common factors include physiologic (like anemia, hypothyroidism), medications (like beta blockers, or longer-acting benzodiazepines), or individual (like depression, anxiety, life stress). Let’s review her recent lab panels and medications before going in to speak with her together.
Dr F and his MS3 look up recent lab results in the electronic health record.
MS3: Well, it looks like her lab results since returning to the clinic in the past 2 months have been essentially normal, except for her LDL cholesterol.
Dr F: I agree. Her lab results have been normal (CBC, CMP, TSH, FT3, FT4, and UA) or corrected to normal in the case of her LDL cholesterol. What do these results suggest about her fatigue?
MS3: I guess that she has no obvious physical cause for her fatigue such as anemia, renal or liver problems, electrolyte imbalances, or hypothyroidism. Right?
Dr F: Yes, I agree. What about her current medications? Anything there that should make her fatigued?
MS3: I don’t think so.
Dr F: So, it seems like factors such as depression, anxiety, or life stress may be worth exploration with regard to Mrs S’s fatigue. How does that strike you?
MS3: What you say makes sense. I know that any adult can become depressed. But, she didn’t seem depressed to me. When I asked if she was depressed, she denied it. Your last two visit notes don’t mention depression.
Dr F: I agree with you. Her initial clinical data do not point toward depression. She has denied direct questions about depressed mood when previously asked. On the other hand, she continues to complain of fatigue and other factors such as physical causes and medication side effects seem less likely upon testing and medication review. I think we should revisit the issue with the patient and see what results.
They enter the room.
Dr F: Mrs S. it’s good to see you again. I was just discussing your situation with my medical student. Your blood pressure and cholesterol are looking great now. But you are still bothered by fatigue.
Mrs S: Yes, doctor. Did you tell him about how tired I am?
MS3: Yes ma’am, I did. Dr Freedy and I reviewed your labs and medications in an effort to make sense of your tiredness.
Mrs S: And?
Dr F: Well, feeling tired or having fatigue can be caused by several factors. Physical problems like a low number of red blood cells (anemia), low thyroid function (hypothyroidism), and kidney or liver problems might cause you to feel tired. But, for you, we know that all of your lab tests in the past 2 months looked for these causes, and the results were normal. Medications can also sometimes contribute. But, you are not on any medications that are typically associated with fatigue. Has your fatigue worsened since starting back on your medications in the past 2 months?
Mrs S: Not really. I’d say that I’m more tired now than I was 1 year ago, though. It’s been getting steadily worse for at least 6 months.
Dr F: Well, that leads us to the third area that may cause fatigue in your age group. Stress, depression, anxiety…these sorts of issues. How are things going in your life? Are you under an increased amount of stress lately?
Mrs S pauses as her eyes well up with tears. She stares straight ahead for a few seconds, looks at Dr F for a few seconds, and then looks down at the floor. She begins to speak.
Mrs S: So much has happened in the last year of my life that I don’t know where to start.
Dr F: Go on. What’s troubling you?
Mrs S: My daughter had a brain aneurysm repaired about 6 months ago. She’s fine now. But her husband couldn’t handle having a sick wife, and he took off. She’s got a young child, no job, no insurance. It’s just not fair, and I’m doing what I can to help her get over it and get back on her feet.
Dr F: Sounds difficult. Anything else?
Mrs S: Well, I’m going through my own divorce after 20 years of marriage. My marriage started to fall apart a few months before my daughter’s problems started. This is my second marriage, and I didn’t expect it to end up in a divorce. My first marriage ended when my husband died from a heart attack.
Dr F: I am sorry. How has all of this affected your finances?
Mrs S: Well, it had everything to do with my lapse in insurance. I’m now back to work after 20 years and just got my insurance benefits, so I’ve come back to the clinic for the sake of my own health. My husband moved out about 6 months ago, and I can’t afford our house alone, so I think I’m going to have to sell it and move out. It’s really not a good time at all for me. I don’t know how all of this will turn out.
Symptoms of depression. She expressed the following symptoms: depressed mood, anhedonia, insomnia, psychomotor retardation, fatigue/low energy, feelings of worthlessness, reduced concentration, but no suicidal thoughts. The patient was educated regarding symptoms of depression and appropriate treatment (including medication and psychotherapy). Based on her treatment preference, she was started on the following medication: Citalopram 10 mg po qday and Zolpidem 5 mg po qhs prn. She is to return to see Dr F within 2–3 weeks. At that time, if she is tolerating the Citalopram, the plan is to increase her dose to 20 mg po qday with a repeat visit in another 2–3 weeks. It is expected that she may use Zolpidem 5 mg po qhs prn intermittently over the next 4–6 weeks while awaiting a therapeutic response to Citalopram. Frequent, supportive, problem-focused physician visits and encouragement toward remaining active are also part of her initial depression treatment plan.) After Mrs S left the consultation to reschedule her next appointment, Dr F and MS-3 sat down to discuss the consultation. This discussion emphasized relevant facts to keep in mind regarding geriatric depression. The following teaching points were offered to MS-3:
- Up to one third of geriatric primary care consultations involve depression
- Chronic medical problems increase the probability for depression (eg, CAD, CVA, cancer, dementia, Parkinson’s Disease)
- Other risk factors for geriatric depression (eg, acute illness, hospitalization, functional decline, bereavement or other loss events, or prior depression, including minor depression)
- Minor depression: natural course of minor depression is 1–2 years of symptoms and functional impairment; up to 50% with minor depression go on to develop major depression
- Tips for managing geriatric depression 1-3
- Educate patient and family/caregivers regarding diagnosis and treatment (both medications and psychotherapy are geriatric treatment options)
- Treat comorbid physical illnesses to maximize function
- Assess psychosocial status and social support network (consider activating sources of support)
- SSRIs are first line agents (“start low and go slow” in terms of dosing selection and changes)
- 6–12 weeks to achieve a treatment response (40% will respond to first agent used)
- Monotherapy preferred in elderly due to possibility of drug-drug interactions
- Consider costs (eg, the following agents are currently on the Walmart $4 list for a 30-day supply: Citalopram, Fluoxetine, Paroxetine, and Trazodone)
- Recurrence common with geriatric depression
- First episode = treat for 12 months with an antidepressant
- Second episode = treat for 12–24 months
- Third episode = treat for 3 or more years
- Consider ECT for patients with severe, non-responsive depression (predictors of positive ECT response: >60 years old, delusions, psychomotor retardation, early morning awakening, and family history of depression)
- Geriatric suicide is particularly lethal (males >65 years 67/100,000, females >65 years 30/100,000)
- Take risk of geriatric suicide seriously
- Assess and treat depression (assessing suicidality is part of depression assessment)
John R. Freedy, MD, PhD, Medical University of South Carolina, Author
Alec Chessman, MD, Medical University of South Carolina, Editor
- Birrer RB, Vemuri SP. Depression in later life: a diagnostic and therapeutic challenge. Am Fam Physician 2004;69:2375-82.
- M, Ten Have TR, Reynolds CF III, et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients. JAMA 2004;291:1081-91.
- Sharp LK, Lipsky MS. Screening for depression measures across the lifespan: a review of measures for use in primary care settings. Am Fam Physician 2002;66:1001-8.
- Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: a systematic review. JAMA 2005;294:2064-74.
- Stoval J, Domino FJ. Approaching the suicidal patient. Am Fam Physician 2003;68:1814-8.
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