Gero Case

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Shikima

Shikima

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75 y/o M with no previous psychiatric history who undergoes general anes for prostate surgery who suddenly stops eating and drinking with some mild depression symptoms. SSRI, SNRI, Remeron and buspar are used as part of his therapy with minimal results. He shows up in the PCP's office with no food/water intake for the past 4 days and stopped all medications. PCP, former gasser, has seen this before in the elderly and hypothesizes that apotosis of neurons from the anes gases used coupled with the poor reserve of the elderly brain has contributed to this process.

Any ideas, theories and/or suggestions for treatment? New one for me.
 
First what's the mechanism and then what am I treating? I thought it was all related to depression, now I'm not so sure....
 
Is he living alone? He cant manage this. Does he need to be inpatient ?
Zyprexa to at least increase his appetite...
 
+1 for delirium. Depression leads to loss of appetite and in the elderly this progresses rapidly to either delirium or pseudodementia. Also, I would think of looking at any opiates prescribed for pain as potential culprits. Psychotherapy can also be very beneficial in this population so long as it is concrete and solution focused, he might be having difficulty with any side effects of the surgery. Of course, taking care of the physiological needs would be primary, but you might be surprised how effective a few hours of psychotherapy can be in a case like this. Also, are they prescribing hormones as those can affect mood significantly. My dad used to (half) joke that he started crying like a girl after being prescribed female hormones for prostate cancer.
 
Good thoughts, not delirium and no psychoses and he's not on hormones. Psychotherapy is being provided. No opiates are currently prescribed either, also a good thought.

I've not heard of postoperative cognitive dysfunction, but is mild-moderate depression with significant loss of appetite common? I don't see where it is. No information on treatment either. He does score quite low.

Criteria: Score:
Age greater than or equal to 70 1
History of alcohol abuse 1
Baseline cognitive impairment 1
Severe physical impairment (reduced ability to walk or perform daily activities) 1
Abnormal blood levels of electrolytes or glucose 1
Thoracic (non-cardiac surgery of the chest or lungs) surgery 1
Abdominal Aortic Aneurysm (AAA) surgery 1
Score: Risk of POCD:
0 2%
1 - 2 11%
3 or more T50%
 
Shikima said:
Good thoughts, not delirium and no psychoses and he's not on hormones. Psychotherapy is being provided. No opiates are currently prescribed either, also a good thought.

I've not heard of postoperative cognitive dysfunction, but is mild-moderate depression with significant loss of appetite common? I don't see where it is. No information on treatment either. He does score quite low.

Criteria: Score:
Age greater than or equal to 70 1
History of alcohol abuse 1
Baseline cognitive impairment 1
Severe physical impairment (reduced ability to walk or perform daily activities) 1
Abnormal blood levels of electrolytes or glucose 1
Thoracic (non-cardiac surgery of the chest or lungs) surgery 1
Abdominal Aortic Aneurysm (AAA) surgery 1
Score: Risk of POCD:
0 2%
1 - 2 11%
3 or more T50%
Click to expand...
I'll give a 3rd vote to possible catatonia. Try a dose of ativan and see what happens. He'll either get better or get worse...or go to sleep.
 
What is his physical status? Was he previously sexually able and now impotent? Previously continent now incontinent? Any chance this is adjustment to surgery outcome? Prostate surgery can have some nasty effects.

Any consideration of a neuropsych battery?
 
Haven't considered a neuropsych testing, but that is something I'll explore. Physical status is that he's relatively healthy but has this low level depression, but more importantly, severe anorexia which caused him to be NPO for a few days caused genuine concern. The appetite suppression and weight loss all happened after surgery - very normal prior to the procedure with general anes.

Sexual function hasn't been discussed.
 
Shikima said:
Physical status is that he's relatively healthy but has this low level depression, but more importantly, severe anorexia which caused him to be NPO for a few days caused genuine concern. The appetite suppression and weight loss all happened after surgery - very normal prior to the procedure with general anes.

Sexual function hasn't been discussed.
Click to expand...
I'd discuss it. We tend to underestimate the importance of sexual activity in the elderly and we almost universally under discuss it.

Given that you have a case of sudden onset depression immediately s/p a surgery that has up to a 50% rate of incontinence or impotence, loss of sexual function could be one cause. Men in their 70's might be culturally reluctant to discuss this with younger physicians, particularly if they're female (not saying you are). Not discussing the sexual component could further the feeling that it's something to not discuss and increase the sense of shame.

Or it could have nothing to do with it! Love this feature of psych. Sometimes it feels like rehearsing to be an understudy...
 
Who is providing psychotherapy and what is their conceptualization and plan? Also, if the depression is mild, then why so many medications? Makes me think the patient might be looking for someone or something to fix him and passive coping is a predictor of poor outcomes. Also, social support? Elderly men without wives have a tougher time or is the wife running the show and increasing his feeling of impotence and dependency. Also, if the therapist is the more touchy/feely type that won't help many older men at all. They tend to respond better to more concrete directive treatments. Ultimately, not eating without a hx of eating issues to me would be a sign of passive suicidality as in no desire to live. Why doesn't he want to live anymore might be the question to ask.
 
smalltownpsych said:
Who is providing psychotherapy and what is their conceptualization and plan? Also, if the depression is mild, then why so many medications? Makes me think the patient might be looking for someone or something to fix him and passive coping is a predictor of poor outcomes. Also, social support? Elderly men without wives have a tougher time or is the wife running the show and increasing his feeling of impotence and dependency. Also, if the therapist is the more touchy/feely type that won't help many older men at all. They tend to respond better to more concrete directive treatments. Ultimately, not eating without a hx of eating issues to me would be a sign of passive suicidality as in no desire to live. Why doesn't he want to live anymore might be the question to ask.
Click to expand...

It had to do with the premise that depression was causing anorexia. I could qualify it as moderate perhaps... not severe in the sense of psychosis. There is a will to live, but he just up and stopped eating/drinking. With the application of psychotropics, he did improve but then backslid. But never returned to his baseline of how he was managing his affairs quite well prior to surgery.

The psychologist wasn't really seeing him and when he has been in session, has been told "just force yourself to eat". It's another bag of worms to discuss later on.

Agree that sexuality is important, and I do have many discussions, but highly unlikely unrelated to this process. There is something else going on, something happened intraoperatively and I don't know what it is.
 
splik said:
I would be tempted to trial low dose methamphetamine which I have had some good success with in older patients including post-operative. it actually can stimulate appetite in these patients including increasing energy and motivation. I typically start at 2.5mg bid and go from there.
Click to expand...
I was thinking the same (methamphetamine is overlooked far too often in treatment for depression of this type) but the anorexia would make me hesitate.

Thoughts on T3?
 
Any neuro-imaging done post surgery? I've seen some cases of significant avolition and almost complete loss of appetite following some diffuse basal ganglia and/or frontal ischemic change. Abulia? In which case, I've heard about some success with bromocriptine.
 
I'll check into the brain scans and neuropsych testing. I'll keep methylphenidate in the back pocket for now until I get some further information.

Right drug for the right symptoms kind of thing in elderly.
 
What other medications is he taking? Which anesthetic agent did he get?

If anesthesia was causing this, then I'd imagine that we'd see more of this sort of thing with old patients who get ECT.
 
shan564 said:
What other medications is he taking? Which anesthetic agent did he get?

If anesthesia was causing this, then I'd imagine that we'd see more of this sort of thing with old patients who get ECT.
Click to expand...

Usual Halanes, NO, Versed(I think, if I heard and recall correctly), and an opiate. Fent/Demerol? Can't remember too clearly as his PCP was speaking quite rapidly. It has been a year since the surgery.
 
Shikima said:
Usual Halanes, NO, Versed(I think, if I heard and recall correctly), and an opiate. Fent/Demerol? Can't remember too clearly as his PCP was speaking quite rapidly. It has been a year since the surgery.
Click to expand...
What other medications is he taking chronically?
 
Shikima said:
Usual Halanes, NO, Versed(I think, if I heard and recall correctly), and an opiate. Fent/Demerol? Can't remember too clearly as his PCP was speaking quite rapidly. It has been a year since the surgery.
Click to expand...
Wait I thought it was 4 days. He's been anorexic for a year?

How much estimated weight loss? Have you explored exactly what he means by anorexic? (Taste alterations, lack of hunger but able to feed self, etc.)
 
Did it seem to you as if I hadn't read that already?
 
Has anyone asked him why he stopped eating and taking his medicine?
 
I've only seen him a couple of times. The anorexia is cross-correlated with the time of surgery. I saw him many months after the surgical event as a new patient. Uncertain why he has no appetite and won't eat/drink. Has had considerable weight loss. There is depression symptoms, and the anorexia is that he doesn't want to eat or drink. Unknown why he stopped taking his medications.

I'm attempting to identify the cause/effect which could help better drive treatment options for him.
 
Ever married / still married? Children? Anything else in his life change around that time?

I've met a good number of old guys who pretty much stopped eating when their wife died. Self attributed to wife being the cook, but I'd also imagine possibly the source of structure in daily activities. Some had more insight than others into that process.
 
I'm still curious if he's on any other medications that might be contributing...
 
upload_2015-12-9_12-12-17.jpeg
 
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