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(Announcer)
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(CLOCK TICKING)
(MUSIC)
(Dr. Peter Salgo)
Welcome to Second Opinion, where each week our healthcare team solves a real medical mystery. When we close this file in a half an hour from now, you'll not only know the outcome of this week's case, you'll be better able to take charge of your own healthcare, and doctors will be able to listen to patients more effectively, too. I'm your host, Dr. Peter Salgo, and you've already met our special guests, who are joining our primary care physician, (Dr. Lisa Harris). Lisa, welcome back.
(Lisa):
Thank you.
(Peter)
Nobody on the team knows this case, so why don't we start informing you a little bit about what's going on? Today we're going to be talking about John. John is seventy-eight years old and has been married for fifty-five years. We meet him in his primary care physician's office for follow-up. He's there eight weeks after a hospital stay for surgical repair of a broken hip. The funny thing about this visit is that his grown daughter and son tell the primary care physician - this is a quote from the chart - "Our dad has completely lost it." They say he won't change his clothes, they have to force him to eat. He says the neighbors are spying on him, that is John says this. He won't take his heart medicine. He's not sleeping and the kids are desperate to know what to do. So, Lisa, if he were in your office, what do you do now?
(Lisa):
So, he's been in the hospital, he's had a major change in his life, so the things that you want to think about are whereas - was there an underlying substance abuse disorder that we didn't know about, like drinking alcohol or other substances? Is there an area of some depression?
(Peter)
So you're thinking of a withdrawal syndrome here?
(Lisa):
Possibly or is there some depression that's going on. He's broken his hip. He can't do the things that he used to do before. Is there some underlying dementia that we didn't recognize before? So there are -
(Peter)
Mm-hmm.
(Dr. Lisa Harris):
- a lot of things that are running through your mind and you want to start -
(Peter)
Would you like some history?
(Lisa):
Yes, I do.
(Peter)
Family history, it says here over the past three years John's wife, two brothers and sister all died. Medication history, he's on a beta blocker, a statin, aspirin and some calcium with Vitamin D. Three years ago had coronary angioplasty, got some stents. A year ago he had a stroke, and the chart says that he recovered without any residual; no way to tell just from talking or looking at him he'd had a stroke. Two months ago, eight weeks ago, we know he fell, fractured his hip, had the surgery, but then there's a lot of notes, and they say that he had postoperative delirium and the medical team in the hospital started talking to the family about how this might be related to his earlier stroke. And when they wrote his discharge summary from the hospital, they say that he had dementia and they put him on donazepil or Aricept, and then following that he didn't adhere to his physical rehab at all. So, Lisa, with that much history, which is quite a bit, you're the PCP. You've been seeing John for more than twenty years. You've never seen any signs of dementia, and here he's got this discharge summary and they put him on Aricept. He leaves the hospital after three and a half days with a diagnosis of dementia. What do you make of that?
(Lisa):
Yeah. I don't think they can make that diagnosis on a short-term stay in the hospital without some other evaluation. There's a -
(Dr. Peter Salgo)
Well, it looks like a whole team looked at him.
(Lisa):
Doesn't really matter. Doesn't seem that they looked at him effectively or even looked at him over time. There are a lot of things that can affect the mental status and the ability of a patient to think and respond. And when you look at this guy, he's had death in the family in three years, he's had two major events that are going to affect his lifestyle, he's certainly on a beta blocker, which can affect his mood and his ability to think and respond.
(Barbara)
As a discharge planner for many years, sadly the most talented medical team often jumps the gun and misinterprets a delirium to be something of a permanent nature without doing a sufficient mental status baseline.
(Michael)
I'm not a doctor, okay?
(Peter)
Right.
(Michael)
Did any doctor look at him as a human being? I mean, really. I mean, he's not just a number on a chart in a bunch of fancy medical words. He is a man who has suffered tremendous, tremendous losses.
(Lisa):
That's exactly the point that I was trying to get to. If this is my patient that I've known for a long time who's had loss of three family members, he's had a heart attack and stroke -
(Michael)
Exactly.
(Dr. Lisa Harris):
and now he's having - he's fallen and had hip surgery, there's a lot going on here.
(Dr. Chris Callahan)
One of the things you see here, though, is with older adults, how complicated it can get very quickly. So, as Dr. Harris was saying, in all of the other sort of issues that have come up with this particular man, three or four chronic conditions, losses of this kind are not uncommon at this age.
(Michael)
My depression was set off by my sister dying very, very suddenly and unexpectedly. She was my only sibling. My mom was ninety-eight years old at the time and doing fine, and she went right down hill. I had to put her into hospice, so I lost her. I had lost my father before. I was the sole survivor.
(Peter)
I'll tell you what leaps out at me from the chart. John thinks the neighbors are spying on him. He sounds, if I may use the word, paranoid. Michael, did you have that?
(Michael)
Oh, my gosh, yes.
(Peter)
Tell me about that.
(Michael)
I - and it was - I was convinced that we were penniless, that we didn't have a dime to our names, that I owed a ton of money to the Internal Revenue Service, and I was either going to - they were going to take my house and they were going to put me in jail, and I was so convinced. Then my accountant said, "Michael, come on. You're going to get a refund this year." I was so convinced that something awful was going to happen with the IRS that when I could get downtown to work, which wasn't very frequently, for lunch I'd go to a senior citizens' place, where all you had to do was show your Medicare card and you would get a hot lunch for two dollars.
(Kathy)
Were you suspicious that something was wrong with you, or did you not even -
(Michael)
Oh, I knew something was wrong.
(Kathy)
Who evaluated John in the hospital? And did they refer to a psychiatrist for a consult?
(Peter)
Well, I can tell you what the chart says and, to be fair, it says a team, and I know that there's a note in this chart, not just from the surgeons, but there was an internist who looked at him preoperatively and saw him postoperatively. So more than one physician saw this person, saw John.
(Kathy)
But that doesn't matter, as Michael pointed out. If you're just having a batch of internists come in or a batch of surgeons come in, then he's not being properly evaluated.
(Barbara)
You simply have to understand, and people sadly don't, our hospital system is really designed for quick fix and out.
(Dr. Eric Caine) One of the ways I think about these things - and I used to do a lot of consultation work - was that this is a situation that's sort of out of control, like a fire's out of control. The kids are coming in and saying, "This is an emergency. We don't know what to do." A primary care doc, I would imagine, would say, "Well, there are a lot of things to do, but the first question is is this fellow safe?" Is he in a position where we can actually assure that he's not going to hurt himself, he's not going to hurt someone else, he's not, in the face of fear, do something drastic?
(Peter)
All right. Lisa, let me tell you more about John. The PCP then says to him, to the family in fact, "Would you please leave the room? I want to talk to John without you here." Why would he do that?
(Lisa):
Because he needs to get an assessment from the patient as to what's going on. So, of course you want information from the family, but your patient is your - is one of your most valuable resources for information.
(Eric)
Getting people out of the room and calming down the room, literally just calming the room down is so important to have a conversation.
(Peter)
So that was a good thing?
(Eric)
Even in the face of his being suspicious and paranoid, it's very important, at that point, to be respectful, to be - to say, "Look, this isn't somebody who's crazy. This is a patient of mine who's having a hard time, and I'm going to try to engage him at his highest level of function."
(Dr. Peter Salgo)
In the office, without the kids, they start asking him questions. What are they looking for, and what would you do for example?
(Eric)
You sort of go through those "Let's get rid of the emergencies" very quickly, and then once we decide it's not a medical emergency, it's not a psychiatric emergency, you've got a little bit of chance now to start to delve into events that happened over the last couple of days or even the last couple of months.
(Peter)
John's doctor did a fairly extensive exam and had a long conversation with him. John could comprehend, but he was misinterpreting the information that he was being given. Here are the adjectives that are in the chart. "Suspicious, resistant, contempt for doctors and the social worker -
(Eric)
We understand that
(Peter)
- resentment about having this interview at all and being tested, reactive to neutral questions, limited eye contact and bizarre thought." His memory and language were on target for age, except for the time around his hip surgery. His recall and ability to learn something new is where it should be for his age. His ten-word recognition was fine. He scored twenty-nine out of thirty on a mini mental status exam with anger. He can recognize common sounds and people, and he got - and he talked about feeling little pleasure and feeling hopeless every day. And he specifically mentioned he wasn't interested in eating at all.
-
(Lisa):
That Aricept really did wonders in about three days, didn't it?
(Peter)
All right. This is a mouthful here.
(Dr. Eric Caine)
Right.
(Peter)
Where are we? What's the diagnosis?
(Eric)
I would actually think that what I would do in - at this point, number one, is think that he's out of the woods on this, quote, dementia -
(Eric)
Or delirium.
(Lisa):
So, now that we're out of the scary woods -
(Male voice)
Right.
(Lisa):
Yeah.
(Peter)
Let me tell you what John's doctor did.
(Dr. Lisa Harris):
Let's see.
(Dr. Peter Salgo)
All right? John's doctor actually clearly had this mental conversation with himself that you've been having here, and he decided that the rapid onset of the cognitive changes that John experienced did not fit with Alzheimer's, which was the diagnosis that John left the hospital with, and that the paranoia that John was complaining of and describing - guess the family was complaining more than John - was worrisome. So he was sent off, John was, to a geriatric psychiatrist. Now, what would a geriatric psychiatrist do that the PCP would not?
(Lisa):
But I have to interject in here. I mean, he's not going to go running off to a geriatric psychiatrist when we haven't figured out the safety of the home. So he would have a social worker, a visiting nurse, a home health aide -
(Dr. Eric Caine)
Right.
(Lisa):
and all the other things in place.
(Eric)
Right. So I was going to say the geriatric psychiatrist, the first thing would be you say is I'm still worried about this guy's safety.
(Lisa):
Right.
(Eric)
This is the opportunity to try to do what you want to call the detective work or the story-building work, but to start to find out who is this man, what's happened to him in his life, where does this now come? But rather than just what is his - you know, I take a slice in time right now and see what his mental status exam was. You talked about his mental status exam earlier. But rather how do we begin to build the story of who this fellow is and really understand, among the possibilities, what - you know, was he ever depressed in the past, what did he lose? He had all these losses in the last few years, but what happened ten, twenty, thirty, forty, fifty years ago and all those sorts of things? And then, also, to begin to ask very important questions about his family history and his upbringing, were there other psychiatric illnesses in the family, were there other situations? And the question that I think is really important is is this new?
(Dr. Chris Callahan)
But I think the other thing, Eric, is as you've sort of unfolded the case as you have, you've sort of gone through a number of transitions. So this is a man that was in the hospital, then he was at home, and then he ends up in Dr. Harris's office. And now we're thinking about referring him to maybe an acute rehab facility, and maybe he's going to end up in geriatric psychiatry. And you have all these transfers of care taking place. Every one of them is an opportunity and a risk for that older adult. All of that ends up in sort of the command module of the primary care doc to know where can I refer this person to, and it changes month to month (inaudible).
(Kathy)
Any person who's been through this with - many elderly people in my family. I can tell you it's very frustrating to not have a command module that you can rely on, especially if you're out-of-state. When you love and adore these people and what they're going through, and it's so important the family knows what they can do, how they can help.
(Barbara)
Yeah.
(Peter)
After seeing this geriatric psychiatrist, they decide - that is to say his PCP, the geriatric psychiatrist decide that, yes, John has a major depression. It doesn't sound like at this moment anybody's particularly surprised. What is a major depression? How do you define it? How bad is it?
(Eric)
They use the term major depression as a way of trying to set it off from the symptom of "I'm sad, down in the dumps," and it's really a whole constellation of things. So it's not only the idea that somebody is really sad or distressed or demoralized, but it's kind of like they've gotten shut off, you know. And there are really, in the simplest sense, two forms. You know, you talk about one form, where someone really has been slowed down, they don't move very much, they're withdrawn, they're isolated, they don't care anymore, they have lost interest, joy, fun, their thinking is slow, their memory's poor and often they're suicidal. There is another form where someone can become very, very agitated, and so there can be the full array of misunderstood thinking, delusional thinking, and even hallucinations.
(Peter)
But John, if you believe his family, has been going on like this for eight weeks -
(Eric)
Sure.
(Peter)
- plus the three and a half days in the hospital. What took everybody so long?
(Chris)
Because there was - there were many things going on with John. I - there are many -
(Eric)
Right.
(Chris)
- other conditions, and we have to be careful here that while John has a depression and a major depression, as his doctors found out, that's not the only thing John has. So John has a whole other list of things that the primary care doc still has to attend to.
(Peter)
John is in his 70's. John's never had this history before. And so the question that comes to my mind is why now? He's had other trauma in his life. Why now?
(Dr. Eric Caine)
It's not - it's common.
(Barbara)
It's common.
(Eric)
It's common.
(Peter)
How common is this?
(Barbara)
You need to know that clinical depression is probably one of the most under diagnosed illnesses in the older adult. There are so many myths about older people, the simplest and most irritating being, well, of course, if you're eighty-five, you've had many losses. Of course you'd be sad. Well, sadness, of course and clinical depression are very different.
(Dr. Peter Salgo)
How common is depression in late life?
(Chris)
In a primary care practice, it'll be five to ten percent of the people, the older adults in primary care. The issue about whether it's five or whether a ten's depends a lot on the -
(Eric)
And remember, depression is not a static thing. It doesn't stay in one place. So you probably have twice as many people. If you use the figure five percent, there's another ten percent who have sort of milder forms -
(Chris)
Yeah.
(Eric)
- some of which will get better, but a third of them maybe will get worse over time. And so it's - it - what it says is it's a big chunk of the PCP's office practice.
(Barbara)
Right.
(Peter)
I just want to pause for a moment -
(Eric)
Okay.
(Peter)
because we've covered an enormous amount of ground here. Let me just sum up a little of what we've been discussing. When a person is not thinking clearly it can be caused by many different issues. Depression is one of them. It is not the only one of them. Lots of things need to be ruled in - ruled out before you can go any further. So now we have the diagnosis made, if you will, of depression right here in the chart. If you're going to treat John, what are the options that you've got? What are they thinking about?
(Michael)
The first thing you should do is a practical thing; talk to the caregiver. Tell the caregiver what to expect and what to say and what not to say. If it wasn't for my wife - God bless her. I had given up hope. She never gave up hope, and that's so important.
(Dr. Peter Salgo)
Maybe some of you here can give me just a laundry list of what does work. What would you consider?
((Chris)):
I mean, it's a good - it's an important message that there are treatments. There are options for treatment. If you're in a primary care physician's office, the two big ones are going to be whether you're going to use medications or whether you're going to use a form of psychotherapy.
(Dr. Peter Salgo)
There's a list, right? There's drugs. He can have shock therapy, electroconvulsive therapy.
(Eric)
Well, let's not call it shock therapy because there -
(Dr. Peter Salgo)
You like ECT?
(Dr. Eric Caine)
Well, yeah, or electrical therapy. There's no convulsion and there's no shock.
(Michael)
I had all three of them.
(Peter) All right.
(Michael)
I had electric shock therapy and...
(Peter)
There's - there is certainly something called CBT.
(Eric)
And - well, that's one of the psychotherapies, and there is a whole array of psychotherapies. That's one. There's interpersonal therapy. There are a number of them, but I think the first question is - or it goes back to the issues of safety. It goes back to the issues of how fast - you know, is this a life-threatening depression? There are life-threatening depressions. I haven't heard anything yet about assessing this fellow's suicide potential.
(Lisa)
Right.
(Eric)
Paranoid, depressed elders often are suicidal, and I want to know, is this a guy who has suicidal thoughts or plans?
(Peter)
The chart does make the point. They started him on some medication. In fact, they put him on mirtazapine, which is Remeron, and they wanted to see whether that would help with the paranoia. What do you think, did it work?
(Eric)
Probably not.
(Peter)
Why not?
(Eric)
And this is one of the issues is he has what's called, in other terms, a major depression with psychotic features.
(Peter)
Well, what they did was they took him off that drug and gave him Zyprexa, which is olanzapine. Did that work?
((Dr. Chris Callahan)):
It certainly could have. It needs some time to work. It's - you're going to need two to four, maybe even six weeks to see if (inaudible) -
(Dr. Peter Salgo)
That's an anti-psychotic.
(Eric)
That's an anti-psychotic.
((Chris)):
Yeah.
(Peter)
Isn't there a black box warning about anti-psychotics in geriatric patients?
(Barbara)
Oh, yes.
(Chris)
Oh, you said Zyprexia.
(Peter)
Black box warning means, from the FDA, whoa, be careful, right?
(Barbara)
And I think that the job of the PCP, the family, the patient, if he's able, and everyone is, in a situation like this, to evaluate, you know, the dangers, and at some point you take a risk on a black box med, if it's going to relieve a symptom.
(Dr. Eric Caine)
The black box warning was largely around people in nursing homes, where they were using the anti-psychotic medications to constrain or restrain them using them chemically.
(Chris)
Who had dementia.
(Eric)
Yeah.
(Peter)
Well, John didn't like the Zyprexa because it gave him side effects he didn't like. So his docs put him on another drug. He was put on Effexor, which is -
(Eric)
Venlafaxine. Venlafaxine.
(Peter)
You want to pronounce that one for me?
(Eric)
Venlafaxin.
(Dr. Peter Salgo)
That's why you're the psychiatrist.
(Eric)
Yeah.
(Peter)
And the Effexor didn't work. So maybe John has dementia after all. These great anti-depressant drugs aren't working.
(Dr. Lisa Harris):
Now, here's the problem. It's more than likely his primary care physician is making a decision on drugs to try. It's not clear how long you've tried him on any of these medications.
(Eric)
Or the dose.
(Lisa):
Or the dose. And what people often do is take someone off of a medication before they've reached a long enough time period in a good effective dose in a long enough time to see efficacy. So within a week you can't expect things to work.
(Peter)
Michael, what was it like for you? Were you on medications? What other therapies -
(Michael)
Oh, my gosh. Let me -
(Peter)
Tell me about it.
(Michael)
I - well, first of all, of course I was on medication. Had twenty-one electric shock treatments. Some people swear by it. They say, "This is what did it for me." In my case, it didn't work, but it was worth a try. And of course I had therapy to try to analyze what was happening. As far as the drugs go, there's such a stigma attached to it. I mean, I had somebody in the medical community, who said, "Oh, I'm so relieved to see you're better, Judge Miller." He said, "And thank God you're off of those drugs," and I said, "What do you mean off of those drugs? I'll probably be taking them for the rest of my life, but I also take high blood pressure pills and nobody asks me, you know, 'Aren't you off those high blood pressure pills yet.'"
(Barbara)
Well, I think that the -
(Peter)
How long did it take for you -
(Barbara)
Yeah.
(Michael)
For me? Yeah.
(Dr. Peter Salgo)
to get to a medication and a regimen that worked and made you feel better?
(Michael)
Two years.
(Peter)
Two years?
(Michael)
Yeah. It started March 2005 and it ended in March of -
(Dr. Eric Caine)
And that's not - that's a common story. So seeing people who need three or four medications along with while they're having psychotherapy, it isn't a question of either psychotherapy or medications. Along with the whole array of things, that this can be such a difficult-to-treat condition, but it also can be one where there's tremendous hope...
(Peter)
Well, John went on taking different meds -
(Eric)
Right.
(Peter)
as you've heard. It took him about four months, not two years. And eventually he wound up on paroxetine, which is Paxil -
(Lisa)
Which is where I would've started.
(Peter)
and he felt better. Do these drugs work differently in older people than in younger people, and have they been tested in the older population or just in the younger population?
((Chris)):
Well, up until recently they hadn't been, say - and by recently I'd say the last five or ten years, but there's good clinical trials now for treatment of depression in older adults. It includes drugs like these. So I think the evidence is there. Your initial question was do they work differently? I think the answer is yes. For every drug, it can work differently in an older person, and partially it's because of the other drugs they're on and the other conditions they have, but there's good evidence that the drugs work. And so that shouldn't be a reason for someone to choose not to try them, but as we've been hearing, it's a little bit chance that you're going to get the first drug and you're going to get a response from it the first time. So you've got to stick at it.
(Dr. Peter Salgo)
Let's sum up for just a moment where we are.
(Barbara)
All right.
(Peter) We're going to come back to more discussion, but again, we've covered a lot over here, and I want to be sure that we sort of put it altogether. Finding the appropriate treatment for depression often takes time and trials. Proper treatment can result in dramatic improvement in mental and physical health, so it's important to take the time necessary to find the treatment that works best for you. And this may mean a number of different drugs, a number of different therapies all mixed together.
(Eric)
And carefully monitored and taken to - as you pointed out, taken to the level where you think they're going to work and having some patience.
(Peter)
What would've happened had John not gotten some medical attention, or Michael not gotten medical attention?
(Eric)
Well, I certainly think about the risk of suicide, and -
(Peter)
That's the worrisome.
(Eric)
That's the - well, remember we talked about being safe, and it wasn't only being safe because he was paranoid, but it was being safe because clearly when you're - when you talk about being hopeless, when you talk about seeing nothing to live for anymore, when you've withdrawn from life, when you're feeling persecuted, then the question of, well, it's not worth it anymore, suicide's not the only bad thing of untreated, too.
(Barbara)
Homicide and -
(Chris)
So all of his other medical illnesses -
(Dr. Chris Callahan)
- as Eric was saying, closing doors are going to get harder to treat -
(Eric) Absolutely.
(Chris)
- if he doesn't sort of get his mood improved and his motivation improved.
(Barbara)
They're going to be non-compliant -
(Peter)
Is John going to be on meds now for the rest of his life?
(Chris)
He could be on medicines for the rest of his life, after he has responded to the medications -
(Barbara)
And that's not a bad thing.
(Chris)
which we've already heard can take a year or more.
(Peter)
Yeah. Michael, you -
(Chris)
He's going to be on them for at least a couple of years.
(Dr. Peter Salgo)
You're on a mission. I can hear it in your voice.
(Michael)
I want to -
(Peter)
And I know you're on a mission.
(Michael)
Yeah.He's
(Peter)
Tell me about that.
(Michael)
I want the people to understand that there is hope. The most important thing is never, never, never give up. For me, of course I contemplated suicide. I'll be honest with you. People who have clinical depression don't want to die; they just want the pain to stop. They just want that pain to stop.
(Kathy)
I think the key message is it is a medical condition.
(Michael)
Absolutely an illness.
(Kathy)
It is not something you did.
(Michael)
It's called an illness. Right.
(Kathy)
It is definitely an illness.
(Michael)
Right.
(Kathy)
It's not anything you did in your past life. It's not anything that has to do with your current life. It's a medical condition -
(Michael)
Right.
(Kathy)
- that you need to get treated just like you would get treated, your heart -
-
(Michael)
Right.
(Kathy)
- or your lungs or anything else.
(Peter)
I can tell you that, having watched all you folks interact now for the half-hour that we've been on the air, the minute these lights go down this show's not over. This is going to -
(Michael)
I can tell you -
(Peter)
This is going out the door -
(Michael)
Right.
(Peter)
- into the parking lot.
(Chris)
Right.
(Dr. Peter Salgo)
You're going to continue to talk. The problem is that we are out of time. I want to thank you all for being here. It's been an amazing discussion. I'm going to sum up a few points before we leave. When a person is not thinking clearly it can be caused by many different issues. Depression is simply one of them. Finding the appropriate treatment for depression often takes time and trial. Proper treatment can result in dramatic improvement in both mental and physical health. So it's important to take the time that's necessary to find the treatment that works best for you. And our final message is this; taking charge of your health means being informed and having honest communication with your doctor. I'm Dr. Peter Salgo and I'll see you next time for another Second Opinion.
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