A 75-year-old woman comes to the office due to difficulty with memory and thinking. The patient has stopped going for walks and has not attended bingo in months; she explains that these activities are no longer enjoyable. She has low energy and difficulty falling asleep. Her appetite has decreased, and she has lost 6.8 kg (15 lb) in the past 3 months.
Medical history is significant for hypertension, well-controlled epilepsy, and type 2 diabetes mellitus. The patient lives alone and drove herself to today's appointment. She has not gotten lost while driving and has had no difficulty caring for herself.
Blood pressure is 138/84 mm Hg, pulse is 76/min, and respirations are 14/min. Neurologic examination is nonfocal, and she scores a 26/30 on the Montreal Cognitive Assessment. Laboratory results, including thyroid function studies, are normal.
Which of the following is the most appropriate pharmacotherapy?

Question

A 75-year-old woman comes to the office due to difficulty with memory and thinking.  The patient has stopped going for walks and has not attended bingo in months; she explains that these activities are no longer enjoyable.  She has low energy and difficulty falling asleep.  Her appetite has decreased, and she has lost >6.8 kg (>15 lb) in the past 3 months.
Medical history is significant for hypertension, well-controlled epilepsy, and type 2 diabetes mellitus.  The patient lives alone and drove herself to today's appointment.  She has not gotten lost while driving and has had no difficulty caring for herself.
Blood pressure is 138/84 mm Hg, pulse is 76/min, and respirations are 14/min.  Neurologic examination is nonfocal, and she scores a 26/30 on the Montreal Cognitive Assessment.  Laboratory results, including thyroid function studies, are normal.
Which of the following is the most appropriate pharmacotherapy?

Quizplus · Accepted Answer

11ec193a_98a6_5d6f_853d_89345d20712a_MD0002_00 This patient's anhedonia, weight loss, disrupted sleep, low energy, and cognitive impairment are consistent with a diagnosis of major depressive disorder (MDD). MDD in the elderly frequently presents with a more prominent cognitive impairment component (eg, subjective memory problems, poor concentration) and can be difficult to differentiate from neurocognitive disorders. Psychotherapy and/or pharmacotherapy are effective treatments for MDD in the elderly. Selective serotonin reuptake inhibitors (eg, sertraline) are considered first-line pharmacotherapy. Cognitive impairment due to MDD in the elderly is reversible and improves when the depression is treated appropriately. Irreversible, progressive cognitive impairment of the kind found in major neurocognitive disorder (ie, dementia) may be accompanied by a prodromal depressive syndrome; however, unlike the cognitive impairment found in MDD, treatment of depression in prodromal major neurocognitive disorder does not reverse the cognitive impairment. The cognitive impairment that accompanies MDD in the elderly is typically less severe than the impairment in major neurocognitive disorder. (Choice A) Bupropion is contraindicated in patients with a seizure disorder because it can lower seizure threshold. (Choices B, C, and E) Although this patient is experiencing cognitive impairment, she is independent with respect to her activities of daily living (eg, bathing, dressing, feeding); this lack of functional impairment makes the diagnosis of major neurocognitive disorder highly unlikely. Although donepezil, memantine, and/or vitamin E may be beneficial in major neurocognitive disorder, they have not been shown to be beneficial in mild neurocognitive disorder or cognitive impairment secondary to MDD. Educational objective: The cognitive impairment that may accompany major depressive disorder in the elderly is reversible and generally improves with treatment of the depression; selective serotonin reuptake inhibitors are first-line pharmacotherapy. __________ References: Recognizing depression in late life (http://www.ncbi.nlm.nih.gov/pubmed/25574901) Prevalence of depression in patients with mild cognitive impairment: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/27893026)

A 75-Year-Old Woman Comes to the Office Due to Difficulty