An 85-year-old man comes to the office due to increasing dyspnea and fatigue, which are affecting his ability to perform activities of daily living. His medical conditions include chronic obstructive pulmonary disease and congestive heart failure. The patient's wife passed away a year ago and he is struggling to come to terms with her death. He misses her and feels hopeless that his medical conditions will ever improve. The patient has stopped going to his community recreation center as "it is such an effort to get there and I don't enjoy it anymore." He admits to occasionally forgetting to take his medications, which include tiotropium, salmeterol, and furosemide.
Physical examination is significant for a prolonged expiratory phase and decreased breath sounds bilaterally, which are unchanged from previous examinations.
Which of the following is the best next step in management of this patient?

Question

An 85-year-old man comes to the office due to increasing dyspnea and fatigue, which are affecting his ability to perform activities of daily living.  His medical conditions include chronic obstructive pulmonary disease and congestive heart failure.  The patient's wife passed away a year ago and he is struggling to come to terms with her death.  He misses her and feels hopeless that his medical conditions will ever improve.  The patient has stopped going to his community recreation center as "it is such an effort to get there and I don't enjoy it anymore."  He admits to occasionally forgetting to take his medications, which include tiotropium, salmeterol, and furosemide.
Physical examination is significant for a prolonged expiratory phase and decreased breath sounds bilaterally, which are unchanged from previous examinations.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98ae_25ac_853d_e75a40d261e7_MD0002_00 This man's sense of hopelessness, lack of enjoyment of previous activities, fatigue, and self-isolation are concerning for depression. In addition, he has multiple other risk factors for suicide, including age, spousal loss, living alone, and physical illness. Although the elderly attempt suicide less often than people in the general population, elderly white men have the highest rate of suicide completion. The priority is to ask the patient about any suicidal thoughts and refer him for emergency psychiatric evaluation if necessary. (Choice B) Although education about medication adherence is important, this patient's nonadherence may be related to untreated depression, and assessing suicidality takes precedence. (Choices C and E) This patient is struggling to come to terms with his wife's death and could benefit from grief counseling or a support group. However, given his presentation and suicide risk factors, he should first undergo assessment for suicidal ideation as he may require immediate intervention. (Choice D) Cognitive screening is part of a comprehensive evaluation of patients with late-life behavioral change, as cognitive impairment is a common symptom of both depression and dementia. However, this patient should first be asked about suicidality, a more immediate concern. Educational objective: Elderly white men have the highest rate of completed suicide. Risk factors include loss of a spouse, feeling depressed or hopeless, and physical illness. There should be a low threshold for suicide screening in this population and emergency psychiatric follow-up if necessary. __________ References: Behavioral emergencies: special considerations in the geriatric psychiatric patient. (http://www.ncbi.nlm.nih.gov/pubmed/28800801) A systematic review of interventions to prevent suicidal behaviors and reduce suicidal ideation in older people. (http://www.ncbi.nlm.nih.gov/pubmed/28766474) Psychiatric emergencies: assessing and managing suicidal ideation. (http://www.ncbi.nlm.nih.gov/pubmed/28372713)

An 85-Year-Old Man Comes to the Office Due to Increasing