A 74-year-old white, widowed man comes to the office at the request of his daughter due to lack of appetite and a 4.54-kg (10-lb) weight loss over the past 4 months. Prior to breaking his hip last year when he fell from a horse, the patient had worked as a rancher for over 50 years. His daughter says he never quite recovered from the fall and refused to participate in an outpatient physical rehabilitation program. The patient says, "I don't want to be around a bunch of disabled people, and those exercises are a waste of time; I just have to accept that my life is over." He says his mood is "bad" but that depression is for "the weak-minded." When asked about suicidal thoughts and plans, he is initially silent; with further prompting he says, "I believe in keeping my options open." The patient had a depressive episode in his late 40s that responded well to antidepressant treatment. He has never attempted suicide. His daughter lives in a nearby city and checks on him once a month.
The patient has a history of hypertension that has been well controlled for many years with atenolol.
Physical examination is notable for decreased mobility, arthritis, and a healed gunshot wound sustained in a hunting accident last year.
Which of the following is the most appropriate next step in management of this patient?

Question

A 74-year-old white, widowed man comes to the office at the request of his daughter due to lack of appetite and a 4.54-kg (10-lb) weight loss over the past 4 months.  Prior to breaking his hip last year when he fell from a horse, the patient had worked as a rancher for over 50 years.  His daughter says he never quite recovered from the fall and refused to participate in an outpatient physical rehabilitation program.  The patient says, "I don't want to be around a bunch of disabled people, and those exercises are a waste of time; I just have to accept that my life is over."  He says his mood is "bad" but that depression is for "the weak-minded."  When asked about suicidal thoughts and plans, he is initially silent; with further prompting he says, "I believe in keeping my options open."  The patient had a depressive episode in his late 40s that responded well to antidepressant treatment.  He has never attempted suicide.  His daughter lives in a nearby city and checks on him once a month.
The patient has a history of hypertension that has been well controlled for many years with atenolol.
Physical examination is notable for decreased mobility, arthritis, and a healed gunshot wound sustained in a hunting accident last year.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98af_d35e_853d_df45c75b9498_MD0002_00 Older men are at very high risk for suicide, particularly through violent means. Patients in this population who commit suicide are also less likely to have a history of suicide attempts or to endorse suicidal ideation. As a result, these high-risk patients require careful suicide assessment and aggressive clinical intervention. This patient has a number of suicide risk factors, including history of depression, advanced age, white ethnicity, widowed marital status, living alone, physical illness, hopelessness, and access to firearms. In addition, his reluctance to answer questions about suicide, belief about suicide as an option, and the statement that his life is over are worrisome. This patient's suicide risk is high and sending him home is inadvisable. The most appropriate next step is hospitalization, during which aggressive treatment of his depression can be initiated in a safe environment. (Choice A) Although beta blockers appear to cause small increases in the risk of fatigue and sexual dysfunction, the previously reported association with increased risk of depression has not been supported. (Choice B) Screening laboratory tests to assess for medical causes of depression and weight loss (eg, thyroid function tests) are necessary. However, hospitalization due to this patient's high risk for suicide takes priority. (Choice C) Home-based physical rehabilitation and nutritional supplementation may be useful strategies after assessment and treatment of the patient's acute depression. Patients with untreated depression are often unable to fully participate in physical rehabilitation due to poor motivation and nonadherence. (Choice E) A combination of cognitive-behavioral therapy and medication is beneficial, but this patient is at high risk for suicide and requires hospitalization to ensure his safety. Specific treatment can be initiated in the hospital setting. Educational objective: Older men have the highest risk of suicide and should be screened carefully for depression. Physicians must perform a careful assessment of risk and protective factors and use clinical judgment to identify those at high risk who require psychiatric hospitalization. __________ References: Helping elderly patients to avoid suicide: a review of case reports from a National Veterans Affairs database. (http://www.ncbi.nlm.nih.gov/pubmed/23274289) When elderly people give warning of suicide. (http://www.ncbi.nlm.nih.gov/pubmed/22449942) Understanding suicide across the lifespan: a United States perspective of suicide risk factors, assessment & management. (http://www.ncbi.nlm.nih.gov/pubmed/28639299)

A 74-Year-Old White, Widowed Man Comes to the Office at the Request