A 66-year-old woman comes to the office with her daughter for evaluation of behavioral changes. The daughter says, "My mother was living with a friend but moved into a one-bedroom apartment 3 months ago to be closer to the family. She was okay the first month but then started getting scared about living on her own. It's gotten so bad, she asked to move in with me last week." The patient has felt tense and appears distracted when spending time with family. She sleeps restlessly through the night due to nightmares and takes early-morning drives around town to "clear my mind." The patient has had no appetite changes or fatigue. The daughter says that the patient was hospitalized a year ago for surgical repair of a hip fracture after slipping in the bathroom. She was unable to move or call 911 and was found 8 hours later by a friend. The patient says she cannot remember details of the fall. Medical history includes hypertension and type 2 diabetes mellitus. Temperature is 37.1 C (98.8 F), blood pressure is 140/80 mm Hg, and pulse is 86/min. The patient is fully oriented. Physical examination shows no abnormalities. Speech is normal. She has no delusions, hallucinations, or suicidal ideation. Which of the following is the most appropriate next step in management of this patient?

Question

A 66-year-old woman comes to the office with her daughter for evaluation of behavioral changes.  The daughter says, "My mother was living with a friend but moved into a one-bedroom apartment 3 months ago to be closer to the family.  She was okay the first month but then started getting scared about living on her own.  It's gotten so bad, she asked to move in with me last week."  The patient has felt tense and appears distracted when spending time with family.  She sleeps restlessly through the night due to nightmares and takes early-morning drives around town to "clear my mind."  The patient has had no appetite changes or fatigue.  The daughter says that the patient was hospitalized a year ago for surgical repair of a hip fracture after slipping in the bathroom.  She was unable to move or call 911 and was found 8 hours later by a friend.  The patient says she cannot remember details of the fall.  Medical history includes hypertension and type 2 diabetes mellitus.  Temperature is 37.1 C (98.8 F), blood pressure is 140/80 mm Hg, and pulse is 86/min.  The patient is fully oriented.  Physical examination shows no abnormalities.  Speech is normal.  She has no delusions, hallucinations, or suicidal ideation.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d7ef_3e2e_bc81_c50bbec1c460_MD0003_00 This patient's presentation is most consistent with posttraumatic stress disorder (PTSD) with delayed expression related to the traumatic experience of fracturing her hip. In addition to fear, tension, distractibility, restless sleep (hyperarousal), and nightmares (reexperiencing), psychological distress in situations that serve as a reminder (eg, patient is now scared to live alone) and inability to remember details of the trauma (avoidance symptoms) are also characteristic of PTSD. Other symptoms may include flashbacks, irritability, dissociation, emotional detachment, negative mood and cognitions, and hypervigilance. The full spectrum of PTSD symptoms may not develop immediately after a trauma, as seen in this patient. The diagnosis is specified as PTSD with delayed expression when full diagnostic criteria are not met until ≥6 months after the trauma. First-line treatment of PTSD includes trauma-focused cognitive-behavioral therapy (CBT) and/or pharmacotherapy with a serotonergic antidepressant (selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor). CBT combines cognitive techniques to help correct maladaptive thoughts about the trauma and exposure-based techniques to help the patient emotionally process the trauma while feeling safe. (Choice A) Advising the patient not to live alone will likely exacerbate her avoidance of dealing with the trauma and fails to address her underlying PTSD. This patient's fear of living alone will likely improve with appropriate treatment of PTSD. (Choice B) Despite having risk factors for vascular dementia, this patient has no history of a cerebrovascular event, and her physical examination is normal. Her attentional deficits and isolated memory impairment of the traumatic event are more consistent with PTSD and do not warrant brain imaging at this time. (Choice C) Although mirtazapine is a sedating antidepressant and may help with restless sleep, it has no demonstrated efficacy in treating PTSD. (Choice D) This patient's memory loss is limited to recalling details of the trauma and is likely a dissociative symptom of PTSD (ie, dissociative amnesia). It is not indicative of dementia, and neuropsychological testing is not warranted. (Choice E) Occupational therapy is indicated when fear of falling and associated activity restriction are due to balance and mobility impairments. However, there is no evidence that this patient has impaired mobility or is restricting her activities. Educational objective: Posttraumatic stress disorder may not develop immediately after a trauma and is specified as "with delayed expression." Trauma-focused cognitive-behavioral therapy and/or serotonergic antidepressants are first-line treatments. References: Occurrence of delayed-onset post-traumatic stress disorder: a systematic review and meta-analysis of prospective studies. (http://www.ncbi.nlm.nih.gov/pubmed/24599261) Psychological mechanisms of effective cognitive-behavioral treatments for PTSD. (http://www.ncbi.nlm.nih.gov/pubmed/25749748)

A 66-Year-Old Woman Comes to the Office with Her Daughter