Tendencias de la población joven

An 88-year-old woman comes in to your office and complains of “soreness in the chest.” She seems distressed and clutches a bottle of pills in each hand. She tells you these are her friend’s medications and asks, “Should I take this (nitroglycerin)? Should I take this (lorazepam)? Should I go out? Should I stay in? What should I do?”

The chest pain is not related to meals or exertion. Nothing seems to make it better or worse. Her physical examination, electrocardiogram (EKG), labs, chest X-ray, and abdominal ultrasound yield no clues. An investigation of the patient’s life stressors is begun.

The patient’s husband died 4 years ago of a myocardial infarction. She lives alone but has a lot of friends, and, since her husband’s death, has resumed an active social life. She does, however, admit to a recent onset of anxious and depressed mood and worries about having a heart attack. She is reluctant to discuss more.

Questions

1. What information does the patient’s EKG contribute to the diagnosis of ischemic heart disease?

2. What could be troubling an 88-year-old woman?

3. What further testing or treatment should be offered to this patient?

Answers

1. About 50% of elderly individuals have abnormalities of the resting EKG – most commonly, intraventricular conduction abnormalities, PR and QT prolongation,

Case Studies in Geriatric Medicine, Judith C. Ahronheim et al. Published by Cambridge University Press. C

Figure 5 The patient’s EKG showing poor R-wave progression.

and reduction in QRS voltage, as well as a more superior and leftward orienta- tion of the QRS vector. This patient’s EKG revealed poor R-wave progression (see Figure 5); although suggestive of underlying cardiac disease, it is a nonspecific find- ing and neither rules in nor rules out cardiac disease. Change in body position appears to affect the precordial leads much more in the elderly than in others, perhaps because of alterations in thoracic anatomy or because of changes in elas- ticity of the great vessels. Thus, the information available on this patient is quite nonspecific.

2. Although cardiac disease can present atypically in the elderly (see Case 15), the patient’s symptoms seem noncardiac in nature and could well be related to stress, as her frustrated affect suggests. Somatic symptoms are a common manifestation of depression and often mask depression in the elderly. Many elderly patients who deny depression will present with somatic complaints rather than classic symptoms of dysphoric mood. Physicians should evaluate and treat these patients based on their particular clinical presentations, while maintaining a suspicion for depression. Disease itself, and the inability to cope with the involution of health at the end of life, can precipitate depression, but older individuals suffer repeated personal losses as well. Death of a spouse is the most obvious major loss that should be inquired about, but very elderly people often outlive siblings, close friends, and sometimes their children. It is very important to inquire whether a distressed patient has

73 Chest pain

recently experienced the death of any of these important people. This particular patient had functioned well for the 4 years following the death of her husband, to whom she had been married since the age of 18, but she had recently started to date again. As a pitfall of her new lifestyle, she had been jilted by a regular gentleman visitor in favor of a younger woman, who herself was over 80 years of age. She did not volunteer this information, and it was not elicited immediately, perhaps because of the embarrassment that such behavior caused her. She may have viewed dating at her age as unseemly or may have felt guilt over renewed sexuality.

Other underrecognized stressors in late life can contribute to depressive symp- toms, including loss of employment, especially among men 60–75 years of age. Other aspects of depression in the elderly are discussed in Case 10.

3. Although cardiac disease can present atypically in the elderly, further cardiac testing may not be warranted in this patient at this time. It would be very important to question her about any symptoms during future visits, but a cardiac workup at this point might cause her undue worry and could be counterproductive. Rather, atten- tion to her stressors would take precedence, and this would represent a worthwhile effort by the primary care physician.

Tests to screen for depression might be revealing, since psychiatric consultation is often strongly resisted by patients who seek care for their symptoms from a primary care physician, and is not always necessary. Simple screening tests for depression in older adults can be effectively employed in primary care. The 30-item Geriatric Depression Scale (GDS) is widely used, but 15- and 5-item GDS instruments do not sacrifice accuracy and reduce administration time. Two questions or even one (e.g. “Do you often feel sad and depressed?”) may be equally effective in uncovering depression (see Williams et al., 2002).

Management of more severe depression is discussed in Case 10. In the present case, supportive psychotherapy, reassurance that her distress over the loss of her gentleman friend would pass, and emphasis of the importance of maximizing her social supports were of immense help. The patient’s chest pain syndrome resolved and she resumed an active social life.

Caveats

1. Somatic complaints in depression differ from “somatization,” which is a disorder consisting of multiple somatic complaints that recur over many years. These complaints cannot be explained by appropriate diagnostic tests, and patients who somatize are thought to have altered sensations of bodily functions that may be amplified with anxiety or life stressors. The “sick role” may also have particular rewards for the patient, such as attention from family members or their physician.

Somatization disorder manifests in younger adulthood and is unlikely in this patient whose first symptoms appeared late in life, and in seeming isolation.

2. Many people who commit suicide have visited their primary care provider in the month preceding their suicide. According to one large review, 43–70% of adults 55 years of age and older had made such a visit, compared with 10–36% of persons aged 35 and younger. Far fewer had made a recent visit to a mental health profes- sional (see Luoma et al., 2002).

R E F E R E N C E S

Luoma, J. B., Martin, C. E., and Pearson, J. L. (2002). Contact with mental health and primary care providers before suicide: a review of the evidence. American Journal of Psychiatry,

139, 909–16.

Williams, J. W., Noel, P. H., Cordes, J. A. et al. (2002). Is the patient clinically depressed?

Journal of the American Medical Association, 287, 1160–70.

B I B L I O G R A P H Y

Gallo, J. J. (1999). Depression without sadness: alternative presentations of depression in late life. American Family Physician, 60, 820–6.

Hoyl, M. T., Alessi, C. A., and Harker, J. O. (1999). Development and testing of a five-item version of the geriatric depression scale. Journal of the American Geriatric Society, 47, 873–8.

Mahoney, J., Drinka, T. J., and Abler, R. (1994). Screening for depression: single versus GDS.

Journal of the American Geriatric Society 42, 1006–8.

Servan-Schreiber, D., Kolb, R., and Tabas, G. (1999). The somatizing patient. Primary Care.

26, 225–42.

Sinoff, G. (2002). Does the presence of anxiety affect the validity of a screening test for depression in the elderly? International Journal of Geriatric Psychiatry, 17, 309–14. Snyder, A. G. (2000). Measures of depression in older adults with generalized anxiety

disorder: a psychometric evaluation. Depression and Anxiety, 11, 114–20.

Wijeratne, C. and Hickie, I. (2001). Somatic distress syndromes in later life: the need for a paradigm change. Psychological Medicine, 31, 571–6.

Case 12