Older Adult Psychiatric Case Study

IDENTIFICATION: The patient is a 75-year-old, married, Caucasian female who is the mother of two adult children and grandmother of seven grandchildren, all of whom are very close. The patient is self-referred to a private psychiatric outpatient office and is seeking therapy and medication management.

CHIEF COMPLAINT: “I need help with my medication and managing depression and anxiety, which I’ve had on and off since high school.”

HISTORY OF CHIEF COMPLAINT: The patient reports that her father is dying, and she has been experiencing worsening of depression and anxiety symptoms over the past few months. She is seeking a psychiatric evaluation at her daughter’s urging. The patient does not enjoy being with her family, not even her grandchildren. She has difficulty falling asleep but then spends the day lying on the sofa and reports feeling like she is “moving through molasses.” She reports feeling tired all the time. She has also stopped going to her volunteer job at her church. She does not read as often as she used to.

She responded to the practitioner’s question of “why depressed now?” by saying that with the imminent death of her beloved father, she is losing her chief ally and support.

In addition to her father’s illness, the patient was diagnosed and treated for colon cancer in the past year. She received psychotherapy at that time which focused on her anxiety about the diagnosis, her denial of its severity, her wish to “not know what she knew,” and, ultimately, end-of-life issues.

PAST PSYCHIATRIC HISTORY: The patient was never hospitalized for psychiatric reasons. She has no history of suicidal thoughts, gestures, or attempts.

The patient described either a partial or negative response from several medications she had been prescribed from her primary care physician (PCP) over the course of several years, including duloxetine fluoxetine, paroxetine, venlafaxine, mirtazapine, bupropion, and escitalopram.

She is currently prescribed clonazepam 2 mg TID by her PCP which she has been taking for several years.

MEDICAL HISTORY: Patient has a history of cardiac arrhythmias, irritable bowel syndrome, gastroesophageal reflux disorder, and a recent diagnosis of metastatic colon cancer.

Patient denies being sexually active with her husband.

HISTORY OF DRUG OR ALCOHOL ABUSE: The patient denies history of drug and alcohol abuse. She reports that she had been prescribed clonazepam 2 mg TID by her PCP and has tried repeatedly to decrease the amount unsuccessfully.

FAMILY PSYCHIATRIC HISTORY: Patient reports that her mother had “excessive” cleaning compulsions and expressed many fears about contamination and safety. The patient describes her father as “riddled with anxiety and depression,” but neither parent sought treatment for any emotional disturbances. She is an only child and does not recall any emotional difficulties in grandparents or other relatives.

PERSONAL HISTORY

Perinatal: No known perinatal complications.

Childhood: Was a good student. The patient did not develop confidence managing age-appropriate activities, such as picking out her clothing and fixing her own hair because her mother dominated these activities.

Adolescence: The patient’s mother dressed her, washed and braided her hair until she was a sophomore in high school, and repeatedly told her that she would never be able to live on her own. Did well academically. Identifies as heterosexual.

Adulthood: The patient’s mother discouraged her from taking a job out of state that she was looking forward to. She believes her anxiety and depression began at that time. Besides her mother dissuading her from pursuing her career, she encouraged her to “marry her high school sweetheart and be a stay-at-home mother.” Although the patient loved being a mother, the patient reports that her marriage has been a source of anxiety from the very beginning, describing her husband as verbally abusive and a “bully.”

The patient’s mother discouraged her from taking a job out of state that she was looking forward to. She believes her anxiety and depression began at that time. The patient has been married for almost 50 years. She reports that she is very close to her children, her grandchildren, and her five sisters-in-law. The patient has worked in the local rectory and church for the past 25 years and is close to the parish priests as well as to her coworkers at the church.

TRAUMA/ABUSE HISTORY: The patient reports that while she was never physically abused, she felt controlled by her mother’s dominance and was verbally and psychologically abused by both her mother and her husband for many years.

MENTAL STATUS EXAMINATION

Appearance: Well-groomed, appropriately dressed, older woman who is slight in stature and of average weight.

Behavior and psychomotor activity: Good eye contact, pleasant, cooperative. Slightly unsteady gait. Patient demonstrated multiple bruises on her arms and legs secondary to ataxia and subsequent falls.

Consciousness: Alert and able to answer all questions appropriately.

Orientation: Oriented to person, place, time, and situation.

Memory: Intact. Good recent and remote memory.

Concentration and attention: Appears to have good concentration during the interview but reports that she has recently had trouble concentrating while reading.

Visuospatial ability: Not formally assessed.

Abstract thought:  Within normal limits, appropriate use of metaphors.

Intellectual functioning:  Patient has high school education and some college but demonstrates higher intelligence based on her curiosity, choice of reading material.

Speech and language: Normal rate and rhythm.

Perceptions:  No abnormalities present.

Thought processes: Goal directed, but evidence of guilt and rumination consistent with depressive symptomatology.

Thought content: Patient is highly anxious and expresses thoughts of sadness and frustration. She is preoccupied with thoughts about the anticipated loss of her father.

Mood:  Depressed and anxious.

Affect: Congruent with mood.

Impulse control: Good.

Judgment/insight/reliability: Good.

Questions:

• Which diagnosis should be considered?
• What is your rationale for diagnosis?
• What tests or tools should be considered to help identify the correct diagnosis?
• What differential diagnosis should be considered?
• What treatment (both pharmacologic and non-pharmacologic) would you prescribe and what is the rationale?
• When would you want to follow up with this patient.

 
 
 
 
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How to Approach the Older Adult Psychiatric Case Study: Diagnosis, Differential Analysis, and Treatment Planning

Step 1: Start With a Focused Case Summary (Brief Intro Paragraph)

Begin with a short clinical summary (4–6 sentences) that frames the case without repeating the entire scenario.

Include:

• Age, gender, referral type

• Primary symptoms (depression, anxiety, functional decline)

• Key stressors (father’s impending death, metastatic cancer)

• Major risk factors (polypharmacy, long-term benzodiazepine use, falls)

Purpose: This shows you understand the clinical picture before jumping into diagnosis.

Step 2: Identify the Primary Diagnosis

Most Likely Primary Diagnosis

Major Depressive Disorder (MDD), recurrent, severe, with anxious distress

Step 3: Provide a Clear Rationale for the Diagnosis

In this section, tie DSM-5-TR criteria directly to patient data.

Explain that the patient meets criteria for MDD based on:

• Persistent depressed mood

• Anhedonia (loss of interest in family, grandchildren, church, reading)

• Psychomotor retardation (“moving through molasses”)

• Fatigue and low energy

• Sleep disturbance

• Impaired concentration

• Functional decline (stopped volunteering, inactive most of the day)

Then explain why “with anxious distress” applies:

• Chronic anxiety since adolescence

• Rumination, guilt, excessive worry

• Long-term benzodiazepine dependence

• Family history of anxiety disorders

Also emphasize:

• Symptoms are not better explained by normal grief alone

• Duration and severity exceed expected bereavement reactions

Step 4: Identify Diagnostic Tests and Screening Tools

List validated tools, especially those appropriate for older adults.

Recommended tools:

• PHQ-9 – assesses severity of depressive symptoms

• GAD-7 – measures anxiety severity

• Geriatric Depression Scale (GDS) – age-appropriate depression screening

• Montreal Cognitive Assessment (MoCA) – screens for cognitive impairment

• Medication review / Beers Criteria – evaluates benzodiazepine risks

• Fall risk assessment – due to ataxia and bruising

Explain briefly why each tool is useful.

Step 5: Discuss Differential Diagnoses (Very Important for Grading)

List differentials and explain why they are less likely.

Differential Diagnoses to Consider

1. Persistent Depressive Disorder (Dysthymia)

   • Less likely due to episodic severity and functional collapse

2. Adjustment Disorder with Depressed Mood

   • Symptoms are more severe, chronic, and impairing than expected

3. Complicated Grief (Prolonged Grief Disorder)

   • Grief is anticipatory, but symptoms predate father’s illness

4. Benzodiazepine-Induced Depressive Disorder

   • Likely contributing factor but does not fully explain lifelong pattern

5. Major Neurocognitive Disorder (Dementia)

   • Unlikely due to intact memory, orientation, and insight

Step 6: Develop a Comprehensive Treatment Plan

Split this into pharmacologic and non-pharmacologic treatment.

A. Pharmacologic Treatment

1. Address Benzodiazepine Dependence (Critical Point)

• Gradual clonazepam taper to reduce:

  • Falls

  • Cognitive impairment

  • Dependence

• Abrupt discontinuation is contraindicated

2. Antidepressant Strategy

Given multiple failed trials:

• Consider sertraline (cardiac-safe SSRI)

• Or vortioxetine (cognitive benefits in older adults)

• Start low and slow due to age and medical complexity

3. Adjunctive Options (If Needed)

• Buspirone for anxiety

• Avoid sedating medications due to fall risk

B. Non-Pharmacologic Treatment

This section often earns high rubric points.

Recommended interventions:

• Cognitive Behavioral Therapy (CBT) – depression and anxiety

• Grief-focused psychotherapy – anticipatory grief

• Trauma-informed therapy – lifelong emotional abuse

• Supportive psychotherapy – cancer and end-of-life issues

• Sleep hygiene education

• Physical therapy referral – gait instability

• Social engagement planning (gradual re-engagement with church)

Step 7: Follow-Up Plan

Be specific and clinically realistic.

• Initial follow-up: 1–2 weeks

  • Monitor side effects

  • Assess suicidality

  • Review taper progress

• Ongoing follow-up: Every 4 weeks

  • Adjust medications

  • Monitor mood, anxiety, sleep, falls

  • Coordinate with oncology and primary care

Step 8: Strong Closing Paragraph

Summarize:

• Primary diagnosis

• Importance of addressing benzodiazepine dependence

• Role of combined medication + psychotherapy

• Need for close follow-up due to age, cancer, and fall risk

Optional (But Highly Recommended): Add References

Include 2–3 peer-reviewed sources from the past 5 years:

• DSM-5-TR

• Geriatric psychiatry guidelines

• Benzodiazepine safety in older adults

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