Sleep Problems and Odd Behavior in a 60-Year-Old Woman

Donald M. Hilty, MD, MBA; Jose Feliberti, MD

Disclosures

February 28, 2019

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 60-year-old woman was referred by a primary care provider to a telepsychiatrist for management of depression. During the evaluation by synchronous video, the patient reported problems sleeping. Mainly, she awakens from sleep without feeling rested in the morning. She reported that an antidepressant had helped in the past. She has tried over-the-counter sleep aids without help. She has found it helpful to have a glass or two of wine to get to sleep but would like to cut back.

Although the patient demonstrated low mood, negative thoughts, and some worry, she expressed no thoughts of suicide or death. She had a satisfactory appetite and had not lost weight. She was also not receptive when given a compliment and often dismissed positive feedback. She showed evidence of anhedonia. She made self-critical comments of not doing enough for the family since her husband died 3 years ago. She had worked as a nurse until age 60 years and is now retired. She lives in a one-bedroom apartment on the third floor of a building with an elevator. She receives Social Security and is supported by her daughter.

Her daughter was invited in for part of the interview and confirmed the patient's history of depression and remission. The patient's daughter also reported that physical illness greatly contributed to the return of her mother's depression. She also reported problems that came and went with memory, attention, and "losing things" over the past 6 months. The patient reportedly appeared to not be doing some daily routines, staying indoors, and consuming wine more often.

The daughter also stated that the patient presented to a medical hospital 2 weeks prior, because her "blood sugar was not in control, and she got really confused." The patient also had spinal stenosis, which flares up during these times. She had not noticed cognitive impairment but had problems with pain control for 2 years because of diabetes and spinal stenosis. Her daughter reluctantly shared that the patient's alcohol consumption has also increased to a glass during the day and usually with dinner, as well.

In terms of the patient's past psychiatric history, she has had at least five episodes of depression over the past 35 years. She has seen a therapist in the past and has had two hospitalizations. One of these hospitalizations occurred after a suicide attempt with pills approximately 15 years prior. Her medication history includes use of the antidepressants fluoxetine, sertraline, and nortriptyline. She has also taken diazepam in the past. She has not taken any mood stabilizers or antipsychotics. Currently, the patient takes mirtazapine (30 mg at bedtime), enalapril (20 mg, twice daily), furosemide (40 mg, once every other day), and metformin (500 mg at dinner).

In terms of her medical history, the patient denies illegal substance abuse and nicotine use. She rarely uses caffeine. She does not regularly exercise. She has type 2 diabetes mellitus and hypertension. She is also allergic to penicillin. Her family history includes depression and alcoholism. Her family does have some stigma around mental illness.

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