Depression OSCE - Depression in Elderly

Case Overview

• Age/Sex: 78-year-old male
• Occupation: Retired factory supervisor
• Setting: Primary care / GP clinic
• Chief complaint: "Feeling low and tired"

Patient Script

Who I Am

I am 78, retired, and I live on my own since my wife died three months ago.

What Brings Me In

I've been feeling low and tired for a few months and I thought maybe you should check me over — I'm not myself.

My Story

For about three months since my wife died, I've felt down most days and have had very little interest in doing things I used to enjoy like gardening or meeting friends. I wake up very early most mornings — usually around 4–5 a.m. — and can’t get back to sleep. My energy is low; I get tired after doing small tasks. I’ve also noticed I’ve lost a little weight — about 4 kg over the last two months — partly because I don’t feel like cooking. I have trouble concentrating on the crossword and sometimes misplace things; I worry it might be the start of memory problems. I have the odd moment where I think "it would be easier if I weren’t here," but I haven’t made any plans. I haven’t been seeing anyone about this — I thought it was just grief and “getting old,” but it isn’t getting better.

My Medical Background

• Past medical history: hypertension (diagnosed 10 years ago), osteoarthritis in knees and lower back
• Current medications: lisinopril 10 mg daily, atorvastatin 10 mg nightly, paracetamol as needed for back pain
• Allergies: none known
• Social: lives alone, wife died 3 months ago, two adult children who live an hour away and visit occasionally; former smoker (quit 35 years ago); drinks about 4–6 units of alcohol per week
• Family history: brother had dementia in his 80s

What I Think & Worry About

• I think maybe I’m just getting old and this is normal.
• I worry I might be losing my memory like my brother did.
• I want to feel like myself again and not be such a burden on my kids.

If You Ask Me About Other Symptoms...

• Sleep: I have early morning waking around 4–5 a.m., hard to get back to sleep.
• Appetite/weight: Eating less, lost about 4 kg in 2 months.
• Energy: Low — tired doing small tasks.
• Cognition: Sometimes my mind goes blank and I forget small things; crossword is harder.
• Mood: Feel sad most days, little interest in hobbies; tearful at times.
• Thoughts of suicide: I have fleeting thoughts like "it would be easier if I died," but no plan and I have not tried anything.
• Pain: I have chronic low back pain that aches after walking (this is usually the same as before).
• Urinary: I sometimes go to the toilet more at night, but no pain when I pass urine.
• Hearing: Getting a bit hard of hearing; I sometimes ask people to repeat themselves.
• Appetite for sex: Not really — less interested than before.
• No chest pain, no breathlessness, no fever, and no visual or auditory hallucinations.

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Clinical Summary

Examination

• General: elderly male, appears tired, somewhat unkempt but clean, makes limited eye contact
• Vitals: BP 136/78 mmHg, HR 76 bpm regular, RR 16/min, Temp 36.6°C, SpO2 97% on air
• Weight: 72 kg (stated loss ~4 kg over 2 months); height 175 cm; BMI 23.5
• HEENT: mild bilateral presbycusis on bedside testing, pupils equal and reactive
• Cardiovascular: normal S1/S2, no murmurs
• Respiratory: clear to auscultation
• Abdomen: soft, non-tender
• Neurological: no focal deficit, gait steady but slightly slow
• Mental state: subdued affect, low mood, psychomotor retardation; coherent speech; normal orientation to time/place/person; no formal thought disorder or hallucinations observed
• Cognitive screen: MMSE 27/30 (difficulty with delayed recall tasks)
• Suicide risk: expresses passive death wishes but denies active plan or intent

Investigations

• CBC: Hb 13.2 g/dL, WCC 6.1 x10^9/L, platelets 230 x10^9/L (no anemia)
• Electrolytes & renal: Na 138 mmol/L, K 4.2 mmol/L, creatinine 82 µmol/L, eGFR >60 ml/min/1.73 m^2 (normal)
• TSH: 1.9 mIU/L (within reference range)
• Vitamin B12: 210 pg/mL (low–normal/ borderline)
• Fasting glucose: 5.6 mmol/L
• Urinalysis: no infection
• ECG: sinus rhythm, rate 75 bpm, no acute changes
• PHQ-9 score: 15 (moderately severe depressive symptoms)
• Geriatric Depression Scale (short): 8/15 (suggestive of depression)

Diagnosis

• Primary diagnosis: Major depressive episode (late-life depression) precipitated by bereavement

  • Supporting evidence: persistent low mood for ~3 months following spouse’s death, anhedonia, sleep disturbance (early morning awakening), reduced appetite and weight loss (~4 kg), reduced concentration, psychomotor slowing, PHQ-9 score 15, functional decline, and passive suicidal ideation without active plan.

• Important differentials:

  • Normal bereavement/grief reaction: expected after loss but less likely because symptoms are prolonged (>2 months), impairing function, and include somatic changes and passive SI.
  • Hypothyroidism: less likely given normal TSH.
  • Medication side effects: lisinopril and atorvastatin less commonly cause depressive symptoms; no recent med changes reported.
  • Vitamin B12 deficiency: borderline level (210 pg/mL) could contribute to fatigue/cognitive symptoms — worth reassessing and considering supplementation.
  • Early dementia / mild cognitive impairment: possible given subjective memory concerns and MMSE 27/30; cognitive testing and follow-up required to distinguish from depression-related cognitive impairment.
  • Alcohol-related mood disorder: unlikely given modest intake (4–6 units/week).

Management

• Immediate safety: assess suicide risk in detail; because he has passive death wishes but no plan, arrange a safety plan, provide crisis contact information, and ensure someone checks on him (contact children or community support) today.
• Initiate treatment for depression in primary care with shared decision-making:
  • Offer psychological therapy (bereavement counselling and/or CBT) and arrange referral to local counselling services or IAPT-type service.
  • Consider starting an SSRI (sertraline) at a low dose (e.g., 25–50 mg daily) with monitoring for side effects, hyponatraemia, and drug interactions — discuss risks/benefits and obtain baseline labs.
• Address reversible contributors:
  • Recheck vitamin B12 with methylmalonic acid if available and consider replacement if levels remain low or symptomatic.
  • Review and optimize pain management for osteoarthritis to help function and mood (avoid contributing sedatives where possible).
• Social and practical measures:
  • Refer to bereavement support groups and social prescribing (day centre, local senior groups) to reduce isolation.
  • Arrange follow-up in 1–2 weeks to reassess mood, safety, and response; ensure close monitoring after initiating antidepressant (side effects, suicidality).
• Consider referral to old age psychiatry or community mental health team if symptoms worsen, active suicidal ideation emerges, or poor response to first-line measures.
• If cognitive impairment persists or progresses, refer for comprehensive cognitive assessment / memory clinic.

Key Learning Points

• Depression in older adults often presents with somatic complaints (fatigue, poor sleep, appetite change) and cognitive complaints rather than explicit complaints of low mood; always ask about mood and loss of interest.
• Distinguish grief from major depression by assessing duration, functional impairment, severity of symptoms (guilt, worthlessness, persistent anhedonia, suicidal ideation) and associated features; bereavement can precipitate major depression.
• Always assess suicide risk in elderly patients with depressive symptoms and arrange timely safety measures, involve family/support, treat reversible causes (B12, thyroid), and offer a combination of psychological and pharmacological therapies with careful monitoring.