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A 74-year-old woman is referred to the psychiatric clinic by her primary care provider for evaluation of a six-month history of progressive low mood, anhedonia, poor appetite with a 12-pound weight loss, insomnia with early morning awakening, and difficulty concentrating. Her family reports that she has also been having trouble remembering appointments, misplacing items, and repeating questions. She retired from teaching three years ago and has become increasingly isolated since her husband passed away 18 months ago. Her medical history includes hypertension controlled with lisinopril and hypothyroidism managed with levothyroxine. Her most recent TSH level was within normal range. She scores 18 out of 30 on the Montreal Cognitive Assessment (MoCA) and 12 on the Patient Health Questionnaire-9 (PHQ-9). The PMHNP must determine the most appropriate next step.
Explanation
When depression and cognitive impairment co-occur in older adults, it is essential to consider depressive pseudodementia, in which depression itself causes significant cognitive deficits. These deficits can include impairments in memory, attention, processing speed, and executive function that may mimic a neurocognitive disorder. The appropriate approach is to treat the depression with an SSRI that is well-tolerated in older adults, such as sertraline, at a low starting dose with gradual titration. Cognitive function should be reassessed after eight to twelve weeks of adequate antidepressant treatment. If cognitive deficits persist despite remission of depressive symptoms, further workup for a primary neurocognitive disorder is warranted.
Key Takeaway
In geriatric patients presenting with concurrent depression and cognitive decline, treat the depression first and reassess cognition after mood symptoms have remitted, as depressive pseudodementia can mimic a primary neurocognitive disorder.