Complex Psychiatric/Medical Adult/Geriatric Patient

Case Presentation

Darron is a 68-year-old white widower and retired accountant. He was referred for psychosocial evaluation at the diabetes clinic after an emergency room (ER) visit to a local hospital. He arrived at the ER with confusion and a severe hypoglycemic episode after taking an overdose of insulin. He denied suicidal intent or alcohol abuse and claimed to have mistakenly taken insulin lispro rather than his insulin glargine dose. The ER staff was suspicious about his claim because there had been eight similar ER visits for severe hypoglycemia within the last two years. He explained these previous events as a result of mixing up the types of insulin he injected.

After psychiatric assessment he was not judged to be a suicidal risk. He was discharged after his blood glucose levels stabilized, and he promised to pursue outpatient mental health treatment. His hemoglobin A1c (A1C) at the time was 7.9% – his lowest on record for several years. Generally, his blood glucose levels displayed wide swings. He explained that high blood glucose levels made him feel more apathetic about eating and depressed about his diabetes self-management.

Personal history

As a child, Darron attained developmental milestones at expected times. His father was in the Army, and as a result, Darron had moved 32 times before he graduated from high school. He was an excellent student throughout high school but only managed mediocre grades in college because of family conflict. He dropped out of college in his junior year and moved to a South Pacific island for one year.

After returning to the United States, he earned an undergraduate degree in English and then a second degree in accounting. After graduation, he married and worked for 20 years as an accountant in a group practice. Later, Darron started his own accounting firm, but he had difficulty keeping organized and recalls being constantly late for business meetings and failing to complete projects on time. In hindsight, Darron believes that he has struggled with depression on and off for > 30 years. He first recalls feeling depressed after his diagnosis with diabetes 36 years ago. He felt more depressed after he lost his 47-year-old sister to colon cancer in 1988, and then his 74-year-old father died from heart disease in 1991. But, he says his life “really fell apart” when his 54-year-old wife died from lung cancer in 1995. He contemplated suicide for three months but never acted. During this desperate period, he marginally functioned, lost many business clients, and was forced to close his company.

Overwhelmed by depression, he moved to the West Coast to live with his mother and worked at unskilled jobs. Diabetes complicated his emotional struggles, with blood glucose control fluctuating wildly and ranging from episodes of ketoacidosis that required hospitalization to severe hypoglycemic events that resulted in car crashes. Depression complicated his diabetes management, and after a hypoglycemia-related auto accident in which he ran over several pedestrians, he decided to stop working and was approved for social security because of psychiatric disability.

He came to the East Coast in 1998 to briefly visit his younger brother and decided to stay. Although he still lives near his brother, he says they have had only sporadic contact since a falling out after Darron “passed out” during a severe hypoglycemic episode. In 2010, Darron got engaged, but his fiancée left him to marry the father of her child. He says he felt devastated by the loss of yet another woman who had “become everything” to him. Since then, he has withdrawn socially and does not leave his apartment unless it is necessary. He has trouble managing his money, keeping his apartment neat and orderly, taking medications on time, and maintaining any structure in his day.

Medical history

Darron punctually arrives at the correct hour but often on the wrong day for his medical appointments. He grapples with neuropathy, retinopathy, and unpredictable blood glucose levels. He monitors his blood glucose levels 8–12 times/day and tries to be careful about what he eats. He also has sleep apnea, and his sleep patterns are highly erratic. He frequently does not fall asleep until 4:00 a.m. and then may only be able to sleep for 2 hours. Often, he will then nap for several hours in the afternoon. He began continuous positive airway pressure treatment for his sleep problems in 2003 but did not tolerate treatment. He has switched to bilevel positive airway pressure (biPAP) within the last 18 months but only tolerates it for up to 3 hours each night. Additional diagnoses include hyperlipidemia, hypertension, atrial fibrillation, Meniere’s disease, tinnitus, and arthritis. His medication list includes atorvastatin, lisinopril, hydrochlorothiazide, warfarin, meclizine, and folic acid. He does not smoke and only rarely drinks alcohol. Only his paternal grandmother had diabetes.

Psychiatric history

Depression has plagued Darron since his diagnosis with diabetes. As noted earlier, his depression intensified after the deaths of his sister and father, but he did not descend into a suicidal mood until his wife died 10 years ago. Four years ago, he underwent electroconvulsive therapy (ECT), and although he continues to have occasional suicidal ideation, he has not made an attempt and has had no further psychiatric admissions. Both of his parents, his brother, and his sister suffered from depression. A maternal aunt suffered from dementia. His mother also struggled with alcohol abuse until her death from emphysema in 2004 at the age of 89. At the time of referral, he was taking fluoxetine, 40 mg, and venlafaxine, 37.5 mg, prescribed by a PMHNP.

Questions

1. Was Darron’s insulin overdose accidental or a suicide attempt based on clinical decision making you would invoke as a PMHNP?

2. What are the causes for his cognitive impairment?

3. How does his depression and cognitive problems affect his diabetes self-management?