Depression as Part of Comprehensive Geriatric Assessmenta Persistent Pain using Multiple Drug: Case Report

Received: 30-Nov-2022, Manuscript No. JDAR-22-84296; Editor assigned: 02-Dec-2022, Pre QC No. JDAR-22-84296 (PQ); Reviewed: 16-Dec-2022, QC No. JDAR-22-84296; Revised: 21-Dec-2022, Manuscript No. JDAR-22-84296 (R); Published: 28-Dec-2022, DOI: 10.4303/JDAR/236212

Introduction

Pain management in the elderly is not only focused on the cause because there are many other aspects that can affect pain such as depression fear of making movements so that passive motion ends in stiffness which ultimately increases the level of pain which can actually be improved comprehensively [1,2]. That is why Comprehensive Geriatric Assessment (CGA) can be a holistic solution when the usual examination does not provide one.

Methods

This is a retrospective case report following analysis of patient clinical data. This study was conducted in accordance with the Declaration of Helsinki (1964) and has received permission from the hospital. The patient provided written informed consent to publish their case details and any accompanying images. The study protocol complies with the requirements of the institute committee of Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

Results

A 66-year-old female patient was admitted to the hospital because of complaints of back pain that she had been experiencing for 4 months and which had worsened within 1 day before she was admitted to the hospital. The pain was sharp and localized in the spinal area around the waist and sometimes made the patient feel as if she had an electric shock in both legs. Complaints did not decrease after the patient took the drug and changed position Mentis Compost Awareness. BP 160/90 mmHg Pulse: 90 times/minute. RR: 20 times/minute. T: 36.7. SpO2: 98% (Nasal Cannula). The patient was assessed for persistent pain low back pain thoracic and lumbar vertebral compression fractures chronic kidney disease stage 5 (hemodialysis) and laboratory result symptomatic epilepsy focal clonic seizures without impaired awareness infiltrating intracranial cause plasmacytoma hospital acquired pneumonia. Hyperkalemia hypomagnesaemia multiple cystic causes multiple myeloma (Table 1).

Table 1: Laboratory Examination.

Conclusion from the bone survey at Johannes Leimana Hospital Ambon April 14, 2022: On the skull a round well-defined lytic lesion with varying sizes gives the appearance of a pounch out lesion. On the humerus well-defined lytic lesions vary in size from the medial 1/3 to the distal 1/3 of the bilateral humeral shaft. On the thorax the pedicle was intact flattened on CV T11 was seen. The lumbar pedicle was intact flattened CV L1 and L2 were seen. There were no lytic or blastic lesions on the pelvis and a T-shaped hyperopaque lesion was seen in the pelvic cavity. There were no lytic or blastic lesions on the femur Thus it can be concluded that thoracic CV compression and lumbar CV compression underlied the occurrence of back pain bone flattening and lytic lesions in the head ribs humerus and spine. The patient was assessed for persistent pain low back pain thoracic and lumbar vertebral compression fractures chronic kidney disease stage 5 (hemodialysis) symptomatic epilepsy focal clonic seizures without impaired awareness infiltrating intracranial cause plasmacytoma hospital aquered pneumonia hypercalcemia hypermagnesemia multiple cystic causes multiple myeloma. hypercoagulable state PADUA score 6 cervical spondyloarthrosis with pacet joint degeneration dektra frontal mass region cause plasmacytoma asymptomatic complicated urinary tract infection stage 2 hypertension nephrolithiasis right kidney adjustment disorder anxiety and depression mild dependence risk sarcopenia and pre-frail. Geriatric syndromes that have occurred are moderate risk of falls (instability) moderate risk of pressure ulcers risk of malnutrition mild dependence risk of sarcopenia and pre-frail.

Treatments performed on patients include the installation of supports to overcome pain maintaining the stability of the lytic area through passive physiotherapy with transfer exercises by avoiding weight bearing in the humerus area education on the use of a TLSO brace to reduce pain stabilizing the compression area on the spine consulting with orthopaedics (K Spain) to stabilize the spine that was experiencing moderate and severe displacement to reduce spinal cord pain and trauma the goal was to prevent pathological fractures.

The patient was categorized as having mild dependence because of her illness. There were some activities that the patient was unable to do with or without assistance. From the results of the Barthel ADL examination a score of 15 was obtained with a mild level of dependence. Pain improvement was necessary so that the patient’s ADL improved. The patient had not been able to stand and walk on her own without assistance because when she felt pain when standing or walking. Activities that required the patient to bend over such as wearing pants were also difficult to do. Muscle strength flexibility and balance exercises could be performed because the pelvis and lower extremities did not have lytic lesions. Installation of the TSLO Brace could help reduce pain. The patient had a risk of sarcopenia due to immobilization. Attempts to maintain a position to avoid pain in the spine can be a cause of sarcopenia. Reduced food intake during illness also caused weight loss in the patient. The results of the SARC F examination showed predictive results of sarcopenia. The patient was advised to be given adequate nutrition and regular physical exercise both during her stay in the hospital and when she recovered at home.

Pre-Frail examination showed that the patient had difficulty with movement due to pain. If not anticipated, the patient may experience a Frail in the future. Motivation is an important thing to give in this condition because if the psychic and spiritual conditions are problematic. the patient will fall into a Frail state. The patient was encouraged to practice passive movements. The get adequate nutrition and hydration strengthen physically and spiritually and get support from the whole family. This scheme can give the best results and prevent Pre-Frail conditions from becoming Frail.

Discussion

In general the patient’s condition improved. This is evident from the reduced pain in the spine due to the administration of drugs. The patient was able to finish her food and sleep. Blood pressure had reached the target reduction pulse was regular and respiration was still within normal ranges. The patient also did not experience shortness of breath or require oxygen during hospitalization.

Pain conditions caused by lytic lesions require comprehensive management. The modality of therapy was constrained because the patient had impaired kidney function. John Willan et al. in challenges and solutions Clinical Intervention in Aging in 2016 regarding multiple myeloma in the very elderly patient stated that a low dose of radiotherapy given with a single dose of 8 grams was sufficient to control pain. Kypoplasty or vertebroplasty may be helpful in vertebral compression fractures that cause pain as pain relief or vertebral stability to prevent fracture [3]. Another study in Indonesia was conducted in Bandung by Fauziani Anggi et al. and the results showed that operative therapy for spinal multiple myeloma improved the patient’s quality of life by reducing pain and improving neurological deficits. Bone union is something that is often experienced by postoperative patients. This did not happen because the therapy given was only supportive [4].

Life expectancy for 5 years in patients with multiple myeloma between the ages of 65-74 years is 1.65 (95% CI). Cancer Research UK says that the life expectancy of myeloma patients decreases with age. Life expectancy for 5 years in men is 75% (15-49 years) and 24% at the age of 80-99 years [5], with this situation the patient’s life expectancy will decrease if there are comorbid conditions such as chronic Kidney disease as hemodialysis will make the condition worse.

Conclusion

CGA is a very important modality in screening to look for other aspects that can affect the condition of the disease the therapeutic modality to be given and the prognosis after persistent pain using multiple drugs.

Acknowledgement

We would like to thank Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

Conflict of Interest

Authors have no conflict of interest to declare.

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Copyright: © 2022 Muhammad Darma Muda Setia, et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.