Geriatric Psychosocial Case Study

Patient Information

Name: Mr. James Carter
Age: 78
Gender: Male
Ethnicity: African American
Marital Status: Widowed
Living Situation: Lives alone in a one-story home
Insurance: Medicare

Chief Complaint

“I don’t feel like myself anymore… I just feel tired and alone.”

History of Present Illness (HPI)

Mr. Carter is a 78-year-old widowed male presenting for evaluation of worsening sadness, fatigue, and social withdrawal over the past 6 months. His wife of 45 years passed away 8 months ago. Since her death, he reports decreased interest in activities he once enjoyed, including attending church and playing cards with friends. He describes poor appetite, difficulty sleeping, and low energy.

He denies active suicidal ideation but expresses passive thoughts such as “Sometimes I wonder what the point is.” He reports increasing forgetfulness, including misplacing items and missing bill payments. His daughter is concerned about his ability to live independently.

Past Medical History

Hypertension
Type 2 Diabetes Mellitus
Osteoarthritis
Hyperlipidemia

Medications

Lisinopril 10 mg daily
Metformin 500 mg twice daily
Atorvastatin 20 mg daily
Acetaminophen as needed

Psychiatric History

No prior psychiatric diagnoses
No hospitalizations
No psychotropic medication history

Social History

Retired factory worker
Former smoker (quit 20 years ago)
No alcohol or drug use
Limited social support
Decreased church attendance

Functional Assessment

Independent with ADLs
Difficulty with IADLs (finances, medication management)
Decreased mobility due to joint pain

Mental Status Examination (MSE)

Appearance: Well-groomed, fatigued
Behavior: Cooperative
Speech: Slow
Mood: Sad
Affect: Constricted
Thought Process: Logical but slowed
Thought Content: No delusions/hallucinations
Cognition: Mild impairment
Insight/Judgment: Fair

Screening Results

PHQ-9: 15 (Moderate depression)
MMSE: 25/30 (Mild cognitive impairment)

Diagnoses (DSM-5-TR)

Major Depressive Disorder, Moderate (F33.1)
Mild Neurocognitive Disorder (F06.7)

Psychosocial Stressors

Bereavement
Social isolation
Chronic illness
Limited support
Financial difficulty

Treatment Plan

Start Sertraline 25 mg daily
Refer to CBT and grief counseling
Encourage social engagement
Consider home health support
Provide safety planning

Follow-Up Plan

Follow-up in 2–4 weeks
Monitor mood and cognition
Adjust treatment as needed