Clinical Assessment and Care Plan for an Aging Patient

Initial Clinical Impressions

The general impression of Mrs. Smith is that she is nearing an end-of-life phase: she is becoming weaker and tired, does not feel like going out much, and experiences a general sadness — though she says she does not feel "sad exactly." Her general mood is pensive and somewhat concerned about her frailty. She is particularly worried about having another fall like the one she had last year and about becoming dependent on caretakers. Her fears are grounded in the experiences of friends and an overall awareness that, at 80, she will not be able to live independently forever. This is no doubt contributing to some degree of depression, which is not uncommon among seniors at this age (Shulman, 2007).

Likewise, her gait pattern — slow, with "reduced walking speed, arm swing and vertical head movements" — is indicative of "sadness and depression" (Michalak et al., 2009). This is consistent with the sense that she is feeling dysphoric lately, withdrawing from society, not going to the store, and not seeing friends as often as she used to. She is aging and perhaps beginning to reflect more on the uncertainty of what lies ahead rather than living in the present.

Additional Information Needed

Additional information I would like to know about Mrs. Smith includes her daily routine, who manages her meal preparations, her daily medications (if any — so as to prevent accidental overdose), and what percentage of food she consumes during mealtimes, given that she reports having little appetite lately. I would also want to know whether she is experiencing any trouble with bowel or bladder voiding, constipation, or incontinence.

Regarding psychological issues, I would want to learn more about her family background and whether there is any history of depression in her family or in her own past. I would also like to know whether she has considered any plans for the future. Addressing the elephant in the room — her age and what lies ahead — could in fact alleviate some of the heaviness weighing on her mind. It would be helpful to explore what she has considered doing should she require caretaking in the future, including whether she would turn to her son or prefer assisted living. She may not want to discuss this subject, but it could be broached gently for the sake of clarity. Discussing possible alternatives — such as home care — could help ease her mind and reduce her sadness. It is important to get seniors talking because "ending social isolation" can be very helpful in addressing sadness (Grundberg et al., 2016).

Differential Diagnoses

Differential diagnoses for Mrs. Smith include depression due to persistent sleep disturbances and dysphoria. Degenerative CNS disease is another possibility, as are chronic fatigue syndrome, anxiety, Type I collagen mutations, and major depressive disorder. She may also be experiencing aortic stenosis, judging from the murmur heard at the right upper sternal border.