By H.R. Christopher O’Brien, PharmD, BCPP, APP
Program Director, In-Home Psychiatric Services
Ms. E., an 80-year-old resident of a Community Care Facility, had recently returned from a five-day hospitalization for sepsis related to a urinary tract infection. In the first week following discharge, she appeared to be recovering well. She was eating her meals, walking short distances with assistance, and occasionally joining group activities. Her behavior, mood, and level of engagement were consistent with her pre-hospitalization baseline.
That changed abruptly. Over the course of 48 hours, Ms. E. became nearly nonverbal. She responded to staff only with nods or head shakes and did not initiate any conversation. Her affect was flat, and she stared off toward the window for extended periods. Staff grew concerned when she refused meals and medications and chose to remain in bed throughout the day. There were no signs of fever, pain, or infection. Her vital signs remained stable, and there had been no recent changes to her medications.
An interdisciplinary assessment was initiated. At first, hypoactive delirium was suspected, given her recent hospitalization and the possibility of lingering effects from sepsis. However, Ms. E. remained oriented to self and place, and she demonstrated no signs of hallucinations, delusions, or fluctuating consciousness. A silent stroke or transient ischemic attack was considered, but a neurologic exam showed no deficits. Staff also reviewed her medications and confirmed that no new sedating agents had been introduced.
A psychiatric consultation was requested. During the evaluation, Ms. E. followed commands and showed awareness of her surroundings, but she spoke only when directly prompted and with minimal words. With nursing assistance, a PHQ-9 depression screening was completed and scored at 22, indicating severe depressive symptoms. Staff recalled that earlier in the week she had expressed guilt over “being a burden” and had started sleeping poorly again.
Based on the clinical picture—sudden withdrawal, psychomotor retardation, minimal verbalization, and a high depression score—the diagnosis of a major depressive episode with psychomotor slowing was made. The team initiated treatment with desvenlafaxine (Pristiq) at 25 mg daily, chosen for its tolerability in older adults. The dose was increased to 50 mg daily after one week without adverse effects. Non-pharmacological support included daily structured check-ins with nursing staff, reintroduction to music therapy, and a gentle morning routine designed to promote engagement.
Over the next four weeks, Ms. E.’s condition improved steadily. In the first week, she remained mostly quiet, though staff noticed that she was sleeping more soundly and began eating small portions again. By the second week, she responded in short phrases and maintained more eye contact. In week three, she initiated conversation during one-on-one time and participated in reminiscence therapy. By the fourth week, she had returned to group meals and shared a story about her hospital stay, even laughing at one point when recalling a nurse she had liked.
This case illustrates a common but often overlooked presentation of depression in the elderly. In older adults, depression may not present as sadness or crying—it can show up as silence, stillness, and withdrawal. It’s easy to mistake these signs for confusion or the progression of dementia, but with attentive observation and proper screening tools, such as the PHQ-9, the true cause can often be uncovered.
For caregivers and facility staff, the takeaway is clear: sudden behavioral changes deserve thoughtful investigation. Depression is treatable, even when it hides behind a blank stare and silence. Ms. E. is a reminder that every quiet patient has a story waiting to be heard—and the right care can help them find their voice again.
