Journal of Geriatric Cardiology : JGC | 2021
Prevention of self-harm through early detection of depression among the elderly with permanent pacemaker: a case report
Abstract
T here is consensus regarding the efficacy and safety of permanent pacemakers (PPM) and other cardiac implantable electronic devices. These devices improve the quality of life by reliving symptoms of bradycardia including dizziness, fatigue and exercise intolerance. The decision to implant a PPM is often made at the time of the initial encounter with the patient, such as when symptomatic bradyarrhythmia is first diagnosed. The implantation procedure is usually performed promptly. However, the psychosocial factors related to having a PPM are frequently underestimated by clinicians. Poor psychological adaption after implantation, particularly among aged patients with undetected psychiatric illness, poses a significant risk to treatment benefit. It is known that both anxiety and depression commonly accompany cardiovascular disease (CVD), leading to reduced quality of life and increased mortality. Depressed elder adults tend to present different symptoms from the young patients, such as somatic symptoms, loss of interest and cognitive changes. Currently, a psychological evaluation before and after PPM implantation is not generally advocated. In this article, we propose that shared decision-making (SDM), employing psychosocial approaches, is critical for aged patients receiving permanent pacing therapy, if successful outcomes are to be maximized. An 87-year-old woman was brought to our emergency department with an extensive self-inflicted wound of the left upper chest wall, exposure of a pacemaker generator with damaged leads, and selflacerations of both wrists. A permanent pacemaker system (DDDR mode, ADAPTA, Medtronic) had been implanted eight years previously with the diagnosis of sick sinus syndrome. Multiple somatic complaints, especially chronic back pain, had impacted the patient’s sleep quality and daily life. The patient also had a diagnosis of general anxiety disorder, and she had been regularly visiting a psychiatric clinic for insomnia over the two years preceding this event. The patient occasionally expressed suicidal ideation but her family did not pay much attention to her suicidal verbalizations. At about 2:00 a.m., during the night immediately prior to emergency department admission, the patient was awaken by general discomfort associating with a feeling of hopelessness. She cut her wrists, for she believed that removing her pacemaker would cause her heart to stop and thereby make her die more quickly. She repeatedly cut into her chest wall, both around and over her pacemaker (Figure 1). In the morning, her family noticed she had not gotten up, and she was found lying in bed, severely injured. The patient was immediately transported to hospital and the pacemaker was safely removed. There was no sign of infection, and no bradycardia was recorded. The cardiologist held a discussion with the patient’s family regarding the patient’s condition and situation. Following discussion, it was decided that due to the unacceptably high risk for future self-harm due to her mental status and the absence of bradycardia at the time, the PPM would not be re-implanted. The guidelines of the American College of Cardiology, American Heart Association, and Heart Rhythm Society, stated that pacemaker implantation is not indicated when significant comorbidities far outweigh the clinical benefit. Psychiatric illness, while not a definitive contraindication, is inJournal of Geriatric Cardiology