ALZHEIMERS Dx (I)

HELEN BROWN

84, FEMALE

Role-play cases simulate real clinical practice to guide how candidates respond to clinical scenarios and real life practice.

You are Alex Brown (daughter), ringing about mum Helen Brown. You are upset about your mum's health.

You live 20 minutes drive from mum.

Mum has been increasingly forgetful in the last 5 years. She has been to a memory clinic and has a diagnosis of Alzheimer’s disease for which she is on Donepezil 10mg. She is not aggressive. She has informed you that she does not want to live in a care home.

In the last 4 months she has started:

To forget her tablets, which you often find on the floor, behind cushions, or the packet unopened.
To ring you up at late nights for a chat, as she thinks it is the morning. She forgets she has spoken to you and she call shortly after.
Forgetting to have her meals; the fridge and cupboards are not empty as they should and you can see stuff left over from the shop 2 weeks ago.
Her personal hygiene is not as good as it was.
The trigger for the consultation was that mum was found wandering on the street in the early hours by the police in her nightie. You had to leave home at night to go pick her up.

Today, Mum is well in herself. These changes have been slowly progressive. She stays indoor all the time unless when you take her out, she has no fever, no urinary symptoms.

You have an older brother, he lives in Australia. Your relationship has broken don because he chooses to use his holidays to attend carnivals in the Carribean instead of coming to UK to help with your mother.

You are coping okay, but it is stressful, you are not depressed, your mood is normal, you no longer sleep ok because of your mum's calls and when she does not call, you are worried about her. You work as an administrator in a local engineering factory. Your partner works away a lot (HGV driver). You have three child, aged 9, 12 and 15 years, so you are very much needed to maintain a supportive and stable home life so they have the best chance at good grades.

Mum is a widow. She does not drive, you have her car keys. She lives in a small bungalow, she still uses the electric cooker, kettle and microwave.

You do her weekly shop and get your kids to help with her laundry when you visit. You see her three times a week but due to work can’t visit more frequently. Calling mum to remind her about her lunchtime meal and taking her tablets is no longer helping.

Mum does not smoke or drink. She has no chest, bowel, urine symptoms, etc. She is not depressed.

Ideas: Mum’s Alzheimer’s is steadily getting worse.

Concerns: Mum's safety regarding medications, wandering, missed meals, and her poor personal hygiene. Your disturbed sleep.

Expectations: Any help would be welcome.

Psycho-social impact: Worried about mum.

You are a doctor in your routine clinic, ready to begin your day of consultations. A patient has been booked to see you,

TELEPHONE CONSULTATION WITH DAUGHTER (HELEN)

PMH: Alzheimer’s disease
DH: Donepezil 10mg a day
Allergies: None

Medical Notes - Last few entries in records:

Today: Telephone consultation requested by Alex Brown (daughter) who has LPA for health and welfare as mum is ‘not coping'.

2 months ago: Telephone call with daughter.

Accidental overdose of paracetamol. She had taken 4 tablets in 1 hour, was not unwell, no abnormal symptoms. Daughter has kept medications away, agrees to keep an eye on her and call back if unwell. Declined any further social help.

6 months ago: Annual Dementia Review with ANP, daughter present.

Confirmed compliance with medication.
Memory slowly deteriorating, coping okay. Able to her self-care with assistance.
BP 130/80
BMI 24
Meds re-authorized.

1. Data Gathering, interpretation and diagnosis

Positive indicators

Social and Psychological impact for both her and mum explored
Support networks explored
Current / lack of service input at present
ICE explored
Progression explored
Other exacerbating factors considered – constipation, UTI/infrection, alcohol, depression etc
Enquires re driving and home safety
Explores how the carer is coping and screens for depression/ carer stress etc

Negative Indicators:

Failure to explore social and psychological impacts: Does not inquire about the impact of Helen’s condition on her daily life and Alex’s life. Misses exploring Helen’s and Alex’s emotional wellbeing.
Lack of support network assessment: Does not ask about other family members or friends who could provide support. Ignores potential community resources.
Current services not considered: Does not check if any services are currently in place for Helen. Fails to explore any recent changes or updates in Helen’s care plan.
Incomplete exploration of progression and exacerbating factors: Fails to ask about the timeline and specific changes in Helen’s condition. Ignores possible causes for recent deterioration, such as infections or new medications.
Neglects safety and practical concerns:Does not ask about Helen’s ability to perform daily activities safely. Overlooks questions about home safety measures.
Misses carer’s stress and coping ability:Does not explore Alex’s coping mechanisms or screen for carer stress and burnout. Fails to ask how Alex is managing her own mental and physical health.

2. Clinical Management and managing medical complexity

Positive Indicators

Discusses Adult Social Care and a needs assessment – e.g. help re bathing, adminstering medication, life line personal alarms but explains there would be a cost to mum.
Practical suggestions – Home frozen food deliveries e.g. Wiltshire farm foods, doing on line shop and having it delivered, GPS pendants, Herbert protocol, dementia café’s, day/night/date large face digital clock, etc
Discusses Age UK resources – shopping and cleaning, personal alarms.
Discusses the value of being registered as a carer and carer support services
Offers referral to in house Social Prescriber regards third sector agencies such as dementia friendly lunch clubs, group activities, loneliness support, well being etc.
Offers to see daughter and mum in surgery. Arranges review with a clear agenda for that review appointment. Appropriate safety netting for both daughter and mum.
Discusses assistive technologies

Negative Indicators

Lack of clear management plan: Fails to create a comprehensive management plan for Helen’s care. Does not discuss follow-up appointments or future care planning.
Insufficient discussion of support services:Does not provide information about local support services, such as dementia cafés, day care, or carer support groups. Ignores the potential for a needs assessment through adult social care services.
Inadequate practical advice:Fails to suggest practical solutions, such as medication management aids or meal delivery services. Does not discuss assistive technologies that could enhance Helen’s safety and independence.
No referral to appropriate resources:Does not refer Alex to resources like Age UK or the Alzheimer’s Society for additional support and information. Overlooks the option of referring to an in-house social prescriber or community dementia nurse.
Safety netting and contingency planning not discussed:Does not provide clear advice on what to do if Helen’s condition suddenly worsens.
Fails to discuss emergency plans for incidents like wandering.

3. Relating to Others

Positive indicators

Encourages contribution
Establishes and maintains rapport
Cues identified
Interested in both carer and patient re SPICE and as people
Shows genuine empathy
Take a constructive and positive approach to helping both her and mum
Achieves a shared management plan

Negative Indicators:

Poor rapport and communication:Does not actively listen or acknowledge Alex’s concerns. Fails to build a trusting and empathetic relationship with Alex.
Lack of empathy and support:Does not express understanding or sympathy for the difficulties Alex and Helen are facing. Ignores verbal and non-verbal cues indicating distress or frustration.
Inadequate encouragement and involvement:Does not encourage Alex to participate in the care planning process. Fails to validate Alex’s role and efforts as a carer.
Misses cues for additional concerns:Overlooks subtle cues that may indicate additional unspoken concerns Alex might have. Does not explore further when Alex mentions stress or difficulty coping.
Dismissive or rushed approach:Appears dismissive or rushed, leading to Alex feeling unsupported or undervalued. Does not allocate sufficient time to address all of Alex’s and Helen’s needs.

These are the key issues in this clinical scenario.

In this scenario:

Important to establish changes in disease progressions since her last review.
Explore the psycho-social impact on the patient and family.
Explore patient safety and capability of living alone.
Exclude possible reversible causes of deterioration such as Vitamin deficiency, infection.
Acknowledge the impact of carer's burden.
Establish wishes for further care, based of patient's or daughter's preference as per LPA.

1. Data Gathering, interpretation and diagnosis

Positive indicators

Social and Psychological impact for both her and mum explored
Support networks explored
Current / lack of service input at present
ICE explored
Progression explored
Other exacerbating factors considered – constipation, UTI/infrection, alcohol, depression etc
Enquires re driving and home safety
Explores how the carer is coping and screens for depression/ carer stress etc

Negative Indicators:

Failure to explore social and psychological impacts: Does not inquire about the impact of Helen’s condition on her daily life and Alex’s life. Misses exploring Helen’s and Alex’s emotional wellbeing.
Lack of support network assessment: Does not ask about other family members or friends who could provide support. Ignores potential community resources.
Current services not considered: Does not check if any services are currently in place for Helen. Fails to explore any recent changes or updates in Helen’s care plan.
Incomplete exploration of progression and exacerbating factors: Fails to ask about the timeline and specific changes in Helen’s condition. Ignores possible causes for recent deterioration, such as infections or new medications.
Neglects safety and practical concerns:Does not ask about Helen’s ability to perform daily activities safely. Overlooks questions about home safety measures.
Misses carer’s stress and coping ability:Does not explore Alex’s coping mechanisms or screen for carer stress and burnout. Fails to ask how Alex is managing her own mental and physical health.

2. Clinical Management and managing medical complexity

Positive Indicators

Discusses Adult Social Care and a needs assessment – e.g. help re bathing, adminstering medication, life line personal alarms but explains there would be a cost to mum.
Practical suggestions – Home frozen food deliveries e.g. Wiltshire farm foods, doing on line shop and having it delivered, GPS pendants, Herbert protocol, dementia café’s, day/night/date large face digital clock, etc
Discusses Age UK resources – shopping and cleaning, personal alarms.
Discusses the value of being registered as a carer and carer support services
Offers referral to in house Social Prescriber regards third sector agencies such as dementia friendly lunch clubs, group activities, loneliness support, well being etc.
Offers to see daughter and mum in surgery. Arranges review with a clear agenda for that review appointment. Appropriate safety netting for both daughter and mum.
Discusses assistive technologies

Negative Indicators

Lack of clear management plan: Fails to create a comprehensive management plan for Helen’s care. Does not discuss follow-up appointments or future care planning.
Insufficient discussion of support services:Does not provide information about local support services, such as dementia cafés, day care, or carer support groups. Ignores the potential for a needs assessment through adult social care services.
Inadequate practical advice:Fails to suggest practical solutions, such as medication management aids or meal delivery services. Does not discuss assistive technologies that could enhance Helen’s safety and independence.
No referral to appropriate resources:Does not refer Alex to resources like Age UK or the Alzheimer’s Society for additional support and information. Overlooks the option of referring to an in-house social prescriber or community dementia nurse.
Safety netting and contingency planning not discussed:Does not provide clear advice on what to do if Helen’s condition suddenly worsens.
Fails to discuss emergency plans for incidents like wandering.

3. Relating to Others

Positive indicators

Encourages contribution
Establishes and maintains rapport
Cues identified
Interested in both carer and patient re SPICE and as people
Shows genuine empathy
Take a constructive and positive approach to helping both her and mum
Achieves a shared management plan

Negative Indicators:

Poor rapport and communication:Does not actively listen or acknowledge Alex’s concerns. Fails to build a trusting and empathetic relationship with Alex.
Lack of empathy and support:Does not express understanding or sympathy for the difficulties Alex and Helen are facing. Ignores verbal and non-verbal cues indicating distress or frustration.
Inadequate encouragement and involvement:Does not encourage Alex to participate in the care planning process. Fails to validate Alex’s role and efforts as a carer.
Misses cues for additional concerns:Overlooks subtle cues that may indicate additional unspoken concerns Alex might have. Does not explore further when Alex mentions stress or difficulty coping.
Dismissive or rushed approach:Appears dismissive or rushed, leading to Alex feeling unsupported or undervalued. Does not allocate sufficient time to address all of Alex’s and Helen’s needs.

The 'Memory Handbook' by Alzheimer's Society

2. Alzheimer's UK: https://www.alzheimers.org.uk/

3. Age UK: https://www.ageuk.org.uk

4. Carer's Support: https://www.nhs.uk/conditions/social-care-and-support-guide/support-and-benefits-for-carers/carer-assessments/

5. Dementia (follow-up in primary care): https://cks.nice.org.uk/topics/dementia/management/follow-up-of-confirmed-dementia-in-primary-care/

Establish a Comprehensive Care Plan: Develop a detailed care plan tailored to Helen’s specific needs and challenges. Include strategies for medication management, meal planning, personal hygiene, and safety measures to address her Alzheimer's disease symptoms.

Utilize Assistive Technologies: Explore the use of assistive technologies to enhance Helen’s safety and independence at home. This could include medication reminders, GPS tracking devices in case of wandering, and smart home devices to automate tasks and provide reminders.

Provide Support and Education for the Carer: Offer ongoing support and education to Alex, the primary carer. This may involve providing information about Alzheimer's disease progression, practical tips for managing caregiving responsibilities, and resources for accessing respite care and support groups.

Implement Regular Follow-Up and Review: Schedule regular follow-up appointments to monitor Helen’s condition and adjust the care plan as needed. Use these appointments as an opportunity to assess both Helen’s and Alex’s wellbeing, address any concerns or challenges they may be facing, and provide additional support as required.

Encourage Engagement with Community Resources: Encourage Helen and Alex to engage with community resources and support services available for individuals with dementia and their carers. This could include dementia-friendly activities, day care programs, support groups, and respite care services to provide both practical assistance and social interaction.