Assessing the mental health needs of older people
Case example 1
Desmond Peters (70) had become very worried about his wife, Sylvia, who was 68, because of her increasing memory problems over the past year. She had had hypertension for many years and was on medication. Their GP told Mr Peters that his wife appeared to be in the early stages of dementia, probably vascular dementia. She then suggested that he phone Social Services to see what they could do to help.
The Duty Officer at the team for older people asked Mr Peters whether he had to help his wife, and Mr Peters admitted that she could still do most things for herself. He asked for information about dementia but the Duty Officer seemed not to know a great deal more than he did. The Duty Officer agreed to put the couple on the waiting list for assessment within the next eight weeks, but said that it did not sound as if they would be eligible for help from Social Services.
The first visit by a social worker was difficult because Mr Peters was very anxious, and Mrs Peters still did not know her diagnosis. Therefore, and without the social worker's knowledge, Mr Peters had arranged to meet the social worker while his wife was out.
The social worker realised that at this stage Mr and Mrs Peters did not need the practical home care, home help and meals services offered by the department. However, she was aware of the high support needs of people in the early stages of dementia, and of the needs of their carers, and felt there was still a role for her in supporting the couple. This support included spending a long time with Mr Peters, attempting to answer some of his questions about dementia. She had to strike a difficult balance, describing some of the ways in which dementia can affect people, while stressing that the illness takes a different course with each individual. She 'recognised that Mr Peter might find too much verbal information all at once overwhelming, and asked if he would like some written information. But Mr Peters said he would rather talk it through.
In addition, the social worker talked with Mr Peters about whether Mrs Peters would benefit from knowing what was wrong with her. Mr Peters felt very strongly that it would only upset her, although he did acknowledge that she sometimes seemed distressed about her memory lapses and said he would think again about this. The social worker stressed that the GP should also have a role in helping Mr Peters talk to his wife about her condition.
The social worker's approach to this issue was based partly on the view that Mrs Peters had a right to know her own diagnosis, partly on the knowledge that it would be easier to assist the couple if they were both able to participate in discussions, and partly on the view that the couple would benefit from being able to discuss the future together in an open way. However, she was aware that Mrs Peters might need support from someone other than her husband in dealing with the knowledge of her diagnosis, and began to think about who might provide this.
The social worker was able to advise Mr Peters about other services in the area which could provide support. In this case, these included the local branch of the Alzheimer's Society. Mr Peters, however, thought that the Alzheimer's Society was probably for people with a much more severe problem and that his wife might find it alarming to be with them.
The social worker arranged to visit again in two weeks' time, and Mr Peters said he would make sure Sylvia was in so they could meet. He agreed that the social worker could speak to their GP about talking to Sylvia about her diagnosis, and about how this might be handled.
Between the two visits the social worker spoke to the GP on the phone. The GP offered to speak to the couple together about the diagnosis and to refer Mrs Peters to the community psychiatric nurses as they had more expertise in supporting people with dementia. The social worker asked the GP to phone Mr Peters and to discuss with him whether he wanted to take up these options.
Meanwhile, the social worker discovered that the Alzheimer's Society had just started a day care service aimed specifically at people in the early stages of dementia, meeting one day each week. The service focused on helping people come to terms with their diagnosis, providing them with an opportunity to discuss any fears and questions with each other. The social worker felt this service might be ideal for Mrs Peters.
On the second visit, Mrs Peters had been told by her husband that the social worker was coming to see her because she had been having difficulties with her memory. This had led to an argument between them, and when the social worker arrived she found Mrs Peters in a defensive and angry mood. Mrs Peters demanded to know what they had been doing, meeting behind her back, and the social worker spent much of the visit trying to establish some trust between them.
She asked Mr Peters if he would mind leaving the room while she spoke with his wife, which he did rather reluctantly. This proved a useful strategy, however, as during her husband's absence Mrs Peters acknowledged that her husband worried about her because he cared about her, even if she could not see what he was fussing about.
After 20 minutes or so Mr Peters came back into the room; by this time Mrs Peters was reminiscing quite fondly about the early days of their marriage, and greeted him pleasantly. She remained unable or unwilling to acknowledge any memory problems to the social worker, however, so the scope for further discussion was limited.
It had become apparent to the social worker that the person expressing the most distress to outsiders was Mr Peters, who needed information about dementia, information about support services, and most of all someone to guide him through the impact of living with a person with dementia. At this stage it was crucial that he receive support in these areas, and after discussion with him the social worker referred him to the Admiral Nursing Service.
The issue of Mrs Peters' knowledge of her diagnosis was more complicated. If she was told, this would need to be done sensitively and with follow-up support. Mr Peters eventually decided to take up the GP's offer to talk to him and his wife together, and also took up the offer of referral to the community psychiatric nurses, who worked with the couple over the following months to help them come to terms with the situation together. In the event, Mrs Peters coped well with the news of her diagnosis, and seemed less agitated about her difficulties if she was reminded that it was not her fault but because of an illness.
The social worker effectively had two clients, one of whom was much more able to express his needs. Although Mrs Peters did not acknowledge any difficulties initially, and may indeed have been less distressed than her husband, the social worker knew from Mr Peters that she did sometimes show distress when she forgot appointments etc. The social worker also felt that Mrs Peters had a right to know what was causing her memory problems, even if she might have difficulty retaining that information. At the same time, the social worker was aware of her own lack of expertise in this area and of the need to ensure that the issue was broached sensitively and that Mr Peters was not just left to 'pick up the pieces' afterwards. The GP also lacked confidence in this area and needed support from the community psychiatric nurses in dealing with the issue.
Simply providing Mr Peters with a list of services would not necessarily have helped him. The social worker thought carefully about what might help and why. The Alzheimer's Society seemed an obvious choice, especially when she found out about the new service, but Mr Peters was fearful of the label 'Alzheimer's'. His meetings with the Admiral nurse helped him come to terms with his wife's illness and to overcome his resistance to referral to the Alzheimer's Society for his wife.
This case demonstrates the difficulty of keeping the focus on the person with dementia, rather than listening solely to the views and preferences of the carer, important as these are. Even if Mr Peters had remained implacably opposed to referral to the Alzheimer's Society, it would have been important for the social worker to work separately with Mrs Peters and to ensure her needs were met. In this case, long-term support for the couple was provided by the Admiral nurse and the community psychiatric nurse, who focused on Mr and Mrs Peters respectively but also liaised effectively with each other.
Where people are not experiencing much difficulty with daily living tasks, and where family relationships are fairly harmonious, it is often felt that there is no role for social workers in a busy community team. In this case, the social worker was put under pressure to 'close the case' after the two visits described above. The work done during her brief involvement, however, meant that the couple were referred to other agencies who could provide support. The social worker also provided Mr Peters with information about the care services that social services could organise if they became necessary, and his good experience of her work meant he felt comfortable about approaching the department again when Mrs Peters began to need much more assistance.
Next: Case example 2