Assessing the mental health needs of older people
Case example 2
Mr Wilson (81) was referred to the hospital social work team for older people following his admission to the acute psychiatric ward for older people, under section 2 of the Mental Health Act (an approved social worker from the adult mental health team undertook the assessment). The admission followed a deterioration in Mr Wilson's mental health and an incident in which he apparently threatened his home help with a knife. Mr Wilson had been diagnosed three years previously with Alzheimer's and at that time the community-based social work team had arranged home help twice each week and meals on wheels. These services had remained in place but had not been reviewed.
The medical team all felt that Mr Wilson needed residential or nursing care. He was verbally abusive to them and would not allow them to assist him with personal care. Mr Wilson's son Ian (52) and daughter Sheila (47) both wanted him to return home, and Mr Wilson himself repeatedly tried to leave the ward and talked angrily of how 'they' were keeping him a prisoner. He also said he wanted to go home, although it was not always clear what he meant by this.
Meanwhile, Mr Wilson's neighbour, who had tolerated him before he became ill but described him as having always been an eccentric, wrote to the Director of Social Services complaining about what he saw as Mr Wilson's neglect by Social Services and stating that Mr Wilson should not be 'allowed' to live by himself.
The social worker conducted a careful assessment of Mr Wilson's needs, speaking to all the agencies involved and the family, and to Mr Wilson himself on several occasions. He felt that Mr Wilson could be supported at home if the care plan was redesigned to meet his increased needs and if there was better communication between all involved. The social worker advocated for Mr Wilson's right at least to attempt living in his own home before other alternatives were considered, and succeeded in persuading the ward team to work towards discharging Mr Wilson on two weeks' trial home leave. By this stage his behaviour on the ward had to some extent settled.
Mr Wilson was discharged home following an assessment in his own home at which the occupational therapist from the ward and the social worker were present. This confirmed that he was unable to cook or prepare snacks, and needed to be reminded to drink. The care package arranged included home care three times each day and weekly visits by the community psychiatric nurse to monitor his mental health. Meals on wheels were cancelled as Mr Wilson had not been eating them for some time. Mr Wilson's son had Enduring Power of Attorney and continued to look after his finances.
During the first week the care package seemed to work well. The home care team had initially been reluctant to work with Mr Wilson following the incident with the knife, but it had been noted on the ward that he responded better to female carers and this appeared to help. He continued to resist personal care assistance but allowed the carers to prepare food for him, prompt him with medication, and undertake a limited amount of cleaning.
However, during the second week the carers frequently arrived to find Mr Wilson had gone out. He had always enjoyed walking and seemed to have reverted to his previous habit of going for long walks around the area several times a day, from which he had so far always returned safely. When the social worker came to visit Mr Wilson after this was reported to him by the home care team, a neighbour accosted him angrily, threatening to complain to the papers about Mr Wilson's treatment.
Meanwhile, Mr Wilson's family continued to want to support him at home and to play a part in his care. The social worker agreed a strategy with them to reduce Mr Wilson's level of risk, including obtaining an ID bracelet and making sure one of them visited him in the later part of each evening to check he was home and to orientate him. The social worker and Mr Wilson's son also spoke to the neighbour and kept him informed about the care package provided, which seemed to reduce some of his anger.
It became clear that Mr Wilson's daily walks meant he would not always be in when the carers came round, thus jeopardising their ability to provide the care he needed. The social worker and home care team manager agreed they would have to monitor this situation and that it might result in a breakdown of Mr Wilson's mental and physical health. However, despite these considerations and the potential risks involved, it was felt that walking was an important activity for Mr Wilson.
A review meeting between all involved at the end of the two-week trial led to an agreement to continue to support Mr Wilson at home. It was recognised that Mr Wilson's son and daughter were crucial to maintaining him at home, especially given his patchy receipt of the home care service, and they were both referred for Admiral Nurse support. It was also agreed that regular review and communication would be essential.
Over the next year Mr Wilson continued to live at home, supported by this mixture of formal and informal care. The neighbour remained unhappy about the situation but the social worker continued to advocate for Mr Wilson's rights. As Mr Wilson became less orientated, however, he had more difficulty finding his way home and on one occasion was found by police in a very confused state next to a busy roundabout. He also became less aware of where he was. When a respite stay was tried he accepted it and made no attempts to leave. Eventually he moved permanently into the nursing home where he had had the respite stay. His family were able to come to terms with this, knowing they had done as much as possible to maintain him at home.
The initial care package was completely inadequate to meet Mr Wilson's needs and needed to be redesigned. It may have contributed to his mental deterioration and admission to hospital.
The social worker was initially the only professional who supported Mr Wilson's wish to return home, and had to work hard to persuade the rest of the ward team. He avoided being rushed into a decision and took time to assess Mr Wilson's needs and discuss care options with his family. The use of a two-week trial period was an essential part of this strategy. It provided an opportunity both to assess Mr Wilson in his own home and to try out a care package. Constant communication during this period was vital to ensure that all elements were working together and to establish trust. The meeting towards the end of the two weeks was also an important forum for outlining difficulties and reaching agreements about the way forward.
Mr Wilson was not able to discuss his wishes for the future, but he communicated his needs and preferences very clearly in a number of ways, for instance in his reactions to the hospital ward and the home carers. Similarly, Mr Wilson's activity of walking could have been stereotyped as 'wandering' by a less skilled social worker, but the social worker talked to Mr Wilson's family and found that it was an habitual behaviour which he seemed to enjoy. But the social worker was not blind to the risks involved and took a number of practical steps to minimise them. A more flexible home care service would have helped reduce some of the risks, for instance if carers were able to return at intervals to fit around Mr Wilson's unpredictable absences. This was not available, however.
Over the months the situation was kept under very close review, involving regular, sometimes daily communication between the agencies and family members involved. As Mr Wilson's needs changed, the care plan was amended accordingly.
The support provided to Mr Wilson's son and daughter was essential. They both benefited from talking to the Admiral nurse about their father's condition and from being taught strategies for how to respond to his behaviour. They also benefited from feeling part of a team of people working together to support their father.
The neighbour remained sceptical about Mr Wilson's continued residence at home. The social worker tried to keep the neighbour informed without breaking confidentiality but did not give in to pressure. Fortunately the social worker's manager supported his handling of the case when the neighbour complained to the Director.