Dementia, Weight Loss, talk to Daughter
Where you are:
You are a F2 working in the neurology department.
Who the patient is:
Mrs. Caroline Parker 88-year-old female has been admitted because of weight loss.Other Information:
She has been suffering from dementia in the last 3 years and has not been taking food properly, recently. All the investigations including Blood tests, ECG, X-ray, Ultrasound and CT scan of the abdomen has been done and have come back normal. Patient has been given some fluids and is able to tolerate a bit now.
It has been decided that invasive and aggressive management is not appropriate. Palliative care has been decided by the consultant. She was very weak on admission, but she has been medically managed.Special Note:
Patient is not available to talk. Consent was taken from the patient to talk to her daughter. The weight loss is only due to dementia.What you must do:
Please talk to her daughter Ms. Gwen Parker, take focused history, explain her mother’s condition, address her concerns and discuss management plan with her.
Dementia: chronic progressive disease that can affect patient’s appetite which may lead to weight loss.
Introduction
Doctor: Hi, I am Dr (name), one of the doctors here. May I confirm your name, our patient’s name and age and your relation to her?
Check understanding:
Doctor: I understand that your mum was admitted due to weight loss, I also understand that she had some tests done, has anyone explained the situation to you?
Paitient’s Relative: Yes, doctor my mum has dementia but I don’t know why she is not eating any more.
D: Can you tell me more about your mum’s dementia?
PR: She has had dementia for the last 3 years and she has been taking medication for it, but she is deteriorating. She has not been eating for the last 4 weeks. Sometimes she takes sips of water.
D: I appreciate you came today out of concern for your mother, thank you for doing that. I understand that taking care of a patient with dementia is not easy and we have many options for you. I would like to discuss them with you in a minute, but I just want to ask you some questions to exclude other causes for her confusion other than dementia, is that ok with you?
Your P1 is weight loss (just quick hx, it’s counselling)
Confusion DDs:
- Any head injury?
- Any fever?
- Any vomiting?
- Any diarrhoea?
- Any cough?
- Any burning sensation while passing urine?
- Any medications that you are aware of?
Questions of dementia:
- For how long has she been diagnosed with dementia?
- What treatment does she take for it?
- How is she at home, bed bound or able to move independently?
- Has she been in any dangerous situation due to dementia?
- Does eat and drink well?
- Does she do things independently or needs your help?
- Have you noticed any inflammation in her mouth?
- Have you tried to feed her yourself?
- Is there anyone else taking care of her besides you?
Questions for the relative:
D: What do you do for a living?
PR: I am an office worker.
D: When you are at work, is there anyone is taking care of her?
PR: Yes.
D: Do you think the home is safe enough when she’s there alone?
PR: She’s bedbound, I don’t think she will come to any harm.
D: How are you coping?
PR: I am the only one who is taking care of her, I try to do my best.
D: Are you managing financially?
PR: Yes, I think I can support her.
D: How is your mood?
PR: I am ok thanks for asking.
D: Are there any specific difficulties you are facing?
PR: No, I just want my mum to be OK.
Management (counselling):
We have 2 parts of Management here
1st: Talking to her about the Palliative treatment
Explain to her that the cause of her mum’s poor feeding is dementia, and theconsultants think that palliative care is the best for her case right now.
Her concerns would be:
PR: What is palliative care?
D: It’s supportive care that makes the patient as comfortable as possible bymanaging the pain and other distressing symptoms. It also involves psychological, social and spiritual support for you and your family or carers. It is offered by a team of doctors and health care professionals.
PR: Why can’t you feed her through NGT or gastrostomy?
D: I appreciate your care about your mother, but her condition is terminal, and this would put stress on her.
PR: Do you mean she is dying?
D: I am really sorry to tell you this, but we are not expecting her to improve.
PR: Will I be able to take her home?
D: Yes of course, I would give you some options to help you while taking care of your mum on a daily basis.
2nd: Giving support:
- Thank you for answering my questions and for your co-operation, before I proceed, do you want me to explain anything regarding dementia or palliative care?
- I know that taking care of a patient with dementia is really overwhelming, especially if you are the only person doing it. I would like to discuss with you what we could do to help you and your mother.
- We can arrange carers who can visit her daily while you are at work. They would wash her and feed her, (if she wanted to eat anything, although I know she is refusing food at the moment and that’s OK if she doesn’t want to eat). And they also do housework to help you. How do you feel about that? They will be there to help you and guide you also on how to care for her as she
deteriorates further. - We can also provide her with adequate pain relief to make her comfortable.
- We have also another option, which is a care home if you think you would not be able to manage.
D: Do you have any concern so far?
PR: I’m not struggling financially right now, but I think I will be pretty soon. I want to know about any support that is available to me?
D: Of course, I understand. There is financial support which is for patients who have dementia and their relatives, it is called Dementia UK. I would speak to my senior and do my best to arrange that for you as soon as possible.
Safety netting:
At any time, if you feel your mother is suddenly confused or has a fever, cough, vomiting, please, come to us immediately.
Special note if the scenario is about a patient whose appetite has decreased
only but not stopped completely.
There is a way of feeding dementia patients called “comfort feeding”:
• Try to give her any food she loves.
• Make sure it is liquidised and easy to digest.
• Use your clean hand to feed her and eat together as a form of bonding.
• Whilst eating you can put on her favourite show on TV to let her enjoy her feeding time more.