Alone with the bottle

Practice
panel: Primary assessment team for older people, Dumfries and Galloway.

This
week’s multidisciplinary panel looks at the case of a heavy drinker who lives
alone, neglects herself and often refuses help.

Case
study

Situation
Annie (not her real name) is a 76-year-old widow who has been married twice.
She has children from both marriages but her son Joe and daughter Sandra (not
their real names) are the only family members who visit. Annie is a chain
smoker, and is a habitual drinker, drinking at least a half of a bottle of
whisky per day. Sandra is also a habitual drinker. Annie has no friends and
only leaves her home to go around to her local shop to collect her pension, buy
alcohol and cigarettes. Her son Joe is becoming increasingly concerned about
his mother’s situation.

problem
Annie did have care in her previous home but it was stopped because she did not
grant carers access to her home. When she did grant access she was abusive and
unpleasant to the the carers.

Annie
had no choice but to move to her present home because her previous home was in
a bad state of neglect and Annie was also neglecting herself. Her new home had
to be furnished with new household items. Annie collects her own pension, but
when Sandra visits on pension days she sits and drinks with her mum and asks
for money. Annie is still drinking a great deal, eating little and has lost
weight. Her personal care and hygiene are very poor, she is doubly incontinent
at times and her home situation is again deteriorating. Annie’s son Joe is at
his wits’ end as he sees history repeating itself once again.

Panel responses

Annette
Cosens
My role as a community occupational therapist is to assess the functional
abilities of an individual within their home and to make recommendations that
may include equipment or adaptations to enable the individual to maintain or
increase those abilities, and to reduce risk as far as possible.

In
this case the risk is behavioural as well as environmental, and Annie’s insight
into her difficulties and motivation to make changes, which she may not see as
positive, would challenge my skills of persuasion.

First,
I would obtain information from my colleagues at the primary assessment team
(PAT) meeting about Annie’s history and current condition and contact her GP as
necessary.

My
initial assessment would involve establishing rapport with Annie and
concentrating on immediate risks within her home environment.

I
would assess the following:

-Chair:
can she get in and out easily?

–
Toilet: is it accessible (continence problems); does she need equipment?

–
Bed: check transfers.

–
Bath: can she get in and out safely and independently; has difficulty partly
influenced her motivation regarding her personal hygiene? Would a shower be
safer considering her use of alcohol and her incontinence?

–
Kitchen: when she does prepare snacks or hot drinks how is her safety – could
gadgets help in reducing risks?

–
Access: are there steps? Does she need handrails to reduce the risk of falls?

–
General mobility: do internal stairs prevent her from getting to the toilet in
time? Has she fallen in the house?

–
Safety awareness: is she aware of fire risk; are there signs of cigarette burns
and so on?

–
Nutrition: enquire about her eating habits as part of the kitchen assessment;
report to PAT meeting colleagues.

The
above assessment may require more than one visit and I would also consider
referring Annie to my community mental health occupational therapy colleagues
so that a plan for treatment and rehabilitation could be established.

June
Rae
Services available through a care management framework have not been
acceptable in the past and a fresh approach needs to be tried. The social
worker in this case is going to have to draw heavily upon colleagues in the
primary assessment team in an attempt to reduce the level of risk from possible
falls and infections due to poor hygiene. Annie should be encouraged to
co-operate with a plan to protect her health.

Clearly,
Annie has sustained multiple loss in her life and the main focus of the social
work intervention in the longer term has to be an exploration of her life
history and personal relationships. There is scope to consider particularly the
relationship with Sandra, but the social worker needs to try to maintain a
supportive relationship with the client.

I
would like to see community nursing staff introducing appropriate nutritional
and vitamin supplements. In addition I would refer Annie to both the dietician
and the health visitor for older people. The client needs to feel cared for but
not judged.

If
Annie could be weighed regularly and had a written record of this to keep she
could possibly start to respond to professionals’ concerns. She also needs to
understand her responsibilities as a householder (on the assumption she is a
council tenant). If I found Annie could not grasp the nature of the concerns, I
would consider requesting a psychiatric assessment since her drinking and
smoking patterns may be masking an underlying cognitive dysfunction.

Assuming
no psychiatric disorder I would attempt to proceed with the case in
consultation with a consultant psychologist. A suitable approach to Annie’s
addictive behaviour pattern needs to be adopted. Behaviour modification
techniques could be used, but Joe would have to be kept fully informed and
willing to follow advice. Really he needs to refer himself to an appropriate
support group. The relationship between Annie and Sandra merits attention. In
giving money over to her daughter Annie may be trying to make amends for poor
parenting.

In
the longer term I would hope the reflective work undertaken would deepen the
client’s self-understanding and self-respect because if this can be achieved
she may be motivated to make positive changes.

User view

Poor
Annie needs to be seen by those working in health and social services as a very
lonely, inadequate old lady who uses her smoking and drinking to fill her
rather empty days, writes Alex Bagnall. To help her they must accept that at
her age it is unwise to try and stop these bad habits. Given help, she may be
able to control her drinking and smoking and have, as outsiders say, a better
quality of life. How can this be achieved?

I
do not approve of the current thinking that everyone must be kept in their own
homes at all costs. Do authorities know how lonely and depressing being stuck
on your own can be? Especially at weekends and bank holidays – those times when
the world and his wife are enjoying themselves, there you are stuck inside your
four walls. So, to compensate for this appalling sense of isolation you seek
comfort – things like sweets and chocolates, and, of course, in Annie’s case a
reliance on drink, cigarettes and so on.

The
best help in the long term for Annie would be to go into a residential care
home. If Annie were placed in the safety of a residential home most of her
money would be used to support her daily living in a civilised way, which at
the present time she is not able to do. Annie’s daughter Sandra would still be
able to visit her as she would presumably look to be placed in a local home.
Hopefully on her visits to her mother she would not get too much money from
her. Obviously she uses this cash to subsidise her own drinking!

I
wonder if her son Joe would be able to support his mother should she decide to
stay where she is. But this would need to be looked into carefully. His ability
to do this, however, is questionable.

With
this scenario all the qualified staff will have to accept that their ability to
help will be quite restricted. Because of the current thinking that authorities
can miraculously help everyone, staff must keep a detailed account of the help
offered to this rather sad lady.

Alex
Bagnall, who lives in Worcestershire, describes herself as an older lady who is
interested in the implementation of "our" National Service Framework.
She also says that she has a functional mental illness that she has learned to
live with over many years.