When anxiety becomes a danger

When an older woman became
too anxious to   carry out routine daily
tasks, her house became very unhygienic and there was a substantial risk to her
health. Social worker Don Traylen, recounts the decisions taken to help her
regain some confidence. Graham Hopkins reports.

The names of any
service users mentioned in this article have been changed.

Case notes

Practitioner: Don
Traylen

Field: Care manager,
older persons and physical disabilities team

Location: East
Cambridgeshire

Client: Martina Jeffrey
is a 78 year-old woman who suffered acute anxiety. She had been known to
Cambridgeshire’s mental health services before she reached 65 and became the
responsibility of the county’s older persons services.

Case History: The
loss of her husband and later loss of contact with her daughter had inflamed
Jeffrey’s levels of anxiety, leading to an inability to manage her own care
effectively. In addition, the memory loss and cognitive decline that comes with
age served only to frustrate and further raise Jeffrey’s anxiety. An assessment
by a psycho-geriatrician concluded that Jeffrey was unable to give consent to
manage her finances. So through social services, and owing to her isolation –
no family, no friends – the court of protection appointed trustees to look
after her interests. She attended a day centre for one day a week, where staff
noted that she appeared very hungry.

Dilemma: Jeffrey is
able to make and understand her decision to stay at home but her high levels of
anxiety make it very difficult for her to carry decisions through.

Risk factor: By
remaining in her own home, Jeffrey’s anxiety might increase and cause her, once
again, to be unable to manage her own care and put her health at risk.

Outcome: With
increased support Jeffrey is managing her anxiety levels and own care well.

Anxiety is a very useful emotion. It can keep us alert and motivate us to deal
with difficult situations. However, if anxiety tightens its grip, becoming too
strong, it can damage our ability to do things.

High levels of
anxiety had seriously affected the ability of Martina Jeffrey to manage her own
care. “She was living in circumstances that were a great risk to her,” says Don
Traylen, a care manager specialising in working with older people with mental
health difficulties, who was allocated Jeffrey’s case. “She was neglecting her
nutrition. Her housing association rented bungalow was unhygienic. The floors
were covered in litter and waste food. There were faeces and urine on bedroom
and lounge carpets.” Jeffrey’s anxiety was causing her to be periodically
incontinent.

Previous work with
Jeffrey had not succeeded. “Some fairly determined intervention was needed,”
Traylen says. “It did seem there was a sort of stalemate with my mental health
colleagues on the community resource team about how to go forward. On
reflection, it seems that the only suggestions for the way forward came from
me. When those plans were put into place the whole resource team did work
together extremely successfully.”

At the time of
Traylen’s intervention, the options seemed to be two-fold: some form of
residential care, “which would certainly remove all those risks confronting her
at that time”; or combining resources to support Jeffrey to remain in her own
home – something she expressly wished to do.

This opened up
Jeffrey to daily risks “around basic bodily functions, of not having enough
nutrition, of the general health and hygiene of the property, which was
infested with vermin”. She attended a day centre one day a week and staff
alerted the team to the fact that she was clearly hungry during her visits. The
concern was well-founded. Frozen, ready-to-cook meals that were delivered for
the rest of the week were stockpiling. “The freezer was switched off to save
money,” says Traylen.

To keep Jeffrey in
her own home, her care package would need reinvigorating and major work done on
her house. Traylen supported Jeffrey to choose designs and colours, and
co-ordinated resources from the housing association (which refitted the doors,
windows, floorings and kitchen), the council (which arranged for the house to
be cleaned and fumigated), and Jeffrey herself (who dealt with the furniture
and so on) to fund the work.

During the three
weeks of work, Jeffrey agreed to move temporarily into a residential care home.
Another possible benefit of this would be that she would get an opportunity to
experience life in residential care, should plans not work out. In fact, her
stay was so positive that last Christmas, Traylen organised with her to return
to the home for 10 days. And, at her own request, she’s booked in again this
year.

“During her stay I
kept her informed of what was going on – what had been completed, what was
happening next,” says Traylen. He also took Jeffrey each week to check on
progress – so she could see for herself what was happening.

With the house
completed, Traylen began negotiating about how she wanted to live her life once
back home. She agreed she wanted to avoid reaching the same situation again.
“To help achieve this outcome we set up a fairly large care plan,” adds
Traylen. “We increased her attendance at day centres to three days a week. Home
care staff would work with her to keep the home clean and assist and supervise
cooking. They also went shopping with her with the understanding that she was
trying to do this herself, giving her every opportunity to make the decisions
about what to buy and to physically handle money – one of the causes of her
anxiety.”

Jeffrey’s care has
been based around her being able to take part in decision-making: actually
being involved in the actions rather than it being done around her or for her.
And her decision-making is rational, says Traylen: “She understands that
process well. She can help and make decisions but the hard part for her is to
act out those decisions, because there is so much anxiety in that aspect of her
life.”

As Jeffrey gets
anxious if she doesn’t know what’s going on, everyone working with her keeps
her informed all the time. “Because of her reduced anxiety she’s able to
function better, she’s calmer and visibly happier. It ended up being an example
of care management at its best, carried out with traditional social work
values,” says Traylen.

Arguments for risk

– Jeffrey made it
very clear that she wanted to remain at home and Traylen, despite initial
scepticism from colleagues, believed that with significant support this was
achievable.

– Although Jeffrey’s
acute anxiety made it difficult for her to care for herself, Traylen was
confident that if he could improve her quality of environment (by cleaning,
fumigating and refurbishing her bungalow) this would lead to a calming of her
anxiety and thus improve her ability to manage her own care.

– With good potential
to succeed, Jeffrey would benefit from relearning life skills, greater independence
and control over her life.

-With supported
independence Jeffrey would have opportunities to shop, cook, clean, and handle
and understand money – all things that would otherwise increase her anxiety and
ability to cope.

– Any removal from
her home into the strange environment of a residential care home could increase
her anxiety and thus be detrimental to her health and well-being.

Arguments against risk

– Jeffrey had been
known to the department for some time. Previous attempts to support her in her own
home safely had failed. Despite support her home and health were poorly
attended to. Any renewed attempt to tackle the situation would be costly in
terms of both money and time.

– Her acute anxiety
had shown no signs of improvement, and had gradually and significantly
deteriorated – to such an extent that the court of protection appointed
solicitors to act as trustees of her finances. She was clearly at risk. Her
poor hygiene practice had resulted in her home being infested with rats.

– With little or no
comprehension of money, and living alone in isolated circumstances, Jeffrey
made herself very vulnerable to potential attack or abuse.

– Jeffrey believed
herself unable to afford basics such as electricity – and so would unplug the
freezer. This would cause her delivered, frozen, ready-made meals to defrost,
making any later attempt to cook them hazardous to her health.

Independent comment

This story
illustrates the careful caring that characterises professionalism at its best,
writes Jef Smith. Ensuring Martina Jeffrey’s welfare and safety was bound to be
complex, and it must have been tempting for Don Traylen and his colleagues to
take the option of removal to a home. She was too vulnerable to protest
effectively, and she had no advocate to question the authorities’ judgment.

Social services use
the power of forcing older people from their own homes very sparingly. Also the
place of self-determination as a key value in our society has been underlined
by human rights legislation. But assembling and delivering the community-based
services that can win a client’s co-operation is not easy. Traylen needed to
persuade agencies to take action on the unhealthy environment of the bungalow,
but maintain his client’s feelings of still being in control. In achieving this
he balanced short and long-term care objectives – facing his client with the
reality of her situation, building her confidence, stepping up day care, and
getting the bungalow cleaned up, but at the same time preparing for a possible
deterioration in her condition which might require permanent admission to a
home.

Good care management
is based on professional assessment, knowledgeable prescription of services and
delivery of a co-ordinated care package. It is less often recognised that it
often demands the skilful use of a relationship; this was the vital additional
ingredient that made this piece of work successful.

Jef Smith is a
writer, trainer and consultant specialising in the care of older people.