When a carer moves on

Case study
The names of service users  mentioned in this article have been
changed

Situation: Edith McSweeney is an 82-year-old woman
who lives alone in a high-rise flat. She suffers with poor mobility
and is using a stick. Her husband died 30 years ago and she has not
remarried.  Her daughter, Alison, who lived nearby, had become
Edith’s main carer even though their relationship had been somewhat
fractious.  Edith has not seen a GP for many years.

Problem: Alison’s husband was appointed to a job
in Brussels which means they have now moved to live in Belgium.
Alison was pleased to go – as it signalled a new and challenging
start for them. However, it meant Edith would lose her carer. It
was only when Alison had actually gone that it became apparent to
Edith how much she relied on her. It seemed that Alison did
everything for her, partly out of a sense of duty, but also because
Edith expected it and ordered her about. This meant that Edith had
lost all her independence skills: she’d never even used the
microwave that she had owned for 12 years. Before long, Edith
experienced a fall trying to get out of bed. At hospital she was
assessed as being in danger of falling again and a community nurse
was allocated the case. The community nurse also referred Edith
onto social services. However, Edith has taken to ringing up the
nurse and the community care worker demanding help and support with
almost every task. She now rings each worker up to 25 times a
day.

Panel responses
Christine Rawson (advanced specialist practitioner)

As an advanced specialist practitioner, I would talk to the members
of the multi-disciplinary team already involved with Edith to
identify what support she is receiving at present. I would do some
detective work regarding medication prescribed, and information at
hospital discharge, including any medical diagnoses.

Visiting Edith at home would enable me to form a relationship with
her and explain my role. I would ask her to tell me how she is
coping and identify any problems from her viewpoint. This may
elicit her feelings about her daughter moving abroad and the impact
this has had on her life. It would also be important to establish
if she is happy taking her medication and if she is able to take it
independently.

I would also liaise with her GP and ask for a general review
including screening her mental health status and risk of depressive
illness. It would be useful to have the views of Edith’s daughter,
and to establish whether or not any other family members are
involved or would be willing to liaise with the care teams.

The number of phone calls she is making to the care staff daily
suggests a high level of anxiety and loss of confidence; with her
consent I would work with her to set goals to reduce this anxiety.
Initially this may mean referring to the intermediate care team
(ICT), enabling an intensive level of support for a short period.
ICT would perform a multi-disciplinary assessment looking at
Edith’s potential for independence and mobility, plus an assessment
of any aids and adaptations needed. It seems that she has not lived
independently for many years and her motivation to do so needs to
be established. Having had a recent fall, she would also be
referred to the falls programme at a local hospital.

Having lost her main carer and frequent visitor, it is likely that
Edith is socially isolated and lonely. As her confidence increases
over time it would be prudent to try to involve her in some local
activities: a local day centre or neighbourhood network would be a
good starting point. Ongoing review would indicate if Edith is able
to cope at home, perhaps with support from social services.

Jackie Dawson (district nurse)

Unfortunately, Edith has two main problems: falling and the loss of
independence. Both these problems would require a referral to
district nursing. As the scenario already mentions a community
nurse, hopefully a rapport with Edith would have been established.
This will enable a partnership between Edith and the district
nursing team in resolving some of the issues highlighted.

The district nursing assessment would first examine the issue of
Edith falling. Unfortunately, falls among older people are all too
common. The government has identified this through the national
service frameworks, aiming to reduce the number of falls. The
assessment by the district nurse would examine the current
medication Edith is taking, as certain types of medication increase
the risk of falling. This would be done alongside a GP review. The
district nurse would also discuss with the GP about any medical
conditions that could be causing Edith to fall, in particular
deteriorating eyesight could be considered.

Prevention of falls is an important aspect of Edith’s management.
This would involve an assessment of Edith’s home environment to
determine potential dangers; we would start by looking out for
loose carpets and rugs. In certain parts of the country a handyman
scheme is in place, where volunteers assist to repair unsteady
stairs and other household problems. Edith’s footwear would be
examined as poor fitting slippers in particular can cause falls.
Edith would be encouraged to use the “message in a bottle” scheme,
whereby she can write her details and medication information and
place it in the plastic bottle which is then stored in the fridge.
A sticker can also be placed in the window of Edith’s home,
providing professionals with similar information should she
fall.

The district nurse may refer Edith to the local falls prevention
team, usually run by physiotherapists and occupational therapists,
where a more in-depth assessment can take place. Regarding her loss
of independence, the district nursing team would encourage her to
gradually gain her confidence in tasks such as cooking. This would
possibly require the involvement of the rehabilitation team. The
district nursing team would encourage Edith to use local
live-at-home schemes.

User view

It is obvious that Edith has become set in her ways and dependent
on her daughter. She seems to have lost her communication skills
and can only demand help, firstly from her daughter and then from
the care workers, write members of Knowsley Older People’s
Voice.
There may be many reasons for her aggressive behaviour, such as
fear and feelings of vulnerability. It is good that she has been
assigned care workers and social care input but services now need
to be put in place to help her regain her independence, if that is
what she requires.

This case raises questions over community members being aware of
the services that are available to help support carers. Alison may
not have become the main carer for Edith if the support of other
agencies were made available. This also would have ensured that
when Alison moved away and was unable to continue to provide care
for Edith then services could have been in place to support
Edith.

It is apparent that she has not had any input from her GP and may
well be suffering from illnesses or conditions, such as heart
disease or blood pressure. She needs a complete medical review to
ensure she is well and start any medication she may need.

It is vital that the causes of Edith’s falls are established.
Following the health review, services such as eye tests and
podiatry care could be made available. Edith would benefit from a
home falls assessment to see if she has any loose carpets or
incorrect footwear causing her to fall.

In Knowsley we have a community independence team. This is a
multi-disciplinary team and the initial assessment is carried out
by an occupational therapist. Following this assessment and the
falls assessment, any suitable aids or adaptations could be
provided. In Knowsley, there are falls prevention groups in each
area of the borough, and Edith could attend the appropriate
group.

The possibility of more appropriate accommodation could be
considered, with Edith’s approval such as a bungalow or sheltered
accommodation. When Edith is more confident in herself, a Senior
Link phone could be provided for her which would give her peace of
mind any time of the day or night.

A link into a befriending service would help to increase Edith’s
trust in other people and increase her independence. 

Knowsley Older People’s Voice is an older people’s forum based
in Knowsley, Merseyside