The scenario

 

• 70 year old patient male
• Lives alone
• Never married and no children
• Previously worked for a local council maintaining parks etc before caring for elderly mother for several years (she died around 5 years ago).
• Has siblings but reports that he does not have a close relationship with them
• Obese
• Suicidal thoughts expressed following an incident where patient was advised to order trousers online because shops didn’t have his size. This caused him to feel overwhelmed and that he could not cope with life as he is computer illiterate and unable to use smart phones.
• Referred to Mental health team by Think Action Psychological Therapy services due to psychotic symptoms.
• Not known to secondary mental health services prior to referral to metal health team earlier this year
• Initial assessment identified paranoid delusions regarding being followed by Russian security services and the patient was also frequently contacting UK agencies including the conservative party.
• Outpatient appointment with Consultant Psychiatrist . Working diagnosis made: Paranoid delusions with obsession and eating difficulty.

 

 

Care Plan

 

1. Patient would be refereed to bereavement services experienced in working with people with dementia. Reminiscence technique can be used to allow him to discuss his late mother, Photos of his mother could be placed near him and staff can investigate to know whether he want to go to his mother’s grave, but he is unable to express this.
2. A change of antidepressant may be beneficial if this has not been tried already. Referral will be made to psychogeriatric services.
3. Patient was encouraged not to keep phoning conservative party agents.
4. Outpatient appointment was arranged with Consultant Psychiatrist
5. As patient was a heavy smoker, he may have nicotine withdrawal, so nicotine patches should be considered.
6. Regular reviews by CPN/Care-Coordinator
7. Patient was advised to contact mental health team and Crisis Team by telephone with increasing frequency due to feelings of low mood and increasing anxiety.
8. A chest infection may be present. Patient should be assessed and treated a broad-spectrum antibiotic rather than being taken to hospital for x-ray, Patient’s temperature would be monitored.
9. Undiagnosed pain or discomfort related to undiagnosed underlying disease or infection (including oral infection) may be present. This can be assessed by using appropriate scales and a detailed history.
10. If swallowing remains a problem, non-oral methods of delivering analgesia (e.g. subcutaneous) can be employed.
11. If patient is not able to resume eating, and drinking, the primary careers should discuss a palliative care plan, for example related to managing care and support.
12. CPN visits/telephone contact increases to monitor risk and medication and to provide support with psycho-social interventions including local computer courses and befriender schemes.
13. Patient expresses concern regarding memory so cognitive testing completed which reveals significant deficits. Referral for CT brain scan completed.
14. Currently the patient is awaiting their CT brain scan which will be discussed with him at his next outpatient appointment.
15. OPA arranged

 

Medication

• Patient prescribed Aripiprazole 5mg daily to treat psychosis.
• Aripiprazole increased to 10mg daily.
• Anti-depressant started (Mirtazapine).