Ruth’s main carer is her daughter Belinda who lives nearby. Belinda is concerned for her mum’s safety and has to make an increasing number of visits to Ruth each day as she keeps leaving the front door open and locking herself out of the house and losing her keys.
Belinda accompanies Ruth on a visit to her GP who, after an initial assessment orders some blood tests to ensure her symptoms aren’t caused by a physical illness. The GP refers Ruth to the local specialist memory service where she receives a full assessment that shows Ruth has Alzheimer’s disease.
Following the diagnosis a full and quick assessment of Ruth’s needs are made, both in their home and at a clinic. Ruth now has a dementia advisor as a constant point of contact to help her navigate the information, support and guidance that she needs.
Following an assessment by the care manager a number of telecare devices are installed in Ruth’s home that alert a monitoring centre if the front door has been left open, or if Ruth has left the house inappropriately at night. As a result, Belinda is able to dramatically reduce the number of visits she has to make and ensures that visits to her mum’s have a more social and relaxing focus.
Jim is 69, a widower who lives alone, six months ago his only daughter moved to Canada.
On a routine check-up the GP notices that Jim’s mood seems low. After eliminating potential physical causes for Jim’s mood, the GP suggests he might benefit from talking therapy and discusses the use of anti-depressants. As Jim’s symptoms are mild his GP agrees with his wishes and refers him to the new psychological therapies services; within 36 hours he is contacted and offered an appointment at his chosen time and place.
Jim is offered 12 weeks of individual therapy, during which he explores his current mood and, with the therapist, successfully develops coping strategies.
While visiting Malika the dementia advisor notices her concern about changes in Asif’s behaviour, every so often Asif has an ‘episode’ in which he can lash out.
Immediate contact is made with Asif’s care manager who arranges a review of their needs. The social care practitioner works with the community psychiatric nurse to review Asif’s recent behaviour and ensure physical illnesses are ruled out.
The nurse works with Malika to develop a plan to reduce the frequency of aggressive episodes, while the care manager arranges for an intensive package of home care to allow regular breaks for Malika. A co-ordinated approach ensures she is supported to care for Asif at home for as long as possible, as per her wishes.
This includes providing Malika and Asif a dementia advisor as a constant point of contact, able to give Malika information and guidance on options available, such as access to a local carers support network.
Following a fall at home John was admitted to hospital with a fractured hip. Before his operation John was assessed for both his physical and mental health so that the hospital can plan who needs to be involved in his care. This minimises the risk of an increase in confusion after surgery.
John underwent successful surgery, and his hospital stay was supported and shortened by a specialist older adults mental health liaison team acting as a link with members in John’s community mental health team, in relaying his likes and dislikes. The Physiotherapy staff were able to adapt the rehabilitation programme to be appropriate to John, and his level of understanding.
Before he was ready to go home, John and his wife received a specialist occupational assessment in order to make sure that they would both be able to manage.
John and his wife are supported at home following his discharge, with occupational therapist visits and support until John is fully mobile.
Due to her severe dementia she needs support and care throughout the day and night.
Of late Clare has become increasingly restless and agitated and is sometimes verbally threatening to both other residents and the care home staff. The staff at the home have received specialist training from the local memory service so that when Clare’s behaviour becomes more challenging they are able to work with her on an individual basis.
As a direct result of the training programme, and the skills the care-staff have developed, Clare is able to stay in the care home and continuity of her care is ensured.
