Case management interventions for Mr. William Doe with dementia and depression

Echo Valley Council

Case Report: Mr. William Doe

Director, Community Options Program

Case Manager

Proposed Interventions and Treatment Plan for Mr. William Doe

Like other developed Western nations, the elderly in Australia are confronted with numerous challenges to living independently as they grow older, including coping with age-related diseases processes such as dementia and obstructive airways disease as well as adjusting to the loss of a spouse. This case report provides a discussion concerning the application of the overarching and practice functions of the case management model described within the organisational and community contexts. A reflective discussion concerning the proposed approach to practice that focuses on decisions and reasons for practice, the effectiveness of the proposed practice and alternative approaches, skills or techniques that may be required to provide appropriate levels of care for Mr. William Doe who is described further below.

Review and Discussion

Overview of Client: "Mr. William Doe"

Mr. William Doe (hereinafter "Mr. Doe") is an 80-year-old Greek-Australian widower who has lived in Australia for the past 40 years. Like many other elderly individuals, Mr. Doe is experiencing the deleterious effects of aging, which have introduced some new problems while exacerbating existing ones. As Kirchengast and Haslinger (2009), this process is natural and should be expected in elderly individuals. For instance, according to Kirchengast and Haslinger (2009) point out, "Inevitably, increasing age is associated with increased exposure to risk factors and reduced adaptability, which results in disease, vulnerability and reduced quality of life" (p. 3).

At present, Mr. Doe appears slightly depressed, and this issue may have been overlooked by his health care practitioners to date. Nevertheless, this is an important issue since, "Depression, even the mild form, impacts many on the life of elderly in many ways. Depressed mood might lead to feelings of hopelessness and helplessness and a reduced meaningfulness of life" (Kirchengast & Haslinger, 2009, p. 5). In addition, Mr. Doe suffers from a slipped disk in his back as well as obstructive airway disease, which is a complex group of conditions associated with progressive airway obstruction which is aggravated by periodic asthmatic attacks; this condition has no disease-modifying therapy currently available (Croxton, 2006) and Mr. Doe has been prescribed home-based oxygen supplementation. In addition, Mr. Doe has been diagnosed as being in the first stages of dementia and has exhibited hoarding behaviors that contribute to an unhealthy home environment. Although Mr. Doe retired, it is unclear if he has a pension and there is concern that he is running out of the money needed to allow him to remain in his own home.

As noted above, Mr. Doe has been a widower for 25 years and has two adult children, a 30-year-old son who lives and works abroad and a 35-year-old daughter who lives 4 hours away. Both the adult son and daughter have kept in contact with their father from time to time, but both of them are involved with their own lives and neither of the adult children is aware of the full extent of Mr. Doe's deteriorating health and financial condition. Finally, Mr. Doe's education level is not indicated, and this factor has been related to the level of success of the types of outcomes that can be achieved through social work interventions, and these issues are discussed further below.

Mild depression

Loneliness and geriatric depression contribute to marked reduction of well being among the elderly. Although major depression is less common among elderly in comparison to middle aged populations, depression is the most prevalent mental function disorder among elderly worldwide. In addition, while depression is not age-related and not a part of normal ageing, especially mild depression has been considered a "normal" effect of aging. Nevertheless, depression in later life remains largely an undetected and untreated condition.

Health services for the treatment of Mr. Doe's mild depression are available through Australia's Community Options Program, Community Aged Care Packages, Aged Care Psychiatry (Psychogeriatric) Services program (Draper, 2004) as well as through Echo Valley hospital's day care program for the elderly and the mental health services team available at Apollos.

Obstructive pulmonary disease

This condition is characterized by chronic airflow limitation resulting from airways disease and emphysema; and bronchiolitis obliterans, a disease causing fixed obstruction involving the distal airways and alveolae (Obstructive airways disease, 2013, para. 2).

Pulmonary rehabilitation (PR) improves exercise capacity and health-related quality of life (HRQoL), and reduces health care utilization (Cecins & Geelhoed, 2008, p. 415). A study by Cecins and Geelhood (2008) found that, "Pulmonary rehabilitation provided in an Australian teaching hospital was associated with a reduction in COPD hospitalisation, and the resultant savings outweighed the costs of providing the program" (p. 416).

Slipped disk

Twice as many men as women suffer from a slipped disk, but the reasons for this difference remain unclear; however, contrary to popular belief, the heavy physical labor performed by Mr. Doe in the past is not associated with a greater risk of a slipped disk (Cavendish, 2005). According to Cavendish, "All slipped disks are in fact ruptured disks. Over 90% of people with a slipped disk recover by resting in bed between 3 days and 3 weeks. If the symptoms persist, patients may have to spend time in the hospital with their legs supported in such a way that pressure on the nerves can be relieved" (p. 1982).

This problem is perhaps the most manageable of the wide of issues confronting Mr. Doe. Assuming sufficient home-based support can be provided, Mr. Doe can effect meaningful improvements through bed rest. In addition, should best rest be insufficient, Echo Valley's hospital has 12 general ward beds and a 20-bed nursing home that could provide the hospital care needed for Mr. Doe's rehabilitation.

Early stage dementia

Generally, dementia is comprised of a constellation of symptoms that indicate chronic and widespread dysfunction (Nazarko, 2008). The global impairment of cognitive capacities is the essential defining characteristic of dementia which presents as difficulty with memory, attention, reasoning, language and comprehension; however, other mental functions, such as marked changes in mood, personality, judgment, and social behavior, are also frequently involved (Nazarko, 2008). The primary goals of the intervention for elderly Australians with early stage dementia are to:

1. Prevent premature or inappropriate admissions to aged care facilities;

2. Provide a comprehensive assessment that encompasses the restorative, physical, medical, psychological, cultural and social dimensions of care need;

3. Ensure the involvement of clients, their carers and other service providers in the assessment and care planning process; and,

4. Improve the appropriateness and range of care services available through the promotion of coordinated services (Draper, 2004, p. 158).

Health services for dementia treatment are available through Australia's Aged Care Psychiatry (Psychogeriatric) Services program (Draper, 2004). Dementia and Cognition

Supplement services are also available to all home care providers that provide care to Australian citizens who meet the eligibility criteria for the supplement (across any of the four levels of Home Care Packages) (Home Care Packages Program Guidelines, 2013). How early in the course of dementia an Aged Care Assessment Team (ACAT) is contacted will differ depending on location and individual circumstances (Draper, 2004). According to Draper, "It is probably best to discuss individual circumstances with a general practitioner. In some parts of Australia, particularly rural and regional areas, Aged Care Assessment Teams are the primary setting for initial dementia assessment and the general practitioner or another health professional might make a referral for this to occur. There may not be any other need for community services at this point" (p. 157).

Hoarding behaviors / home maintenance

This is an urgent health care issue for Mr. Doe. According to Steketee, Frost and Kim (2001), "Hoarding is a debilitating disorder characterized by the acquisition of a large volume of possessions that clutter living areas to such a degree that living spaces cannot be used for their intended purpose" (p. 176).

In addition, the volunteer meals on wheels program can provide Mr. Doe with a hot meal 3 days per week.

Financial

Because Mr. Doe owns his home, he may be eligible to participate in Australia's reverse mortgage alternative known as the Property Options for Pensioners and Investors which provides an income stream for individuals such as Mr. Doe to allow them to remain in their own homes as long as possible (Property Options for Pensioners and Investors, 2013). This alternative is particularly attractive for Australia retirees today following reforms by the Australian government: "As a POPI is not a reverse mortgage, there is no risk that you will lose the equity you have worked hard to build in your home. Bank reverse mortgages were forcing many Australian retirees into negative equity, this led the federal government to mandate protection laws. Equity is protected" (Property Options for Pensioners and Investors, 2013).

If home-based care alternatives fail to provide Mr. Doe with the level of support he requires, there is a medium support retirement village in town of 15 units that has recently been completed; bed availability, though, remains unknown at this time.

Reflective Discussion

Babies born today have a 50-50 chance of living to be 100 years old, and social workers are going to be confronted with a rapidly growing elder population in the future. As a result, elderly individuals with a number of complex and intractable problems such as Mr. Doe will become increasingly commonplace. In this regard, Kirchengast and Haslinger (2009) report that the World Health Organization has projected that depressive illness during old age will become the second-leading cause of global disability by 2020. According to Kirchengast and Haslinger (2009), "Old age depression may be the commonest but also the most reversible mental health problem. Nevertheless depression affects quality of life and even heath related quality of life during old age." Therefore, quality of life considerations for the elderly in Australia demand multidisciplinary community-based solutions. As Moore (2009) points out, caring social work interventions should take into account "the perspectives, interests, wishes capacities, fears and desires of the person requiring [case management] care [which] values people over systems' (p. 3).

Conclusion

Complex problems demand complex solutions and the research clearly showed that Mr. William Doe is faced with some profound challenges as he seeks to live a high quality life in his own home for as long as possible. Not only is Mr. Doe challenged by many of the physical and cognitive maladies that are associated with the aging process including the loss of a spouse, his money is running out and he is in the early stages of dementia for which there is no cure currently available. Moreover, Mr. Doe has been engaging in hoarding behaviors that endanger his physical safety by creating a fire hazard and limiting his ability to enjoy the full range of comforts that his home should afford. Fortunately, Mr. Doe may be eligible to participate in Australia's Property Options for Pensioners and Investors which would provide him with the income stream he needs to remain in his own home for as long as possible. In addition, notwithstanding the geographically remote nature of Echo Valley, the community provides a comprehensive range of multidisciplinary health services that can be delivered in a personalized fashion through the home and community care program.