Edward is a 69-year-old retired engineer diagnosed with Dementia, vascular type. His admission under the Mental Health Act was initially triggered by escalating agitation and physical aggression directed towards his wife. He was admitted to hospital after the breakdown of his respite placement at a specialist nursing home.
In hospital Edward continued to present with both verbal and physical aggression. He made attempts to abscond and required a high level of support and observation.
Edward has a number of chronic medical conditions including diabetes for which he is prescribed insulin. Due to agitation and impaired concentration, he seldom met his food or fluid requirements and, at the time of referral to St Peter’s, he required fluids via subcutaneous infusion which could only be safely completed whilst he slept.
Edward was being nursed within a specialist dementia unit; however, his needs could only be met segregated away from the general ward population and this had significant impact on him as well as fellow patients of the unit.
On admission to St Peter’s, he was initially prone to falls which were being contributed to by high doses of psychotropic medication that he was prescribed. Sedation also contributed to a reluctance to maintain adequate hydration and Edward often refused to accept medication for both physical and mental health treatments.
What did Edward’s commissioners want to achieve?
- Treat and stabilise mental disorder
- Improve behaviour and reduce the number of adverse incidents
- Improve Edward’s quality of life
What did we do to achieve these goals?
Careful pre-admission planning was undertaken by various specialists at St Peter’s. This led to the design of a bespoke accommodation suite which was adapted to promote independence and minimise risk of injury to Edward. He was at high risk of falls and had a tendency to cause significant property damage. At the previous hospital he had removed curtain rails, damaged furniture and he broke glass panels.
The accommodation suite at St Peter’s offered Edward an en-suite bedroom and a lounge and dining area that was for his exclusive use. He was initially supported by one staff member at all times. When calm Edward could access the wider ward environment. However, his accommodation suite provided him with a lower stimulus environment when agitated.
His bedroom and lounge were decorated and included photographs of his family, his dogs and his motorcycles.
Edward was admitted on our assessment and treatment pathway which allowed for a complete and comprehensive assessment from psychiatrists, psychologists, occupational therapists, physiotherapists, speech and language therapists and the nursing team. The team reassessed his pharmacological treatments and implemented a positive behavioural management plan as an alternative approach to managing aspects of his behaviour, allowing Edward to progress to our recovery and wellbeing pathway.
What were the outcomes for Edward?
- Through the implementation of changes to his pharmacological treatments and adopting a person-centred behavioural support plan it was possible to gradually improve Edward’s mental state and behaviour as well as his physical health.
- Edward begun to spend more time within communal areas of the unit. He also accepted restrictions to his diet as he was assessed as having dysphagia. His sleep pattern improved, and it was possible to reduce levels of observation at night with staff responding to his needs by utilising a bed and door alarm.
- It was possible to reduce the prescription of antipsychotic medication and to discontinue the prescription of Benzodiazepines. Edward began to communicate more effectively. The introduction of an antidepressant significantly improved his mental state and behaviour.
- Edward was able to engage meaningfully with the visits from his family which included his family bringing his pet dogs to visit him.
- It was possible to introduce periods of Section 17 leave which enhanced his quality of life and built strong therapeutic alliance.
- Edward no longer needed the bespoke accommodation suite and transferred to Upper Caldicot Unit which is a 6-bed unit that he shares with 5 other men of similar age and with similar needs.
- Edward was now fully compliant with all prescribed medication and no longer required a covert medication pathway.
- He occasionally became agitated, wishing to return home, but it was possible, through the implementation of a person-centred care plan, to reassure him and incidents of aggression have reduced.
- As a consequence of being on lower amounts of psychotropic medication, Edward’s mobility improved and he went from requiring a wheelchair to using a rollator walking frame to eventually no longer needing the rollator frame.
- His access to community activities were increased and he recently visited a pitch and putt golf course and enjoyed re-engaging with his old hobby. He is now keen to return to fishing and is also engaged with our music therapist and started to play guitar after many years.
- We have been able to reduce observations and Edward no longer requires 1:1 levels of observation and support.
- We are now working with Edward’s commissioning team with a view to discharging Edward to accommodation of lesser restriction and closer to his home; we look forward to discharging him back to his local area.
