In-depth study of a patient with chronic illness

Patient 's Narrative

Condition of the patient

The patient is an 88-year old woman who feels that her condition has made her a prisoner in her own home . She had fallen twice in ay due to anxiety . She needs a Zimmer frame to walk but since her apartment is on the fourth floor of a complex with no elevators , she is unable to leave the house without assistance . She is depressed and strongly believes in euthanasia . Her inability to leave her home has made depressed very much . She has very little social

support and gets visits once in a week from a close friend . Her inability to leave her home has taken away everything from her . She is unable to do her basic activities . She used to enjoy cinema , travel , and museums etc . which she used to do a lot off

Medical History

The medical history of the patient is given with reference to the past recent months

-10 /2007 anxiety state - does not want to be home alone

-10 /2007 fall but no serious injury

-06 /2007 Foot ulcer on her left hallux at site of her bunion

-06 /2007 Atrial Fibrillation

-05 /2007 injured leg due to fall

-07 /2003 depression

-02 /2003 hip fracture (impacted sub capital fracture

-12 /2001 hypertensive- started atenolol

-12 /1996 GI reflux

-03 /1967 abdominal hysterectomy and bilateral salpingoophorectomy for fibroids

-01 /1953 Thoracotomy - bilateral for TB

Social History

never smoked or elicit drugs

does not drink now - used to drink about 1 unit a week

lives home alone

no living family members - never close to them either

1 close friend visits once a week

Does not leave her house , but can just manage in her house on her own

Never married and no children

Summary of Active Problems

The main problem of the patient is the number of falls she has been having like due to her atrial fibrillation . This is also connected to the fact that she is unable to leave her apartment . She cannot leave her place without an elevator . It is impossible to get down or up four flights of stairs in her condition . The sores on her feet are also a big problem for her . Makes it even more difficult to walk and be independent . She has a number of time requested for a chiropodist but has not been able to find one that can come to her place

Her other major problem is her depression . She tries to be strong and a little aggressive however she found it difficult to keep that side of her when I gave her the and other magazines to keep her company She became a little emotional but tried to hide her tears

Her atrial fibrillation is an active problem that she takes regular digoxin for but she is unaware of any problems with her heart . Finally her depression is a serious active problem that is likely to become much worse as she is unable to leave her place . She will become more isolated from society and her surroundings

Underlying Pathology

Depression in the elderly and falls related isolation

When depressive symptoms are present

Unexplained physical symptoms

Repeated presentations with non-specific complaints

Self neglect

Chronic pain or physical disability

Coexisting dementia

Social isolation

Living in residential or nursing homes

Previous history of depression or similar problem

Family history of depression

Atrial fibrillation

Atrial fibrillation (AF ) is the most common sustained cardiac arrhythmia and increases in prevalence with age . The prevalence of AF is approximately 2-3 in those above 65 years of age and 6-8 in those of above 80 years of age . Management approaches consist of therapies to control the ventricular rate or therapies to restore and maintain sinus rhythm . Randomized trials have not demonstrated a superiority of Rhythm Control versus Control in elderly patients with AF . The most devastating consequence of AF is stroke . Antithrombotic therapy should be initiated to prevent thromboembolism . Warfarin should be prescribed in patients at high risk of systemic thromboembolism . The INR should be maintained between 2-3 IU

Foot Ulcers

Diabetic foot ulcers are sores on the feet that often occur in people with diabetes . People with diabetes mellitus , a dis in which blood sugar levels are abnormally high , are at risk for foot ulcers . The elevated blood sugar levels that occur with diabetes mellitus damage blood vessels , causing them to thicken and leak . Over time , this thickening means they are less able to supply the body , especially the skin , with the blood it needs to remain healthy . Plaque is also more likely to build up in blood vessels (called atherosclerosis , which causes poor circulation . Poor blood supply to the skin often leads to ulcers , especially on the feet . Because of the poor circulation , these ulcers are slow to heal and often become deep and infected . A foot ulcer looks like a painful , red sore on the foot . When infected , it will ooze pus and have a foul-smelling discharge

Integrated Clinical Material

Depression : The patient admits that her depression came on quite suddenly and she has felt it much more since her recent falls which thus led her to unable to leave her apartment . Her depression was increasing and was scaled as 14 /20 (moderate ) on The Macarthur initiative on depression primary care questionnaire . She is currently on the antidepressant FLUOXETINE but thinks its ridicules now to treat it when the problem is just the need to get out of her apartment . It is likely that her condition will worsen very rapidly . She is isolated and alone most of the time

Atrial Fibrillation : It was likely discovered in hospital when she was having a number of falls . She is unaware of her heart problem and thus not likely to have any other presentations other than her faints /falls She is currently on digoxin for the atrial fibrillation and calcium carbonate colecalciferol to maintain the strength of her bones . Her prognosis depends on the worsening of her heart . At the moment it doesn 't seem to be the case . She has no signs of heart failure or uncontrolled atrial fibrillation

Foot ulcers : These are quite common in the elderly . She is not diabetic but her age makes her more susceptible to injuries . Her reduced mobility likely also reduces proper circulation to the feet reducing sensation At her age it also makes it difficult to maintain proper care for her feet , since she has also been unable to bring a chiropodist to her house . The ulcer presented as a very painful sore on her left hallux at site of her bunion . It has been getting worse and treatment previously included antibiotics (magnapen . The ulcer can be easily treated and the prognosis is good with the proper care however that currently is no happening and therefore likely to get worse

Management /Treatment

The prescribed medication at present is as follows

Digoxin 125 mg - taken one in the morning at 9am

Sivamstatin : 20 mg - a take one at night

Calcium carbonate colecalciferol 1 .25g 10 mg - take 2 in the evening 6pm

Furosemide 20 mg - 1 every morning

Enalapril 10 mg - 1 twice a day

Lansoprazole 30mg - 1 in the morning

Alendronic acid 70 mg - 1 weekly

Paracetamol 500 mg - take 2 twice a day

Asprin 75mg - 1 in the morning with food daily

Fluoxetine 20 mg- 1 in the morning 9am

The specific treatment to the patient 's present condition is given as below

Depression

Selective Serotonin Reuptake Inhibitors (SSRI 's

Now regarded as first line treatment

Include fluoxetine , sertraline , citalopram and paroxetine

Relatively free of dangerous side effects

Relatively safe in overdose

Consider prescribing generic citalopram , fluoxetine is associated with fewer withdrawal /discontinuation symptoms

Note higher propensity for fluoxetine for drug interactions

Choice of preparation depends on individual factors e .g . availability of liquid preparations , previous good response , side effects etc

Sertraline has the best evidence base for use in ischaemic heart disease

Paroxetine may be difficult to discontinue

Therapeutic effects may not occur for up to 8 weeks in older people

Initial dose should be smaller than for younger adults especially for very elderly or frail individuals

Therapeutic trial should continue until largest tolerated dose has been provided for 6-8 weeks

Common side effects include nausea , diarrhoea , postural hypotension and hyponatraemia

Preparations are not consistently sedative

St Johns Wort should not be taken simultaneously with SSRI 's

Tricyclics

Include amitryptiline , imipramine , clomipramine , dosulepin and lofepramine

Not recommended as first line treatment in elderly people because of the side effect pro and toxicity in overdose

Dosulpin should only be initiated by specialist mental health care professionals including GPs with Special Interest in Mental Health

Some people have taken these preparations (tricyclics ) for many years and it may be justifiable in some cases to continue them (some patients on low doses for pain

May be considered if SSRI 's have been ineffective or not tolerated

Lofepramine is less cardiotoxic and therefore is safer than other tricyclics

ECG should be carried out before starting a tricyclic

Monoamine oxidase inhibitors

Irreversible MAOI 's such as phenelzine or tranylcypromine should no longer be initiated by Primary Care

Advice should be obtained from secondary care for individuals who have taken these preparations for many years . The reversible MAOI moclobemide , is occasionally used

General points on anti depressant medication

Non-compliance is common problem wit hall anti-depressants . Explanation reassurance , encouragement and compliance aids may all help

Consider providing written information in a user friendly format about anti-depressants

Atrial Fibrillation

The aim of treatment and management is to

To relieve symptoms of heart failure , hypotension or angina that can be directly attributed to a rapid heart rate

To improve overall cardiac function

To improve exercise tolerance

To reduce the risk of thromboembolism and stroke

Treatment requires rhythm or rate control depending on the category of AF

Rhythm control - should be tried first for patients with persistent AF

? Who are symptomatic

? Who are younger

? Presenting for the first time with lone AF

? Secondary to a treated or corrected precipitant

? With congestive heart failure

Rate control - should be tried first for patients with persistent AF

? Over 65 years

? With coronary artery disease

? With contraindications to antiarrhythmic drugs

? Unsuitable for cardio version e .g . patients with contraindications to anticoagulation or following a TOE , structural heart disease that precludes long-term maintenance of sinus rhythm , long duration of AF (i .e 12 months , history of multiple failure attempts at cardio version

Foot ulcers

If an ulcer develops , the ulcer must be kept very clean . You can do this by washing the feet daily with mild soap or a saline solution and keeping the ulcer covered with clean , dry dressings . Your doctor may recommend complete bed rest with the head kept higher than the feet Often , doctors prescribe an antibiotic ointment to prevent infection Oral antibiotics may also be needed if the ulcer becomes infected Ulcers can become so deep and infected that the foot needs to be surgically amputated

Adaptive Mechanisms

1 . Physical and psychological coping strategies

She loves reading and listening radio . These two hobbies kept her sane as she says . A number of magazines brought by me made her very tearful She walks outside her front door , just for fresh air as there is no much of scenery . Her career taught her some stretching exercises which she practice to keep away from being stiff by the end of a day

2 . Adaptations made by family

She has no family and has a very little social support . Only one old person , a friend of her visits her , even he stopped being regular due to bad health

3 . Assessment of unmet needs

Her unmet need is to transfer to a special house where she can access the outside without stairs , and where the demands of social living are very high . Having sheltered accommodation by social services may also give her the opportunity to be with others similar to her situation and hope this will provide her with social support which she lacks now

Role of the health services

The patient 's general practitioner has been very supportive . He has provided a number of phone consultations and did home visits to her to assess her physical and social condition . He has done appropriate referrals and prescribed the appropriate medications . Most importantly he recommended her to social housing , careers , meals on wheels and a district nurse . The primary health care team included the practice nurse (monitored her BP and assessed her sores , community care team included the career that brings her breakfast and dinner everyday and keeps her hygienic and does her food shopping . Social services provide lunch for her through Meals on Wheels and have arranged for a cleaner to clean her house weekly and provide her with a community alarm service that is linked to the ambulance services

How effective are the interventions

The interventions may be somewhat effective but does not provide the social support she requires . The pressure and demand on social services means that her application to move community care will take a very long time possibly causing serious consequences . Her condition is clearly deteriorating and the likely cause would be her isolation . However there is a huge pressure on the social services as there are many patients worse than this patient

Ethical dimensions

This is a very confidential data I acquired promising the patient it would be a secret . She is very keen regarding the details not to be kept open . She expects true secrecy from me . She dislikes people knowing about her inability to do things on her own . And regarding the autonomy , she is an independent woman she is competent and fully able to make her own decisions . She never waits to take decisions , as there is no one in specific to take care of her . And her only friend has also become sick due to which she completely lost social support . As she has very little social support she expects at least her friend to make it to her , may not be as frequent as earlier as but not worse than leaving her alone

She believes strongly in euthanasia as mentioned earlier , but she would never kill herself . That is what I could make from her words...