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The dementia patient who 'needed sedating'

How many GPs have been asked by a nursing home over the phone for a prescription? Dr Mandy Fry remembers a case which would have ended in disaster if she’d agreed.

How many GPs have been asked by a nursing home over the phone for a prescription? Dr Mandy Fry remembers a case which would have ended in disaster if she'd agreed.

The case

Brenda was a 74-year-old resident at a local nursing home who had moderate Alzheimer's disease. The nursing home staff rang to request some sedation for her as she had recently started calling out and disturbing her fellow residents.

Although this was a change in her behaviour, the staff didn't seem unduly concerned and would happily have accepted a prescription over the phone. But the current controversies about medicating patients with dementia – and the fact that this was new behaviour – meant I felt I had to see her.

At first the nursing staff seemed reluctant to allow me to actually visit Brenda as she was having lunch and simply showed me her medication chart. But

I insisted they bring her back to her room so I could examine her properly. She walked back to her room with help but was crying out as she did and unable to tell me whether she had pain.

We helped her lie down on the bed and I found some yellowing bruising on her left thigh and in fact the leg appeared slightly shortened. She continued to cry out whether I moved her leg or not. I asked the nursing staff about the bruising and they were adamant she couldn't have fallen without their knowledge.

I felt I simply couldn't exclude a fractured neck of femur despite her ability to bear weight on the limb.

So I contacted her family and arranged for her to be X-rayed at our local hospital.

This move seemed to surprise the nursing staff, who were clearly expecting me simply to prescribe some sedation.

The outcome

The X-ray revealed Brenda had an impacted fractured neck of femur of her left leg. She was transferred to the local orthopaedic service where she had surgical fixation. She went back to the nursing home just under a fortnight later by which time she was much more settled and no longer called out. Her mobility also improved significantly.

Why it nearly went wrong

It's not unusual for nursing homes to request medication over the phone, and it's expected that the behaviour of people with dementia may deteriorate as their disease progresses.

So it would have been all too easy to give in and to prescribe without making a full assessment of the situation.

Also, given that obtaining a history directly from Brenda was virtually impossible, it would have been all too easy to just rely on the nursing home staff's observations and not formally examine her.

Arranging imaging is also not the easiest of task, given that it required sorting out an ambulance and an escort.

Balancing the upset of removing Brenda from her familiar environment with the likelihood of a treatable outcome was also tricky, which is why I felt it was important to try to get the family and nursing home staff on board. Of course that needed to be balanced against the possibility that Brenda may have been in significant pain.

I felt it was my duty to relieve her discomfort if at all possible, given that pain is notoriously difficult to assess in patients with dementia.

The moral of the story

Behavioural changes in patients with dementia need to be fully assessed before acceding to requests to use medication, in order to identify any underlying cause such as pain from an undetected injury.

Also the inability to get a clear history from the patient should not preclude the use of examination as a diagnostic tool before considering the need for further investigations. Targeted investigations may well be appropriate even in individuals with quite advanced disease, but each case needs to be weighed up on its merits.

This was one case where giving in to the demand for a prescription would have prolonged the agony felt by a vulnerable patient unable to communicate her pain.

Dr Mandy Fry is a GP in Cirencester, Gloucestershire, and senior primary care lecturer at Oxford Brookes University

Near miss

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