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When you think an old man may have hit his demented wife

Case history

Nellie is 84 and lives with her husband Stanley, who is 85. For the past five years Nellie has become increasingly forgetful and has been diagnosed as having dementia. Stanley is the devoted sole carer, although he is becoming increasingly frail himself. Their son lives more than 50 miles away. Nellie refuses to attend the psychiatric day centre and is largely housebound. Stanley is finding it increasingly difficult to cope with her memory loss and acknowledges that he gets frustrated with her. But he will not accept help from social services. He would never 'send her away' against her will, as she has always been an excellent wife and mother. Nellie has been referred to community psychiatric nurses several times, but is always discharged after a few months.

You visit Nellie, who has a chest infection, and you notice a large bruise on her chest wall. Stanley says she fell over going to the toilet.

Dr Leila Davis

'My suspicions are aroused as the chest bruising is in an unusual site'

Dr Christine Maple

'Stanley may be suffering from depression'

My first concern would be for the patient. Is there any underlying injury? Did Stanley seek medical help when the injury occurred and if not why not? I would also ask about the nature of the fall: does it sound plausible? If there is doubt I may wish to take things further.

At first I would take things gently and sympathetically, asking how he is coping. How much help and support is he getting from his family?

I would try to persuade Stanley to accept some help, and suggest referral to social work again or an organisation such as Crossroads. This should give him some respite, whether in the home to allow him time to get out of the house, or away from home to give him a break. District nursing can often help with practical support in addition to any benefits the couple may be entitled to such as care allowance, which may enable Stanley to get more help.

Assuming Stanley is also a patient of mine, I would ask about his mental heath. Often carers get forgotten and he may be suffering from depression or stress. Spouses of demented patients often feel ashamed when they cannot cope. Stanley may need time and sympathy to realise he hasn't failed his wife. With care and understanding he may begin to realise the time has come to accept help. The Princess Royal Trust for Carers may be helpful, enabling Stanley to meet other carers for support.

Dr John Couch

'It is odd his son has not contacted me'

Nellie and Stanley's generation tend to endure problems without outside help. Usually it takes a crisis to change this.

Assuming the chest infection is not bad enough for admission, my responsibility for Nellie's welfare is predominant. I would check for other signs of recent injury and spend time listening to Stanley and checking how this and any other injuries occurred. At Nellie's age accidental falls are common so I would not jump to conclusions. Stanley has been open about his frustration so would probably own up if the injuries were non-accidental.

They should be reassured that permanent care outside the home is a last resort and would only ever happen with their agreement. I would tell Stanley that part of the 'treatment' for Nellie's condition is extra care, and that their quality of life will improve. Relieving the pressure on him will allow them to have a better relationship. If his own health suffers Nellie would certainly need to go into care.

I would get another social services assessment, especially if Nellie's injuries are not accidental. The choice of friendly, sympathetic carers is vital. I would find out why the CPN signed them off and hopefully restore regular visits. I would also want to talk to their son. It is odd that he has not contacted me already, although this may not bode well for useful involvement. I would monitor their situation regularly.

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