Case studies

Case study 1: Care for an older Chinese man with dementia and diabetes

Mr Lam is an 80-year-old Chinese man who suffers from dementia. He has a Mini Mental State Examination (MMSE) score of 11/30 which along with his presenting history indicates moderate disease. He is considered to lack the capacity to make decisions regarding his general welfare.

He has a wife, a son and two daughters.

His condition has progressed to the stage where he is at serious risk of injury as he wanders away from home and gets lost. Mr Lam has poorly controlled diabetes, which further complicates his diagnosis of dementia, as he becomes confused and disoriented.

Mr Lam lives with his family. They are unable to manage his care and to provide a protected environment. Mr Lam refuses any intervention, including hospitalisation to stabilise his diabetic condition. He does not have an Enduring Power of Attorney in place for his future care. The Mental Health Services for Older People (MHSOP) team consults with the head of the family (the client’s son) and other family members about how best to proceed with getting the appropriate care for their father.

Unfortunately, despite discussions, no definite decisions are made in the best interests of the client. Mr Lam’s son refuses to allow his father to go to hospital or into residential aged care, as his belief is that it will upset his father greatly and that it would be culturally shameful. The team seek a second opinion from a geriatrician who recommends that a palliative approach is reasonable in order to respect the wishes of the client and his family. The physician also recommends treatment of diabetes at home with oral medication. The geriatric team attempts to follow this recommendation and consults the family.

To reduce the risk further, they suggest that the son move in with his father to reduce the burden of care on his wife and to increase his father’s safety. However, to the team’s surprise, all the women in the family support involuntary admission and the son has to change his mind about hospitalisation.

Interestingly, Mr Lam does not object to hospital admission. Whilst in hospital, his diabetes is stabilised and after six weeks he is transferred to a residential aged care facility with medical facilities.

Issues for consideration:

• The Mental Health Services for Older People (MHSOP) team’s understanding of culturally competent care for Mr Lam including the power of filial piety.
• There is intense cultural shame attached to admitting elders to residential aged care facilities in Chinese cultures.
• Addressing the son’s guilt about hospitalising his father.
• Consider the decision-making preferences of the client and family.

Case study 2: Supporting Mrs Chang to care for her husband

Mrs Chang and her husband have been in New Zealand for 21 years. They were married in China in 1966.

Background

Mrs Chang cares for her husband, who was diagnosed with dementia nine months ago. Mr Chang’s memory problems started a few years ago, initially he would forget small things. This has escalated to accusations that Mrs Chang is stealing things. Up until now Mrs Chang has believed that her husband is mildly confused but as he is now accusing her of stealing things, she now thinks that there is something seriously wrong with him. Mrs Chang states that her husband has always been grumpy by nature but his character has recently changed significantly and he has become very aggressive. Mrs Chang is embarrassed by his behaviour. She says: “To be honest it’s getting worse and worse but we have been a couple for many years”.

The diagnosis

Nine months ago, Mrs Chang took her husband to the general practitioner. He assessed Mr Chang and suggested a referral to a psychiatrist at North Shore Hospital. Initially, Mr Chang was diagnosed with psychosis and was hospitalised for two months. He was started on medications to “calm him down and to help him sleep and another medication”. Mrs Chang says she doesn’t know what the third medication is for. Mrs Chang stopped the sleeping tablets after her husband was discharged, as he was very sleepy all the time.

The current situation

Since Mr Chang was returned home Mrs Chang has to watch him all the time. She is constantly worried that her husband will walk out of the house and get lost. Mr Chang has disappeared twice and it has taken hours for the family to find him. It is very frightening for Mrs Chang as her husband doesn’t know what he is doing and cannot find his way home. She worries constantly about his safety. She doesn’t like to bother the police, so family go and search for him when he goes missing.

Mr Chang is “getting much worse” and Mrs Chang is not sure how she will cope in the future. Her husband’s behaviour can be very aggressive and Mrs Chang worries that she will not be able to calm him down or manage his behaviour. Mrs Chang has talked to the GP about her husband’s change in behaviour. His response was that she should carry on with the medications at the same dose. She says: “I just have to listen to instructions and carry on”. The only support person the family has is a Mandarin-speaking social worker from the local hospital who they find very helpful.

Mrs Chang feels a strong obligation to look after her husband. She feels he needs somebody who understands him although his behaviour is very disruptive and difficult to deal with at times, e.g., switching channels on the TV all the time, constantly on the go, and waking three to four times in the night. Mr Chang is often incontinent in the bed. Mrs Chang is on “standby all the time, even at 3am in case of disaster”. Mrs Chang finds it very tiring and stressful. She never knows what is going to happen next.

The son runs a takeaway business and works long hours. He is not available to offer help, the grandchildren are at school, and friends are no longer involved because Mr Chang’s behaviour has become so disruptive. Mrs Chang says: “I begin to wonder what kind of life I have”. The social worker is looking for a suitable rest home but Mrs Chang doesn’t feel that it is right for somebody else to have to look after her husband. Mrs Chang admits she lives day to day, she also has a real fear about the safety of rest homes and worries about burglars – although the social worker has reassured her that resthomes are safe places.

Case study 3: Helping Mr and Mrs Lee decide on care for Mrs Lee’s mother.

Background

Mr and Mrs Lee live with Mrs Lee’s mother and have done so for the past 18 years. The family are Chinese and speak Cantonese. They migrated to New Zealand from Hong Kong twenty years ago. Mr Lee’s mother-in-law (Mrs Cheung), aged 77 years, has had memory problems for about the last four years. Initially she was forgetful but her mental state has deteriorated, for example, she has started hanging clean washing on the line; is unable to recognise her grandson; and has set fire to the kitchen so that the fire brigade had to be called to extinguish the fire.

The diagnosis

Mrs Lee takes her mother to see the general practitioner. The GP accepts straight away that there is a problem and refers Mrs Cheung to a specialist. The specialist is a junior doctor who gives the family information but provides nothing in writing and no translated information. The family are not told about an Enduring Power of Attorney or Advance Directives.

The current situation

The Lee family recognise that their mother is unsafe at home but they have had no professional advice regarding the options available to them for the care of Mrs Cheung.