Dementia: the case of Alex

Mary Jo has been contacted by her maternal grandmother and asked to

come and visit so that they can talk about her grandmother’s concerns

about her second husband, Alex.

Mary Jo is a little apprehensive as Grandma has asked her at this stage not

to mention anything to her mother or to her two older brothers and their

wives.

[David, 33 years old, is the elder of Mary Jo’s two brothers; his wife is

Maria; they have two children: Jimmy, six years old, and Thomas, four

years old. Barry, the younger brother, is married to Anna; both are 30 and

they have only one child, Leah, three years old. Sadly Anna miscarried last

year but they are optimistic about having more children.]

Mary Jo is also aware that her own mother has not really accepted her

mother’s (Grandma’s) decision to marry Alex, a Mediterranean man, 12

years ago now, and eight years after her grandfather had died suddenly due

to an aortic aneurism. Mary Jo has always liked Alex as he is a jovial person

who clearly loves and respects her grandmother, often buying her jewellery

and other presents and very often fresh flowers. Mary Jo assumed that her

mum was grieving for her own father and that that got in the way of her

accepting her mother’s second marriage. Mary Jo’s mother had emphasised

how different the personalities of the two men were and explained that as

an only child she had always been her father’s ‘princess’. These thoughts

and more were going through Mary Jo’s mind as she travelled by train to

her grandmother’s home to stay overnight. She knew something was wrong

because Grandma had said, ‘You will understand because you are a nurse.’

Mary Jo was concerned that Alex’s ‘memory problems’ were getting worse

and was worried about how she could best help her grandmother.

Grandma met Mary Jo at the door; she was wearing a brace on her left arm

and clearly sporting a healing right ‘black eye’. Mary Jo couldn’t contain

herself and started quizzing her grandmother about what had happened.

Had Alex hit her? This was no good; how could she live with domestic

violence? Something had to be done! Mary Jo stopped when she realised

that her grandmother was just sitting softly weeping while she had gone on

and on.

Mary Jo suddenly saw herself as attacking and criticising the woman she

had come to help. She drew her breath and said, ‘Oh Grandma, I am so

sorry for how I have just behaved! I can see that you’ve been hurt, and

that has upset me because I love you. I’ll put my bag in the spare room,

check on Alex and we’ll meet in the kitchen and have a cuppa. Is that OK?’

Mary Jo’s grandmother nodded and took a few breaths to steady her crying.

Mary Jo was cross with herself for being so… She couldn’t find the words

but knew she would not have behaved that way if she had been at work.

Prompting questions, set 1

• Can you record a genogram for Mary Jo from the above information?

If you have been able to do this, share its elements with your fellow

students in the discussion forum.

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What other information would be informative? What are the benefits of a

genogram in aged care?

• What significance can be placed on the family dynamics?
• If Mary Jo wants to let her mother know about her concerns, how should

she deal with the fact that she has promised not to talk to other family

members?

• What might account for Mary Jo’s response to seeing her grandmother’s

injuries?

• How prevalent is aggressive behaviour between people with dementia and

their carers?

• What advice can be provided to help prevent and minimise aggressive

behaviour?

In the kitchen

Mary Jo informed her grandmother (Matilda) that Alex was asleep in his

recliner.

Mary Jo and Matilda did have a cuppa, with Mary Jo listening to what

Matilda said and allowing her to tell the story as she had experienced it.

Mary Jo also learnt that Matilda had put off approaching her granddaughter,

as she was still embarrassed that Alex had hit her and twisted her arm. It

was so out of character for him but it really had scared her, and she still

felt a bit on edge because it might happen again. She thought that it

related to his wanting a cigarette and her saying no because she didn’t

want to bother at the time. She was not able to distract him from the idea.

Her grandmother continued, ‘He got up to look for his smokes and spotted

them and then went to light one. But in his agitation, he tried to put the

match in his pyjama pocket when it was still alight. I was trying to stop him

from burning himself—thank God they were good cotton and not synthetic—

and God knows what he thought but he hit out at me and grabbed my arm.

Then when he saw me crying he was all ‘lovey dovey’ and not aware of

what had just happened!’

Mary Jo thought about the number of smokers who are admitted to hospital

but don’t get to smoke while they are there. She quietly wondered how

much crankiness and worse could be attributed to nicotine withdrawal.

Prompting questions, set 2

• How might you as a health professional respond to this story?
• Why is Alex’s wife feeling guilty and embarrassed?
• What problem-solving techniques could be employed to assist with the

issue of unsafe smoking?

• If one of the options selected were for Alex to undertake a quit smoking

program what would be required?

Further disclosure

Mary Jo and Matilda got into the flow of interacting and maintaining the

routine that had been pretty well established between Matilda and her

husband. Mary Jo was pleased to be able to prepare the meal her

grandmother had planned and observed her grandparents holding hands

while watching the TV together. Although Mary Jo offered, Matilda did not

accept any assistance with toileting or caring for Alex. Mary Jo was

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mpressed with her grandmother’s ability to help Alex maintain the skills he

did have; she seemed to wind into her conversation with him the

suggestions and cues about what needed to be done or focused on. There

wasn’t that babying approach that Mary Jo had so often seen and

sometimes knew she resorted to at the hospital just to get the task done.

Later that evening Mary Jo and Matilda were able to spend time together

again.

At this time Matilda revealed that their GP had suggested that she needed

to start thinking about putting Alex into residential care. This was her worst

fear as they had in fact made part of their marriage vows to care for each

other in their latter years. She did not deny that he had hit her but felt that

with more help and information she could do better.

The doctor had given Alex a definite diagnosis of dementia, and probably

Alzheimer’s disease. Matilda wanted to know whether the type of dementia

made any difference to what she should do. The doctor was also reluctant

to discuss how long this might go on for. Matilda understood that no one

had a crystal ball but felt that it would help her if she knew some of what

was in store and had some timeframe to work from. She was thinking of

visiting relatives in Holland before she got too old to manage such a trip but

didn’t know what was best to do.

Matilda said that she hadn’t properly answered the doctor’s questions about

Alex‘s incontinence because that would have just made things worse. She

explained that Alex had had some urinary incontinence for a year or more

but this had been mostly at night or he had just used the wrong place or

thing to urinate in. But over the past month he had been wetting himself

and was now occasionally incontinent of faeces as well.

Again Mary Jo disciplined herself from jumping in and answering the parts

of the questions she could answer. She was feeling that her grandmother

had a new level of trust in her and she wanted to live up to that trust.

Somehow it also really mattered to understand what her grandmother was

experiencing.

Their conversation extended beyond ‘Alex’s problems’ to Mary Jo’s learning

more about her own (and Alex’s) extended family in Europe and some

catching up about what Mary Jo was up to at work and in her rather inactive

social life.

Towards the end of the evening Mary Jo said that she felt that the

Alzheimer’s Association was the best source of information for her

grandmother and that she would be happy to go along with her and support

any steps or stages she chose along the way. When her grandma was ready

Mary Jo was also willing to approach the social worker and get the full

information about nursing home assessment and admission and what that

entailed.

Prompting questions, set 3

• What influence does the type of dementia have on the onset, progression

and prognosis of the condition?

• What factors contribute to the likelihood of aggressive behaviour in people

experiencing dementia?

• Identify what community resources are available in your community to

answer Matilda’s questions.

• What could account for the changes in Alex’s continence issues?

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What resources and advice could be made available to Alex in his own

home?

• How would you as a health professional support Matilda’s plans to travel to

Europe?

Epilogue

Matilda did explore the information and community resources available to

her and Alex. She found that the carers’ support group was very welcoming

and good at sharing helpful information.

The continence nurse specialist did an assessment and Alex was found to be

constipated, with some faecal overflow, and his dietary habits and exercise

regime were adjusted under her supervision.

Mary Jo became a regular visitor and support to her grandmother. The

range of topics that they discussed together expanded and sometimes even

surprised Mary Jo.

What you need to do to meet your learning outcomes

 Explore these websites

Explore the following websites, which provide information about dementia.

Australian Government Department of Health and Ageing 2007, Dementia,

http://www.health.gov.au/dementia.

AIHW 2007, Dementia in Australia: national data analysis and development,

AIHW Cat. No. AGE 53, AIHW, Canberra,

http://www.aihw.gov.au/publications/index.cfm/title/10368.

Dementia Training Study Centres: http://www.dtsc.com.au/

Bridges-Webb, C & Wolk, J 2003, Care of patients with dementia in general

practice: guidelines, NSW Department of Health, Sydney,

http://www.health.nsw.gov.au/pubs/2003/pdf/care_dementia_guide.pdf.

Dementia Care Australia: http://www.dementiacareaustralia.com

Alzheimer’s Australia: http://www.alzheimers.org.au

Simons, LA, Simons, J, McCallum, J & Friedland, Y 2006, ‘Lifestyle factors and

risk of dementia: Dubbo study of elderly’, Medical Journal of Australia,

vol. 184, no. 2, January, pp. 68-70,

http://www.mja.com.au/public/issues/184_02_160106/sim10682_fm.pdf

Department of Human Services, Victorian Government Health Information 2004,

A guide for assessing older people in hospitals, developed by the Centre for

Applied Gerontology, Bundoora Extended Care Centre, Northern Health,

http://www.health.vic.gov.au/acute-agedcare/assessing-older-people.pdf.

This guide provides one of the major discussions in the field regarding the

pros and cons of assessments and other tools that are available.

Tameside Council, The single assessment process for older people, frequently

asked questions, http://www.tameside.gov.uk/sap.

This web resource about the single assessment process (SAP) was developed

by the Department of Health in the UK. It discusses different types of

assessment scales and social problems facing the older person.

Ministry of Health [NZ] and New Zealand Guidelines Group 2003, Best practice

evidence-based guideline summary, ‘Assessment of older people with complex

needs’, New Zealand Government,

http://www.nzgg.org.nz/guidelines/0030/Specialist_summary.pdf.