Monday, 1 June 2009

The little girl with the rat on her shoulder

I always find it fascinating how certain forms of dementia can produce the most vivid and outlandish of hallucinations in older people. One man was troubled because “there are 3,474,263 people in my room and they won’t go away.” When I went to assess another elderly man he had pulled up his fitted carpet and piled all his furniture in the corner of the room. When I asked him why he had done this he told me that “there’s lots of calves coming out of the floor and I’m trying to find out where they’re coming from.” There was also a pair of dogs with a litter of pups in the corner, and he would not go into his bedroom because “the ceiling’s covered with thousands of spiders.”

Ethel was an elderly lady with Lewy body dementia. She lived alone, with help from a caring neighbour and some input from home carers. She started to ring the police on a daily basis because “This bloke is there with his 6 dogs in my back garden, and his whole family… He sleeps in the garden now – I can’t sleep because I don’t know what he’ll be up to next.” When I assessed her last year, she was adamant that this man existed. He took out his duvet every evening and slept on her garden bench. On that occasion she spent a month in hospital detained under Sec.2 MHA, and on discharge agreed to take medication and accept a package of home care -- although she was still absolutely convinced there was a man living in her garden.

A few months later the older people’s psychiatrist came to see me. The man in the garden was causing Ethel more problems, to the extent that she had started to ring the police again and was going out at night to try and sort him out. He had now been joined by a little girl, who had a rat on her shoulder and had stolen her door key and would get into her house at night and steal her crisps.

I went round with the psychiatrist, Ethel’s GP and her psychiatric nurse. She readily let us in, and equally readily told us all about the man, his dogs and the little girl with a rat on her shoulder. The man was “getting on her nerves.”

Although it was clear that Ethel was hallucinating (I did check her back garden just to be sure, and although I could see no-one, she could see him “as clear as day”), the existence of symptoms of mental disorder is of course not enough on its own to justify detention under the Mental Health Act. There has to be evidence of risk to the patient and/or others, as well as evidence that alternatives to hospital admission had been tried and failed.

In Ethel’s case, she was taking medication, since carers were coming in daily and making sure she took it. However, the medication was clearly not making the slightest difference to her mental state. The appropriateness or otherwise of detention rested on risk to herself or others. While there was no risk to others by her behaviour (apart from irritation of the police), she was at risk by wandering about at night in search of phantoms, and even more importantly, was at risk of self neglect. It became clear on assessment that Ethel was not drinking enough fluids, and was not eating adequately. She was very thin and looked physically unwell. There was a stone cold cup of coffee on her coffee table which she claimed she had only just made. She told us she had had “a steak and kidney pie and chips – and a sandwich” that day. However, there was no evidence of cooking in her kitchen, which was spotlessly clean, and there was no food waste or wrappers in her bin. There was hardly anything in her fridge except for half a dozen eggs whose use by date had passed over 6 months previously. There were few tins in her cupboard, and most of these had use by dates several years in the past. Nevertheless, she continued to maintain that she was eating heartily.

In the circumstances, we concluded that she did indeed need to be admitted to hospital for treatment, and this time we decided to go for a Sec.3. “I wouldn’t have told you about that man, and the little girl with the rat, if I’d known you would do that,” she said when I told her.

She complained of chest pains on the way to hospital. I began to panic inside – it doesn’t look good if your patient dies before you get them to hospital – but her nurse examined her and reassured her that it was indigestion.

“But I haven’t had anything to eat today,” she said.

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