HoNOS65+ case study written vignette - Mrs Chan

Mrs Chan is a 74-year-old widow who lives alone in a two-bedroom unit in Central Auckland. She grew up in Hong Kong and immigrated to New Zealand when she was twelve. She speaks fluent English. She was trained as a nurse but has not worked since she was married at the age of 26. She has five grown up children who live in Auckland and Wellington. Her husband died of a stroke five years ago.

She was diagnosed with bipolar disorder in her mid-30s. She has been on lithium for over twenty years. Her manic episodes were usually triggered by non-adherence to her medication, but she has been compliant with her medication in the past few years. She was last unwell with a depressive episode around the time of her husbands’ death. Her last manic episode was over ten years ago, and she was admitted to a psychiatric unit under the Mental Health Act. Mrs Chan does not smoke or drink alcohol.

She was diagnosed with Parkinson’s disease eight years ago and she currently takes anti-parkinsonism medication. She mobilises with a low walking frame. She receives the New Zealand superannuation, and her unit is mortgage free. She manages her own finances and has no financial concerns. She usually cooks for herself and has home help twice a week for housework and shopping. Her family thinks the frequency of the home support could be increased because, despite the installation of bathroom rails and an easy access shower, Mrs Chan has had a number of falls in the past month. Her last fall was twelve days ago when she was climbing out of the bath, and she sustained a small graze on her left shin. Prior to the falls she would walk to the local shops for the newspaper each morning, but she now feels unsafe (even with her walking frame) and has therefore become more house-bound in recent weeks. Apart from home help, she has no regular visitors however the home support worker reported that she regularly helps her skype her adult children and grandchildren. She can no longer continue with her hobbies such as sewing because of her increasing hand tremors.

One of her daughters, Elizabeth, brought her into the emergency department one week ago. She presented with a three-day history of acute confusion, nausea and vomiting. She was disorientated to time and couldn’t recognise her usual home help worker or her daughter. Her home help reported that she had been getting more forgetful about everyday events over the past few weeks and had strongly denied that some events had occurred for example taking pills, eating meals and skyping grandchildren. Mrs Chan was also seeing ‘little people’ playing in her living room and had become increasingly agitated as they did not go away when she attacked them with a broom. She was very frightened and said that over the past 10 days she has not been able to get to sleep for fear of the little people.

On admission to the hospital, she was found to have a urinary tract infection. She was prescribed an antibiotic medication. Her lithium level was checked, and it was 1.5 mmol/L (therapeutic range = 0.5 to 1.0 mmol/L). The medical team stopped the lithium and referred her to the liaison psychiatry team for further assessment.

The liaison psychiatry team finds her to be very low in mood. She is currently talking about the world coming to an end and she is fixed with the belief that she committed a serious crime twenty years ago. She now believes she should be punished by stabbing herself with a sharp kitchen knife, although she denies ever having thoughts of taking her life. Her mobility has deteriorated further because she refuses to take her anti-parkinsonism medication, thinking they are poison. She cannot get out of bed independently. Two nurses are now required to assist her for showers and other activities of daily living. She is incontinent of both urine and faeces.