Practice Dilemma - Disinhibited patient

The Dilemma - The district nurses approach you to discuss an elderly man who they have been treating for a chronic leg ulcer. The patient has also been diagnosed with an alcohol addiction. The nurses have been visiting him at home and he has started to open the door to them only half dressed and he has become somewhat disinhibited altogether. What should you do?

The GP should arrange a home visit to assess the patient (Photograph: SPL)
The GP should arrange a home visit to assess the patient (Photograph: SPL)

A GP's view
Dr Chris Hall is a GP in County Down, Northern Ireland

This is not an uncommon set of circumstances. I would be interested to find out whether the patient has a history of contact with the local elderly care services and if there is a package of care in place for him. Has he had any recent significant life events, such as the death of his wife, or a move into an unfamiliar environment?

Before all that is considered, I would rule out something more medically acute, such as a toxic confusional state, hepatic encephalopathy or even a brain tumour. If the nurses feel that he is consensual to blood sampling, then it would be useful to get some urgent baseline investigations. If these are unremarkable, could medication be causing his confusion?

It would be wise to liaise with the district nurses in co-ordinating a joint visit. Another possibility, and one which would certainly warrant referral to the elderly psychiatry services, is that he may be developing a psychotic illness.

If the patient denies us entry to his house, and given the risk he poses to himself, urgent contact with social services and the police is required. In any case, hospital admission seems likely in the circumstances.

A medico-legal opinion
Dr Jim Rodger is head of professional services with the UK-wide medical defence organisation MDDUS

The district nurses have alerted the GP to an elderly patient about whom they have concerns. The doctor must act on these concerns and is obliged to arrange to visit this patient.

The GP may first telephone the patient and say they have been asked to call and see him because the district nurses have asked them to review the patient's present condition. The leg ulcer is a pretext but the doctor should say the nurses have had concerns about his ability to care for himself.

The patient may decline the visit but the doctor is still obliged to make the visit. The GP may be refused entry to the house. The GP should then make a judgment as to whether the patient's health or the health of others is at risk. There are measures that can be taken, after discussion with the appropriate public health authorities, to admit the patient to hospital without his consent.

The GP may gain access and if there is, based on clinical judgment, a physical problem, admission to hospital, with or without patient consent, may be necessary.

If the GP thinks the patient has a mental health condition, they can arrange admission, either voluntarily or by compulsion using the Mental Health Act and the co-operation of the local mental health officer.

A patient's response
Antony Chuter is an expert patient

Nobody should ever feel threatened in their workplace, nor should they have to deal with inappropriate behaviour. The age of this patient is immaterial; he is a housebound patient with a substance misuse problem.

The GP should consider whether the behaviour is related to a medical condition, medication, injury or deterioration of his mental capacity. On one hand the practice could give a warning and then remove this patient from their list but this would not take into account the vulnerability of this patient or any medical condition or injury which could be causing this change.

One option is for the GP to carry out a home visit with the nurse to check the patient's physical and mental health. If the patient is not unwell, the GP needs to make it clear that the patient's behaviour is not appropriate.

There is also the underlying problem of his substance misuse; treating this could help in many ways and his behaviour may be linked to this problem.

Being alone, housebound, unhappy, isolated and perhaps with a knowledge that things will not improve could be problematic for this patient. He needs support and a proper diagnosis.

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