Abstract
You are working in a community learning disabilities team and have been asked to speak to Mr Chris Harlow, the carer of Mr George Elliott, a 32-year-old man who has a diagnosis of moderate learning disability. Staff at the care home have been concerned about recent changes in Mr Elliott’s behaviour.
Practice Stations
Station 7.1: Recent Change in Behaviour
Station 7.2: Capacity Assessment
Station 7.3: Down’s Syndrome
Station 7.4: Explanation for Patient with Learning Disability
Station 7.1 (90 Seconds)
Candidate Instructions
You are working in a community learning disabilities team and have been asked to speak to Mr Chris Harlow, the carer of Mr George Elliott, a 32-year-old man who has a diagnosis of moderate learning disability. Staff at the care home have been concerned about recent changes in Mr Elliott’s behaviour.
Please elicit a collateral history from Mr Harlow and address any concerns he might have.
Actor Instructions
You are Mr Chris Harlow, a support worker at the care home that Mr George Elliott resides in. George is a 32-year-old man with moderate learning disability and has lived at the care home for around five years. You have been George’s key worker for the past two years. You are eager to speak to the doctor about George’s presentation.
You have noticed that in the last six weeks, George has become more withdrawn, less happy, and less verbally communicative. He has been isolating himself in his bedroom, rather than spending time in the communal areas of the care home as he used to. He has even stopped coming to the dining room for meals, causing some concerning weight loss. He has also stopped going to the day centre that he used to enjoy attending twice a week. You and your colleagues have noticed he is not sleeping as well at night, and is often found crying in the middle of the night.
If asked, he doesn’t seem to really enjoy anything at all at present.
If asked, he has not been observed to be responding to voices or visual hallucinations or presented with any other bizarre behaviour.
There has also been one episode of aggression, where George hit out at a staff member when prompted to come out of his room. George was very distressed, and two staff members were needed to de-escalate his behaviour. You are concerned that another episode like this could occur unpredictably and about George’s risk of injury to staff. He has also been observed to bang his head on the wall on a number of occasions, albeit sustaining no injuries as a result. He does not do anything else that might hurt himself, and he has never expressed suicidal thoughts. He does not have a history of suicide attempts.
If asked, you have not noticed any suspicious bruises on George’s body, and you are unaware of any reports of abuse at the care home.
You are baffled by this change, as George has always been a happy, cheerful man. He is well liked and interacts well with staff and other residents.
You understand George to have an IQ of 41. He is able to verbally communicate with very basic skills in English. He can carry out basic self-care tasks with support from staff. You think his learning disability may have a genetic cause, but you do not know more specific details. He does not have an established diagnosis of attention deficit hyperactivity disorder. Although not formally diagnosed with autism spectrum disorder, he exhibits autistic traits in line with his moderate level of learning disability. He does not have a history of seizures.
If asked about physical health, you know that George was reviewed two days ago by the local GP, who found he was severely constipated and has prescribed him laxatives. He has yet to pass faeces. No other health problems were identified. You do not think there are any problems with his memory recently.
If asked about visitors or relatives, you have noticed that George’s mother has been visiting the care home less often recently due to increased work commitments – from once a week to once a month. There has been no other change in the environment of the care home that you think could have triggered this.
Feedback Domains
Knowledge
The candidate at first facilitates the staff member to provide a relatively detailed narrative history of the change in behaviour and their own concerns, prompted appropriately by the candidate on occasion – particularly to seek additional either tangentially related or substantially missing information.
Specifically, the candidate ensures that the history includes information relevant to identifying any underlying causes, any plausible differential diagnoses, and any risks or concerns, such as the following:
Biological – Are there any new changes in physical health, as well as any established or undiagnosed conditions that might explain symptoms (see Physical Health domain below)? Are there any symptoms of mental illness, especially those that are often comorbid in people with a learning disability? These include not only depression (present in this scenario: sleep and appetite disturbance, anhedonia, tearfulness), but also anxiety, psychosis, mania, ADHD, ASD, and dementia.
Psychological – Has the patient expressed any new beliefs about themselves or the world around them that might be distressing, or spoken about a traumatic memory they might be recalling or processing?
Social – Particularly key are changes in relationships or visitors, any potential signs of current abuse, and any other material changes in living circumstances. Could the patient be worried about debt or someone’s health? Have they fallen out with a friend? Are they being exploited in any way?
Risk Assessment
The candidate performs a thorough risk assessment, in particular paying attention to the following:
Risk to self – Self-neglect is a particular concern. To the extent that they are responsible for aspects of their own care, are they still maintaining this? Are they eating well? Self-harm can be more common due to frustration with difficulties in communicating or sometimes understanding unmet needs. Head banging is a more common mode of self-harm than in the general population. The candidate must ask about suicidal thoughts and attempts.
Risk to others – Is there aggression toward staff? Is the setting still safe to manage any risks? What interventions have been tried?
Risk from others – The candidate absolutely must ask about the possibility of physical or sexual abuse, especially if there are any new suggestive signs (not the case in this scenario) such as direct reports, bruising, incontinence, or challenging behaviours limited to one staff member or situation.
Physical Health
The candidate considers and enquires directly about any possible organic causes such as constipation, infection, or changes in medication (if the patient had epilepsy, the candidate might ask whether aggressive episodes had occurred with features of consciousness-impairing epileptic activity).
In this scenario, the patient is severely constipated and potentially runs the risk of impaction and bowel obstruction. Although this is unrelated to the depressive presentation, it must not be missed (untreated bowel obstruction can be fatal), and it would be reasonable to suggest suppositories.
Author’s Note
It is so important in the CASC and in clinical practice to avoid complacently accepting a single plausible explanation for a presentation or attributing all symptoms to a single cause. Patients with a learning disability may struggle to communicate their needs and are especially vulnerable to this sort of ‘diagnostic overshadowing’, where a clinician misattributes a particular behaviour or symptom to learning disability, prematurely stops investigating, and misses something crucial.
Station 7.2 (90 Seconds)
Candidate Instructions
You are working in a liaison psychiatry team and have been asked to speak to Mr Matthew Pearson, a 35-year-old man who has been admitted to a surgical ward with a right-sided neck of femur fracture. He has been advised by the orthopaedic surgeons that he needs to go to theatre urgently in order to fix the fracture, due to the risk of avascular necrosis and non-union. Mr Pearson has refused. The surgical team has requested your help in assessing Mr Pearson’s capacity to make this decision.
He has a diagnosis of mild learning disability (IQ 63) and is able to verbally communicate. His pain medication has been optimised today, and he has calmed down and consented for you to talk to him.
Please assess Mr Pearson’s capacity to make the decision to refuse surgery on his fractured femur, and explain the outcome of your assessment to him.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
