Memory Problems Keeps Running Out of Tablets Early — Free SCA Practice Case

Character Overview: You are Rhodri Ellacott, 52, calling about your father Aubrey, who is 81 and lives alone in his own bungalow, two hours' drive from you. You work in IT support for a council, you work from home on Thursdays, and you have a partner, Nia, and two teenage children. Your mother Valerie died two years ago. She used to fill a weekly tablet box for your father, and since then he has managed his own tablets from the boxes the pharmacy sends. This morning he rang to say the chemist had "short changed" him and his tablets had run out. You asked the neighbour to check, and she found all four boxes empty, although they were collected fourteen days ago. Your father has mild memory problems. You are anxious, practical and quietly guilty that you live so far away. You speak quickly and apologise a lot. You are polite and cooperative, and you want a clear plan.

Opening Sentence: "Hello, doctor, it's Rhodri Ellacott. I'm ringing about my dad, Aubrey. He's 81 and his memory's not good, and his month's supply of tablets has gone in two weeks. He's said it's fine for me to talk to you, it's on his record."

History if Asked (Data Gathering Phase)

• ●What has gone missing: "Four boxes, the blood pressure one, the two for his diabetes and the cholesterol one. They were collected two weeks ago, they're all empty, and the labels say twenty eight days. Mrs Okeke next door found them in the kitchen. She also found about six odd tablets in a mug by the kettle and a couple in his cardigan pocket. I've no idea which ones they are."
• ●The pharmacy: "I rang them. They say it was the right amount, the same as always. It's not their mistake."
• ●How he takes them: "Mum did a weekly box every Sunday. After she died he just took them out of the boxes himself. I ring most evenings and ask if he's had them and he always says yes. The other week he said 'better twice than not at all'. I think when he can't remember whether he's taken them, he takes them again."
• ●Whether he has been unwell: "He says he's fine. He sounded normal on the phone this morning and told me he'd had his tablets and some toast."
• ●Why you are ringing now: "He has none left, and I'm worried about what he's already taken."
• ●Today: "I can't get there until the weekend. Mrs Okeke popped in a few minutes ago and says he's up, dressed and chatting as normal."
• ●Eating and drinking: "It's mostly toast, tinned soup and ready meals. The fridge has out of date things in it. His trousers have got loose. He has a small whisky every evening, he always has. He drinks a lot of tea."
• ●Diabetes checks at home: "He's never had a machine to test his sugar. I wouldn't know how."

Ideas, Concerns, Expectations

Gating note: Rhodri does not raise any of the following himself. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for.

• ●Ideas: He thinks his father keeps taking tablets again because he forgets he has already taken them, and that the pharmacy is not at fault. "He just doesn't remember, and he'd rather take too many than miss any."
• ●Concerns: He fears the tablets could have harmed his father already. He looked online and read that diabetes tablets can send you into a coma. He is also afraid his father can no longer cope alone, and he feels guilty about the distance. "I keep thinking, what if he's collapsed in the house. I should be nearer."
• ●Expectations: He hopes the doctor can tell him whether his father is all right, have the pharmacy send the tablets in a dosette box, and arrange for the next month's supply today. "Could you ask the chemist to put them in one of those boxes with the days on, and send them out?"

If Asked: Medical History and Medications

Gating note: Rhodri answers each of these plainly when the doctor asks about it.

• ●Health problems: "Diabetes for years, blood pressure, and the memory diagnosis four months ago. They said it's mild and early. He didn't want a memory tablet, he said he takes enough."
• ●Medicines: "Losartan, metformin twice a day, gliclazide in the morning and atorvastatin at night. No herbal things, and he buys nothing from the chemist."
• ●Allergies: "None that I know of."
• ●Hospital admissions: "None."
• ●Kidneys: "They said something about his kidneys being a bit tired at the last check, but nothing to worry about."
• ●Driving: "He gave up the car after the diagnosis. His choice, I was proud of him."

Social History and Lifestyle Impact

• ●Home: Aubrey lives alone in a bungalow with a steep step at the back. Valerie died two years ago and he is lonely. Mrs Okeke next door pops in most days. He refuses carers: "He said he doesn't want strangers in his house."
• ●Rhodri: Works full time, drives over at weekends, and rings his father most evenings. He has a sister, Corinne, in Canada who is not involved.
• ●Daily function: Washes and dresses himself, heats microwave meals, forgets appointments, repeats himself and loses track of the day. Rhodri sorts his bills. There is no lasting power of attorney.
• ●Mood and safety: Quieter and lonelier since Valerie died. He has never said anything about not wanting to carry on. If asked about the tablets being taken on purpose: "No, absolutely not. He told me he wants to get them right so he stays well."
• ●Pharmacy: The village pharmacy sends boxes. Aubrey asked for boxes because he found the packs with days on them fiddly.
• ●Availability: Rhodri has his phone by him all day and can ring his father and Mrs Okeke straight away. His father can get to the surgery if the neighbour drives him.

If Asked: Associated Symptoms

Gating note: Rhodri answers these only when asked. Every one is negative unless stated.

• ●If asked about shakiness, sweating, hunger, confusion or turns: "He told me about a funny turn in the kitchen last week. He'd gone all shaky and sweaty. He had a sweet tea and a biscuit and it passed in about half an hour. I thought it was just old age."
• ●If asked about falls or dizziness: "He grabbed the worktop and bruised his hip last week. He didn't bang his head. He says he gets light headed when he stands up."
• ●If asked about drowsiness or being harder to wake: "No, he's been his normal self."
• ●If asked about vomiting, diarrhoea or tummy pain: "No, none."
• ●If asked about passing less urine or drinking little: "I don't think so. He drinks lots of tea."
• ●If asked about breathing, chest pain or palpitations: "No."
• ●If asked about fits or collapse: "No."
• ●If asked about muscle pain, bruising or bleeding: "Nothing like that."

Responses to Management (The Negotiation Phase)

• ●If the doctor says his father needs to be assessed today:
  • ●Reaction: Relieved but worried about logistics. "I'm two hours away. Would someone go to him, or could Mrs Okeke bring him in? He hates fuss." He agrees to ring his father and to ask Mrs Okeke. If the doctor wants to speak to his father: "He can be cagey on the phone, but he'll talk to you."
• ●If the doctor explains what extra doses might do:
  • ●Reaction: Frightened, then steadier. "Is the diabetes tablet the dangerous one? Could he have a low sugar and not know?" If given a clear, honest answer about what is and is not likely: "Right, so it could be nothing, but we can't assume that." He asks what signs to look for.
• ●If the doctor discusses the next tablets:
  • ●Reaction: Practical. "He's got none, so what does he take tonight? Can't you just send the next month today?" If told some tablets may be held back or supplied in small amounts until he has been checked: "Will he be all right without his blood pressure tablet for a day or two?" Accepts a clear answer.
• ●If the doctor suggests a dosette box or other ways to make tablets safer:
  • ●Reaction: Hopeful, then doubtful. "I thought a dosette would sort it." If told a box alone will not stop him taking it twice: "So what would? Who would do it? He won't have carers in." He accepts a short daily visit to prompt him if it is framed as help, and asks whether the pharmacy could deliver weekly.
• ●If the doctor raises capacity, power of attorney or living alone:
  • ●Reaction: Defensive, then relieved. "Are you saying he can't stay in his own home? I don't want him in a home." If told the aim is to keep him safe at home: "Does he sign a power of attorney while he can still understand it? Can we do that together?" He asks, quietly, whether the memory will get worse.
• ●If the doctor gives safety netting or follow up:
  • ●Reaction: Wants specifics. If it is vague, such as "ring us if he gets worse": "Worse how? What would make it an ambulance?" He repeats back clearly the signs and who to phone, and asks when someone will ring him back.