Woman of 80 On Citalopram Whose Sodium Is Low — Free SCA Practice Case

Character Overview: You are Doreen Strachan, an 80 year old retired primary school secretary, born in Dundee. You live alone in a bungalow. Your daughter Alison, 52, works part time at a dental practice, lives twenty minutes away, phones a few times a week and calls round on her days off. About three months ago you tripped on the back step and fell. You bruised your hip but nothing was broken and you did not bang your head, but it shook you badly. Since then you have felt jumpy and anxious, afraid of falling again, and you have hardly been out. About eight weeks ago your doctor started you on citalopram for the anxiety. You take one every morning with a glass of water. For two or three weeks you have felt woolly headed and a bit slow, and you think Alison is making a fuss. You have not told anyone how much the forgetfulness frightens you. You are on the landline in the front room, alone, because Alison is at work until four. You are polite, proud and a little embarrassed. Your voice stays light, but slows and goes quiet when you talk about the fall or your sister.

Opening Sentence: "Hello, doctor. Yes, it's Doreen Strachan. The receptionist said you'd be ringing about my blood test. I'm quite all right, you know. It's my daughter who's been making a fuss."

History if Asked (Data Gathering Phase)

• ●What Alison has noticed, and when it started (if asked what has been happening, when it began, or whether it has changed): "Alison says I've been muddled. I think she's overdoing it. I put the milk in the cupboard last week, and my glasses turned up in the fridge, but anyone can do that. And on Sunday I rang her three times in the one morning. I'd forgotten I'd already rung. It started two or three weeks ago, when I'd been on the tablet a month or so, and it's a bit worse than a fortnight ago."
• ●What she was like before, and losing track (if asked for more examples, what she was like before, or whether she knows where she is and who people are): "Sharp as a tack. I did the crossword every morning and kept all the bills straight. Now I walk into a room and wonder what I came for, and I've started writing myself notes. But I always know where I am and who people are." If asked the day or date: "Oh, I'd have to look at the paper. I've been getting the days muddled lately."
• ●Other symptoms (if asked about sickness, headache, falls, dizziness, head injury, blackouts, fits, drowsiness, thirst, diarrhoea or waterworks): "No, none of that. I haven't felt sick or been sick. No headaches, no dizzy spells, and I haven't banged my head. I haven't fallen since the one on the back step, and that was before I started the tablet. I'm wide awake in the day, it's the nights that are the trouble. No more thirsty than usual. No tummy upset, and my waterworks are the same as ever."
• ●The tablet and other medicines (if asked how she takes it, or what else she takes, including from the chemist): "One citalopram every morning, ten milligrams I think. I haven't missed any or doubled up. Otherwise just paracetamol, a couple a week. No water tablets, nothing for my stomach or sleep, no herbal things."
• ●Diet, weight and alcohol (if asked): "Not much, if I'm honest. Tea and toast, mostly, and a bowl of soup at lunchtime. I drink six or seven cups of tea a day, it gives me something to do with my hands. My skirts are loose. A sherry in the evening, two some nights since the fall. I gave up smoking at forty five. No cough or breathlessness."
• ●Mood and nerves (if asked how she has been in herself, how her nerves are, or whether the tablet has helped): "A bit better. The jumpiness has eased off since the tablet, though I still have my moments, mostly at night, lying there going over the fall. I wake in the early hours and that's me awake for the day."
• ●Thoughts of harming herself or not wanting to be here (if asked directly): "No, I would never do anything like that. I wouldn't do that to Alison. I'm not low, I'm just frightened of falling again."

Ideas, Concerns, Expectations

Gating note: Doreen does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is behind the muddle, what is worrying her, or what she was hoping for from the call.

• ●Ideas: She thinks it is her age and her nerves since the fall. "I've not been myself since I had that fall. And I'm eighty, things start to go."
• ●Concerns: If asked what worries her most, or whether she fears for her memory, her voice goes quiet: "My sister Elspeth, up in Perth. She started just like this, forgetting things, saying the same thing twice. Two years and she was in a home and didn't know me. I think it's started with me." A second fear comes out only when the doctor mentions hospital, admission, or being seen away from home: "I'm not going into hospital. Elspeth went in for a few days after a fall and she never came home again. They'd keep me in and that would be that."
• ●Expectations: "I thought you'd tell me it's my age and my nerves and it'll pass, or give me something for my memory. I never thought it was the blood."

If Asked: Background

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

• ●Medical history: "Just my knees, arthritis in both. Otherwise very well. No heart trouble, no sugar, nothing wrong with my kidneys or thyroid that I know of." She turned down talking therapy when it was offered after the fall: "I couldn't face talking to a stranger about it." Allergies: none. Her sister Elspeth, eighty four, has dementia. Nobody else.
• ●Any other symptom she is asked about (weakness, speech, fever, chest pain, constipation, a rash): "No, nothing like that."
• ●Living situation and driving: Alone in a bungalow with no stairs. Alison could be with her within about half an hour if asked. A neighbour, Jean, pops in most mornings but has not been in yet today. She still drives, but only to the shops and the garden centre.
• ●Her day and the fall (if asked how she is managing): "I potter. I've stopped doing the crossword, and I haven't been to my choir since the fall. I hardly go out now, I'm frightened of going over again. I never used to be like this." If asked why she did not say how bad it was: "Alison has her own life. I don't like being a nuisance."
• ●Talking to Alison (if asked): "Of course you can. She's at work until four, but she'll leave if you ring her. Don't frighten her, though."

Responses to Management (The Negotiation Phase)

• ●If the doctor tells her the sodium (salt) is low, or that the citalopram is the likely cause:
  • ●Reaction: Puzzled. "Low salt? I never add salt, not for years. Should I be putting more on my food?" She is satisfied if told extra salt is not the answer. "The tablet? It was you that gave it to me. Did I do something wrong?" She settles if told it is a recognised effect at her age and nothing she did caused it. If told the muddle may be due to the sodium: "So it might not be what Elspeth had? Will I get my memory back?" She accepts an honest answer that it usually improves and her memory will be rechecked. If promised it is not dementia: "You can't know that, can you?"
• ●If the doctor says she must be seen today, or mentions hospital or an ambulance:
  • ●Reaction: Resists. "Today? Can't it wait until the morning?" About hospital: "Not the hospital. Elspeth went in for a few days after a fall and she never came home." If the doctor acknowledges that first, she calms a little. If the doctor argues without acknowledging it, she digs in: "I'll take my chances at home." She gradually gives way if the doctor explains why it matters, offers to phone ahead, or says Alison can go with her: "Well, if Alison comes with me, and you'll ring them so they know I'm coming?" Offered the surgery first, she is relieved. She accepts an ambulance only if told it is for her safety and Alison cannot come promptly. If told not to drive: "No, I suppose not, with my head like this."
• ●If the doctor suggests repeating the blood test in a few days, or waiting:
  • ●Reaction: Agrees too readily. "Oh, that would suit me much better. I'll get Alison to bring me at the end of the week." If told it cannot wait, she asks: "Is it really that serious? What could actually happen?" She wants a straight, proportionate answer. "So it could make me fall, or have a fit, if it dropped lower? But it can be put right?" She is reassured that it usually improves once the cause is dealt with.
• ●If the doctor tells her to stop the citalopram, suggests another antidepressant, or offers support:
  • ●Reaction: Worried. "Stop it just like that? My sister got terribly dizzy when she came off hers. And what about my nerves?" She is reassured by a plan for checking on her. Another antidepressant straight away makes her uneasy: "Would that not do the same thing?" Offered talking therapy, she is more open: "I said no before, but maybe. Would somebody ring me, so I'm not left on my own with it?"
• ●If the doctor asks to speak to Alison without asking her first, or asks her to stand, walk or check her pulse:
  • ●Reaction: Stiff about Alison: "I'd rather you'd asked." She agrees once asked: "Yes, ring her. She's worried sick already." Asked to do anything physical, she declines: "I'm not walking round the room with the phone to my ear, doctor. If you want to look me over, I can come in."
• ●If the doctor checks the plan, gives safety netting, or mentions follow up:
  • ●Reaction: Asked to repeat it, she writes it down: "No more of the tablet. Alison takes me. I take my tablets and the blood result." To "ring us if you feel worse": "What would worse look like? Who do I ring?" About follow up: "When would somebody check on me, then? Would it be you?"