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One of the great truths of life is that you cant do it all alone.You need help along the way.-Benjamin Carson Sr., M.D

A Helping HandFAMILY CASE PRESENTATIONEmille May Almeda, M.D.March 27, 2014

ObjectivesTo present a case of a patient who has caregiver strain

To analyze family dynamics and resources using the appropriate assessment tools

To describe the manner in which I handled the case

To formulate and discuss a wellness plan for the family

Objectives

Rationale for Choosing the CaseIncrease communication with other family members

Primary care to the patient and her family

Our PatientTess57 / FWidowRoman CatholicFrom Iligan CityCurrently residing in Pasig

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Chief ComplaintIntermittent nape pain and dizziness

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History of Present Illness6 months prior to initial consultIntermittent nape pain and dizziness

Episodes of elevated BP

No other associated symptoms

Increased symptom frequency8

Review of SystemsGeneral(-) fever (-) weight loss (-) weaknessHEENT(-) epistaxis (-) hoarseness (-) coldsRespiratory(-) cough (-) hemoptysisGastrointestinal(-) BM changes (-) abdominal painGenitourinary(-) dysuria (-) frequency (-) hematuriaMSK(-) joint pains (-) swellingNeurologic(-) loss of consciousness (-) seizurePsychiatric(-) insomnia (-) hallucinations (-) delusionsDermatologic(-) rashes (-) jaundice9

Past Medical HistoryNo known co-morbidities

No allergies

No previous hospitalizations / operations10

Personal-Social HistoryNon-smoker

Non-alcoholic beverage drinker

(-) Use of illicit drugs11

Family Medical HistoryHypertension mother

Diabetes mother

CVA paternal aunt

Schizophrenia brother 12

Physical ExaminationGeneralAwake, non-cooperative, not in cardiorespiratory distressVital SignsBP 150/90 (both arms) HR 82 RR 18 T 37 C Ht 155 cm Wt 54 kg BMI 22.5HEENTAnicteric sclerae, pink palpebral conjunctivae, (-) oral lesions, (-) tonsillopharygeal congestion(-) neck vein engorgementChest & LungsSymmetric chest expansion, clear breath sounds(-) adventitious breath soundsCVSAdynamic precordium, distinct heart sounds,Normal rate and rhythm, (-) heaves, thrills or murmurs13

Physical ExaminationAbdomenFlat, normoactive bowel sounds, (-) guarding (-) mass, (-) tenderness (-)organomegalyExtremitiesFull and equal pulses, pink nail beds(-) edema, (-) jaundice, (-) cyanosisCRT < 2 secondsMSK(-) range of motion deficits(-) joint swellingNeuroE4V5M6Cranial nerves intactFundoscopy: (+) ROR, clear media, (-) H/E(-) Sensorimotor deficits elicited14

Assessment

Hypertension Stage II

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Initial ManagementFBS, lipid profile, Crea, KUrinalysis12 L - ECGDiagnosticsTherapeuticsLosartan-Hydrochlorothiazide 50 mg- 12.5 mg tab OD16

1st FMC Follow-UpGood compliance with medications

Decrease in frequency of symptoms

No new subjective complaints

BP range: 100 150/ 70 90

Usual BP 120/80

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1st FMC Follow-UpLaboratoryLaboratory ResultsUrinalysisColoryellowSG1.025pH6.0SugarNegAlbNegRBC0-1WBC0-1Epith CellfewCast0Crystal0Serum ChemistriesFBS87.27Crea0.69Cholesterol197.13TG95.58HDL55.25LDL118.42K4.2ECGRegular Sinus RhythmNormal axis18

Conversations

Doktora, meron pa ba akong pwedeng gawin para laging normal ang BP ko?Ngayon lang kasi ako nagkaroon ng sakit.Iniisip ko na kapag mataas ang BP ko ay lumalala ang sakit ko.19

Conversations

Diet & Exercise Prescription

Family Support20

Conversations

Wala namang pwedeng tumulong sa akin.Kapag lumala ang sakit ko mag-isa lang ako.21

Santos Family Genogram (PGH -FMC, 11/4/13)

Conversations

Palagay ko nga lumubha ang karamdaman ko simula ng bumalik ako ng ManilaLagi kasi akong pagod o nag-aalalaMinsan nag-aabot sila ng pera pero hanggang doon na lang23

Family Timeline1956 - 1966FATHERMOTHERSailorHousewifeAuthoritativeDemocraticRarely at homeAlways with the familyROLANDOTESSYolandaEDNAELSA24

Death of father

Financial constraints

Tess quit school for work

Tess had less time spent to play with siblings1968ROLANDOTESSYolandaEDNAELSA25

TESS

Transfer to Manila for work

Stayed in aunts house

Sends money to Mindanao1977ROLANDOTESSYolandaEDNAELSA26

TESS

Quick Courtship

Marital Conflict

Spontaneous abortion

Breakdown of marriage 1979 - 1980

ROLANDOTESSYolandaEDNAELSA27

Tess focused on work

Yolanda, Rolando & Edna transferred to Manila to work

Edna stayed in Mindanao to take care of their mother

1980sROLANDOTESSYolandaEDNAELSA

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Yolanda & Edna found spouses & moved to different households1980sROLANDOTESSYolandaEDNAELSA

Rolando & partner stayed with Tess in their aunts house

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Rolando developed behavioral changes

Confined at the National Center for Mental Health Tess, Yolanda & Edna would visit during confinement

Diagnosed with paranoid schizophrenia

1986 - 1987ROLANDOTESSYolandaEDNAELSA30

Rolando married Irma & had a son Bernard

Tess, Irma & their aunt aided Rolando

Rolando was able to return to previous activities

1986 - 1991ROLANDOTESSYolandaEDNAELSA31

Their aunt suffered a stroke with subsequent residuals

Tess, Rolando & Irma took care of their aunt

Yolanda & Edna occasionally visits but are not active caregivers

1991 - 1992ROLANDOTESSYolandaEDNAELSA32

Their mother suffered from diabetic complications

Elsa called seeking caregiver assistance

Yolanda, Rolando & Edna had growing families & found it difficult to leave

Tess transferred back to Mindanao2004 - 2007ROLANDOTESSYolandaEDNAELSA33

Rolando had a good relationship with his wife Irma

Irma died from a vehicular accident

Rolando had increased behavioral changes after

Rolandos relationship with his son Bernard became increasingly strained2007 October 2013ROLANDOTESSYolandaEDNAELSA34

Rolando confined for the 2nd time at the National Center for Mental Health

Bernard & his family left & cannot be contacted

Yolanda & Edna visit Rolando but find it difficult to care for him & their families at the same time

Tess asked to return to care for RolandoOctober 2013ROLANDOTESSYolandaEDNAELSA35

Circular QuestionsWho-does-what-and-when?When someone gets sick in your family Who does he go to first?Previously: MotherCurrently: TessWho assists that person?Elsa (youngest sister)Who does he consult when he doesnt know what to do?ElsaWho decides when admission is necessary?Siblings spouses;Yolanda & EdnaWho will pay for this admission?Yolanda & EdnaWho will stay with this patient?Tess36

Subsequently

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Patient Health Questionnaire 2: Screening Instrument for DepressionOver the past two weeks, how often have you been bothered by any of the following problems?

TESSLittle interest or pleasure in doing thingsNot at allFeeling down, depressed, or hopelessNot at allAdapted from patient health questionnaire (PHQ) screeners. http://www.phqscreeners.com. Accessed September 6, 2011 Maurer, D.M. (2012). Screening for Depression. American Family Physician.85(2): 139 144.38

Caregiver StrainPhysical, personal, emotional and financial stress incurred by a caregiver as a result of, or in relation, to his/her caregiving role/s Panganiban-Corales, A.T. & Medina, M.F.(2011). Family Resources Study: part 1: family resources, family function and caregiver strain in childhood cancer. Asia Pacific Family Medicine 2011, 10:1439

More than 80% of caregivers of schizophrenics report moderate to high levels of subjective burden

Major reasons for caregiver strain- Financial burden- Disruption of routine family activities, leisure and interaction- Effect on physical & mental healthLasebikan, V.O. & Ayinde, O.O. (2013). Family Burden in Caregivers of Schizophrenia Patients: Prevalence and Socio-demographic Correlates. Indian Journal of Psychologic Medicine. Jan Mar 35 (1): 60 66.Caregivers of Schizophrenic Patients40

Significantly lower quality of life compared to regular caregivers

Increased risk for illness and depression, insomnia, anxiety and other psychiatric concerns

Their ability to cope with caregiver stress diminishes with age

Caregivers of Schizophrenic PatientsMargetic, B.A. et al. (2013). Quality of Life of Key Caregivers of Schizophrenia Patients and Association with Kinship. Central European Journal of Public Health. Dec 21(4): 220-3. Ampalam, P. et al. (2012). A Comparative Study of Caregiver Burden in Psychiatric Illness and chronic medical illness. Indian Journal of Psychiatry. July Sep 54(3): 239 243. 41

Modified Caregiver Strain Index

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Tendency for Caregiver StrainTess had taken over Rolandos care

Re-opened their sari-sari store

Rolandos independence on ADLs

Amiable with Rolando

Family understands & accepts Rolandos condition

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Tendency for Caregiver StrainDifference in sleep-wake cycle

Difficulty leaving Rolando alone

Difficulty in accessing other available caregivers

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Conversations

Ako lang naman kasi ang single sa pamilya45

Conversations

Ako na lang ang laging nag-aalaga. Pero ngayong ako naman ang nagka-sakit, mag-isa lang ako.Kapag lumala ang sakit ko, sino ang mag-aalaga sa akin?

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Family MapELSAYolandaRolandoEDNATESSBernard47

Repetitive patterns of behavior when a family member is illThe most immediately available family member/s would provide initial care

Tess is contacted to either be a co-caregiver or the actual primary caregiver

Tess accepts the role, does the job well and does not demand much assistance from others

The other family members become more laid back in their responsibilities & complacent of Tesss abilities48

SCREEM49

EdnaHousewife from Taguig

Primed by Tess regarding nature of PGH consult

Understands & accepts Rolandos condition

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Initial AGPAR Score

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Key PointsWhile Tess finds a problem with the current family situation, Edna (and possibly other members of the family) do not share the same insight

Tess has difficulty assigning tasks to other people

Their family has always managed to be strong and united despite various adversities

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Intentional Family CounselingFinancial assistance

Can talk to her sister over the phone readily

mabait at madaling kausapin

TessEdna54

Intentional Family CounselingGood sister

Lagi siyang handang tumulong. Hindi lang sa amin kundi pati sa ibang tao ay matulungin siyaTessEdna

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Intentional Family CounselingBetter communication

Family to be more expressive of their feelingsTessEdna

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Intentional Family CounselingPhysical assistance in taking care of their brother

TessEdna

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CompromiseEdna will try harder to take care of Rolando during the weekends

Both will persuade Yolanda to also be more active

Tess to be more open and communicative58

Hindi ka dapat mag-alala tungkol diyan. Magkapatid tayo. Syempre hindi ka naman namin kayang iwanan.

Pasensya na. Masyado lang ata ako nag-aalala

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After InterventionTESS

More relaxed

No new subjective complaints. BP levels within normal range

Tess & Rolando have adjusted to each others sleep-wake cycle60

After Intervention

ROLANDO

Rolando is independent on ADLs and compliant with medications & psychiatric follow-up

Manages to take care of their sari-sari store for a longer period of time

* Not their actual store61

After Intervention

EDNA

Takes over Rolandos care every Saturday or Sunday about 1-2 weeks apartEdna was able to speak to Rolandos son Bernard but there is still uncertainty if the latter will come back62

AGPAR After Intervention

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Modified Caregiver Strain After Intervention

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Wellness GoalCurrent SituationAction PlanEnsure that family members can cope with new responsibilitiesTess is still the main caregiverEdna and her family take over every 1-2 weekends

Yolanda still does not visit

Rolando takes care of himself & stands in at their storeSiblings are still unable to contact Rolandos son BernardTess to designate tasks to her siblings more effectivelyExpress appreciation to Edna for her efforts and encourage her further Persuade Yolanda to be a more active caregiverEncourage Rolando to take on more responsibilities (ex: household chores)Continue persuading Bernard and his family to returnWELLNESS PLAN65

Wellness GoalCurrent SituationAction PlanIndividual wellness plan for each family memberRolando prefers to do follow-ups with a familiar psychiatrist

Tess has BP measurements done every 2-3 days

Other siblings have no known medical illness Search availability of other caregiversEncourage Rolando to continue regular check-ups but also persuade him to visit PGH Tess still on continuity service. Encourage regular check-up at LHCPeriodic health exam for all family membersSearch for available support groups within the community, local hospitals &/or PGHWELLNESS PLAN66

Wellness GoalCurrent SituationAction PlanNurture better communication between family membersRolando and Tess regularly communicate at home Better communication with Tess and Edna

Tess speaks to her sisters over the phone when neededContinue open communication among family membersEncourage family events (going to church, eating out)Persuade Yolanda & Rolando to join Tess & Edna on follow-up at PGHWELLNESS PLAN67

INSIGHTS

Caring for family members with SchizophreniaTaking care of the personal needs of the caregiver first

Encourage and support treatment of the patient

Monitor medication

Watch for signs of relapse

Preparation for crisis situations

Ensure a stable, supportive place to liveSmith, M. & Segal, J. (2014). Helping a Person with Schizophrenia: Overcoming Challenges While Taking Care of Yourself. www.helpguide.org 69

INSIGHTS

Thank you very muchand Good Morning!