Case Studies

Case 11: Change in behaviour

Lesley, 45 years, lives with her elderly mother Mavis who is 78 years old. Lesley has Down's syndrome and attends a day service 3 days per week. Lesley is mobile but needs help with washing and cleaning her teeth. She is overweight and does not participate in regular exercise, despite being encouraged by her mother and her key worker. She is active and has a good social life during the daytime. As Lesley does not go out many evenings, Mavis stays at home to support Lesley. Mavis volunteers as a charity shop worker four times per week.

Lesley has a boyfriend who she spends time with at the day service, and occasionally goes to the cinema with him on Saturday afternoons. David lives in a residential home, and this is the only contact they have. Both Lesley and David seem happy with the arrangement, and it has been ongoing for the past 10 years. Recently, David has complained to staff in his residential home that Lesley has become 'angry' and that once or twice while they have been at the cinema, Lesley has hit him.

When this is reported to the day services staff, they too have noted that Lesley has 'changed' and has become a little more irritable. However, Lesley's key worker has noted that she believes Lesley may be pre-menopausal and that it's a normal process.

In the past few months, Mavis has become concerned about Lesley's apparent deterioration in self-help skills, and reports that Lesley is becoming agitated and forgetful. Mavis has also reported that Lesley has slapped her a few times when she 'couldn't have her own way'. In the past 2 weeks, Mavis has told Lesley's key worker that Lesley has not only become verbally aggressive, but has also kicked Mavis in the stomach, and yesterday threw a saucepan at her, hitting her on the head and causing a cut to her scalp. Mavis feels that she is now finding it too difficult to care for Lesley, and wants help. The general practitioner (GP) has suggested that Mavis contact the duty team, as she is concerned about Mavis's safety if Lesley remains at home with her.

• 1. What health factors could be at play in this scenario?

  Show Answer

  Correct answer: If you suspect it may be due to hormonal changes, there are steps you can put in place as the learning disability (LD) nurse to support Lesley:

  • Arrange a GP visit to check hormone levels and other symptoms which Lesley may have.
  • Check Lesley's thyroid levels.
  • Ensure an annual health check is carried out as part of the GP visit.

  Other health checks you may want to consider:

  • Ask the GP to carry out a mini-mental state examination as part of the screening process for early onset dementia.

• 2. What other factors do you need to take into account as the LD nurse?

  Show Answer

  Correct answer: You need to consider whether it's appropriate to convene a multi-disciplinary team meeting (MDT) to consider the risks being posed by Lesley's current behaviour.

  • Risk to Lesley's mother, Mavis. For example, involve a social worker to support Mavis in carrying out a carer's assessment.
  • Safeguarding measures that can be put in place to support Mavis and Lesley.
  • Involve David's key worker, as he is also potentially at risk.
  • Support for Lesley as a 'vulnerable adult'.
  • Check Lesley has a current 'person-centred plan' in place that is meeting her needs.
  • Review the current support package: Is the day service meeting Lesley's needs?
  • Transition plan: for example, what will happen to Lesley as Mavis becomes older and less able to cope?
  • How will this change be supported in the best interests of Lesley?

  The only certainty is that the current situation needs to be addressed before it deteriorates further.