Colin is a 56-year-old man who presents with diabetes and reduced vision. He smokes 40 cigarettes a day, and has no desire to reduce this or cease smoking. He has poor self-care skills, has high blood pressure, for which he takes medication and a history of mental health problems (psychosis). Colin is also epileptic, experiencing a tonic-clonic seizure approximately once in every 2 months. He is unmotivated, does not want to participate in any daily activities and is reluctant to engage with either peers or carers. He is currently unkempt, not eating regularly and reports that he is seeing angels in his home.
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1. What is the full history of his mental health problems?
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Correct answer: A detailed history and observation of Colin's past episodes of psychosis and his current mental health status are essential, as well as ascertaining what medication he may be taking in order to support a stable state of health. When and how do his hallucinations occur, and what form do they take? How long has he been having them?
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2. What health care checks should be carried out to support Colin as a priority?
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Correct answer:
He has diabetes, is neglecting his self-care and does not eat regularly. It would be essential to test his blood sugar levels to ascertain how well controlled his diabetes is. There should also be a medication review to check what effect his anticonvulsant medication is having on his body, and also a check of his blood pressure to ensure that any anxiety related to his current mental health state was not causing a rise in his BP.
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3. What is his current level of vision and why is this relevant?
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Correct answer: It is important to know if his vision has changed and if so, if it is related to his diabetes or of another origin. It would be essential to gain a measure of his visual acuity, to see if his vision had changed, and could this be related to the deterioration in his self-care skills? Damage to the eyes from diabetes can lead to secondary glaucoma. Does he need further ophthalmic treatment? Has his vision deteriorated significantly and quickly? If so, it could be due to Charles Bonnet Syndrome, which is characterised by a swift reduction in vision. Common symptoms of acute glaucoma can include a halo effect in the vision - could this be the 'angels'?
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4. What would be the best way to take Colin's case forward?
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Correct answer:
It is essential to rule out physical health causes before a specific mental health diagnosis is made. Whether his current difficulties are caused by a physical health or mental health problem, it is affecting not only his health but also his social care, as his ability to self-care has deteriorated, which in itself will create further physical health problems. He is unable to access community facilities and therefore he cannot purchase food, or access any external support independently, increasing his risk of anxiety and depression. In this particular case, the gentleman has been neglecting his diet; his Diabetes has been poorly controlled, hence his vision has deteriorated, particularly quickly, and this has resulted in visual hallucinations which are of a physical cause rather than deterioration in his mental health.
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5. What support would you put in place for Colin?
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Correct answer:
Immediate ophthalmic support should be sought for Colin to assess the damage to his eyes and ensure that correct diagnosis is made and necessary treatment prescribed. Visual hallucinations of this nature are often reduced by recognising that they are not caused by mental ill health and reassurance. Distraction from the hallucinations will also help. He will need an increase in his care support to help him through this episode, to maximise the use of his residual vision, to relearn some of his self-care skills and would benefit from a low-vision assessment. An increase in his care package would also support him to organise his meals, in order to regulate his blood sugar and gain better control over his diabetes. Monitoring of his other health conditions should be carried out by the general practitioner.
