Faculty Bibliography

Case: Ms. A is a 77 year old woman with multiple uncontrolled psychi-atric co-morbidities, including complicated grief, hoarding, and major depressive disorder, as well as a recent diagnosis of mild to moderate Alzheimer's dementia. She lives alone, and has no family. Her only support is an acquaintance, Ms. M. Ms. A can perform her ADLs independently, but is becom-ing increasingly dependent for her IADLs. She is unreliable in self-administration of her medications, and has missed paying the rent on multiple occasions. Ms. M has been assisting, feeling obligated to do so, but does not wish to be responsible for Ms. A's care. Though she comes to each visit, she is declining to be Ms. A's healthcare proxy. Ms. A declines to hire a health aide due to financial concerns and poor insight. Ms. A's hoarding behavior has led to threat of eviction, and her labile affect with outbursts over the death of her brother over one year ago are socially and emotionally incapacitating. Attempts have been made by her interdisciplinary team and multiple community agen-cies to offer the medical care she needs and ensure her safety in the home. However, barriers have persisted. Multiple organizations have declined to offer mental health services in the home on the basis of co-morbid dementia and concern for inability to participate in inter-ventions. Adult protective services has limited their involvement given the patient's unwillingness to allow them into her home. Per Ms. M, there has been a progressive cognitive and functional decline, and the degree of her own caregiver burden is becoming untenable.
Discussion(s): Community organizations are designed to help older adults age in place safely, and many offer essential mental health services. However, they are currently inadequate in their singular focus for those with co-morbid psychiatric illness and dementia. Furthermore, as older adults with dementia decline, their depen-dence on community services and the caregiver increase. What happens when there is no one willing and able to perform that duty? This case highlights this question, and the potential role of legal guardianship. How can we ensure that Ms. A's mental health and overall safety are addressed, and Ms. M has appropriate caregiver support?

The decision of whether or not to use artificial nutrition or hydration is one with which many health care providers, patients, and families struggle. These decisions are particularly challenging in the setting of life-limiting illness, which is often associated with a prolonged decline because of medical advances in these patient populations. A patient-centered and family-centered approach helps to attain high-quality care in this special population.