Dementia, Wandering, and a Discharge Decision
An 82-year-old woman with moderate Alzheimer's disease has been in an acute hospital for 9 days after a fall at home that caused a stable pubic ramus fracture. She is now mobile with a rollator and one-person supervision, but she has wandered twice at night, once into another patient's bay and once toward the ward exit. She lives alone in a second-floor apartment with no lift. Her daughter lives 40 minutes away and works full time; a son lives abroad. The daughter says she 'cannot possibly take her mother in' but is adamant that 'she must not go into a home.' The patient's Mini-Mental State Examination score is 18/30, and she cannot reliably recall the discharge plan from one day to the next. She has no formal diagnosis of dementia recorded in the discharge summary, only 'cognitive impairment.' The occupational therapist's home visit found loose rugs, poor lighting, and a bathroom with no grab rails. The ward is under pressure for beds, and the discharge coordinator has asked you to 'sign her off as safe with a care package' by tomorrow. Funding for a home care package has been approved for 4 visits per day for 2 weeks, then reviewed.
1. Assess the discharge plan. What are the specific risks, and is 'safe with a care package' a defensible conclusion on the available information?
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The proposed discharge is not defensible as stated. Break it into components:
Risks that the care package does not address:
- Wandering at night: four visits per day do not cover the night. A woman who has twice headed for the ward exit is at risk of leaving the apartment, using stairs, or being found outside. The second-floor flat with no lift compounds fall and exit risk.
- Cognitive impairment without a diagnosis: an MMSE of 18/30 with functional decline and wandering meets the clinical picture of at least moderate dementia. Recording only 'cognitive impairment' leaves the next team without a working diagnosis and undermines access to dementia-specific services. A memory clinic or old-age psychiatry referral should be initiated.
- Home hazards: loose rugs, poor lighting, and no bathroom grab rails are modifiable and should be addressed before or at discharge, not left to a 2-week review.
- Decision-making capacity: she cannot recall the plan day to day, which raises questions about her ability to consent to the discharge arrangement and to manage at home. Capacity is decision-specific; assess it explicitly rather than inferring from the MMSE.
What is defensible: a discharge is possible only if the care package is redesigned to cover the night, the home is made safer, the diagnosis is documented, and the daughter's role and limits are clarified in writing. 'Sign her off' by tomorrow is a bed-pressure instruction, not a clinical judgement; the correct response is to state what would make discharge safe and what cannot be assured, and to escalate to the consultant and discharge coordinator.
2. The daughter refuses residential care but says she cannot take her mother in. How do you work with this conflict while respecting the patient's rights?
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The conflict is between the daughter's stated values ('not a home'), her practical limits (full-time work, 40 minutes away), and the patient's safety and autonomy. Manage it in stages:
- Separate the daughter's beliefs from the patient's needs. Ask what 'a home' means to her - fear of poor care, loss of the family home, guilt. Name the concern without endorsing or dismissing it.
- Establish the patient's own views. With moderate dementia she may still express preferences about where she lives. Use a structured conversation, involve those who know her, and record her wishes. If capacity for this decision is lacking, a best-interests process is required, not the daughter's preference alone.
- Offer the full range of options, not a binary. Home with an enhanced package including night cover and assistive technology (for example a door sensor or GPS-enabled pendant with consent), extra care housing, a short trial of residential respite, or a move nearer the daughter. Present each with its risks and benefits.
- Be clear about limits. If home cannot be made safe within the resources available, say so plainly and explain why. Do not promise what the system cannot deliver.
- Escalate appropriately. Involve the multidisciplinary team, social work, and where the patient lacks capacity and there is disagreement, the local safeguarding or best-interests framework. Document the discussion, the options offered, and the reasoning.
The professional stance is neither to capitulate to the daughter's demand nor to override the family. It is to give an honest account of risk, support the family to make an informed choice, and ensure the patient's interests are represented.
3. What should be documented and handed over before any discharge, and what would you refuse to sign?
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Document before discharge:
- A working diagnosis of dementia (or an explicit statement that assessment is pending) and a referral to memory services or old-age psychiatry.
- A capacity assessment for the specific decisions at hand (discharge destination, managing finances, consent to care), with the reasoning.
- The patient's expressed wishes and the family's views, including the daughter's stated limits.
- The care package in detail: times of visits, tasks, night cover (or its absence), and the review date.
- Home modifications completed or scheduled: grab rails, lighting, rug removal.
- Wandering risk assessment and the plan: door sensor, pendant, neighbour alert, or other measures, with consent where required.
- A falls plan and who to contact.
- The name of the clinician accountable for the plan and the escalation route.
What to refuse to sign: a statement that she is 'safe' when night-time risk is unaddressed, the diagnosis is undocumented, and the home hazards remain. Sign instead a factual record: what has been arranged, what remains unsafe, what has been escalated, and to whom. Frame it as 'discharge deferred pending X' or 'discharge agreed with the following residual risks and mitigations' rather than a blanket safety certification. Notify the consultant and discharge coordinator in writing the same day, and record that bed pressure was a factor raised but did not determine the clinical decision.