Brief:
You are a case manager of a community case management team and you are tasked to attend to the below case. Please read the following letter for case management service and answer all the ensuing questions.
Dear Manager,
Request for case management service
I was recommended by a Residents’ Committee (RC) member of my parents’ block to enquire about the case management service of your organisation. I would like someone to attend to my parents to see what kind of services can help my mother in caring for my father who has dementia. My mother has been a caregiver for my father for 20 years and is experiencing a lot of stress lately. My parents stay at Blk xxx, Ang Mo Kio Ave 5. My father, Chia Chong Tat, 82, is a big tall man with high blood pressure and high cholesterol.
He has left-hemisphere stroke 20 years ago which later developed into vascular dementia. He has follow-up medical appointments at a polyclinic for his chronic illnesses and TTSH for his dementia. He has mild dementia and his behavioural symptom is getting worse. Lately, he keeps accusing my mother, Oei Ah Mei, 72, of having an affair.
It sounds ridiculous and of course, it is all due to his hallucinations. Because of this, my father refuses to take his medication as he claimed that this is the mother’s plot to drug him so that she can spend time with her “mister”. This accusation pains my mother very much who is the sole caregiver of him. As a result, my mother has to stay home most of the time, otherwise, she has to bring my father along whenever she goes out.
My mother has expressed that she is under a lot of stress from caring for my father. My mother has degenerative arthritis and is diagnosed with stage one breast cancer lately by KKH. She needs to go for an operation and hence requires interim care for herself and also my father, but I am not able to provide the needed care for them. Please advise if you can help us. My parents are both Peranakan Chinese. They have been married for more than five decades and have two sons and one daughter (Amy (me), 52; John, 50; David, 48). David was divorced and has been working in America for three years.
He came back to Singapore only once and he hardly keeps contact with any of the family members. He has never been close to anyone of us as he is a loner. John is married and migrated to Australia 12 years ago. He has two children with his wife (Jennifer, 18; Janet, 11). The family visits my parents once a year during Christmas. John provides a monthly allowance of $600 to our parents. I am the only child residing in Singapore.
I am married and have a daughter, Isabella (aged 30), who gave birth to a baby boy last year (Joshua, 1). I have been a homemaker since marriage and help to take care of Joshua while Isabella and her husband are at work. We all stay in the same house at Yishun. My husband is 65 years old working as a secondary school teacher. He is planning for retirement as he has had a pass-by done last year and we think it is better for him to slow down his life. Isabella and I will give my parents pocket money occasionally whenever we are able to.
I used to visit my parents once a week to help with their household chores like buying groceries and housekeeping, and also check-in on their well-being. Since Joshua was born, I have been busy taking care of him and could only visit my parents once every fortnight; sometimes with my husband, sometimes with Isabella and Joshua, when they are free. I have not been visiting my parents for the last three weeks as my husband was not well.
I talked to my mother over the phone and heard her complaining about my father’s conditions. She cried over the phone whenever I called her. My parents used to be a loving couple and would always do things together. They were coworkers in the same company and my father caught my mother’s attention despite many admirers at her workplace. My father was an engineer and my mother has been a homemaker since marriage.
They have a 4-room purchased HDB flat which is fully paid off and some saving to tie over after my father’s retirement, however, the money was gradually depleted since my father’s stroke two years after his retirement and later developed into vascular dementia. Luckily, both received some subsidies for medical needs. My parents have traveled quite a bit after my father’s retirement as they did not get a chance to do so when my siblings and I were younger. Ever since his stroke, my father’s travel plans were halted, as were his active retirement plans.
My father was depressed about his condition for a while as he always said he was useless. After his stroke, my father first walked with a quad stick and subsequently used a walking frame as he got frailer. He can still walk with his walking frame within the house now, but he needs to sit in a wheelchair whenever he goes out of the house. He sleeps a lot in the day and when he is awake, he will only watch television and has no interest to do any other thing.
My mother has frequent knee pain due to her degenerative arthritis and it has been difficult for her to push my father around outside of the house, especially now the area is under upgrading and some areas at the void deck have been blocked off. We will do so only when my husband and I visit them, and my husband will help to wheel my father downstairs for a walk. On good days when my mother’s knees were not in pain and before my father’s condition deteriorated, my mother used to attend the activities organised by the RC and chit chat with the neighbors at the wet markets. She is no longer doing these due to my father’s latest mental condition and then the Circuit Breaker. I think she still keeps in contact with her neighbor Mdm Lee who stays one floor above her. They used to join RC activities together.
My father has developed behavioural symptoms from his dementia lately and has accused my mother of seeing another man behind his back. He would not sleep at night and he would question my mother whenever she goes out of the house to run errands and goes to the toilet between her sleep. He would accuse her of sneaking out of the house to see her “mister”. My mother has to wait until my father takes his afternoon nap to do grocery shopping. If my father wakes up before my mother reaches home, my father will question my mother and scold her for not being faithful.
My mother has been so stressed about this and felt embarrassed when neighbors passed by the window and overheard the accusation. My mother is so upset that she seldom goes out of the house or socialise with neighbors now. The doctor who attended to my mother did advise her to go for total knee replacement two years ago, but my mother did not consider it. She was afraid that she would not able to take care of her father after her surgery. Being a Peranakan woman, my mother is a tough lady and will always insist on taking care of everything in the household without many complaints. However, with her lately diagnosed breast cancer, she must go for an operation. Though my father can take care of his daily living with some help, the couple has never been separated for long and my mother will worry about my father very much when she is to be hospitalised. Being the only child residing in Singapore, the responsibility of taking care of my parents fall squarely on me and just me. My two brothers are overseas, and they cannot do much to help.
I feel so helpless as I have to take care of my grandson and not able to do much for my parents. Although my father can take care of himself in terms of bathing, eating, and changing his clothes, he will require some assistance due to his dementia condition and weak limbs on one side. He is not able to go out to buy his own food, not only that he will not be able to walk to the coffee shop, he will also not be able to recognise the way home. My mother has been taking care of all his needs. I will not be able to afford a domestic helper to assist my parents, and it is difficult to ask John to contribute more money as he has two schooling children to support. David is out of the picture as he has never helped with family matters.
My mother has five siblings; two elder brothers have passed away and two living brothers are old and not well. Only her younger sister will visit her once a month. Aunty Lucy is a widow with two children just a few years younger than me. My father is from Malaysia and he is the eldest son. His four younger siblings are all married with grandchildren and stay in Malaysia. We used to meet the relatives when they came to Singapore to visit my parents during Chinese New Year. They did not visit my parents in the last two years as they could not talk much to my father due to his dementia. Anyway, we are not very close to the relatives of my father and we cannot ask them for any help since they stay so far from us.
I hope there would be some services provided to assist my mother in caring for my father so that my mother can have peace of mind to go for her knee operation. Putting my father in a nursing home will not be an option as my mother is still able to care for him at home, perhaps with some help. My mother may also require some interim help during and after her operation. We will need some persuasion for her to accept help. You can contact me at 8181xxxx if you need more information. Appreciate your help.
Regards, Amy Chia
- Analyse key aspects of concern over the needs of the older adult and the caregiver based on your holistic assessment of NINE (9) risk factors affecting the duo’s circumstances (for example, physical and functional health, financial wellbeing, etc.). You are expected to include a genogram and analyse the complex interactions of factors affecting the older adult’s and the caregiver’s quality of life in order to make a weighty assessment.
- Discuss the strengths and weaknesses of adopting the whole family/family-centric case management model in the above case. Support your discussion with relevant literature.
- Apply case management skills in formulating a SMART care plan to improve the quality of life of the older adult and his/her caregiver. The care plan should include: § FIVE (5) desired outcomes for Mr. and Mrs. Chia based on the key aspects of concern identified in question (a) with justification § THREE (3) appropriate instruments to measure the outcomes with explanation § THREE (3) key interventions to achieve each of the outcomes The care plan should demonstrate your ability in prioritising care needs and mobilizing the families and community resources. The care plan should also be guided by the chosen case management model.
- Appraise TWO (2) ethical challenges that may arise when intervening in this case. Besides seeking advice from your supervisor, your multi-disciplinary team or a domain expert, propose at least one strategy with justification to address each of the challenges identified to ensure ethical practice.
- “In many cases, caregivers do not recognise their need for emotional support and self-care.” Examine the above statement and state your reasons with support from the literature and reference from the case. Propose THREE (3) strategies to address the gaps in supporting caregivers like Mrs. Chia.
- Bibliography/ References should be according to APA format. Appendices should include the proposed instruments and assessment tools if any. Appropriate academic language, proper structure, and organisation of assignments should be adopted.
