- Email: [email protected]
Chronic disease and independence in old age: A case study
Radiography (2006) 12, 253e257
CASE REPORT
Chronic disease and independence in old age: A case study Pauline J. Reeves* Radiology Department, Arrowe Park Hospital, Upton, Wirral CH49 5EP, United Kingdom Received 28 February 2005; accepted 15 June 2005 Available online 3 August 2005
KEYWORDS Care of the elderly; Holism; Leflunomide; National Service Frameworks; Protrusio acetabuli; Reductionism; Rheumatoid arthritis
Abstract This report uses case study methodology to examine the issue of longterm care of the elderly in the United Kingdom, including where that care should take place. The report will examine the difficulties inherent in maintaining independent living for the elderly (in particular the danger and cost of falls). The case study presented is that of an elderly female patient who had suffered from chronic rheumatoid arthritis for over 10 years. She was admitted to hospital several times from December 2003 to January 2004. The discussion of her case is set in the context of the sociology of ageing; long-term care of the elderly and the UK National Service Frameworks, of which standard six relates to falls in the elderly. The report will also consider the problems in deciding whether it is necessary to terminate independent living for an individual. ª 2005 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Introduction Diagnostic radiography practice is inherently reductionist,1,2 in that it is based on medical requests for imaging of different body parts. From an early stage, therefore, radiographers tend to think of patients in terms of those body parts: using such phrases as ‘there’s a chest in the cubicle’; ‘there’s a lumbar spine on a trolley to come round’.1 This is further compounded by the fact that, unlike other allied health professions, the focus is not on patient rehabilitation, but on a tangible product e an * Tel.: C44 151 678 5111x2985/8567. E-mail address: [email protected]
image which needs to be of sufficient quality to facilitate a medical diagnosis. The development of a holistic model of patient care in radiography (see Fig. 1) was an attempt to place the patient (rather than the image) at the centre of radiography practice.1,2 Most radiographers (unlike other allied health professionals) will never see their patients again once they have been examined, which tends to contribute to psychological ‘distancing’ of radiographers from the lives and individual circumstances of their patients.2 This report analyses the issues which surround the care of elderly patients with chronic disease. The increase in the normal lifespan means that
1078-8174/$ - see front matter ª 2005 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2005.06.003
254
P.J. Reeves Assessment/planning
Patient communication
Patient care
Patient
Sequencing/adaptation
Speed/efficiency
Evaluation of images
Figure 1
Holistic model of patient care in radiography.
patients are surviving longer with chronic diseases, of which a prime example is arthritis.3 This report presents the case history of a patient with longstanding rheumatoid arthritis who was admitted to hospital on numerous occasions between the beginning of December 2003 and mid-January 2004.
Literature review
Whatever the level of support, however, the frail elderly person is susceptible to falls, resulting from changes in eyesight and levels of depth perception as a result of ageing. Falls in the elderly cost £981 million per year, of which 60% is a cost to the NHS. It is estimated that, in any one year, 30% of those over 65 have a fall.6 Hip fractures cost the NHS £1 billion a year; many patients die as a result and many lose their independence. This is regarded as such a major problem that strategies to prevent falls comprise one of the standards of the new National Service Framework for Older People.7 Standard six (Falls) aims ‘to reduce the number of falls which result in serious injury and ensure effective treatment and rehabilitation for those who have fallen’. This has resulted in national projects such as slipper exchanges whereby elderly people are encouraged to bring their slippers (such as backless mules) and receive in exchange a free pair of ‘safe’ slippers with non-slip soles and which zip up. Critics of such schemes are reminded that giving away free slippers at £15 a time is very little when set against the cost to the NHS of hip fractures.
Sociology of ageing Rheumatoid arthritis The growing numbers of elderly people, as a proportion of the worldwide population, mean that the sociology of ageing has become an important area for study. The characterisation, for example, of the increasing numbers of the elderly as ‘a social problem’4 gives cause for concern as this, in itself, is a biased viewpoint. The concern is raised by the proportions of elderly people who are living beyond the age of 75. This group has been referred as the ‘frail elderly’, who may require assistance with the activities of daily living, especially those who are living with chronic diseases such as arthritis.5 Long-term care has been defined as: ‘Assistance provided over an extended period of time because of health problems that limit a person’s ability to perform routine everyday tasks’.3 Long-term care is provided in a number of settings, including the client’s home. This is an important feature of care of the elderly in the UK, and it is argued that the cost is less than that of support in residential or nursing home.4 It has also been argued that the Government has used implicit privatisation to shift the costs of support for the elderly away from the State onto individuals and their families. Individual support within the private home has been seen as one way of preventing ‘bedblocking’ within acute hospitals, as it frees up places in care homes for those more in need; for example, those who do not have family support.
Rheumatoid arthritis is a chronic systemic, inflammatory arthritis which affects women more than men. It is a symmetrical protracted, progressive disease which tends to lead to crippling deformities, especially in the hands and feet, although the disease is said to progress towards the trunk and, eventually, can involve virtually every joint in the body.8 Patients become susceptible to infection and secondary organ dysfunction.9 The disease begins as an inflammation of synovial membranes. This causes joint effusion and thus the earliest radiographic changes are periarticular soft-tissue swellings. Periarticular osteoporosis gradually occurs as a result of increased blood flow in the area. Granulation tissue forms around the synovial membranes and thickens to form pannus which erodes both the articular cartilage and the bony cortex. Fibrous scarring occurs and eventually there is ankylosis across the joint which contributes to the development of the characteristic deformity pattern of advanced disease.9
Case study The patient was a female aged 77 who had suffered for at least 10 years from chronic rheumatoid arthritis. The lady lived at home with relative and carer support. Until March 2003 she
Chronic disease and independence in old age had been reasonably mobile but study of her case notes revealed that from March until December 2003 she had been experiencing decreasing mobility. The patient lived alone but was visited by carers four times daily for purposes which included meal preparation. However she had not been feeding herself (possibly as a direct result of poor mobility). She was admitted to hospital for two weeks at the beginning of December 2003. At the time of admission she stated that she had been feeling dizzy for the past week and was assessed by the occupational therapists as a safety risk owing to her reduced mobility. She had also been losing weight and was found on admission to have a urinary tract infection. Pressure area care was administered to the sacrum and the patient was assessed as having a Waterlow score of 23. She was, however, keen to return home and was discharged back to home two weeks later. The author first met the lady during an afternoon shift on Christmas Day when she was admitted through the Accident and Emergency Department following a fall at home. She was referred to the X-ray department with a request for pelvis and right hip and a chest X-ray and came round to the department sat up on a trolley. The lady was fully conscious and aware of her surroundings. On positioning the patient for the AP chest X-ray she was in no apparent pain, but examination of the resultant image found that she had a dislocated right shoulder (see Fig. 2). A red dot was applied to the film and the A&E Department was informed by telephone as this was an unexpected finding. The pelvic film also showed a probable undisplaced fracture of the lesser trochanter which was later confirmed (Fig. 3). There were also old fractures of the right inferior pubic ramus. The lady was admitted to an orthopaedic ward under the care of a general surgeon. The report on the patient’s chest X-ray noted that there were also healing rib fractures on the right side, together with the anterior dislocation of the right shoulder. The radiologist also noted that there was erosive change in the left shoulder consistent with rheumatoid arthritis. The assessment was that her shoulder had been dislocated for some time but it proved impossible to pinpoint exactly when she had sustained this injury (or indeed the healing rib fractures). The suspicion remains that she had been discharged home from her previous admission with the dislocated shoulder. She was taken to theatre five days later for manipulation under anaesthetic of her dislocated shoulder but this was unsuccessful. She was referred to a specialist orthopaedic surgeon but
255
Figure 2 2003.
Anteroposterior (AP) chest film, December
declined the option of an open reduction and physiotherapy was requested to aid mobilisation. At a ward round on 5th January further X-rays of her pelvis were requested in order to ensure that there were no displaced fractures (Fig. 4). At that time the surgeon commented ‘‘she will presumably require long-term care in a nursing home’’. The radiologist’s report on Fig. 4 stated: ‘There is marked loss of joint space of the right hip with sub-articular sclerosis, acetabular protrusion and some collapse of the femoral head suggesting avascular necrosis. Healing fracture of the lesser trochanter on the right. Old fractures of the right pubic rami.’
Figure 3 Collimated AP right hip and pubic rami, December 2003.
256
P.J. Reeves
Figure 4
AP pelvis, January 2004.
On 18th January 2004 the patient was discharged home having been assessed as fully independent. A report by a social worker, written immediately prior to her discharge, stated that the lady had a stair lift and Zimmer frames at home and would be discharged to the same care plan as previously, i.e. four carer visits daily. The report stated that the patient had regained the level of mobility that she had prior to admission. The notes also recorded that she was now living with her son. Only four days later the patient was again admitted to hospital, this time to a medical ward. On admission through the hospital’s Medical Assessment Unit doctors suspected a chest infection (although this was not confirmed on X-ray) and there was also a palpable mass in the right iliac fossa. The patient remained in hospital from that time until she died at the end of April 2004.
tion (used to treat rheumatoid arthritis) and immobilisation or disuse.8 Examination of a chest X-ray taken of the patient in February 2003 (Fig. 5) shows a probable early subluxation of the right shoulder, but certainly no evidence of the rib fractures which were seen in December 2003. It is difficult to estimate the level of bony osteoporosis on plain films but the lack of contrast between the ribs and lung tissue may well indicate poor bone density. It is unfortunate, but likely, that the dislocation of the shoulder and the fractures of the ribs (and possibly those of the pubic rami) were caused by poor lifting practices on the part of the visiting carers; for example, the placing of arms in the axilla of the patient to move them. As the osteoporosis became compounded by immobility, however, it may have taken very little force to occasion the fractures. It was clear by the patient’s lack of discomfort on Christmas day, that the injuries were fairly longstanding. Joint subluxation in rheumatoid arthritis is caused by inflammation of the ligaments which causes laxity.8 The joint laxity is further compounded by destruction of the bone and cartilage.12 The disease is symmetrical in nature and therefore one would expect to see deterioration in both shoulder joints if one were affected (see Fig. 2). Other classic signs of rheumatoid arthritis are mentioned in the radiologist’s report on the pelvis projection (Fig. 4), including sub-articular sclerosis and protrusio acetabuli.13 The notes record that the patient’s rheumatoid arthritis had been treated for some time with the drug leflunomide. Leflunomide acts to modify the immune response and inhibit cell proliferation.9 The side effects of this drug are numerous but include dizziness, headache, heartburn, stomach
Discussion A study of over 4000 women aged 60e79 found that arthritis and coronary heart disease were both important contributors to limitation of locomotor activity and to difficulties with social participation.10 The unfortunate trade-off for the maintenance of independent living (as in this case) may well be loneliness and loss of social intercourse resulting from restriction of movement. Visits from carers are not sufficient to compensate for the loss of the ability to interact socially with peers. The depression which may result from this can contribute to deterioration in health. Rheumatoid arthritis may affect any large joint in the body and is also associated with marked osteoporosis.11 Other factors which precipitate osteoporosis include prolonged steroid administra-
Figure 5
AP chest, February 2003.
Chronic disease and independence in old age pain and loss of appetite and/or vomiting. Any of these could have accounted for both the patient’s pubic rami injuries (from a fall) and for the poor nutritional state which was encountered on admission to hospital in early December. Certain drugs may actually increase the risk of the patient having a fall. It is argued that falls can be clear markers of declining function and may be the sign that a chronic disease is worsening.6 It is not clear from the notes whether anyone actually visited her home between March 2003 and her first admission in December to check whether the level of carer support was functioning satisfactorily for her needs. It seems likely that it took her admission to hospital for anyone to question whether such support was actually enough. It is clear that she had physiotherapy and occupational therapy assessment whilst in hospital for the first admission in December 2003, but it also seems that her condition was declining at that time such that the repeated admissions were inevitable. However it seems also surprising that the lady spent 2 weeks in hospital in mid-December only to be discharged and readmitted only 4 days later with a palpable mass in the abdomen. Considering the patient had been admitted for pelvic fractures, how was a palpable mass missed? What level of clinical examination could have missed this?
Conclusions Independence is very important to any individual; when an elderly patient becomes frail and/or immobile there may be some very difficult decisions to take with regard to the individual’s ability to continue living at home. As patients live longer with chronic conditions such as rheumatoid arthritis, the line beyond which even a major level of carer support in the home is no longer enough is easily blurred and may be difficult to determine. There are trade-offs inherent in the decision to maintain independence in the face of deteriorating locomotor function which include possible social isolation and slow deterioration of the condition which may go unnoticed. Chronic diseases such as rheumatoid arthritis can spark a downward spiral from which it is difficult for the patient to recover; pain and deterioration in joints make the patient more immobile. In turn this compounds osteoporosis which can further predis-
257 pose the patient to injury. It is difficult to determine in this case study exactly how the lady’s injuries and malnutrition came about but it is clear that, despite four visits per day by carers, the system appeared to have failed her. It is important for radiography professionals to try to see beyond the immediate reductionism represented by constant requests to X-ray body parts. Case studies are an important part of both undergraduate and postgraduate curricula since they force the radiographer to take a holistic approach to the chosen patient. The ‘hit & run’ aspect of radiography2 means that our clinical encounters tend to be brief and episodic with very few opportunities to follow up on patients or to consider the circumstances surrounding the injuries or conditions with which they are admitted to hospital.
References 1. Culmer PJ. Chesney’s care of the patient in diagnostic radiography. 7th ed. Oxford: Blackwell Science; 1995. p. 1 [chapter 1]. 2. Reeves P. Models of care and their use in the education of student radiographers. PhD thesis, University of Wales, Bangor; 1999. 3. Harris DK. Sociology of ageing. 2nd ed. Harper & Row; 1990. 4. Bond J, Coleman P, Peace S. Ageing in society. 2nd ed. Sage Publications; 1993. 5. Dowd SB, Durick D. Addressing the needs of elderly radiology patients. Radiologic Technology 1995;66(5): 299e304. 6. Fuller GF. Falls in the elderly. American Academy of Family Physicians; 2000.!http://www.afp.org/afp/20000401/2159. htmlO [accessed 4/5/04]. 7. Department of Health. National Service Framework for Older people; Standard 6 (Falls).!http://www.dh. gov.uk/policyandguidance/healthandsocialcaretopics/ olderpeoplesO; 2003 [accessed 4/5/04]. 8. Eisenberg RL, Dennis CA. Comprehensive radiographic pathology. 2nd ed. Missouri: Mosby Year Book Inc.; 1995. 9. King R. Arthritis, Rheumatoid.!http://www.emedicine. com/emerg/topic48.htmO; 2003 [accessed 17/5/04]. 10. Adamson J, Lawlor DA, Shah E. Chronic diseases, locomotor activity limitation and participation in older women: cross sectional survey of British Women’s Heart & Health Study. Age & Ageing 2004;33:293e8. 11. Helms CA. Fundamentals of skeletal radiology. 2nd ed. WB Saunders Co.; 1995. 12. Dandy DJ, Edwards DJ. Essential orthopaedics & trauma. 4th ed. Churchill Livingstone; 2003. 13. Chapman S, Nakielny R. Aids to radiological differential diagnosis. 4th ed. Saunders; 2003.
CASE REPORT
Chronic disease and independence in old age: A case study Pauline J. Reeves* Radiology Department, Arrowe Park Hospital, Upton, Wirral CH49 5EP, United Kingdom Received 28 February 2005; accepted 15 June 2005 Available online 3 August 2005
KEYWORDS Care of the elderly; Holism; Leflunomide; National Service Frameworks; Protrusio acetabuli; Reductionism; Rheumatoid arthritis
Abstract This report uses case study methodology to examine the issue of longterm care of the elderly in the United Kingdom, including where that care should take place. The report will examine the difficulties inherent in maintaining independent living for the elderly (in particular the danger and cost of falls). The case study presented is that of an elderly female patient who had suffered from chronic rheumatoid arthritis for over 10 years. She was admitted to hospital several times from December 2003 to January 2004. The discussion of her case is set in the context of the sociology of ageing; long-term care of the elderly and the UK National Service Frameworks, of which standard six relates to falls in the elderly. The report will also consider the problems in deciding whether it is necessary to terminate independent living for an individual. ª 2005 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
Introduction Diagnostic radiography practice is inherently reductionist,1,2 in that it is based on medical requests for imaging of different body parts. From an early stage, therefore, radiographers tend to think of patients in terms of those body parts: using such phrases as ‘there’s a chest in the cubicle’; ‘there’s a lumbar spine on a trolley to come round’.1 This is further compounded by the fact that, unlike other allied health professions, the focus is not on patient rehabilitation, but on a tangible product e an * Tel.: C44 151 678 5111x2985/8567. E-mail address: [email protected]
image which needs to be of sufficient quality to facilitate a medical diagnosis. The development of a holistic model of patient care in radiography (see Fig. 1) was an attempt to place the patient (rather than the image) at the centre of radiography practice.1,2 Most radiographers (unlike other allied health professionals) will never see their patients again once they have been examined, which tends to contribute to psychological ‘distancing’ of radiographers from the lives and individual circumstances of their patients.2 This report analyses the issues which surround the care of elderly patients with chronic disease. The increase in the normal lifespan means that
1078-8174/$ - see front matter ª 2005 The College of Radiographers. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.radi.2005.06.003
254
P.J. Reeves Assessment/planning
Patient communication
Patient care
Patient
Sequencing/adaptation
Speed/efficiency
Evaluation of images
Figure 1
Holistic model of patient care in radiography.
patients are surviving longer with chronic diseases, of which a prime example is arthritis.3 This report presents the case history of a patient with longstanding rheumatoid arthritis who was admitted to hospital on numerous occasions between the beginning of December 2003 and mid-January 2004.
Literature review
Whatever the level of support, however, the frail elderly person is susceptible to falls, resulting from changes in eyesight and levels of depth perception as a result of ageing. Falls in the elderly cost £981 million per year, of which 60% is a cost to the NHS. It is estimated that, in any one year, 30% of those over 65 have a fall.6 Hip fractures cost the NHS £1 billion a year; many patients die as a result and many lose their independence. This is regarded as such a major problem that strategies to prevent falls comprise one of the standards of the new National Service Framework for Older People.7 Standard six (Falls) aims ‘to reduce the number of falls which result in serious injury and ensure effective treatment and rehabilitation for those who have fallen’. This has resulted in national projects such as slipper exchanges whereby elderly people are encouraged to bring their slippers (such as backless mules) and receive in exchange a free pair of ‘safe’ slippers with non-slip soles and which zip up. Critics of such schemes are reminded that giving away free slippers at £15 a time is very little when set against the cost to the NHS of hip fractures.
Sociology of ageing Rheumatoid arthritis The growing numbers of elderly people, as a proportion of the worldwide population, mean that the sociology of ageing has become an important area for study. The characterisation, for example, of the increasing numbers of the elderly as ‘a social problem’4 gives cause for concern as this, in itself, is a biased viewpoint. The concern is raised by the proportions of elderly people who are living beyond the age of 75. This group has been referred as the ‘frail elderly’, who may require assistance with the activities of daily living, especially those who are living with chronic diseases such as arthritis.5 Long-term care has been defined as: ‘Assistance provided over an extended period of time because of health problems that limit a person’s ability to perform routine everyday tasks’.3 Long-term care is provided in a number of settings, including the client’s home. This is an important feature of care of the elderly in the UK, and it is argued that the cost is less than that of support in residential or nursing home.4 It has also been argued that the Government has used implicit privatisation to shift the costs of support for the elderly away from the State onto individuals and their families. Individual support within the private home has been seen as one way of preventing ‘bedblocking’ within acute hospitals, as it frees up places in care homes for those more in need; for example, those who do not have family support.
Rheumatoid arthritis is a chronic systemic, inflammatory arthritis which affects women more than men. It is a symmetrical protracted, progressive disease which tends to lead to crippling deformities, especially in the hands and feet, although the disease is said to progress towards the trunk and, eventually, can involve virtually every joint in the body.8 Patients become susceptible to infection and secondary organ dysfunction.9 The disease begins as an inflammation of synovial membranes. This causes joint effusion and thus the earliest radiographic changes are periarticular soft-tissue swellings. Periarticular osteoporosis gradually occurs as a result of increased blood flow in the area. Granulation tissue forms around the synovial membranes and thickens to form pannus which erodes both the articular cartilage and the bony cortex. Fibrous scarring occurs and eventually there is ankylosis across the joint which contributes to the development of the characteristic deformity pattern of advanced disease.9
Case study The patient was a female aged 77 who had suffered for at least 10 years from chronic rheumatoid arthritis. The lady lived at home with relative and carer support. Until March 2003 she
Chronic disease and independence in old age had been reasonably mobile but study of her case notes revealed that from March until December 2003 she had been experiencing decreasing mobility. The patient lived alone but was visited by carers four times daily for purposes which included meal preparation. However she had not been feeding herself (possibly as a direct result of poor mobility). She was admitted to hospital for two weeks at the beginning of December 2003. At the time of admission she stated that she had been feeling dizzy for the past week and was assessed by the occupational therapists as a safety risk owing to her reduced mobility. She had also been losing weight and was found on admission to have a urinary tract infection. Pressure area care was administered to the sacrum and the patient was assessed as having a Waterlow score of 23. She was, however, keen to return home and was discharged back to home two weeks later. The author first met the lady during an afternoon shift on Christmas Day when she was admitted through the Accident and Emergency Department following a fall at home. She was referred to the X-ray department with a request for pelvis and right hip and a chest X-ray and came round to the department sat up on a trolley. The lady was fully conscious and aware of her surroundings. On positioning the patient for the AP chest X-ray she was in no apparent pain, but examination of the resultant image found that she had a dislocated right shoulder (see Fig. 2). A red dot was applied to the film and the A&E Department was informed by telephone as this was an unexpected finding. The pelvic film also showed a probable undisplaced fracture of the lesser trochanter which was later confirmed (Fig. 3). There were also old fractures of the right inferior pubic ramus. The lady was admitted to an orthopaedic ward under the care of a general surgeon. The report on the patient’s chest X-ray noted that there were also healing rib fractures on the right side, together with the anterior dislocation of the right shoulder. The radiologist also noted that there was erosive change in the left shoulder consistent with rheumatoid arthritis. The assessment was that her shoulder had been dislocated for some time but it proved impossible to pinpoint exactly when she had sustained this injury (or indeed the healing rib fractures). The suspicion remains that she had been discharged home from her previous admission with the dislocated shoulder. She was taken to theatre five days later for manipulation under anaesthetic of her dislocated shoulder but this was unsuccessful. She was referred to a specialist orthopaedic surgeon but
255
Figure 2 2003.
Anteroposterior (AP) chest film, December
declined the option of an open reduction and physiotherapy was requested to aid mobilisation. At a ward round on 5th January further X-rays of her pelvis were requested in order to ensure that there were no displaced fractures (Fig. 4). At that time the surgeon commented ‘‘she will presumably require long-term care in a nursing home’’. The radiologist’s report on Fig. 4 stated: ‘There is marked loss of joint space of the right hip with sub-articular sclerosis, acetabular protrusion and some collapse of the femoral head suggesting avascular necrosis. Healing fracture of the lesser trochanter on the right. Old fractures of the right pubic rami.’
Figure 3 Collimated AP right hip and pubic rami, December 2003.
256
P.J. Reeves
Figure 4
AP pelvis, January 2004.
On 18th January 2004 the patient was discharged home having been assessed as fully independent. A report by a social worker, written immediately prior to her discharge, stated that the lady had a stair lift and Zimmer frames at home and would be discharged to the same care plan as previously, i.e. four carer visits daily. The report stated that the patient had regained the level of mobility that she had prior to admission. The notes also recorded that she was now living with her son. Only four days later the patient was again admitted to hospital, this time to a medical ward. On admission through the hospital’s Medical Assessment Unit doctors suspected a chest infection (although this was not confirmed on X-ray) and there was also a palpable mass in the right iliac fossa. The patient remained in hospital from that time until she died at the end of April 2004.
tion (used to treat rheumatoid arthritis) and immobilisation or disuse.8 Examination of a chest X-ray taken of the patient in February 2003 (Fig. 5) shows a probable early subluxation of the right shoulder, but certainly no evidence of the rib fractures which were seen in December 2003. It is difficult to estimate the level of bony osteoporosis on plain films but the lack of contrast between the ribs and lung tissue may well indicate poor bone density. It is unfortunate, but likely, that the dislocation of the shoulder and the fractures of the ribs (and possibly those of the pubic rami) were caused by poor lifting practices on the part of the visiting carers; for example, the placing of arms in the axilla of the patient to move them. As the osteoporosis became compounded by immobility, however, it may have taken very little force to occasion the fractures. It was clear by the patient’s lack of discomfort on Christmas day, that the injuries were fairly longstanding. Joint subluxation in rheumatoid arthritis is caused by inflammation of the ligaments which causes laxity.8 The joint laxity is further compounded by destruction of the bone and cartilage.12 The disease is symmetrical in nature and therefore one would expect to see deterioration in both shoulder joints if one were affected (see Fig. 2). Other classic signs of rheumatoid arthritis are mentioned in the radiologist’s report on the pelvis projection (Fig. 4), including sub-articular sclerosis and protrusio acetabuli.13 The notes record that the patient’s rheumatoid arthritis had been treated for some time with the drug leflunomide. Leflunomide acts to modify the immune response and inhibit cell proliferation.9 The side effects of this drug are numerous but include dizziness, headache, heartburn, stomach
Discussion A study of over 4000 women aged 60e79 found that arthritis and coronary heart disease were both important contributors to limitation of locomotor activity and to difficulties with social participation.10 The unfortunate trade-off for the maintenance of independent living (as in this case) may well be loneliness and loss of social intercourse resulting from restriction of movement. Visits from carers are not sufficient to compensate for the loss of the ability to interact socially with peers. The depression which may result from this can contribute to deterioration in health. Rheumatoid arthritis may affect any large joint in the body and is also associated with marked osteoporosis.11 Other factors which precipitate osteoporosis include prolonged steroid administra-
Figure 5
AP chest, February 2003.
Chronic disease and independence in old age pain and loss of appetite and/or vomiting. Any of these could have accounted for both the patient’s pubic rami injuries (from a fall) and for the poor nutritional state which was encountered on admission to hospital in early December. Certain drugs may actually increase the risk of the patient having a fall. It is argued that falls can be clear markers of declining function and may be the sign that a chronic disease is worsening.6 It is not clear from the notes whether anyone actually visited her home between March 2003 and her first admission in December to check whether the level of carer support was functioning satisfactorily for her needs. It seems likely that it took her admission to hospital for anyone to question whether such support was actually enough. It is clear that she had physiotherapy and occupational therapy assessment whilst in hospital for the first admission in December 2003, but it also seems that her condition was declining at that time such that the repeated admissions were inevitable. However it seems also surprising that the lady spent 2 weeks in hospital in mid-December only to be discharged and readmitted only 4 days later with a palpable mass in the abdomen. Considering the patient had been admitted for pelvic fractures, how was a palpable mass missed? What level of clinical examination could have missed this?
Conclusions Independence is very important to any individual; when an elderly patient becomes frail and/or immobile there may be some very difficult decisions to take with regard to the individual’s ability to continue living at home. As patients live longer with chronic conditions such as rheumatoid arthritis, the line beyond which even a major level of carer support in the home is no longer enough is easily blurred and may be difficult to determine. There are trade-offs inherent in the decision to maintain independence in the face of deteriorating locomotor function which include possible social isolation and slow deterioration of the condition which may go unnoticed. Chronic diseases such as rheumatoid arthritis can spark a downward spiral from which it is difficult for the patient to recover; pain and deterioration in joints make the patient more immobile. In turn this compounds osteoporosis which can further predis-
257 pose the patient to injury. It is difficult to determine in this case study exactly how the lady’s injuries and malnutrition came about but it is clear that, despite four visits per day by carers, the system appeared to have failed her. It is important for radiography professionals to try to see beyond the immediate reductionism represented by constant requests to X-ray body parts. Case studies are an important part of both undergraduate and postgraduate curricula since they force the radiographer to take a holistic approach to the chosen patient. The ‘hit & run’ aspect of radiography2 means that our clinical encounters tend to be brief and episodic with very few opportunities to follow up on patients or to consider the circumstances surrounding the injuries or conditions with which they are admitted to hospital.
References 1. Culmer PJ. Chesney’s care of the patient in diagnostic radiography. 7th ed. Oxford: Blackwell Science; 1995. p. 1 [chapter 1]. 2. Reeves P. Models of care and their use in the education of student radiographers. PhD thesis, University of Wales, Bangor; 1999. 3. Harris DK. Sociology of ageing. 2nd ed. Harper & Row; 1990. 4. Bond J, Coleman P, Peace S. Ageing in society. 2nd ed. Sage Publications; 1993. 5. Dowd SB, Durick D. Addressing the needs of elderly radiology patients. Radiologic Technology 1995;66(5): 299e304. 6. Fuller GF. Falls in the elderly. American Academy of Family Physicians; 2000.!http://www.afp.org/afp/20000401/2159. htmlO [accessed 4/5/04]. 7. Department of Health. National Service Framework for Older people; Standard 6 (Falls).!http://www.dh. gov.uk/policyandguidance/healthandsocialcaretopics/ olderpeoplesO; 2003 [accessed 4/5/04]. 8. Eisenberg RL, Dennis CA. Comprehensive radiographic pathology. 2nd ed. Missouri: Mosby Year Book Inc.; 1995. 9. King R. Arthritis, Rheumatoid.!http://www.emedicine. com/emerg/topic48.htmO; 2003 [accessed 17/5/04]. 10. Adamson J, Lawlor DA, Shah E. Chronic diseases, locomotor activity limitation and participation in older women: cross sectional survey of British Women’s Heart & Health Study. Age & Ageing 2004;33:293e8. 11. Helms CA. Fundamentals of skeletal radiology. 2nd ed. WB Saunders Co.; 1995. 12. Dandy DJ, Edwards DJ. Essential orthopaedics & trauma. 4th ed. Churchill Livingstone; 2003. 13. Chapman S, Nakielny R. Aids to radiological differential diagnosis. 4th ed. Saunders; 2003.