Yean Chee Yeow
Community Care Manager
Health Management Unit
Eastern Health Alliance

Eighty-year-old Mr R* lives with his 65-year-old second wife in a 3-room flat. The couple have no children of their own. Of his three children from his first marriage, two of his daughters are living overseas while his only son has passed on.

Previously, Mr R remained mobile with the aid of a walking frame and attended day care at Aspiration Lodge while his wife worked as a cleaner from 6am to 3pm. She started her day at 4am preparing breakfast and administering his insulin injection before leaving for work. She would then give him a call at 12 noon to remind him to take his medication and eat the porridge she had prepared. Mrs R was often home by 4pm to attend to her husband’s needs.

Things took a turn for the worse when Mr R became increasingly agitated and fell frequently. One occasion, he wondered downstairs on his own, flagged down a taxi and could not articulate to the driver his intended destination. Subsequently, the taxi driver drove him to Police Cantonment Complex where Mrs R had to bring him home. For safety reasons, Mrs R installed a new lock on their gate only to have Mr R stabbed at it with a pair of scissors. He also attempted to hit her. The episode resulted in her calling the police who advised Mrs R to admit her husband to hospital. Upon his admission to Changi General Hospital (CGH), Mr R was diagnosed with Vascular Dementia with functional decline.

A burnt-out Mrs R felt guilty for being unable to cope and remained fearful of her husband’s increasing agitation. She considered applying for a voluntary nursing home placement with the blessings of her two step-daughters who were willing to contribute to the nursing home fee. The R family’s case was referred to the Aged Care Transition (ACTION) Team Care Coordinator.

The option of participating in the Singapore Programme for Integrated Care for the Elderly (SPICE) was presented to couple. The care coordinator brought Mrs R to Peacehaven Bedok Multi-Service Centre to tour the centre’s facilities. Expressing her interest in pursuing the option, the ward staff recommended SPICE referral to the Agency for Integrated Care (AIC) prior to Mr R’s discharge.Upon follow-up, the care coordinator discovered that Mrs R had changed her mind about participating in SPICE. An urgent home visit was conducted urging Mr R to give SPICE a try, a request he acceded to. Eventually, the programme worked out to the benefit of the elderly couple and also won their hearty approval.

Other initiatives undertaken by the care coordinator include assistance with Mr R’s MediFund application and constant supervision of his medical appointment attendance. A glucometer with test strips was donated to the family and Mrs R was educated on blood glucose monitoring and diabetic control management. In addition, grab bars, non-slip treatment of toilet floor, and ramps in the home were installed under HDB’s Enhancement for Active Seniors programme. Mrs R was also counselled on the importance of self-care and respite care. The couple remain independent in their own home to date.

Key Learning Points:

  1. Assessment of the patient’s level of functioning prior to admission provides insight into resources available post discharge and to connect patient to the right site of care.
  2. Goal setting with patient and his caregiver helps break processes down into manageable steps and empower caregiver to be in better control of the situation.
  3. Case managers should be vigilant at all times and continue to build closer relationship with patient and caregiver.