Ruby, who is 80 and lives in Tamworth, had been having some memory problems, so her GP referred her to memory services for an assessment.  

When the appointment letter arrived, Ruby’s daughter, Becky, called the phone number given, because she was worried that her mum’s problems were getting much worse. Ruby was very confused and sometimes aggressive. She asked a lot for her husband, who had died six years earlier. When visiting, Becky sometimes found the oven left on and that her mum had not been taking her medication.  

The dementia duty worker asked the Dementia Home Treatment team to get involved, and arranged for a diagnostic assessment.  

Support for Ruby’s physical health needs, and diagnosing dementia 

A community mental health nurse visited Ruby within two days. Ruby was assessed at home, with her daughter there, and the findings were discussed with the multi-disciplinary team.   

The nurse asked Ruby’s GP to do an urgent review, because Ruby had a leg ulcer infection, and her confusion was getting worse. She asked the occupational therapist (OT) – who is part of the Home Treatment team – to assess the risks to Ruby from cooking and other daily activities.  

The district nurse came in to treat Ruby’s leg ulcer, prescribing antibiotics and dressings. Because the infection was serious, Ruby needed a short stay in a general hospital. A few weeks after she left hospital, a consultant psychiatrist assessed her and diagnosed dementia. 

A treatment plan could now be agreed. The community nurse and OT made further visits to address risks and see whether the treatment plan was working.  

Positive outcome  

Becky feels there has been a huge improvement in her mum’s quality of life. She is taking  

anti-dementia medication at a stable dose. She has ongoing support, but the team don’t need to intervene so often. 

The community nurse arranged for Alzheimer’s Society Dementia Advisers (a voluntary partner) to support Ruby and her daughter. The adviser offered practical help and advice on applying for carers’ support and other benefits.  

She referred Ruby to social services via Staffordshire Cares. Ruby now has a care package (help at home), which helps with personal hygiene and other daily living needs.