When is dementia not dementia: a lesson in listening

In the last few weeks, working as a GP, it seems like I’ve seen more pneumonia and bronchitis than at any time in the last 20 years. As a practice, we’ve also had a number of our elderly patients admitted as emergencies, sometimes after seeing one of us and sometimes when they’ve sought hospital care directly. On several occasions they were found collapsed or semi-conscious at home. Some, sadly, passed away whilst others spent several weeks recuperating in and out of hospital.

Of course many of those who were ill could be managed at home. Many others, I suspect, never sought or received any care. They come from a generation that doesn’t expect or like to demand too much attention. They are also, all too often, already frail and less able to articulate their needs than their younger neighbours. So that while we saw no end of coughs and colds and sore throats amongst fit and young people for whom honey and lemon was the most effective option we also had two elderly patients who tried but failed to get their voices heard.

One gentleman knew he was unwell, worse than he’d been before, and called for an appointment. Was it in emergency he was asked? Because there was a lot of flu around and the practice was inundated. I’m imagining that part of the story. As I imagine this dignified but frail gentleman assuring our receptionist that there was no urgency, that he didn’t want to take up the doctor’s time. What I do know is that he agreed that tomorrow would be fine and didn’t even try to insist he be seen. The next day his niece couldn’t get an answer when she phoned. So she came round to find her uncle unconscious on the floor with pneumonia. Two weeks later he was discharged from our local hospital. 

Another elderly lady had been causing increasing concern to her family over many months. She was becoming confused and was hallucinating. She came to see us with a concerned relative who no longer felt able to cope. A referral to the local and excellent psychogeriatrician followed. Except it wasn’t dementia, although, admittedly, it usually is. Instead this lady had a urinary infection and her confusion was secondary to this. The next day she was found collapsed and spent four weeks in hospital.

An old man who won’t demand. An old lady who defies the odds and isn’t demented, just suffering from an undiagnosed infection. The first waited for care too long because we failed to recognise that it is often the most needy patients who ask the least. The second was failed because we didn’t listen properly, forgetting to remind ourselves that, even in the elderly, there is more than one cause of confusion.

Not that it’s always easy to listen properly, in an active or even proactive way. Medical receptionists have, at any one time, a number of loud and demanding voices to respond to. Encouraging the undemanding needy to be more assertive requires a different mindset and a nuanced understanding of the cultural and generational subtleties determining who gets access to health services. For doctors too there’s the danger that  we begin to see what we expect to see: old people becoming more confused because of declining cognitive function; flu rather than meningitis as the cause of headache in the winter season.

And so I’m sharing with you all the lessons we all re-learnt this winter at our practice. We need to listen not only to what is said but also what isn’t said. And we need to listen to the person in front of us, unique in all their wonderful and vulnerable glory. Because confusion isn’t always dementia and because we sometimes need to shout loud on our patients’ behalf.