Simulated Patient Scenario

Non-Urgent Welfare Check

Scenario Details

Scenario: Welfare Check - Elderly Living Alone

Simulated Patient: 82-year-old Female

Actor/Actress: Student Actor (Patient), Neighbour (briefly on scene)

MDT Information

Non-Urgent Response - Welfare Check
Caller (neighbour) concerned for elderly female neighbour (82yo)
Hasn't seen patient for 3 days, mail piling up, curtains drawn
Patient lives alone, known to be frail
Police requested to attend for potential forced entry if no answer
Location: Residential house

On Arrival

You arrive at a suburban house. Mail is visibly piled up in the letterbox. The curtains are drawn. A concerned neighbour meets you and reiterates their concerns, stating the patient usually collects her mail daily. Police arrive simultaneously. After knocking loudly and calling out with no response, police force entry via the front door.

You enter the house behind police. The house is dark and cluttered. You find the patient sitting in an armchair in the dimly lit living room, wearing nightclothes. She appears frail, thin, and somewhat dishevelled but looks up as you enter.

Scene Safety Note: Allow police to ensure the immediate internal environment is safe before full entry. Be aware of potential environmental hazards (clutter, poor hygiene).

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Frail elderly female, alert but appears weak, potentially neglected environment.
Response	Alert, turns head to voice, responds verbally with quiet voice. Appears oriented but slow to respond. (AVPU = A)
Airway	Clear and self-maintaining.
Breathing	Rate and depth appear normal. No obvious respiratory distress.
Circulation	Skin pale, appears dry. Radial pulse palpable, regular rate and rhythm.
Disability	Alert (GCS 15), but seems lethargic and weak. No obvious focal deficits noted initially.
Exposure/Environment	Indoor living room. Cluttered environment. Patient appears thin, wearing nightclothes. Assess for signs of injury, hygiene, temperature.

Secondary Survey and Simulation Progression

History (obtained from patient - may be slow or slightly confused)

Allergies	NKDA
Medications	Frusemide, Metoprolol, Paracetamol Osteo. (Medication blister packs visible nearby, some doses appear missed).
Past Medical History	Heart Failure (mild), Hypertension, Osteoarthritis, Macular Degeneration (poor eyesight). Husband died 2 years ago. Limited mobility (uses walker frame usually).
Last Oral Intake	Unsure, "Maybe yesterday?". Reports poor appetite. Cup of tea on table appears cold.
Events Preceding / Current Situation:	Patient states she hasn't felt well for a few days, "just tired and weak". Reports difficulty getting out of her chair due to weakness and knee pain. Has stayed in chair mostly for last 2 days. Admits to missing some medication doses because it was "too hard to get up". Denies any specific fall, chest pain, significant shortness of breath, or acute illness symptoms (fever, cough). Reports reduced fluid intake because "it's hard to get to the toilet". Social Situation: Lives alone. Has daughter who lives interstate, visits infrequently. Neighbour helps with shopping sometimes. No formal care services currently in place.

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	18
Lung Sounds (L/R)	Clear bilaterally.
SpO2 (%)	95% (Room Air)
EtCO2 (mmHg)	Not indicated
Pulse Rate (/min.)	70, regular
CRT (sec.)	3 sec (Slightly delayed)
ECG rhythm	Sinus Rhythm
12-lead ECG	Sinus Rhythm. No acute changes.
BP (mmHg)	110/65 (Slightly low - consider baseline and dehydration)
Skin	Pale, cool peripheries, dry mucous membranes, decreased skin turgor.
Pain (/10)	Reports mild knee pain (3/10), denies other pain.
GCS (/15: E,V,M)	15/15 (E4, V5, M6) - but appears lethargic.
BGL (mmol/L)	6.0
Pupils (mmL/mmR)	Equal and Reactive (PERL).
Temp. (°C)	36.1 (Slightly low)

Physical Examination

General Appearance: Alert but lethargic, frail, thin. Poor personal hygiene noted.
Hydration Status: Dry mucous membranes, decreased skin turgor, slightly delayed CRT. Signs consistent with mild-moderate dehydration.
Mobility: Difficulty standing from chair even with assistance due to weakness and reported knee pain. Walker frame nearby but dusty.
Skin: Check pressure areas (sacrum, heels) - may have redness/early breakdown due to immobility.
Environment: House cluttered and dusty. Limited fresh food visible in kitchen. Multiple medication packs noted, some doses missed. Potential trip hazards.
Neurological: GCS 15, oriented. Moves all limbs but generally weak.
Cardiovascular/Respiratory: Chest clear. Heart sounds normal. No peripheral oedema.

Assessment and Treatment

Appropriate Management Focus

Primary Survey (ABCDE): Confirm no immediate life threats. Identify dehydration, weakness, poor mobility, and potential self-neglect / failure to cope.
Detailed Assessment: Focus on hydration status, nutritional status, mobility, medication compliance, and social supports. Assess home environment for safety and suitability.
Communication & Rapport: Build rapport with patient using empathetic and respectful communication. Assess cognitive function and capacity gently.
Address Immediate Needs: Offer fluids orally if able to tolerate. Assist with mobility if safe. Ensure patient is warm.
Consider Underlying Causes: While no acute illness reported, consider if underlying infection, medication issues, or worsening chronic conditions contributing to decline.
IV Access / Fluids: Consider IV access and cautious fluid administration (e.g., 250-500mL Sodium Chloride 0.9%) if moderate-severe dehydration suspected and oral intake poor, being mindful of heart failure history.
Social & Functional Assessment: Determine patient's ability to manage activities of daily living (ADLs), access food/fluids, manage medications, and maintain personal hygiene. Assess social support network.
Disposition Planning (Crucial):
- **Transport to ED:** Strongly recommended due to functional decline, dehydration, weakness, poor mobility, missed medications, inability to cope at home, and lack of immediate support. Patient is currently unsafe at home.
- Explain rationale for transport clearly and compassionately.
- If patient has capacity and refuses transport: This is a high-risk situation. **Consult with clinical support/supervisor.** Explore all alternatives. Attempt to contact family (with consent). Liaise with police on scene regarding immediate safety concerns. Document refusal, capacity assessment, risks explained, and alternative plan thoroughly. Referral to GP/community services alone is unlikely sufficient for immediate safety.
Referrals (If Transporting): Ensure handover highlights social concerns, functional decline, and need for comprehensive geriatric assessment / social work input in ED.
Teamwork & Communication: Liaise with police regarding entry and initial findings. Communicate plan clearly to patient. Detailed handover to ED focusing on medical and significant social/functional issues.

Debrief Focus Points

Recognizing presentations of "failure to cope" or self-neglect in the elderly.
Importance of assessing social determinants of health (isolation, support systems).
Assessing hydration, nutrition, mobility, and medication management in vulnerable patients.
Environmental assessment for safety and clues to patient's condition.
Communication strategies with frail or potentially confused elderly patients.
Rationale for transport vs. non-transport in complex social/medical situations.
Managing patient refusal in high-risk non-transport scenarios (consultation, documentation).
Importance of interagency collaboration (police, hospital social work, community services).
Comprehensive handover including social and functional concerns.