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Dementia in the new age of telephone consultations during Covid-19

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approaches to dementia care, communication

Working at NHS 111 during the coronavirus pandemic has given me a new insight into the difficulties of living with dementia that I did not expect. Telephone consultations have had to morph from being a useful option B for busy professionals, too strapped for time to make it out to GP surgeries, to an all-important necessity in the face of the devastating pandemic we face today.

As GPs closed their doors back in March and vulnerable patients began their many months of shielding, NHS 111 became a lifeline for medical needs. As a medical student turned call handler I rapidly learnt the ins and outs of telephone history taking and triaging. I soon realised, however, that our formulaic training did not suffice for the communicational nuances that come with the territory of telephone consultations. No more was this apparent than when talking to elderly people with memory difficulties.

At 111, the only past medical history we have is the information from a patient’s previous calls. We do not know the reasons behind a caller’s memory or communicational difficulties and so can only assume a level of dementia, to the detriment of the patient. The confusion that you hear down the phone could be due to encephalopathy, meningitis, medication side effects or even alcoholism but with limited time and information, these important differentials are often disregarded.

A very limited picture of a patient’s state is painted over the phone. The caller’s level of panic, pain and breathlessness can usually be decerned through their voice. Apart from these subtle hints, however, the actual content of conversation is the most important information-gathering one can do over the phone. We are unable to read facial expressions, watch body language or carry out any physical examinations. This is not so much an issue if the caller has an adequate level of English, is articulate in their descriptions, is calling from a quiet location with enough service, is able to describe a clear timeline and answer questions appropriately. This does not happen often unfortunately!

With the added difficulty of dementia on top of an already limited form of communication, the conversations are challenging to say the least. The caller might not know their own demographics, not understand simple questions, become distressed easily or have forgotten how their illness came about. We often get callers who read off a script, repeating the same four sentences throughout the phone call, unable to engage in any form of dialogue.

In light of the covid pandemic, telephone consultations are a vital tool in modern day medicine but are not a perfect fix. I believe it is important for medical students to be trained in how to conduct them and to also be very aware of their limitations. The dangers associated with missing information needs to be recognised so that call handlers learn to be extremely cautious. In the age of apps, algorithms and picture-sending services, nothing can replace the invaluable skills of a face-to-face consultation with an experienced clinician.

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