Haematologist – Myeloma and dementia

Jim was admitted to the general medical ward for observation and further tests. On admission, he became even more agitated and confused. His reports of pain were variable and he became disorientated and distressed after Annie had gone home.

The treating geriatrician suspected Jim had myeloma and sought advice from the Haemato-oncology Centre at a neighbouring hospital. She reported that Jim was reluctant to get out of bed, his mobility had deteriorated further, his pain was variable but he could articulate the level of it. Since being admitted to hospital, she noted that he had increasing difficulties swallowing.

She also added she didn’t think Jim had the capacity to consent to treatment or any necessary tests and procedures, so an incapacity consent form would need to be discussed with Annie and signed.

Q1: Based on the above information, what would the advice be?

It was agreed that Jim did not have the capacity to consent, but Annie was very willing to provide family consent to allow investigations to be carried out.

The results of the serum free light chain test showed that Jim had free kappa (k) light chain levels of 50.4 mg/L (range 3.3 – 19.4 mg/L); free lambda (l) light chain levels of 20.6 mg/L (range 5.7 – 26.3 mg/L) and a free k/l ratio of 2.44 (range 0.26 – 1.65).

No lytic lesions other than those previously observed in the skull were found during the subsequent skeletal survey. There was no evidence of any other bone damage or pathological fractures elsewhere.

A spinal MRI scan was organised but required a transfer to a different hospital. Again, because of the change of environment, it was a distressing ordeal for Jim and he was sedated for the scan.

Spinal fracture was confirmed. There were no signs of soft tissue infiltration and it was not clear whether this was a consequence of osteoporotic fracture or myeloma.

On balance, given Jim’s level of pain, despite given analgesia and the possibility of improvement if myeloma was confirmed, it was agreed that he should be transferred to the nearby Haemato-oncology Centre.

Q2: Jim is now under your care. What would you do?

Jim’s bone marrow biopsy, taken from the iliac crest, exhibited significant degenerative changes and focal fibrosis. Immunohistochemical staining revealed a slight prominence of k light chains and atypical plasma cells with eccentric nuclei. However, plasma cell percentage was borderline for myeloma.

Jim was prescribed oxycodone for his back pain but he found it difficult to swallow the pills and refused to take them. Morphine injections were administered but his facial expressions and body language indicated that this did not provide much relief. Fentanyl patches appeared to provide better pain-relief but it was still difficult to assess the extent of pain Jim was in. He was still reluctant to get out of bed and slept most of the time although he was more alert after a blood transfusion.

Q3: What would you do now?

Jim was diagnosed with non-secretory myeloma. On learning that myeloma was a cancer, Annie became very upset. It was explained to her that treatments were available to reduce the progression and relieve symptoms, but because of the frail state of his health, Jim might not be able to tolerate the anti-myeloma treatment. She asked for time to speak with her family before any treatment was started. She also expressed her alarm that Jim’s health appeared to have declined since being admitted to hospital and was convinced his dementia had worsened.

Jim’s geriatrician was asked to assess him. She felt he was showing signs of delirium rather than a worsening of his dementia and, at this point, was reluctant to prescribe any medication for him. She suggested Annie and the nurses create a safe and secure environment for Jim whilst he was an in-patient with few abrupt changes that might cause distress. She also asked to be included in the multidisciplinary meetings.

After deliberating with her family, Annie agreed the haematologists should do whatever was in Jim’s best interest.

Q4: What would you do now?

It was decided at the MDT that Jim should receive palliative care and be transferred to a hospice. This was explained to Annie who relayed the news to their children. Unfortunately, the two sons did not take the news well and were very reluctant to believe there was no treatment for Jim’s myeloma. They demanded a second opinion.