Nurse – 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. The advice from the Haemato-oncology centre was to order a serum free light chain test in the first instance.

Q1: As the nurse involved with Jim’s care, what would be the priority to consider when discussing the investigation that may need to be done to reach a diagnosis?

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 for further diagnostic testing.

Q2: As the decision has been made that a bone marrow biopsy is no longer avoidable, what would you see as your role now?

Jim’s bone marrow biopsy showed significant degenerative changes and focal fibrosis. Immunohistochemical staining revealed prominence of k light chains and a high percentage of abnormal plasma cells that was indicative of myeloma.

Q3: At this point, can you identify any holistic needs that may need addressing for Jim?

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. There are a number of options to consider: CTDa, Velcade, MPT or palliation.

Q4: As Annie wants the haematologists to do whatever is in Jim’s best interests – how should the decision to treat be made?

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.

Q5: What do you see as your role in this situation?