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Determining decision-making capacity is part of everyday business for health care professionals working with older adults. We used a modified Delphi approach to develop an inclusive curriculum for a capacity education e-tool with global application and clinical relevance to a range of disciplines. The tool comprised: (i) 25 questions forming a “pre-test” for the adaptive and personalized e-Learning platform; (ii) a learning module based on the participant’s response to the “pre-test”; (iii) a “post-test” (the same baseline 25 questions) to test knowledge translation. The tool was tested on 31 health care professionals across Israel (8), Canada (15), and Australia (8) from the following disciplines: General Practitioners (GP) (19), Internal Medicine (1), Palliative Care GP (2); Palliative Care Physician (2), Geriatrician (2); and one of each: Psychologist, Occupational Therapist, Psychiatrist, Aged Care Researcher, and Aged Care Pharmacist. The mean baseline pre-test score was 19.1/25 (S.D. =1.61; range 15–22) and post-test score 21.7/25 (S.D.= 1.42; range 18–24); with a highly significant improvement in test scores (paired t-test P < 0.0001; t=10.81 on 30 df). This is the first such pilot study to demonstrate that generic capacity principles can be taught to health care professionals from different disciplines regardless of jurisdiction.
To follow-up a cohort of older people who self-harmed, their carer, and general practitioner (GP) and examine their reflections on the self-harm, care experiences, and outcomes.
Qualitative in-depth interviews.
Two teaching hospitals and associated community services.
Twelve-month follow-up of participants aged 80 or older who self-harmed, their nominated carers, and GPs.
A geriatric psychiatrist gathered data through patient and carer interviews using a narrative inquiry approach and from medical records. Interviews were audio recorded and transcribed. N-VIVO facilitated data organization for thematic analysis. Questionnaires sent to the patient’s GP examined their perspectives and aspects of care relating to the self-harm.
Nineteen patients (63% baseline sample), 29 carers (90.6%), and 11 GPs (36.7%) were available at follow-up. Themes emerging from patients were “denial and secrets;” “endless suffering;” “more invalidation;” “being heard;” and “miserable in care.” Themes from carer interviews were “denial and secrets;” “patient’s persistent wish to die;” “abandonment by clinicians;” “unending burden for the carer;” and “distress regarding placement.” General practitioner themes were “the problem is fixed;” “the troops have arrived;” and “I understand.”
Factors contributing to self-harm persisted at follow-up. Positive and negative responses were identified in the older person’s system, highlighting areas for potential intervention. A conceptual framework for understanding self-harm in the very old was derived that emphasized the importance of understanding individual needs, the interpersonal context of the older person, and carer burden. Interventions should improve communication, facilitate shared understanding of perspectives, and provide support at all levels.
India, along with the rest of the world, is aging rapidly, but more so. Of a total population of over 1.2 billion, the aging population over 60 years is 109 million, projected to rise above 300 million by the year 2050, exceeding the younger population. One important ramification of this highly populous and under-resourced setting is that it provides a ripe environment for elder abuse (Chokkanathan and Lee, 2005), a problem besetting vulnerable aging populations globally (Patterson and Ploeg, 2007).
Behavioral and psychological symptoms of dementia (BPSD) are virtually ubiquitous in dementia. Excessive recourse to use of psychotropics which have high risk to benefit ratio remains a global problem. We aimed to identify components of quality prescribing in BPSD to develop a tool for quality prescribing and to test this tool.
We used Delphi methodology to identify elements of quality prescribing in BPSD. The tool was tested by a range of medical and nursing professionals on 48 patients, in inpatient and ambulatory settings in Northern Sydney Local Health District, Australia.
Consensual opinion using Delphi method was that quality prescribing in dementia comprised ten factors including failure to use first line non-pharmacological strategies, indication, choice of drug, consent, dosage, mode of administration, titration, polypharmacy, toxicity, and review. These elements formed the quality use of medications in dementia (QUM-D) tool, lower scores of which reflected quality prescribing, with a possible range of scores from 0 to 30. When inter-rater reliability was tested on a subgroup of raters, QUM-D showed high inter-rater reliability. A significant reduction in QUM-D scores was demonstrated from baseline to follow-up, mean difference being 5.3 (SD = 3.8; 95% confidence interval 4.1–6.4; t = 9.5; df = 47; p < 0.001). There was also a significant reduction in score from baseline to follow-up when rated by clinical nurse consultants from a specialized behavior assessment management service (BAMS) (N = 12).
The QUM-D is a tool which may help to improve quality prescribing practices in the context of BPSD. In this setting, we consider quality prescribing, and accordingly the obligations of prescribers, to be an inclusive concept rather than just adding to the mantra of “not prescribing.”
The International Psychogeriatric Association (IPA) capacity taskforce was established to promote the autonomy, proper access to care, and dignity of persons with decision-making disabilities (DMDs) across nations. The Asia Consortium of the taskforce was established to pursue these goals in the Asia-Pacific region. This paper is part of the Asia Consortium's initiative to promote understanding and advocacy in regard to surrogate decision-making across the region.
The current guardianship laws are compared, and jurisdictional variations in the processes for proxy decision-making to support persons with DMDs and other health and social needs in China, Japan, Thailand, and Australia are explored.
The different Asia-Pacific countries have various proxy decision-making mechanisms in place for persons with DMDs, which are both formalized according to common law, civil law, and other legislation, and shaped by cultural practices. Various processes for guardianship and mechanisms for medical decision-making and asset management exist across the region. Processes that are still evolving across the region include those that facilitate advanced planning as a result of the paucity of legal structures for enduring powers of attorney (EPA) and guardianship in some regions, and the struggle to achieve consensual positions in regard to end-of-life decision-making. Formal processes for supporting decision-making are yet to be developed.
The diverse legal approaches to guardianship and administration must be understood to meet the challenges of the rapidly ageing population in the Asia-Pacific region. Commonalities in the solutions and difficulties faced in encountering these challenges have global significance.
The leaving of a will prior to death by suicide is a relatively
To determine the frequency and details of will content in suicide
Coroner records for 1565 deaths by suicide in Toronto (2003–2009) were
reviewed for (a) will content and (b) the presence of depression,
psychotic illness, dementia and intoxication prior to death.
In total, 59 (20.7%) of 285 available suicide notes were found to have
will content. Of those who left a will, 43 (72.9%) were reported to have
a major mood or psychotic disorder, but none had dementia. Fifteen of 19
toxicology samples showed alcohol, sedative hypnotic/benzodiazepine,
opioid and/or recreational drugs were present.
A substantial minority of suicide notes may also include testamentary
intent. The observed high rate of mental illness and substance use around
the time of death has important clinical implications for understanding
the mindset of people who die by suicide and hence also legal
implications regarding testamentary capacity.
Mental health professionals are frequently involved in mental capacity determinations. However, there is a lack of specific measures and well-defined procedures for these evaluations. The main purpose of this paper is to provide a review of financial and testamentary capacity evaluation procedures, including not only the traditional neuropsychological and functional assessment but also the more recently developed forensic assessment instruments (FAIs), which have been developed to provide a specialized answer to legal systems regarding civil competencies.
Here the main guidelines, papers, and other references are reviewed in order to achieve a complete and comprehensive selection of instruments used in the assessment of financial and testamentary capacity.
Although some specific measures for financial abilities have been developed recently, the same is not true for testamentary capacity. Here are presented several instruments or methodologies for assessing financial and testamentary capacity, including neuropsychological assessment, functional assessment scales, performance based functional assessment instruments, and specific FAIs.
FAIs are the only specific instruments intended to provide a specific and direct answer to the assessment of financial capacity based on legal systems. Considering the need to move from a diagnostic to a functional approach in financial and testamentary capacity evaluations, it is essential to consider both general functional examination as well as cognitive functioning.