Mental capacity to consent to treatment and admission decisions in older adult psychiatric inpatients

Abstract

Patients can have capacity to make decisions in one area but not in others. Many people are admitted and treated in a way that is contrary to the human rights legislation. The new Deprivation of Liberty Safeguards in England and Wales are likely to apply to a significant proportion of older inpatients. Most people wanted doctors to make treatment and admission decisions and very few wanted their family to make decisions on their behalf.

Consent in Impaired Populations

“…Using cutoffs derived from an earlier study, they concluded that the proportion of subjects impaired on at least one competence-related function was 20% for the depressed group, 54% for those with schizophrenia, and 68% for those with AD. Indeed, when decisional competence was assessed among 99 newly admitted elderly psychiatric patients in a British study using the MacCAT-T, a clinical diagnosis of any type of dementia was the strongest predictor of incapacity, followed by insight and MMSE score [18]. Of interest, in the German study, attending physicians tended to be less sensitive than the MacCAT-T in detecting impairment.…”

“…Perhaps expectedly given the level of cognitive impairment, the group showed extremely poor performance on understanding and appreciation; reasoning could not even be assessed in subjects with this degree of disability. Lai et al [36] developed a measure of capacity to make decisions about everyday life and tested it in 39 patients with diagnoses ranging from MCI to moderate dementia (MMSE score, [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30]. Performance showed moderate to strong correlations with MMSE and MacCAT-T scores.…”

“…Karlawish et al [7] came up with roughly comparable findings in 44 patients with AD of varying severity but suggested that the upperlevel cutoff might be set at ≥23, although that would allow a small percentage of incapable patients to go undetected. However, everyone agrees that the MMSE should be used only as a screening device and that for difficult cases, especially in the intermediate range of scores (roughly [18][19][20][21][22][23][24][25] in which the MMSE is of limited utility, a more focused competence assessment is required.…”

“…Karlawish et al [7], for example, tested 48 patients with very mild (Mini-Mental State Examination [MMSE] score >23), mild (MMSE score 20-23), and moderate (MMSE score [11][12][13][14][15][16][17][18][19] Alzheimer's dementia (AD) with the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) [8], the most widely used instrument in studies of treatment competence, and compared their scores with those of 102 family caregivers. Demented patients scored lower on all four scales-understanding, appreciation, reasoning, and choice-and were more likely to be rated incompetent by three independent psychiatrists who reviewed audiotapes of the interviews.…”

Facilitating decision-making by people with dementia: is spousal support gendered?

“…of Health, 2005); for example, equating the presence of dementia with a lack of capacity. Similarly, whilst people with severe dementia may have more impaired capacity overall (for example, Maxmin et al 2009), nonetheless, as they can retain capacity in particular areas, their 'decision-specific' capacity must be assessed before making decisions on their behalf. The Act covers health care, personal welfare, financial and property decisions (for example, Sections 17 and 18).…”