Deathbed wills: assessing testamentary capacity in the dying patient.

BACKGROUND: Deathbed wills by their nature are susceptible to challenge. Clinicians are frequently invited to give expert opinion about a dying testator's testamentary capacity and/or vulnerability to undue influence either contemporaneously, when the will is made, or retrospectively upon a subsequent challenge, yet there is minimal discourse in this area to assist practice. METHODS: The IPA Capacity Taskforce explored the issue of deathbed wills to provide clinicians with an approach to the assessment of testamentary capacity at the end of life. A systematic review searching PubMed and Medline using the terms: "deathbed and wills," "deathbed and testamentary capacity," and "dying and testamentary capacity" yielded one English-language paper. A search of the individual terms "testamentary capacity" and "deathbed" yielded one additional relevant paper. A focused selective review was conducted using these papers and related terms such as "delirium and palliative care." We present two cases to illustrate the key issues here. RESULTS: Dying testators are vulnerable to delirium and other physical and psychological comorbidities. Delirium, highly prevalent amongst terminal patients and manifesting as either a hyperactive or hypoactive state, is commonly missed and poorly documented. Whether the person has testamentary capacity depends on whether they satisfy the Banks v Goodfellow legal criteria and whether they are free from undue influence. Regardless of the clinical diagnosis, the ultimate question is can the testator execute a specific will with due consideration to its complexity and the person's circumstances? CONCLUSIONS: Dual ethical principles of promoting autonomy of older people with mental disorders whilst protecting them against abuse and exploitation are at stake here. To date, there has been scant discourse in the scientific literature regarding this issue.

Practical guidelines for the acute emergency sedation of the severely agitated older patient.

The vulnerability of older people to serious underlying medical illness and adverse effects of psychotropics means that the safe and effective treatment of severe agitation can be lifesaving, the primary management goals being to create a safe environment for the patient and others, and to facilitate assessment and treatment. We review the literature on acute sedation and provide practical guidelines for the management of this problem addressing a range of issues, including aetiology, assessment, pharmacological and non-pharmacological strategies, restraint and consent. The assessment of the agitated older patient must include concurrent assessment of the likely aetiology of, the risks posed by, and the risks/benefits of management options for, the agitation. A range of environmental modifications and non-pharmacological strategies might be implemented to maximize the safety of the patient and others. Physical restraints should only be considered after appropriate assessment and trial of alternative management and if the risk of restraint is less than the risk of the behaviour. Limited evidence supports a range of pharmacological options from traditional antipsychotics to atypical antipsychotics and benzodiazepines. It is advised to start low and go slow, using small increments of dose increase. Medical staff are frequently called to sedate agitated older patients in hospital settings, often after hours, with limited access to relevant medical information and history. Safe and effective management necessitates adequate assessment of the aetiology of the agitation, exhausting all non-pharmacological strategies, and resorting to pharmacological and/or physical restraint only when necessary, judiciously and for a short-term period, with frequent review and the obtaining of consent as soon as possible.

Creative solutions for severe dementia with BPSD: a case of art therapy used in an inpatient and residential care setting.

Behavioral and psychological symptoms of dementia (BPSD) are common, distressing and compromise care. Their diverse etiology necessitates targeted, individualized treatment. We present a case of an 82-year-old with severe dementia and BPSD, and with limited response to a range of pharmacological and non-pharmacological treatments. Individualized art therapy was developed in an inpatient setting using felt material cut into shapes and coloring with stencils and pre-drawn line drawings utilizing preserved skills of coloring, while supporting frontal-executive and language deficits. The activity was replicable and carried over to the residential care setting and supported by family and professional carers.

World psychiatric association section of old age psychiatry consensus statement on ethics and capacity in older people with mental disorders.

The World Psychiatric Association (WPA) Section of Old Age Psychiatry, since 1997, has developed Consensus Statements relevant to the practice of Old Age Psychiatry. Since 2006 the Section has worked to develop a Consensus Statement on Ethics and Capacity in older people with mental disorders, which was completed in Prague, September 2008, prior to the World Congress in Psychiatry. This Consensus meets one of the goals of the WPA Action Plan 2008-2011, "to promote the highest ethical standards in psychiatric practice and advocate the rights of persons with mental disorders in all regions of the world". This Consensus Statement offers to mental health clinicians caring for older people with mental disorders, caregivers, other health professionals and the general public the setting out of and discourse in ethical principles which can often be complex and challenging, supported by practical guidance in meeting such ethical needs and standards, and to encouraged good clinical practice.

Secrets to psychological success: why older doctors might have lower psychological distress and burnout than younger doctors.

BACKGROUND: Doctors have long been exposed to situations that can induce psychological distress. Long hours, little acknowledgement, poor sleep and high-stress work environments all contribute to making doctors prone to psychological distress and burnout, which have been much studied in younger doctors, but less so in older doctors. Little is known about whether there are differences in psychological distress among different age groups of doctors. METHODS: Doctors (n = 158) were recruited from in and around the St George Hospital, a major teaching hospital in Sydney, Australia. Participants completed a self-report questionnaire, comprising the Maslach Burnout Inventory (MBI), and Kessler 10 Psychological Distress Scale. Demographic details were collected. A subsample (n = 51) completed a semi-structured interview about issues related to burnout. These data were subjected to qualitative analysis. RESULTS: Older doctors and doctors with more years of experience had significantly lower scores on MBI subscales of Depersonalization and Emotional exhaustion, and K-10 measured psychological distress. Aspects of working conditions such as being in private practice were associated with increased scores on MBI subscales of Personal accomplishment, and lower scores on MBI subscales of Emotional exhaustion and Depersonalization, and K-10 measured psychological distress. Older doctors more frequently worked in private practice. These quantitative findings were supported by the qualitative data that suggested that older doctors perceived that they experienced less psychological distress compared with earlier in their careers, which they attributed to the development of protective defences in their relationship with patients and the liberation afforded by accumulation of experience and changed work conditions. CONCLUSIONS: Findings from this study suggest that older, more experienced doctors report lower psychological distress and burnout than younger doctors which the older doctors attributed to lessons learned over their years of training and practice. It may be of considerable value to find ways to more efficiently pass on these lessons to younger doctors to aid them in dealing with this challenging profession. By soliciting older doctors to aid in this transfer of knowledge, this approach may also have the added benefit of assisting older doctors in transitioning from an active clinical practice to a role of mentoring the new physician cohort.

The wills of older people: risk factors for undue influence.

BACKGROUND: As people live longer, there is increasing potential for mental disorders to interfere with testamentary distribution and render older people more vulnerable to "undue influence" when they are making a will. Accordingly, clinicians dealing with the mental disorders of older people will be called upon increasingly to advise the courts about a person's vulnerability to undue influence. METHOD: A Subcommittee of the IPA Task Force on Testamentary Capacity and Undue Influence undertook to establish consensus on the definition of undue influence and the provision of guidelines for expert assessment of risk factors for undue influence. RESULTS: International jurisdictions differ in their approach to the notion of undue influence. Despite differences in legal systems, from a clinical perspective, the subcommittee identified some common "red flags" which might alert the expert to risk of undue influence. These include: (i) social or environmental risk factors such as dependency, isolation, family conflict and recent bereavement; (ii) psychological and physical risk factors such as physical disability, deathbed wills, sexual bargaining, personality disorders, substance abuse and mental disorders including dementia, delirium, mood and paranoid disorders; and (iii) legal risk factors such as unnatural provisions in a will, or provisions not in keeping with previous wishes of the person making the will, and the instigation or procurement of a will by a beneficiary. CONCLUSION: This review provides some guidance for experts who are requested by the courts to provide an opinion on the risk of undue influence. Whilst international jurisdictions require different thresholds of proof for a finding of undue influence, there is good international consensus on the clinical indicators for the concept.

Australian pathways and solutions for dealing with older impaired doctors: a prevention model.

Our ageing medical workforce poses many challenges, not the least of which is acknowledging the contributions of ageing practitioners who continue to practise safely and competently while ensuring that those who are incompetent by virtue of impairment are identified, assessed and either rehabilitated or encouraged to retire. Hitherto, there has been little attempt to review approaches to impairment on a national basis in Australia, let alone with a focus on older doctors. Information regarding pathways for dealing with impairment was obtained from the websites and confirmed by representatives of regulatory bodies of every state or territory in Australia. Using a prevention model we outline the current Australian regulatory processes, address some of the barriers and suggest some solutions to dealing with the older impaired doctor. Much of the focus in dealing with the older impaired doctor is tertiary prevention based, that is, reducing the negative influence of established impairment. There is some uniformity in the way that Australian regulatory bodies deal with impairment that espouses the dual goals of protecting the public and rehabilitating the doctor. The approach is typically individualized and multi-levelled, beginning with assessment followed by rehabilitation where appropriate. A range of secondary and primary prevention measures is proposed for dealing with the problem of the older impaired doctor. These include educating the medical community, encouraging early notification and facilitating career planning and timely retirement of older doctors. This will have benefits both in protecting the public as well as preventing an undignified and humiliating end to often-unblemished careers in medicine.

Physician don't heal thyself: a descriptive study of impaired older doctors.

BACKGROUND: The growing and welcome interest in the issues leading to distress and impairment in younger doctors has not been mirrored by a focus on the similar issues in older doctors which is surprising given the aging medical workforce. OBJECTIVES: To improve understanding of impairment in older doctors and to facilitate the planning of primary prevention strategies. METHOD: Consecutive case records of notifications to the Impaired Registrants Program of the New South Wales Medical Board, Australia, of doctors over 60 years from January 2000 to January 2006 (N = 41) were examined. Details of demographics, type of practice, nature of referral, medical morbidity, cognitive examination, psychiatric diagnosis and outcome of assessment were recorded. RESULTS: Impaired older doctors suffered cognitive impairment (54%), substance abuse (29%) and depression (22%) and 17% had two comorbid psychiatric conditions. Twelve percent had frank dementia. Two work patterns--the "workhorse" and the "dabbler"--were observed, as was a culture of postponed retirement due to a sense of obligation and working "until you drop." Impaired older doctors were found to have higher chronic illness burden compared with community norms. Almost half were the subject of patient complaints or of poor performance within ten years of presentation. CONCLUSION: To our knowledge there has been no other comprehensive examination of patterns of impairment in older doctors. Older doctors are prone to suffer "the four Ds": dementia, drugs, drink and depression. We need to encourage mature doctors to adapt to age-related changes and illness and validate their right to timely and appropriate retirement.

Investigation of Alzheimer's disease-related pathology in community dwelling older subjects who committed suicide.

BACKGROUND: Older people have a higher risk of completed suicide than any other age group worldwide. The contribution of neurodegenerative disease to this risk remains controversial. AIMS: To investigate prevalence of Alzheimer's disease-related (AD) pathology in older suicide victims. METHODS: Ratings of AD pathology using Braak and CERAD protocols were compared in 143 community-dwelling suicide victims aged 65 years or more and 59 motor vehicle accident victims autopsied at the request of an Australian Coroner's Court. RESULTS: There were no significant differences in plaque score or neurofibrillary tangle staging between suicide and control groups. None of the subjects with a history of dementia had neuropathologically confirmed AD. CONCLUSIONS: Our study is the second and largest investigation of the prevalence of AD neuropathology in the elderly suicide population. Unlike the previous study, we did not find an increased prevalence of AD neuropathology despite a history of dementia in 6.3%, implicating other pathologies such as Lewy Body or Vascular dementia in the aetiology of dementia in elderly suicide victims.

Children of a cohort of depressed patients 25 years later: psychopathology and relationships.

BACKGROUND: While many studies have examined cross-sectional or short-term effects of parental depression on children, few have studied such children many years later when they reach adulthood. It was hypothesised that children of patients hospitalised for depression 25 years ago would have more psychological morbidity and relationship difficulties than children of a surgical comparison group. METHOD: Children (n=94) of depressed patients and a surgical control group (n=31) admitted to a teaching hospital 25 years ago were compared on measures of psychiatric morbidity, personality, marital and family relationships. RESULTS: Compared with control children, children of depressed patients demonstrated trends for higher rates of non-phobic anxiety and substance disorders, but neither psychological morbidity overall nor affective disorder specifically. Compared with control children, children of depressed patients rated their relationships with fathers who were spouses of female patients more negatively. Having consciously tried to make their own intimate relationships different from that of their parents, children of depressed patients and their partners reported significantly more caring in their relationships compared with control children and their partners. CONCLUSION: In this study of the effects of parental depression on children 25 years on, adult children of depressed patients demonstrated significant resilience as evidenced by similar rates of overall psychiatric morbidity and quality of intimate relationships to controls. They may be at risk for specific disorders such as anxiety and substance disorder and have problematic relationships with the "well" spouses of depressed patients particularly if the "well" spouse is their father.

Neuropsychological performance and dementia in depressed patients after 25-year follow-up: a controlled study.

BACKGROUND: Previous research has yielded conflicting evidence regarding the long-term cognitive outcome of depression. Some studies have found evidence for a higher incidence of subsequent cognitive impairment or dementia, while others have refuted this. METHOD: Depression, neuropsychological performance, functional ability and clinical variables were assessed in a sample of patients who had been hospitalized for depression 25 years previously. RESULTS: Data were available on 71 depressed patients (10 of whom were deceased) and 50 surgical controls. No significant differences were found between depressed subjects and controls on any neuropsychological measure. Ten depressed patients but no controls were found to have dementia at follow-up (continuity corrected chi2 = 5.93, P < 0.01). Presence of dementia was predicted by older age at baseline. Vascular dementia was the most common type. CONCLUSIONS: We conclude that this study did not find evidence that early onset depression is a risk factor for Alzheimer's disease, but that for a small subgroup there appears to be a link with vascular dementia. Several plausible explanations for this link, such as lifestyle factors, require further investigation.

A 25-year longitudinal, comparison study of the outcome of depression.

BACKGROUND: There is still a relative paucity of information about the long-term course of depression. METHODS: Consecutive patients admitted to a teaching hospital psychiatry unit with symptoms of depression, previously assessed at 6 months and 2, 5 and 15 years after index admission, were reviewed at 25 years (N = 49, including eight informants of deceased probands, of an original 145 with major depression (DEPs)). Prospective psychiatric (N = 22) and retrospective surgical (N = 50) control groups assessed after 25 years were used for comparison. RESULTS: A further decade of follow-up confirmed the chronicity of depression. Of depressed patients (DEPs) followed for the full 25-year-period only 12% of the 49 original DEPs recovered and remained continuously well, 84% experienced recurrences, 2% experienced an unremitting course and another 2% died by suicide. Note that in the first 15-year-period 6% (9/145 DEPs) committed suicide, a further 38 died and 32 were lost to follow-up. They experienced an average of three episodes of depression over the 25 years. In the decade since the 15-year follow-up, 27% improved in clinical outcome (including four of five previously chronically depressed patients), 55% remained unchanged and 18% worsened; and the number of episodes per year declined. Patients initially diagnosed with neurotic or endogenous depression had similar long-term outcomes. The criteria for a current DSM-III-R disorder were met by 37% of DEPs, including 11% with depression or dysthymia. On the global assessment of functioning scale 78% of the DEPs had some impairment compared to 62% of psychiatric controls and 40% of surgical controls. CONCLUSION: Even after 25 years, severe depressive disorders appear to have poor long-term outcomes. Patients with chronic outcomes over 15 years can improve when followed over longer periods.

Practical guidelines for the treatment of behavioural complications of dementia.

A step-by-step approach to management of behavioural problems in dementia is outlined. Initial strategies include assessment of the underlying cause and consideration of non-pharmacological methods of treatment. If pharmacotherapy is required, the altered pharmacokinetics in the elderly and the variable efficacy of different psychotropic drugs should be kept in mind. Recommendations regarding drug dosage, monitoring and review are given.

Caring for the institutionalised elderly: how easy is it?

In the light of long-standing criticism of nursing homes an assessment of staff's ability to provide care was required. By creating a profile of nursing home staff it may be possible to explain and predict difficulties in providing care. One hundred and five staff from 15 nursing homes and 18 hostel staff were interviewed to examine demographic characteristics, attitudes to the job and to the elderly, as well as sources of stress in the workplace. Staff were predominantly female, with children, and had a strong sense of altruism and desire to nurture. They foster an atmosphere of care and protection and may unwittingly encourage dependence. This may preclude challenge and rehabilitation for nursing home residents. Constraints such as staff shortages, stress (35.3 per cent cases on the General Health Questionnaire), lack of training, conflict among staff and lack of support may hamper care. These problems could be addressed by additional training and incentives for staff, increased staff cooperation and communication. Medical practitioners and other health professionals have a significant role to play in assuming greater responsibility for supporting the caregivers in nursing homes.