Changes to Deprivation of Liberty Safeguards and what they mean for clinical practice

290426387_7c1de63f94_zSarah Goldberg is Associate Professor in older persons care at the University of Nottingham; Rowan Harwood is Professor of geriatric medicine at Nottingham University Hospital; Adam Gordon is Honorary Secretary of the British Geriatrics Society and a consultant geriatrician

Health care professionals in England and Wales, have been slightly Janus-faced about Deprivation of Liberty Safeguards (DoLS) since the roll-out in response to the Bournewood judgement in 2008.

On one hand they have been seen as an important adjunct to the 2005 Mental Capacity Act, protecting vulnerable patients from the worst vagaries of best interest assessments. On the other hand, they are considered logistically burdensome, generating both additional paperwork and workload for hard-pressed health and social care professionals.

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Deprivation of liberty safeguards

In March this year, the Supreme Court handed down its judgement on two cases which will have significant impact in determining whether arrangements made for the care and/or treatment of an individual lacking capacity to consent to those arrangements amount to a deprivation of liberty.shutterstock_46716664

Key points of the Supreme Court Judgement: The Court ruled that there is a deprivation of liberty in terms of Article 5 of the European Convention on Human Rights if the person is under continuous supervision and control and is not free to leave, and the person lacks capacity to consent to these arrangements. Whether the person objects to the arrangement or not is irrelevant, as is the ‘relative normality of the placement in the context of the person’s needs.’ Continue reading

A new look at case reports in Age and Ageing journal

David Stott is Professor of Geriatric Medicine at the Institute of Cardiovascular and Medical Sciences at the University of Glasgow and is Editor in Chief for Age and Ageing journal. Here he introduces two case reports from the latest issue of the journal.Web

The inclusion of case reports in Age and Ageing emphasises the clinical focus of the journal. Typically they illustrate either classic presentations of uncommon diseases or unusual presentations or aspects of common diseases in older people. At their best case reports provide a blueprint for high-quality clinical decision making and health care in ‘tricky’ cases. They often carry general lessons that can be learned from specific challenging circumstances. Case reports are generally valued by our readers, providing clinical education and giving balance to the journal’s content.

In the current issue of the journal we report a case of an unusual infection causing acute neurological deterioration (a stroke mimic), and of a rare but treatable disease, Anti-N-Methyl-D-Aspartate (NMDA) receptor encephalopathy. In both these cases failure to make the diagnosis would likely have carried catastrophic consequences.

In this issue we have a new development, adding a short expert commentary by Tom Hughes (from Cardiff) to the case reports which places them in a wider context, helping to bring the implications of the cases to the fore. Continue reading

Good mental health care is a part of good geriatrics

Tom Dening is Professor of Dementia Research at the Institute of Mental Health at the University of Nottingham. He tweets at @TomDening shutterstock_162166118

Sir Simon Wessely (yes, we are going through a phase where the RCPsych Presidents get gongs – I suppose it’s cheaper than investing in mental health services) has made some eloquent points about the current state of mental health provision.

He didn’t specifically mention older people, though of course they have common mental disorders like depression. Also he didn’t talk about the complex world where physical and mental ill health conspire against people and bring them into contact with geriatrics or old age psychiatry, or both. Continue reading

When simple is no longer simple

Lawla Law has recently published her paper Effects of functional tasks exercise on older adults with cognitive impairment at risk of Alzheimer’s disease: a randomised controlled trial in Age and Ageing journal. This week she described the findings of the trial on the OUP blog:

Cognitive impairment is a common problem in older adults, and one which increases in prevalence with age with or without the presence of pathology. Brain AgingPersons with mild cognitive impairment (MCI) have difficulties in daily functioning, especially in complex everyday tasks that rely heavily on memory and reasoning. This imposes a potential impact on the safety and quality of life of the person with MCI as well as increasing the burden on the care-giver and overall society. Individuals with MCI are at high risk of progressing to Alzheimer’s diseases (AD) and other dementias, with a reported conversion rate of up to 60-100% in 5-10 years. These signify the need to identify effective interventions to delay or even revert the disease progression in populations with MCI.

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Sow’s Ear: Silk Purse – with a little help from our friends

Dave Jolley is an Honorary Reader in Old Age Psychiatry at the University of Manchester. Claire Hilton is a Consultant Old Age Psychiatrist at Central and North West London NHS Foundation Trust’s Older People and Healthy Ageing Service. Their editorial Fit for purpose? Dementia and the healthcare professions was recently published in Age and Ageing journal.shutterstock_144783289

Deborah Mayne and her colleagues find that even geriatricians who are prepared to be identified as Dementia Champions fear they do not know enough about dementia and had to struggle to obtain sufficient and appropriate education in their training years.

Most of the morbidity of the population is compressed into late life and multiple pathologies commonly occur across the physical-mental spectrum.  Among older people, dementia is found nearly everywhere; depression, anxiety and delirium are common; and sometimes other mental disorders are found.   Continue reading

Links between depression and syncope in older people

Jaspreet Bhangu is a Clinical Research Fellow and Specialist Registrar in Geriatric Medicine in Dublin Ireland. His paper The relationship between syncope, depression and anti-depressant use in older adults was recently published in Age and Ageing journal.depression and syncope

The Irish LongituDinal study on Ageing (TILDA) is a large scale, nationally representative, study on ageing in Ireland. TILDA collects information on all aspects of health, economic and social circumstances from people aged 50 and over in a series of data collection waves once every two years. In addition to providing vital information for strategic planning and policy for older people in Ireland, it provides a rich scientific database to further study common diseases in older adults.  It has recruited over 8000 people and has captured important data on falls and syncope in older people. Continue reading

Mental wellbeing of older people in care homes

The BGS is one of many organisations who support the National Institute for Health and Care Excellence (NICE) in their commitment to improve quality standards for mental wellbeing of older people in care homes.shutterstock_45554728

NICE has published a new quality standard to help care homes tackle loneliness, depression and low self-esteem in older people. Also available is the NICE Pathway for mental wellbeing and older people overview, which sets out the guidance and resources in a simple format. Continue reading

Is the Abbreviated Mental Test Score the best we’ve got?

Dr Thomas Jackson and Professor John Gladman discuss a recent review of screening tools for dementia in general hospitals.shutterstock_88989310

Thomas Jackson says:

Geriatricians will often diagnose dementia for the first time in hospital as a crisis admission. Here the diagnosis is usually straightforward but we are left with a feeling that the crisis may have been preventable had a diagnosis been made earlier. Dementia is very much a hot topic at the moment. There has been the recent political drive to raise rates of diagnosis through an appeal by the Prime Minister and introduction of a financial incentive to improve dementia detection in hospitals (a Commissioning for Quality Innovation Payment or CQUIN). Getting the diagnosis of dementia right, and in a timely fashion, is important for the patient, their carers and medical professionals looking after them. Diagnosis gives reassurance to patients and carers about worrying symptoms, as well as allowing access to specialised health and social care services. Making the diagnosis in hospital enables healthcare professionals to ensure they get the best care.  However, we need the right tools to help us get things right.  Continue reading

A specialist medical and mental health unit

Dr Rowan Harwood is‎ a consultant physician, professor of geriatric medicine at Nottingham University Hospital NHS Trust

There is a lot of criticism of how we manage cognitively impaired patients in acute hospitals. And advice on how to do it better. The hope has been that more expert and co-ordinated services would improve outcomes and save resources. But there has been little in the way of rigorous evaluation.

We developed a specialist medical and mental health unit with the ambitious objective of demonstrating best practice. We enhanced the ward environment, ward staffing and skill mix, including mental health specialist nurses, therapists and psychiatry, trained all staff to a high level in the person centred philosophy of care, and endeavoured to engage family carers more fully.

After 18 months of operation we ran a randomised controlled trial, published in the BMJ. This video abstract describes the intervention and trial results.To illustrate the challenges and capture the essence of compassionate person-centred care, we made a 23 minute documentary, called Today is Monday. Footage from this is used to illustrate the abstract.

The full 23-minute film is available for training purposes; interested readers are welcome to discuss this with me Rowan.Harwood@nuh.nhs.uk.