Civil detentions of older adults under successive Scottish mental health legislation: a comparative analysis.

BACKGROUND: Many countries have adopted new mental health legislation, with the detention of adults for treatment of mental disorders remaining an integral part of such policies. However, there are relatively few publications on the use of mental health legislation in the detention of older adults. This paper examines the civil detention of older adults in one Scottish region under successive mental health legislation. METHOD: This prospective study collected data primarily by clinician-based interviews on all emergency detentions under the Mental Health (Scotland) Act 1984 of older adults in 1994 and compared these with all emergency and initial short-term detentions under the Mental Health (Care and Treatment) (Scotland) Act 2003 of older adults during 2008 in the same Scottish region. RESULTS: There were a total of 124 detentions, with an initial rate of 68 increasing to 141 detentions per 100,000 of the respective over-65 year age populations, a two-fold increase. Compared to the 1994 patient cohort, the 2008 cohort had higher rates of over 85-year-olds (18.4% v 5.4%) and organic mental disorders (74.7% v 56.8%) and were significantly more likely to be detained by consultant psychiatrists (73.6% v 18.9%) during working hours (87.4% v 48.6%) and proceed to six-month detention orders (31% v 10.8%). CONCLUSION: The observed higher rates and longer periods of detention in the 2008 cohort may reflect changes in clinical attitudes and legal requirements from a previous reliance on the common law doctrine of necessity to the requirements of a more legalistic framework, and may signal future clinical requirements, given the aging population, pointing towards the need for earlier recognition and management of clinical issues in an attempt to minimize the "necessity" of clinico-legal intervention.

Detentions of older adults under the Mental Health (Care and Treatment) (Scotland) Act 2003.

This study prospectively examined all initial emergency and short-term detention orders of older adults under the Mental Health (Care and Treatment) (Scotland) Act 2003 in a Scottish health region in 2008 to determine differences in characteristics and outcomes by patients' age, gender and those detained by consultant compared with non-consultant clinicians. Detention order papers were scrutinized, the detaining practitioners were interviewed and case records were examined. Appropriate statistical analyses were performed. For the 87 detentions, subjects were Caucasian, male (54%) and 45% were aged 80 years or older. Ninety-four percent of detentions occurred on a weekday, during working hours (87%), in hospital (67%) with consultants initiating 74% of orders. Detention rates ranged from 66 to 171 per 100,000 over-65s. Seventy-five percent of patients had an organic disorder, 46% exhibiting psychotic symptoms. The older group had higher rates of confusion, organic diagnoses, but lower levels of previous psychiatric admissions. Consultants were more likely to detain patients with a wider variety of disorders, with more admissions to and detentions in psychiatric hospital care. Final detention outcomes were significantly different between the consultant and non-consultant groups. The results indicated few differences between the genders, but differences were more significant between the age cohorts and were further influenced by the grade of the detaining clinician. Further research is required to examine the influence that community mental health teams, advance statements and the use of guardianship and incapacity legislation have on the increasing rates of mental health detentions in the aging population.

New insights on how to adjust the release profile from coated pellets by varying the molecular weight of ethyl cellulose in the coating film.

The major aims of this work were to study the effect of the molecular weight (Mw) of ethyl cellulose (EC) on the drug release profile from metoprolol succinate pellets coated with films comprising EC and hydroxypropyl cellulose (HPC) with a weight ratio of 70:30, and to understand the mechanisms behind the different release profiles. A broad range of Mws was used, and the kinetics of drug release and HPC leaching followed. The higher the Mw of EC, the slower the HPC leaching and the drug release processes. Drug release occurred by diffusion through the pores created in the coating by the HPC leaching. A novel method was used to explain the differences in the release profiles: the effective diffusion coefficient (De) of the drug in the coating film was determined using a mechanistic model and compared to the amount of HPC leached. A linear dependence was found between De and the amount of HPC leached and, importantly, the value of the proportionality constant decreased with increasing Mw of EC. This suggests that the Mw of EC affects the drug release profile by affecting the phase separated microstructure of the coating and the hindrance it imparts to drug diffusion.

Principles, patient welfare and the Adults with Incapacity (Scotland) Act 2000.

The law surrounding decision-making for adults who lose their capacity varies considerably internationally. In many cases legislation has taken a protective and consequently restrictive role for adults with incapacity and often the issue of capacity assessment within the appropriate legal framework is circumvented. In Scotland, the introduction of the Adults with Incapacity (Scotland) Act 2000 modernised that nation's approach to incapable adults. This article describes briefly the pre-2000 Act situation in Scotland, discusses the main provisions of the Act, reviews the use of principles in incapacity legislation in Britain, and discusses issues relating to patient welfare. The use of principles to extend patient autonomy into incapacity is demonstrated and compared with the English and Welsh Mental Capacity Act 2005 (the 2005 Act) through a discussion of how the principles in each of those Acts promotes particular ideologies of decision making. Finally, the article examines recent Scottish case law relating to the 2000 Act and discusses how the courts are currently interpreting the principles of the Act.

A psychiatric intensive care unit for older adults: an interval comparison of admissions.

BACKGROUND: Published information on psychiatric intensive care provision and requirements of older adults is limited. This audit aims to describe and compare demographic data, clinical characteristics and outcomes of patients admitted to a Scottish regional psychiatric intensive care unit (PICU) for older adults during two 18-month periods five years apart. METHOD: Data on all patients admitted to the PICU for older adults during the two sample periods, commencing 2001 and 2006 respectively, were collected prospectively by the clinical care team, and included information on previous psychiatric contact and detentions under mental health legislation, diagnoses, cognitive ratings, reasons for transfer to the PICU, treatments and outcomes. Continuous variables were subject to statistical analyses. RESULTS: Twenty-one and 20 male patients were admitted during the 2001 and 2006 cohorts respectively, with equivalent mean ages of 72.9 years. The majority of patients were married, diagnosed with dementia, with similar levels of previous psychiatric admissions and detentions under mental health legislation. The commonest reason for transfer to the PICU was physical aggression. The 2006 cohort exhibited shorter inpatient stays prior to transfer to, and shorter durations of stay in, the PICU. CONCLUSIONS: The PICU for older adults provides a function similar to the PICU for general adults. The cohorts were similar on most recorded variables, with noted differences possibly reflecting increased awareness and acceptance of the service, reduced tolerance by staff of aggressive behaviors by patients, and enhanced community services in the region. These perceptions warrant further study and clarification.