Disorders of Consciousness, Past, Present, and Future.

This paper, presented as the 2019 Cambridge Quarterly Neuroethics Network Charcot Lecture, traces the nosology of disorders of consciousness in light of 2018 practice guidelines promulgated by the American Academy of Neurology, the American College of Rehabilitation Medicine and the National Institute on Disability, Independent Living and Rehabilitation Research. By exploring the ancient origins of Jennett and Plum's persistent vegetative state and subsequent refinements in the classification of disorders of consciousness-epitomized by the minimally conscious state, cognitive motor dissociation, and the recently described chronic vegetative state-the author argues that there is a counter-narrative to the one linking these conditions to the right to die. Instead, there is a more nuanced schema distinguishing futility from utility, informed by technical advances now able to identify covert consciousness contemplated by Jennett and Plum. Their prescience foreshadows recent developments in the disorders of consciousness literature yielding a layered legacy with implications for society's normative and legal obligations to these patients.

Are Randomized Control Trials the Best Method to Assess the Effectiveness of Community Treatment Orders?

Many jurisdictions have enacted community treatment order (CTO) legislation that requires a person, who suffers from a severe mental disorder, to follow a treatment plan when living in the community. CTOs have been a source of debate because of controversies on whether evidence of effectiveness should only be considered from randomized controlled trials (RCTs). RCTs are considered the "gold standard" method to evaluate effectiveness of simple therapeutic interventions such as medication, but they are problematic for evaluation of complex interventions because valid attribution of causation in complex interventions is not guaranteed with RCTs. CTOs are complex interventions that require the interaction of many individuals and organizations to achieve their effects and effectiveness research must measure these complexities of delivery and outcomes. This paper examines conceptual, methodological and analytical challenges of CTO research within the context of RCTs and other research designs. It also discusses the current state of knowledge on effectiveness of CTOs. Finally, we suggest a way forward by presenting alternative causal inference approaches and potential models for evaluation complex interventions, such as CTOs. We propose that these approaches should be used alongside other research designs in a nuanced approach that may involve using findings from initial studies to refine the intervention and/or its implementation.

Interventions to prevent or reduce the level of frailty in community-dwelling older adults: a scoping review of the literature and international policies.

Background: frailty impacts older adults' ability to recover from an acute illness, injuries and other stresses. Currently, a systematic synthesis of available interventions to prevent or reduce frailty does not exist. Therefore, we conducted a scoping review of interventions and international policies designed to prevent or reduce the level of frailty in community-dwelling older adults. Methods and analysis: we conducted a scoping review using the framework of Arksey and O'Malley. We systematically searched articles and grey literature to identify interventions and policies that aimed to prevent or reduce the level of frailty. Results: fourteen studies were included: 12 randomised controlled trials and 2 cohort studies (mean number of participants 260 (range 51-610)), with most research conducted in USA and Japan. The study quality was moderate to good. The interventions included physical activity; physical activity combined with nutrition; physical activity plus nutrition plus memory training; home modifications; prehabilitation (physical therapy plus exercise plus home modifications) and comprehensive geriatric assessment (CGA). Our review showed that the interventions that significantly reduced the number of frailty markers present or the prevalence of frailty included the physical activity interventions (all types and combinations), and prehabilitation. The CGA studies had mixed findings. Conclusion: nine of the 14 studies reported that the intervention reduced the level of frailty. The results need to be interpreted with caution, as only 14 studies using 6 different definitions of frailty were retained. Future research could combine interventions targeting more frailty markers including cognitive or psychosocial well-being.

Preference for Independent Housing of Persons with Mental Disorders: Systematic Review and Meta-analysis.

Choice of housing has become an important political and therapeutic goal for psychiatric rehabilitation. We conducted a systematic review and meta-analysis of proportions of studies on preference for independent housing. A subgroup analysis compared studies with homeless and non-homeless consumers. The meta-analysis included 8 studies with 3134 consumers. The overall proportion of consumers who had expressed a preference for living independently was 0.84. There were only marginal differences between studies with homeless and non-homeless consumers. In a given service planning area, the rate of independent housing settings should exceed the rate of more institutionalized settings by a wide margin.

The long-term care insurance law in Israel: present and future.

Aging in place is a core component of the policy on aging in Israel. This was well expressed in the Long-Term Care Insurance law enacted in 1986 and implemented in 1988. Under the law, disabled persons can receive in-kind home- and community-based services to enable frail older adults to age in place and to complement or supplement the care provided primarily by family caregivers who are legally responsible for caregiving of their elderly family members. This article presents the main principles of the law and reviews the amendments that this law has undergone during the past 22 years. Finally, some core issues and dilemmas are discussed.

Predictors of shared decision making with people who have a serious mental illness and who are under justice supervision in the community.

Shared decision making (SDM) can be an effective method for promoting service involvement among persons with serious mental illness (SMI). This survey study sought to identify predictors of positive attitudes toward the use of SDM with people with SMI who are living under probation and parole supervision. Supervising officers' (n = 291) perceptions of the capabilities of supervisees with SMI to contribute to their supervision plans, and their familiarity with recovery-oriented mental health services, were positively associated with attitudes toward using SDM. Training officers in common human goals and mental health recovery may advance SDM with supervisees with SMI.

The right to live independently and be included in the community.

The segregation and isolation of people with disabilities are global problems, rooted in legislation and policy, social norms and traditional practices. The right to live independently and be included in the community, contained in article 19 of the United Nations Convention on the Rights of Persons with Disabilities, was created to combat the phenomenon of institutionalization and to spur efforts towards its eventual eradication. This essay offers a commentary on article 19, drawing on its drafting history, on the interpretation provided by the responsible UN body and on the efforts by that body to monitor and encourage compliance. It emphasizes the extent of the transformation required to realize the full ambition of the article and the need for cooperation across UN treaty bodies.

Grounding the right to live in the community (CRPD Article 19) in the capabilities approach to social justice.

For advocates of the rights of persons with disabilities, particularly persons with mental disabilities, the human right to live in the community as an equal member is seen to be central and, often, even as the basis for all other human rights. Yet, despite its articulation in human rights law in the Convention on the Rights of People with Disabilities (CRPD), foundational issues about the right remain undertheorized and unclear. This paper brings to bear the capabilities approach, a normative framework about human well-being, social development and social justice, to this central concern in disability rights, mental health ethics, and international human rights law: protecting and respecting a person's right to live in a community as an equal. We argue that this human and moral right is best conceptualized as a capability to live in the community as an equal member. The capabilities approach provides this capability with a strong ethical framework and conceptual resources to guide reasoning and its practical realization.

Nursing Homes Without Walls for Aging in Place.

ABSTRACTGiven the urgency of finding cost-effective and innovative solutions to providing community services for aging in place, novel solutions that take advantage of existing infrastructure are clearly needed. In this sequential mixed-method study, we chose to explore the role that nursing homes could play in offering services to a non-traditional target population, namely seniors with loss of independence living in the community. Forty-two (n = 42) nursing homes in the province of New Brunswick completed an online survey, and 10 agreed to participate in face-to-face interviews. Results show that 100 per cent of participants agreed that nursing homes could offer services to seniors in their communities for aging in place. Results suggest that nursing homes are cost-effective, innovative solutions for aging in place.

Will housing tenure drive unequal outcomes for Consumer-Directed Care recipients?

Initiatives to promote consumer choice are increasingly a feature of Australian welfare policies and programs. Consumer Directed Care (CDC) for older people and the National Disability Insurance Scheme for people younger than 65 years with a disability are two examples of this move towards consumer choice in policy and program development. The ability for service users to benefit from these programs is premised on the fact that their housing is stable and suitable. Yet, there is evidence that this is not the case, and many older people and people with disabilities experience significant housing challenges and stress. This article focuses on CDC and its implications for one particular group under housing stress - low-income older renters. Might they be at risk of limited access to home care services, and what are the broader local neighbourhood implications of this policy?

Transitioning to Adulthood from Foster Care.

Transitional age foster youth do not typically receive the types of family supports their nonfoster peers enjoy. Many foster youth experience multiple adversities and often fare worse than nonfoster peers on long-term functional outcomes. Governments increasingly recognize their responsibility to act as parents for state dependents transitioning to adulthood and the need to provide services to address social/emotional supports, living skills, finances, housing, education, employment, and physical and mental health. More research is needed to inform the development of effective programs. Transitional age foster youth benefit from policies promoting a developmentally appropriate, comprehensive, and integrated transition system of care.