Guardianship: A medicolegal review for clinicians.

Guardianship may pose an ethical dilemma for physicians, who must balance protecting vulnerable patients from potential safety concerns with respecting their autonomy. Older adults with dementia are particularly susceptible to loss of independence and the ability to participate in medical decision making. To have the capacity for medical decision making, individuals must understand relevant information, appreciate their circumstances, demonstrate reasoning, and express a consistent choice free from coercion. Although capacity assessments are usually task-specific, geriatricians and other specialists may be asked to comment on capacity more globally. These determinations may be used to support a Petition for the Appointment of a Guardian of a Legally Incapacitated Adult, the legal process of pursuing guardianship in probate court. Assigned guardians may be known to the incapacitated individual (e.g., a family member or friend) or may be professional guardians with no prior relationship to the ward. Guardians are encouraged to use substituted decision-making, taking into account the ward's previously expressed values and preferences. Although a number of viable alternatives to guardianship exist, numerous systemic barriers may prevent these from being fully explored. The ongoing need for guardianship should be periodically revisited and reassessed. Data about guardians and wards is shockingly sparse, as there are no centralized databases. Laws and regulations for guardianships vary significantly between states. Physicians can serve as important allies and advocates for patients with cognitive impairment at risk of incapacity, can help preserve their autonomy for as long as possible, and ensure appropriate protections are in place if the patient does lose their decision-making ability.

Dementia Care Across a Tertiary Care Health System: What Exists Now and What Needs to Change.

OBJECTIVES: This study explored the process of care for persons living with dementia (PLWDs) in various care settings across a tertiary care system and considers challenges and opportunities for change. DESIGN: Aimed at quality improvement, qualitative interviews were conducted with key stakeholders in dementia care across geriatric outpatient clinics, medical and psychiatric emergency departments, and the main hospital in 2016. SETTING AND PARTICIPANTS: Forty-nine interactive interviews were conducted with a purposive and snowball sampling of health care professionals (physicians, nurses, social workers, administrators) and families in a large, academic health care system. MEASURES: Qualitative interview guides were developed by the study team to assess the process of care for PLWDs and strengths and challenges to delivering that care. RESULTS: Key themes emerging from the interviews in each care setting are presented. The outpatient setting offers expertise, a multidisciplinary clinic, and research opportunities, but needs to respond to long waitlists, space limitations, and lack of consensus about who owns dementia care. The emergency department offers a low nurse/patient ratio and expertise in acute medical problems, but experiences competing demands and staff turnover; additionally, dementia does not appear on medical records, which can impede care. The hospital offers consultative services and resources, yet the physical space is confined and chaotic; sitters and antipsychotics can be overused, and placement outside of the hospital for PLWDs can be a challenge. CONCLUSIONS AND IMPLICATIONS: Five key recommendations are provided to help health systems proactively prepare for the coming boom of PLWD and their caregivers, including outpatient education, a dementia care management program to link services, Internet-based training for providers, and repurposing sitters as Elder Life specialists.

Delirium and mental health history as predictors of aggression in individuals with dementia in inpatient settings.

OBJECTIVES: Aggressive behaviors by patients with dementia present risk to health care workers and patients. An information processing model, developed to study aggressive behaviors among children, was applied to study aggression among older hospital patients with dementia. Hypotheses were that delirium and mental health or depression history, would relate to increased risk of aggressive behaviors. METHOD: Electronic medical records were sampled for one year (n = 5008) and screened using the EMERSE search engine and hand review for dementia (n = 505) and aggressive behavior in individuals with dementia (n = 121). Records were reviewed for mental health history and presence of delirium. RESULTS: Regression analyses found interaction effects representing delirium and mental health or depression history associated with greater risk of aggressive behavior. Significant main effects were found for both dementia and mental health or depression history. Of the lowest risk group, 12% of patients exhibited aggression compared to 24%-35% of those with delirium, mental health or depression history, or the combination of these risk factors. CONCLUSION: Delirium is the leading correlate of aggressive behaviors in hospitalized patients with dementia, and delirium or history of mental health diagnosis may lead to increased risk of aggressive behaviors in this setting.