Geriatric Psychiatry

1. Cultural Issues in late
Life and
Forensic Evaluation
of the Older Adult
PRESENTER: EIKEEN P. DARAUAY

2. Objectives:
To discuss the importance of ethnicity in psychiatric care of elderly
To know the tools or approaches needed to care for culturally diverse
elders effectively?
To introduce the basics of forensic psychiatry and the courts
 To know some of the legal issues encountered in geriatric practice
To know how to assess capacity/ competence in elderly

3. Definition of Terms
Culture:
attitude of a population that are learned and which are passed down from
generation to generation
It represents beliefs or behavior patterns that define a group
Culture includes language, religion and spirituality, family structures, life-cycle
stages, ceremonial rituals, and customs, as well as moral and legal systems
It is an open, dynamic system that undergo continuous change over time

4. Definition of Terms
Ethnicity:
Based on place of origin or religion
Ethnicity is a culturally constructed group identity used to define peoples and
communities
It may be rooted in a common history, geography, language, religion, or other shared
characteristics of a group, which distinguish that group from others
Ethnicity may be self assigned or attributed by outsiders

5. Definition of Terms
Race:
composed of several ethnic groups that intermarry
Race is a culturally constructed category of identity that divides humanity into groups
based on a variety of superficial physical traits attributed to some hypothetical
intrinsic, biological characteristics
The construct of race has no consistent biological definition, but it is socially
important because it supports racial ideologies, racism, discrimination, and social
exclusion, which can have strong negative effects on mental health.

6. Cultural Formulation
1. systematic review of the individual's cultural background,
2. the role of the cultural context in the expression and evaluation of symptoms
and dysfunction
3. the effect that cultural differences may have on the relationship between the
individual and the clinician.

7. Cultural Formulation in DSM 5
Outline:
1. Cultural identity of the individual
2. Cultural explanation of the individual's illness
3. Cultural factors related to the psychosocial environment and levels of functioning
4. Cultural elements of the relationship of the individual and the clinician
5. Cultural assessment for diagnosis and care

8. Cultural identity of the individual:
Describe the individual's racial, ethnic, or cultural reference groups that may influence his
or her relationships with others, access to resources, and developmental and current
challenges, conflicts, or predicaments.
Language abilities, preferences, and patterns of use are relevant for identifying difficulties
with access to care, social integration, and the need for an interpreter.
Other clinically relevant aspects of identity may include religious affiliation, socioeconomic
background, personal and family places of birth and growing up, migrant status, and sexual
orientation.
For immigrants and racial or ethnic minorities, the degree and kinds of involvement with
both the culture of origin and the host culture should be noted separately.
Cultural Formulation

9. Cultural conceptualizations of distress:
Describe the cultural constructs that influence how the individual experiences,
understands, and communicates his or her symptoms or problems to others
These constructs may include cultural syndromes, idioms of distress, and explanatory
models or perceived causes
The level of severity and meaning of the distressing experiences should be assessed in
relation to the norms of the individual's cultural reference groups.
Cultural Formulation

10. Psychosocial stressors and cultural features of vulnerability and resilience:
Identify key stressors and supports in the individual's social environment and the role of
religion, family, and other social networks in providing emotional, instrumental, and
informational support
Social stressors and social supports vary with cultural interpretations of events, family
structure, developmental tasks, and social context
 Levels of functioning, disability, and resilience should be assessed in light of the individual's
cultural reference groups.
Cultural Formulation

11. Cultural features of the relationship between the individual and the clinician:
Identify differences in culture, language, and social status between an individual and clinician
that may cause difficulties in communication and may influence diagnosis and treatment
Experiences of racism and discrimination in the larger society may impede establishing trust
and safety in the clinical diagnostic encounter
Effects may include problems eliciting symptoms, misunderstanding of the cultural and clinical
significance of symptoms and behaviors, and difficulty establishing or maintaining the rapport
needed for an effective clinical alliance.
Cultural Formulation

12. Overall cultural assessment:
Summary of the implications of the components of the cultural formulation identified
and other clinically relevant issues or problems as well as appropriate management and
treatment intervention.
Cultural Formulation

21. Cultural Competence
Cultural competence involves the following:
1. Cultural Sensitivity - awareness and empathy for emotions, values and belief
systems of people from other cultures.
◦ can enhance compliance and treatment outcomes
2. Knowledge of the particular culture - read books or consult/ talk with local experts
3. Competence in interaction and treatment- adjust interaction to establish proper
and helpful nprofessional relationship with the minority patient

22. Indicators of Poor-Relationship
1. Premature Termination
2. Non-compliance with treatment
3. Inadequate histories
4. Failure to establish therapeutic alliance

23. Cultural Difference in
Prevalence of Psychiatric Illness
ECA (epidemiologic catchment area) program, studied rates of mental illness, using
interview schedule in minority samples.
Result: lower rates of all psychiatric diagnosis for ethnic minority elders than younger
patients.
Issue in diagnosis: Idioms used to describe feelings and distress
Asian: use geography rather than color as idiom in depression

24. Medication Precautions for
Elderly
1. Sequential trials of single psychotropic medication rather than
polypharmacy
2. Begin with low doses (usual starting dose of one-half)
3. Titrate slowly, then continue to advance to an effective dose, not
exceeding maximum recommended dose

25. Forensic Evaluation of the Older
Adult

26. Forensic Evaluation of the Older Adult
Objectives:
1. To introduce the basics of forensic psychiatry and the courts
2. To know some of the legal issues encountered in geriatric practice
3. To know how to assess capacity/ competence in elderly

27. Forensic Psychiatry
Involves interface between clinical psychiatry and the legal system.
The application of scientific and clinical knowledge to help the judge answer specific
legal question
Psychiatrists makes valuable contribution to the social demands of justice and
fairness, help clarify the issues in an accurate but not overly technical manner.

28. Forensic Requests
1. Evaluation for competence to stand trial
2. Request for a medical report/ medical testimony
Who should do a forensic evaluation: The treating clinician or an independent examiner?
Independent examiner: preferable to provide neutral and objective analysis of the clinical data
without compromising the clinician's treatment alliance to his patient
Treating Psychiatrist: Best to answer on the capacity to make treatment decisions or need of
guardianship

29. The Legal World
CLINICAL WORK/ PSYCHIATRIST
scientific language by clinicians
Standards/opinion deal with relative odds,
likelihoods, and statistical prognoses
Built around supportive paradigm of treatment
alliance
Needs to stick to facts and scientific data rather
than distorting opinion for the sake of winning
the case.
COURT/ ATTORNEY
descriptive language defined by law
legal standards: beyond reasonable doubt, clear
and convincing evidence, preponderance of
evidence
Designed on adversarial paradigm
Both sides advocate for winning the case

30. Role of Psychiatrist in the Courtroom
1. Fact Witness: Testify on what has occurred in the treatment of the patient.
Offers information only and not expert opinion on lrgal issues
May describe diagnosis and treatment, give relevant clinical observtions but not admitted to offer fina
opinions regarding specific legal question
2. Expert witness:
after admission of CV; cross examination
With specialized technical knowledge needed by jury to come to a decision.
Allowed to offer opinion e.g. lack of appropriate decision-making capacity, but ultimate decision is left to the
court.

31. Rights of Patients on release of medical records
1. Confidentiality: Right to privacy of medical information, not to be divulged to 3rd party without consent
2. Privelege: Confidentiality applied to testimony in the legal setting
Subpoena: Often a mechanism used by lawyer to ask for information, often without patient's consent.
It does not compel us to release the records, but it does compel us to respond, and not to ignore the
request.
Appropriate response: Notify patient and lawyer before releasing record

32. Capacity Assessment
Conceptual Basis: Autonomy; Vulnerability; Capacity; Undue Influence
1. Autonomy is the highest principle in Legal, Psychological and Medical Issues
Patient Autonomy: Consider patient's need for information and his ability to reach a fully informed and
uncoerced decision.
YOU HAVE THE RIGHT TO MAKE YOUR OWN DECISIONS, GOOD OR BAD, STUPID OR SMART, WHETHER
OTHERS AGREE OR NOT, if you have the CAPACITY to make them & you are not UNDULY INFLUENCED.

33. Components of Informed Consent
1. Information disclosure: need to be provided with relevant information for a medical decision
Insufficient disclosure of information: malpractice
2. Voluntariness: giving cnsent freely without undue pressure or coercion
3. Competence/ capacity: ability to understand, appreciate, and manipulate relevant information in a
rational manner as part of the decision-making process.
Clinicians evaluates patient's Decision-making capacity/ability.
Only a judge decide for incompetence.

34. Conceptual Basis: Autonomy; Vulnerability; Capacity; Undue Influence
2. Vulnerability: Any Condition Severe Enough That Another Person Could Use It To Unduly
Influence You or Take Advantage of You.
Most Vulnerable Conditions Are Diagnosable Disorders ( Dementia/cognitive impairment,
Psychiatric disorders, Depression, Anxiety, Grief, Disability, Substance abuse) that can lead to
lack of capacity

35. Conceptual Basis: Autonomy; Vulnerability; Capacity; Undue Influence
3. Capacity: “a threshold requirement for persons to retain the power to make decisions for themselves” (Appelbaum
& Gutheil, 1991)
Clinical Use: denote a professional clinical judgment as to whether an individual has the requisite minimal ability to
successfully carry out a specific task (e.g., drive a car) or make a specific decision (e.g., refuse a medical treatment).
Capacity issues arise most frequently when an individual makes a decision that puts his or her health, assets
property, or self at risk and lacks the insight or the willingness to accept help.
Legal Use: specific ability under law sufficient to carry out a specific action. Courts (judges and sometimes juries) may
consider and decide matters of civil capacity (e.g., Does this individual have the capacity to execute a will or make a
treatment decision?) or criminal capacity (e.g., Does this individual have the capacity to stand trial?)

36. Components of Decisional Capacity
1. Understanding the information
2. Appreciating its relevance for the person's particular situation: assess insight
3. Rationally manipulating the relevant information to reach a decision: assess reasoning
4. Expressing a consistent choice

37. Under the common law, and consistent with Article 12 of the UN Convention on the Rights of
Persons with Disabilities: a person is always presumed to have capacity to make decisions.
There are three areas or domains of decision-making: personal, financial and health.
Within these domains there are numerous types of capacity decisions or capacity tasks.
You can have capacity to make one kind of decision but not another.
A person’s capacity can vary in different circumstances, at different times, and even within domains
for different types of decisions.

38. Understanding the information
Make sure that the patient has had access to relevant information
a. for medical treatment: risks, benefits and alternatives of the proposed treatment
b. preparing a will: hs/her financial information
c. to stand trial: evaluator needs to speak to attorney to understand charges, potential
consequences and likely judicial process to be faced by the client

39. Appreciation
“Appreciate” requires ability to relate information to one’s own circumstance, to identify consequences to
self and others of the decision, to weigh risks against benefits for self.
Does the patient appreciate that he has psychiatric illness or that he is charged with a crime?
e.g. a. Manic patient who refuses treatment because of grandiosity, clearly lacks insight and needed
appropriate treatment
b. MR patient who does not recognize that setting fire to a home was a crime, lacks appreciation of the
legal consequences he faces

40. Reasoning
Refusal to take meds: a patient who had memorized the warning signs of his antipsychotics may
still have impaired reasoning if his refusal is based on his delusional belief
Patient refusal for ECT: patient may have impaired reasoning when he is much concerned on
electrocution and brain liquidation than a patient who is concerned with effects of transient
confusion and memory loss from the procedure.

41. Expression of choice
What does the patient want? Can she clearly express his decision?
Consistency of choice expression may be an issue in geriatric patients with variable cognitive
impairment
Clear consent may have been given in the morning but it might be different at night (patients
more cognitively intact at daytime than at night)

42. Four Conditions That
Impair Capacity Under The Law
1. Cognitive Impairment
2. Severe Mood Disturbance
3. Perceptual Distortion
4. Thought Processing Defects

43. Conceptual Basis: Autonomy; Vulnerability; Capacity; Undue Influence
Undue Influence: exerting inappropriate influence over a vulnerable person in order to change
his/her decision or behavior.
e.g.
The perpetrator’s “will” is substituted for the “will” of the victim
Victim acts subject to the will or purposes of the perpetrator
Victim agrees to give the perpetrator money or property

44. Assessment of Undue Influence
Examine the dynamic interplay between the victim and the perpetrator
Medical diagnosis, mental illness, cognitive impairment is not necessary
Affected by mental capacity, medical issues and environmental factors
Manipulation, coercion, compulsion or restraint occurs as a direct result of the relationship

45. Any assessment of capacity must include
1. global assessment of the person’s mental state and cognitive function - ideally with an estimate of
severity and an assessment of the specific executive and functions of judgment, reasoning and planning
which are relevant to decisionmaking
2. a functional assessment of decision-making i.e. whether the person can show, using their own words, an
understanding of the decision (as defined by the relevant legal test ) in the domain in which they are
making a decision (not just “yes, I understand”).

46. When assessing capacity to consent to treatment
consider:
1. The “what” of the consent:
Does the person understand the general nature and effect of the proposed treatment?
what it is and what it involves;
risks and benefits of the treatment; and
alternatives to, or consequences of not having, the treatment; and Has the person indicated
consent

47. 2. The “freedom” of the consent: Has all the relevant information been given to the person in a
way they can understand? Are they making the decision freely and voluntarily and not being
unduly influenced?
A person has a right to refuse treatment.
Consider the person’s religious or cultural beliefs or other vi ews when assessing capacity.
If the person lacks capacity to give informed consent about treatment, is not objecting to it, and
the treatment is not urgent or special, then consent must be sought from a “person responsible”

48. Testamentary Capacity- Capacity to make a will/ last testament
Capacity to:
1. Understand that the testator is executing a will at the time
2. Understand the nature and extent of his property and assets
3. apprreciate his natural heirs, relationship to living desendants, spouse and other relatives whose interest
might be impacted by the will.
evaluation may be audio/videotaped for future challenge

49. Capacity to Manage Financial Affairs – Financial decisions
consider:
1. The ability of the person to undertake financial tasks.
Does the person know their assets? Can they read a bank st atement? Can they use a
chequebook or ATM card? Can they identify currency and its relative value? Do they understand
what bills they have and any debts they have? Have they planned for the future?
The person does not have to manage financial tasks in the best possible way, but they must be
able to manage them.

50. Capacity to Manage Financial Affairs – Financial decisions
consider:
2. If the person lacks capacity to manage their affairs, they do not need a financial management
order unless there is a need or it is in the best interests of the person to have someone else make
their financial decisions.
Can they afford food? Do they pay crucial bills such as rent, electricity, water, rates or a crucial
accommodation bond?
If they are unfamiliar with their financial affairs or have never managed their own affairs, have they
made appropri ate alternative arrangements for the management of their est ate?
Is there a working alternative or informal arrangement already in place (e.g. a family member
looking aft er their affairs, a Power of Attorney, an accountant)?
3. If the person cannot manage all of their affairs decide whether there are parts of their finances
that they can manage

51. Capacity to participate in court and other legal proceedings
Competence to stand trial, to plead guilty, and to defend oneself: assessed according to standard in Dusky
vs US
1. Defendant must have sufficient present ability to consult with his lawyer with a reasonable degree of
rational undestaning
2. Have rational as well as factual understanding of the proceedings against him
Capacity to be witness: requires ability to
1. appreciate distintions between truth and falsehood,
2. understand questions
3. contain oneself appropriately in courtroom setting
4. sustain examination and cross-examination

52. Capacity to participate in Research
Informed consent: voluntariness, competence, and adequate information necessary. They must
recognize that they are giving consent for research, with its inherent risks, benefits and
alternatives.
Other issues: confidentiality of answers to assessment tools
Subjects with impaired decision-making capacity: may have a substituted informed consent
(appointment of a guardian) or consent from designated proxy (family member in the absence
of relevant advance directive)

53. End-of-life care/ Advance Directives
An ACD is a written/oral statement by a capable adult regarding wishes, preferences, values and
beliefs about future treatment decisions, including end-of life treatment.
It may include instructions about future use or restriction of particular medical treatments and/or
the details of a preferred substitute decision-maker. It is used when the person loses capacity.
DNR and refusal to certain procedures

54. 2 types of Advance Directives
1. Instructional Directives
Living will- specifies what kind of care an individual wants or does not want, if later he becomes unable to
participate competently in medical decision-making
Individual must be competent when he executes the living will

55. 2 types of Advance Directives
2. Proxy Directives: e.g. health care proxy or durable power of attorney for medical decision
Allows the person to designate another individual as health care proxy, to act on her behalfwhen he becomes
incompetent to make treatment decisions
The proxy may follow the living will, but also giving the proxy authority to act according to appropriate standard in
circumstances not addressed in the will. He acts according to the expressed wishes and values of the impaired
person, based on:
a. substituted judgement standard: what the person would likely have chosen
b. Reasonable persn standard: what other patients in similar situation and context would reasonably have decided
c. Best interest standard: objective balancing of overall risk and benefit

56. Capacity to execute advance care directives
consider:
1. The “what” of the Advance Care Directives: Can the person understand the nature and effect of the
instructions given about their health care preferences, any treatment options they are requesting or prohibiting,
and the consequences of doing so? Do they have enough information about treatment options and alternatives
(including no treatment) availabl e? Do they suffer from conditions that might affect capacity to make such a
decision such as delirium or depression?
2. The “who” of the ACD:
3. The “freedom” of the ACD: Has all the relevant information been given to the person in a way they can
understand? Are they making the appointment freely and voluntarily and not being unduly influenced or
“schooled”?

57. End-of-life care/ Advance Directives
The process of advance care planning should not be based on a static document, but on a more
dynamic practice that supports patients and their substitute decision-makers to think ahead
and formulate goals of care as they confront the challenge of a progressive illness trajectory.
Such a practice should start early, be reassessed regularly with changes in health, and be
sensitive to the patient’s idea about their aut onomy – do they want to know about and be
involved in decisionmaking or would they rather trust others to make treatment decisions on
their behalf?

58. Functional (Non-decisional) Capacity
The capacity to drive
A diagnosis of dementia should be viewed as a warning sign that an individual may not be competent
to drive, or will lose that competency at some stage in the future.
However, a diagnosis does not determine individual ability to drive. There should be a routine
review regarding the person’s ability to drive safely

59. Guide to consent to Health Care for Adults who can not Consent