Abuse and Neglect Concerns for Patients Under Psychiatric Evaluation for Decision Making Capacity: A Retrospective Subgroup Analysis

Abstract: Background


Neurocognitive disorders increase risk of incapacitation (Sessums 2011), as well as abuse and neglect (Cooper 2014), but no past research examines abuse and neglect in patients undergoing psychiatric evaluation for decision-making capacity. This retrospective subgroup analysis explores the clinical context when concern mandatory report of abuse or neglect (MRAN) arises and psychiatric decision-making capacity evaluations are requested.





Methods


For hospital encounters with decision-making capacity consultation requests, at an academic tertiary center within a 12-month period, encounter documentation was manually reviewed for extraction of ethical context factors, including concern for MRAN. Independent protocolized review of MRAN encounters by a psychiatrist and social worker extracted demographics, social history, neurological and psychiatric comorbidities, abuse characteristics, capacitation status, and hospitalization length of stay. Discrepancies were mediated by a third reviewer. The study was approved by the IRB, and descriptive statics were performed in Excel.





Results


Of 145 hospital encounters, 20 (13.8%; 19 individual patients) featured concern for MRAN. Average age was 58 years (47% geriatric; n=9). Geriatric patients lived home alone in 66.7% (n=6) cases. Relationship status was single in 60% (n=6) non-geriatric cases, but varied in the geriatric sample. Overall, 89.4% (n=17) patients were on disability or retired. Most common disposition was a nursing home (47.4%; n=9). A neurocognitive disorder was diagnosed in most cases (78.9%; n=15), and mood disorders were the most common psychiatric comorbidity (57.9%; n=11). The geriatric sample demonstrated concern for neglect in 88.9% (n=8) cases, while non-geriatric cases featured variable abuse categories. Of 13 cases where an abuser was identified, 61.5% (n=8) were partners and 61.5% (n=8) cohabitated. Initial MRAN documentation was most commonly by social work and case management, with median 0 days to psychiatric consultation (range -3 to 23). Incapacitation determination was determined in 65% encounters (n=13). Common additional ethical context factors were disposition conflict (50%; n=10), outpatient nonadherence (40%; n=8), decision maker determination (35%; n=7), guardianship process (35%; n=7) inpatient nonadherence (25%; n=5).





Discussion


This is the first study to describe abuse context and possible risk factors for abuse and neglect in psychiatric evaluation of decision-making capacity contexts. Intellectual disability, neurodegenerative disorders, and severe neurological disorders in patients on disability, or with incapacitation, perhaps should increase vigilance to screen MRAN, and review of social work documentation. Abuse and neglect are underreported in the consultation psychiatry context (Cooper2009) and is an area warranting further academic attention.





Conclusion


Screening for abuse and neglect may be warranted when consulted for psychiatric evaluation of decision-making capacity in the setting of intellectual disability or neurodegenerative disorders






References:


Cooper C, Livingston G: Clin Geriatr Med 2014;30:839–850.


Cooper C, et al.: Amer J Geriatric Psychiatr 2009;917(10):826–838.


Sessums LL, et al.: JAMA 2011;27;306(4):420-7.