Capacity assessment and consent in the cognitively impaired patient

Textbook Core — 10 Points

Latest Updates — 2 Points

CAPACITY ASSESSMENT ALGORITHM

Specific decision required | Presume capacity -> Optimise: treat delirium/pain/depression, hearing aid, glasses, | quiet room, simple language, best time of day Assess the FOUR elements: Understand -> Appreciate -> Reason -> Communicate a Choice | ALL PRESENT?

| \ YES NO | \ Patient decides Advance Directive? --yes--> follow it (even if unwise) | no Nominated Representative / surrogate / POA? --yes--> they decide | no BEST-INTERESTS decision by lead clinician (+ guardianship if required)

| DOCUMENT everything; REASSESS when the reversible cause clears Appendix. Consolidated Night-Before Master Sheet [all 32 questions]

One line of core content and one latest update for every topic in this compilation, merged from all three source sets.

Topic Must-write core Must-write latest update

Psychogeriatrics

Delusional disorder Non-bizarre delusion ≥1 month, function preserved; partition Xanomeline–trospium (KarXT) FDA 2024, first delusions in VLOSLP; sensory loss + isolation are key risks; muscarinic antipsychotic; ATLAS — amisulpride atypicals at ¼–⅓ dose 100 mg Bipolar in late life Late-onset mania = secondary mania until proved otherwise; ISBD OABD: lithium 0.4–0.8 mEq/L (60–79 y), 0.4– irritability not euphoria; GERI-BD — lithium ≈ divalproex 0.7 (≥80 y)

Somatoform / New onset after 60 is rare — exclude organic disease and ICD-11 Bodily Distress Disorder; FND is a rule-in conversion depression; Hoover's sign; CBT first-line; avoid repeat diagnosis investigations Grief Complicated grief ≥6 months; risk = sudden/traumatic death, Prolonged Grief Disorder — DSM-5-TR ≥12 months, ambivalent relationship; psychotherapy first-line ICD-11 ≥6 months Personality disorders Cluster A prominent, B burns out, C persists; new-onset ICD-11 — single dimensional diagnosis, severity + change = organic (FTD) until proved otherwise; Diogenes 5 trait domains syndrome Sexual dysfunction Desire persists in old age; ED predicts CVD; SSRIs Vaginal oestrogen / prasterone / ospemifene safe commonest drug cause; PLISSIT model; PDE-5i first-line for GSM (NAMS-IMS)

Benzodiazepine 10% community, 25% nursing home; SDS score ≥6; convert ASAM 2025 — taper most older adults, 5–10% dependence to diazepam and taper over months; withdrawal → confusion, every 2–4 weeks, no forced taper; BIND seizures Nicotine dependence Quitting benefits even in the 70s; 5 A's; combination NRT / Cytisinicline — ORCA-2/ORCA-3, efficacy like varenicline / bupropion; cessation raises clozapine and varenicline, fewer GI effects olanzapine levels Substance misuse Three categories — medications, sanctioned substances, Cannabis fastest-rising in ≥65; Beers 2023 opioid illicit; prescribed BZD/opioid misuse dominates; non- + BZD/gabapentinoid caution confrontational age-specific programmes work better MHCA 2017 Sec 4 capacity, Sec 5 advance directive, Sec 14 NR, Sec 18 Ayushman Bharat Vay Vandana — ₹5 lakh cover access, Sec 21(4) insurance, Sec 89/90 supported admission, for all aged ≥70, mental health included Sec 115 suicide Capacity and consent Capacity is clinical, competence is legal; four elements; Supported over substituted decision-making decision-specific; unwise ≠ incapable; MacCAT-T / ACE; (UNCRPD Art 12); 2024 Lancet Commission — early optimise before declaring absent ACP GDS Yesavage 1982; somatic items excluded; GDS-15 cut-off ≥5; USPSTF 2023 Grade B — screen all adults where GDS-30 cut-off ≥11; invalid if MMSE <15 → Cornell Scale follow-up exists Mood, Anxiety & Suicide Depression — MDD 1–5% community; symptoms 8–16%; higher in primary USPSTF 2023 Grade B — screen all adults including prevalence care, hospital and LTC; LASI ~8% in Indians ≥60 ≥65 Depression — "Depression without sadness"; somatic complaints; Lancet Commission 2024 — depression a presentation psychomotor symptoms; nihilistic delusions; anxious distress modifiable dementia risk factor specifier; bereavement exclusion removed Depression — Stepped care; SSRI first-line at half dose; 6–12 weeks for full OPTIMUM 2023 — aripiprazole augmentation, treatment effect; ≥1 year after first recurrence, lifelong after second remission 28% vs 19%, fewer falls Antidepressants Sertraline/escitalopram first; avoid TCAs and paroxetine; Hyperbolic tapering (Maudsley 2024); withdrawal is hyponatraemia, falls, GI bleeding, QTc; mirtazapine if not relapse anorexia + insomnia ECT First-line if severe, psychotic, catatonic, suicidal or not ELEKT-D 2023 — ketamine non-inferior in non-eating; efficacy undiminished with age; seizure threshold psychotic TRD; ultrabrief right unilateral ECT rises; older age predicts better response; reversible cognitive effects only Suicide WHO at age 75: men 50/100,000, women 16/100,000; India NSPS 2022 — 10% reduction by 2030; NCRB attempt-to-completion 4:1 vs 200:1; 20–50% see the PCP elderly suicides up 40% from 2019 to 2022 within a week; depression strongest risk factor, self-harm strongest predictor Anxiety (general) Not normal ageing; most prevalent yet most under-treated; USPSTF 2023 — Grade B for 19–64, I-statement agoraphobia and panic > phobias > GAD; SSRIs first-line, up for ≥65 to 6 weeks; no antipsychotics; benzodiazepines short-term only GAD Half lifelong, half onset within last 5 years; health-centred MBSR non-inferior to escitalopram (JAMA Psychiatry worry; buspirone an option; exclude medical, drug and 2023); Beers 2023 withdrawal causes Phobias Agoraphobia commonest; fear of falling is the geriatric- World Falls Guidelines — assess "concern about specific phobia, rare in the young; vicious cycle of activity falling" in every falls assessment restriction; graded exposure + CBT; avoid benzodiazepines OCD DSM-5 own chapter; new onset after 60 is organic (basal TMS approved for OCD; deep TMS (H7 coil) for ganglia, FTD); Y-BOCS; ERP first-line; SSRIs need higher dose refractory cases and 10–12 weeks Mood disorders DSM-5 split into depressive and bipolar; persistent depressive ISBD lithium 0.4–0.8 mEq/L (60–79 y), 0.4–0.7 (≥80 overall disorder ≥2 years; secondary mania; apathy is not y)

depression Psychosis, Therapeutics, Personality & Alcohol Late-life psychosis ~60% of new-onset psychosis in late life is secondary; the Xanomeline–trospium (KarXT), FDA 2024 — first six D's — delirium, disease, drugs, dementia, depression, muscarinic antipsychotic delusional disorder; treat the cause, correct sensory loss, then low-dose atypical Late-onset LOS 40–59 y, VLOSLP ≥60 y (late paraphrenia); female ATLAS — amisulpride 100 mg/day, the only schizophrenia predominance; deafness and isolation; partition delusions; placebo-controlled RCT in VLOSLP negative symptoms and thought disorder rare Atypical D2 + 5-HT2A; quarter to a third of adult dose; quetiapine in Brexpiprazole, FDA May 2023 — first drug antipsychotics DLB/PD; boxed warning of stroke and death in dementia; approved for agitation in Alzheimer's dementia monitor weight, glucose, lipids, QTc, EPS; review every 3 months ECT >50% of recipients are older adults; first-line if severe, ELEKT-D 2023 — ketamine non-inferior in non-psychotic, catatonic, suicidal or not eating; efficacy psychotic TRD; ultrabrief right unilateral ECT undiminished by age but seizure threshold rises; older age predicts better response; reversible cognitive effects; no absolute contraindication CBT Structured, time-limited, 8–20 sessions; thought records, Digital and remote CBT effective in older adults; behavioural activation, graded exposure, homework; CBT-I first-line for chronic insomnia problem-solving therapy best where executive dysfunction; adapt for sensory and cognitive deficits Agitation — non-drug Almost all people with dementia become agitated; look first IPA consensus definition of agitation; 2023–25 for pain, infection, constipation, retention, network meta-analyses favour tailored activity, dehydration, drugs, delirium; DICE and ABC; tailored massage, animal-assisted intervention activity, music, massage, animal-assisted, light therapy; carer training Personality change Normal ageing = maturation, not rigidity; traits are ICD-11 — single dimensional diagnosis with accentuated under stress; new personality change in old severity + 5 trait domains; "personality change age is organic until proved otherwise — FTD is the due to another medical condition" retained prototype; drugs do not help separately Diogenes syndrome Tetrad — extreme self-neglect, domestic squalor, social Hoarding disorder now a distinct DSM-5/ICD-11 withdrawal, refusal of help, with hoarding and no shame; half diagnosis; specialised CBT, not forced clearance are primary; premorbid paranoid/schizoid/OC traits; home visit essential; ~45% five-year mortality Alcoholism in the Early-onset "survivors" two-thirds vs late-onset "reactors" WHO 2023 — no safe level; US Surgeon General elderly one-third; reduced body water and hepatic metabolism → 2025 — alcohol the third leading preventable higher levels; CAGE and SMAST-G; inpatient detox with cause of cancer lorazepam and thiamine; non-confrontational programmes double abstinence OP poisoning essay DUMBBELS; decontaminate and protect staff; atropine by AHA 2023 poisoning guidelines; India NSPS 2022 — dose doubling to clear chest, dry axillae, HR >80; pesticide restriction as the leading pillar pralidoxime early (benefit debated); watch intermediate syndrome at 24–96 h and OPIDN at 2–3 weeks; psychiatric assessment before discharge Cross-Cutting Themes the Examiner Rewards