How do health and social care professionals in England and Wales assess mental capacity? A literature review

PURPOSE: To review evidence describing how health and social care professionals in England and Wales assess mental capacity, in order to identify ways to improve practice. METHODS: A systematised literature review was completed. Electronic databases of published medical, health and social care research and gray literature were searched. Journal articles and research reports published between 2007 and 2018 were included if they met predefined eligibility criteria. Evidence from included studies was synthesized using thematic analysis. RESULTS: 20 studies of variable methodological quality were included. The studies described assessments carried out by a range of multidisciplinary professionals working with different groups of service users in diverse care contexts. Four main themes were identified: preparation for assessment; capacity assessment processes; supported decision-making; interventions to facilitate or improve practice. There was a lack of detailed information describing how professionals provided information to service users and tested their decision-making abilities. Practice reported in studies varied in terms of its conformity to legal requirements. CONCLUSIONS: This review synthesized evidence about mental capacity assessment methods and quality in England and Wales and analyzed it to suggest ways in which practice might be improved. Implications for rehabilitation: Mental capacity assessment practice in England and Wales varies and is not always consistent with legal requirements, risking inconsistent and inaccurate judgements about capacity and exposure to legal action. Interventions have been developed to help professionals to engage in supported decision-making, and improve their mental capacity assessments and documentation in line with legal standards. These interventions include training and practical resources, such as assessment flowcharts, checklists and documentation aids. Such interventions would benefit from robust evaluation before they are implemented more widely

Evaluation of the MCAST, a multidisciplinary toolkit to improve mental capacity assessment

Purpose: To evaluate the usability and acceptability of the Mental Capacity Assessment Support Toolkit (MCAST) in healthcare settings and whether its use was associated with increased legal compliance and assessor confidence. Materials and methods: A mixed methods convergence triangulation model was used. Multidisciplinary professionals used the MCAST during mental capacity assessments for UK hospital patients with diagnoses of stroke or acute or chronic cognitive impairment. Changes in legal compliance were investigated by comparing scores on case note audits before and after implementation of the MCAST. Changes in assessor confidence and professionals’ perceptions of the MCAST’s usability and acceptability were explored using surveys. Patients’ and family members’ views on acceptability were determined using semi-structured interviews. Data were integrated using triangulation. Results: Twenty-one professionals, 17 patients and two family members participated. Use of the MCAST was associated with significant increases in legal compliance and assessor confidence. Most professionals found the MCAST easy to use and beneficial to their practice and patients. Patients and family members found the MCAST materials acceptable. Conclusions: The MCAST is the first toolkit to support the needs of individuals with communication disabilities during mental capacity assessments. It enables assessors to deliver high quality, legally compliant and confident practice

An exploration of mental capacity assessment within acute hospital and intermediate care settings in England: a focus group study

© 2016 Informa UK Limited, trading as Taylor & Francis Group. Purpose: To explore approaches to the assessment of mental capacity within acute hospital and intermediate care settings in England. Methods: Two focus group interviews were conducted with multidisciplinary staff (n = 13) within a large hospital trust. Data were analysed using a Framework approach. Results: Three main themes were identified: (i) the assessment process; (ii) staff experience of assessment; (iii) assessing capacity for patients with communication difficulties. Staff identified the main patient groups, patient decisions and professionals involved in capacity assessment. They described using both formal and informal approaches to assess capacity and specific methods to identify and support the needs of patients with communication difficulties during the assessment process. Most staff reported finding capacity assessment challenging, due to time pressures, a perceived lack of knowledge or skills and encountering practice that is not consistent with legal requirements. Staff stated a need for initiatives to facilitate and improve practice. Conclusions: These findings provide confirmatory evidence that mental capacity assessment is complex and challenging and that staff would benefit from additional support and resources to aid their practice. It provides new evidence about the methods used by staff to assess capacity, particularly for patients with communication difficulties. Implications for Rehabilitation This study contributes to our understanding of how staff assess capacity in hospital and intermediate care settings. Mental capacity assessment is a complex activity and many staff reported finding it challenging. Patients with communication difficulties need additional support during capacity assessments but may not always receive this. Current practice needs to be improved and staff need support and resources to achieve this

What do people with aphasia want to be able to say? A content analysis of words identified as personally relevant by people with aphasia

Background Word finding is a common difficulty for people with aphasia. Targeting words that are relevant to the individual could maximise the usefulness and impact of word finding therapy. Aims To provide insights into words that people with aphasia perceive to be personally relevant. Methods and procedures 100 people with aphasia were each asked to identify 100 words that would be particularly important for them to be able to say. Two speech and language therapist researchers conducted a quantitative content analysis of the words selected. The words were coded into a framework of topics and subtopics. The frequency with which different words and topics were selected was then calculated. Outcomes and results 100 participants representing 20 areas of the United Kingdom ranged in age from 23 to 85 years. Word finding difficulties ranged from mild to severe. The sample of 9999 words selected for practice included 3095 different words in 27 topics. The majority of words selected (79.4%) were from the topics ‘food and drink’ (30.6%), ‘nature and gardening’ (10.3%), ‘entertainment’ (9.4%), ‘places’ (7.3%), ‘people’ (6.7%), ‘house’ (6.5%), ‘clothes’ (5.2%) and ‘travel’ (3.5%). The 100 words types chosen with the greatest frequency were identified. These account for 27 percent of the 9999 words chosen by the participants. Discussion Personally relevant vocabulary is unique to each individual and is likely to contain specific or specialist words for which material needs to be individually prepared. However there is some commonality in the words chosen by people with aphasia. This could inform pre-prepared materials for use in word finding therapy from which personally relevant words could be selected for practice

Improving Practice in Supported Decision-Making and Mental Capacity Assessment

Current models of evidence-based practice are predicated on the inclusion of patients / service users in decisions about their healthcare. In the United Kingdom (UK), healthcare policy and legislation requires practitioners to provide support with decision-making and, if necessary, complete mental capacity assessments to identify if service users can make informed decisions. People with communication disabilities may have difficulties understanding, thinking and talking about decisions and may require communication support. In this paper, I discuss the current challenges associated with mental capacity assessment and supported decision-making. I propose that healthcare professionals should look beyond legal and policy imperatives to consider the ethical foundations for their practice, when they face such challenges. I compare two conceptual approaches to ethical reasoning. I describe a practical solution to the clinical challenge – the development of the MCAST, a toolkit to support multidisciplinary staff to assess mental capacity and provide support to service users with communication disabilities during the decision-making proces

On-site and Off-site Impact of Watershed Development: A Case Study of Rajasamadhiyala, Gujarat, India

Detailed case study of Rajsamadhiyala watershed in the semi-arid tropical area of Gujarat in India revealed that rainwater harvesting through watershed management doubled the production of groundnut and other major crops, increased cropping intensity by 32% in eight years. With improved groundwater availability diversification with high-value crops like cumin, vegetables and fruits was observed. Food, fodder, fuel sufficiency substantially improved along with the increased incomes, literacy and social development. Substantial investment of 16.25 million rupees [US$ 0.36 million) in rainwater harvesting in one village created storage capacity to harvest 16% of mean annual rainfall of 503 mm which is equivalent to 100% of potential runoff during a normal year. Considering percolation seepage and evaporation losses 40% of annual mean rainfall could be harvested and stored. However, because of geological formation in the Deccan plateau where soils are formed over a layer of weathered trap laid on hard rock during normal rainfall years, these structures overflow 2-3 times in the rainy season. Downstream villages Aniyala and Kasturba Dham benefited in terms of increased groundwater availability, reduced siltation and flooding through the base flow seepage water and excess runoff. Detailed studies in two downstream villages showed increased productivity, however, by 25-30%, improved groundwater availability by 25%, and reduced distressed migration. Dedicated leadership helped the villagers to chalkout the path to prosperity. Vast potential to increase productivity by 80-90% remains to be harnessed through adoption of increased water use efficiency measures, as most benefits are due to increased water availability only. However, looking at the trends of over-exploitation of groundwater by doubling the number of borewells and pumping hours call for urgent steps to develop suitable social/legal mechanisms for sustainable use of water resources through integrated water resource management. Improved water availability through public investment triggered private/ individual investment in agriculture in rainfed areas further hastening the process of development

Management of Fracture Risk in Patients with Chronic Obstructive Pulmonary Disease (COPD): Building a UK Consensus Through Healthcare Professional and Patient Engagement

Introduction: Osteoporosis and bone fractures are common in chronic obstructive pulmonary disease (COPD) and contribute significantly to morbidity and mortality. Current national guidance on COPD management recommends addressing bone health in patients, however, does not detail how. This consensus outlines key elements of a structured approach to managing bone health and fracture risk in patients with COPD.Methods: A systematic approach incorporating multifaceted methodologies included detailed patient and healthcare professional (HCP) surveys followed by a roundtable meeting to reach a consensus on what a pathway would look like.Results: The surveys revealed that fracture risk was not always assessed despite being recognised as an important aspect of COPD management by HCPs. The majority of the patients also stated they would be receptive to discussing treatment options if found to be at risk of osteoporotic fractures. Limited time and resource allocation were identified as barriers to addressing bone health during consultations. The consensus from the roundtable meeting was that a proactive systematic approach to assessing bone health should be adopted. This should involve using fracture risk assessment tools to identify individuals at risk, investigating secondary causes of osteoporosis if a diagnosis is made and reinforcing non-pharmacological and preventative measures such as smoking cessation, keeping active and pharmacological management of osteoporosis and medicines management of corticosteroid use. Practically, prioritising patients with important additional risk factors, such as previous fragility fractures, older age and long-term oral corticosteroid use for an assessment, was felt required.Conclusion: There is a need for integrating fracture risk assessment into the COPD pathway. Developing a systematic and holistic approach to addressing bone health is key to achieving this. In tandem, opportunities to disseminate the information and educational resources are also required

Epigenetic signatures of starting and stopping smoking

Acknowledgements: This work was supported by Alzheimer's Research UK Major Project Grant [ARUK–PG2017B–10]. Generation Scotland received core funding from the Chief Scientist Office of the Scottish Government Health Directorates [CZD/16/6] and the Scottish Funding Council [HR03006]. We are grateful to all the families who took part, the general practitioners and the Scottish School of Primary Care for their help in recruiting them, and the whole Generation Scotland team, which includes interviewers, computer and laboratory technicians, clerical workers, research scientists, volunteers, managers, receptionists, healthcare assistants, and nurses. Genotyping of the GS:SFHS samples was carried out by the Genetics Core Laboratory at the Wellcome Trust Clinical Research Facility, Edinburgh, Scotland and was funded by the Medical Research Council UK and the Wellcome Trust (Wellcome Trust Strategic Award “STratifying Resilience and Depression Longitudinally” (STRADL) [104036/Z/14/Z]. DNA methylation data collection was funded by the Wellcome Trust Strategic Award [10436/Z/14/Z]. The research was conducted in The University of Edinburgh Centre for Cognitive Ageing and Cognitive Epidemiology (CCACE), part of the cross–council Lifelong Health and Wellbeing Initiative [MR/K026992/1]; funding from the Biotechnology and Biological Sciences Research Council (BBSRC) and Medical Research Council (MRC) is gratefully acknowledged. CCACE supports Ian Deary, with some additional support from Dementias Platform UK [MR/L015382/1]. HCW is supported by a JMAS SIM fellowship from the Royal College of Physicians of Edinburgh. AMM and HCW have received support from the Sackler InstitutePeer reviewedPublisher PD

Inferring cost of transport from whole-body kinematics in three sympatric turtle species with different locomotor habits

Chelonians are mechanically unusual vertebrates as an exoskeleton limits their body wall mobility. They generallymove slowly on land and have aquatic or semi-aquatic lifestyles. Somewhat surprisingly, the limitedexperimental work that has been done suggests that their energetic cost of transport (CoT) are relatively low.This study examines the mechanical evidence for CoT in three turtle species that have differing degrees ofterrestrial activity. Our results show that Apolone travels faster than the other two species, and that Chelydra hashigher levels of yaw. All the species show poor mean levels of energy recovery, and, whilst there is considerablevariation, never show the high levels of energy recovery seen in cursorial quadrupeds. The mean mechanical CoTis 2 to 4 times higher than is generally seen in terrestrial animals. We therefore find no mechanical support for alow CoT in these species. This study illustrates the need for research on a wider range of chelonians to discoverwhether there are indeed general trends in mechanical and metabolic energy costs

Clinical and cost effectiveness of computer treatment for aphasia post stroke (Big CACTUS): study protocol for a randomised controlled trial

Background Aphasia affects the ability to speak, comprehend spoken language, read and write. One third of stroke survivors experience aphasia. Evidence suggests that aphasia can continue to improve after the first few months with intensive speech and language therapy, which is frequently beyond what resources allow. The development of computer software for language practice provides an opportunity for self-managed therapy. This pragmatic randomised controlled trial will investigate the clinical and cost effectiveness of a computerised approach to long-term aphasia therapy post stroke. Methods/Design A total of 285 adults with aphasia at least four months post stroke will be randomly allocated to either usual care, computerised intervention in addition to usual care or attention and activity control in addition to usual care. Those in the intervention group will receive six months of self-managed word finding practice on their home computer with monthly face-to-face support from a volunteer/assistant. Those in the attention control group will receive puzzle activities, supplemented by monthly telephone calls. Study delivery will be coordinated by 20 speech and language therapy departments across the United Kingdom. Outcome measures will be made at baseline, six, nine and 12 months after randomisation by blinded speech and language therapist assessors. Primary outcomes are the change in number of words (of personal relevance) named correctly at six months and improvement in functional conversation. Primary outcomes will be analysed using a Hochberg testing procedure. Significance will be declared if differences in both word retrieval and functional conversation at six months are significant at the 5% level, or if either comparison is significant at 2.5%. A cost utility analysis will be undertaken from the NHS and personal social service perspective. Differences between costs and quality-adjusted life years in the three groups will be described and the incremental cost effectiveness ratio will be calculated. Treatment fidelity will be monitored. Discussion This is the first fully powered trial of the clinical and cost effectiveness of computerised aphasia therapy. Specific challenges in designing the protocol are considered. Trial registration Registered with Current Controlled Trials ISRCTN68798818 webcite on 18 February 2014