The report details the deprivation of rights faced by mental health patients who are involuntarily admitted under the current BC Mental Health Act. The use of restraints and seclusion, treatment without consent, and lack of adequate oversight are among the issues explored.

The report states that BC’s mental health system has fallen behind other provinces due to its failure to engage in systemic review, and recommends an independent law reform commission be established to overhaul the Mental Health Act. The report emphasizes that “The Mental Health Act detention system does not just need a few amendments or tweaks, it needs to be overhauled.” The report also sets out specific recommendations aimed at the BC Government, Mental Health Review Board, Ministries of Health and Mental Health and Addiction, Legal Services Society, and Office of the Ombudsperson.

Recommendations for the BC Government include a call to review and amend the Mental Health Act to:

• Create legal criteria to govern the use of restraints and seclusion;
• Create a statutory framework for prompt, independent rights advice on detention and detention renewal;
• Establish equal health care consent rights for physical and mental health care decisions;
• Ensure legal reviews of detention take place at periodic intervals for all detainees; and
• Create an independent administrative body that provides effective oversight of the conditions of detention.

In addition, there are recommendations for the Mental Health Review Board aimed at improving process and procedure with respect to Review Panel Hearings, as well as addressing oversight and accountability mechanisms for the Review Panel.

Recommendations directed at the Ministries of Health and Mental Health and Addiction focus on the creation of standardized provincial policies and training to assist in remedying many of the issues identified by CLAS in the areas of detention decisions; the use of restraints and seclusion; access to information and legal advice; documentation and authorization of psychiatric treatment; Review Panel Hearing processes; and oversight mechanisms of the Mental Health Act detention system.

Finally, the report recommends that the Legal Services Society improve funding available to detainees, and that the Office of the Ombudsperson review the scope of their current systemic investigation of the BC system for Mental Health Act detentions and forced psychiatric treatment.

The issues of consent to health care and the use of restraints in the context of older adults in BC are topics under consideration by the Canadian Centre for Elder Law, in collaboration with the Alzheimer’s Society of BC, in their current project: Health Care Consent, Aging and Dementia: Mapping Law & Practice in BC.

The post Community Legal Assistance Society Publishes Report on BC’s Mental Health System first appeared on British Columbia Law Institute.

In February, the Canadian Psychological Association celebrated Psychology Month to highlight the contribution of Canadian psychology and to let Canadians know how psychology works to help them live healthy lives. The Canadian Nurse magazine took the opportunity to think about psychology in numbers and published a few key statistics. For example, they reported that 6.7 million Canadians live with a mental health problem or illness at any given time, nearly 20 percent of the country’s population.

Meds and seniors in numbers

When it comes to older adults, a number of reports have highlighted some statistics worth reflecting on. In the United States, a new study released in February 2017 demonstrates that there has been a rise in the number of American seniors who take three or more medications that affect their brains. The study considered seniors’ use of opioid painkillers, antidepressants, tranquilizers and antipsychotic drugs.

A review of U.S. Centers for Disease Control and Prevention data shows that the use of these drugs in people over 65 more than doubled from 2004 to 2013. Researchers indicate this finding is a cause for concern as the combined use of drugs that act on the central nervous system can lead to falls, affect driving ability, and cause memory and thinking problems. Another finding of the study was that nearly half of seniors taking these drug combinations did not have a formal diagnosis of a mental health condition, insomnia or pain condition—the three main types of problems for which these drugs are typically prescribed.

This study resonates with findings in Canada, where seniors are the heaviest users of prescription medicines. A study from the Institute for Research on Public Policy released in January 2017 notes that on average, two-thirds of seniors take five or more prescription drugs over the course of a year and one-quarter take 10 or more. It is estimated that as much as half of the medications given to seniors are taken incorrectly or are overprescribed, increasing the likelihood of drug reactions and interactions, and without evidence they are safe and effective for them. The study calls for a comprehensive national strategy to address inappropriate prescribing practices that lead to the unsafe use of medications by seniors.

Another study led by Steve Morgan, a professor in the school of population and public health at the University of British Columbia, and published in 2016, found that the prescribing of potentially inappropriate medications for older adults is common and costly in Canada, especially for women.

In regards to the specific use of antipsychotic medications, a report released in February 2016 by the Canadian Institute for Health Information shows that in 2014, 39 per cent of seniors in long-term care facilities were prescribed at least one anti-psychotic and that nearly one-quarter of residents were chronic users of antipsychotic medications. Antipsychotics refer to a class of drugs used to control symptoms in patients with psychotic disorders such as schizophrenia and related disorders.

In 2015, a study led by Tara Gomes, a scientist at Li Ka Shing Knowledge Institute of St. Michael’s Hospital and the Ontario Drug Policy Research Network found that the use of anti-psychotic drugs by seniors in their homes and other community settings in Ontario had jumped by 26 percent in five years. Trends in the rate of antipsychotic use varied across provinces, with the rate decreasing slightly in B.C. and Ontario, while increasing in New Brunswick and P.E.I.  For example, in facilities across B.C., an average of 27 percent of residents are taking antipsychotics without a matching psychiatric diagnosis, according to the 2017 Residential Care Facilities Quick Facts Directory, produced by the B.C. Seniors Advocate.

Antipsychotics and people living with dementia

The use of antipsychotics in seniors remains a complex question. People living with Azheimer disease and related dementia experience a range of symptoms. The symptoms include, but are not limited to, changes in mood, delusions and hallucinations, and responsive behaviours. Responsive behaviours, which may include agitation, aggression, and verbal outburst, can be particularly challenging for caregivers and can possibly result in incidents. In June 2016, the B.C. Seniors Advocate released a report focused on the issue of resident to resident aggression in BC’s care homes. Most of the incidents occurred in facilities with a high proportion of residents with complex care needs, and the report made specific recommendations on reporting, staffing levels, staff training and facility design and security systems.

To treat responsive behaviours, antipsychotics are commonly prescribed, and the Canadian Institute for Health Information report found that residents with severe cognitive impairment and those exhibiting highly aggressive behaviour were more likely to have used an antipsychotic.

However, the report also noted that the use of antipsychotics among residents without behavioural symptoms (about 20 percent) may suggest use contrary to treatment guidelines.

While there are cases where antipsychotic medications are warranted, most antipsychotic medications are not approved to treat dementia and can cause side effects that include sedation, a sudden drop in blood pressure, falls, fractures, stroke and death.

Alternative approaches

Some institutions in Canada and elsewhere are developing “person-centred” approaches which consider the needs of the residents first and are exploring non-drug therapies such as exercise, music, gardening, and pet therapy. The Canadian Institute for Health Information notes that a large proportion of seniors in long-term care facilities exhibiting severe aggression were not treated with antipsychotics, suggesting that non-drug alternatives were being considered, even in the most serious cases.

The right to health care consent

Whatever health treatment options are considered, people living with dementia and their substitute decision makers have a right to be consulted on medication choices. In collaboration with the Alzheimer Society of B.C., the Canadian Centre for Elder Law has launched a new project on the law, policy and practice with respect to health care consent in British Columbia.

Over the next few months, we will be holding consultation focus groups in communities across B.C. to learn about people’s experiences around consent to treatment and medication.

If you are a person living with dementia, a caregiver or substitute or supportive health care decision maker for a person living with dementia, you may be able to participate. Please contact us at: igroc@bcli.org.

The post New reports shed light on seniors and antipsychotic medications first appeared on British Columbia Law Institute.

In collaboration with the Alzheimer Society of B.C., the CCEL is reviewing the law, policy and practice of health care consent, with the ultimate goal of making recommendations for improvements in this area.

The project arose from a concern that people living with dementia, family members, and the people who make decisions on their behalf are not always consulted on treatment options and medication. Instead, community care facilities and physicians sometimes appear to be making decisions about medication and treatment. At the same time statistics suggest an overuse of medication by older people in B.C.

For example, in 2015, a report released by the B.C. Seniors Advocate highlighted that more than a third of B.C. care home residents were prescribed antipsychotic medications although only four percent had been diagnosed with a psychiatric disorder. Since then, there has been a decrease in the misuse of antipsychotics, but the Seniors Advocate still notes that more could be done in this area.

An estimated 70,000 people in British Columbia are living with Alzheimer’s disease or another dementia, and the number is growing as the population is aging. The right to health care consent is a pressing issue that impacts all of us; however, people with disabilities and diseases, such as dementia, may face greater barriers to ensuring their rights are respected.

Behind the statistics, there are individuals and their personal stories. No other organization in B.C. is better connected to the real experiences of people living with dementia than the Alzheimer Society of B.C.

The Society, created in 1981, is committed to helping build a dementia friendly society – a place where people living with the disease are welcomed, acknowledged and included. They also provide support, education and information for people living with dementia and their families throughout the province, champion advocacy efforts and enable research into the causes and cure of dementia.

Q&A with Barbara Lindsay, Alzheimer Society of B.C.

A lawyer by training, Barbara Lindsay, the Society’s director of Advocacy & Education Marketing & Communications has been a passionate advocate for the rights of people living with dementia since she started working with the Society 20 years ago. In recent years, the Society has identified Dementia-Friendly Communities as a strategic priority. “We want to transform how society views people living with dementia,” she says. “When you talk to families, you see how challenging this disease is. The health care system, the financial system, and the legal system are just not set up to meet their needs.”

We recently met with Barbara to talk about her insights on this new project and what she hopes to achieve through the Society’s collaboration with the CCEL.

Why is health care consent relevant to people living with dementia? 

Barbara: Members of our community identified this issue as a complex area of law. One thing the law says is that we always go to the person at the center of the decision to seek consent, but that doesn’t happen in practice. Often, when people living with dementia are in a care facility, there is an assumption that they are not capable of making decisions so medications are provided without their input. When family members meet with the care facility team, the staff will inform them of the medications they provide, but consent is assumed. Many families tell us that it is only when they receive the bill from the care facility that they find out about the medications that are given to the person they are supporting. They are not told what these drugs are for, what they do or what the side effects are, so they are not really involved in the decision-making. The conversation doesn’t happen.

Yet, it is a legal right to make your own decision. In this context, you are the consumer of health services, and you have the right to be told what the service is, how it will be administered, and you can say yes or no to elements of the service, which includes medication.

What do people typically know about consent rights?

Barbara: Families don’t always know what their rights are, but they are also finding that care providers are not always clear on the rights and the law as well. For example, maybe care providers have some knowledge, but they feel confined by the tight time frame with the number of people they need to care for, and they don’t execute the consent process because they feel they need to take shortcuts. Or, perhaps they don’t even understand the law at all.

Why is it important to conduct this project now?

Barbara: There is a strong emphasis on accountability in care facilities and a growing awareness that everyone has a right to give informed consent. The United Nations has just started to look at the rights of people living with dementia in the context of the rights of persons with disabilities.

What are you hoping to accomplish with this project?

Barbara: We hope to make recommendations for policy, law, and practice changes and understand what the levers for change are, whether it is through more education for health care providers, new regulations in care facilities, or for doctors to become more engaged in terms of ensuring consent.

Our focus at the Society is to transform the way people living with dementia experience their world. We hope that health care providers can understand that people living with dementia and their families have real needs, and that they have to meet those needs. Alzheimer’s disease or another dementia is a difficult diagnosis to receive. There are many things you need to do, and it can feel overwhelming, so when you think of trying to fight for your rights, it can take a back seat to everything else.

To fight for your rights can be hard, so we would like a system where people don’t have to. We would like to ensure that an individual’s rights are honoured, that the process of informed consent is valued and actually happens without you having to push.

What’s next: how to get involved

In the next few months, the CCEL and the Alzheimer Society of B.C. will be holding consultations and focus groups in communities across B.C. to learn about people’s experiences around consent to treatment and medication. If you are a person living with dementia, a caregiver or substitute health care decision-maker for a person with dementia, we want to hear from you. If you would like to participate, please contact Isabelle Groc: igroc@bcli.org

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Photos, courtesy of the Alzheimer Society of B.C.:

– Jim Mann has been living with dementia for the last 10 years and is a passionate advocate for the rights of people living with dementia in BC

– Barbara Lindsay, Alzheimer Society of B.C.’s director of Advocacy & Education Marketing & Communications

The post Informed health care consent, aging and dementia: making it happen first appeared on British Columbia Law Institute.