Standard 9: Awareness of mental health, dementia and learning disability

Amara This standard covers three very large subjects. Where do you want to start?

Nadia With the three Ds, because getting them confused is doing active harm right now in a lot of services. Delirium, dementia and depression.

Amara Tell them apart for me.

Nadia Delirium is acute. Hours or days. Attention and consciousness fluctuate, so the person is bright at eleven and completely away with it at three. It is a medical emergency. Dementia is chronic and progressive over months and years, and consciousness is clear. Depression can look exactly like cognitive decline in an older adult, and tends to produce I do not know rather than a wrong answer.

Amara What causes delirium?

Nadia Almost always something simple. Infection, particularly urine and chest. Constipation. Pain. Dehydration. A medication change. Urinary retention. Which is the good news, because nearly all of it is reversible if somebody acts.

Amara So what is my rule on a shift?

Nadia Any sudden change in cognition is delirium until proven otherwise, and it needs medical review today. Not at the next routine visit. Not on Monday. Delirium carries significant mortality, and the commonest failure is recording it as having a bad day.

Amara Let us do the Mental Capacity Act, because I hear it quoted constantly and usually wrongly.

Nadia Five principles and they are worth memorising. Assume capacity. Take all practicable steps to help the person decide before concluding they cannot. An unwise decision is not incapacity. Anything done for someone lacking capacity must be in their best interests. And choose the least restrictive option that still achieves the purpose.

Amara How is it wrongly used?

Nadia As a blanket label. He lacks capacity, full stop. That is unlawful. Capacity is decision specific and time specific. A woman may lack capacity to decide where to live and absolutely retain capacity to decide what to wear, what to eat, and whether to have a flu jab. You assess the decision in front of you, at the time it needs making.

Amara And the test itself?

Nadia Two stages. First, is there an impairment or disturbance in the functioning of the mind or brain. Second, does that mean the person cannot do one of four things. Understand the relevant information. Retain it long enough to decide. Use or weigh it. Or communicate the decision by any means at all.

Amara By any means at all. That is doing some work in that sentence.

Nadia It is. Blinking counts. A squeeze of a hand counts. Before you decide somebody cannot communicate a decision, you had better have tried more than asking them a question in a busy room.

Amara What about DoLS? Every service says it differently.

Nadia Start with the test, which comes from the Cheshire West case, and it is two limbs. Is the person under continuous supervision and control. And are they not free to leave. If both are true and the person lacks capacity to consent to those arrangements, that is a deprivation of liberty and it must be authorised.

Amara Even if they seem perfectly happy?

Nadia Even then. That is the bit that surprises people. The judgment was explicit that a gilded cage is still a cage. Contentment is not consent, and a good placement still needs lawful authority.

Amara Who authorises it?

Nadia In a care home or hospital, through the Deprivation of Liberty Safeguards. In supported living or a person's own home, it needs a Court of Protection order instead.

Amara Last part. Learning disability. What do I most need to know?

Nadia One phrase. Diagnostic overshadowing. People with a learning disability in England die on average many years earlier than the general population, and the LeDeR reviews keep finding avoidable causes. A big driver is that when something new happens, it gets attributed to the learning disability or to autism instead of being investigated.

Amara Give me the concrete version.

Nadia A man with a learning disability becomes withdrawn and stops eating. That is not a behavioural episode until physical causes have been excluded. Constipation. Toothache. Reflux. An ear infection. Check the body before you reach for the behaviour chart. And make sure the annual health check is actually happening, because it is the single most protective thing available and it is frequently missed.