1. A Brief Overview of the Mental Health Act and the Confused Patient BY NATASHA WESTBROOK

2. Overview  What is the Mental Health Act?  Different types of mental health acts  The confused patient – definitions  Causes and risk factors  Presentation  History and Assessment  AMTS  Investigations  Management

3. The Mental Health Act  The Mental Health Act 1983 (which was substantially amended in 2007) is the law in England and Wales that allows people with a ‘mental disorder’ to be admitted to hospital, detained and treated without their consent – either for their own health and safety, or for the protection of other people.  The Mental Health Code of Practice contains guidance that health professionals should follow when detaining and treating people under the Mental Health Act. Two key principles of this are: - that the person who is detained and treated against their will must be as fully involved in planning treatment as possible. - that care and treatment should be provided in the least restrictive way possible

4. Informal Patients  Admitted to a psychiatric hospital voluntarily  Likely that they know they are unwell  There is no restrictions for leave for the patient ie. They can leave the ward for however long they like  Whilst on the ward there is still a duty of care for the patients from all healthcare professionals

5. Section 5(4)  This is a temporary nursing hold section (usually used by Mental Health nurses)  Lasts for up to 6 hours and it is rarely used  If there was no doctor available to complete an assessment and a service user needed to be prevented from leaving the hospital, because there was an immediate concern about their health or safety or for the protection of others, the registered mental health nurse could use Section 5(4) to provide immediate safety.

6. Section 5 (2)  This is a temporary clinician hold section (used by a ward doctor or approved clinician until a Mental Health Assessment can occur)  Lasts for up to 72 hours  The assessment itself will be by an Approved Mental Health Professional and two doctors, usually a doctor who is responsible for the service users care and if possible the second doctor also knows the service user, such as their GP. It cannot be 2 doctors from the same ward or team.  The assessment by the Approved Mental Health Professional and doctors will decide whether the person needs further detention under section 2 or 3 or whether the section 5 (2) could be rescinded and the person could remain in hospital on an informal basis.

7. Section 2  Also known as an Assessment Order - lasts up to 28 days  This has to be signed by 2 doctors and an approved social worker who all agree that the patient is mentally unwell and requires further assessment in a psychiatric hospital  A section 2 cannot be renewed  Treatment can be given against a patient’s will  The patient can appeal against their section – must be within 14 days

8. Section 3  Also known as a Treatment Order – lasts up to 6 months  This can be renewed for another 6 months or even a year  The doctor has to state the category of mental illness the patient is thought to be suffering from (e.g. mental illness, psychosis, mental impairment)  Treatment can be given – but after 3 months, either: the patient has to consent to treatment OR a third doctor has to review the patient and give their consent for treatment to be given  this within the 6 month period

9. Section 4  This is an emergency detainment section used for further assessment of the patient – lasts up to 72 hours  Only one doctor is required to say urgent admission is required. The application is then completed by another mental health professional or the patients nearest relatives.  During the 72-hour period, a second doctor should review the patient. The outcome may be that the individual is detained under Section 2 or Section 3.

10. Section 135 and 136  Section 135 – allows the police to gain entry into someone’s premises to allow an assessment under the Mental Health Act to be made, or to return someone who has left the hospital and is absent without leave. A warrant from a Magistrates' Court is required before this power can be used. For patients who are to be assessed for detention, the police must be accompanied by an approved mental health professional (AMHP) and a doctor.  Section 136 – allows the police to take someone from a public place to a place of safety, if they think he or she needs immediate care or control. A 'place of safety' might be a mental health hospital, an accident and emergency department, or a police cell. Lasts for up to 72 hours

12. The confused patient… Definitions  Although “confused” or confusional state are terms we use everyday they do not have a precise meaning and are best avoided.  The term Delirium is more accepted and is defined as an acute, transient and reversible state of confusion, usually the result of other organic processes(infection, drugs, dehydration etc.), the onset is acute and the cognition of the patient can be highly fluctuant over a short period of time.

13. Causes and risk factors  Acute Infections  Prescribed drugs  Toxic substances  Surgical  Vascular disorders  Metabolic causes  Vitamin Deficiencies  Endocrinopathies  Trauma  Epilepsy  Neoplasia  Urinary retention  Constipation

14. Presentation  Acute or subacute presentation.  Fluctuating course.  Consciousness is affected  Poor concentration.  Memory deficits  Abnormalities of sleep-wake cycle  Abnormalities of perception  Agitation.  Emotional lability.  Psychotic ideas are common but of short duration and of simple content.  Neurological signs - eg, unsteady gait and tremor.

16. History  Take a usual history and focus on: -Current diagnoses – consider dementia & depression as standalone causes or in conjunction with delirium -Medications – perform a medication review – opiates / calcium supplements etc -Vascular problems – previous Strokes / MI / ischaemic limbs ↑ likelihood of vascular dementia - Other presenting complaints - History of recurrent admissions  Collateral History  Cognitive Assessment

17. Abbreviated Mental Test Score  Age  Time to the nearest hour  Address for recall e.g. 42 West Street  Year  Name of this place  Name two people e.g. doctor, nurse  DOB  Year of start of World War I (or a famous event)  The name of the current Monarch  Count backwards from 20 -1

18. Investigations  Observations – BP, HR, RR, O2 sats, temperature  Full Examination  Bloods – FBCs, U+Es, TFTs, LFTS, INR, calcium, glucose, B12, folate and haematinics  Urine Dip Depending on Hx you may consider:  CT head  CXR  Blood cultures

19. Management  Treat the UNDERLYING CAUSE!  Supportive management from healthcare professionals and friends and family if possible  Use the least restrictive method to keep patients safe, try to avoid using sedative medication  Preventative measures e.g. consider stopping medications that induce delirium

20. Capacity  In order to have capacity, a person must be able to: ◦Understand the information about the decision presented to them ◦Retain this information long enough to make a decision ◦Be able to weigh up the information in order to arrive at their decision ◦Communicate their decision (verbally or non-verbally) If any one of the above points is absent, they are deemed to lack capacity

21. DOLS (Deprivation of Liberty Safeguards)  Deprivation of Liberty Safeguards (DoLS) are a set of rules within the Mental Capacity Act. These rules apply if the patient can't make certain decisions about how they are cared for.  These rules only apply if the patient is looked after in a hospital or care home  DOLS are designed to ensure: ◦A patient, who has their liberty deprived, has an independent representative to act upon their behalf ◦That the deprivation of their liberty is reviewed on a regular basis ◦That the patient – or their representative as assigned above – has a legal basis on which to challenge the deprivation of liberty through the court of protection

22. An Example An 80-year old suffering from advanced dementia and recurrent falls who, following IM nailing of a fractured neck of femur is now poorly mobile, but wants to be discharged home. Her family and the medical team feel she needs placement to a nursing home ◦If she lacks the capacity to understand that she would be unsafe for a discharge home in view of her inability to care for herself, feed herself etc. one would argue that placement in a nursing home is in her best interests ◦However, a nursing home placement goes against her own (albeit non-capacitous) wishes ◦A DOLS would be required as part of proceeding with arranging a nursing home placement, and for keeping her on the ward whilst this process is completed

23. DOLS cont… ◦An emergency DOLS will last for up to 7 days, but can be extended upon request if the standard DOLS is not yet in place ◦A standard DOLS should be applied for at the same time, the formal assessment of which must take place within 21 days of application submission ◦The standard DOLS should be left in place for as little time as possible, but can last for up to 12 months, with ongoing reviews ◦The assessment includes Age, Mental Health, Mental Capacity, Best Interests, Eligibility and No Refusals

24. Thank you!