Family conflict in dementia: prodigal sons and black sheep

The relationship at the heart of the experience of daughter caregivers of a parent with dementia: An interpretative phenomenological analysis

BACKGROUND

Parents with dementia require emotional, physical, psychological and financial support from their child caregivers to continue living at home. Daughter caregivers have been shown to be more involved in self-care and household tasks and to experience higher levels of distress than son caregivers.

OBJECTIVE

The aim of this study was to investigate the experience of daughter caregivers who provide informal care for a parent with dementia living in their own home.

METHOD

Semi-structured interviews were conducted with 11 daughter caregivers of a parent with Alzheimer's disease. Interviews were analysed using Interpretative Phenomenological Analysis.

RESULTS

Three axes emerged from the analyses: [1] the before conditions the after: the quality of the previous relationship with the parent with Alzheimer's disease is a determining factor and allows the identification of three profiles of daughter caregivers: 'the grateful', 'the resentful' and 'the ambivalent', [2] when the relationship protects against the sense of burden: the feeling of being invaded by the caregiving situation is influenced by the quality of the relationship with the parent with Alzheimer's disease, and [3] alone or almost: the support network is desired when it is absent but kept at arm's length when it is present.

DISCUSSION

The results underline the importance of assessing the quality of attachment and supporting the relationship with the parent (especially when the relationship prior to the disease was difficult). Daughter caregivers should also be encouraged to delegate tasks and refocus their actions related to their values. Family mediation sessions may be planned to improve the organisation of care and set up an efficient collaboration.

Family Communication about Diagnostic Genetic Testing for Younger-Onset Dementia

Younger-onset dementia (YOD) refers to onset before 65 years of age and may be associated with a genetic cause. Family communication surrounding any genetic risk is complex, and this process may be further complicated in a YOD context due to its effects on cognition, behaviour, and associated psychosocial consequences. This study aimed to investigate how individuals experience family communication about potential genetic risk and testing for YOD. Thematic analysis was performed on verbatim transcripts of nine semi-structured interviews undertaken with family members who attended a neurogenetics clinic due to a relative diagnosed with YOD. The interviews explored the participants’ experiences of learning that YOD might be inherited and the ensuing family communication about genetic testing. Four key themes emerged: (1) a clinical diagnostic odyssey was common and could be a motivator for genomic testing, (2) pre-existing family tension and/or disconnection was a common barrier, (3) family members’ autonomy was considered, and (4) avoidant coping strategies influenced communication. Communication regarding potential YOD genetic risk is a complicated process and may be influenced by pre-existing family dynamics, individual coping mechanisms, and a desire to promote autonomy in relatives. To promote effective risk communication, genetic counsellors should pre-emptively address family tensions that may be exacerbated in the context of genetic testing for YOD, with awareness that family strain during a preceding period of diagnostic odyssey is common. Genetic counsellors can offer psychosocial support to facilitate coping with this tension in an adaptive way. The findings also indicated the importance of extending genetic counselling support to relatives.

Easing the burden of dementia caregiving: Protocol development for a telephone-delivered mindfulness intervention for rural, African American families

Background

There have been few interventions targeted for rural African American (AA) caregivers of persons with dementia despite their unique cultural, geographic, health-related and socio-economic needs, including relatively less access to-and willingness to engage with-formal supports and resources. One effective intervention, Mindfulness-based stress reduction (MBSR), has been found to be culturally acceptable in AA populations; however, no studies have assessed feasibility, acceptability and impact of an adapted mindfulness intervention targeting rural AA dementia caregivers.

Aims

The purpose of this study is to 1) determine the feasibility and acceptability of a telephone-delivered mindfulness training intervention in decreasing caregiver burden among rural, AA, informal caregiving teams of people with dementia; 2) to explore the effects of the training on caregiver burden and relevant secondary outcomes for both caregiving team members, including emotional regulation, tolerance of uncertainty, emotional and physical health, family conflict within the informal caregiving team, and self-efficacy; and 3) to explore comfort with and willingness to adopt technologies to access mindfulness practices and existing caregiving educational resources.

Methods

Our study utilizes a single-group, uncontrolled design to assess the feasibility and acceptability of telephone-delivered mindfulness training designed to alleviate burden for rural caregivers of AA individuals with moderate to severe dementia. A care partner-the person who provides additional help -is included in the intervention. The primary outcome is feasibility of the telephone-delivered mindfulness intervention as assessed by an 85% retention rate with completion of at least 6 of the intervention sessions. Pre- and post-participation interviews assess acceptability.

Coproducing care and support delivery in healthcare triads: Dutch case managers for people with dementia at home using strategies to handle conflict in the healthcare triad

Dutch policy stipulates that people with dementia should remain at home for as long as possible. If they need care, they must preferably appeal to family, friends and neighbours. Professional help and nursing homes are deemed last resorts. Therefore, case managers must coproduce their public services increasingly in healthcare triads with both people with dementia (PWDs) and their informal caregivers. Case managers are professionals who provide and coordinate care and support for PWDs and their informal caregivers during the entire trajectory from (suspected) diagnosis until institutionalisation. The literature on coproduction has focused on the bilateral interactions between service providers and users rather than the multilateral collaborative relationships through which many public services are currently delivered, as is the case in dementia care. Little is known about how frontline workers, case managers in this study, handle conflicts in these healthcare triads. Our study addresses this gap in the coproduction literature and explores the action strategies case managers use to handle conflicts. We interviewed 19 Dutch case managers and observed 10 of their home visits between January and May 2017. We focused on the end stage of dementia at home, just before admission to a nursing home, as we assumed that most conflicts occur in that phase. The findings reveal that the case managers use a variety of action strategies to resolve and intervene in these conflicts. Their initial strategies are in line with the ideals underlying coproduction; however, their successive strategies abandon those ideals and are more focused on production or result from their own lack of power. We also found that current reforms create new dilemmas for case managers. Future research should focus on the boundaries of coproducing public services in triadic relationships and the effects of current welfare reforms aimed at coproducing public services in healthcare triads.

What factors affect paramedics' involvement of people with dementia in decisions about their care? A qualitative study

BACKGROUND

Paramedics are frequently called to people with dementia, but decision making can be challenging due to lack of information or difficulties in assessment. Best-practice dementia care should be holistic and involve people with dementia in decisions as far as possible.

AIMS

To explore how paramedics make decisions when attending people with dementia, with a particular focus on factors that impact on how, and to what degree, paramedics involve people with dementia in these decisions.

METHODS

A generic qualitative research approach was used. Data were collected through semi-structured individual interviews with seven paramedics. The interviews were recorded and transcribed verbatim and subsequently analysed using thematic analysis.

RESULTS

Four themes were identified that all touched on challenges to delivering person-centred care. Themes identified were: 1) paramedics' differing approaches to assessing capacity and making best interest decisions; 2) communication and developing a rapport; 3) interconnections with others important to the person with dementia; and 4) the impact of paramedics' values and attitudes.

CONCLUSION

The involvement of people with dementia is sometimes limited by medical, social or clinician-dependent factors. This study highlights how paramedics' values and communication skills influence their interactions with people with dementia. As the paramedic role evolves, there is an opportunity to embed person-centred care in practice and to ensure that education equips paramedics with the skills and ethical frameworks needed to deliver high quality dementia care.

The Role of the Medical Expert in the Retrospective Assessment of Testamentary Capacity

OBJECTIVES

Physicians and other mental health experts are increasingly called on to assist the courts with the determination of testamentary capacity. We aim to improve the understanding of the retrospective assessment of testamentary capacity for medical experts in order to provide more useful reports for the court's determinations and to provide a methodology for the retrospective assessment of testamentary capacity.

METHOD

Medical experts with experience in the retrospective assessment of testamentary capacity collaborated with lawyers who practice estate litigation. The medical literature on the assessment of testamentary capacity was reviewed and integrated. The medical experts provided a clinical perspective, while the lawyers ensured that the case law and legal perspective were integrated into this review.

RESULTS

The focus and limitations of the medical expert are outlined including the need to be objective, nonpartisan, and fair. For the benefit of the court, the medical expert should describe the nature and severity of relevant medical, psychiatric, and cognitive disorders, and how they may impact on the specific criteria for testamentary capacity as defined by the leading case of Banks v Goodfellow. Medical experts should opine only on the issue of vulnerability to influence and defer to the court to determine the facts of the case regarding any influence that may have been exerted.

CONCLUSIONS

Although the ultimate determination of testamentary capacity is a legal one, medical experts can help the court achieve the most informed legal decision by providing relevant information on clinical issues that may impact the criteria for testamentary capacity.

Systematic review of measurement properties of instruments assessing nurses' attitudes towards the importance of involving families in their clinical practice

AIMS

To identify, appraise and describe the characteristics and measurement properties of instruments assessing nurses' attitudes towards the importance of involving families in their clinical practice.

DESIGN

Psychometric systematic review.

DATA SOURCES

The PubMed, CINAHL, PsycINFO, Web of Science, and Cochrane Library databases were searched from their time of inception to June 2018.

REVIEW METHODS

Two reviewers independently assessed the eligibility of studies, extracted data, and appraised the methodological quality of the studies using the COSMIN checklist.

RESULTS

A total of 19 studies representing 5 instruments were included. Two instruments-a revised version of the Families' Importance in Nursing Care: Nurses' Attitudes scale (FINC-NA-R) and the Family Nurse Practice Scale (FNPS)-obtained higher scores for most of their properties. The instruments used in the remaining eight studies require further assessment of their psychometric properties.

CONCLUSION

This psychometric review offers a synthesis of the quality of the available instruments and gives a better understanding of nursing theory-based tools. The FNPS and FINC-NA-R instruments seem to be the most suitable measures of nurses' attitudes towards the importance of involving families in their clinical practice.

IMPACT

The growing emphasis on improving nurse-family relationships and the quality of care provided makes it necessary to have valid and reliable instruments for assessing nurses' attitudes towards the importance of involving families in their clinical practice. This paper provides evidence that will help clinicians and researchers make decisions about the most suitable instrument based on a critical appraisal and comparison of the measurement properties according to a rigorous methodology.

The marriage of psychology and law: testamentary capacity

Banks v. Goodfellow [1870. LR 5 QB 549 (Eng.)] is almost 150 years old, yet still stands as authority for the principle that unsoundness of the mind will not rebut testamentary capacity where it does not affect the will itself. Readers of this journal would know that psychology has advanced greatly during this sesquicentenary, and yet the law relating to testamentary capacity has remained relatively stagnant. We review the present laws relating to decision-making for adults with impaired capacity, particularly in Queensland, and also review various models of gauging decision-making capacity in other jurisdictions. We argue that qualified experts should be enlisted to make determinations about testamentary capacity when questions of capacity arise. We also argue the case for the development of scientifically validated protocols to assess decision-making capacity in the testamentary context.

I just can't please them all and stay sane: Adult child caregivers' experiences of family dynamics in care-giving for a parent with dementia in Australia

Family caregivers of people with dementia who live within the community often experience stress and poor quality of life due to their care-giving role. While there are many factors that affect this, one influential factor is the family context. This study focussed on adult child caregivers. It examined the specific ways that family dynamics contribute to adult child caregivers' distress in the context of caring for a parent with dementia. Semi-structured interviews were conducted with 17 participants who were adult child primary caregivers for a parent with dementia who was living within the community. Interviews were audiotaped and transcribed verbatim. Transcripts were analysed using thematic analysis. Four themes were identified that represented areas of particular concern and distress for the caregivers: family expectations and caregivers' lack of choice in adopting the care-giving role; denial and differential understandings of dementia among family members; differential beliefs and approaches to care-giving among family members; and communication breakdown between family members. The findings demonstrate several avenues for further research including the development of interventions to support adult child caregivers and address problematic family dynamics within the context of caring for a parent with dementia.

Validation of family conflict scales for family caregivers of persons with dementia in long-term care facilities and exploration of family conflicts and support

ABSTRACTBackground:The aim of the study was to develop a family conflict scale for family caregivers of persons with dementia in long-term care facilities and to explore the relationship between family conflicts and family support.

METHODS

The scale was developed through forward- and back-translations, interviews with 12 staff members in long-term care facilities, and cognitive interviews with 12 family caregivers who met operational definitions in this study. The test was conducted with 334 family caregivers and a retest was conducted with 318 family caregivers who had indicated willingness to participate further.

RESULTS

The internal consistency was relatively high for all subscales (Cronbach's α >0.87); sufficient retest reliability was demonstrated for all subscales (intraclass correlation coefficient >0.69). Confirmatory factor analysis supported a three-factor model. Convergent and discriminant validity for each of the family conflict scale subscales, family APGAR, and the Symptom Check List-90 Items-Revised were acceptable. Family caregivers who received no family assistance for caregiving perceived more conflict in their family than those receiving family assistance.

CONCLUSIONS

The Japanese version of the family conflict scale for family caregivers of persons with dementia in long-term care facilities was developed. The reliability and validity of the scale were verified. When providing support to family caregivers in long-term care facilities, it is necessary to consider the family from multiple viewpoints, including family conflicts and support conditions from other family members.

A Customized Intervention for Dementia Caregivers: A Quasi-Experimental Design

Objective: The aim of this study is to test the effects of a customized intervention on distress among caregivers of persons with dementia (PWD) using a quasi-experimental design. Method: Fifty-one spouse caregivers in the experimental group and 51 in the control group participated in the study. The effects of the intervention were examined by comparing caregivers' responses with questionnaires at pre-intervention baseline (T0) and immediately after intervention (T1). Differences were quantified using repeated-measures ANOVA. Results: The analyses indicated a stabilizing effect of the intervention on caregivers' perceptions of PWD's daily functioning, self-esteem related to caregiving, quality of family support, and feeling of distress. Linear increases were observed regarding sense of preparedness and impact on daily routine, while no differences (interaction and linear effects) were observed for degree of self-efficacy, depression, impact on finances, or self-rated health. Conclusion: These findings show a preliminary efficacy of the intervention proposed in this study to prevent the exacerbation of caregivers' distress.

[Family-centered care: A model for approaching dementia care in the community]

Along with ageing population, there has been an increase in the prevalence and incidence of chronic and debilitating conditions, such as dementia which, in turn, has increased the demands for long term care in the community. This is challenging current health care systems that wish to provide an appropriate response whilst intensify its efforts to contain costs. This paper, through a critical reflection, argues for an integrative, positive, and systemic care approach, focused not only on the person with dementia but also on the entire family unit. For this purpose, it approaches the impact that dementia has for the family, and therefore for Primary Health Care professional. In addition care strategies aimed at strengthening the whole family system are suggested.

Working alliances not loggerheads: understanding and addressing dissonance between families and treating teams in older people's mental health

OBJECTIVES

To identify and describe common sources of dissonance which arise for treating teams in older person's mental health and the strategies for addressing them.

METHODS

A literature review was conducted with the terms: 'family conflict and treatment team', 'family therapy and old age' and 'family caregiver'.

RESULTS

We discuss the importance of an alliance with families regarding older people's mental health, and the contribution of engagement, attachment and family dynamics to dissonance. We offer strategies to prevent and address dissonance.

CONCLUSIONS

To prevent and manage dissonance, its causes need to be identified and understood. Routinely 'thinking family' first, then 'knowing' and 'hearing' the family are crucial steps to enhancing communication with families.

Present status and road map to achieve inclusive and holistic care for dementia in a Japanese community: analysis using the Delphi method

BACKGROUND/AIMS

Dementia is a priority issue in the public health realm. However, few reports address problems of dementia in the real world or provide comprehensive road maps to solve these problems.

METHODS

Nine groups of questions covering 4 topics were discussed using the Delphi method, relating to (1) current achievements and challenges regarding inclusive and holistic care in the community, (2) patients who are at a high risk of being excluded from care, (3) suggestions for a road map for the establishment of better and more inclusive medical and social care, and (4) unmet needs of patients with dementia.

RESULTS

In total, 477 opinions were obtained. Family issues, psychological/behavioral symptoms, and complications secondary to physical disorders are main factors for being excluded from care. To create a road map for care we have to address the topics of reaffirming care principles, multidisciplinary coalitions, and education for stakeholders.

CONCLUSION

Further effective collaboration to promote dementia care is required.

Living With Dementia: An Exploratory Study of Caregiving in a Chinese Family Context

This qualitative study explored themes that described families taking care of elderly relatives with dementia in Chinese society. Ten families were invited for two in-depth family interviews involving spousal caregivers, child caregivers, and care recipients. Five themes resulted: positive affection as coping strategies, power and control in the caregiving relationship, adult children's involvement in caregiving, sibling rivalry, and intergenerational conflicts. The ways these themes functioned and helped in dementia care, the research implications, and limitations are discussed.

Review of family therapy and dementia: twenty-five years on

BACKGROUND

We reviewed the literature on family therapy and dementia to investigate the following: what is known about the use of family therapy in the context of living with dementia; what are the challenges of working in this context; and what guidelines/models are available to guide family therapists working with families living with dementia.

METHODS

We searched English language literature from 1992 onwards, classified the resulting papers into broad categories of theoretical, expository, or research (descriptive, quantitative, or qualitative), and conducted a narrative review to draw learning points from the identified papers.

RESULTS

In total 31 papers were identified: five theoretical, 11 expository; and 15 research papers. Several papers described methodologies; psychotherapeutic interventions applied to family members; or complex intervention packages in which the role of family therapy could not be separately identified, rather than family therapy. A range of outcomes were investigated, often involving the caregiver. Several authors suggest areas in dementia care where family therapy is likely to be beneficial.

CONCLUSIONS

Although the literature on family therapy and dementia has grown over the past 25 years and suggests potentially useful roles for therapy, a number of challenges exist in terms of context, family, and therapy itself. There is a need for further research, particularly into the following fields: How to evaluate the success of therapy; how to ensure treatment integrity; how to make techniques from family therapy available more widely; and how to train the health and social care workforce in working with families.

The experience of self and threats to sense of self among relatives caring for people with Alzheimer's disease

This study explored how the relatives of people with Alzheimer's disease expressed Self 2 and Self 3 according to Harré's social constructionist theory of selfhood. Having a relative with Alzheimer's disease affects one's life. In this study, we concentrated on how close relatives of people with Alzheimer's disease experienced their sense of self. This study was descriptive and qualitative. Interviews were conducted with 20 relatives of 10 people with Alzheimer's disease from 2009 to 2011. The data were analysed according to Harré's social constructionist theory of selfhood including Selves 2 and 3. Participants reported that Alzheimer's disease challenged their personal attributes, relations and positioning. Understanding how Alzheimer's disease affects the sense of self among close relatives is important, as this knowledge is pivotal for supporting these relatives who are often informal caregivers in ways that enable a fulfilling and meaningful life.

African American and non-African American patients' and families' decision making about renal replacement therapies

We conducted focus group meetings of African American and non-African American patients with end-stage renal disease (six groups) and their family members (six groups), stratified by race/ethnicity and treatment. We elicited differences in participants' experiences with shared decision making about initiating renal replacement therapy (RRT; that is, hemodialysis, peritoneal dialysis, or a kidney transplant). Patients were often very sick when initiating RRT, and had little, if any, time to make a decision about what type of RRT to initiate. They also lacked sufficient information about alternative treatment options prior to initiation. Family members played supportive roles and shared in decision making when possible. Reports were similar for African American and non-African American participants. Our findings suggest that a greater emphasis on the improved engagement of patients and their families in shared decision making about RRT initiation is needed for both ethnic/racial minorities and nonminorities.

Testamentary capacity and delirium

BACKGROUND

With the aging of the population there will be a substantial transfer of wealth in the next 25 years. The presence of delirium can complicate the evaluation of an older person's testamentary capacity and susceptibility to undue influence but has not been well examined in the existing literature.

METHODS

A subcommittee of the IPA Task Force on Testamentary Capacity and Undue Influence undertook to review how to assess prospectively and retrospectively testamentary capacity and susceptibility to undue influence in patients with delirium.

RESULTS

The subcommittee identified questions that should be asked in cases where someone changes their will or estate plan towards the end of their life in the presence of delirium. These questions include: was there consistency in the patient's wishes over time? Were these wishes expressed during a "lucid interval" when the person was less confused? Were the patient's wishes clearly expressed in response to open-ended questions? Is there clear documentation of the patient's mental status at the time of the discussion?

CONCLUSIONS

This review with some case examples provides guidance on how to consider the question of testamentary capacity or susceptibility to undue influence in someone undergoing an episode of delirium.

Predictors of family conflict at the end of life: the experience of spouses and adult children of persons with lung cancer

PURPOSE

Guided by an explanatory matrix of family conflict at the end of life, the purpose of this article was to examine the correlates and predictors of family conflict reported by 155 spouses and adult children of persons with lung cancer.

DESIGN AND METHODS

A cross-sectional statewide survey of family members of persons who died from lung cancer was conducted as part of the larger study on the Assessment of Cancer CarE and SatiSfaction in Wisconsin.

RESULTS

Significant bivariate correlations were found between family conflict and family context variables (i.e., a history of conflict, younger respondent age, race, and specified end-of-life care wishes of the patient), conditions (i.e., greater physical and psychological clinical care needs of the patient), and contributing factors (i.e., communication constraints and family asserting control). In the multivariate model, significant predictors of family conflict included prior family conflict, race, communication constraints, and family members asserting control; the model explained 72% of the variance in conflict.

IMPLICATIONS

Implications for routine assessment and screening to identify families at risk and recommendations for the development and testing of interventions to facilitate shared decision making and enhance open communication among at-risk families are highlighted.

End of life decision-making for cancer patients

This article reviews research on end-of-life (EOL) decision-making in general and published guidelines on communicating with patients about EOL treatment options. The literature on EOL decision-making, most of which concerns advance care planning decisions, has identified several factors that influence treatment choices including race, religiosity, current health, and family conflict. This literature also documents widespread lack of understanding about dying and palliative care and fears of abandonment by health care providers. This article reviews guidelines for communicating with patients, stresses the role of prognostication in good decision-making, and provides numerous suggestions for initiating and structuring conversations with patients and families about EOL care.

Family caregivers of people with dementia

Family caregivers of people with dementia, often called the invisible second patients, are critical to the quality of life of the care recipients. The effects of being a family caregiver, though sometimes positive, are generally negative, with high rates of burden and psychological morbidity as well as social isolation, physical ill-health, and financial hardship. Caregivers vulnerable to adverse effects can be identified, as can factors which ameliorate or exacerbate burden and strain. Psychosocial interventions have been demonstrated to reduce caregiver burden and depression and delay nursing home admission. Comprehensive management of the patient with dementia includes building a partnership between health professionals and family caregivers, referral to Alzheimer's Associations, and psychosocial interventions where indicated.

The psychosocial impacts of multimedia biographies on persons with cognitive impairments

PURPOSE

The purpose of this feasibility pilot project was to observe Alzheimer's disease (AD) and mild cognitive impairment (MCI) patients' responses to personalized multimedia biographies (MBs). We developed a procedure for using digital video technology to construct DVD-based MBs of persons with AD or MCI, documented their responses to observing their MBs, and evaluated the psychosocial benefits.

METHODS

An interdisciplinary team consisting of multimedia biographers and social workers interviewed 12 family members of persons with AD and MCI and collected archival materials to best capture the families' and patients' life histories. We filmed patients' responses to watching the MBs and conducted follow-up interviews with the families and patients at 3 and 6 months following the initial viewing. Qualitative analytic strategies were used for extracting themes and key issues identified in both the filmed and the interview response data.

RESULTS

Analysis of the interview and video data showed how evoked long-term memories stimulated reminiscing, brought mostly joy but occasionally moments of sadness to the persons with cognitive impairments, aided family members in remembering and better understanding their loved ones, and stimulated social interactions with family members and with formal caregivers.

IMPLICATION

This study demonstrates the feasibility of using readily available digital video technology to produce MBs that hold special meaning for individuals experiencing AD or MCI and their families.

Men family caregivers' experience of nonsupportive interactions: context and expectations

Men's involvement as family caregivers has grown as the prevalence of dementia has increased. Men rely on support from others for caregiving but also experience nonsupportive interactions. The purpose of this ethnographic study of 34 men (24 spouses and 10 sons) caring for a relative with dementia, 5 assisting caregivers, and 15 professionals was to identify primary caregivers' perceptions of nonsupportive and supportive interactions in relationships with kin and friends as well as professionals. Thematic analysis of transcribed data generated from interviews, diaries, and focus group discussions revealed the nature of men's caregiving journeys, the characteristics of their social networks, and their expectations of supportive interactions. The nonsupportive interactions men caregivers experienced included a lack of orientation to the caregiving situation, an unsatisfactory linkage to support sources, insufficient support, and hurtful interactions. Information about nonsupportive interactions can sensitize kin and friends as well as professionals to the complexity of men's experience and potentially avoid unintended negative consequences of support efforts.

The wills of older people: risk factors for undue influence

BACKGROUND

As people live longer, there is increasing potential for mental disorders to interfere with testamentary distribution and render older people more vulnerable to "undue influence" when they are making a will. Accordingly, clinicians dealing with the mental disorders of older people will be called upon increasingly to advise the courts about a person's vulnerability to undue influence.

METHOD

A Subcommittee of the IPA Task Force on Testamentary Capacity and Undue Influence undertook to establish consensus on the definition of undue influence and the provision of guidelines for expert assessment of risk factors for undue influence.

RESULTS

International jurisdictions differ in their approach to the notion of undue influence. Despite differences in legal systems, from a clinical perspective, the subcommittee identified some common "red flags" which might alert the expert to risk of undue influence. These include: (i) social or environmental risk factors such as dependency, isolation, family conflict and recent bereavement; (ii) psychological and physical risk factors such as physical disability, deathbed wills, sexual bargaining, personality disorders, substance abuse and mental disorders including dementia, delirium, mood and paranoid disorders; and (iii) legal risk factors such as unnatural provisions in a will, or provisions not in keeping with previous wishes of the person making the will, and the instigation or procurement of a will by a beneficiary.

CONCLUSION

This review provides some guidance for experts who are requested by the courts to provide an opinion on the risk of undue influence. Whilst international jurisdictions require different thresholds of proof for a finding of undue influence, there is good international consensus on the clinical indicators for the concept.

Abuse by marriage: the exploitation of mentally ill older people

OBJECTIVES

(i) To raise awareness about the vulnerability of mentally ill older persons to abuse by others seeking to gain by marriage; (ii) to outline key legal cases from common law countries; and (iii) to provide guidelines for health care professionals who encounter this issue in practice.

METHOD

We present two cases: the first case involved an 87-year-old widower who married his carer--50 years his junior--in a religious ceremony while hypomanic. The second case involved an 82-year-old widow with moderate dementia who married her boarder, the marriage subsequently being found void in the Family Court of Australia on the basis that her consent was not real because she was incapable of understanding the nature and effect of the marriage ceremony.

RESULTS

Abuse by marriage may be of a psychological, sexual, social or financial nature.Older people with impaired judgement and inability to appraise others due to mental illness may be persuaded to execute legal documents such as marriage certificates.

CONCLUSION

Health care professionals may have a role in the identification and management of this kind of abuse. There are legal means to address this problem ranging from guardianship and financial management to family law court applications to seek a decree of nullity/invalidity of the marriage.