We present the case of a 76-year-old male with mild cognitive impairment and delirium who was referred to consultation-liaison psychiatry for an assessment of capacity to choose discharge. Cases involving \"dispositional capacity\" are complex and increasingly frequent, with momentous consequences for patients and their families, but are rarely discussed in the literature. In this article, experts in functional assessment, cognition, and ethics provide guidance for this commonly encountered clinical scenario based on their experience and available literature. We review the content and formulation of occupational and physical therapy assessments and their utility to the consultation-liaison psychiatrist. We also examine the relationship of cognitive impairment to decisional capacity and offer suggestions on a structured approach to evaluation. Finally, we discuss the ethical and systemic considerations of dispositional capacity and explore potential pitfalls that can lead to interprofessional conflict and missed opportunities in patient care.

An important and unresolved question in the context of the implementation of coordinated specialty care (CSC) for early psychosis in the United States is the extent to which youth and young adults from marginalized backgrounds are able to equitably access CSC services. In this brief report, we describe pathways between a county hybrid juvenile competency restoration and mental health problem-solving court (\'Court\'), serving youth with high rates of psychosis and multiple risk factors for poor long-term outcomes, and local CSC services. We found that the Court was overall successful in linking youth with psychosis to care, but in the majority of cases this was not CSC programming more specifically. Drawing on Court and CSC records as well as family interviews, we report on factors contributing to low linkage to CSC, including family-side barriers (lack of transportation, preference for lower intensity / lower demand services) and provider-side barriers, including eligibility criteria such as duration of psychosis, that ultimately exclude otherwise eligible Court-involved youth.

In February 2022, the Court of Protection was faced with the question of whether a kidney transplant was in the best interests of William Verden. The case highlighted the legal, ethical and clinical complexities of treating potential kidney transplant patients with impaired decision-making. Above all, it exposed the potential risk of discrimination on the basis of disability when treatment decisions in relation to potential kidney recipients with impaired capacity are being made. In this paper, we draw on the Verden case to (1) examine the role of the Court of Protection in cases relating to patients with impaired decision-making capacity who require a transplant, (2) to highlight the lack of empirical data on patients who have faced inequitable access to transplant and (3) highlight the shortcomings of the existing legal and regulatory framework in England and Wales guiding clinical decision making for patients in William\'s position. We consequently argue that there is a clear need for action to ensure equitable access to transplant for those in William\'s position. Furthermore, we suggest that there is a responsibility incumbent on policy makers and clinicians alike to develop a meaningful, and meaningfully operational, framework centred on preventing discrimination against potential organ recipients based on their decision-making capacity.

Sexual assault perpetrated by older adults is still an underreported crime and is not fully understood. To describe a series of cases of sexual assault by Brazilian older adults and discuss the associated factors based on the literature. This is a cross-sectional descriptive analysis of five cases of older adults accused of sexual assault in the Forensic Psychiatry sector of the Medical Legal Institute (Coroner\'s Office) in the City of Belo Horizonte\'. This review focuses on five cases involving male defendants with a mean age of 59.75 years; two with previous psychiatric treatment, and one with a previous criminal record. Their victims were prepubescent children, four of them female. Psychiatric conditions related to forensic diagnosis included dementia, schizophrenia, alcohol-related substance use disorder, paraphilia, and one without a psychiatric diagnosis. The final forensic report on all five cases found that two of the older adults diagnosed with a mental disorder in two were considered to have a mental illness that completely impaired the cognitive and volitional domains; two other adults were diagnosed with mental health disturbance that partially impaired these domains; and the last adult was diagnosed and found without mental health impairment. While the incidence of sexual crimes committed by older adults is low, the absolute number of cases has expected to rise due to population aging. Assessing the factors related to this type of crime is therefore an initial step to understanding and formulating preventive strategies.

Although the National Institute of Medicine Social Security committee recommended that a person\'s financial capacity should be defined and assessed as real-world performance, there has been scant progress on creating methods to translate this idea into reliable methods. The current clinical comment focuses on analyzing actual financial management and decision-making in an evaluation to determine whether the older person needed a conservator.
A case study is used to illustrate how to take a feasible approach to analyzing financial management and decisions and applying those to financial capacity assessment.
By employing a person-centered analysis of checking and credit card statements and using a semi-structured interview, the clinician was able to assess the financial management and decision-making skills of an older adult.
Clinical gerontologists have an ethical prerogative to enhance autonomy where possible. Analyzing a person\'s actual financial management records as opposed to hypothetical and perhaps unfamiliar financial tasks may represent a step forward in person-centered assessment of financial management and capacity.
Clinical gerontologists are often asked to provide financial capacity assessments. Using a person-centered approach to assessing financial management and financial decision-making offers a new and reliable method of assessing financial capacity.

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The authors present an unusual criminal case of delusionally motivated, serial intrafamilial killings by a psychotic offender. Because the offender retained instrumental rationality and killed his victims by stealth, viz. surreptitious poisoning, the killing of his first victims went undetected. Persecutory delusions of being poisoned not uncommonly result in defensive violence, whereas in this case, religious delusions resulted in the mentally ill person killing others by poisoning them. Here, the psychotic offender killed his victims by means of poisoning based upon motivation driven by religious delusions. This case illustrates the importance of index of suspicion and appropriate investigation of mysterious deaths, and careful forensic psychiatric assessment to distinguish delusional versus extreme overvalued belief-motivated killings in addressing the insanity defense.

We present an unusual case of an acutely unwell patient with an upper gastrointestinal bleed whose resuscitation efforts were delayed by the discovery of his, similarly, acutely unwell pet on the medical high dependency unit. We highlight the challenges this provided the clinical team and focus on the issues relating to patient safety, consent and multidisciplinary action which may be more relevant to daily clinical practice.

Tourette Syndrome is a neurodevelopmental disorder that is associated with the presence of multiple motor and one or more verbal tics. In this case report, we present a 16 years old Tourette syndrome patient who was diagnosed with comorbid Attention Deficit Hyperactivity Disorder. The patient was evaluated for legal responsibility after she made untrue allegations saying that a bus driver had sexually harassed her. We summarize the case and review the current literature to assess the socio-legal aspects of Tourette syndrome.

How (if at all) can the right to liberty of a child under Article 5 European Convention on Human Rights (\'ECHR\') be balanced against the rights of parents, enshrined both at common law and under Article 8 ECHR? Is there a limit to the extent to which parents can themselves, or via others, seek to impose restrictions upon their disabled child\'s liberty so as to secure their child\'s interests? This case considers the answers to these questions given by and the implications of the decision of the Supreme Court in September 2019 in Re D (A Child) [2019] UKSC 42.