Category: Health / Medical

17 May

Dementia and Driving: A Compatible Combination?

Hull & Hull LLP Capacity, Elder Law, Estate & Trust, General Interest, Health / Medical, In the News Tags: , , , , , , , , , , , , 0 Comments

A conversation about driving with dementia exploded in the press in recent weeks. Everyone is weighing in on this debate, with potential stakes running obviously high. Certainly the decision to take away a patient’s licence could never be undertaken lightly, so how can a physician accurately determine driving risks associated with dementia?

A patient’s score on the Mini-Mental Status Examination (MMSE) score, when considered on its own, is a surprisingly poor predictor of a driver’s ability to drive safely. In fact, studies have shown that as many as 76% of patients with mild dementia are still able to pass an on-road driving test. Last month, in a strong effort to refine the entire process of assessing driving risk associated with dementia, the American Academy of Neurology issued updated guidelines for physicians. These updated practice parameters take into account the following characteristics that have proven useful for identifying patients at increased risk for unsafe driving:

Clinical Dementia Rating Scale (CDR);
• A caregiver’s rating of a patient’s driving ability as ‘marginal’ or ‘unsafe’;
• The patient’s driving history, including accidents and citations;
• Self-reported ‘situational avoidance’ [Studies have shown that self-restricted driving, perhaps by avoidance of highway driving or night driving, or driving in inclement weather, or simply reduced overall mileage, is an accurate indicator of a driver at increased risk];
• An MMSE score of 24 or less; and
• Aggressive or impulsive personality characteristics.

This multi-faceted risk assessment brings the Americans more in line with the current Canadian approach, as outlined in the Canadian Medical Association’s document: Determining Medical Fitness to Operate Motor Vehicles CMA Driver’s Guide which takes this stance: "The driving ability of people with mild dementia should be tested on an individual basis. Studies have shown that a significant percentage of those in the early stages of dementia are able to operate a motor vehicle safely."

Jennifer Hartman, guest blogger

10 May

No Time for a Doctor? There’s an App for That.

Hull & Hull LLP Estate & Trust, General Interest, Health / Medical Tags: , , , , , 0 Comments

One of my first blogs (now colloquially referred to as the ‘thumb blog of 2008’) delved into the subject of cyberchondria, which was defined in the Globe and Mail as ‘hypochondria on metaphorical steroids, its effects amplified by the staggering number of disastrous outcomes the Web can provide’. Well if ever there was a black hole from which the cyberchondriac could never hope to escape, it would be found in the Apps catalogue on your iPhone and would go by the collective name “Medical Apps”.

I’m no dummy. I can see the value in Heartwise Blood Pressure Tracker; you type in your blood pressure and heart rate and can then monitor trends over time. Handy app if I have a blood pressure problem. I get that.

Speaking of blood pressure, though, I’ll venture a guess that the Infections App would really do a number on a hypochondriac; everything you could ever want to know about anthrax, dengue fever, monkeypox and more, all at your fingertips.

And the temptation to self-diagnose must be irresistible if you’ve downloaded X-Rays, a nifty little App (free, no less), for identifying any sort of abnormality as a result of disease, injury, or simply poor genetic misfortune.

What I do find most unnerving are the Apps that are obviously targeting physicians. Instant ECG: An Electrocardiogram Rhythms Interpretation Guide is one example. Not sure how confidence-inspired I would be to watch my cardiologist whip out his iPhone to make sure I wasn’t in atrial fibrillation. Ditto for “ICU Pearls”, which the developer describes as ‘pearls of wisdom’ for the ICU doctor. Call me ungrateful, but if I’m in the ICU, I’m probably not there for a life lesson.

I scored an iTouch for Mother’s Day this year. I’m already getting wicked finger cramps exploring the full scope of what it can do. But don’t worry about me, there’s an App for that.

Jennifer Hartman, guest blogger


03 May

Cognitive Screening Tools

Hull & Hull LLP Capacity, Estate & Trust, Health / Medical Tags: , , , , , , , , , 0 Comments

In the course of reviewing medical records in advance of estate litigation, one will encounter a wide variety of cognitive screening tools used to identify cognitive impairment. A handful of these tools are described here:

Confusion Assessment Method (CAM): an ICU assessment tool used to detect the presence or absence of delirium. A CAM assessment is usually carried out once every 8-12 hours (once per nursing shift). Results are presented as either ‘CAM-positive’, or ‘CAM-negative’, indicating the presence or absence of delirium, respectively.
Mini-Mental Status Examination (MMSE): a quantitative measure of cognitive status in adults. Despite its well-documented limitations, the MMSE is the most widely used standardized cognitive screening test in both clinical practice and research. Scores (out of a maximum 30 points) are paired with an associated level of impairment, i.e. no impairment, mild impairment, moderate impairment or severe impairment.
The Montreal Cognitive Assessment (MoCA): a rapid cognitive screening instrument used to detect mild cognitive impairment. This user-friendly tool assesses attention and concentration, executive functions (these are the high-level abilities that control more basic abilities and behaviours), memory, language, conceptual thinking, visuoconstructional skills, calculation and orientation. Studies have shown the MoCA to be far more sensitive than the Mini-Mental Status Examination (MMSE) in its ability to detect mild cognitive impairment.

There are dozens of other cognitive screens in use including the Mini-Cog, the Rowland Universal Dementia Assessment Scale (RUDAS), the Clinical Dementia Rating (CDR), the Memory Impairment Screen (MIS), and the recently published Self-Administered Gerocognitive Examination (SAGE). In the context of a dispute regarding testamentary capacity, cognitive screening results are valuable for the estate practitioner, in that they provide tangible, measurable, time-sensitive information regarding the testator’s cognitive functioning, and serve as a tool for assessing the progression of the impairment.

Jennifer Hartman, guest blogger

28 Apr

Capacity Litigators Beware: DSM-IV to be Revised

Hull & Hull LLP Capacity, Estate Planning, Health / Medical, In the News Tags: , , , , , , 0 Comments

A fifth edition of the Diagnostic and Statistic Manual of Mental Disorders (known as the "DSM-IV") is imminent, according to the chair of the task force responsible for the fourth edition, Dr. Allen Frances, quoted in this National Post article.  The DSM-IV is considered the most authoritative manual for defining and classifying mental illnesses. 

The relevance to capacity litigation is that the language doctors use to talk about patients and record their observations may change, perhaps significantly.  According to Dr. Frances, revisions to the definitions of attention-deficit hyperactivity disorder, autism and childhood bipolar disorder (i.e., manic depression) resulted in an unintended 40-fold increase in rates of diagnosed bipolar disorder.  A patient’s diagnosis is a major variable in his or her treatment.  There was a dramatic increase in prescriptions of anti-depressants over this period.

Revised definitions would not necessitate corresponding changes in legal capacity, of course.  The tests for the various levels capacity are functional in nature; they evaluate an individual’s observed ability to make decisions and do things.  Good capacity assessments tell a story, and the elements of the story must support the conclusions reached.  If not, the assessment will be rejected.  Re Koch is instructive on this point.  It is hard to read the judgment and imagine that including medical terms would have made any difference at all. 

On the other hand, changes to the DSM-IV may be very relevant for expert opinions on capacity given after an individual’s death, where the opinion relies heavily on medical reports and observations of treating physicians to assess an individual’s capacity at a specific time during that individual’s life. 

Have a great day,

Christopher M.B. Graham – Click here to learn more about Chris Graham.



30 Mar

Upcoming ‘Medical/Health Series’ of Blogs

Hull & Hull LLP Capacity, Estate & Trust, General Interest, Health / Medical, In the News Tags: , , , , , , , 0 Comments

The next Medical/Health series of blogs is scheduled to hit the platform on Monday May 3rd, 2010.  The series will run every Monday thereafter in the month of May (with the exception of Victoria Day), for a total of four blogs.

To keep things fresh, relevant and engaging, we are inviting suggestions for topics from you.  Is there a specific medical condition you’d like to see an overview for?  We have blogged on strokes, brain injury, alcohol abuse, pharmaceutical abuse, dementia, the Ontario Mental Health Act, and palliative care, just to name a few.  Perhaps you would like to see one of these capacity-related topics explored in more detail?

Please forward your suggestions to .

23 Feb

Admission to a Psychiatric Facility under the Ontario Mental Health Act

Hull & Hull LLP Capacity, Estate & Trust, Ethical Issues, Health / Medical Tags: , , , , , , , , , 0 Comments

Yesterday’s blog spoke to the issue of an Application for Psychiatric Assessment (Form 1) under the Mental Health Act R.S.O. 1990. To review, upon completion of the psychiatric assessment, the patient must either be released or admitted as an involuntary patient, a voluntary patient, or an informal patient.

Involuntary Patient: Before you become an involuntary patient, a doctor must assess you and place you on a Form 3 (Certificate of Involuntary Admission), which lasts for two weeks. The Mental Health Act speaks very specifically to the legal criteria that must be met in order for such a Certificate to be completed. An involuntary patient is not permitted to leave the hospital or psychiatric facility.

Voluntary Patient: There is no portion of the Mental Health Act that authorizes a psychiatric facility to detain a voluntary patient. In this regard, a voluntary patient can leave the facility at any time, as long as they do not pose a risk to themselves or others. If they were to be identified as posing a risk to themselves or others, then they must be made an involuntary patient (by means of a Form 3) in order to be detained.

Informal Patient: An informal patient is either a child under the age of 16 years, or someone who is incapable of making treatment decisions for themselves (as defined by the Health Care Consent Act) and who therefore has been admitted to the facility under the consent of another person (i.e. ‘substitute decision-maker’; usually a concerned family member). The informal patient cannot be held against their will in the hospital, however, an informal patient can be made ‘involuntary’ if a doctor deems that a Form 3 is necessary.

Jennifer Hartman, Guest Blogger


21 Feb

Application by Physician for Psychiatric Assessment under the Ontario Mental Health Act: The Form 1

Hull & Hull LLP Capacity, Estate & Trust, General Interest, Health / Medical Tags: , , , , , , , , 0 Comments

Under the Ontario Mental Health Act, a Form 1 refers to an Application by Physician for Psychiatric Assessment, or APA.  A Form 1 allows a doctor to hold a patient in a hospital or psychiatric facility for up to 72 hours in order to complete a psychiatric assessment.  In order to sign a Form 1, the doctor must have examined the patient within the 7 day period prior to the Form 1 being signed, after which the Form 1 expires.  In addition, the doctor must find that the patient meets one of two sets of criteria, depending on whether or not they are deemed capable of consenting to treatment in a psychiatric facility within the meaning of the Health Care Consent Act

The physician’s clinical opinion can, in consideration of what is appropriate in the circumstances, be based on their own observations, or in combination with facts communicated to the physician by others (e.g. family members, friends).

Once the Form 1 has been signed, anyone can bring (or force) the person into a psychiatric facility for assessment within the 7 day period before the Form 1 expires.  Upon completion of the psychiatric assessment, the patient must either be released, or admitted as an involuntary patient, a voluntary patient or an informal patient.  Tomorrow’s blog posting will explore these options in greater detail.

Jennifer Hartman, Guest Blogger

24 Jan

A Devastating Inheritance: Huntington’s Disease

Hull & Hull LLP Capacity, Estate & Trust, General Interest, Health / Medical Tags: , , , , , , , , , , , 0 Comments

Huntington’s disease (HD) is a progressive, degenerative brain disorder that causes certain nerve cells in the brain to waste away. Huntington’s is inherited, and if one of your parents has Huntington’s disease, you would have a 50% chance of getting the gene for the disease. Everyone who carries the gene will develop the disease. Since the HD gene was isolated in 1993, one can be tested to see if they are a carrier, however because there is no cure for HD, some people choose not to be tested.

About 1 in 10,000 Canadians has HD.

There are two types of HD: i) adult-onset, the most common form, with symptom onset in the mid 30s and 40s; and ii) early onset, which accounts for about 16% of all HD cases, with symptoms developing in childhood or adolescence.

Huntington’s disease is associated with three types of symptoms:

· Movement symptoms, referred to as chorea, which consist of jerking, involuntary movements (‘tics’) of the limbs, trunk or face;
· Cognitive symptoms including a gradual impairment of concentration, memory, judgment, reasoning, decision-making and learning. This cognitive decline starts in a very subtle fashion, but eventually results in dementia; and
· Psychiatric symptoms may include depression, and psychotic behaviours such as delusions, hallucinations, paranoia and inappropriate outbursts.

HD usually runs its course in about 10 to 30 years, with a strong correlation between an earlier onset and a more rapid progression of the disease.

Jennifer Hartman, Guest Blogger

18 Jan

When the Bottle Hits Back: Korsakoff’s Syndrome

Hull & Hull LLP Capacity, Estate & Trust, General Interest, Health / Medical Tags: , , , , , , , , 0 Comments

Korsakoff’s syndrome is a brain disorder usually associated with chronic, excessive alcohol consumption. At the physiological level, Korsakoff’s is caused by a thiamine (vitamin B1) deficiency, which ultimately affects the brain and the central nervous system. In the context of alcoholism, this thiamine deficiency comes about as a result of poor diet as well as an impeded ability of the stomach lining to absorb vitamins.

Korsakoff’s predominantly affects men between the ages of 45 and 65. Women tend to develop the disease at an earlier age than men. According to the Alzheimer’s Society UK, it takes about 20 years for the disease to develop in men, whereas it takes about half that time to develop in women.

At first glance, one with Korsakoff’s syndrome may appear fairly normal. An in-depth assessment, however, would reveal symptoms including:

· Memory loss, particularly of events post-onset of the disease;
· Impaired ability to acquire new information;
· Lack of insight into the condition;
· Perseveration (repetitive comments or questions);
· Eye movement disorders; and
· Confabulation, or ‘falsification of memory’ in which the sufferer makes up events to cover up their inability to remember events.

Once Korsakoff’s develops, recovery is unlikely, however the progression of the disease can be halted with abstinence from alcohol. Treatment for Korsakoff’s is comprised of thiamine therapy, as well as the administration of medications usually given to people with Alzheimer’s disease.

Jennifer Hartman, Guest Blogger

11 Jan

Through the Looking Glass: Lewy Body Dementia

Hull & Hull LLP Capacity, Estate & Trust, General Interest, Health / Medical Tags: , , , , , , , , , , 0 Comments

After Alzheimer’s Disease, Lewy body Dementia (LBD) is one of the leading causes of dementia in the elderly, accounting for up to 20% of cases of dementia.

In Lewy body Dementia, abnormal protein structures called Lewy bodies develop in regions of the brain responsible for thinking and movement. These Lewy bodies were first described in 1912 by Friederich Lewy, a colleague of Alois Alzheimer.

LBD symptoms closely resemble those of both Alzheimer’s disease and Parkinson’s disease. The Alzheimer’s-like symptoms of LBD include fluctuating levels of attention and alertness, and a progressive loss of memory, language, reasoning and higher mental functions such as calculation. The Parkinson’s-like symptoms of LBD include rigidity, stiffness, stooped posture and a shuffling gait. Complex, well-formed, but oddly unthreatening visual hallucinations are one of the earliest and most common (>80% incidence) symptoms of LBD and usually consist of people, children or animals.

Here are some more quick facts about LBD:

· LBD is slightly more common in men than women. The average age of onset is 75 to 80 years of age.
· There is no single test to diagnose LBD. Like Alzheimer’s disease, a diagnosis of LBD is considered ‘possible’ or ‘probable’ after other possible diagnoses are considered and eliminated.
· Lewy body Dementia usually has a rapid onset and rapid progression. The average span of time between diagnosis and death is about 5 to 7 years.
· There are no know therapies to slow the progression of LBD, nor is there a known cure. The goal of treatment is to control the cognitive, psychiatric and motor symptoms of the patient.

For additional information, click here for the Alzheimer Society of Canada or here for the Alzheimer Society of Toronto. The Lewy Body Dementia Association is also an excellent resource.

Jennifer Hartman, Guest Blogger


Enter your email address to subscribe to this blog and receive notifications of new posts by email.