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Introduction, the aims and scope of safeguarding adults’ services, the crpd and supported decision-making, supporting people living with dementia to take part in safeguarding decisions in england, case law references.

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Safeguarding People Living with Dementia: How Social Workers Can Use Supported Decision-Making Strategies to Support the Human Rights of Individuals during Adult Safeguarding Enquiries

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Jeremy Dixon, Sarah Donnelly, Jim Campbell, Judy Laing, Safeguarding People Living with Dementia: How Social Workers Can Use Supported Decision-Making Strategies to Support the Human Rights of Individuals during Adult Safeguarding Enquiries, The British Journal of Social Work , Volume 52, Issue 3, April 2022, Pages 1307–1324, https://doi.org/10.1093/bjsw/bcab119

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Dementia may make adults more susceptible to abuse and neglect and such mistreatment is recognised as a human rights violation. This article focusses on how the rights of people living with dementia might be protected through the use of supported decision-making within safeguarding work. The article begins by reviewing the aims and scope of adult safeguarding services. It then describes how the concept of ‘legal capacity’ is set out in the UN Convention on the Rights of Persons with Disabilities (CRPD) and how this differs from the concept of ‘mental capacity’ in the Mental Capacity Act 2005. Focussing on practice in England, it is argued that tensions between the CRPD and domestic law exist, but these can be brought into closer alignment by finding ways to maximise supported decision-making within existing legal and policy frameworks. The article concludes with suggested practice strategies which involve: (i) providing clear and accessible information about safeguarding; (ii) thinking about the location of safeguarding meetings; (iii) building relationships with people living with dementia; (iv) using flexible timescales; (v) tailoring information to meet the needs of people living with dementia and (v) respecting the person’s will and preferences in emergency situations.

Dementia is an umbrella term used to refer to a range of conditions leading to impairments in memory, language and sensory awareness. Whilst the causes of abuse and neglect are complex, research shows that older adults with dementia experience higher rates than those without dementia ( Fang and Yan, 2018 ). Such mistreatment is recognised as a human rights violation by the World Health Organisation ( WHO, 2016 ). Speaking at the Global Action Against Dementia conference in 2015 the UN Independent Expert on the Enjoyment of all Human Rights by Older People stated that:

the rights and needs of person’s with dementia have been given low priority in the national and global agenda. In particular, with the progression of the disease, as their autonomy decreases, persons with dementia tend to be isolated, excluded and subject to abuse and violence (cited in Cahill, 2018 , p. 3).

The WHO Call for Action and Global Action Plan, which was adopted in May 2017, called on countries to: ‘promote mechanisms to monitor the protection of the human rights, wishes and preferences of people with dementia and the implementation of relevant legislation, in line with the objectives of the UN Convention on the Rights of Persons with Disabilities (CRPD) and other international and regional human rights instruments’ ( WHO, 2016 , para 20). These aims align with the principles of social work, which is committed to advocating and upholding the human rights of clients and communities ( International Federation of Social Workers, 2014 ).

Supported decision-making is viewed as a key mechanism for delivering the rights of persons with disabilities under the CRPD. This model is founded in Article 12.3 of the CRPD and is predicated on the principle that, ‘all people are autonomous beings who develop and maintain capacity as they engage in the process of their own decision-making even if at some level support is needed’ ( Devi et al. , 2011 , p. 254). The support model is in contrast to substituted decision-making regimes, which are systems where, ‘(i) legal capacity [the formal ability to hold and to exercise rights and duties] is removed from a person, even if this is in respect to a single decision; (ii) a substitute decision-maker can be appointed by someone other than the person concerned, and this can be done against his or her will and (iii) any decision made by a substitute decision-maker is based on what is believed to be in the objective best interests of the person concerned, as opposed to being based on their will and preferences’ ( Committee on the Rights of Persons with Disabilities, 2014 , para 27). Supported decision-making acts in contrast to substituted decision-making through providing a ‘conceptual and practical bridge’ ( Gooding, 2013 , p. 432), which seeks to respect the individual’s will and preference, whilst viewing decision-making as an interdependent process ( Sinclair et al. , 2019 ). It allows for consideration of a disabled person’s decision-making ability, the environmental demands for decision-making and the support that is required to enable the person to decide ( Shogren and Wehmeyer, 2015 ). The approach is informed by the social model of disability, which highlights how barriers (physical, attitudinal and structural) perpetrate disadvantage for disabled people; and feminist critiques of individualism, which explore how autonomy develops within the context of social relationships ( Donnelly, 2019 ).

Attention has been paid to the ways in which the CRPD should be applied in situations where people are living with dementia ( Keeling, 2016 ; Sinclair et al. , 2019 ). However, debates remain as to how supported decision-making should be interpreted and applied in practice. Research indicates that people living with dementia are often positive about supported decision-making ( Sinclair et al. , 2019 ) although there are complex practice issues to be dealt with, particularly when the person supporting an individual may be a source of risk. Social workers are often involved in such situations and yet little analysis has been carried out on this subject, an issue that this article seeks to address.

Concerns about adult abuse and neglect have led to the development of adult protection systems, most notably in the UK, the USA, Canada and Australia; initially developed as a response to concerns about elder abuse in the 1980s and 1990s. A key policy document, the Toronto Declaration on the Global Protection of Elder Abuse highlighted the need for a universal human rights framework for older adults ( WHO, 2002 ). It asserted that legal frameworks to address elder abuse were often missing, meaning that abuse might be recognised, but not adequately dealt with. Such arguments influenced responses by governments enabling the traditional focus on elder abuse to be broadened, to concepts of ‘vulnerable adults’ or ‘adults at risk’ more generally ( Donnelly et al. , 2017 ).

To some degree UK policy and law had begun this process earlier through reference to the Human Rights Act 1998 . For example, the No Secrets guidance on adult abuse in England referred to abuse as, ‘a violation of an individual’s human and civil rights by any other person or persons’ ( DH, 2000 , para 2.5). There remain, however, contested ideas on definitions. The term ‘adult safeguarding’ has not been defined internationally and there are differences in definitional thresholds ( Mackay, 2018 ). Thus, all four countries in the UK explicitly state that risk of (as well as actual) harm, abuse or neglect are grounds for making an enquiry. The terminology thereafter varies: the term abuse or neglect is used in Wales and England; in Northern Ireland it is abuse, exploitation or neglect; and Scotland has the most expansive term of harm on its own. Whilst safeguarding law and policies vary across national systems, social workers tend to play a lead role in England, Scotland, Northern Ireland, Novia Scotia and British Colombia ( Donnelly et al. , 2017 ). The rationale is that social workers possess particular skills in assessment, working across professional boundaries and in enabling individuals through self-directed support. These systems have identified that they value social work knowledge. For example, The Care and Support Statutory Guidance in England states that social workers are likely to be the most appropriate professionals to make enquiries about abuse or neglect within families or informal relationships ( Department of Health and Social Care, 2020 , para 14.8) and highlights the importance of the principal social work role ( Whittington, 2016 ). Nonetheless, little has been done to consider how social workers might explicitly protect the human rights of people living with dementia within safeguarding practice.

The CRPD (Article 1) states that, ‘Persons with disabilities include those who have long-term physical, mental, intellectual or sensory impairments’, which may hinder their participation in society. This definition clearly places people living with dementia within its remit, making them subject to its rights and protections. The CRPD marks a paradigm shift for the rights of persons with disabilities as it adopts a social model of disability (identifying the need for society to adapt to the needs of the disabled person), in contrast to a medical model (focussing on cure) or a social welfare model (focussing on a person’s limitations) ( Bartlett, 2012 ). The CRPD states that people with disabilities should be free from exploitation, violence and abuse and that state parties should take, ‘all appropriate legislative, administrative, social, educational and other measures to protect persons with disabilities, both within and outside the home’ (Article 16.1). Furthermore, those with disabilities are given positive rights and entitlements (such as the right to provision of services) by the CRPD, in contrast to the European Convention of Human Rights, which protects individuals’ negative rights (e.g. the right to be free from undue interference or abuse from others).

National safeguarding legislation has increasingly identified the need to involve those experiencing abuse or neglect in the process ( Donnelly et al. , 2017 ), making the issue of decision-making of central importance. For example, the Care Act (2014) put safeguarding in England on a statutory footing. It is therefore essential to consider how autonomy and decision-making are conceptualised within the CRPD and how this should inform decision-making within national safeguarding practice. Protecting a person’s legal capacity and promoting their involvement in decision-making are central to the CRPD. Legal capacity can be understood as a person’s ability to hold rights, and to exercise them on an equal basis with others ( Bach and Kerzner, 2010 ). It differs from the concept of mental capacity, which is concerned with the decision-making skills and competencies of a person, which may differ between individuals. So, from a safeguarding perspective, people living with dementia should have rights to be engaged and participate in decision-making in the safeguarding process and should also receive support to exercise these rights. Article 12 of the CRPD states that people with disabilities should be afforded legal capacity on an equal footing to others and that States should take measures ‘to provide access by persons with disabilities to the support they may require’ (Article 12.3). In English law, there is also recognition that people may have mental capacity but remain vulnerable to abuse due to manipulation or undue influence from others. In these cases, the court may exercise its ‘inherent jurisdiction’ to intervene in a way that is compliant with the CRPD ( Series, 2015 ) (although it is beyond the scope of our article to consider the complexities of inherent jurisdiction here). Nonetheless, the CRPD Committee’s Interpretation of Article 12 identifies that people with disabilities cannot be viewed as having exercised their legal capacity unless they have been supported to decide for themselves. This view is reflected in the statement that:

State Parties’ obligation to replace substitute decision-making regimes by supported decision-making requires both the abolition of substitute decision-making regimes and the development of supported decision-making alternatives. (United Nations Committee on the Rights of Persons with Disabilities, 2014 , para 28)

However, the UN Committee’s interpretation of Article 12 has been viewed as problematic by some as it states that substituted decision-making mechanisms are outlawed by the CRPD. The removal of substituted decision-making in all circumstances may cause a range of practical problems in adult safeguarding where an individual is unable to decide for themselves (as may be the case when an individual is living with advanced dementia and experiencing abuse or neglect) ( Freeman et al. , 2015 ; Gooding, 2015 ). No state who is a signatory to the CRPD has followed this binary approach to decision-making in the field of capacity laws, partly because of possible, perverse outcomes that might follow. For example, the Mental Capacity Act (2005) (MCA) in England and Wales defines mental capacity in relation to decision-making and states that individuals should be assumed to have mental capacity, unless it can be established otherwise on the balance of probabilities. The MCA states that consideration of capacity must be decision and time specific. In the context of an adult safeguarding case, this means that once it has been established by the decision-maker that the person lacks mental capacity, section 4 of the MCA allows for a form of substituted decision-making by allowing the decision-maker to act in the person’s ‘best interests’. However, this places the MCA in tension with the CRPD due to its focus on decision-making capacity rather than legal capacity ( Martin et al. , 2016 ).

Current State responses to the CRPD tend to involve a hybrid mix of safeguards and processes that professionals are expected to adhere to in order to support the exercise of a person’s legal capacity ( Davidson et al. , 2016 ). In doing so, in a more limited way than the CRPD strives for, improved approaches to supported decision-making can go some way to protect the legal rights of persons living with dementia. Several arguments are presented for such approaches. First, people living with dementia will have formed a range of moral, political, social and other views before developing the condition ( Donnelly, 2019 ). The use of mental capacity laws allows these former wishes and values to be used in preference to their current views (which may have altered radically since the onset of dementia). For example, in Briggs v Briggs [2016] Charles J. gave primacy to previously expressed wishes, in line with the ‘enabling’ ethos of the MCA deciding that, ‘an earlier self can bind a future and different self’ (para 53). As noted by Ruck Keene et al. (2017 , p. 135), this can be promoted when the previously expressed and current wishes are consistent, either because they match (see Westminster City Council v Sykes [2014] ) or because the person who lacks capacity is no longer able to express their wishes (see PS v LP [2013] ). However, it becomes more problematic when there is a clash between a person’s past and present wishes. Domestic case law is inconsistent and the CRPD is silent on the primacy point. Ruck Keene et al. (2017 , p. 138) suggest that the CRPD Committee’s interpretation of Article 12, ‘drives inexorably towards prioritisation at all points of a person’s immediately identifiable wishes and feelings’. But this approach could be problematic in a safeguarding context for persons with dementia who might express a current preference, which puts them at risk.

Second, older adults experience higher levels of abuse and neglect than other disabled groups and tend to afford greater weight to professional review and protection ( Bach and Kerzner, 2010 ; Donnelly, 2019 ). This indicates the need for legal frameworks which balance notions of empowerment and safeguarding. Such circumstances have led some to argue that supported decision-making should be the preferred option to accommodate a person’s rights under the CRPD, but that mental capacity laws are required where individuals with conditions, such as dementia may place themselves at serious risk and where there is danger in delay ( Freeman et al. , 2015 ).

Social workers are required to work within existing legal frameworks, despite the earlier stated tensions that exist between the interpretation of legal capacity identified by the CRPD and domestic laws. It is crucial that they find ways to maximise the rights of individuals to exercise their legal capacity whilst ensuring compliance with these domestic laws.

The following section explores how supported decision-making can be facilitated in England, one of four jurisdictions in the UK. The population of England was 55.6 million in 2018 ( Office for National Statistics, 2018 ). The most recent estimate of people with dementia, in 2013, found that 685,812 people were living with dementia ( Prince et al. , 2014 ). As in some other jurisdictions, social workers play a lead role in safeguarding and substitute decision-making processes, using a range of laws and policies, now described and discussed.

The legal and policy context for safeguarding in England

In England, the Care Act, 2014 (CA) is the key legislation for safeguarding. The Care and Support Statutory Guidance describes this as a process of, ‘Protecting an adult’s right to live in safety, free from abuse and neglect’ (para 14.7). In cases where a safeguarding referral for a person living with dementia is made, practitioners must consider their duties under section 42(1) of the CA which requires the Local Authority to consider whether there is reasonable cause to suspect that an adult:

Has care and support needs;

is experiencing, or is at risk of abuse and neglect; and

as a result of their needs is unable to protect themselves from the abuse or neglect or risk of it.

This process may not be linear and actions to safeguard a person may take place as part of the section 42(1) process or during a general assessment of need ( LGA/ADASS, 2019a ). Safeguarding decisions must be focussed on the principles inherent within the CA, notably the duty to promote well-being under section 1, and should adopt a flexible approach focussing on what matters to the individual. Decisions must also be grounded in the six safeguarding principles contained in the Care and Support Statutory Guidance (empowerment, prevention, proportionality, protection, partnership and accountability). Workers need also to consider how abuse can be prevented (Care and Support Statutory Guidance, para 2.1) and should draw on the Making Safeguarding Personal approach. This is a sector-led initiative supported by the Local Government Association, the Association of Directors of Adult Social Services and other bodies. It promotes a personalised approach, where adults at the centre of the safeguarding process are asked what their preferred outcomes are. A number of studies suggest that these initiatives can promote increased confidence amongst staff when involving service users in decision-making ( Cooper, 2015 ; Butler and Manthorpe, 2016 ). The principles of the MCA must also inform any safeguarding interventions (see further below).

Tensions between English law and the CRPD

The CRPD is an international treaty and therefore does not have the same status and enforceability as domestic law. Although it is not directly legally binding on the UK, it is nevertheless of persuasive authority. The Court of Appeal has affirmed the influence of the CRPD ( Burnip v Birmingham City Council and Another [2012] ), and there is evidence that CRPD principles are informing the jurisprudence of the higher courts, for example, in relation to decisions about the management of a person’s property and deprivations of liberty ( LB Haringey v CM [2014] ; P ( by his litigation friend the Official Solicitor ) v Cheshire West and Chester Council & Anor [2014]). However, judges have also urged caution when considering how the CRPD should shape domestic law. For example, Hayden J. noted that, whilst courts should seek to interpret and apply national laws in line with international obligations, ‘the court cannot by a process of statutory construction simply ignore or rewrite the clear provisions of the MCA [Mental Capacity Act]’ ( Lawson, Mottram and Hopton, RE ( appointment of personal welfare deputies [2019]) ). This makes it clear that practitioners must follow domestic law and cannot use the CRPD to circumvent it.

Despite the disparities between Article 12 and the substitute decision-making regime of the MCA, the MCA nevertheless has an empowering ethos and includes several mechanisms which are designed to promote autonomy and support the decision-making ability of individuals. Foremost, section 1(2) of the MCA states that individuals are assumed to have mental capacity, unless it can be established otherwise, and that they should be supported, as far as possible, to make their own decisions. The MCA (section 1, statutory principle 2) and Code of Practice ( Department of Constitutional Affairs, 2007 , Chapter 3) make clear that, before deciding that someone lacks capacity, practitioners should take practical steps to help individuals to decide for themselves, including providing relevant information; communicating in an appropriate way and putting the person at ease.

The best interests checklist in section 4 includes a list of factors for the substitute decision-maker to consider. The list expressly includes the person’s wishes and feelings. Whilst they are not determinative, the court has made it clear that they must be central to the decision-making process. For example, in Wye Valley NHS Trust v Mr B [2015] the Court of Protection stated that it may in some circumstances support a person’s incompetent wishes and feelings. There is a growing evidence in the case law of the court’s willingness to engage with ‘the person and their identity’. As Series (2014) has argued, by prioritising this subjective approach to discerning best interests, the MCA can be applied in ways, which accord with the CRPD’s approach. Sections 24–26 of the MCA make provision for advance decision-making, which allows a person with mental capacity to refuse specific treatments in the future, should they lose capacity. This is regarded by the Court of Protection as a key mechanism for promoting a person’s ‘capacity to shape and control’ decisions affecting their life ( Barnsley Hospitals NHS Foundation Trust v MSP [2020]). Sections 9–14 of the MCA provide further mechanisms through which people can take out a Lasting Power of Attorney (LPA). It is a legal document stating who an individual would like to manage their property and finances or health and welfare should they lose mental capacity to make such decisions. Whilst LPAs can be viewed as problematic (because they allow for decision-making on behalf of the person), they can be made to work in a CRPD context as long as the LPA holder focuses on the subjective views/wishes, etc. of the individual (rather than objective criteria) in making decisions ( Series, 2014 ).

Supported decision-making with people living with dementia in practice

Safeguarding decisions may focus on a range of complex areas, including domestic abuse, physical abuse, sexual abuse, financial abuse, discrimination or neglect. Dementia may affect a person’s ability to make decisions about abuse or neglect and this generally becomes more severe over time ( Fetherstonhaugh et al. , 2013 ). Nonetheless, a person’s ability to decide can be enhanced through support by professionals and carers; particularly where the dementia is mild or moderate. At a practical level, supported decision-making focuses on the environmental demands for decision-making (such as consideration for the procedure in question, the physical space that the person is in and the relationship between the individual and the decision-maker). It also focuses on the support that is required to enable the person to decide ( Shogren and Wehmeyer, 2015 ). Currently, there are no empirically tested decision tools that have been designed to help people living with dementia to engage in safeguarding ( Wied et al. , 2019 ). However, practitioners can design strategies, based on the principles of supported decision-making, which tailor information to the needs of people with dementia and seek to involve them as much as possible in the decision-making process. In the following section, we consider how such strategies may be used, drawing on the research evidence.

In order for safeguarding to be effective, people living with dementia need to be clear what safeguarding means. This is important as the first principle of safeguarding is empowerment (Department of Health and Social Care, 2020); meaning that adults should be supported and encouraged to make their own decisions with informed consent. Such consent can only be achieved if the person with dementia is clear about the enquiries which may be made and what their options are. The MCA Code of Practice places emphasis on providing information to the person, stating that it should be tailored to their needs and ‘in the easiest and most appropriate form’ ( DCA, 2007 , para 3.8). This is crucial because the literature suggests that giving people with mental impairments excessive information is often challenging because of problems of cognitive retention ( Wied et al , 2019 ). Local Authorities must therefore consider the most effective strategies for informing the public about safeguarding. Whilst the sections of the CA associated with safeguarding (sections 42–47) have been in force since 2015, levels of public awareness about safeguarding remain unclear. To ensure that people with dementia have adequate and appropriate information to make a decision, Local Authorities need to provide accessible and clear information, setting out the types of abuse, which may be experienced and how people can report it. This can be achieved by using clear and simple language with a focus on consistency of expression, as well as pictures or drawings ( Wied et al. , 2019 ). When explaining the safeguarding process at an individual level, practitioners may draw on public information as communication aids, but need to explain to individuals how it applies to them. Research indicates that people living with dementia are better able to engage where workers adopt a spirit of collaboration, highlight what they are expecting of them and work with them to define what it is they need to decide on ( Groen-van de Ven et al. , 2017 ). Practitioners should therefore explain the nature of the safeguarding concerns from the outset, identifying first how it has been raised and then what information is required.

Within any supported decision-making process, consideration should also be given to the location of the meeting. The MCA Code of Practice advises that practitioners should choose a quiet place where discussions cannot be easily interrupted ( DCA, 2007 , para 3.13). Current research on this issue is limited but indicates that people living with dementia find it harder to make decisions in noisy or cluttered environments ( Wied et al. , 2019 ). Interviewing a person in a quiet room rather than a busy area is likely to improve communication. Efforts should also be made to limit the number of people taking part in an interview, particularly if they are unfamiliar to the person (Fetherstonhaugh et al. , 2016).

Supported decision-making relies on building a relationship with the person. This is something that is currently overlooked in the MCA Code of Practice, which focusses more broadly on providing information and putting the person at ease ( DCA, 2007 , paras 3.10–3.15). In order to build an effective relationship, several factors should be borne in mind. A recent study found that persons with dementia prefer to be supported by people that they know well ( Sinclair et al. , 2019 ). Where family members are not suspected of abuse or neglect, then social workers and other professionals should engage with them so that they can provide advice on the person’s preferences and how best to involve them in decisions. Whilst people living with dementia may be fully autonomous, they may also engage in shared decision-making with carers or may delegate decision-making ( Smebye et al. , 2012 ). When people with dementia consent to these arrangements, they should be considered as ways of facilitating decision-making. In cases where it is not possible to work with family members or carers and communication is challenging, advocacy under section 68 of the CA (2014) should be considered, although this can only be provided if the conditions of the CA are met. Representation by an Independent Mental Capacity Advocate (IMCA) can also be considered where safeguarding issues arise, even where the person has friends or family (s. 4, Mental Capacity Act, 2005 . It should, however, be noted that advocacy provision across England is patchy, with most Local Authorities failing to meet the spending recommendations prescribed by the Local Government Association, making person-centred practices a challenge ( Dixon et al. , 2020 ). When building relationships with the person, practitioners also need to assess their attitude to risk. Recent safeguarding guidance has placed an emphasis on positive risk-taking, in which individuals are enabled through a careful consideration of the risks in question ( LGA/ADASS, 2019b ). Nonetheless, research has found that people living with dementia and family carers often conceptualise risk in negative terms because of its emotive connotations ( Stevenson et al. , 2019 ). A way of dealing with this dilemma is to encourage people living with dementia to view risk in terms of ‘likelihood’ to enable positive risk-taking. Social workers should also be aware that people living with dementia may be concerned about the risks which social care services may pose to them. For example, lesbian women with dementia have been known to conceal their sexual identities because they fear discrimination by services ( Westwood, 2016 ). Social workers therefore need to consider the person’s personal and cultural needs. With lesbian and gay service users this may be achieved through taking account of the person’s sexual identity, making sure that it is explicitly acknowledged in safeguarding plans and through facilitating access to support networks where required.

Time is an important issue if people living with dementia are meaningfully to be engaged in decision-making. The MCA Code of Practice places emphasis on the timing of conversations, stating that decisions should not be rushed and that unnecessary time limits should be challenged where the decision is not urgent ( DCA, 2007 , para 3.14). This guidance is supported by research which has found that supported decision-making processes are more likely to be effective where a person living with dementia is given time to recognise the issues they face and consider the options to enable a final decision to be made ( Smebye et al. , 2012 ; Fetherstonhaugh et al. , 2013 ). Ideally, time should be ring-fenced, to enable an assessment of the person’s life story, and conducted at a pace that they feel comfortable with and at the time of day during which they function best. These recommendations are congruent with guidance by the Local Government sector ( LGA/ADASS, 2019a , b ), which has encouraged practitioners to view safeguarding as a series of conversations with the person, drawing on a strengths-based approach. There are possible organisational impediments to these aspirations where resources are limited. In some instances, however, local authorities have supported a flexible approach. For example, the London Safeguarding Adults Board (2019) states that a divergence from target timescales may be justified for a number of reasons including the need to provide supported decision-making. Nonetheless, there may be situations where immediate risks prevent engagement with the person over time, discussed in more detail, below.

Practitioners should design strategies that tailor information to the needs of people with dementia. As mentioned above, there are no empirically tested decision-tools to enable clients to engage in safeguarding ( Wied et al. , 2019 ). The MCA Code of Practice, however, provides guidance on what steps can be taken to tailor the information to the individual and ensure it is ‘relevant’, including not giving too much detail; providing a ‘broad simple explanation’ and outlining the risks, benefits and effects of the decision (2007; para 3.9). It has been found that strategies which build a relationship with the person through helping them to feel useful and productive are most effective ( Fetherstonhaugh et al. , 2013 ). At a practical level, this involves writing options down, to ensure the retention of information; the use of lists to explore options and using visual aids (such as pictures or photographs) to compensate for memory problems. Limiting decisions to two or three options to prevent the person experiencing ‘sensory overload’ has also been found to be important ( Smebye et al. , 2012 ; Fetherstonhaugh et al. , 2013 ). However, this option needs to be considered carefully. Not giving the full range of options may lead to over-simplifying or withholding important information. This is problematic from a legal perspective as it limits how informed the decision can be, thereby impacting on the person’s rights. When deciding how to proceed, workers need to consider the person’s individual preferences for decision-making as well as the potential consequences of the decision. Further sources of support from family/friends or professional advocacy services should be considered as a way of maintaining the person’s legal capacity, as recommended by the MCA Code of Practice ( DCA, 2007 , para 5.69).

Consideration needs to be given to principles of safeguarding where an urgent decision needs to be made. Whilst the MCA makes no explicit reference to safeguarding, it aims to balance an individual’s right to make decisions with ‘their right to be protected from harm if they lack capacity’ ( DCA, 2007 , para 1.4). Relying solely on the concept of mental capacity may not accord with the approach to legal capacity within the CRPD, but can be viewed as necessary in cases where a person with a mental health problem is at serious risk and there is danger in delaying decisions ( Freeman et al. , 2015 ). Whilst section 4 of the MCA allows for a best interests decision to be made, the person’s legal capacity can still be protected where workers are able to draw on advance decisions, designed to attend to previous choices made by the person ( Series, 2014 ; Keeling, 2016 ). In order to maximise legal capacity, these should be referred to first, although in practice their use is likely to be limited, as they focus on advance refusals of medical treatment. Where neither an advance decision, a LPA, or a court-appointed deputy exists, practitioners need to resort to a best-interests decision-making process in line with the MCA, although this should be viewed as a last resort after all other decision-making avenues have been explored. To maximise the person’s rights, all efforts should be made to consider the subjective wishes of the person within this process. In these circumstances, practitioners should endeavour to resume supported decision-making once the person is out of immediate danger.

Finally, it should be noted that there are some limits to the research evidence as it stands. Although the CRPD has led to an increased emphasis on supported decision-making, research on supported decision-making remains at an early stage, particularly with regards to dementia ( Wied, 2019 ). Whilst current research may inform practice, many of the studies focus on aspects of supported decision-making, such as user-involvement or participation, rather than on the supported decision-making process as a whole. It should also be noted that much of the existing evidence draws on qualitative research. Whilst such research has provided valuable insights, there is a need for studies that test the effectiveness of supported decision-making for people with different types of dementia. Such developments have the potential to lead to empirically tested decision-making tools with greater levels of validity.

Dementia leaves individuals more susceptible to abuse and neglect and action is required to address this. Social workers play a key role within adult safeguarding systems internationally and have an opportunity to address such abuse, yet little analysis has been carried out on this issue. The CRPD provides social workers with the opportunity to strengthen human rights protection for people with dementia, through the application of supported decision-making. This opportunity should be welcomed whilst recognising practice dilemmas, particularly in navigating the tensions between international frameworks and domestic law. In England, these are illustrated by the CRPD’s insistence on supported decision-making in Article 12, compared with the MCA which embraces a substitute decision-making model, albeit with elements of supported decision-making built into the process. Despite these tensions, steps can be taken to maximise the legal capacity of people living with dementia to promote the ethos of the CRPD through adopting a range of supported decision-making strategies.

Social workers must adhere to the provisions in the MCA and take appropriate steps to aid decision-making ‘before’ an assessment of mental capacity is made, in line with the guidance in the MCA Code of Practice. Additionally, key measures should also be taken to maximise supported decision-making. Local authorities should be required to provide clear and accessible information to the wider public and to people living with dementia, their family and carers. These should explain what safeguarding is, how the safeguarding process works and how to access it. It is imperative that social workers clearly explain to the person how the safeguarding concern has been raised, associated issues and what information they require. Drawing on the research evidence, it has been argued that key steps are involved in good quality safeguarding interventions that are service user focussed. For example, people living with dementia should be interviewed in quiet areas, with care being taken to minimise the number of attendant people in the room. Skills in building effective relationships are critical for the practitioner. People living with dementia prefer to be supported by people that they already know, although advocacy under the CA should be considered where this is not possible and advocacy under the MCA may be considered where the person lacks capacity. Social workers also should be mindful that people with dementia often frame notions of risk differently to that of professionals. This awareness and knowledge can help build on the preferences of the person. The importance of time is central to decision-making processes. Ideally it should be ring-fenced in order to learn about the person’s life story, and to enable assessments to be conducted at a pace that the person feels comfortable with, and at the time of day at which they function best. The use of visual aids, diagrams and lists have been shown to assist the person to retain information and make decisions. Consideration should also be given to limiting options to enhance comprehension. Where immediate risks prevent this, the person’s capacity should be protected through ascertaining wishes expressed in advance decisions or through an LPA, or court appointed deputy, where they exist.

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Dementia Action Alliance

The local dementia action alliance website has closed.

The Local Dementia Action Alliance (LDAA) website, hosted by Alzheimer's Society, closed on 5 January 2024 .

We recognise the fantastic work and huge commitment from Local Dementia Action Alliances and the many member organisations who have been working hard to make their local communities more dementia friendly.

If you would like any more information or guidance about the closing of the Local Dementia Action Alliance website, please email [email protected]

Dementia friendly resources

If you would like to take action to make your organisation or local area more dementia friendly, please take a look at the online information resource on Alzheimer's Society's website. Its purpose is to help groups, businesses and organisations continue to identify practical actions they can take to be more dementia friendly.

We hope the resource will be useful in helping local groups continue to lead and deliver on local plans to improve the quality of life for people affected by dementia.

As well as Alzheimer's Society resources, there are many other fantastic resources to support groups that want to make their community more dementia friendly such as the World Health Organisation's toolkit on Towards a dementia inclusive society and the Age Friendly Cities framework .

The Dementia Friends initiative will continue to run, helping more people to understand dementia, reducing the stigma surrounding the condition and ensuring awareness of dementia is available to everyone. To find out more, please visit dementiafriends.org.uk .

Coercive Control

dementia safeguarding case study

Case study 5: Betty

Download the whole case study as a PDF file

Download the whole case study as a PDF file

Betty and Godfrey are an older married couple. Godfrey received a diagnosis of dementia 18 months ago, and has been attending a respite centre two days per week to support Betty to cope with her caring role. The day centre staff have observed Betty being rough with Godfrey and so raised a safeguarding concern with Adult Social Care – but looking into Betty and Godrey’s file, it becomes apparent that Godfrey has been abusive to Betty in the past.

This case study considers issues around working with older people experiencing domestic abuse, dementia and longstanding abuse, and carers as perpetrators and victims of domestic abuse.

When you have looked at the materials for the case study and considered these topics, you can use the critical reflection tool and the action planning tool to consider your own practice.

Case details

Download the vignette as a PDF file

Download the case details as a PDF file (550KB)

Betty and Godfrey have been married for 52 years. Betty is originally from Barbados and Godfrey from St Kitts. They have three children. Marcus and Gloria live in the USA. Angela, who is a carer for her son with complex needs, and her husband live nearby.

Godfrey is living with dementia after a diagnosis 18 months ago. Their GP made a referral for a carer’s assessment for Betty due to her being stressed due to Godfrey’s ‘increasingly unreasonable demands’. As a result Godfrey attends a day care centre two days a week to give Betty some respite. Godfrey is described as ‘a real charmer’ and is popular with the staff and centre members.

The centre staff have noted that there is a ‘volatile’ relationship between Betty and Godfrey. Incidents include Betty trying to drag Godfrey out of the car to get him into the centre and Betty talking sharply to Godfrey because he was refusing to leave the centre when she came to pick him up. The staff find Betty trying at times. She gives them very specific instructions about how to provide support to Godfrey, for example what he can and can’t eat. They have found Godfrey likes food that Betty says he doesn’t like.

Recently staff assisting Godfrey found that he had bruising on both of his upper arms. A nurse who was visiting said they could be from being grabbed. Godfrey said that it was true, Betty had grabbed him when they were having a row, but that it was nothing to worry about ‘just the ups and downs of married life’. The nurse told Godfrey about safeguarding and he said he didn’t want a referral made.

When the nurse discussed this with the centre manager they decided that as Godfrey might not have had the capacity to make the decision about going ahead with a safeguarding referral because of his dementia, and because he might be at risk of harm before his next day at the centre, they would make a safeguarding referral.

Notes on Godfreys and Betty’s social care files refer to the police having attended the household twice in the last 8 months after calls from Betty during the late evening in which she said Godfrey was out of control and hurting her.

How would you make safe enquiry with each of Godfrey and Betty?

Who will meet with each of them?

How will you contact them to arrange the meeting?

In this section are two downloadable PDFs – one is a partly completed assessment form related to this case study, and another is an example of what a completed form could look like.

Suggested exercise

Download the partly completed assessment as a PDF file

Download the partly completed assessment as a PDF file (503KB)

Download the completed assessment as a PDF file

Download the completed assessment as a PDF file (502KB)

Use the partly completed assessment form:

  • What actions would you discuss with Betty to ensure her immediate and longer term safety?
  • What precautions would you need to take to avoid putting her at higher risk of harm?
  • What is your analysis of the situation? Is coercive control occurring? What is the evidence of this?
  • What is your conclusion?

Download the resource as a Word file (206KB)

Download the blank DASH_RIC as a Word .doc file (226KB)

The purpose of the DASH risk checklist is to give a consistent and simple tool for practitioners who work with adult victims of domestic abuse in order to help them identify those who are at high risk of harm and whose cases should be referred to a MARAC meeting in order to manage their risk. If you are concerned about risk to a child or children, Safe Lives recommend that you should make a referral to ensure that a full assessment of their safety and welfare is made.

There are two downloads on this page.

One shows a blank DASH risk checklist, with quick start guidance from Safe Lives. The key point is to remember that your professional judgement is key in making a decision about risk; a tool can help, but the score it comes out with is not definitive.

This is especially relevant when working with people with care and support needs, for whom some of the questions may not be relevant.

word icon

Download the case study DASH-RIC as a PDF file (206KB)

The other shows an example of a completed DASH relating to this case study, for you to critique and appraise.

Suggested exercise:

  • Read the case details and full assessment document for this case study.
  • Using the information contained, fill out a blank DASH risk assessment tool.
  • Discuss how you found it; did you have all the required information? Would you be able to get all the required information in practice? Would you make a referral to MARAC?

This section picks out three main topics from the case study featured. For Betty and Godfrey’s case study, the topics include:

Working with older people experiencing domestic abuse/lifelong coercive control

Dementia and longstanding domestic abuse, the role of the marac.

A selection of references, tools and further reading for each topic is below.

‘A  review of the impact of domestic abuse for older women  in Health and Social Care in the Community in 2011 highlighted that the issue is significant but that health and social care professionals fail to recognise domestic abuse between older couples.’

This is referred to in an article by Natalie Valios, 26 March 2015, in Community Care which summarises the outcome of the serious case review into the death of Mary Russell. The article offers key pointers for social workers and provides useful links: http://www.communitycare.co.uk/2015/03/26/domestic-abuse-doesnt-stop-at-60/

McGarry et al’s (2011) review of the literature investigating older women’s experience of domestic abuse points to the longer term effect of physical abuse, the psychological impact at the time and cumulatively in later life, and emotional issues which many felt unable to disclose to others – a significant barrier to reporting in older age being that women ‘had kept their experiences ‘hidden’ from family friends and neighbours’ for many years.

The voices of older women survivors – in the accounts of sixteen women, aged 63-79, who had experienced domestic abuse – are highlighted in McGarry and Simpson, (2011).

McGarry et al (2011) also detail some information on the lack of research on the experiences of older women from ethnic minorities, concluding that ‘taken as a whole, the voices of older women from ethnic minorities remain unheard and this clearly represents an additional deficit in knowledge and understanding.’ (2011:11) Social workers working with Betty will need to consider possible limitations of their knowledge base and be proactive in this respect.

Case study 1 Ayesha focuses on intersectionality and building cultural capability .

Advice for health and social care professionals – for example those working in care homes who may be particularly well placed to support older people to begin to talk about domestic abuse and coercive control in their intimate relationships – is available here:

Live Fear Free: Supporting a client who is experiencing domestic abuse or sexual violence.

‘Safe Lives’ offer a range of useful information on working with older people experiencing domestic abuse: http://www.safelives.org.uk/node/861

There is a surprisingly limited amount of research on this topic although findings from Dr Lucy Knight and Professor Marianne Hester’s research highlights that the onset of dementia in the situations studied led to an escalation in the severity of the domestic abuse: http://www.rcpsych.ac.uk/pdf/Knight%20Lucy.pdf

Other papers look at issues related to but not quite focused on the experience of domestic abuse for people with dementia, for example ‘elder abuse’. The lack of separation of domestic abuse and coercive control from ‘elder abuse’ in the literature to date makes it difficult to draw conclusions about domestic abuse and older people.

Blog post: Perpetrators with dementia

Case study example from Solace Women’s Aid: Older domestic violence victims feel helpless in the face of long-term abuse

Podcast: For their Spotlight series, Safe Lives have developed a number of podcasts which explore issues relating to domestic abuse and people with social care needs. One of these is focused on changing attitudes towards older people and domestic abuse.

Access the podcast recording here : Domestic abuse and older people: Are attitudes changing?

Access the transcript of the podcast here

See also Tool 2, Reflection on attitudes towards older people and domestic abuse.

A useful summary of research findings on MARAC processes has been produced by NIHR School for Social Care Research and Manchester Metropolitan University which recognises that MARAC domestic violence processes and safeguarding processes may need to be followed in parallel. This can be found in Tool 3, below.

‘MARACs are ‘multi-agency risk assessment conferences’ that share information about the top 10% high risk domestic violence cases in order to produce co-ordinated actions to reduce the risk and increase victim safety.’

Rachel Robbins et al’s (2014) paper draws attention to the potential and limits of the Multi-Agency Risk Assessment Conferences (MARACs) in supporting adults with social care needs who also experience domestic violence.

Tool 1 below gives specific guidance on MARAC processes with older people.

Tool 1: Safe Lives guidance for MARACS, hidden victims: older people

Tool 2: reflection on attitudes towards older people and domestic abuse, tool 3: nihr domestic violence, adult social care and marac.

Download the whole case study as a PDF file

Download the tool as a PDF file (191KB)

Historically, older people (60+) experiencing domestic abuse have formed part of a ‘hidden’ group.

There is a need to focus on their experiences and the barriers they face when being identified as victims (or perpetrators) and also in being provided with safe and appropriate services.

There are various reasons why this is not happening in a consistent way across the UK. Services are typically set up with younger clients in mind, older people are less likely to call 999, and particular cultural or generational attitudes often exist towards marriage and family life. Abuse can often be hidden behind other physical and mental health conditions, and a lack of awareness among some professionals prevents recognition of this underlying cause.

There has been an expectation that the introduction of the Care Act 2014 would improve the identification, reporting and response to older victims of domestic abuse, and significant work in Wales and in some areas of England has begun to raise awareness around the specific needs of older victims and perpetrators. Maracs must ensure that wider safeguarding concerns are addressed; this is especially pertinent in older people's cases where there may be an increased chance that the perpetrator and/or victim will require support relating to physical or mental health needs.

This tool outlines:

  • What is different about older victims’ experiences of domestic abuse?
  • What should happen before MARAC?
  • Who are the right people to be at the table?
  • What research to do before the meeting (e.g. impact of abuse on the victim, and their views and wishes)
  • What representatives from different agencies should offer
  • What effective action planning during MARAC looks like
  • Tips for professionals working outside the MARAC

Download the whole case study as a PDF file (534KB)

Download the tool as a PDF file (534KB)

For this exercise, first of all read the podcast transcript or listen to the podcast

Spotlight Episode 3: Domestic abuse and older people: are attitudes changing? (Safe Lives, 2016)

The podcast features a discussion between Jane, an IDVA (Independent Domestic Violence Advocate) based in a hospital and Mel, who is Adult Social Care’s representative on a local MARAC.

The tool highlights sections of the podcasts as a reference to start off discussion and debate about practice in your areas.

It includes reflective questions on issues including:

  • Challenges to practice in this area
  • Use of Domestic Violence Protection Orders (DVPOs)
  • Identifying coercive control
  • The line between concerned or stressed carer, and perpetrator of domestic abuse
  • Barriers to older people accessing support
  • The use of MARAC

Download the whole case study as a PDF file (160KB)

Download the tool as a PDF file (160KB)

This tool summarises a study which was interested in identifying and assessing the effectiveness of social care’s contribution to the development of MARACs and the protection of adults facing domestic abuse, using the city of Manchester as a case study site.

The researchers attended MARACs, interviewed members of MARAC partner agencies and adult social care workers, undertook focus groups with survivors of domestic violence, and focus groups with specialist domestic abuse practitioners.

The 4-page summary outlines:

  • Key points from the research
  • Findings: service user perspectives
  • Findings: agency perspectives
  • Interviews with adult social care

Questions for reflection on reading the report are outlined below.

  • What is the threshold for MARAC in your area?
  • How would you use your professional judgement to make a case for an older person who might not meet the threshold for MARAC, but is at high risk, to be included in MARAC?
  • Can you see any tensions between using a Making Safeguarding Personal approach, and MARAC?
  • How can these tensions be overcome?

There is also comprehensive reference to MARAC procedures in the LGA & ADASS guide to support practitioners and managers which is available here:

Adult safeguarding and domestic abuse: a guide to support practitioners and managers (LGA and ADASS, 2015)

(see also Case study 3 John Topic – Complex caring relationships )

Further reading:

Knight L and Hester M (2014) Domestic abuse and dementia: what are the characteristic features and patterns of longstanding domestic abuse following the onset of dementia? Safe Vol 48 (4) pp 10-14.

McGarry J, Simpson C and Hinchliff-Smith K (2011) The impact of domestic violence on older women: a review of the literature. Health and Social Care in the Community , 19,1, 3-14 Available here: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2524.2010.00964.x/full

McGarry J. & Simpson C (2011) Domestic abuse and older women: exploring the opportunities for service development and care delivery. The Journal of Adult Protection , 13, 6, 294-301. Available here: http://www.reducingtherisk.org.uk/cms/sites/reducingtherisk/files/folders/resources/victims/Domestic_abuse_and_older_women_McGarry_and_Simpson.pdf

Robbins R, McLaughlin H,  Banks C,  Bellamy C,  Thackray  D (2014) ‘Domestic violence and multi-agency risk assessment conferences (MARACs): a scoping review’,  The Journal of Adult Protection , Vol. 16 (6), pp.389 – 398

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  • Peer review
  • Carolyn Stephens , honorary professor of global health 1 ,
  • Nicolas Mays , professor of health policy 2 ,
  • Rita Issa , clinical research fellow 3 ,
  • Lesley Perkins , general practitioner 4 ,
  • Rebecca Scott , general practitioner 4
  • 1 UCL Bartlett Development Planning Unit, London School of Hygiene and Tropical Medicine, London, UK
  • 2 Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
  • 3 Institute of Global Health, UCL, London, UK
  • 4 Bromley-by-Bow Health Centre, London, UK
  • Correspondence to: C Stephens Carolyn.Stephens{at}lshtm.ac.uk

Primary care has a key role

Elder abuse is a major public health problem, facing one in six older people globally (defined as aged 60 and older). 1 2 Older people with dementia are at much higher risk, 3 and the disease is predicted to affect over a million people in the UK by 2025. 4

In 2021, a report by the House of Lords described abuse of older people, particularly those with dementia, as complex, poorly measured, and hidden. 5 Physical abuse includes violence, but psychological and financial abuse is recorded as the most common form of harm, including manipulation of older people to obtain assets through marriage, wills, and abuse of lasting powers of attorney. 6 Controlling and coercive behaviour by perpetrators and social isolation of victims make elder abuse difficult to detect or tackle. 7 The UK General Medical Council recommends that health professionals should be familiar with different types of abuse in order to identify patients at risk, noting that many abuses are now criminal offences. 8

UK policy changes—and challenges

Since the previous editorial on this subject in The BMJ in 2011, 9 UK legislation has substantially changed. New domestic abuse crimes have been introduced, including forced marriage (2014) 10 and coercive and controlling behaviour (2015). 11 The Domestic Abuse Act 2021 introduced a statutory definition of domestic abuse in UK law for the first time. 12 The Forced Marriage Unit was established in 2005 to protect victims coerced into marriage, and the Office of the Public Guardian was established in 2007 to protect people from abuse of powers of attorney. In health and social care, adult safeguarding guidance and multiagency safeguarding teams now exist. 8 Together, these have great potential to prevent abuse or intervene when it occurs.

We do not yet know whether these changes have led to more action against abuse. This is because basic data on the scale of elder abuse in the UK are lacking, creating “systematic invisibility.” 13 For example, the Crime Survey for England and Wales excluded respondents older than 59 until 2017 (it still excludes people older than 74) and does not survey group residences, thereby excluding elderly people in care homes. 14

Little evidence also exists to quantify action taken by responsible authorities. In the year to March 2020 alone, the police recorded 758 941 domestic abuse related crimes in England and Wales, including 24 856 offences of coercive control. The proportion of domestic abuse cases declined by age for women and increased for men, but the data are not disaggregated further. 15 Most domestic abuse cases are closed by police with no further action. 16

The Forced Marriage Unit recorded 11 519 reports of forced marriages between 2012 and 2020. We calculate that 9% (1048 cases) involved people with learning difficulties or mental incapacity, and 20% of victims were male. 17 Reports of forced marriages of older people have increased over the past five years. 17 To date, only four prosecutions have been brought for forced marriage, none involving older people or those with limited mental capacity. 18

Between 2015 and 2021 the Office of the Public Guardian investigated around 12 000 cases of potential abuse of power of attorney. 19 Again, the majority ended in no action. In 2017 Denzil Lush, a now retired senior judge at the Court of Protection, wrote that he would never sign a lasting power of attorney because “I have seen so much of the pathology associated with powers of attorney and the causes and effects when things go pear-shaped, that I find it difficult to recall cases where powers have operated smoothly.” 20 His coauthor, Caroline Bielanska, commented on the increased digitalisation of the Office of the Public Guardian’s processes and increased risks of manipulation of older people. 20

Two more proposed changes to UK law risk substantially increasing financial abuse of older people: the Law Commission proposes to “modernise” marriage law 21 ; and the Ministry of Justice proposes “modernising” lasting powers of attorney. 22 Both proposals aim to make procedures simpler and easier. Although both include limited safeguards, lawyers and experts argue that these are unlikely to prevent vulnerable individuals, particularly older people with failing capacity, being coerced into either marriage or powers of attorney. 23 24

Role of health professionals

Health professionals have a vital role in protecting vulnerable older people from abuse. General practitioners and practice teams are often the professionals in closest contact with older patients, and may be the only contact for those who are socially isolated. Primary care is therefore an important space for identifying and recording elder abuse. 25 Health professionals can also support marriage registrars who become concerned about possible coercion in a marriage process and support solicitors concerned about coercion in the context of powers of attorney or wills. 26 They can also back MPs lobbying for change. Together, these actions support Age UK’s call to increase the visibility of elder abuse. 13

When protecting vulnerable older adults, health professionals must weigh up the ethical imperative to maintain patient-doctor confidentiality against a duty to escalate concerns to third parties—in patients’ best interests—if abuse is witnessed or suspected. 27 28 Furthermore, guidance needs to be developed urgently on the new duties for health professionals to cooperate, enshrined in the 2021 Domestic Abuse Act. 29 Given the increasing risks of elder abuse in the UK and the rapidly changing legislative environment, health professionals, especially in primary care, would welcome more training—and support—on how to detect, record, and report suspected abuse, so the appropriate action can be taken.

Acknowledgments

We thank the Office for National Statistics Centre for Crime and Justice for statistical support.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following: CS has personal experience of some of the issues raised in the editorial. RS is employed by St Helen’s Church Bishopgate as safeguarding officer for one day a week.

Provenance and peer review: Commissioned; externally peer reviewed.

  • Mikton CR ,
  • Gassoumis ZD ,
  • ↵ World Health Organization. World failing to address dementia challenge. 2021. https://www.who.int/news/item/02-09-2021-world-failing-to-address-dementia-challenge
  • ↵ Alzheimer Research UK. Dementia statistics hub. 2021. https://www.dementiastatistics.org/statistics-about-dementia/prevalence/
  • ↵ House of Lords.Domestic abuse of older people. 2021. https://lordslibrary.parliament.uk/domestic-abuse-of-older-people/
  • ↵ Crown Prosecution Service. Domestic abuse. Legal guidance . 2021. https://www.cps.gov.uk/legal-guidance/domestic-abuse#a44
  • ↵ Safe Lives. Safe later lives: older people and domestic abuse. 2016. https://safelives.org.uk/sites/default/files/resources/Safe%20Later%20Lives%20-%20Older%20people%20and%20domestic%20abuse.pdf
  • ↵ General Medical Council. Adult safeguarding ethical hub. 2021. https://www.gmc-uk.org/ethical-guidance/ethical-hub/adult-safeguarding
  • ↵ UK Government. Anti-social Behaviour, Crime and Policing Act 2014. Part 10: Forced Marriage. 2014. https://www.legislation.gov.uk/ukpga/2014/12/part/10/enacted
  • ↵ UK Government. Serious Crime Act 2015 Part 5 Domestic Abuse. Section 76 Controlling or coercive behaviour in an intimate or family relationship. 2015. https://www.legislation.gov.uk/ukpga/2015/9/section/76/enacted
  • ↵ UK Government. Domestic Abuse Act 2021. 2021. https://www.legislation.gov.uk/ukpga/2021/17/contents/enacted
  • ↵ Age UK. No age limit: the blind spot of older victims and survivors in the domestic abuse bill. 2020. https://www.ageuk.org.uk/globalassets/age-uk/documents/reports-and-publications/age_uk_no_age_limit_sept2020.pdf
  • ↵ Office for National Statistics. Domestic abuse victim characteristics, England and Wales: year ending March 2020. 2021. https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/domesticabusevictimcharacteristicsenglandandwales/yearendingmarch2020#data-sources-and-quality
  • ↵ Office for National Statistics. Domestic abuse and the criminal justice system, England and Wales: November 2020. Responses to and outcomes of domestic abuse cases in the criminal justice system. 2021. https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/domesticabuseandthecriminaljusticesystemenglandandwales/november2020
  • ↵ Her Majesty’s Inspectorate of Constabulary and Fire and Rescue Services. The police response to domestic abuse. An update report. 2019. https://www.justiceinspectorates.gov.uk/hmicfrs/wp-content/uploads/the-police-response-to-domestic-abuse-an-update-report.pdf
  • ↵ Forced Marriage Unit. Statistics 2020. 2021. https://www.gov.uk/government/statistics/forced-marriage-unit-statistics-2020/forced-marriage-unit-statistics-2020
  • ↵ Forced marriage—why is the conviction rate so poor? Safeguarding hub blog. Vulnerable adults, 2018. https://safeguardinghub.co.uk/forced-marriage-why-is-the-conviction-rate-so-poor/
  • ↵ Office of the Public Guardian. Office of the Public Guardian annual reports 2015-2020. https://www.gov.uk/government/collections/opg-annual-reports
  • ↵ Lush D. Lasting and enduring powers of attorney. 8th ed. 2017. https://www.lexisnexis.co.uk/store/__data/assets/pdf_file/0005/492296/Cretney-Lush-Foreword.pdf
  • ↵ Law Commission. Property, family and trust law. Weddings. 2021 https://www.lawcom.gov.uk/project/weddings/
  • ↵ Ministry of Justice. Modernising lasting powers of attorney. Safe, simpler and fit for the future. 2021. https://consult.justice.gov.uk/opg/modernising-lasting-powers-of-attorney/
  • ↵ Law Society. Modernising lasting powers of attorney—Law Society response. 2021 https://www.lawsociety.org.uk/campaigns/consultation-responses/modernising-lasting-powers-of-attorney-law-society-response
  • ↵ General Medical Council. Guidance on professional standards and ethics for doctors Decision making and consent. London, GMC, 2020. https://www.gmc-uk.org/-/media/documents/gmc-guidance-for-doctors-decision-making-and-consent-english_pdf-84191055.pdf
  • ↵ Gilg J-Y. Preventing elderly financial abuse. Family Law 2017 https://www.familylaw.co.uk/news_and_comment/preventing-elderly-financial-abuse#.WjeX69LyjRY
  • ↵ General Medical Council. Disclosures for the protection of patients and others. 2021. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/confidentiality/disclosures-for-the-protection-of-patients-and-others
  • O’Brien JG ,
  • Collins C ,
  • ↵ Domestic Abuse Act 2021. Duty to co-operate with Commissioner. https://www.legislation.gov.uk/ukpga/2021/17/section/15/enacted

dementia safeguarding case study

  • NICE Guidance
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Dementia: assessment, management and support for people living with dementia and their carers

NICE guideline [NG97] Published: 20 June 2018

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About this guideline

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Why is it needed?

What does it cover, how has it been developed, how does it relate to statutory and non-statutory guidance.

Dementia is a term used to describe a range of cognitive and behavioural symptoms that can include memory loss, problems with reasoning and communication and change in personality, and a reduction in a person's ability to carry out daily activities, such as shopping, washing, dressing and cooking. The most common types of dementia are: Alzheimer's disease, vascular dementia, mixed dementia, dementia with Lewy bodies and frontotemporal dementia. Dementia is a progressive condition, which means that the symptoms will gradually get worse. This progression will vary from person to person and each will experience dementia in a different way – people may often have some of the same general symptoms, but the degree to which these affect each person will vary ( Dementia Gateway, Social Care Institute for Excellence ).

A report published by the Alzheimer's Society found that in 2013 there were approximately 815,000 people living with dementia in the UK. If current trends continue, this number is expected to increase to 1,143,000 by 2025. In England, the National Dementia and Antipsychotic Prescribing Audit found that approximately 31,000 people were newly diagnosed with dementia in 2011. This is an increase of 8% between 2006 and 2011. Finally, in December 2017, there were 456,739 people on GP registers with a formal diagnosis of dementia, up from approximately 290,000 people in 2009/10, with the majority of this difference accounted for by an increase in diagnosis rates.

The Alzheimer's Society report found that in 2013 the total cost of dementia in the UK was estimated to be £26.3 billion. Of this, approximately £4.3 billion consists of health care, and approximately £10.3 billion consists of social care. The remaining £11.6 billion accounts for estimated unpaid care contributions.

Providing care and support is very complex, because of the number of people living with dementia and the variation in the symptoms each person faces. This has led to considerable variation in practice. Areas that pose particular challenges for services and practitioners may include:

coordinating care and support between different services

what support carers need, and how this should be provided

staff training.

This guideline makes evidence-based recommendations aiming to support these areas of practice.

Dementia also has significant costs for health and social care services. Because of this, it is important to ensure that people living with dementia can get the care and support they need, and that services provide this in an efficient and cost-effective way.

In addition, new methods for diagnosing and assessing dementia have been developed. Amyloid imaging techniques have been licensed for use in the UK, and new evidence is available for cerebrospinal fluid examination. There is also evidence on different approaches to assess and diagnose dementia subtypes. The guideline makes new recommendations on dementia diagnosis, based on a review of the latest evidence.

This guideline addresses how dementia should be assessed and diagnosed. It covers person-centred care and support, tailored to the specific needs of each person living with dementia. As part of this, it can help professionals involve people living with dementia and their carers in decision-making, so they can get the care and support they need. It also addresses care coordination and staff training, and how dementia may impact on the care offered for other conditions.

The guideline does not cover every aspect of dementia care or support, or areas where recommendations would be the same for people with or without dementia. It focuses on areas where:

there is variation in practice, and enough evidence is available to identify what works best

people living with dementia need different care and support to people in the same situation who do not have dementia.

This guideline has been developed by a multidisciplinary guideline committee, using an extensive review of research evidence. To ensure that the committee had the necessary social care expertise, a subgroup of social care practitioners was recruited to develop recommendations in this area.

Given the costs of dementia and the financial pressures facing health and social care services, the committee focused on making recommendations in areas where there is good evidence available. This will help services make the most of limited resources. For areas with a lack of evidence, the committee has made recommendations for future research (on health and social care topics) to address gaps in the evidence base. Future updates of the guideline will look at any relevant new research that has been published.

Some recommendations are made with more certainty than others. We word our recommendations to reflect this. In the sections on interventions we use 'offer' to reflect a strong recommendation, usually where there is clear evidence of benefit. We use 'consider' to reflect a recommendation for which the evidence of benefit is less certain. For more information see making decisions using NICE guidelines .

The guideline complements existing legislation and guidance. It describes how services and professionals can provide high-quality care and support.

The Prime Minister's Challenge on Dementia 2020 sets out the UK Government's strategy for transforming dementia care within the UK. The aims of the strategy include:

improving diagnosis, assessment and care for people living with dementia

ensuring that all people living with dementia have equal access to diagnosis

providing all NHS staff with training on dementia appropriate to their role

ensuring that every person diagnosed with dementia receives meaningful care.

Since the 2006 NICE guideline on dementia was developed, key new legislation has been implemented. The Care Act 2014 created a new legislative framework for adult social care, and also gives carers a legal right to assessment and support.

Relevant legislation and statutory guidance

NHS England (2015) Accessible Information Standard

Care Act 2014

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

Department of Health (2014) Care Act 2014: Statutory Guidance for Implementation

Department of Health (2014) Positive and Proactive Care: Reducing the need for restrictive interventions

Health and Social Care Act 2012

Equality Act 2010

Mental Capacity Act 2005

Human Rights Act 1998

Relevant policies and non-statutory guidance

Information Commissioner's Office (2017) Guide to the General Data Protection Regulation

NHS England (2017) Dementia: Good Care Planning

NHS England (2015) Implementation guide and resource pack for dementia care

Skills for Health, Health Education England and Skills for Care (2015) Dementia Core Skills Education and Training Framework . This framework was commissioned and funded by the Department of Health and developed in collaboration by Skills for Health and Health Education England in partnership with Skills for Care

Department of Health (2014) NHS Outcomes Framework 2015 to 2016

Department of Health (2014) Adult Social Care Outcomes Framework 2015 to 2016

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Safeguarding and protection in dementia care

Last updated: 9 November 2022

Safeguarding is about protecting children and adults from abuse or neglect and educating those around them to recognise the signs and dangers.

The five types of abuse

The Social Services and Well-being (Wales) Act 2014 outlines five types of abuse:

  • psychological

The definition of an adult at risk

The Act describes an adult at risk as someone who:

  • is experiencing or is at risk of abuse or neglect
  • has care and support needs (whether or not their local authority is meeting any of those needs), and
  • as a result of those needs is unable to protect them self against the abuse or neglect or the risk of it.

You have a duty to report adults at risk to the local authority where the person lives.

Ensure that you have the appropriate level of safeguarding training for your role.

Useful resources

Find out more about safeguarding and protection in dementia care.

Safeguarding training

Case studies and training about safeguarding

We want your feedback

Help us to improve the Dementia resource for care professionals by telling us what you think about it in our short four question survey .

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Healthy Lifestyle and Cognition in Older Adults With Common Neuropathologies of Dementia

  • 1 Rush Institute for Healthy Aging, Rush University Medical Center, Chicago, Illinois
  • 2 Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
  • 3 Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, Illinois
  • 4 Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois
  • 5 Department of Pathology, Rush University Medical Center, Chicago, Illinois
  • Editorial Harnessing Brain Pathology for Dementia Prevention Yue Leng, PhD; Kristine Yaffe, MD JAMA Neurology

Question   What is the impact of lifestyle interventions on cognition in older adults as a preventive measure?

Findings   In this cohort study, a higher lifestyle score (ie, healthier lifestyle) was associated with better cognitive function proximate to death independently of Alzheimer disease pathology burden; that is, neither the strength nor the significance of the lifestyle-cognition association changed substantially when β-amyloid load, phosphorylated tau tangle, or other dementia-related brain pathologies were included in the regression model.

Meaning   A healthy lifestyle may provide a cognitive reserve to maintain cognitive abilities independently of common neuropathologies of dementia.

Importance   A healthy lifestyle is associated with better cognitive functioning in older adults, but whether this association is independent of the accumulation of dementia-related pathologies in the brain is uncertain.

Objective   To determine the role of postmortem brain pathology, including β-amyloid load, phosphorylated tau tangles, cerebrovascular pathology, and other brain pathologies, in the association between lifestyle and cognition proximate to death.

Design, Setting, and Participants   This cohort study used data from the Rush Memory and Aging Project, a longitudinal clinical-pathologic study with autopsy data from 1997 to 2022 and up to 24 years of follow-up. Participants included 754 deceased individuals with data on lifestyle factors, cognitive testing proximate to death, and a complete neuropathologic evaluation at the time of these analyses. Data were analyzed from January 2023 to June 2023.

Exposures   A healthy lifestyle score was developed based on self-reported factors, including noncurrent smoking, at least 150 minutes of physical activity per week, limiting alcohol consumption, a Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diet score higher than 7.5, and a late-life cognitive activity score higher than 3.2. The lifestyle score ranges from 0 to 5, with higher scores reflecting a healthier lifestyle.

Main Outcomes and Measures   The global cognitive score was derived from a battery of nineteen standardized tests. Brain pathology measures included β-amyloid load, phosphorylated tau tangles, global Alzheimer disease pathology, vascular brain pathologies, Lewy body, hippocampal sclerosis, and TAR DNA-binding protein 43.

Results   Of 586 included decedents, 415 (70.8%) were female, 171 (29.2%) were male, and the mean (SD) age at death was 90.9 (6.0) years. Higher lifestyle score was associated with better global cognitive functioning proximate to death. In the multivariable-adjusted model, a 1-point increase in lifestyle score was associated with 0.216 (SE = 0.036, P  < .001) units higher in global cognitive scores. Neither the strength nor the significance of the association changed substantially when common dementia-related brain pathologies were included in the multivariable-adjusted models. The β estimate after controlling for the β-amyloid load was 0.191 (SE = 0.035; P  < .001). A higher lifestyle score was associated with lower β-amyloid load in the brain (β = −0.120; SE = 0.041; P  = .003), and 11.6% of the lifestyle-cognition association was estimated through β-amyloid load.

Conclusions and Relevance   This study found that in older adults, a healthy lifestyle may provide a cognitive reserve to maintain cognitive abilities independently of common neuropathologies of dementia.

  • Editorial Harnessing Brain Pathology for Dementia Prevention JAMA Neurology

Read More About

Dhana K , Agarwal P , James BD, et al. Healthy Lifestyle and Cognition in Older Adults With Common Neuropathologies of Dementia. JAMA Neurol. Published online February 05, 2024. doi:10.1001/jamaneurol.2023.5491

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Identifying Mixed Dementia With Lewy Bodies and Alzheimer Disease Using Multitracer PET Imaging: A Case Study

Affiliation.

  • 1 Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
  • PMID: 38350092
  • DOI: 10.1097/RLU.0000000000005081

We reported imaging findings with complex signs that were corresponded with both dementia with Lewy bodies (DLB) and Alzheimer disease (AD) in the case of a 78-year-old woman. Initially suspected as DLB due to cognitive and movement issues, diagnostic support included the cingulate island sign on 18F-FDG PET, positive 131I-MIBG cardiac scintigraphy, and DAT PET. However, MRI indicated hippocampal atrophy, and 18F-FDG PET showed hypometabolism in the medial temporal lobe, suggesting the possibility of concomitant AD. Subsequent detection of β-amyloid pathology and tau accumulation in the brain further supported the concurrent presence of AD pathology.

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  • v.14(4); 2017 Jul

A Case Report of a 37-Year-Old Alzheimer's Disease Patient with Prominent Striatum Amyloid Retention

Yoo hyun um.

1 Department of Psychiatry, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.

Woo Hee Choi

2 Department of Radiology, Division of Nuclear Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea.

Won Sang Jung

3 Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea.

Young Ha Park

Chang-uk lee.

4 Department of Psychiatry, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.

Hyun Kook Lim

With recent advancement in amyloid imaging, diagnostic application of this new modality has become a great interest among researchers. New ligands, such as 18F- florbetaben, florbetapir and flutemetamol, have been discovered to overcome limitations of preexisting ligand Pittsburgh compound B. We report here a case of a 37-year-old male patient whose initial complaints comprised of gradual cognitive decline, apraxia, disorientation and sleep disturbances. 18F-Florbetaben amyloid imaging of the patient showed diffuse amyloid retention with prominent striatal uptake. This finding supports the clinical utility of amyloid imaging in diagnostic process of early-onset AD. Moreover, striatal dominant uptake pattern demonstrated in this patient include some meaningful clinical implications that warrant special attention among clinicians.

INTRODUCTION

Amyloid deposition has long been considered one of the pathognomonic markers of Alzheimer's disease (AD). Moreover, disruption in amyloid hypothesis has been frequently discussed as important targets of intervention for many years. 1 To date, most validated research results have been narrowed down to yield a model for biological trajectory of AD, where amyloid deposition far precedes clinical symptoms. 2 Thus, early detection of amyloid deposition has emerged a major target of intervention in AD patients. In this regard, amyloid imaging has emerged as an effective diagnostic tool that could enable early intervention in patients in AD trajectory, and the clinical utility of amyloid imaging has become a main topic of interest among researchers over the recent years. 3 If validated further, clinical usage of amyloid imaging is expected to extend beyond confirming AD pathology in patients with high risk factors, helping to differentiate AD from various types of dementia in those who present with atypical course or symptoms. 4

Pittsburgh compound B has been the first ligand used to detect amyloid deposition in AD patients. 5 However, its short half-life and resultant limitations in applying it to clinical setting have resulted in the development of new ligands for detecting amyloid deposition, such as 18F-florbetaben, florbetapir and flutemetamol. 6 Amyloid deposition usually initiates from temporal and orbitofrontal cortices, which later extends to frontal, parietal, precuneus, anterior and posterior cingulate cortices. 7 However, differential uptake patterns in autosomal dominant gene carriers have been noted that warrant special clinical attention. While typical amyloid deposition occurs from cortical structures, those with autosomal dominant gene carriers demonstrated initial amyloid deposition in striatum. 8 , 9

We report here a case where a case of early-onset AD patient who received a confirmatory diagnosis of AD by beta-amyloid imaging. There is relatively few evidence on the clinical application of beta-amyloid imaging in early-onset AD patients, and therefore, we expect our case can contribute to this line of inquiry. Moreover, validity of utilizing beta-amyloid imaging in differential diagnosis of dementias will be discussed.

A 37-year old male patient visited outpatient clinic, with complaints of gradual cognitive decline which had started 3 years earlier. Working as an industrial researcher, he started to make serious calculation mistakes that made him quit the job and began working as a manager in a company. However, his frequent forgetfulness, along with aggravation in recent memory impairments hampered him from fulfilling his duties, making him change jobs frequently. Apraxia and apathy had started 2 years before his visit to our clinic, and disorientation to time and person was worsened to a degree which it became impossible to commute daily between his workplace and home. At time of his visit to our clinic, not only he was fired from his recent job, but also he needed frequent reminder from his family to maintain hygiene. His sleep disturbance became prominent, frequently waking up middle of the night self-talking.

Before his visit to our clinic, he had visited two hospitals for evaluation and management of his symptoms, but to no avail. For a thorough examination of his symptoms, he was immediately admitted to our psychiatric ward. His laboratory findings did not reveal any abnormalities, and his tests for human immunodeficiency virus, syphilis all turned out to be negative. Upon his psychiatric admission, a neuropsychological test battery was implemented to evaluate the patient's cognitive status. He scored 22 in Mini-mental status examination, 1 in Clinical dementia rating scale (CDR), 10 and 4.5 in Clinical Dementia Rating-Sum of Box score(CDR-SB). 11 In his cognitive tests, in contrast to his relatively preserved language function, he displayed serious impairments in free recall, 20-minute delayed recall and recognition.

Brain magnetic resonance imaging demonstrated global cerebral atrophy of grade 1 by cortical atrophy scale 12 and notable medial temporal lobe atrophy of grade 2 by medial temporal lobe atrophy visual rating scale ( Figure 1A and B ). 13 Atypically early onset of dementia symptoms made the patient an eligible candidate for amyloid positron emission tomography (PET) imaging. 14 18-Florbetaben PET images revealed diffuse amyloid deposition with score 3 in brain beta-amyloid plaque load (BAPL), 15 with predominant amyloid deposition in the striatum ( Figure 1C and D ).

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The patient's history, along with neuroimaging results and cognitive test results all satisfied the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association Alzheimer's (NINCDS-ADRDA) criteria16 for probable Alzheimer's disease with high level of evidence. 5 mg of donepezil was prescribed, and the patient was discharged on the 10th day of his admission. To control his persistent cognitive decline even after the discharge, donepezil was increased up to 23 mg with combination of memantine, which was also increased up to 20 mg. His cognitive decline has been relatively plateaued, but we advised the patient and his caregiver to regularly visit the clinic for monitoring of his symptoms.

This is one of the few case reports that demonstrated diagnosis of early-onset AD by 18F-florbetaben PET imaging. The patient demonstrated early onset of cognitive decline with accelerated deterioration. The fact that he meandered along various departments at different hospitals for confirmatory diagnosis reflect major role amyloid imaging played in the diagnostic process of the patient.

Amyloid imaging is usually indicated in patients with progressive MCI with dubious etiology, patients with atypical presentations and clinical course, and patients with early-onset progressive dementias. 14 Considering the patient in the case exhibited dementia symptoms at atypically early age, amyloid imaging was appropriately prescribed to diagnose the etiology of his cognitive decline. Integration of information attained from his history, clinical data indicated his diagnosis to be early-onset AD.

There have been relatively few reports utilizing 18F-labelled amyloid beta PET tracers that include clinical implications related to autosomal dominant AD. One study adopted 18F-florbetaben PET imaging in Down syndrome patients, suggesting potential role of amyloid imaging in identifying population at risk of dementia. 17 Similar study was conducted on patients with Down syndrome, but with 18F-florbetapir tracer. 18 An attempt to differentiate Down Syndrome pathology from AD has also been made with 18F-florbetapir tracer. 19 Future studies on autosomal dominant AD with 18F-labelled amyloid beta PET tracers could increase validity of adopting these new ligands in the diagnostic process.

Most notable test results in the case report arise from uptake patterns of 18F-florbetaben PET imaging. Unlike typical uptake patterns demonstrated by late-onset AD patients, where striatum is usually involved in the later course of illness, there was a dominant striatal uptake pattern in the patient. A previous study conducted on nondemented young adults with Down syndrome compared their results with that of studies conducted on autosomal dominant early-onset AD patients, where two groups of subjects concordantly showed predominant striatal uptake. 8 Indeed, previous studies on autosomal early-onset AD patients consistently showed high striatal amyloid deposition. 20 , 21 The aforementioned finding could explain 18F-florbetaben uptake patterns in the case.

The underlying mechanisms have been discussed in prior studies on the relatively early involvement of the striatum in autosomal dominant early-onset AD patients. Axonal mistrafficking induced by presenillin-1 gene mutation has been suggested as a potential culprit for striatal amyloid deposition in one animal study. 22 Such axonal mistrafficking is considered to stem from disruption in APP processing. 22 Indeed, APP processing patterns differed between autosomal dominant AD patients and sporadic AD patients. 23 Striatal vulnerability to early stages of tau protein accumulation in autosomal dominant AD has also been elucidated, and such phenomenon is considered more toxic to induce significant striatal neuronal injury. 24

The most prominent limitation of our case report is lack of genotype testing in the patient. If the genetic testing had been done, one missing puzzle in the diagnosis of patient would have been complete. Nevertheless, we believe our case report affirms diagnostic usefulness and clinical application of amyloid imaging in the differential diagnosis of early-onset dementia. We expect more prevalent use of amyloid imaging with accumulation of evidences and validation studies over time.

Acknowledgments

This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning (NRF-2015R1C1A1A02036578).

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