Appointment of a guardian for the institutionalized mentally frail: is it necessary?

To the Editor: Senior citizens are the most rapidly growing age group worldwide. They are also aging; in 2007, 27% of the 651 age group were octogenarians or older. More than 20% of those 801 suffer from amoderate to severe form of dementia, their needs often exceed the resources of their families, and placement in a nursing home is sometimes inevitable. In Israel, approximately 4% of the elderly reside in long-term care institutions. Of the 30,200 total number of beds in the 403 institutions for the elderly, there are 19,900 beds (65.8%) for nursing home and mentally frail patients. In Israel, departments for the mentally frail are registered as hospital departments, and are under the supervision of the Ministry of Health Ordinances for registration of hospitals, which is distinct from homes for the independent aged and/or the infirm that are subject to the ‘‘Residential Home Supervision Regulations: living conditions and treatment of independent and/or infirm elderly.’’ Before admission to a residential home, the candidate independent or infirm elderly person must have a written expert evaluation by the home’s physician and social worker confirming his or her capacity to express his or her opinion, and must then sign informed consent for admission. When capacity is lacking, a legal guardian (for the body of the patient), who is appointed by court order, or a person who was granted Power of Attorney for Health Care by the patient, when he or she was still able to do so, must provide written informed consent for admission. The authors retrospectively reviewed patient files, and interviewed the staff of 2 psychogeriatric departments at LevHasharon Mental Health Center, Israel, to examine guardian status of inpatients diagnosed as mentally frail. Of the 65 inpatients, 60 had legal guardians for their person and property, 1 had a guardian for assets only, and 4 patients had no legal guardians. Thirty patients had legal guardians before admission, who indeed consented to admission to the closed wards for the mentally frail. The remaining 31 guardians were appointed at the initiative of the hospital staff, following diagnosis of "mentally frail," and admission to the department for the mentally frail. Of the 60 patients who had legal guardians, 29 were family members (brother, sister or children; none were spouses). Thirty-one of the guardians were public agencies, including state-appointed attorneys, and the 1 guardian for assets was appointed by the Office of the General Guardian. Family Court decides who the guardian will be. There was no correlation between the 30 patients who had guardians before admission and the type of guardian (family or public agency). The Israeli Law for the Treatment of the Mentally Ill deals with the subject of involuntary hospitalization and the