Last Resort of Individuals with Dementia Threatened

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A recent Wisconsin Supreme Court decision held that individuals with dementia cannot be placed involuntarily into “units for the acutely mentally ill.”1 This creates a treatment vacuum for people with dementia who develop behavioral disturbances too severe to be managed elsewhere. Ironically, one premise for the court's decision was that, under Wisconsin law, civil commitment required amenability to “treatment,” which was defined as “rehabilitation.” The court ruled that because individuals with dementia cannot be rehabilitated, they cannot be civilly committed. Can individuals with psychiatric or behavioral disturbances caused by dementia be cured? No. Can they be treated? Most certainly yes. In spite of recent data on the dangers and limitations of pharmacological therapies for behavioral disturbances due to dementia, there is much (including a safe environment and nonpharmacological therapy) that inpatient psychiatric facilities can offer to individuals with dementia.2-5 Many people experience improvement or resolution of their symptoms.4, 5 In Wisconsin, a fundamental misunderstanding about the care of individuals with dementia has resulted in the exclusion of individuals with dementia from the civil commitment process. That process is an unpleasant but necessary step on the path to stabilization for many people with psychiatric or behavioral symptoms of dementia. It is our hope that the misunderstanding in Wisconsin will be quickly corrected. Perhaps even more important, we hope that Wisconsin's mistake does not spread to other states. California and Florida are the two states with the greatest number of people aged 65 and older. There is a real possibility that both could follow Wisconsin. California's attorney general has concluded that individuals with Alzheimer's disease may be held for 72 hours in the first step toward civil commitment,6 but further detention must be for treatment.7 A California court could, as in Wisconsin, conclude that treatment is not possible for dementia. Indeed, one California court upheld a conservator's determination that an individual's “inability to care for himself [was] not a product of a mental disorder for which treatment [was] available in a state mental hospital, but a result of dementia.”8 The definition of “mental illness” in Florida is broad enough to include dementia and even specifies that etiology is irrelevant.9 The Florida Supreme Court has held that a person who is involuntarily committed has a right to treatment.10 Florida statutes codify and broaden this right to include “such medical, vocational, social, educational, and rehabilitative services as his or her condition requires in order to live successfully in the community.”9 This broad definition of treatment may appear encouraging, but a court could conclude that civil commitment is inappropriate for individuals with advanced dementia who will never be able “to live successfully in the community.” Success in treating individuals with dementia, as with other mental illnesses, often means modest and sometimes temporary improvement in symptoms. To twist that unfortunate reality into a reason to deny supportive care in what may be the best setting is a legal blunder of colossal proportions. We must educate policy-makers to reverse the Wisconsin error and to prevent its spread. Conflict of Interest: Neither author has any conflict of interest. Author Contributions: Fredrick Vars provided legal analysis. Caroline Harada provided medical expertise. Both contributed significantly to the drafting. Sponsor's Role: No sponsor.