1. Assessing Capacity: A Primer for the Busy Healthcare Professional
Michael R. Villanueva, PsyD, ABPP-CN
Providence Medford Medical Center
Grand Rounds June

2. Conflicting Goals Respecting Pt Autonomy
Acting in the Best Interest of the Pt

3. Approaching the task Who is my cognitively impaired pt?
How do I assess the impaired pt?
When do I refer?
What is the relationship between being cognitively impaired and incapacitated?
What are the rules regarding medical decision making capacity?
What do I do if pt lacks capacity?

4. How did we get into this mess?
Pts suffer cognitive as well as physical decline
Pts with dementia do not always appreciate their level of decline
Elder pts sometimes have inadequate social supports and resources
Pts with marginal cognitive function can decline rapidly after episode of delirium

5. Risk factors for cognitive impairment
Age
Delirium
Cardiovascular disease
Head injury
Stroke
Amputation
Dialysis
Parkinsons or Parkinsonism
Hypoxemia
Diabetes
Multiple Sclerosis
Radiation, chemotherapy

6. What is the risk of cognitive impairment?
Prevalence of dementia 45% after age 85
Prevalence of dementia in pts over 80 with Parkinson’s 69%
Significant Cognitive Impairment in MS: 40 to 50% of community dwelling sample
Odds of developing dementia within three mos after CVA: 1 in 4.

7. Delirium – DSM IV Disturbance of consciousness Change in cognition
Reduced clarity
Reduced focus
Change in cognition
Development over a short period of time
Caused by medical/physiological condition
Development over short period of time
Disturbance tends to fluctuate during course of the day

8. Dementia – DSM IV
Acquired cognitive impairment due to brain dysfunction
Severity sufficient to interfere with usual social or occupational function
Deterioration in two or more neuropsychologic domains
Changes must represent decline from previous level

9. Dementia After Stroke 451 consecutive stroke pts admitted to hospital
Assessed at 3 mos post cva
Dementia in 25% of sample
J of Neuol Neurosurg and Psychiatry, 2009 Aug 80(8)

10. Delirium after CVA
263 consecutive acute ischemic stroke pts ages 55 – 85
Delirium in 19% of sample
Low ed, pre cva cognitive decline, and stroke severity were delirium risk factors
Post stroke delirium associated with dementia 3 mos post cva
Early delirium also associated with reduced survival
Int J of Geriatric Psychiatry 2011, May 10

11. Dementia and depression
Do not quickly dismiss cognitive dysfunction because the pt is “just depressed”
VA data base, 281,540 pts (55 and older) reviewed
None had dementia at baseline
Those with h/o of depression and dysthymia were twice as likely to develop dementia
Am J Geriatric Psychiatry 2011 May 18

12. Hospital pts vs. Controls
Pts without known cerebral injury hospitalized on a rehabilitation floor
Control: matched community dwelling individuals
Hospitalized pts scored more poorly than controls on 9 of 10 neuropsychologic tests
PM R 2011 May; 3(5):

13. How do I assess cognition?
During history
Discussion with caregivers and family
Chart review
Mental status exam

14. History
Vague
Inconsistent
Poor remote recall not normal aging

15. Caregivers and Family Evidence of change
Evidence of tasks being taken over
Reports cw apathy
Do not be fooled by reports of depression

16. Chart review Med list (are they on Aricept?) Memory concerns
Medication non-compliance

17. Mental Status Exam
MMSE
MoCA

18. MMSE
0 – 30
Covers registration, STM, orientation, calculations, visuo-motor, language
Weak on executive function
Highly reliant on intact language
Enjoys broad use

19. MoCA 0 – 30 Norms for pt groups
Covers multiple domains, fluency, stm, attn/exec, visuo-spatial, naming, abstract reasoning
Canadian (so others are paying for the free lunch)
Less robust assessment of orientation

20. When should I refer? Standard test score higher than expected
Complicated history needing help with etiology and prognosis
Difficulties getting pt through mental status screen
Dementia mild to moderate and pt has been getting by marginally
When Dr. Dickinson returns from maternity leave

21. Therapy Resources
PT can help comment on pt’s practical safety awareness with transfers and ambulation
OT can comment on the pt’s ability to perform important self care activities in a safe manner
SLP can comment on pt’s use of language to express needs, and can comment on pt’s response to treatment to understand level of deficit

22. My pt is cognitively impaired…
What does that mean regarding medical decision making
Discharge planning
Medication management

23. Be Specific
Know what ability is needed for what task

24. Six Different Capacities
Medical Capacity
Sexual Capacity
Financial
Testamentary
Driving
Independent Living Capacity

25. Basic Underlying Philosophy and Legal Considerations
All adults are presumed to have capacity
We all have a “right to folly” (Justice Douglas)
Support pt decisions we disagree with if pt has capacity
Protect pt from dangerous decisions if pt does not have capacity

26. References
Oregon State Bar Publication Online (with assistance from Timothy L. Jackle, attorney at law, Foster Denman LLP)
Assessment of Older Adults with Diminished Capacity: A Handbook of Psychologists
American Bar Association/American Psychological Association Assessment of Capacity in Older Adults Project Working Group (available through the APA website)

27. Assessment of Capacity is part of our clinical assessment
It is part of obtaining consent, and therefore integral to the evaluation of the cognitively impaired pt

28. Medical Capacity
Capacity means an individual’s ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health-care decision
Uniform Health-Care Decision Act of 1993, 1994

29. Medical Capacity
Decisional Capacity in health care is rooted in the concept of Informed Consent
Such consent must be:
Competent
Voluntary
Informed

30. Medical Consent: Functional Elements
Expressing a Choice
Understanding
Appreciation
Reasoning

31. Expressing a Choice Cannot communicate a treatment choice
Vacillate so much that cannot determine pt’s true wishes

32. Understanding
Often considered to be primary in consideration of medical capacity
The ability to comprehend diagnostic and treatment related information

33. Appreciation
Ability to relate treatment information to one’s personal situation
Ability to infer possible benefits of treatment and
Accept or believe diagnosis

34. Reasoning Ability to state rational explanations
Process information logically
Process information in a consistent manner

35. Cognitive Underpinnings of Medical Capacity – Expressing a Choice
Need to assess expressive and
receptive language
Use yes/no assessment
Have them follow basic commands
Ask them to describe a very recent event

36. Understanding Assess memory Assess comprehension
What happened earlier today?
Where are we?
What procedure is scheduled?
Assess comprehension
Why are we doing the procedure?

37. Appreciation and Reasoning
Executive Function and Mental Flexibility
Counting backward
Verbal Fluency
Discuss benefits and risks

38. Modifying Factors Regarding Medical Consent
Risk of harm
Blood Draw vs. CABG
Values
Treatment worse than disease
Impose Care on family

39. Consent Capacity Instruments
Aid to Capacity Evaluation (ACE)
Semi Structured Interview

40. Aid to Capacity Evaluation (ACE) Etchells et al (1999)
Provides structured interview to elicit main facets of capacity:
Understand the medical problem
Understand the treatment
Understand alternatives to treatment
Understand option of refusing treatment
Ability to make decision not based on Psych Factors
Ability to perceive consequences of
Accepting
Refusing

41. Pt is impaired and can not make medical decisions
Now what

42. Sources of Legal Authority
There is detailed information regarding sources of legal authority for withdrawal of life support
Not as much guidance on discharge to home vs. assisted living

43. Incapacitated
A condition in which a person’s ability to receive and evaluate information effectively or to communicate decisions is impaired to such an extent that the person presently lacks the capacity to meet the essential requirements for the person’s physical health or safety.

44. Incapable
Incapable means that in the opinion of the court in a proceeding to appoint or confirm authority of a health care representative, or in the opinion of the principal’s attending physician, a principal lacks the ability to make and communicate health care decisions to health care providers…

45. Incapacity Ultimately competence is a legal decision
Capacity can not be determined in the abstract, a person is incapacitated to a specific task
Capacity is interactive and is influenced by demands of environment as well as the individual
Capacity is not necessarily static

46. Presumed Competent
A lawyer should presume an older client has necessary mental competency to make legal choices
Oregon law presumes a person to be competent absent an adjudication of incompetence
Capacity to perform a particular act is examined at the time of the act

47. Action Items if Patient Lacks Capacity
Identify Proxy Decision Maker already established
Identify close family able to discuss pattern of wishes
Wait to see if pt “clears”
Assess during times of optimal clarity
Involve social services to help establish appointed decision maker

48. If Pt is Incapable
Advance Directive (Not pertinent for most of our decision making)
Prior Executed POA
If temporary wait and treat
Can rely on family members (little law on the subject)

49. Power of Attorney
Competence to assign power of attorney akin to competence to enter into contract
“A person can enter into a valid contract if the person’s reasoning ability enables the person to understand the nature of the transaction in which the person is engaged, and to understand its quality and consequences”.

50. Steps to Take Temporary guardianship Limited or full guardianship
Assess implied consent

51. Capacity to Live Independently
Limited functional abilities
Danger due to cognitive/psychiatric
Cannot accept or use assistance

52. Functional Components
Activities of Daily Living - ADLs
Eating, bathing, toileting
Instrumental Activities of Daily Living – IADLs
Higher level: Financial and Household management

53. Key ADLs and IADLs Diet Hygiene Maintain household Transportation
Handle emergencies
Compensate for deficits

54. Three part framework to understand living independently
Understanding
Able to discuss basic requirements of taking meds, buying groceries, etc
Application
Which tasks can pt perform and which ones can be done by others as directed by the pt
Judgment
Pt may be able to discuss need for help, but does he keep firing caregivers?

55. Cognitive Predictors of Poor Functional Status
Royall et al (2007) J Neuropsychiatry and Clinical Neuroscience
Literature Review: Cognitive correlates of ADLs and IADLs
Domain specific cognitive function weakly associated with functional outcome
General Cognitive Screening measures moderately associated with ADL/IADL success (MMSE)

56. Failure to Remain in the Home
Night Time Activity
Immobility
Incontinence

57. Importance of Modifying Factors
Diagnosis/Prognosis
Is the state of lack of capacity temporary?
Risk of Harm
Is the decision likely to have much impact?
Undue Influence
Is the patient under the control of others?
Environmental/Social Support
Can the potentially harmful decision be corrected by supervision?

58. Guardianship
In Oregon law, courts can impose guardianship when a pt becomes incapacitated
Incapacitated:
Unable to make or communicate decisions necessary to provide for person’s basic physical health and safety

59. Guardianship requires 3 considerations
Disabling condition
Functional disability
Cognitive impairment

60. Summary Identify cognitively impaired pts
Use base rates to raise awareness and alertness
Assess Pts with suspicion of impairment with mental status exam
Refer pts when doubt remains regarding cognitive function, implications, and etiology
Help determine whether or not the level and type of cognitive difficulty affects competence
Assist in clinically improving capacity, defer to proxy decision maker, or allow the wishes of a competent pt AMA