Ramsey-Klawsnik Training Materials 2 Discussion Complexities of mental capacity Challenges in screening capacity Possible inaccurate assumptions Role of physical & mental illness, disability, developmental disabilities, dementia, neglect and abuse Cultural issues Gentle, respectful methods for screening Using screening tests
Ramsey-Klawsnik Training Materials 3 Mental Capacity An evolving clinical and legal concept
Ramsey-Klawsnik Training Materials 4 Clinically An individual – Has capacity – Has diminished capacity or – Lacks capacity
Ramsey-Klawsnik Training Materials 5 Legally An individual has or lacks capacity
Ramsey-Klawsnik Training Materials 6 Current Thinking Capacities NOT capacity
Ramsey-Klawsnik Training Materials 7 Capacities Decisional - ability to make decision Executional - ability to execute May be able to make decision but not personally execute
Ramsey-Klawsnik Training Materials 8 Abilities/Domains Provide medical consent Consent to APS intervention Make financial decisions Manage finances Engage in contracts/marry Make a sound will Drive Consent to sexual activity Manage ADLs or IADLs
Ramsey-Klawsnik Training Materials 9 Current Thinking Evaluations should assess specific domains Limited court orders only for impaired domain(s) Avoid global descriptions when only limited impairments
Ramsey-Klawsnik Training Materials 10 Procedures for Assessing Interview, observe & interact Obtain collateral data Formal tests –Functional assessment –Physical exam with lab tests –Psychological, including I.Q. –Neuropsychological –Medical tests of brain functioning –Psychiatric
Ramsey-Klawsnik Training Materials 11 Concerns Capacity lack may be temporary Neglect/abuse can decrease capacity Disability can mask capacity Brief, crude testing can be harmful
Ramsey-Klawsnik Training Materials 12 Between a Rock & a Hard Place APS workers expected to assess/screen Not able to determine capacity Critical decisions hinge on capacity Difficult to obtain formal testing Quickie tests can lead to false readings Problems with 1x assessment
Ramsey-Klawsnik Training Materials 13 Mental Illness & Capacity Most with dx MI have capacity Major MI can cause psychosis & temporary incapacity Effect of psych meds + or -
Ramsey-Klawsnik Training Materials 14 Case Example Does this woman lack capacity? What is the evidence that she does or does not have capacity? How would you further assess?
Ramsey-Klawsnik Training Materials 15 Mrs. T. Police referred harmless but deranged 79 yo widow to APS, repeat nuisance calls Lives alone – children out of area Calls police: invaders in her attic No heat due to no gas
Ramsey-Klawsnik Training Materials 16 Mrs. T. Owned home in middle-class area Home clean, well-maintained Has raised 4 kids, worked in office Independent in ADLs & IADLs Hygiene good, memory intact Drives, does errands Adamant little people in attic stealing Appeared paranoid, delusional
Ramsey-Klawsnik Training Materials 17 Physical Disability & Capacity Many with physical disabilities mistaken as incapacitated CP, MS, Parkinson's Disease, Lou Gehrig Disease (ALS), aphasia Case example: Harold, has CP
Ramsey-Klawsnik Training Materials 18 Need with Physical Disabilities Communication remedies Time, observation, interaction Background & collateral info May need specialists to assess
Ramsey-Klawsnik Training Materials 19 Disease/Injury Illness and treatment affect capacity Infections, fluid in lungs, etc. Meds can alter cognition Post-surgery or trauma NOT time to assess capacity
Ramsey-Klawsnik Training Materials 20 Mrs. N. 74 y.o. independent widow Fell, broke hip, surgery resulted MD used MMSE one day post-op Mrs. N. failed MD diagnosed & charted dementia Outcome…
Ramsey-Klawsnik Training Materials 21 Developmental Disabilities Include intellectual disabilities I.Q. of 70 or below Many with DD have capacity Specific testing required
Ramsey-Klawsnik Training Materials 22 Dementia & Capacity Dementia typically progressive Capacity retained early-mid stages Abilities tend to fluctuate Need multiple reads at various times
Ramsey-Klawsnik Training Materials 23 Dementia Diagnosis Requires Multiple cognitive deficits, including memory impairment Gradual onset At least one of: –Aphasia – language disorder –Apraxia – motor impairment –Agnosia – failure to recognize items Disturbance in executive functioning –Planning - organizing –Sequencing - abstracting Must be decline & severe impairment
Ramsey-Klawsnik Training Materials 24 Caution re: Dementia Dx Dementia dx should not be interpreted as person not accurate reporter Abuse & neglect disclosures should NOT be discredited d/t dementia
Ramsey-Klawsnik Training Materials 25 Neglectful Care Can profoundly affect cognition –Malnutrition –Dehydration –Untreated illness, infection –Lack of sleep –Over- under-medication –Isolation Much caution needed in assessing
Ramsey-Klawsnik Training Materials 26 Case: Mr. W. Arrived at ER in poor condition Disclosed abuse & neglect to nurse APS report made Admitted then displayed confusion Disclosures dismissed, dementia diagnosed Transferred to LTC Outcome…
Ramsey-Klawsnik Training Materials 27 Abuse & Capacity Diminished capacity increases abuse risk Abuse can cause cognitive problems –Illness, injury, trauma, loss, etc. Cognitive limitations can result in being discredited when report actual abuse
Ramsey-Klawsnik Training Materials 28 Deliberate Interference Abuser may hinder victim abilities to exploit Over, under-drug, isolate, disorient, deny adaptive devices
Ramsey-Klawsnik Training Materials 29 Case: Lady From Georgia Moved to Ohio at sons urging There, imprisoned in his home Isolated, exploited, abused, neglected Drugged,presented as self-neglecting Crude assessment by MDs Son obtained guardianship FE, neglect, abuse increased
Ramsey-Klawsnik Training Materials 30 Screening Capacity Clinically complex, especially when –Abilities fluctuate –Communication barriers exist Limitations with brief tests Impact on client and rapport Risk of false positive/negatives
Ramsey-Klawsnik Training Materials 31 Consider When assessing cognitive abilities…
Ramsey-Klawsnik Training Materials 32 Culture & Language Culture, speech & language of both client and tester impact test accuracy
Ramsey-Klawsnik Training Materials 33 Consider Am I seeing client at his/her worst? Am I seeing client at his/her best? Is the functioning typical?
Ramsey-Klawsnik Training Materials 34 Consider - Is Client Hungry, thirsty, sick, drugged, sleep deprived, fearful, in pain or crisis, grieving, acutely anxious, preoccupied?
Ramsey-Klawsnik Training Materials 35 If Person Not at Baseline Functioning below normal displayed Cognitive assessment inappropriate Intervention may be needed
Ramsey-Klawsnik Training Materials 36 Consider: Have I build rapport? Have I explained my role? Have I sought consent? Am I communicating clearly?
Ramsey-Klawsnik Training Materials 37 Consider: Is situation conducive to assessing? Physical conditions Privacy Safety Are there urgent unmet needs?
Ramsey-Klawsnik Training Materials 38 Key Observation and interaction over time necessary to fully assess esp. when disabilities exist Also need reliable history
Ramsey-Klawsnik Training Materials 39 Use Collateral Data Beware tainted reports Obtain multiple opinions Obtain basis for opinions Records may be inaccurate
Ramsey-Klawsnik Training Materials 40 Testing No standard test battery for evals Must select appropriate tests APA/ABA urge: functional assessments that describe task- specific deficits
Ramsey-Klawsnik Training Materials 41 Evaluation Problems Many clinicians not trained to test functional & cognitive ability Testing that is too brief or crude Using the wrong measures Relying upon false data Language/communication barriers Testing client in crisis or distress Global conclusions from limited data
Ramsey-Klawsnik Training Materials 42 Natural Assessment Observe, interview, interact Observation and open-ended questions best practice
Ramsey-Klawsnik Training Materials 43 Natural Opportunities Observe person & environment Does appearance suggest A&O? Clues in clients environment
Ramsey-Klawsnik Training Materials 44 Natural Opportunities Gentle, non-threatening conversation Can client converse? –Understand what is said –Process & hold thoughts –Formulate responsive answers Assess memory through asking history Use environmental clues –Photos, hobbies, abilities, needs, habits
Ramsey-Klawsnik Training Materials 45 Other Opportunities Client sign & date forms Observe client do task –Are steps planned? –Is behavior meaningful? –Is desired goal reached?
Ramsey-Klawsnik Training Materials 46 Questions When Tests Used Is tool validated, normed, standarized, acceptable measure? Is tester qualified, trained & experienced to administer & score this test, authorized to use? Is tester in a role in which testing is appropriate?
Ramsey-Klawsnik Training Materials 47 Testing Questions Cont Is elder in situation in which he/she can perform up to ability? Has tester built rapport, used conversation to engage and assess, obtained background info & permission to test?
Ramsey-Klawsnik Training Materials 48 Testing Questions Cont Has effective communication been established between tester & elder? Is there clear purpose & reason for the test? How will the results be used?
Ramsey-Klawsnik Training Materials 49 Summary Use great caution in drawing conclusions re: mental capacity Consider: –Conditions under which capacity tested –How tested –Possible ulterior motives Assess at multiple times, use multiple methods
Ramsey-Klawsnik Training Materials 50 Do Observe & document client statements, appearance, behaviors, environment, abilities Avoid rash conclusions Avoid statements re: cause of problems When capacity in question, seek quality formal evaluation Advocate for clients unfairly judged
Ramsey-Klawsnik Training Materials 51 Thank you! And Good Luck in serving elders!