Assessing Capacity: A Primer for the Busy Healthcare Professional Michael R. Villanueva, PsyD, ABPP-CN Providence Medford Medical Center Grand Rounds June 29 2011

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

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?

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

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

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.

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

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

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) 865-70

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

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

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): 426-32

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

History Vague Inconsistent Poor remote recall not normal aging

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

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

Mental Status Exam MMSE MoCA

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

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

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

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

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

Be Specific Know what ability is needed for what task

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

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

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)

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

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

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

Medical Consent: Functional Elements Expressing a Choice Understanding Appreciation Reasoning

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

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

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

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

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

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

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

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

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

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

Pt is impaired and can not make medical decisions Now what

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

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.

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…

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

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

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

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)

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”.

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

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

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

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

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?

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)

Failure to Remain in the Home Night Time Activity Immobility Incontinence

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?

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

Guardianship requires 3 considerations Disabling condition Functional disability Cognitive impairment

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