Capacity Evaluation

MacArthur Foundation

Commented on justice and housing benefits for MHMR clients with legal problems.

Focus: What can the client do ?

Office of Aging Protective Services Legal authority and mandate

Investigate and protect vulnerable elders

PA Law

Pennsylvania Probate Estates and Fiduciaries Code

Mental Health Procedures Act 169 Department of Motor Vehicles

Legal Areas of Interest

Finances Medical Level of Care Type of Agent Comments on Caregivers Comments on Relationships Comments on Conditions Living Will Testamentary Will

Driving Appearance in Court Making Change Prognosis End of Life Decisions

Voting

Legal Requirements

Choice

Understanding

Appreciation

Reasoning

“ Do they ‘get’ it?’

“ I just don’t ‘get’ it.

“ They used to …

“ But they were a …

Executive Function is in the Middle

Choice

Appreciation

Reasoning

Understanding

Legal Instruments

Representative Payee Agent Power of Attorney Durable Power of Attorney Limited Guardian (specify) Plenary Guardian Temporary Guardian Third Party Agents Family Agents

Competing Interest, Mandate, Discipline

Legal

Patient / Family

Medical

Financial

Cooperative Interest, Mandate Discipline

Patient

Family Financial

Medical

Legal

Patient Well-Being

General Overview

Documentation of ADL and IADL self-perception and actual performance with a diagnosis and a prognosis will give you the answers to these areas interest.

It’s like a GAT

History Emphasizing health, finances, decision making

Physical Screening Tools Diagnosis Level of Care Who makes what decisions

Assessment Tools

MMSE MOCA GDS Alcohol Screening CAM Others

Documentation for Each Domain: Does the patient have CUAR?

How do they demonstrate CUAR?

How does their disease disrupt CUAR?

Can your remedy disruption of CUAR?

Non-Directed Questioning

Who ? What ? When ? Where ? Why ? How ?

The six question words should give you all the detail you need for each situation.

Be curious / nosey

Kleinman Type Questions

How does that work for you?

Collaborate All Testimony with Evidence Your Observation Your Testing Family Neighbors Agencies Staff Bank Accounts Bills

Medication Counts Injection Demonstration Blood Sugars Blood Pressure Calendar Records Environment

Reality Check

The Agency Wouldn’t Have Called You if Everything Was OK

Financial Incapacity: a Dementia Timeline Loss of Financial Capacity

Patients overestimate abilities Anosgnosia

Family inaccurately estimates abilities Conflict, Secondary Gain, Caregiver Strain, Depression

Lotteries, Scams, Undue Influence Unpaid bills, Informal Representative Payees Neglect / Abuse Poverty

Medical Incapacity: a Dementia Timeline Loss of Medical Capacity + Isolation

Medication, Appointment and Preventive Non-compliance

Failure to seek acute care Failure to seek care for ADL and IADL loss Less Health Care costs prior to detection Equal Health Care costs after detection Co-morbid psychiatric/mental health/

behavioral/drug abuse Emergent Guardianship / Medical Placement

Agent Incapacity: a Dementia Timeline Loss of Agency

Absent / Ignored / Forgotten Documents Failure to self-direct Informal Agents Undue Influence and Secondary Gain Neglect / Abuse Poverty

Testamentary Capacity

Identify Assets Identify Heirs

Knows what a will is Understands financial

import of will Absence of Coercion Absence of Delusion Presence of Mind

In breadth and depth Affection

Living Will Capacity

Need both Financial and Medical Capacity to do this.

Confusion between Living Financial Gifts and End-of-Life Instructions need to be differentiated in the interview.

Driving Capacity

A moving target

On road testing by an Occupational Therapist with driver’s certification is the gold standard.

Court Appearance Capacity

Behavioral Problems Adaptation Issues Continence Issues Ambulatory Ability Reasonable Accomodations May be waived by client / counsel

Safety

Fire Emergency 911 Evacuation Enviromental Detecting and Avoiding Unscrupulous

Persons

Sexuality

Consent

Marriage as a Financial Contract

Marriage as a Legal Contract

Testamentary Will problems

Voting Capacity

Little or no literature

Most patients with limited capacity fail to vote

Unscrupulous persons capture incapacitated persons voting rights

Things the Court Will Want to Know Diagnosis, and Determination of Diagnosis Formal Testing Prognosis, Reversibility Treatments and Their Effects Ability to Make Court Appearance Ability to Handle Small Sums of Money Least Restrictive Level of Care Least Restrictive Guardianship of Person and Estate

and Duration End of Life Recommendations

An Onion of Capacities

ADL

Other IADL

Financial, Medical, Vulnerability

CUAR

Executive Function

Things the Court Will Want of You Name Employer Retained by LCOA Credentials Previous Testimony Record Swearing in Date, Time, Place and witnesses of the

evaluation

Common Diagnoses

Dementia Parkinson’s Depression Ambulatory Dysfunction Family Dysfunction Hypovitaminosis Drug Toxicity “Non-compliance”

Things I do

Driver Cessation PA Non-Driver Photo ID MA-51 SS letters Call people

References

Zapf PA, Skeem JL, Golding SL. Factor structure and validity of the MacArthur Competence Assessment Tool-Criminal Adjudication. Psychol Assess. 2005 Dec;17(4):433-45. PubMed PMID: 16393010.

J Am Geriatr Soc. 2009 Jun;57(6):978-84. Epub 2009 Apr 17.Awareness of functional difficulties in mild cognitive impairment: a multidomain assessment approach . Okonkwo OC, Griffith HR, Vance DE, Marson DC, Ball KK, Wadley VG. Dementia Clinical Research program, Brown Medical School and Rhode Island Hospital, 110 Lockwood Street, Suite 430, Providence, RI 02903, USA. Ozioma_Okonkwo@brown.edu

J Am Geriatr Soc. 2008 Apr;56(4):667-76. Epub 2008 Feb 15.Healthcare costs and utilization of vulnerable elderly people reported to Adult Protective Services for self-neglect. Franzini L, Dyer CB. School of Public Health, University of Texas, Houston, Texas 77030, USA. Luisa.Franzini@uth.tmc.edu

Alabi, TO; Haines CA; Predicting Survival From In-Hospital CPR. Clinical Geriatrics 2009 Dec Marson, DC et al. Assessing Financial Capacity in Patients with Alzheimer Disease. Archives of Neurology 200,

57:877-884. American Medical Association. Baker, RR, et al. A practice Guideline for Assessment of Competency and Capacity of the Older Adult.

Professional Psychology: Research and Practice. 1998 Vol 29, No. 2, 149-154. Vazzana R, et al. Trail Making Test Predicts Physical Impairment and Mortality in Older Persons. Journal of the

American Geriatrics Society. Vol 58:719-723, 2010. The American Geriatrics Society Ngyuen, HT, Grzywacz, JG, et al. Linking Glycemic Control and Executive Function in Rural Older Adults with

Diabetes Melliltus. Journal of the American Geriatrics Society. 58:1123-1127, 2010 The American Geriatrics Society

Saito, H, Niswaki, Y, et al. Hearing Handicap Predicts the Development of Depressive Symptoms After 3 Years in Older Community-Dwelling Japanese. Journal of the American Geriatrics Society. Vol 58:93-97, 2010The American Geriatrics Society

Panza, F; Capruso, C, et al. Effect of Donepezil on the Continuum of Depressive Symptoms, Mild Cognitive Impairment, and Progressive Dementia. Journal of the American Geriatrics Society. Vol 58: No 2, 389. The American Geriatrics Society

References

Okura, T; Plassman, BL, et al. Prevalence of Neuropsychiatric Symptoms and Their Association with Functional Limitations in Older Adults in the United States: The Aging, Demographics, and Memory Study. Journal of the American Geriatrics Society Vol 58:330-337, 2010. The American Geriatrics Society

Boyle, PA; Buchman, AS, et al. Physical Frailty is Associated with Incident Mild Cognitive Impairment in Community-Based Older Persons. Journal of the American Geriatrics Society. Vol 58:248-255, 2010. The American Geriatrics Society

Griffith, HR; Stewart, CC, et al. Magnetic Resonance Imaging Volume of the Angular Gyri Predicts Financial Skill Deficits in People with Amnestic Mild Cognitive Impairment. Journal of the American Geriatrics Society. Vol 58:256-274, 2010. The American Geriatrics Society

Shao, J; Barclay, S, et al. The Oldest Old in the Last Year of Life: Population- Based Findings from Cambridge City over-75s Cohort Study Participants Aged 85 and Older at Death. Journal of the American Geriatrics Society Vol 58:1-11, 2010. The American Geriatrics Society

Stephan, B; Matthews, F; et al. Early Cognitive Change in the General Population: How Do Different Definitions Work? Journal of the American Geriatrics Society. Vol 55:1534-1540, 2007. The American Geriatrics Society

Federman, Alex; Sano, M; et al. Health Literacy and Cognitive Performance in Older Adults. Journal of the American Geriatrics Society Vol 57:1475-1480, 2009. The American Geriatrics Society

Wakefield, D; Moscufo, N; et al. White Matter Hyperintensities Predict Functional Decline in Voiding, Mobility, and Cognition in Older Adults. Journal of the American Geriatrics Society. Vol 58:275-281, 2010. The American Geriatrics Society

Pavlou, M, Lachs, M. Could Self-Neglect in Older Adults Be a Geriatric Syndrome? Journal of the American Geriatrics Society. Vol 54:831-842, 2006. The American Geriatrics Society

References

Testamentary Capacity. Clinical Geriatrics. June 2009 pg 18-24 Appelbaum, PS. Assessment of Patients’ Competency to Consent to Treatment. New England

Journal of Medicine Vol 357:1834-1840.