Capacity Assessment in Older People

INTERACTIVE CASE WORKSHOP

CAGP HALIFAX | OCTOBER 13, 2018KAREN REIMERS, MD FRCPCADJUNCT ASSISTANT PROFESSOR, UNIVERSITY OF MINNESOTA

Faculty/Presenter Disclosure

Capacity Assessment in Older People: Interactive Case Workshop

Faculty: Karen Reimers, MD FRCPC

Relationships with financial sponsors: None

Disclosure of Financial SupportThis program has received no financial support

This program has received no in-kind support

Mitigating Potential Bias

Not needed

Outline

1. Assessment of capacity in older adults2. Case examples3. Top 10 Tips

Why capacity?

Capacity is fundamental

● Capacity = ability to make one’s own decisions● Fundamental to ethical principle of respect for

autonomy● Key component of informed consent to medical

treatment● Inherent aspect of all clinician-patient interactions

Many capacity questions•Medical decisions

•Ability to live independently

•Managing finances

•Driving

•Work, fitness for duty

•Sexual consent

ABA/APA 2008

Assessing capacity

Capable until proven otherwiseCapacity assessments begin with the presumption that a person has adequate capacity to make decisions

How to assess capacity

● face-to-face interview● series of open-ended questions that relate to the

decision at hand

Clinical judgment

● In most cases, capacity judgment is made by the evaluating clinician

Shulman 2007

Evaluate at least one of the four decision-making abilities

● understanding● expressing a choice● appreciation● reasoning

Appelbaum 2007, Karlawish 2017

Understanding

Know the meaning of information

● What is the illness?● What is the treatment?● Risks and benefit of treatment for illness?

Expressing a choice

Clearly communicate a choice when presented with multiple treatment options

Frequent reversals of choice in the setting of neurologic or psychiatric conditions may indicate lack of capacity

Appreciation

Ability to recognize how facts are relevant to the patient personally

Stating how illness

● affects him/her now ● could affect him/her in the future

Impaired insight or delusional beliefs → may lack capacity on basis of failed appreciation of facts

Reasoning

Ability to compare options (comparative reasoning)

Ability to infer consequences of a choice (consequential reasoning)

Ask questions to

● elicit patient’s values● require the patient to compare the consequences of

what he wants to do with what he does not want to do

Risk for impaired capacity

● Older adults● Hospitalized patients● Neurodegenerative diseases (eg, Alzheimer disease

and Parkinson disease)● Traumatic brain injury● Delirium● Psychiatric illnesses

The 3 Ds

1.Dementia

2.Delirium

3.Depression

https://rnao.ca/bpg/courses/delirium-dementia-and-depression-older-adults

Case 1: Hospital consult

“Altered mental status, assess for competence”

Capacity vs. Competence

Capacity = Person’s ability to make a decision

Denotes decision-making abilities in the context of a specific choice, such as medical treatment

Clinicians assess capacity to decide whether patients can make their own decisions

Competence = Legal judgment, informed by an assessment of capacity

Relates to whether individuals have the legal right to make their own decisions

Capacity is a clinical assessment

How urgent is it?

Depends on

● expected duration of impairment● severity of the impairment● seriousness of the decision

Capacity is not static

● particularly relevant in hospitalized patients

● treatment of reversible factors such as delirium or medication side effects repeated assessments

● surrogate can be designated

The patient’s MMSE score is 23/30. Is he competent to make decisions about medical treatment?

Limitations of MMSE, MoCA

● Brief measures of overall cognition are not a substitute for an assessment of capacity

● Higher scores may or may not correlate with full capacity to make decisions

MMSE and MoCA● can be useful in predicting the likelihood of impaired capacity● shown to correlate with capacity to consent to complex research studies

MMSE can assist in stratifying the risk that an individual with AD lacks capacity

● <16/30: highly correlated with an inability to understand and appreciate, highly correlated with impaired capacity

● >24/30: correlate with retained decision-making abilities● In between: variable sensitivity and specificity → decision-specific

capacity assessment

In one study, a MoCA score ≤22 had a sensitivity of 90 percent for detecting individuals incapable of providing their own consent

Karlawish 2017

The patient has a long history of bipolar disorder. How does mental illness affect capacity?

Diagnosis is not a substitute for capacity assessment

● Diagnostic labels cannot substitute for an assessment of capacity

● Limited association with severity of mood and other neuropsychiatric symptoms

Depression and capacity

● less impact on decision making abilities than has been assumed

● Inpatients and outpatients with depression typically perform well on all four decision making abilities

Karlawish 2017

The patient has a history of alcohol misuse. How does substance abuse affect capacity?

Substance abuseIn 300 psychiatric consultations for decisional capacity,

● 41 percent of patients had substance use disorder.

● Of these, 37 percent were found to have impaired decisional capacity

In comparison, capacity was impaired in

● 17 percent of those with mood disorder● 54 percent of those with cognitive disorder

Karlawish 2017

Case 2: Discharge planning

Can Jim live independently?

Multi-disciplinary Team

•Medical providers

•Facility staff

•Mental health professionals

•Adult protective services

•Family

•Attorneys

Case 3: Clinic visit

Should Bill stop driving?

Lee 2017

Multimodal driver assessment

1. Medical2. Psychological3. Practical Driving Assessment

● Assess executive dysfunction● Clock Drawing Test● Caregiver concern about driving● Specialized on-road testing if driving safety is uncertain

ABA/APA 2008, Rapoport 2014

AGS 2016

Bill refuses driving capacity assessment. How to proceed?

Fostering trust and respect

Explain that

● one of the main goals of a capacity assessment is to better understand the patient’s own values and preferences

● a judgment will still need to be made based on the available information so that care can proceed

● an assessment is an essential source of information

Karlawish 2017

Bill’s family disagrees with your driving capacity assessment findings.

Family conflict

Lack of agreement as to whether a patient has capacity is

● relatively common● one of the causes of clinical

stereotypes such as the “demanding” or “difficult” family

Karlawish 2017

Bill lacks driving capacity. Is Bill’s doctor required by law to notify transportation authorities?

Case 4: Keeping up with the bills

Does Maria need someone to make financial decisions for her?

Lichtenberg 2016

Video: Financial capacity

How to assess for testamentary capacity?

Testamentary Capacity

A testator must know

1. what a will is

2. class of individuals that represents the testator’s potential heirs (“natural objects of one’s bounty”)

3. nature and extent of one’s assets

4. general plan of distribution of assets to heirs

Should a substitute decision maker get involved? If so, who?

Substitute decision maker

● impairment severe enough that patient judged to lack the capacity to make a decision

● Ideally chosen by patient in advance● In absence of a designated surrogate, laws

vary● Generally hierarchy of spouse, adult

children, parents, siblings, and other relatives

Does Maria need a guardian?

Formal guardianship● Rarely necessary unless patient has no health care surrogate

or next of kin● Guardian is assigned by a judge in a court of law; legal

determination that the patient is decisionally incompetent

Occasionally necessary if

● multiple first-degree relatives who cannot agree on an approach to medical care despite mediation by the health care team

● next of kin is clearly acting in self interest rather than the best interest of the patient

Case 5: An impaired colleague

How to evaluate a colleague with occupational impairment?

Video: Capacity to work

Fitness for duty

•Physicians may have difficulty assessing their own competency to practice

•Employers may require a fitness for duty evaluation

•May cover a range of medical and psychiatric disorders that also limit major life activities

Case 6: A new relationship

Capacity to consent to sex

1. Mechanics of the act2. Only adults over 16 should do it (difference between

adults and children)3. Both (or all) parties need to consent to it4. There are health risks involved, STIs5. Women may become pregnant6. Sex is part of having relationships with people and may

have emotional consequences

Mackenzie 2015

Sexual consent capacity in older adultsAwareness of the relationship

◦ Who is initiating

◦ Delusion

◦ Level of comfort

Ability to avoid exploitation

Consistent with formerly held beliefs

Able to say no

Awareness of potential risks

relationship may be time limited

Prepare for possible end of relationship

Lichtenberg 2007

Wilkins 2016

Top 10 Tips

1. Identify the specific capacity question

2. Presume competence unless proven otherwise

3. Diagnosis does not determine capacity

4. Communicate clearly with the evaluee

5. Review medical record and other information sources

6. Obtain independent information if needed

7. Avoid excessive reliance on screening tests

8. Consider multiple hypotheses in every case

9. Avoid making long range projections

10. Get help from colleagues if needed

Good luck!

Contact

Karen Reimers, MD FRCPC

3208 West Lake St., #14

Minneapolis, MN

Tel. 612 326 0679

reimers@psychmds.com

References

American Geriatrics Society (2016) Clinician’s guide to assessing and counseling older drivers, 3rd edition. New York.

American Bar Association and American Psychological Association Work Group. (2008) 'Assessment of older adults with diminished capacity: A handbook for psychologists', Washington, DC: ABA/APA.

Amjad, H., Roth, D. L., Samus, Q. M., Yasar, S. and Wolff, J. L. (2016) 'Potentially unsafe activities and living conditions of older adults with dementia', Journal of the American Geriatrics Society, 64(6), pp. 1223-1232.

Appelbaum, P. S. (2007) 'Clinical practice. Assessment of patients' competence to consent to treatment', N Engl J Med, 357(18), pp. 1834-40.

Appelbaum, P. S. (2010) 'Consent in impaired populations', Current neurology and neuroscience reports, 10(5), pp. 367-373.

Appelbaum, P. S. and Gutheil, T. G. (2007) Clinical handbook of psychiatry & the law. 4th edn. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

Bennett, J. M., Chekaluk, E. and Batchelor, J. (2016) 'Cognitive tests and determining fitness to drive in dementia: a systematic review', Journal of the American Geriatrics Society, 64(9), pp. 1904-1917.

Edersheim, J., Murray, E. D., Padmanabhan, J. L. and Price, B. H. (2017) 'Protecting the Health and Finances of the Elderly With Early Cognitive Impairment', The journal of the American Academy of Psychiatry and the Law, 45(1), pp. 81.

Giebel, C. M. and Montaldi, D. (2017) 'Deconstructing the performance of everyday activities: a case in dementia', International Psychogeriatrics, pp. 1-11.

Gopal, A. A. (2015) 'Physician-Assisted Suicide: Considering the Evidence, Existential Distress, and an Emerging Role for Psychiatry', The journal of the American Academy of Psychiatry and the Law, 43(2), pp. 183-190.

Karlawish, J. (2017) Assessment of decision-making capacity in adults. UpToDate, edited by Ted. W. Post, ed. Waltham, MA

Karlawish, J. (2009) The Short Portable Assessment of Capacity for Everyday DecisionMaking (ACED). Available at https://www.ono.ac.il/wp-content/uploads/The_Short_Portable_ACED.pdf

Lee, L. and Molnar, F. (2017) 'Driving and dementia Efficient approach to driving safety concerns in family practice', Canadian family physician, 63(1), pp. 27-31.

Lichtenberg, P. A., Qualls, S. H. and Smyer, M. A. (2015) 'Competency and decision-making capacity: Negotiating health and financial decision making', in Lichtenberg, P. A. et al (eds.) APA handbook of clinical geropsychology, Vol. 2: Assessment, treatment, and issues of later life. Washington, DC, US: American Psychological Association, pp. 553-578.

References

Lichtenberg, P. A. (2012) 'Misdiagnosis of Alzheimer's disease: Case studies in capacity assessment', Clinical Gerontologist, 35(1), pp. 42-56.

Lichtenberg, P. A. (2016) 'Financial exploitation, financial capacity, and Alzheimer’s disease', American Psychologist, 71(4), pp. 312.

Liddle, J., Bennett, S., Allen, S., Lie, D. C., Standen, B. and Pachana, N. A. (2013) 'The stages of driving cessation for people with dementia: needs and challenges', International Psychogeriatrics, 25(12), pp. 2033-2046.

Lyness, J. M. 'End-of-Life Care: Issues Relevant to the Geriatric Psychiatrist', The American Journal of Geriatric Psychiatry, 12(5), pp. 457-472.

Mackenzie, R. and Watts, J. (2015) 'Capacity to consent to sex reframed: IM, TZ (no 2), the need for an evidence-based model of sexual decision-making and socio-sexual competence', International journal of law and psychiatry, 40, pp. 50-59.

Marson, D. C. (2013) 'Clinical and ethical aspects of financial capacity in dementia: a commentary', The American Journal of Geriatric Psychiatry, 21(4), pp. 382-390.

Marson, D. C., Martin, R. C., Wadley, V., Griffith, H. R., Snyder, S., Goode, P. S., Kinney, F. C., Nicholas, A. P., Steele, T. and Anderson, B. (2009) 'Clinical interview assessment of financial capacity in older adults with mild cognitive impairment and Alzheimer's disease', Journal of the American Geriatrics Society, 57(5), pp. 806-814.

Mills, W. L., Regev, T., Kunik, M. E., Wilson, N. L., Moye, J., McCullough, L. B. and Naik, A. D. (2014) 'Making and Executing Decisions for Safe and Independent Living (MED-SAIL): Development and Validation of a Brief Screening Tool', The American Journal of Geriatric Psychiatry, 22(3), pp. 285-293.

Moye, J. and Marson, D. C. (2009) 'Assessment of decision-making capacity in older adults: An emerging area of practice and research', Focus, 7(1), pp. 88-97.

Moye, J., Marson, D. C. and Edelstein, B. (2013) 'Assessment of capacity in an aging society', American Psychologist, 68(3), pp. 158.

Mueller, T., Haberstroh, J., Knebel, M., Oswald, F., Kaspar, R., Kemper, C. J., Halder-Sinn, P., Schroeder, J. and Pantel, J. (2017) 'Assessing capacity to consent to treatment with cholinesterase inhibitors in dementia using a specific and standardized version of the MacArthur Competence Assessment Tool (MacCAT-T)', Int Psychogeriatr, 29(2), pp. 333-343.

References

Piersma, D., Fuermaier, A. B., de Waard, D., Davidse, R. J., de Groot, J., Doumen, M. J., Bredewoud, R. A., Claesen, R., Lemstra, A. W. and Vermeeren, A. (2016) 'Prediction of fitness to drive in patients with Alzheimer's dementia', PLoS one, 11(2), pp. e0149566.

Qualls, S. H. and Smyer, M. A. (2008) Changes in decision-making capacity in older adults: Assessment and intervention. John Wiley & Sons.

Rapoport, M. J., Naglie, G., Herrmann, N., Zucchero Sarracini, C., Mulsant, B. H., Frank, C., Kiss, A., Seitz, D., Vrkljan, B., Masellis, M., Tang-Wai, D., Pimlott, N. and Molnar, F. (2014) 'Developing physician consensus on the reporting of patients with mild cognitive impairment and mild dementia to transportation authorities in a region with mandatory reporting legislation', Am J Geriatr Psychiatry, 22(12), pp. 1530-43.

Sessums, L. L., Zembrzuska, H. and Jackson, J. L. (2011) 'Does this patient have medical decision-making capacity?', Jama, 306(4), pp. 420-427.

Shulman, K. I., Cohen, C. A., Kirsh, F. C., Hull, I. M. and Champine, P. R. (2007) 'Assessment of testamentary capacity and vulnerability to undue influence', American Journal of Psychiatry, 164(5), pp. 722-727.

Trachsel, M., Hermann, H. and Biller-Andorno, N. (2015) 'Cognitive fluctuations as a challenge for the assessment of decision-making capacity in patients with dementia', American Journal of Alzheimer's Disease & Other Dementias®, 30(4), pp. 360-363.

Wilkins, J. (2016) 'Ethical Considerations Regarding Capacity Assessments for Consent to Sexual Activity in Older Adults with Dementia Living in Residential Care Settings', The American Journal of Geriatric Psychiatry, 23(3), pp. S113.

Wood, S. and Liu, P.-J. (2012) 'Undue influence and financial capacity: A clinical perspective', Generations, 36(2), pp. 53-58.