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Assessing Decision Making Capacity in Adult Protective Services Clients Jason Schillerstrom, MD schillerstr@uthscsa.edu

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Learning Objectives Describe the process of decisional capacity assessments. Understand the reluctance of some primary care physicians to evaluate capacity. Describe the relationship between executive function and self-care abilities.

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Scope of the problem and risk assessment

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Scope of the problem How many elders >65yrs in Texas? How many 18-64yrs with disability in Texas? How many completed in-home investigations in FY 2013? How many validated in-home investigations? How many guardianships are there in Texas?

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Scope of the problem How many elders >65yrs in Texas? 2,954,972 How many 18-64yrs with disability in Texas? 1,710,430 (elders + disabled = 4,665,402) How many completed in-home investigations in FY 2013? 69,383(=1.5% of elders + disabled) How many validated in-home investigations? 48,392 How many guardianships are there in Texas? 52,000 ( = 1.1% of elders + disabled)

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Questions to Answer for APS Does the APS client have a psychiatric diagnosis? Does the client have decision making capacity? What level of care do they need? Do they need to be emergently removed from their home?

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Texas Legal Definition of Incapacity in Guardianship An incapacitated person is an adult who, because of a physical or mental condition, is substantially unable to provide food, clothing, or shelter for himself or herself, to care for the individuals own physical health, or to manage the individuals own financial affairs.

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Texas Legal Definition of Incapacity in Guardianship An incapacitated person is an adult who, because of a physical or mental condition, is substantially unable to provide food, clothing, or shelter for himself or herself, to care for the individuals own physical health, or to manage the individuals own financial affairs.

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Ethical, Legal, or Clinical Issues to Consider First Should the client be notified that I am coming? Should the client be informed about the purpose of my evaluation? How much information should I get from APS? Are they biasing my assessment? Should the capacity assessment be completed by a physician unknown to the client (me) or the clients physician?

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Decisional Capacity and the Primary Care Physician Is the PCP the best person to do the evaluation? Should the PCP have to do the capacity evaluation? What are reasons the PCP may not want to do the evaluation?

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PCPs and Capacity Determinations No compensation Risk of subpoena Little training in capacity assessments and not a routine assignment These assessments are very different from the medical model Potential fracturing of the doctor-patient relationship

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Scientific Dilemmas? How reliable is IADL self report? Proxy report? What is the best way to measure functional status in these cases? What cognition(s) are essential to functional and decisional capacity?

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Which Cognitive Functions are most Essential to Decisional Capacity? Memory Orientation Language Math Visuospatial Executive Function

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That set of cognitive processes that allow one to act independent of the environment instead of displaying behaviors mediated by the environment. When executive processes deteriorate, people become dependent on habits and routine.

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Executive Screens Verbal Fluency Task FAS - >10 words in 1 minute Verbal Trailmaking Task Past 5E

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Stroop Color Delis-Kaplin Executive Function System (D-KEFS). Pearson Education, Inc.; San Antonio, TX. (2001)

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Stroop Number Delis-Kaplin Executive Function System (D-KEFS). Pearson Education, Inc.; San Antonio, TX. (2001)

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Stroop Interference Delis-Kaplin Executive Function System (D-KEFS). Pearson Education, Inc.; San Antonio, TX. (2001)

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The Executive Interview 25 item multitask assessment 0 = correct response 1 = partial error 2 = complete error Scoring Range Approximations: Young adults: 0-7 Elderly retirees: 8-14 Assisted Living: 15-22 Nursing Home: 23-30 Locked Units: >30

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Clock Drawing Tasks

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CLOX: An Executive Clock Drawing Task back

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Instructions: CLOX1 1) Place the blank (back) side of the CLOX form in front of the subject. 2) State Draw me a clock that says 1:45. Set the hands and numbers on the face so that a child could read them. 3) Once the subject begins the task, no further assistance is allowed (i.e. no prompting or repeat instructions). State Sir/Maam, its up to you for each question.

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Circular face present? Age: 64 years GDS: 5/15 MIS: 8 MMSE: 28 CLOX1: 5 CLOX2: 11

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Only numerals 1-12 among the numerals present? Age: 83 years GDS: 2/15 MIS: 6 MMSE: 18 CLOX1: 7 CLOX2: 7 EXIT25: 36

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Arrow pointing inward Age: 85 years GDS: 1/15 MIS: 2 MMSE: 15 CLOX1: 7 CLOX2: 12 EXIT25: 36

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Intrusion from face Intrusion from circle below Age: 60 years GDS: 1/15 MIS: 8 MMSE: 30 CLOX1: 6 CLOX2: 13 EXIT25: 26

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Who has capacity?

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7 years, 4 months MMSE: 25/30 CLOX1: 6/15 CLOX2: 11/15 Verbal fluency (S): 2 words EXIT25: 14/50

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10 years, 5 months MMSE: 27/30 CLOX1: 12/15 CLOX2: 13/15 Verbal fluency (S): 14 words EXIT25: 8/50

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Executive Function Determines Level of Care % Variance in Level of Care Among N=148 CCRC Residents (Total Model R 2 = 0.57)

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Executive Function predicts decisional abilities. Schillerstrom JE, et al. Executive function and capacity to consent to a noninvasive research protocol. Am J Geriatri Psychiatry 2007; 15:159-162

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Key Points Guardianships are common and rare. Executive function is the cognitive domain that best predicts self care abilities. Executive function predicts a persons ability to understand, appreciate, and use reasoning to make personal decisions.

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Case Example - 1 88yr HF referred for neglect recidivistic case. Lives by self in San Antonio. House is in severe disrepair, squalorous, animal feces throughout, human waste in toilet and bathtub, severe insect infestation, dead dog recently discovered. PCP knows patient and believes she may have capacity (She misses appts but takes her meds. She has bad hygiene but she has capacity.). Family seems to either underestimate health/safety hazards or overestimate her abilities. They brought her a broom 4 days ago. Utilities are frequently disconnected. APS and family have had them paid and reconnected on multiple occasions.

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Case Example - 1 Past Psychiatry History: previously diagnosed with dementia. Past Medical History: unknown Medications: unknown

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Case Example - 1 Social History: Raised in San Antonio 4yr Sociology degree Divorced >10 years No biological children has step-children Denies tobacco and alcohol Retired receptionist; earns $550/month Receives meals-on-wheels.

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Case Example - 1

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Case Example - 2

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Risk Factors What are this clients modifiable risk factors for future neglect? What are this clients non-modifiable risk factors for future neglect? What options does the APS Specialist have?

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UTHSCSA Geri Psych Battery TestCognitive Domain RangeCut-point MISMemory0-8