Assessing Decision Making Capacity in Adult Protective Services
Clients Jason Schillerstrom, MD [email protected]
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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)
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
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