Assessing Capacity: A Primer for the Busy Healthcare Professional

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

2. Conflicting Goals • Respecting Pt Autonomy • Acting in the Best Interest of the Pt

3. 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?

4. 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

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

6. 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.

7. Delirium – DSM IV • Disturbance of consciousness • 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

8. 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

9. 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

10. 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

11. 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

12. 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

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

14. History • Vague • Inconsistent • Poor remote recall not normal aging

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

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

17. Mental Status Exam • MMSE • MoCA

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

19. 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

20. 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

21. 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

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

23. Be Specific • Know what ability is needed for what task

24. Six Different Capacities • Medical Capacity • Sexual Capacity • Financial • Testamentary • Driving • Independent Living Capacity

25. 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

26. 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)

27. 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

28. 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

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

30. Medical Consent: Functional Elements • Expressing a Choice • Understanding • Appreciation • Reasoning

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

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

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

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

35. 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

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

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

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

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

40. 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

41. Pt is impaired and can not make medical decisions • Now what

42. 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

43. 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.

44. 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…

45. 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

46. 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

47. 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

48. 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)

49. 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”.

50. Steps to Take • Temporary guardianship • Limited or full guardianship • Assess implied consent