Capacity Evaluation

1. Capacity Evaluation

2. MacArthur Foundation • Commented on justice and housing benefits for MHMR clients with legal problems. • Focus: What can the client do ?

3. Office of Aging Protective Services • Legal authority and mandate • Investigate and protect vulnerable elders

4. PA Law • Pennsylvania Probate Estates and Fiduciaries Code • Mental Health Procedures • Act 169 • Department of Motor Vehicles

5. 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 Areas of Interest

6. Choice Understanding Appreciation Reasoning “ Do they ‘get’ it?’ “ I just don’t ‘get’ it. “ They used to … “ But they were a … Legal Requirements

7. Executive Function is in the Middle

8. Legal Instruments • Representative Payee • Agent • Power of Attorney • Durable Power of Attorney • Limited Guardian (specify) • Plenary Guardian • Temporary Guardian • Third Party Agents • Family Agents

9. Competing Interest, Mandate, Discipline

10. Cooperative Interest, Mandate Discipline

11. 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.

12. It’s like a GAT • History • Emphasizing health, finances, decision making • Physical • Screening Tools • Diagnosis • Level of Care • Who makes what decisions

13. Assessment Tools • MMSE • MOCA • GDS • Alcohol Screening • CAM • Others

14. 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?

15. Who ? What ? When ? Where ? Why ? How ? The six question words should give you all the detail you need for each situation. Be curious / nosey Non-Directed Questioning

16. Kleinman Type Questions • How does that work for you?

17. Your Observation Your Testing Family Neighbors Agencies Staff Bank Accounts Bills Medication Counts Injection Demonstration Blood Sugars Blood Pressure Calendar Records Environment Collaborate All Testimony with Evidence

18. Reality Check The Agency Wouldn’t Have Called You if Everything Was OK

19. 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

20. 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

21. 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

22. 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 Testamentary Capacity

23. 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.

24. Driving Capacity • A moving target • On road testing by an Occupational Therapist with driver’s certification is the gold standard.

25. Court Appearance Capacity • Behavioral Problems • Adaptation Issues • Continence Issues • Ambulatory Ability • Reasonable Accomodations • May be waived by client / counsel

26. Safety • Fire • Emergency • 911 • Evacuation • Enviromental • Detecting and Avoiding Unscrupulous Persons

27. Sexuality • Consent • Marriage as a Financial Contract • Marriage as a Legal Contract • Testamentary Will problems

28. Voting Capacity • Little or no literature • Most patients with limited capacity fail to vote • Unscrupulous persons capture incapacitated persons voting rights

29. 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

30. An Onion of Capacities

31. 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

32. Common Diagnoses • Dementia • Parkinson’s • Depression • Ambulatory Dysfunction • Family Dysfunction • Hypovitaminosis • Drug Toxicity • “Non-compliance”

33. Things I do • Driver Cessation • PA Non-Driver Photo ID • MA-51 • SS letters • Call people

34. 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

35. 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

36. 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.