Jason Schillerstrom MD schillerstruthscsaedu Learning Objectives Describe the process of decisional capacity assessments Understand the reluctance of some primary care physicians to evaluate capacity ID: 673856
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Slide1
Assessing Decision Making Capacity in Adult Protective Services Clients
Jason
Schillerstrom
, MD
schillerstr@uthscsa.eduSlide2
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.Slide3
Scope of the problem and risk assessmentSlide4
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?Slide5
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)Slide6
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?Slide7
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 individual’s own physical health, or to manage the individual’s own financial affairs.Slide8
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 individual’s own physical health, or
to manage
the individual’s own financial affairs.Slide9
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 client’s physician?Slide10
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?
Slide11
PCP’s 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 relationshipSlide12
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?Slide13
Which Cognitive Functions are
most Essential to Decisional Capacity?
Memory
Orientation
Language
Math
Visuospatial
Executive FunctionSlide14
Executive Function
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.Slide15
Executive Screens
Verbal Fluency Task
FAS - >10 words in 1 minute
Verbal Trailmaking Task
Past “5E”Slide16
Stroop Color
Delis-Kaplin Executive Function System (D-KEFS). Pearson Education, Inc.; San Antonio, TX. (2001)Slide17
Stroop Number
Delis-Kaplin Executive Function System (D-KEFS). Pearson Education, Inc.; San Antonio, TX. (2001)Slide18
Stroop Interference
Delis-
Kaplin
Executive Function System (D-KEFS). Pearson Education, Inc.; San Antonio, TX. (2001)Slide19
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: >30Slide20
Clock Drawing TasksSlide21
CLOX: An Executive Clock Drawing Task
backSlide22
Instructions: CLOX1
Place the blank (back) side of the CLOX form in front of the subject.
State “Draw me a clock that says 1:45. Set the hands and numbers on the face so that a child could read them.”
Once the subject begins the task, no further assistance is allowed (i.e. no prompting or repeat instructions). State “
Sir/Ma’am, it’s up to you
” for each question.Slide23
Circular face present?
Age: 64 years
GDS: 5/15
MIS: 8
MMSE: 28
CLOX1: 5
CLOX2: 11Slide24
Only numerals 1-12 among the numerals present?
Age: 83 years
GDS: 2/15
MIS: 6
MMSE: 18
CLOX1: 7
CLOX2: 7
EXIT25: 36Slide25
Arrow pointing inward
Age: 85 years
GDS: 1/15
MIS: 2
MMSE: 15
CLOX1: 7
CLOX2: 12
EXIT25: 36Slide26
Intrusion from “face”
Intrusion from circle below
Age: 60 years
GDS: 1/15
MIS: 8
MMSE: 30
CLOX1: 6
CLOX2: 13
EXIT25: 26Slide27
Who has capacity?Slide28
7 years, 4 months
MMSE: 25/30
CLOX1: 6/15
CLOX2: 11/15
Verbal fluency (S): 2 words
EXIT25: 14/50Slide29
10 years, 5 months
MMSE: 27/30
CLOX1: 12/15
CLOX2: 13/15
Verbal fluency (S): 14 words
EXIT25: 8/50Slide30
Executive Function Determines Level of Care
% Variance in Level of Care Among N=148 CCRC Residents (Total Model R
2
= 0.57)Slide31
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; 15:159-162Slide32
Key Points
Guardianships are common and rare.
Executive function is the cognitive domain that best predicts self care abilities.
Executive function predicts a person’s ability to understand, appreciate, and use reasoning to make personal decisions.Slide33
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
appt’s
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.Slide34
Case Example - 1
Past Psychiatry History: previously diagnosed with “dementia”.
Past Medical History: unknown
Medications: unknownSlide35
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.Slide36
Case Example - 1Slide37
Case Example - 2Slide38
Risk Factors
What are this client’s modifiable risk factors for future neglect?
What are this client’s non-modifiable risk factors for future neglect?
What options does the APS Specialist have?Slide39
UTHSCSA Geri Psych Battery
Test
Cognitive Domain
Range
Cut-point
MIS
Memory
0-8
<
4
MMSE
General cognition
0-30
<
24
EXIT25
Executive function
0-50
>
15
CLOX1
Executive function
0-15
<
10
CLOX2
Visuospatial
function
0-15
<
12
GDS
Depression
0-15
>
5Slide40
APS Clients Compared to Geri-Psych Clinic Patients
Psychometric performance of APS clients vs. geriatric psychiatry outpatients
APS Clients
(n=76)
Geropsych Clinic
(N=61)
F/
c
2
p
MMSE
mean
% fail
22.1 (6.5)
51%
23.3 (6.4)
52%
0 (1,92)
0.01
ns
ns
CLOX1
mean
% fail
7.4 (4.0)
75%
9.3 (4.2)
47%
4.79 (1,92)
9.34
0.03
0.002
CLOX2
mean
% fail
10.6 (3.2)
64%
11.6 (3.8)
43%
3.17 (1,91)
4.64
ns
0.03
EXIT25
mean
% fail
24.3 (6.4)
89%
17.3 (7.6)
63%
15.7 (1,87)
10.11
<0.001
0.001
GDS
mean
% fail
3.6 (3.2)
29%
5.2 (3.9)
51%
6.07 (1,112)
5.8
0.02
0.02
Schillerstrom
JE, et al. Executive function in self-neglecting adult protective services referrals compared with elder psychiatric
outpatients.American
Journal of Geriatric Psychiatry 2009; 17:907-910.Slide41
Cognitive Correlates of Money Management
Screening
Measures
r
p
R
2
(n=41)
p
EXIT25
0.69
<0.001
0.34
<0.001
MIS
-0.25
0.15
MMSE
-0.41
0.01
CLOX1
-0.45
0.006
CLOX2
-0.40
0.02
GDS
-0.15
0.40
Schillerstrom
JE,
Birkenfeld
EM, Yu AS, Goldstein DJ, Royall DR. Neuropsychological correlates of performance based functional status in elder Adult Protective Services (APS) referrals for capacity assessments. Journal of Elder Abuse and Neglect (in press).
Slide42
Cognitive Correlates of Telephone Ability
Screening
Measures
r
p
R
2
(n=40)
p
EXIT25
0.61
<0.001
0.37
<0.001
MIS
-0.41
0.014
0.09
0.02
MMSE
-0.55
<0.001
CLOX1
-0.28
0.10
CLOX2
-0.27
0.11
GDS
0.07
0.68
Schillerstrom
JE,
Birkenfeld
EM, Yu AS, Goldstein DJ, Royall DR. Neuropsychological correlates of performance based functional status in elder Adult Protective Services (APS) referrals for capacity assessments. Journal of Elder Abuse and Neglect (in press). Slide43
Squalor Dwellers
Neuropsychological
Performance of APS
Referrals Living in Squalor
Neuropsych
Screen
Squalor-Dwelling
(
n
= 50)
Non-Squalor Dwelling
(
n
= 183)
t
df
p
MIS
5.6 (
±
2.5)
4.2 (
±
2.7)
2.27
145
0.025
GDS
4.0 (
±
3.9)
3.7 (
±
3.3)
-.03
184
0.98
CLOX1
8.6 (
±
2.4)
7.1 (
±
3.4)
1.72
189
0.088
CLOX2
11.2 (
±
2.4)
10.3 (
±
2.9)
1.17
185
0.245
MMSE
24.5 (
±
4.0)
22.1 (
±
5.7)
1.91
187
0.058
EXIT25
24.4 (
±
5.1)
25.3 (
±
6.3)
0.27
173
0.79Slide44
Recidivism
Screening Instrument
Recidivistic
(n = 141)
Non-Recidivistic
(n = 95)
t
p
EXIT25
26.6
22.9
4.17
<0.001
MIS
4.2
4.7
0.98
0.16
MMSE
21.9
23.5
2.02
0.02
CLOX1
6.8
8.1
2.79
0.002
CLOX2
10.3
10.8
1.27
0.10
GDS
3.4
4.1
1.54
0.06Slide45
Survival Estimates – CLOX2
0.00
0.25
0.50
0.75
1.00
0
500
1000
1500
2000
analysis time
Pass CLOX2
Fail CLOX2
Kaplan-Meier survival estimatesSlide46
Case Example - 1
Geriatric Depression Scale: 6/15
Memory Impairment Screen: 5/8
MMSE: 18/30
CLOX1: 6/15
CLOX2: 10/15
EXIT25: 28/50Slide47
Does this client have capacity?
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 individual’s own physical health, or
to manage
the individual’s own financial affairs.Slide48
Case Example - 1
What can we predict about her ability to maintain a safe shelter if only offered a “heavy cleaning”?
What can we predict about her ability to manage her healthcare needs?
What can we predict about her financial management?
What can we predict about her mortality?
What should the next step be?Slide49
Case Example #2
59yr black female
has been paralyzed for 15 years with very limited use of upper and lower extremities.
She
moved to San Antonio to
live in
house
with
provider
services.
However, she has cycled through multiple providers due to personality conflict issues.
She
often has bed sores that evolve into open wounds that she struggles to care for.
Two
years ago one of these wounds was discovered to be severely infected with maggots crawling in it. Slide50
Case Example #2
Her primary care physician
is frustrated with
the client’s ambivalence regarding her medical needs.
She
struggles to use her wound vacuum appropriately which results in delayed healing.
She is a frequent 911
caller. Calls
911 for inappropriate requests such as to come light a cigarette for her.
She frequently calls state agencies to complain about the care she receives.
She owes $13,000 in taxes.
She
depends on neighbors for general support.Slide51
Case Example #2 – Client’s Home
Her
home appears to be poorly maintained.
It
is cluttered, the fence is falling down, and significant repairs need to be made (the door for example is significantly warped).
Her
refrigerator is crammed with food.
Her
kitchen is messy and does not appear safe for food preparation in its current state.Slide52
Case Example #2 – Collateral Info
Assisted living social worker reports
that the patient has a difficult personality and requires extensive hands-on care.
Her
judgment is questionable in that she becomes angry when others offer to help.
However
, her moods have improved with time and the client seems generally happy.
The
client seems to understand her limitations and reluctantly accepts help.
The
client has not seemed confused or disoriented since being admitted.Slide53
Case Example #2 – Client Interview
The client states that she needs significant support services but her preference is to continue to live in her own home.
She
states she has been at the current facility for 1 month. She says it was a difficult transition but that they treat her well and she feels safe.
She
reports her income is $723/month and that her monthly bills exhaust her financial resources. She estimates her electricity is $200/month and that her water bill is $40/month. She also has cable and cell phone bills.
She
knows she owes property taxes and states she is trying to get on a payment plan to take care of them. She understands her medical condition of paralysis and denies other medical issues.
She
understands she needs assistance with personal hygiene, cooking, cleaning, laundry, and transportation.Slide54
Case Example #2 – Medical History
Past Medical History:
1. C5 spinal cord injury with secondary paralysis
2.
anemia
3.
hyponatremia
Medications:
1. Norco
2. Valium
3. Baclofen
4. folate
5.
Surfak
6. morphine sulfate
7. omeprazole
8.
VancomycinSlide55
Case Example #2: Neuropsychological Testing
Oriented
4/5 to
time
Oriented
5/5 to
place
3/3
registration
memory
3/3
recall
memory
C
oncentration
is intact to WORLD
backwards
Executive
function is intact: able to complete a verbal trails task; 8 item verbal fluency, no errors in anomalous sentence repetition; successfully completes a go/no-go taskSlide56
Does this client have a physical condition? mental condition?
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 individual’s own physical health, or
to manage
the individual’s own financial affairs.Slide57
What is this mental condition?
Distorted
world view and perception of self and
others.
I
solates
others through manipulation and
constantly
places herself at risk through self-destructive acts.
P
atterns
of unstable interpersonal
relationships
F
rantic
efforts to avoid
abandonment
Impulsivity
R
ecurrent
self-mutilating behaviors through neglect of wound
care
I
ntense
episodic
irritability
and inappropriate anger
S
tress
related paranoiaSlide58
Prognosis
What is the likelihood of her seeking treatment?
What is the likelihood her self neglect will continue?
What are the least restrictive interventions available?
What should the court do?Slide59
Questions and Discussion