Assessing Capacity: A Primer for the Busy Healthcare Professional

Michael R. Villanueva, PsyD, ABPP-CNProvidence Medford Medical Center

Grand Rounds June 29 2011

Conflicting Goals

Respecting Pt Autonomy

Acting in the Best Interest of the Pt

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?

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

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

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.

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

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

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

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

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

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

How do I assess cognition?

During history Discussion with caregivers and

family Chart review Mental status exam

History

Vague Inconsistent Poor remote recall not normal

aging

Caregivers and Family

Evidence of change Evidence of tasks being taken over Reports cw apathy Do not be fooled by reports of

depression

Chart review

Med list (are they on Aricept?) Memory concerns Medication non-compliance

Mental Status Exam

MMSE MoCA

MMSE

0 – 30 Covers registration, STM,

orientation, calculations, visuo-motor, language

Weak on executive function Highly reliant on intact language Enjoys broad use

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

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

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

My pt is cognitively impaired…

What does that mean regarding medical decision making

Discharge planning Medication management

Be Specific

Know what ability is needed for what task

Six Different Capacities

Medical Capacity Sexual Capacity Financial Testamentary Driving Independent Living Capacity

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

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)

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

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

Medical Capacity

Decisional Capacity in health care is rooted in the concept of Informed Consent

Such consent must be:CompetentVoluntaryInformed

Medical Consent: Functional Elements

Expressing a Choice Understanding Appreciation Reasoning

Expressing a Choice

Cannot communicate a treatment choice

Vacillate so much that cannot determine pt’s true wishes

Understanding

Often considered to be primary in consideration of medical capacity

The ability to comprehend diagnostic and treatment related information

Appreciation

Ability to relate treatment information to one’s personal situation

Ability to infer possible benefits of treatment and

Accept or believe diagnosis

Reasoning

Ability to state rational explanations

Process information logically

Process information in a consistent manner

Cognitive Underpinnings of Medical Capacity – Expressing a Choice

Need to assess expressive and receptive language

Use yes/no assessmentHave them follow basic commandsAsk them to describe a very recent

event

Understanding

Assess memory What happened earlier today? Where are we? What procedure is scheduled?

Assess comprehension Why are we doing the procedure?

Appreciation and Reasoning

Executive Function and Mental Flexibility Counting backward Verbal Fluency Discuss benefits and risks

Modifying Factors Regarding Medical Consent

Risk of harm Blood Draw vs. CABG

Values Treatment worse than disease Impose Care on family

Consent Capacity Instruments

Aid to Capacity Evaluation (ACE) Semi Structured Interview

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

Pt is impaired and can not make medical decisions

Now what

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

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.

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…

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

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

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

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)

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”.

Steps to Take

Temporary guardianship Limited or full guardianship Assess implied consent

Capacity to Live Independently

Limited functional abilities Danger due to

cognitive/psychiatric Cannot accept or use assistance

Functional Components

Activities of Daily Living - ADLs Eating, bathing, toileting

Instrumental Activities of Daily Living – IADLs Higher level: Financial and Household

management

Key ADLs and IADLs

Diet Hygiene Maintain household Transportation Handle emergencies Compensate for deficits

Three part framework to understand living independently

Understanding Able to discuss basic requirements of taking

meds, buying groceries, etc Application

Which tasks can pt perform and which ones can be done by others as directed by the pt

Judgment Pt may be able to discuss need for help, but

does he keep firing caregivers?

Cognitive Predictors of Poor Functional Status

Royall et al (2007) J Neuropsychiatry and Clinical Neuroscience

Literature Review: Cognitive correlates of ADLs and IADLs

Domain specific cognitive function weakly associated with functional outcome

General Cognitive Screening measures moderately associated with ADL/IADL success (MMSE)

Failure to Remain in the Home

Night Time Activity

Immobility

Incontinence

Importance of Modifying Factors Diagnosis/Prognosis

Is the state of lack of capacity temporary?

Risk of Harm Is the decision likely to have much impact?

Undue Influence Is the patient under the control of others?

Environmental/Social Support Can the potentially harmful decision be corrected by

supervision?

Guardianship

In Oregon law, courts can impose guardianship when a pt becomes incapacitated

Incapacitated: Unable to make or communicate

decisions necessary to provide for person’s basic physical health and safety

Guardianship requires 3 considerations

Disabling condition

Functional disability

Cognitive impairment

SummaryIdentify cognitively impaired ptsUse base rates to raise awareness and alertnessAssess Pts with suspicion of impairment with

mental status examRefer pts when doubt remains regarding

cognitive function, implications, and etiologyHelp determine whether or not the level and

type of cognitive difficulty affects competenceAssist in clinically improving capacity, defer to

proxy decision maker, or allow the wishes of a competent pt AMA