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Capacity Assessment in Older People
INTERACTIVE CASE WORKSHOP
CAGP HALIFAX | OCTOBER 13, 2018KAREN REIMERS, MD FRCPCADJUNCT ASSISTANT PROFESSOR, UNIVERSITY OF MINNESOTA
Faculty/Presenter Disclosure
Capacity Assessment in Older People: Interactive Case Workshop
Faculty: Karen Reimers, MD FRCPC
Relationships with financial sponsors: None
Disclosure of Financial SupportThis program has received no financial support
This program has received no in-kind support
Mitigating Potential Bias
Not needed
Outline
1. Assessment of capacity in older adults2. Case examples3. Top 10 Tips
Why capacity?
Capacity is fundamental
● Capacity = ability to make one’s own decisions● Fundamental to ethical principle of respect for
autonomy● Key component of informed consent to medical
treatment● Inherent aspect of all clinician-patient interactions
Many capacity questions•Medical decisions
•Ability to live independently
•Managing finances
•Driving
•Work, fitness for duty
•Sexual consent
ABA/APA 2008
Assessing capacity
Capable until proven otherwiseCapacity assessments begin with the presumption that a person has adequate capacity to make decisions
How to assess capacity
● face-to-face interview● series of open-ended questions that relate to the
decision at hand
Clinical judgment
● In most cases, capacity judgment is made by the evaluating clinician
Shulman 2007
Evaluate at least one of the four decision-making abilities
● understanding● expressing a choice● appreciation● reasoning
Appelbaum 2007, Karlawish 2017
Understanding
Know the meaning of information
● What is the illness?● What is the treatment?● Risks and benefit of treatment for illness?
Expressing a choice
Clearly communicate a choice when presented with multiple treatment options
Frequent reversals of choice in the setting of neurologic or psychiatric conditions may indicate lack of capacity
Appreciation
Ability to recognize how facts are relevant to the patient personally
Stating how illness
● affects him/her now ● could affect him/her in the future
Impaired insight or delusional beliefs → may lack capacity on basis of failed appreciation of facts
Reasoning
Ability to compare options (comparative reasoning)
Ability to infer consequences of a choice (consequential reasoning)
Ask questions to
● elicit patient’s values● require the patient to compare the consequences of
what he wants to do with what he does not want to do
Risk for impaired capacity
● Older adults● Hospitalized patients● Neurodegenerative diseases (eg, Alzheimer disease
and Parkinson disease)● Traumatic brain injury● Delirium● Psychiatric illnesses
The 3 Ds
1.Dementia
2.Delirium
3.Depression
https://rnao.ca/bpg/courses/delirium-dementia-and-depression-older-adults
Case 1: Hospital consult
“Altered mental status, assess for competence”
Capacity vs. Competence
Capacity = Person’s ability to make a decision
Denotes decision-making abilities in the context of a specific choice, such as medical treatment
Clinicians assess capacity to decide whether patients can make their own decisions
Competence = Legal judgment, informed by an assessment of capacity
Relates to whether individuals have the legal right to make their own decisions
Capacity is a clinical assessment
How urgent is it?
Depends on
● expected duration of impairment● severity of the impairment● seriousness of the decision
Capacity is not static
● particularly relevant in hospitalized patients
● treatment of reversible factors such as delirium or medication side effects repeated assessments
● surrogate can be designated
The patient’s MMSE score is 23/30. Is he competent to make decisions about medical treatment?
Limitations of MMSE, MoCA
● Brief measures of overall cognition are not a substitute for an assessment of capacity
● Higher scores may or may not correlate with full capacity to make decisions
MMSE and MoCA● can be useful in predicting the likelihood of impaired capacity● shown to correlate with capacity to consent to complex research studies
MMSE can assist in stratifying the risk that an individual with AD lacks capacity
● <16/30: highly correlated with an inability to understand and appreciate, highly correlated with impaired capacity
● >24/30: correlate with retained decision-making abilities● In between: variable sensitivity and specificity → decision-specific
capacity assessment
In one study, a MoCA score ≤22 had a sensitivity of 90 percent for detecting individuals incapable of providing their own consent
Karlawish 2017
The patient has a long history of bipolar disorder. How does mental illness affect capacity?
Diagnosis is not a substitute for capacity assessment
● Diagnostic labels cannot substitute for an assessment of capacity
● Limited association with severity of mood and other neuropsychiatric symptoms
Depression and capacity
● less impact on decision making abilities than has been assumed
● Inpatients and outpatients with depression typically perform well on all four decision making abilities
Karlawish 2017
The patient has a history of alcohol misuse. How does substance abuse affect capacity?
Substance abuseIn 300 psychiatric consultations for decisional capacity,
● 41 percent of patients had substance use disorder.
● Of these, 37 percent were found to have impaired decisional capacity
In comparison, capacity was impaired in
● 17 percent of those with mood disorder● 54 percent of those with cognitive disorder
Karlawish 2017
Case 2: Discharge planning
Can Jim live independently?
Multi-disciplinary Team
•Medical providers
•Facility staff
•Mental health professionals
•Adult protective services
•Family
•Attorneys
Case 3: Clinic visit
Should Bill stop driving?
Lee 2017
Multimodal driver assessment
1. Medical2. Psychological3. Practical Driving Assessment
● Assess executive dysfunction● Clock Drawing Test● Caregiver concern about driving● Specialized on-road testing if driving safety is uncertain
ABA/APA 2008, Rapoport 2014
AGS 2016
Bill refuses driving capacity assessment. How to proceed?
Fostering trust and respect
Explain that
● one of the main goals of a capacity assessment is to better understand the patient’s own values and preferences
● a judgment will still need to be made based on the available information so that care can proceed
● an assessment is an essential source of information
Karlawish 2017
Bill’s family disagrees with your driving capacity assessment findings.
Family conflict
Lack of agreement as to whether a patient has capacity is
● relatively common● one of the causes of clinical
stereotypes such as the “demanding” or “difficult” family
Karlawish 2017
Bill lacks driving capacity. Is Bill’s doctor required by law to notify transportation authorities?
Case 4: Keeping up with the bills
Does Maria need someone to make financial decisions for her?
Lichtenberg 2016
Video: Financial capacity
How to assess for testamentary capacity?
Testamentary Capacity
A testator must know
1. what a will is
2. class of individuals that represents the testator’s potential heirs (“natural objects of one’s bounty”)
3. nature and extent of one’s assets
4. general plan of distribution of assets to heirs
Should a substitute decision maker get involved? If so, who?
Substitute decision maker
● impairment severe enough that patient judged to lack the capacity to make a decision
● Ideally chosen by patient in advance● In absence of a designated surrogate, laws
vary● Generally hierarchy of spouse, adult
children, parents, siblings, and other relatives
Does Maria need a guardian?
Formal guardianship● Rarely necessary unless patient has no health care surrogate
or next of kin● Guardian is assigned by a judge in a court of law; legal
determination that the patient is decisionally incompetent
Occasionally necessary if
● multiple first-degree relatives who cannot agree on an approach to medical care despite mediation by the health care team
● next of kin is clearly acting in self interest rather than the best interest of the patient
Case 5: An impaired colleague
How to evaluate a colleague with occupational impairment?
Video: Capacity to work
Fitness for duty
•Physicians may have difficulty assessing their own competency to practice
•Employers may require a fitness for duty evaluation
•May cover a range of medical and psychiatric disorders that also limit major life activities
Case 6: A new relationship
Capacity to consent to sex
1. Mechanics of the act2. Only adults over 16 should do it (difference between
adults and children)3. Both (or all) parties need to consent to it4. There are health risks involved, STIs5. Women may become pregnant6. Sex is part of having relationships with people and may
have emotional consequences
Mackenzie 2015
Sexual consent capacity in older adultsAwareness of the relationship
◦ Who is initiating
◦ Delusion
◦ Level of comfort
Ability to avoid exploitation
Consistent with formerly held beliefs
Able to say no
Awareness of potential risks
relationship may be time limited
Prepare for possible end of relationship
Lichtenberg 2007
Wilkins 2016
Top 10 Tips
1. Identify the specific capacity question
2. Presume competence unless proven otherwise
3. Diagnosis does not determine capacity
4. Communicate clearly with the evaluee
5. Review medical record and other information sources
6. Obtain independent information if needed
7. Avoid excessive reliance on screening tests
8. Consider multiple hypotheses in every case
9. Avoid making long range projections
10. Get help from colleagues if needed
Good luck!
Contact
Karen Reimers, MD FRCPC
3208 West Lake St., #14
Minneapolis, MN
Tel. 612 326 0679
References
American Geriatrics Society (2016) Clinician’s guide to assessing and counseling older drivers, 3rd edition. New York.
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Appelbaum, P. S. (2007) 'Clinical practice. Assessment of patients' competence to consent to treatment', N Engl J Med, 357(18), pp. 1834-40.
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Lichtenberg, P. A., Qualls, S. H. and Smyer, M. A. (2015) 'Competency and decision-making capacity: Negotiating health and financial decision making', in Lichtenberg, P. A. et al (eds.) APA handbook of clinical geropsychology, Vol. 2: Assessment, treatment, and issues of later life. Washington, DC, US: American Psychological Association, pp. 553-578.
References
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Lichtenberg, P. A. (2016) 'Financial exploitation, financial capacity, and Alzheimer’s disease', American Psychologist, 71(4), pp. 312.
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References
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