Upload
hugh-merritt
View
215
Download
0
Tags:
Embed Size (px)
Citation preview
Capacity Evaluation
MacArthur Foundation
Commented on justice and housing benefits for MHMR clients with legal problems.
Focus: What can the client do ?
Office of Aging Protective Services Legal authority and mandate
Investigate and protect vulnerable elders
PA Law
Pennsylvania Probate Estates and Fiduciaries Code
Mental Health Procedures Act 169 Department of Motor Vehicles
Legal Areas of Interest
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 Requirements
Choice
Understanding
Appreciation
Reasoning
“ Do they ‘get’ it?’
“ I just don’t ‘get’ it.
“ They used to …
“ But they were a …
Executive Function is in the Middle
Choice
Appreciation
Reasoning
Understanding
Legal Instruments
Representative Payee Agent Power of Attorney Durable Power of Attorney Limited Guardian (specify) Plenary Guardian Temporary Guardian Third Party Agents Family Agents
Competing Interest, Mandate, Discipline
Legal
Patient / Family
Medical
Financial
Cooperative Interest, Mandate Discipline
Patient
Family Financial
Medical
Legal
Patient Well-Being
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.
It’s like a GAT
History Emphasizing health, finances, decision making
Physical Screening Tools Diagnosis Level of Care Who makes what decisions
Assessment Tools
MMSE MOCA GDS Alcohol Screening CAM Others
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?
Non-Directed Questioning
Who ? What ? When ? Where ? Why ? How ?
The six question words should give you all the detail you need for each situation.
Be curious / nosey
Kleinman Type Questions
How does that work for you?
Collaborate All Testimony with Evidence Your Observation Your Testing Family Neighbors Agencies Staff Bank Accounts Bills
Medication Counts Injection Demonstration Blood Sugars Blood Pressure Calendar Records Environment
Reality Check
The Agency Wouldn’t Have Called You if Everything Was OK
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
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
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
Testamentary Capacity
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
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.
Driving Capacity
A moving target
On road testing by an Occupational Therapist with driver’s certification is the gold standard.
Court Appearance Capacity
Behavioral Problems Adaptation Issues Continence Issues Ambulatory Ability Reasonable Accomodations May be waived by client / counsel
Safety
Fire Emergency 911 Evacuation Enviromental Detecting and Avoiding Unscrupulous
Persons
Sexuality
Consent
Marriage as a Financial Contract
Marriage as a Legal Contract
Testamentary Will problems
Voting Capacity
Little or no literature
Most patients with limited capacity fail to vote
Unscrupulous persons capture incapacitated persons voting rights
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
An Onion of Capacities
ADL
Other IADL
Financial, Medical, Vulnerability
CUAR
Executive Function
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
Common Diagnoses
Dementia Parkinson’s Depression Ambulatory Dysfunction Family Dysfunction Hypovitaminosis Drug Toxicity “Non-compliance”
Things I do
Driver Cessation PA Non-Driver Photo ID MA-51 SS letters Call people
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. [email protected]
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. [email protected]
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
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
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.