Transcript CAPACITY AND ADULT PROTECTIVE SERVICES

Assessing Decision Making Capacity
in Adult Protective Services Clients
Jason Schillerstrom, MD
[email protected]
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.
Scope of the problem and risk
assessment
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?
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)
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?
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.
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.
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?
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?
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 relationship
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?
Which Cognitive Functions are
most Essential to Decisional Capacity?
Memory
 Orientation
 Language
 Math
 Visuospatial
 Executive Function

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.
Executive Screens

Verbal Fluency Task
◦ FAS - >10 words in 1 minute

Verbal Trailmaking Task
◦ Past “5E”
Stroop Color
Delis-Kaplin Executive Function System (D-KEFS). Pearson Education, Inc.; San Antonio, TX. (2001)
Stroop Number
Delis-Kaplin Executive Function System (D-KEFS). Pearson Education, Inc.; San Antonio, TX. (2001)
Stroop Interference
Delis-Kaplin Executive Function System (D-KEFS). Pearson Education, Inc.; San Antonio, TX.
(2001)
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: >30
Clock Drawing Tasks
CLOX: An Executive Clock Drawing
Task
back
Instructions: CLOX1
1)
Place the blank (back) side of the CLOX form in front
of the subject.
2)
State “Draw me a clock that says 1:45. Set the hands
and numbers on the face so that a child could read
them.”
3)
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.
Circular face present?
Age: 64 years
GDS: 5/15
MIS: 8
MMSE: 28
CLOX1: 5
CLOX2: 11
Only numerals 1-12 among the numerals
present?
Age: 83 years
GDS: 2/15
MIS: 6
MMSE: 18
CLOX1: 7
CLOX2: 7
EXIT25: 36
Arrow pointing inward
Age: 85 years
GDS: 1/15
MIS: 2
MMSE: 15
CLOX1: 7
CLOX2: 12
EXIT25: 36
Intrusion from “face”
Intrusion from circle below
Age: 60 years
GDS: 1/15
MIS: 8
MMSE: 30
CLOX1: 6
CLOX2: 13
EXIT25: 26
Who has capacity?
7 years, 4 months
MMSE: 25/30
CLOX1: 6/15
CLOX2: 11/15
Verbal fluency (S): 2 words
EXIT25: 14/50
10 years, 5 months
MMSE: 27/30
CLOX1: 12/15
CLOX2: 13/15
Verbal fluency (S): 14
words
EXIT25: 8/50
Executive Function Determines
Level of Care
45
40
35
30
25
20
15
10
5
0
EXIT25 #MEDS MMSE CIRS
AGE NHBPS
ED
% Variance in Level of Care Among N=148 CCRC
Residents (Total Model R2 = 0.57)
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; 15:159-162
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.
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.
Case Example - 1

Past Psychiatry History: previously
diagnosed with “dementia”.

Past Medical History: unknown

Medications: unknown
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.
Case Example - 1
Case Example - 2
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?
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
>5
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/c2
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.
Cognitive Correlates of Money Management
Screening
r
p
Measures
R2
p
(n=41)
EXIT25
0.69
<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
0.34
<0.001
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).
Cognitive Correlates of
Telephone Ability
Screening
r
p
Measures
R2
p
(n=40)
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).
Squalor Dwellers
Neuropsychological Performance of APS Referrals Living in
Squalor
Squalor-
Non-Squalor
Dwelling
Dwelling
(n = 50)
(n = 183)
MIS
5.6 (±2.5)
GDS
Neuropsych
t
df
p
4.2 (±2.7)
2.27
145
0.025
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
0.79
Screen
Recidivism
Screening
Instrument
Recidivistic
(n = 141)
NonRecidivistic
(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
0.06
Survival Estimates – CLOX2
0.00
0.25
0.50
0.75
1.00
Kaplan-Meier survival estimates
0
500
1000
analysis time
Pass CLOX2
1500
Fail CLOX2
2000
Case Example - 1

Geriatric Depression Scale: 6/15

Memory Impairment Screen: 5/8

MMSE: 18/30

CLOX1: 6/15

CLOX2: 10/15

EXIT25: 28/50
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.
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?
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.
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.
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.
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.
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.
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. Vancomycin
Case Example #2:
Neuropsychological Testing

Oriented 4/5 to time

Oriented 5/5 to place

3/3 registration memory

3/3 recall memory

Concentration 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
task
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.
What is this mental condition?

Distorted world view and perception of self and others.

Isolates others through manipulation and constantly places herself at
risk through self-destructive acts.

Patterns of unstable interpersonal relationships

Frantic efforts to avoid abandonment

Impulsivity

Recurrent self-mutilating behaviors through neglect of wound care

Intense episodic irritability and inappropriate anger

Stress related paranoia
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?
Questions and Discussion