1 ADDRESSING CAPACITY ISSUES: COMBINING THE UNIQUE PERSPECTIVES OF OCCUPATIONAL THERAPISTS AND SOCIAL WORKERS Anne O Loughlin Social Worker Gemma Byrne Occupational Therapist St. Mary s Hospital Phoenix Park
2 CAPACITY At present, however, there is no generally applicable definition of capacity at common law or in statute (LRC, 2006 Vulnerable Adults and the Law par1.61) Indeed there is an inextricable link between the law on capacity and human rights since if a person is judged to lack legal decision- making capacity, this results in the removal of autonomy (LRC 2006 Vulnerable Adults and the Law:2:06)
3 A CONCEPTUAL MODEL OF ASSESSMENT (MOYE ET AL, 2007 GERONTOLOGIST47(5)) Medical condition Cognition EVERYDAY FUNCTIONING care of self; financial; medical; home and community life; civil or legal INDIVIDUAL VALUES, PREFERENCES, AND PATTERNS RISK OF HARM/LEVEL OF SUPERVISION NEEDED Means to Enhance Capacity
4 CAPACITY- NOT JUST THE FUNCTIONING OF THE MIND Of central importance is the need to take a broad view of capacity, from the situated perspective of the individual, paying attention to values as well as facts...our decisions are made against a backdrop of values...values creep in when we decide to do things (Hughes, J How We Think About Dementia)
5 FAILURE TO ACCURATELY ASSESS CAPACITY Overestimating decision- making capacity may cause persons to be left in harmful environments Underestimating capacity may inadvertently limit a person s rights when, in fact decisionmaking ability remains preserved (Naik, 2006 JEAN 18.4) Although a clinical capacity opinion is not a legal finding, it often serves as important evidence in legal proceedings.
6 MULTIDISCIPLINARY TEAMS To move beyond specific disciplinary approaches it is critical that each discipline educate each other about their own perspectives in order to reduce the risk of misunderstandings (Dong, 2005 JEAN 17.3).
7 Occupational Therapy and Cognitive Assessments
8 Overview Cognition-definition and overview Cognitive Screening Tools MMSE MoCA RUDAS ACE-III Functional Assessments
9 Cognition Defined as the mental processes associated with attending, processing, storing, retrieving and manipulating information. The brain is the director of what we do, we are functional beings and it allows us to do all that we wish and need to do. Older age, neurological event and other unforeseen circumstances can often impact on our brain functioning. Cognitive deficits are often the indicators of such problems occurring within the brain.
10 Cognition Sensation Information from sense organs to nervous system; sight, hearing, touch, taste, smell Cognition Ability to perceive, represent and organise objects, events and their relationship to one another in an appropriate way; mental processes that allow us to recognise, learn, remember and attend to changing information around us. Perception Processes involved in making sense of the senses; the way we interpret the information gathered and processed by the senses.
11 Executive Skills Praxis Memory Object Recognition Visual & Spatial Perception Attention Sensory Registration
12 Applying cognition to function When patients present to our service, these cognitive deficits are often self-described (by patient or carer) in terms of functional problems e.g. forgetting to take medications, poor ability to attend to the day (implications for important appointments), leaving appliances switched on when finished using them, poor attention to detail when managing finances, falling more frequently etc.
13 Accurate assessment of cognitive functioning and/ or impairment is increasingly important for clinicians Early diagnosis provides opportunity for medication management and compensatory strategy training Helps identify at-risk clients Provide education to family and/or carers Living wills for end of life care Power of attorney An effective cognitive assessment should reveal whether there is reason to suspect that parts of the brain are working less effectively than they should be.
14 Cognitive Screening Tools Mini-Mental State Exam (MMSE) Montreal Cognitive Assessment (MoCA) Rowland Universal Dementia Assessment Scale (RUDAS) Addenbrooks Cognitive Assessment (ACE-III)
15 MMSE Brief screening tool, quick, no training required 30 questions; screens orientation, attention/concentration, memory, language and perception Scoring Normal Mild Cognitive Impairment Moderate Cognitive Impairment 0-10 Severe Cognitive Impairment
16 MMSE Limitations Patients with high premorbid intelligence or education show a ceiling effect thus leading to false negatives Great age, limited education, foreign culture, and sensory impairment can produce false positives. Consequently, MMSE score needs adjustment for age and education It is now copyrighted so there is a cost to use It does not assess higher level executive functioning skills Insensitive to MCI Misclassifies aphasic patients
17 MOCA Initially designed as a brief screening tool for mild cognitive impairment Evaluates multiple domains of cognitive functioning Available free of charge and is a one page 30 point test that takes 10mins to administer Short-term memory, visuospatial, executive, attention, concentration and working memory, language and orientation A cut-off of 25 and below indicates cognitive impairment Excellent sensitivity in identifying MCI and AD
19 RUDAS Designed to detect dementia and monitor cognitive functioning over time 6 items- 12 domains- memory, visuospatial, praxis, visuoconstructional, judgement and language A score of less than 22 indicates the potential of cognitive impairment Strong correlation with the MMSE Better diagnostic accuracy than MMSE Excellent test-retest and inter-rater reliability It evaluates executive function which is absent from MMSE Not influenced by language, education or gender
20 ACE-III Multi-domain assessment taking 12-20mins to administer- free of charge 5 cognitive domains with comparable contribution to the total score of 100, higher scores indicate better cognitive functioning Domains include attention/orientation, fluency, language, memory, and visuospatial function. The inclusion of the clock drawing test assesses further cognitive areas i.e. Perceptual ability Much research published- however more research into the strengths and limitations
21 Functional Assessments Washing and Dressing assessments PADL Kitchen assessment DADL Home Visit We are most concerned with the daily problems that arise out of such cognitive impairments. Regardless of how well or how poorly a person scores, its how well they can function safely on a day-to-day basis- this is the most important factor.
22 Remember! A score doesn t make a person! People can score poorly on standardised tests however, remain able to function at a high level at home due to well established routines, habits and supports. Cognition can fluctuate depending on a number of factors.. Medications Medical illness Dehydration Delirium Sleep deprivation Depression
23 IN SUMMARY Cognition is one of the many factors that a team use to base clinical decisions The MDT are enabled to consider these results in the overall evaluation of a client and their status Cognitive assessments are key instruments in establishing strengths, weaknesses and guidance for treatment No one assessment will tick all the boxes
24 Experience will often direct our assessment choice Despite the worthwhile benefits of scoring systems and correlations between assessments, the key outcome we are striving for is optimum functioning for the individual in the most appropriate environment which enables such participation. Determining a persons capacity to make a decision needs to be a team assessment and decision.
25 WHEN CLIENT SAYS NO Yet, the moral responsibilities of the professionals rarely end at the point when the client says no. Honouring autonomy does not preclude further understanding of the values underlying an individual s decision making or help clarify a patient s anxiety of what is at stake. Understanding the patient s values, continued attempts to persuade the patient, and ongoing conversations with the patient are ethically valid choices (Dong and Gorbien, 2005 JEAN 17.3)
26 INTERPLAY BETWEEN CAPACITY AND MISTREATMENT The importance of the psychosocial realm in the assessment and interpretation of capacity emerges as critical in situations of abuse Issues of power and gender influence assessment The ability to maintain relational connections may be more pivotal than autonomy and independence for women (O Connor et al, 2009 JEAN 21.2)
27 MOVING BEYOND CAPACITY: UNDUE INFLUENCE Undue influence is the substitution of one person s will for the true desires of another. Fraud, duress, threats or other types of pressure often accompany it. It occurs when one person uses his or her role and power to exploit the trust, dependency, and fear of another. Vulnerability: illness; cognitive impairment; emotional impairment; deeply isolated; major life transitions; bereaved ; close ties to the perpetrator (Quinn, M Undoing Undue Influence JEAN 12:2)
28 SELF-NEGLECT The fact that a patient is able to simply state risks and benefits of an intervention does not necessarily mean that he or she believes they apply to their own situation (Appreciation) Older adults who self neglect lack the capacity to make decisions (decisional capacity ) and the capacity to execute decisions regarding their health, safety and independent living (executive capacity)(naik et al, 2006 JEAN 18.4)
29 CAPACITY We should think very broadly when we are making decisions for other people and when we are making judgements about their abilities to make decisions. We are amongst other things emotional, evaluative and volitional creatures... and our decision making reflects our complex make- up. Judgements about the decision making of others must allow enough space for this breadth of consideration (Hughes, J How We Think About Dementia: 95)
30 CAPACITY : IN THE FUTURE?? Person s capacity to be construed functionally (understand, retain, use or weigh information, communicate) Importance of past and present will and preferences; beliefs and values; and other factors person would be likely to consider if he or she were able to do so Consider views of others: carers, those interested in welfare, healthcare professionals (Assisted Decision-Making (Capacity) Bill 2013 S.3)