Guardian or No Guardian: A Clinician’s Perspective on Capacity Kyle S. Page, PhD, ABPP Geriatric Psychologist Edward Hines, Jr. Veterans Affairs Hospital
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Guardian or No Guardian: A Clinician’s Perspective on Capacity
Kyle S. Page, PhD, ABPP Geriatric Psychologist
Edward Hines, Jr. Veterans Affairs Hospital
VETERANS HEALTH ADMINISTRATION
Disclaimer
• Views expressed in this presentation are my own and do not reflect official policy of the Department of Veterans Affairs
• No financial conflicts of interest or relationship with commercial products
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Outline
I. Brain Changes
II. A Clinician’s Evaluation
III. Increasing Support
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When the Brain Changes
What did your brain do to get you here today?
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Normal Brain Aging
• In practice, we can capture different “domains” or brain abilities with testing, such as:
– Language skills
– Reasoning abilities
– Attention / Concentration
– Memory
– Thinking speed
5
6
30
40
50
60
20 yrs old 40 yrs old 60 yrs old 80 yrs old
Vocabulary Reasoning Memory Speed
Based o
n S
althouse (
2010)
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Decision Making in Later Life
7
Experience/ Background
Cognitive Shortcuts
Different Priorities
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The Clinical
Evaluation
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Recent Decisions?
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Using the Term “Capacity”
“an individual’s physical or mental ability; a legal status presumed to apply to all adults”
(American Bar Association and American Psychological Association, 2008)
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Historical Shifts
Clinical Judgment
Research and Standardization
Legal Reforms
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Capacity Myths
1. Capacity is “all or nothing”
2. Lack of capacity is permanent
3. Lack of one type of capacity means lack of the others
4. Only a specialist can decide
5. If they agree with the recommendations, they probably have capacity
(Ganzini et al., 2005)
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ABA/APA Framework
Legal Standard Functional Elements
Diagnoses
Cognitive Underpinnings
Psychiatric or Emotional Factors
Values
Risk Considerations
Steps to Enhance
Clinical Judgment
(Am
erica
n B
ar A
sso
cia
tio
n a
nd
Am
erica
n P
sych
olo
gic
al A
sso
cia
tio
n
Asse
ssm
en
t o
f C
ap
acity in
Old
er A
du
lts P
roje
ct W
ork
ing G
rou
p, 2
00
8)
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The Basic Approach
14
Clinical Interview Collateral Information
Standardized Cognitive Measures
Performance-Based / Capacity Assessments
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Components of Consent Capacity
I want to
discharge right
now!
Understanding Appreciation Reasoning Expressing
a Choice (Grisso & Appelbaum, 1998)
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Supporting the Individual
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Cognitive Change due to Disease
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Subjective Decline
Mild Cognitive Impairment
Major Neurocognitive
Disorder
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Other Influences on Decision Making
• Increasing Pain
• Decreasing Sleep
• Worsening Mood
• Temporarily Distracted
• Being Overwhelmed
• Medication Side Effects
• Mood Disorders
• Anxiety / Trauma
• Psychotic Disorders
• Education
• Health Literacy
• Lack of Inclusion
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Some Ways of Supporting
• Take time to repeat information
• Summaries / bullets of information (verbal and written)
• Deliver information through multiple methods
• Give time for person to process
• Review information again later (or at their best time)
• Share most important points at the end
• Involve others in process 19
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