Screening for Decision-Making Ability When Working with APS Clients

We create experiences that transform the heart, mind, and practice.

The Academy is a project of San Diego State School of Social Work.

Serving over 20,000 health and human services professionals annually, the Academy’s mission is to provide exceptional workforce development and learning experiences for the transformation of individuals, organizations and communities.

​

We create experiences that transform the heart, mind, and practice.

About APSWI & The Academy

• Adult Protective Services Workforce Innovations (APSWI)
• Training program of the Academy for Professional Excellence, a project of the San Diego State University School of Social Work.

​

• APSWI provides innovative workforce development to APS professionals and their partners.

​

• The Academy provides workforce development and learning experiences to health and human service professionals.

We create experiences that transform the heart, mind, and practice.

Academy Programs include:

Introductions and Housekeeping

Housekeeping:

• Breaks, lunch, cell phones, exists

​

Intros: Choose one and share using a few words:

• Concerned most about when it comes to screening for decision-making ability?
• Most frustrating part of screening for decision-making ability?
• What has been most helpful when screening for decision-making ability?

​

​

APS Core Competencies

• National Adult Protective Services Association (NAPSA) has a core curriculum with 23 core competencies
• This is Module 17

​

For more information visit: https://theacademy.sdsu.edu/programs/apswi/

Agree, Disagree, Unsure

• Do you Agree, Disagree, or are Unsure with the following statements?

Training Goal and �Learning Objectives

Goal is to assist in identifying factors that affect clients’ decisional capacity, and in knowing when/how to seek a professional evaluation

​

Learning Objectives:

• Define autonomy and decision-making incapacity
• Distinguish between decision-making capacity and decision-making ability
• Describe factors that may influence a client’s decision-making ability
• Identify key questions and approaches used to screen client decision-making ability, including working with special populations.
• Identify implications for case planning as a result of a finding of limited decision-making capacity

​

What is Autonomy?

• Autonomy is the highest principle in legal, psychological and medical issues.�
• “Autonomy” means the right to make one’s own decisions.

​

Source: Kemp 2005

​

What is Decision-Making �Capacity?

• Decision-making Capacity (decisional capacity) is the ability to adequately process info in order to make a decision based on that info
• Task-specific or domain-specific

​

• Types of decisions include:
• Medical Consent Capacity
• Sexual Consent Capacity
• Financial Capacity
• Testamentary Capacity
• Capacity to live independently

Capacity or Ability?

Differs between who is assessing the person

​

• Capacity when talking about a professional assessment and determination

​

​

​

• Ability if professional assessment has not been completed

Attributes of Decision-Making �Capacity

Decision-Making May Vary…

​

• As a result of physical or mental stress.
• According to the complexity of the decision.
• From day to day.
• From morning to evening.

​

​

Capacity Evaluation

• A physical examination,
• A neurological examination,
• Short- and long-term memory assessment,
• Assessment of executive function
• Set of abilities that control and regulate someone’s ability to anticipate outcomes and to adapt behavior to changing situations.
• Examination for any existing psychological disorders.
• Diagnosis of any existing addictive syndromes.

​

• All should be included, if unavailable, the most possible

What is Incapacity?

• As it relates to decisional capacity is:
• The inability to receive and evaluate information
• Or to make or communicate decisions to such an extent that an individual is unable to meet essential requirements for:
• physical health,
• safety,
• or self-care,
• Even with the appropriate technological assistance.

​

Incapacity

• Legal: a judgement about one’s legal rights and responsibilities
• Clinical: a judgement about one’s functional abilities, including decision-making

Implications of a Judgement of �Incapacity

• Should be the very last resort for APS professionals
• Clients may lose the right to:
• Make decisions about medical treatment and personal care,
• Marry,
• Enter into contracts,
• Testify in court,
• Participate in research,
• Choose where to live.

​

Assessing Incapacity

• Influenced by both the experience of the interviewer AND the tests that were used

​

​

What is Executive Function?

Executive Function is:

• A higher-level set of cognitive process that coordinate lower-level cognitive functions
• Arrives late and leaves early
• Often described as the “Conductor” or “Control Panel”
• Responsible for “filtering and prioritizing” info during the decision-making process
• E.g.: What do I need to focus on to make this decision?

What is Executive Function �Responsible For?

• Abstract reasoning
• Adapting to change
• Planning and executing
• Anticipating outcomes
• Inhibiting inappropriate responses and impulse control
• Initiating and managing time

​

Many happen subconsciously

​

​

​

Executive Function and �Problem Solving

• Perception
• Recognizing a problem
• Foreseeing outcomes if not addressed
• Formulating a plan
• Executing the plan
• Evaluating the results ***

​

Medical Conditions

May affect or appear to cause decisional-capacity

• Dehydration
• Congestive heart failure
• Chronic lung disease
• Urinary tract infection
• Diabetes
• Mini-stroke

​

Handout #2

Medical Issues

• Older adults represent just over 16% of the population, but consume 30-40% of Rx and 35% of over-the-counter drugs
• 65-69 y/o ~ take 14 Rx/yr, 80-84 y/o ~ take 18 Rx/yr
• 15-25% of Rx use in older adults in considered unnecessary or inappropriate
• Over/Under medication, non compliance and adverse drug reactions are responsible for 28% of hospitalizations of older adults

Aging and Decision-Making

• America’s population is aging at an expeditious rate
• Estimated that almost half of individuals 85 y/o+ have some level of cognitive impairment
• By 2030, approx. 1.2 million people with intellectual disabilities will be at least 60 y/o.

Activity: Differentiating �Neurocognitive Disorders, Delirium �and Depression

Handout #3

• What are the indicators client may have cognitive impairment?
• Does client appear to have an NCD, delirium or depression?
• What more information do you need and how would you get it?

​

​

Neurocognitive Disorders, �Delirium and Depression

• What has your experience been with people who had any of the three?

​

Neurocognitive Disorders �Defined

Handout #4

Irreversible NCDs

• Alzheimer’s Disease
• Vascular Neurocognitive Impairment
• Parkinson’s Disease
• Frontal-Temporal NCD
• NCD with Lewy Bodies
• Alcohol-related NCD

​

Causes of Reversible NCD

• Drugs, dehydration, depression
• Electrolyte imbalances
• Emotional disorders
• Metabolic disorders
• Endocrine disorders
• Nutritional Deficiencies
• Trauma
• Tumor
• Infections
• Acute illness, arteriosclerosis complications
• Seizures, strokes, sensory deprivation

Delirium

Characteristics:

• Acute confused state
• Disturbance in alertness, consciousness, perception and thinking
• Sudden onset

​

Can be caused by:

• Infection, dehydration, chemical imbalance, head trauma, anesthesia, etc.

Handout #5

Depression

• Often undiagnosed or under-diagnosed in older adults
• Symptoms can affect decision-making capacity:
• Sleep disturbance
• Loss of energy and/or loss of interest in usual activities
• Sense of hopelessness, worthlessness or suicidal ideation
• Capacity issues caused by depression fluctuate and may be reversible with appropriate treatment

Handout #6

Case Study Activity

• Each group is assigned a case study # correlated with your group # (e.g. group 2 works with case study #2)
• Each case study reflects the psychological, physical and environmental factors that affect the client(s)
• Purpose: find out as much info as possible about the factors affecting the client(s)’ decision-making ability.
• Group Leader has key information that group members try to identify by asking questions using Small Group Information as a guide

Handout #7

Case Study Activity Debrief

• What was the most surprising thing you missed when asking your Group Leader Questions?

​

• What was your group’s “go-to”, where did you feel most comfortable?

​

• Any other thoughts on the activity?

​

Juan Garcia, 28y/o

• Possible Self-Neglect (medical),
• Undocumented immigrant from El Salvador
• Recent TBI from car accident, complaining of headaches
• Does not want to go to hospital again.

Mark Hudson, 85y/o, Widower.

• Possible Self-neglect
• Reclusive, home filled with dishes, food left out, dirty clothes.
• Daughter wants the State to take guardianship.

Rob and Wilma Benson, 70’s,

• Possible financial exploitation by their adult child.
• Wilma has a head injury
• Rob has various health conditions.

***content warning

Sharon Delay, 22y/o

• Possible sexual abuse.
• Has a developmental disability.
• In a relationship and is sexually active.
• Sister appointed as conservator to manage finances and concerned about sexual activity.

Anna Kovacs, 82y/o, Widow

• Possible Self-Neglect (medical)
• Emigrated from Hungary, limited English.
• Has Diabetes and confused about Rx
• Has developed gangrene on foot, discharged from rehab with a wheelchair and no in-home care.

​

Capacity Considerations

Kemp’s four basic questions to consider:

1. Can they understand relevant information?
• Do you know that you have a serious cut on your leg?
2. What is the quality of their thinking process?
• How can you get treatment for your wound?
3. Are they able to demonstrate and communicate a choice?
• Do you want to get treatment for your wound?
4. Do they appreciate/understand the nature of their own situation?
• What will happen if you don’t get your wound treated?

​

​

Cognitive Domains

• Orientation
• Attention
• Memory
• Language
• Visual-Spatial Organization
• Executive Functioning

​

Orientation

• Being ‘oriented’ or knowing about person, place and time- who they are, where they are, day/month/year

​

• Mostly tied to short-term memory

​

• Many factors can impact a person’s state of orientation:
• Alertness, attentiveness, language capabilities

​

• Orientation is just one piece of the evaluation puzzle

​

Attention

Can occur in:

• Cases of focal brain lesions due to stroke or other injury
• Cases of NCDs or inflammation of the brain
• Behavioral or mood disorders
• Hallmark of delirium

Memory

• Used to store and recall info needed to make decisions
• Immediate memory
• Recent memory
• Remote or Long-Term memory

Language

• Verbal fluency
• Ability to produce spontaneous speech fluently w/o undue word-finding pauses or failure in word searching
• Comprehension
• Ability to derive meaning from what is written or said

​

• Strokes, NCDs and Traumatic Brain Injuries have profound impact on language.

​

Visual-Spatial Organization

• Ability to tell where objects, including own body parts, are in space.
• Very sensitive to brain dysfunction and deficits can indicate even mild delirium.
• Listen for getting lost in previously familiar environments, difficulty estimating distance or complete tasks like using to phone to call someone

Executive Functioning

• Allows brain to absorb information, interpret information and make decisions

​

• One’s ability to command and control complex goal directed actions.

​

• Deficits are associated with disruptive behaviors and self-care limitations among people living with Alzheimer’s disease.

APS Professional’s Toolbox

• APS interviews
• Formal Screening Tools
• Professional Evaluations
• Other Considerations

​

​

*Culturally Responsive in all methods

​

​

Decision-Making Assessment �Skills

What information would be important to know about their clients in order to do an accurate assessment?

​

Your experience with:

• Language or Communication differences
• Cultural/ethnic diversity
• Setting the stage
• Cognitive impairments

Setting the Scene

Before the interview:

• Location?
• People present?
• Best time?

​

When you meet:

• Client’s comfort
• Environmental factors

​

​

Handout #10

Framing the Questions

Assessing their ability to:

• Understand and follow instructions
• Understand risks and benefits
• Make and execute a plan
• And evaluate the results of the plan

​

​

​

Purpose is to learn as much as you can about:

• Their understanding of relevant information.
• The quality of their thinking process.
• Their ability to demonstrate and communicate a choice.
• Their understanding of their personal situation.

​

​

Specific Decision-Making Areas

Medical Consent

• What options/treatments are you thinking about to manage this condition?
• How does this diagnosis impact your ability to live independently or your quality of life?

Sexual Consent

• If you engage in sexual activity, what are some possible outcomes of doing so?
• What aspects of being in a relationship are important to you?

Financial Consent

• Can you give me an overview of how your finances are being managed?
• How would you like your finances to be managed?

Live Independently

• What social supports do you have to help you live independently?
• Is there a certain point that you would no longer want to live independently in the community?

​

​

Case Study Activity

In same groups as before, develop and practice asking decision-making ability-related questions.

• Use Handout #11
• Some will be the APS professional group
• Some will be the Client group

​

1. Prep in your groups
2. Conduct interview
3. Debrief

Standardized Tools

• Provide another dimension to help you decide when it’s important to get further assistance
• Scores may fluctuate depending on many variables
• Cannot be used alone
• Weave questions into the interview
• APS professionals are a useful and resourcerful tool!

Benefits and Limitations of �Commonly Used Tools

• Handout #1
• Review benefits and limitations of each tool.

​

• What have your experiences been like?

Professional Evaluations

Medical Evaluations:

• Decision-making capacity assessment should be a routine part of medical care.

​

• Collaboration between APS, Medical and standardized tools.

Clinical Evaluations:

• Who is qualified and designated to conduct evaluations?

​

• How can you identify these people in your area?

​

• Are there MOUs or protocols in place to refer/collaborate?

Handout #12

Other Considerations

• Some interventions can improve decisional capacity
• Correct management of medication
• Providing clearer or simplified information
• Changing the environment
• Supported Decision-Making

Case Study Activity- �Case Planning

• Rejoin same groups from earlier
• Handout #13
• Review your groups decision
• Decide on most appropriate, immediate next step
• Prepare a report out

Report Out

Provide a 5-minute description of:

• The client
• Your group’s assessment of the need for further evaluation or not
• Next step in case planning process

Wrap-Up

• Screening for decision-making ability is challenging
• What is a key takeaway from today’s training?
• Questions?

Resources and Evaluations

• APSWI: https://theacademy.sdsu.edu/programs/apswi/
• NAPSA: https://www.napsa-now.org/
• NCEA: https://ncea.acl.gov/

​

Evaluations

Thank You!

​

Follow us on Social Media:

​

@Acad4ProfExcell

@sdsu-academy-for-professional-excellence/

@TheAcademySDSU

@SDSUAcademy

We envision a world where the quality of life for individuals, organizations, and communities is transformed to a healthier place.

Change background color of this block in title slide to match primary program color (color intertwined with the red in the logo and color of acronym font)