Assess the decisions of older people

In a recent Zoom conference call, four California Adult Protective Services workers, using a tool called Interview for Decisional Abilit...


In a recent Zoom conference call, four California Adult Protective Services workers, using a tool called Interview for Decisional Abilities, or IDA, were trying to determine if anything fishy was going on with an 82-year-old woman whom they knew as Mrs K.

Adult Protective Services agencies in each state receive reports of possible cases of neglect, self-neglect, abuse or exploitation of older adults and other vulnerable adults. But agency workers are constantly faced with a thorny question: does the adult in question have the capacity to make a decision about their medical care, living arrangements or finances – even if it’s not the decision? that the family, doctor or financial advisor think should be taken?

IDA was developed by two geriatricians to help train adult protective service workers on how to handle this problem. The program helps them learn how to use a structured interview procedure to gather information about a client’s decision-making ability. The two dozen California staff who took the course had already completed 10 hours of one-on-one online instruction; now they were practicing their new interview techniques in small groups, doing role-playing games with facilitators.

Ms. K, a fictional character, was played by Bess White, special projects administrator at Weill Cornell Medicine. In the script, a bank manager had reported some suspicions: Ms. K had $60,000 in a savings account but her withdrawals had increased sharply from $600 per month to $600 per week. A younger man – her nephew, she said – had started accompanying her to the bank, where a teller thought the man had seemed controlling and intimidating. An investigator who visited Ms. K at home learned that her only credit card had expired and she was low on cash.

But Ms. K denied being financially exploited; her nephew lived with her, she said, and helped with household chores and went to doctor’s appointments. He used the bank withdrawals to buy their groceries.

In the exercise, one of the APS trainees found that Ms. K had grasped the basic concept of financial abuse. Ms K had heard of news scams, she said. And yes, she understood that a friend or relative could benefit from it in the same way.

So the interviewer continued, “What do you think could happen if someone took another person’s money without their permission?

Mrs White, as Mrs K, replied: ‘I suppose the person could take it and take it until there was nothing left.’ But when the interviewer probed further to see if Ms K understood that she herself might face this risk, she hesitated. She relied on her nephew, Ms K said; she didn’t want to upset him.

IDA was developed by Dr. Mark Lachs, co-chief of geriatrics and palliative medicine at Weill Cornell Medicine, and colleagues, and Dr. Jason Karlawish, geriatrician and co-director of the Penn Memory Center. “People have a right to make bad decisions,” Dr. Lachs said in an interview. But, he added, policymakers must be able to understand the risks they face and the potential consequences.

“How can you walk into a brokerage office at 90 and say, ‘I’ve had Treasuries for 50 years, but now I want to put my last $200,000 in Bitcoin’ – and no one raises an eyebrow? ” says Dr. Lachs. “We’re going to come back to that and say, ‘What were we thinking? “”

In addition to applying the IDA to cases of financial neglect or abuse, California APS workers used it to assess a range of issues, including self-neglect, health and safety issues, denial of physical care or medical treatment, and physical or psychological or sexual abuse. .

“It’s not meant to replace a psychiatrist, but it does tell you when to contact a psychiatrist,” Dr. Lachs said. Clients whose interviews with IDA reveal an inability to understand the risks or consequences should receive a full professional assessment, he added.

To date, approximately 500 APS workers — in New York, Massachusetts and two regions in California — have taken the course and received certification. Kansas APS workers will undergo training this summer.

But Drs. Lachs and Karlawish think IDA could have broader uses. Trust and estate lawyers and financial firms are already asking about this.

Discharge planners can use the IDA to assess whether a patient has the ability to insist on going home instead of going to rehab. A chain of assisted living facilities reached out to Dr. Lachs, wondering if IDA could help ensure new residents understood the complicated contracts they were signing.

The IDA interview tries to answer three basic questions about a particular problem or risk, Dr. Karlawish said: “Do you recognize that this is happening? Do you think this could happen to you? Can you come up with a plan to fix it, reasoning and weighing the pros and cons? »

Depending on the complexity of a problem, people with diagnosed cognitive impairments or even dementia may still possess sufficient understanding to manage it.

Someone who demonstrates this three-part understanding during the IDA interview likely has the ability to make a decision, including a decision not to fix the problem. Someone who lacks this understanding needs a more comprehensive assessment, perhaps including consultation with family members or social service agencies. In extreme cases, this could lead to possible guardianship or curatorship.

Problems managing finances often serve as an early warning sign of incapacity, said Dr. Daniel Marson, a neuropsychologist at the University of Alabama at Birmingham who has studied the subject for 25 years.

“Financial capacity is probably the first higher-order functional capacity affected by neurodegenerative disorders and by normal aging,” he said. Using money effectively requires complex thinking, ranging from “something basic like using an ATM to more complicated things like ‘How do I handle this call from a telemarketer?'”. , institutionalization – can be devastating.

Although the the incidence of dementia has decreased in the United States and Europe, the aging of these populations means that more individuals will develop it.

What’s more, in a six-year study, Dr. Marson and his colleagues found that older adults who had been diagnosed with mild cognitive impairment – often a precursor condition to dementia – also struggled more and more. “There were diminished financial skills over time,” he said.

Other institutions have tried to tackle the problem of diminished decision-making capacity. Last year, the American Bar Association updated its “Assessing Older Persons with Disabilities: A Handbook for Lawyers.” The Bar Association and the American Psychological Association have also published manuals for judges and psychologists.

The Financial Industry Regulatory Authority, or FINRA, has published online courses on financial abuse of older adults and other vulnerable investors. His rules allow a member firm to temporarily suspend transactions and disbursements where it believes it to be exploitative. It also allows member companies to ask investors for a “trusted contact person” to consult in the event of suspicion of exploitation.

The IDA program is focused on APS workers for now because “the typical agency is understaffed, underfunded and struggling,” Dr. Karlawish said. California APS agencies handle about 30,000 cases involving the elderly each month, according to state data, and “are asked to make capacity decisions that a chair of a psychiatry department might struggle with.” , said Dr. Lachs.

California staff at the Zoom training session, kindly asking Ms White – as Ms K – how she might respond to the bank manager’s suspicions, ultimately concluded she didn’t need a professional check-up . It seemed like she understood her options.

Giving his nephew access to his savings account might not have been the wisest decision. But the decision was his.

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