An 89-year-old man calls 911 after falling in his home and is admitted to the hospital for kidney failure, malnutrition and dehydration. The paramedics report that when they arrived, the man was confused and that they found spoiled food, urine and human feces throughout the house, as well as empty beer bottles and medications scattered about. A brain scan shows the patient has no acute problems and after he's given medication, his cognition improves, though he continues to have some memory and reasoning problems. He wants to go home.
The medical team asks for your input: Does he have adequate decision-making capacity to check himself out of the hospital?
Psychologists in hospitals across the country face similar scenarios every day, and as the population ages, practitioners will increasingly be asked to assess the decision-making capacity of older adults, says Jennifer Moye, PhD, director of geriatric mental health at VA Boston. Yet, many psychologists receive little formal training on the topic, she says.
Fortunately, they can now turn to a new tool developed by the American Bar Association Commission on Law and Aging and APA. In September, the ABA-APA Working Group on the Assessment of Capacity in Older Adults released the third in a series of handbooks on assessing older adults with diminished capacity. The working group was established in 2003 and is supported by the APA Office on Aging and the Office of General Counsel. Its latest book targets psychologists; in 2005 and 2006, the group released handbooks on the topic for lawyers and judges, respectively.
"The issue of civil capacity is one that falls at the intersection of mental health and law ... but we have these two separate bodies of knowledge," says Moye, one of six psychologists in the group. "A major goal of these handbooks has been to serve as vehicles of improved communication between clinical and legal professionals."
The handbook written for psychologists helps practitioners move from theoretical understandings of cognitive capacity to the nitty-gritty of everyday life, Moye says. In a variety of settings, psychologists often must determine whether a person is capable of providing medical consent, handling financial tasks or living independently, she notes.
"We're really trying to bridge that gap between the traditional cognitive assessment and the applied functional assessment," Moye says. The lawyers' handbook advises legal professionals on how to collect appropriate data and make relevant observations to make a preliminary determination about a client's capacity. It also provides guidance on how to work with psychologists to define a client's mental health and functional prognosis, notes Charles Sabatino, JD, director of the ABA Commission on Law and Aging and one of the group's two attorneys.
The judges' handbook provides guidance on six "pillars" of capacity assessment—medical condition, cognition, everyday functioning, values and preferences, risk and level of supervision, and means to enhance capacity. It further advises judges gathering this information at each step of the judicial process on how to determine if an older adult requires guardianship. It also includes several model forms, including a court investigator report, clinical evaluation form and order for guardianship of person and estate, as well as additional Web resources for judges to use in their own courtrooms, Sabatino says.
Now that all three handbooks have been completed, the working group has shifted its focus to education. Members have presented the materials at more than 50 professional conferences and continuing-education workshops across the country. So far, there's substantial evidence of the group's success, notes Dan Marson, JD, PhD, director of the University of Alabama at Birmingham's Alzheimer's Disease Center and the group's only member with both a legal and psychological background. The handbooks and the conceptual models presented within them have been cited in 14 journal articles or book chapters, and as of December, 14,521 handbooks had been distributed in print and 30,430 had been downloaded from the APA and ABA Web sites.
What's driving this interest is, in part, that 31 states now explicitly recognize psychologists as experts qualified to assess capacity under guardianship, and many states are pushing for more extensive clinical evaluation of older adults during guardianship proceedings, says Moye. In fact, using guidelines in the judges' handbook, Massachusetts and Vermont recently modified their states' capacity evaluation forms in all court districts.
These efforts have transformed the ways psychologists, lawyers and judges think about assessing older adults, she adds. "We're trying to make it so that people have the complete set of information they need in order to guide the right outcome for older adults."
Copies of the Assessment of Older Adults with Diminished Capacity Handbooks may be downloaded for free at www.apa.org/pi/aging. For more information about the project, or for single hard copies of the psychologist handbook, please contact Deborah DiGilio, director of APA's Office on Aging via e-mail.