Diminished Mental Capacity Charlotta Eaton, MD Volunteer, Leadership Board Alzheimer’s Association Montana Chapter

What is Capacity UNDERSTANDING of the relevant information CONSISTENCY of opinions / responses within and between interviews APPRECIATION of the significance of the information as it applies to the person’s own situation Ability to REASON with relevant information and to engage in a logical process of weighing options Ability to EXPRESS a choice

Understanding – The ability to comprehend basic information about a problem, potential solutions, and risks and benefits associated with the current situation. – The ability is often impaired in mild to moderate dementia. It may be influenced by level of education and intelligence and how information is presented.

Consistency Knowing a person over the years helps understand values, choices. Watch for warning signs: memory lapses, forgetting appointments or dates, change in appearance or hygiene, mood swings, change in personality.

Appreciation – The ability of a person to recognize how a problem or solution pertains to her or his specific situation. – Impairments manifest as a loss of insight or behaviors of denial. Depending upon the type and complexity of the decision, the range of impairment varies considerable among those with mild to moderate dementia.

Reasoning – The ability to consider potential solutions to problems: demonstrating how one solution is better than another; describing how a solution would affect her or his life; demonstrate a logical thought process in determining a choice. – This ability is frequently impaired in mild and especially in moderate stages of dementia and may decline rapidly with the progression of the dementia.

Expressing a Choice – The ability to make a clear choice for the current situation and communicate it. – Choosing is often preserved despite the presence of impairments in other decisional abilities, worsens with more advanced stages of dementia.

Medical Care Capacity – People have the fundamental right to self determine their medical care. – To proceed with a medical intervention that a person has refused may constitute assault and battery. – To honor a refusal of treatment by a person who lacks decision making capacity may subject him or her to needless harm. – Determined for each particular clinical situation.

Ability to understand the medical problem Do you understand what is making you ill, sick, uncomfortable right now? Do you understand why you are here?

Ability to understand treatment options Do you understand that this treatment is for the problem that is making you ill? Is there more than one way to treat the problem you have? Do you understand what could happen to you if you have this treatment? Do you understand that the treatment could have side effects?

Ability to understand the right to refuse or stop treatment Do you understand that you can say no if you don’t want this treatment? Do you understand that you can ask for this treatment to stop if you decide you no longer want it? Do you understand what could happen to you if you decide not to have this treatment?

Ability to make a rational decision Can you tell me why you have decided to have (or to refuse) this treatment? Do you think that we are trying to help you or to harm you?

Functional Situations Implications of Capacity People who must perform own ADLs to live independently. People whose decision making capacity determines how much assistance they receive in long term care facilities People with cognitive impairment who do not have dementia

Life implications Ethical Clinical Financial Legal Every day use, not just for medical cases For choosing food, clothing, living situation

Capacity versus Competence Capacity is a medical assessment. Competence and incompetence are legal designations determined by courts and judges. All adults are presumed competent unless determined incompetent by the courts. An adult may possess legal competence but lack the capacity to make specific treatment decisions.

Cognitive Ability Measured and tested – VAMC SLUMS, the TYM test, MMSE – Many others Used as for basis for deciding about Capacity May be used to follow dementia

Cognitive Ability Perception: Recognition and interpretation of sensory stimuli Attention: Ability to maintain concentration on a particular object, action, or thought Memory: Short term / working memory (limited storage) and Long term memory (unlimited storage)

Cognitive Ability Motor Skills: Ability to mobilize our muscles and bodies and to manipulate objects Language: Ability to translate sounds into words and generate verbal output Visual and Spatial Processing: Ability to process incoming visual stimuli, understand spatial relationship between objects, visualize images and scenarios

Cognitive Ability Executive Functions: goal oriented – Flexibility: switch to a different mental mode – Theory of Mind: insight into other’s worlds, plan, likes and dislikes – Anticipation: prediction using pattern recognition – Problem solving: define a problem and choose a solution – Decision making: make decisions based upon problem solving, emotions, and incomplete Information

Cognitive Ability Executive Functions: – Working Memory: capacity to hold and manipulate information – Emotional Self Regulation: ability to indentify and manage one’s own emotions – Sequencing: ability to break down complex actions into manageable units and prioritize them – Inhibition: ability to withstand distractions and internal urges

Capacity The mental ability to understand the nature and effects of one’s acts

How to apply to life Focus on what the person can do – If recent memory loss, refer to older memories for verification of values and consistency Do not be misled by cooperativeness or social skills Pay attention over time – Watch for progression of dementia Consider recent events and it’s affect – Recent illness, visual or hearing loss, trauma – Watch for depression Be aware of ageist stereotypes