1. Advanced Directives: What to Assess with Seniors
Daniel Maher, CNP
Anneke Flannick, LCSW

2. Decisional Capacity 1. Ability to understand relevant information;
2. Ability to appreciate the situation and its likely consequences;
3. Ability to manipulate information rationally [i.e., to reason]; and
4. Ability to evidence a choice.
Ref: Applebaum & Grisso, 1998

3. Assessing Capacity First things first: Can they see? Can they hear?
Can they understand?

4. Assessing Capacity Start with presumptions of capacity
Assess ability to make decision, not outcome
Recognize & root out “ageism”
Capacity is task-specific & situation-specific
Diminished capacity may be reversible & temporary

5. Assessing Capacity
Don’t confuse communication challenges with diminished capacity
Culture Counts!
Consider underlying factors – grief, depression, stress, malnutrition, health literacy
Find ways to boost capacity
Dig deeper, seek collateral information

6. Assessing Cognition
MMSE
Clock Drawing
Animal naming

7. MMSE
It’s not a trick!
Can be administered serially so cognitive decline can be tracked.
Education dependent.
Remember that it is a SCREENING test, not a diagnosis!

8. The following authorized translations of the MMSE are currently available:
Afrikaans Albanian Arabic Argentinean Spanish Armenian Austrian German Belgian Dutch Belgian French Bengali Bosnian Brazilian Portuguese Bulgarian Chilean Spanish Chinese Chinese for Hong Kong Chinese for Malaysia Chinese for Singapore Chinese for Taiwan Croatian Czech Danish Dutch Estonian Farsi
Filipino Finnish French French Canadian German Greek Gujarati Hebrew Hindi Hungarian Indian English Israeli English Italian Japanese Kannada Korean Latvian Lithuanian Macedonian Malay Malayalam
Marathi Norwegian Polish Portuguese Punjabi Romanian Russian Serbian Slovakian Slovene Sotho South African English Spanish Swedish Tamil Telugu Thai Turkish UK English Ukrainian Urdu U.S. Spanish Vietnamese

9. Mini-Mental State Examination Score by Age and Educational Level
0-4y
5-8y
9-12y
>=12y
Total
18-24 23 28 29 30
25-29 27
30-34 25 26
35-39
40-44
45-49
50-54
55-59 22
60-64
65-69
70-74 21
75-79
80-84 19
>=85 20 24

10. Clock Drawing
Draw a clock Put in all the numbers Set the hands at ten past eleven.
1 point for the clock circle 1 point for all the numbers being in the correct order 1 point for the numbers being in the proper special order 1 point for the two hands of the clock 1 point for the correct time.
A normal score is four or five points.

11. Clock Drawing
Test results The test can provide huge amounts of information about general cognitive and adaptive functioning such as memory, how people are able to process information and vision.
A normal clock drawing almost always predicts that a person's cognitive abilities are within normal limits.

13. Animal Naming Instructions
“Tell me the names of as many animals as you can think of, as quickly as possible.”
If the person says nothing for 15 seconds, say “A dog is an animal. Can you tell me more animals?”
If the person stops before 60 seconds, say “Any more animals?”

14. Animal Naming Scoring
Count all animals, including birds, fish, reptiles, insects, humans, extinct animals, etc. Credit can be given for general category terms (e.g., dog) and for specific instances (e.g., terriers) when both are given. Credit only one item when people name the same animal at different developmental stages (e.g., sheep, lamb).
If the score is less than 14, further testing should be done.