FACTORS AFFECTING CAPACITY Psychosocial Factors Affecting Capacity –Psychosocial factors include one’s surroundings, way of life & things that affect relationships between the adult and their environment. • Life Changes • Major Life Events • Social Support • Spirituality • Social Status Physical Factors Affecting Capacity-Factors which have a physical component and affect mental/physical health • Genetics • Illness • Disease • Diet Environmental Factors Affecting Capacity-Those factors that impact survival, safety, development, etc. • Household Composition (who lives in the home) • Structural Damage Prognosis What could happen as a result of impaired decision making?
APS Process & Capacity Exercise
Using #s 1 – 6, take a few minutes to correctly order the steps in the APS process:
Provide Protective Services
Obtain Service Authorization
Mini Mental Status Examination The "Mini" Mental Status Exam is a quick way to evaluate cognitive function. It is often used to screen for dementia or monitor its progression. [See Page 120 in Bates A Guide to Physical Examination, 7th Ed ] Folstein Mini Mental Status Examination Task
"Tell me the date?" Ask for omitted items.
One point each for year, season, date, day of week, and month
"Where are you?" Ask for omitted items.
One point each for state, county, town, building, and floor or room
Register 3 Objects
Name three objects slowly and clearly. Ask the patient One point for each item to repeat them. correctly repeated
Ask the patient to count backwards from 100 by 7. One point for each correct Serial Sevens Stop after five answers. (Or ask them to spell "world" answer (or letter) backwards.)
Recall 3 Objects
Ask the patient to recall the objects mentioned above.
Point to your watch and ask the patient "what is this?" One point for each correct Repeat with a pencil. answer
Repeating a Phrase
Ask the patient to say "no ifs, ands, or buts."
Give the patient a plain piece of paper and say "Take One point for each correct this paper in your right hand, fold it in half, and put it action on the floor."
Show the patient a piece of paper with "CLOSE YOUR EYES" printed on it.
One point if the patient's eyes close
Ask the patient to write a sentence.
One point if sentence has a subject, a verb, and makes sense
One point if the figure has ten corners and two intersecting lines
Ask the patient to copy a pair of intersecting pentagons onto a piece of paper.
One point for each item correctly remembered
One point if successful on first 1 try
A score of 24 or above is considered normal. Adapted from Folstein et al, Mini Mental State, J PSYCH RES 12:196-198 (1975)
Questions about this assessment tool? E-mail [email protected]
Name Is patient alert? __/1 __/1 __/1
__/3 __/3 __/5
1 1. What day of the week is it? 1 2. What is the year? 1 3. What state are we in? 4. Please remember these five objects. I will ask you what they are later. Apple Pen Tie House Car 5. You have $100 and you go to the store and buy a dozen apples for $3 and a tricycle for $20. How much did you spend? 1 2 How much do you have left? 6. Please name as many animals as you can in one minute. 0 0-4 animals 1 5-9 animals 2 10-14 animals 3 15+ animals 7. What were the five objects I asked you to remember? 1 point for each one correct. 8. I am going to give you a series of numbers and I would like you to give them to me backwards. For example, if I say 42, you would say 24. 0 87 1 649 1 8537 9. This is a clock face. Please put in the hour markers and the time at ten minutes to eleven o’clock. 2 Hour markers okay 2 Time correct 1 10. Please place an X in the triangle. 1
Age Level of education
Which of the above figures is largest? 11. I am going to tell you a story. Please listen carefully because afterwards, I’m going to ask you some questions about it. Jill was a very successful stockbroker. She made a lot of money on the stock market. She then met Jack, a devastatingly handsome man. She married him and had three children. They lived in Chicago. She then stopped work and stayed at home to bring up her children. When they were teenagers, she went back to work. She and Jack lived happily ever after. 2 What was the female’s name? 2 What work did she do? 2 When did she go back to work? 2 What state did she live in? TOTAL SCORE
SCORING HIGH SCHOOL EDUCATION 27-30 21-26 1-20
Normal MNCD* Dementia
LESS THAN HIGH SCHOOL EDUCATION 25-30 20-24 1-19
* Mild Neurocognitive Disorder SH Tariq, N Tumosa, JT Chibnall, HM Perry III, and JE Morley. The Saint Louis University Mental Status (SLUMS) Examination for Detecting Mild Cognitive Impairment and Dementia is more sensitive than the Mini-Mental Status Examination (MMSE) - A pilot study. J am Geriatri Psych (in press).
Mini Cognitive Check Suggested questions to assist with assessing an individual’s cognitive abilities. Assessing Orientation What is your full name? How old are you? When is your birthday? What is the highest school grade you completed? What is your address, including the street, city, and state? What is today’s date, including the day, month, and year? What is the current season? Assessing Delayed Word Recall Have adult repeat each word, one at a time. Next, have the adult repeat each word, one at a time, then use the word in a complete sentence. (Example: Monkey. The monkey ate a banana.) Monkey Train Book Baby Dog Repeat the words consecutively. Next, ask the adult to repeat the words consecutively. Ask the adult to remember the 5 words. Inform him/her that you will move on to the next section and when finished, you would like for them to repeat the words again. Assessing Judgement There may be more than one correct answer to these questions. Think about what a reasonable answer is. (Example: Where do people go when they are sick? Doctor or Hospital What would you do if you opened your medication bottle and the pills looked different than they usually do?
What would you do if you locked yourself out of your home? What would you do if you were at home alone and could see, or smell smoke? What would you do if you were having severe chest pains and shortness of breath? What would you do if someone broke into your house while you were there? Assessing Computation Use simple mathematics when assessing computation skills. Some adults may not be as educated as some others. 2+3= 3+6= 4 + 10 = 2x5= 4x5= 10 x 10 = 12 - 6 = 16 - 8 = 20 - 10 = Assessing Ability to Identify Simple Objects/Naming Pick out several objects from the environment where you are conducting the interview. Point to each object, one at a time. Ask the adult to identify each object, one at a time. Assessing Comprehension Ask the adult to take his/her left hand and place it on top of his/her head. Ask the adult to take his/her right thumb and touch his/her nose with hit. Ask the adult to take both hands and place them over his/her ears. Ask the adult to wiggle his/her nose with his/her right middle finger. Ask the adult to clap his/her hands five times.
The Mini-Mental State Exam Patient___________________________________ Examiner ____________________________ Date ____________ Maximum 5 5 3
Score ( ) ( ) ( )
2 1 3
( ) ( ) ( )
1 1 1
( ) ( ) ( )
Orientation What is the (year) (season) (date) (day) (month)? Where are we (state) (country) (town) (hospital) (floor)? Registration Name 3 objects: 1 second to say each. Then ask the patient all 3 after you have said them. Give 1 point for each correct answer. Then repeat them until he/she learns all 3. Count trials and record. Trials ___________ Attention and Calculation Serial 7’s. 1 point for each correct answer. Stop after 5 answers. Alternatively spell “world” backward. Recall Ask for the 3 objects repeated above. Give 1 point for each correct answer. Language Name a pencil and watch. Repeat the following “No ifs, ands, or buts” Follow a 3-stage command: “Take a paper in your hand, fold it in half, and put it on the floor.” Read and obey the following: CLOSE YOUR EYES Write a sentence. Copy the design shown.
Total Score ASSESS level of consciousness along a continuum ____________ Alert Drowsy Stupor Coma
"MINI-MENTAL STATE." A PRACTICAL METHOD FOR GRADING THE COGNITIVE STATE OF PATIENTS FOR THE CLINICIAN. Journal of Psychiatric Research, 12(3): 189-198, 1975. Used by permission.
A series provided by The Hartford Institute for Geriatric Nursing ([email protected]
Handout 5 Instruction for the MMSE 1. What year is it? 2. What month is it? 3. What is today’s date? 4. What day of the week is it? 5. What season is it? 6. What building are we in? 7. What floor are we on? 8. What city are we in? 9. What state are we in? 10. What country are we in? Please repeat the following three objects: Apple Penny Table (If necessary, repeat the three objects until the client is able to name all three) I want you to remember these three objects and I will ask you in a little while to tell me again what these three items are. _______________________________________________________ Starting from 100, have the client subtract 7’s from the remainder (up to 5 times). Do not give the client the answers. (Answers: 93,86,79,72,65). _______________________________________________________ If the client will not or cannot do the subtraction exercise, ask the client to spell “WORLD” backward. (Answer “DLROW”) Ask the client to tell you what the three objects were that you wanted them to remember. Please tell me what this is? (Show them a pen) Please tell me what this is? (Show them a watch) Please repeat the following: “No if’s and’s or but’s” _______________________________________________________ Find out what hand the client writes with. Then ask the client to do the following: Take the paper in the hand they do not write with, fold it in half and place it on the floor. Please read this sentence and do what it says. Please write a sentence. _______________________________________________________ Please copy this design.
Handout 7 Administrative Offices 5425 East Broadway, PMB #358 Tucson, Arizona • 85711 Tel: 520-750-8868 Fax: 520-584-9220 Email: [email protected]
Bennett Blum, M.D., Inc. Forensic and Geriatric Psychiatry Consultation PARADISE-2: Summary of Use PARADISE-2 is a review of 16 behaviors and cognitive functions. Each component is described in lay terms, and so may be assessed by non-medical professionals; however, each also corresponds to well-known brain functions. The 16 components are listed below: PARADISE-2 Protocol of Functional Mental Capacity (Blum, 2002, 2005, 2006) Past behavior Abstract concepts Remember information Alternatives – considered Delusions Illness Strategic thinking Emotional factors
Pertinent parties Alertness - problems Responsibilities Attention - problems Decision making abilities Impact Significance Express desires
Evaluation is performed for each decision, or period of time, in question. After obtaining information from sources (ideally, from multiple sources), list which of these abilities fall under the headings “clear impairment,” “no impairment,” “conflicting information,” or “insufficient information.” When completed, PARADISE-2 provides a detailed behavioral description that clarifies matters in legal settings, and may be used to guide further medical evaluation. This analysis requires significantly more information and time than is usually available in outpatient settings; however, US and international courts have found this method to be of greater assistance than traditional medical assessments. PARADISE-2 is used internationally, and is the partial basis for new international legal precedent and standard for evaluating certain types of competency.
Permission granted for use in APS Core Financial Exploitation Training 2009.
Handout 7 Administrative Offices
Bennett Blum, M.D., Inc. Forensic and Geriatric Psychiatry Consultation
5425 East Broadway, PMB #358 Tucson, Arizona • 85711 Tel: 520-750-8868 Fax: 520-584-9220 Email: [email protected]
Evaluating Mental Capacity - PARADISE-2 Model of Mental Capacity (Blum 2002-2006) Past behavior Abstract concepts Remember information Alternatives – considered Delusions Illness Strategic thinking Emotional factors
Pertinent parties Alertness Responsibilities Attention Decision making abilities Impact Significance Express desires
____________________________________________________________ Questions to Consider 1. How does the current behavior compare with past behavior? 2. Did the person understand the abstract concepts (ex. what is a will, avoiding detection and capture)? 3. Are there concerns about memory? 4. Are/were alternatives known and considered? 5. Were the decisions free from delusions? 6. What were the effects of co-existing illness, medications, toxic substances, etc.? 7. Did the person engage in or display strategic thinking and analysis? 8. What were the relevant emotional factors affecting the decision, if any? 9. Did the person know the pertinent parties? 10. Were there concerns about the person's degree of alertness (i.e. consciousness) or attention when information was presented, or when executing the decision? 11. Did the person know his/her responsibilities and the responsibilities of the other involved parties? 12. Did the person have difficulty making or maintaining decisions? 13. Did the person understand the impact of the decision (i.e. the likely objective outcome) or behavior? 14. What is the significance of the decision (i.e. the subjective evaluation of the likely outcome)? 15. Did the person have difficulties expressing desires?
Permission granted for use in APS Core Financial Exploitation Training 2009.
The Short Portable Mental Status Questionnaire (SPMSQ) Question
1. What are the date, month, and year? 2. What is the day of the week? 3. What is the name of this place? 4. What is your phone number? 5. How old are you? 6. When were you born? 7. Who is the current president? 8. Who was the president before him? 9. What was your mother's maiden name? 10. Can you count backward from 20 by 3's? SCORING:* 0-2 errors: normal mental functioning 3-4 errors: mild cognitive impairment 5-7 errors: moderate cognitive impairment 8 or more errors: severe cognitive impairment *One more error is allowed in the scoring if a patient has had a grade school education or less. *One less error is allowed if the patient has had education beyond the high school level. Source: Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of American Geriatrics Society. 23, 433-41. Compiled by the Great Plains Area Chapter of the Alzheimer's Association, 1999.