Rights Responsibilities Rhetoric Disclaimer This speaker’s presentation represents the opinions of the author (s), and not necessarily those of the Conference Organisers – the Guardianship Board of South Australia, the South Australian Public Advocate, The Chief Psychiatrist, SA Health and the South Australian Public Trustee, or their organisations. The contents are for general information only. They are not intended as professional advice – for that you should consult a suitably qualified practitioner in the relevant field of law, mental health, guardianship, advocacy, estate administration or trusteeship. The Conference Organisers expressly disclaim all liability for any loss or damage arising from reliance upon any information in these papers. Copyright ©2009. Copyright in this material is retained by the author(s). Permission to publish in this format has been granted to the Conference Organisers – the Guardianship Board of South Australia, the South Australian Public Advocate, The Chief Psychiatrist, SA Health and the South Australian Public Trustee. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the Copyright Act 1968, no part may be reproduced by any process without written permission from the author. Organised by the SA Guardianship Board and the Chief Psychiatrist, SA Health in association with: Neuropsychology & Mental Capacity Assessments Amie Foran – Royal Adelaide Hospital Dr Rochelle Goodinson – Hampstead Rehab Centre Julia Kuring – Repatriation General Hospital Dr Elissa O’Connell – Hampstead Rehab Centre Dr Emma Scamps – Brain Injury Rehab Service Objectives To increase participants’ ... ...knowledge of the process of neuropsychological assessment relevant to determination of decisionmaking capacity ...knowledge of the specific cognitive functions related to decision making ability ...ability to utilise neuropsychological assessment reports effectively ...understanding of when referral to a neuropsychologist may (or may not) be necessary and/or useful Clinical Psychology Clinical psychologists are specialists in the assessment, diagnosis and treatment of psychological problems and mental illness Referrals for: Depression (incl. bipolar disorder) Anxiety disorders Personality disorders Psychosis Grief and loss Traumatic events Adjustment (retirement/health problems/dementia) Clinical Neuropsychology Assessment, diagnosis and treatment of psychological disorders associated with conditions affecting the CNS Understand brain/behaviour relationships Identify cognitive strengths/weaknesses Differential diagnosis Strategies for rehabilitation Education: consumers, families, carers, other health professionals Decision making capacity Training Qualifications Undergraduate degree in psychology (3yrs plus honours), plus Masters (2yrs), or clinical Doctorate (3yrs), or combined Masters/PhD (4yrs) in Clinical Neuropsychology State registered – but soon to be National Australian Psychological Society (APS) APS College of Clinical Neuropsychologists Membership restricted to psychologists who have completed specialised training and supervised experience in the field. Settings Paediatric Rehabilitation Neuroscience Mental Health Geriatric/Aged Care Medico-Legal Public vs Private Practice Public Eligibility criteria Waiting lists (longer) Private Fees Waiting lists (shorter) Private Health Insurance (minimal) No Medicare Objectives To… ...increase participants’ knowledge of the process of neuropsychological assessment relevant to determination of decision-making capacity ...discuss the advantages of using Neuropsychology in capacity assessments Decision Making Capacity: In a neuropsychological assessment of DMC: The person has the ability to “understand and appreciate (relevant) information” (Darzins et al. (2000). “Who can decide?” p 2) That the person has received pertinent information That they reasonably know risks, alternatives, consequences of decision Their choices depend on their personal values and goals Decision Making Capacity Is Not: A bad decision A decision with which we do not agree Based solely on a person having a degree of cognitive impairment or a mental illness To the Neuropsychologist, Decision-Making Capacity is Specific To: The Domain Financial, Life-style, Medical etc. The Decision For example, within Medical – consent to blood test versus consent to complex surgery. That Period of Time Decision-Making Capacity is Specific: This is why neuropsychologists request a specific referral question Rather than a referral for: “Capacity assessment” We prefer: “Does this person have the capacity to appoint an EPOA at this time?” Neuropsychologists Have skill in the clinical interview and test interpretation Have experience in translating test results to everyday function Can integrate mood, personality and cognitive factors which contribute to decision making capacity Have experience in differentiating psychopathology from organic brain impairment Neuropsychological Assessment Involves advanced training in the application and interpretation of neuropsychological tests for a range of disorders and contexts across the lifespan (paediatric to geriatric) Requires strong knowledge of brain structure, function and dysfunction, and the effects of multiple factors on cognitive, emotional and behavioural function Uses a scientist-practitioner model and evidence-based practice to take a hypothesis testing approach to assessment Neuropsychological Tests Are sensitive to impairment Test performance is not based just on the endscore “Norms” take into account the person's age, education and gender Comparison is made with pre-morbid functioning Neuropsychological Assessment Versus Screening Tools Mini-Mental State Exam (MMSE), Frontal Assessment Battery (FAB) etc. often used to screen cognitive functioning These tests use an end score, either out of 30 (for MMSE) or 18 (for FAB) Some difficulties in interpretation can arise with these scores Neuropsychological Assessment Versus Screening Tools What if English is their second language? What if the person is of high pre-morbid intellect/ or ID? What if they have had numerous screens (learning effects)? What if they cannot use their hands to draw or write/ are illiterate/ cannot see well and then the test is /28 (for MMSE). What does 25/28 mean? What does 27/30 mean for an 87 year old with Yr 7 education who had learning difficulties at school? What if their cognitive deficits lie in domains other than those which these screens assess? Advantages of Neuropsychological Assessment Objective, valid and reliable method of comprehensively assessing many domains of cognition Can assess abilities related to decision making Analyse task demands (handle a compensation/ lump sum payout vs. daily budget) Advantages of Neuropsychological Assessment Neuropsychological tests can provide specific information about: Are these scores “normal” for age, ed, gender or do they represent cognitive decline from premorbid? Is their decision-making capacity likely to change? What process is breaking down? Can strategies be employed that may assist this person’s ability to understand and appreciate the information? Take Home Points Neuropsychological assessment… Is more than simply administering tests. It is a process Our training, background and highly standardised tests enable us to play a valuable role in the assessment of decision-making capacity Objective To increase participants’… … knowledge of the specific cognitive functions related to decision making ability Assessment of Capacity Assessment is multi-layered 1. Background information 2. Interview with the individual (ideally seen over more than one occasion) 3. Formal neuropsychological testing 4. Personality and values 1. Assessment: Background Information Researching the individual; Interview with relevant other’s (family, carers, other staff) Literature review/evidence-based research Reviewing medical files, brain scans Contacting the GP, other specialists 2. Assessment: Interview With the Individual Assists in determining the individual’s awareness and insight into their abilities and disabilities As important as the test results themselves Interview Questions Is the individual; Aware of the need for assessment? Understand why other’s are concerned? Able to acknowledge their functional and/or cognitive limitations? Realistic about the impact their deficits may have on their safety? Able to identify how they will minimise their safety risks? Interview Questions Aware of their options? If not, are they open to different options? Able to see the dis/advantages of these options? Able to foresee the likely consequences of their decision? Communicate their reasoning behind their decision? (other factors?) 3. Aspects Of Functioning Important To Assessment 1. 2. 3. 4. 5. 6. 7. 8. 9. Insight Orientation and Attention/Concentration Working memory Language Arithmetic Memory (short and long term) Executive Functioning (initiate, reason, abstract, problem solve, use judgement, form and apply strategies, plan, think flexibly) Emotions/Mood Other factors Attention & Concentration Can the person take in the important information? Can they maintain their concentration for long enough to think through the information? Can they block out irrelevant information that may interfere with their ability to make this decision? Language Can the person understand the information provided? Can they generate and articulate their responses in a way that effectively communicates their wishes? Memory Can they learn new information? Can they retain information long enough to consider all the relevant facts? Is their decision consistent over time? Executive functioning Can they hold multiple-pieces of information in their mind at the one time to compare and evaluate them? Are they open to learning about different ideas or options or are they overly rigid in their thinking? Can they engage in basic problem-solving & reasoning? Can they convert their intentions/verbalisations into actions? Can they set goals, plan how to achieve it, monitor their performance, and evaluate the consequences of their behavior? Emotions/mood Is there uncontrollable fear or worry? Do they have depressed mood? Does this lead to non-compliance? Is the person’s thinking disorganised? Are they hallucinating? 4. Other Factors Values about guardianship: wants, preferences for whom? How decisions are made: alone or with others? Goals and quality of life: what are the person’s valued relationships, activities? What are the individual's likes and dislikes, hopes and fears? What are their cultural and religious beliefs? Take Home Points Given the comprehensive nature of the Ax and importance of decision, the entire process for a neuropsychological capacity assessment could take several hours (eg., up to a full day or more, in very complex cases) The information gathered from the assessment is interpreted and produced in a neuropsychological report for the Tribunal Objectives To increase participants’ ... … ability to utilise neuropsychological assessment reports effectively …understanding of the confounds of neuropsychological capacity assessments, and the collaboration with other professionals when forming an opinion around mental capacity The Neuropsychology Report Referral question History Presentation Assessment results Summary, conclusions and opinion The report can provide a recommendation for the tribunal around a person’s decision making capacity, but the tribunal decides if a person is competent The Audience The consumer Acute medical and allied health professionals Rehabilitation professionals Carers Family The Tribunal When To Use A Report The question of capacity needs to have been addressed in the report for the report to be appropriate for use in a GSB hearing If the question of capacity has not been addressed, it is not appropriate to send the report to the GSB. A new referral to the neuropsychologist is required Confounds Of Neuropsychological Assessment Confounds can impact on the neuropsychological assessment results and present challenges in interpreting these results Confounds What are the common confounds to testing and test interpretation: Non-standardized administration Environmental factors Interruptions Mood effects Fatigue Confounds Pain Medication effects English as a Second Language Difficulty estimating premorbid level of functioning Test-retest effects Effort Controlling For Confounds Modify environment Use appropriate interpreters Use hearing devices Develop rapport Consultation With Others Medical staff Nurses Carers Allied Health Professionals Family and other interested parties Take Home Points Specific referral questions enable neuropsychology reports to be appropriate for the GSB Neuropsychology reports need to address the issue of mental capacity for them to be appropriate for use in a GSB hearing Confounds to assessment are carefully controlled for Case Studies Case Study 1 - Anna Background 79 year old Lives alone with Domiciliary Care support (3x wk showering) 2 daughters live in UK 2 friends have EPOA Anna Medical Left parietal CVA 3 weeks prior to Ax Previous right CVA with residual left homonymous hemianopia & left hemiparesis Pulmonary fibrosis (on home oxygen) GORD Anxiety/depression Hypertension Anna – current issues Reduced mobility Reduced upper limb functioning (L>R) Reduced vision SP recommended soft diet Reduced memory Concerns re planning/ problem solving Treating team recommending RCF Anna wanting to return home Anna – formal NP Ax Premorbid : low average Orientation : reduced, knew location Attention & working memory low average, attended well over 1 hr session Language markedly compromised word-finding & fluency responses appropriate, followed instructions Memory markedly reduced, subtle benefit from prompting recalled conversation, incorporated previous info into later responses, consistent over time Anna – formal NP Ax Executive Functioning Borderline good response to hypothetical emergency problemsolving scenario identified goal, plan, and how to monitor Emotions/Mood elevated symptoms of depression, anxiety & stress identified her concerns & potential management strategies, willing to consider treatment options Anna – Interview Articulated her desire to return home and treating team’s recommendation for RCF Aware of physical & cognitive limitations & potential safety risks; willing to accept help Identified advantages of home & both advantages and disadvantages of RCF without prompting With closed questions identified disadvantages of home Anna – Interview Could see likely consequences of home & RCF Clear and consistent in reasons given for decision Willing to consider RCF if trial at home unsuccessful No evidence of tangential thoughts, disordered thinking, perseveration or delusions Recommendation - Anna Support needed for complex decision making due to reduced cognitive abilities Strategies to be considered: Allow extra time Summarise key points & repeat new info No clear evidence to suggest she was not currently capable of making decisions in relation to returning home or moving to an RCF (i.e. must assume she does have capacity) Case Study 2 - Bill Background 65 year old Lives with his 89 year old mother No children Nil formal supports Receives DSP Bill Medical Current admission (2 months prior to Ax) dizziness, confusion & wrist injury post fall. Auditory & visual hallucinations noted during admission. Prostatitis ETOH abuse Recurrent falls Previous suicide attempts Bill – current issues Cognitive impairment ?ETOH related (ETOH abuse) Pathological gambling Depression with suicidal intent (increase in anti-depressant) Learning disability in reading and writing OT assessment Unable to read bank statements/complete simple bank forms Vulnerable to financial exploitation Concerns re risk of losing savings/inheritance to gambling Treating team recommending Administration order Bill wants to retain control of his finances Bill – formal NP Ax Premorbid : low average Orientation : preserved Attention & working memory low average, variable attention over 80min session Language word-finding preserved, listening comprehension 4yrs:4m responses relevant (but inconsistent), followed instructions Memory mildly reduced recalled conversation, unable to incorporate previous info into later responses, consistent in decision, inconsistent in details provided re finances Bill – formal NP Ax Executive Functioning Extremely low verbal reasoning, rigid/concrete poor response to hypothetical banking problem-solving scenario Identified goal (stick to budget) but unable to identify reasonable plan or how to monitor performance of plan Emotions/Mood elevated symptoms of depression, anxiety & stress willing to consider treatment options Bill – Interview Articulated his desire to retain control of his finances and aware of options of Public Trustee/family as administrators Aware he had spent a large sum of money in 12 month period & risk of losing savings; unwilling to accept help Identified disadvantages of Administrator without prompting With closed questions identified advantages of selfmanagement Unable to acknowledge potential advantages of Administrator or disadvantages of self-management Bill – Interview Unable to see likely consequences of self-management & Administrator Risk of over-spending vs limited access to money Clear and consistent in his desire to retain control of his finances Inconsistent in details provided re his finances (e.g. assets, debts, strategies to limit spending) Unwilling to consider Administrator in any instance Evidence of disordered thinking, rigidity Recommendation - Bill Support needed for complex decision making due to reduced cognitive abilities Strategies to be considered: Allow extra time Use clear, concrete information & examples Suggest he is not currently capable of making decisions in relation to managing his finances (self-management vs Administrator); recommend application to GSB for Administration order. Objective To increase participants’... …understanding of when referral to a Clinical Neuropsychologist may (or may not) be necessary and/or useful. Conclusion Question time Key Indicators for Referral Diagnostic formulation Distinguishing the impact of different diagnoses Extent of cognitive difficulties is unknown History is unclear Borderline cognitive status Previous level of functioning is unknown Key Indicators for Referral Presentation is inconsistent with behaviour or functioning Psychological confounds Poor effort, malingering or symptom exaggeration Challenging behaviours Legal issues (i.e. order may be contended) Risks to consumer, staff and/or others Do Not Refer to Neuropsychology Not medically stable Not able to comprehend simple commands Overtly confused or delirious Intoxicated (note exceptions) Recent changes to medication or planned intervention that could change mentation, Severe receptive language difficulties Severely dysphasic (note exceptions) Not compliant Writing a Referral to Neuropsychology Your/the referrer’s name and contact details The consumer’s name, age and gender The reason/s for referral Specific referral question The consumers’ primary diagnosis Relevant medical and psychiatric history If an interpreter is required Writing a Referral to Neuropsychology Factors that may effect administration of pen and paper tasks Vision or hearing impairments The presence of behaviours that will impede testing (effort, aggression, etc) Planned date of discharge, surgery, transfer, tribunal hearing, and other information to assist with planning Summary Neuropsychologists are well qualified to conduct capacity assessments Neuropsychology assessments are comprehensive and time consuming to reflect the significance of the opinion given Neuropsychologists assess for domain and decision specific mental capacity The most appropriate referrals are often those that are complex, diagnostically challenging or when there are significant confounds present Reports addressing specific referral questions will be most appropriate for the GSB Discussion Organised by the SA Guardianship Board and the Chief Psychiatrist, SA Health in association with Rights Responsibilities Rhetoric