Determining if an older adult can make and execute decisions to live safely at home: A capacity assessment and intervention model

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Abstract

Determining an older adult's capacity to live safely and independently in the community presents a serious and complicated challenge to the health care system. Evaluating one's ability to make and execute decisions regarding safe and independent living incorporates clinical assessments, bioethical considerations, and often legal declarations of capacity. Capacity assessments usually result in life changes for patients and their families, including a caregiver managing some everyday tasks, placement outside of the home, and even legal guardianship. The process of determining capacity and recommending intervention is often inefficient and highly variable in most cases. Physicians are rarely trained to conduct capacity assessments and assessment methods are heterogeneous. An interdisciplinary team (IDT) of clinicians developed the capacity assessment and intervention (CAI) model at a community outpatient geriatrics clinic to address these critical gaps. This report follows one patient through the entire CAI model, describing processes for a typical case. It then examines two additional case reports that highlight common challenges in capacity assessment. The CAI model uses assessment methods common to geriatrics clinical practice and conducts assessments and interventions in a standardized fashion. Reliance on common, validated measures increases generalizability of the model across geriatrics practice settings and patient populations.

Introduction

Older adults commonly report living safely and independently in their own home as one of their major life goals (Naik et al., 2005). Assessment of one's ability to live independently is an important priority for health care professionals caring for older adults, perhaps as important as managing medical comorbidities (Schulman-Green et al., 2006, Huang et al., 2007). Assessment is difficult, however, as living independently involves multiple functional domains. As people age, they face a variety of physical, mental, and social challenges. Even minor deficits in several domains can present as a significant functional disability (Naik et al., 2006). Cognitive function, affect and judgment are important for safe and independent living, and deficits in these domains are linked to impaired executive control function (the ability to perform complex, goal-directed behavior) (Workman et al., 2000). Impairments in executive control function limit one's ability to implement plans of actions related to everyday living and execute choices that maintain one's safety when encountering unexpected circumstances (Workman et al., 2000).

Assessing the capacity to make and execute decisions is a central aspect of deciding if an older adult can live independently. Lacking capacity is not synonymous with having disabilities or being dependent. A disabled older adult may be able to utilize assistive devices or services performed by others to ensure personal daily needs are met. The subset of older adults who lack capacity for safe and independent living are also different from those who rationally refuse to conform to social norms. Cooney et al. (2004) warn that “eccentric, risky, or even foolish decisions should not be confused with impaired capacity”.

Capacity determination is a complex, cross-disciplinary process that ideally involves a range of professionals. It requires knowledge of medicine, ethics, and the law (Moye and Marson, 2007). The legal definition of capacity is usually thought of as an all or nothing phenomena, which can be problematic as real-world situations are rarely black and white (Moye et al., 2007a). Many court initiated determinations of capacity assess a limited set of functional domains, when all five domains of safe and independent living should be evaluated (Moye et al., 2007b). These domains consist of (1) personal needs and hygiene, including bathing, toileting, dressing, and feeding; (2) the condition of the home environment, including basic repair and maintenance and the physical structure of one's living environment; (3) activities for independent living, including shopping, cooking, cleaning and laundry, using telephone and transportation; (4) medical self-care, including medication management, wound care, and appropriate illness self-monitoring; and (5) financial affairs, including daily transactions like managing a checkbook and paying bills as well as judgment with basic financial decisions (Naik et al., 2008).

In contrast to the legal approach, clinicians usually view capacity as a gradient. A person may lack the capacity to manage her entire estate but be able to navigate everyday monetary responsibilities. Similarly, a person may retain capacity in one functional domain (personal care and hygiene), but lack capacity in another (medical self-care). The lack of comprehensive and standardized procedures for CAI represents a significant clinical and scientific gap.

The geriatrics team at Quentin Mease (QM) Community Hospital is part of the Harris County Hospital District (HCHD), a tax supported health care system in Harris County, Texas and affiliated with Baylor College of Medicine. Clinicians noted that 70–80% of all patients seen in the clinic or during home visits were vulnerable older adults with questionable capacity for safe and independent living. Clinicians expressed a need for developing a systematic process to evaluate vulnerable patients and to provide them with the services they needed. In addition, they were confronted by the reality that few geriatrics health care professionals receive adequate training in capacity assessment. To address these gaps in care, the geriatrics team at QM developed a standardized process to assess capacity for safe and independent living in vulnerable older adults.

Section snippets

Overview of the CAI model

The CAI model represents this effort. The CAI model consists of a stepwise process (Fig. 1) to guide health care professionals through a comprehensive capacity assessment. First, health care providers, family members, or social services agencies such as adult protective services (APS), refer patients to the QM geriatrics program. Second, one or more trained clinicians conduct a comprehensive assessment (Step 2 of Fig. 1) by examining the older adult's ability to make and execute decisions in

Step 1: the referral

Mr. B is an 80 year old African American male referred by APS for a capacity assessment. Home health providers assisted Mr. B daily, but did not fulfill all of his needs. His three children occasionally provided additional assistance with instrumental activities of daily living (IADLs) and other aspects of his care. More recently, Mr. B had become increasingly aggressive toward the family, often using foul language. In addition, he was increasingly reliant on family and friends with even basic

Barrier to consider: delays in delivering care

There are several obstacles that must be overcome in order to ensure successful treatment of patients using the CAI model. Most assessments are initially conducted in the patient's home, so the situation can be quite variable. Often little to no past medical history is available. Family members may be reluctant or unable to implement new plans of care. Patients often do not share treatment goals with clinicians and family members, which can undermine the intervention process. Even if the family

Barrier to consider: the importance of determining capacity beyond guardianship

There is great variability in the scope and format of clinician capacity assessments (Moye et al., 2007a, Moye et al., 2007b). While appointing a legal guardian is one possible outcome of a capacity assessment, it should not be considered the only outcome. In actuality, guardianship is a low effectiveness but high resource option, and should be considered as a last resort. If guardianship proves to be the best course of action, however, the CAI model will provide a consistent, valid, and

Conclusion

The CAI model provides a systematic approach to initiating, conducting, and following through an assessment of an older adult's capacity to make and execute decisions regarding safe and independent living in the community. The need for assessing the capacity for safe and independent living is surprisingly common among vulnerable community-living older adults. Guardianship should be an option of last resort as many patients see significant improvements in their quality of life with less invasive

Conflict of interest statement

None.

Acknowledgments

This study was supported by a bioethics project grant from the Greenwall Foundation (Naik, PI), the Practice Change Fellows Program (Regev) supported by the Hartford Foundation and Atlantic Philanthropies. The capacity assessment and intervention model receives ongoing support from the Harris County Hospital District and the Houston VA HSR&D Center of Excellence (HFP90-020). Dr. Naik is also supported by an NIA K23 grant (5K23AG027144). Felicia Skelton was supported by a medical student

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