Evaluating the decisions of older adults

During a recent Zoom conference call, four California Adult Protective Services workers, using a tool called Interviewing for Decision Abilities, or IDA, were trying to figure out if something fishy was going on with an 82-year-old woman they knew as Mrs K

Adult Protective Services agencies in every state receive reports of possible neglect, self-neglect, abuse, or exploitation of older persons and other vulnerable adults. But agency workers are constantly faced with a troubling question: Does the adult in question have the ability to make a decision about his or her health care, living conditions, or finances, even if it’s not the decision that the family, doctor, or financial advisor believe that should be taken?

IDA was developed by two geriatricians to help train Adult Protective Services workers on how to manage that problem. The program helps them learn how to use a structured interview procedure to gather information about a client’s decision-making ability. The two dozen California staff members who took the course had already completed 10 hours of individual online instruction; they were now practicing their new interview skills in small groups, role-playing with the facilitators.

Mrs. K, a fictional character, was being played by Bess White, special projects manager at Weill Cornell Medicine. In the scenario, a bank manager had reported some suspicions: Mrs. K had $60,000 in a savings account but her withdrawals had increased considerably, from $600 a month to $600 a week. A younger man, her nephew, she said, had begun accompanying her to the bank, where a teller thought the man seemed controlling and intimidating. An investigator who visited Mrs. K at her home learned that her only credit card had expired and that she was low on cash.

But Mrs. K denied having been financially exploited; her nephew lived with her, he said, helping her with housework and driving her to doctor’s appointments. She used the bank withdrawals to buy her groceries.

In the exercise, one of the APS students had made sure that Mrs. K grasped the basic concept of financial exploitation. Mrs. K had heard about scams in the news, she said. And yes, she understood that a friend or family member could be taken advantage of in a similar way.

The interviewer then continued, “What do you think would happen if someone took someone else’s money without their permission?”

Mrs. White, in the role of Mrs. K, replied, “I suppose the person could take it and take it until there is nothing left.” But when the interviewer probed further to see if Ms. K understood that she might be facing this risk herself, she resisted. She trusted her nephew, Mrs. K said; she didn’t want to disturb him.

IDA was developed by Dr. Mark Lachs, co-director of geriatrics and palliative medicine at Weill Cornell Medicine, and colleagues, and Dr. Jason Karlawish, a geriatrician and co-director of the Penn Memory Center. “People have the right to make bad decisions,” Dr. Lachs said in an interview. But, he added, decision makers must be able to understand the risks they face and the possible consequences.

“How can you walk into a brokerage office at 90 years old and say, ‘I’ve owned Treasuries for 50 years, but now I want to put my last $200,000 in Bitcoin,’ and no one raises an eyebrow?” Dr. Lachs said. “Let’s look back and say, ‘What were we thinking?'”

In addition to applying the IDA to cases of financial neglect or abuse, California APS workers used it to assess a variety of issues including personal neglect, health and safety questions, refusal of physical care or medical treatment, and physical, psychological or sexual abuse. sexual. .

“It’s not meant to replace a psychiatrist, but it tells you when to contact a psychiatrist,” said Dr. Lachs. Clients whose interviews with IDA reveal an inability to understand risks or consequences should receive a full professional evaluation, he added.

To date, some 500 APS workers, in New York City, Massachusetts and two California regions, have taken the course and received certification. Kansas APS workers will receive training this summer.

But the Drs. Lachs and Karlawish believe that IDA could have broader uses. Trust and estate attorneys and financial firms are already asking them about it.

Hospital discharge planners can use IDAs to assess whether a patient has the ability to insist on going home instead of rehabilitation. A chain of assisted living facilities contacted Dr. Lachs and asked if IDA could help ensure new residents understood the complicated contracts they were signing.

The IDA interview attempts to answer three fundamental questions about a particular problem or risk, Dr. Karlawish said: “Do you recognize that this happens? Do you think this could be happening to you? Can you come up with a plan to deal with it, reasoning and weighing the pros and cons?

Depending on the complexity of a problem, people with diagnosed cognitive impairment or even dementia may still possess enough understanding to handle it.

Someone who demonstrates that tripartite understanding during the IDA interview is likely to have the ability to make a decision, including a decision not to address the issue. Someone without that understanding needs a more comprehensive evaluation, which may include consultation with family members or social service agencies. In extreme cases, it could lead to eventual guardianship or conservatorship.

Problems managing finances often serve as an early warning of disability, said Dr. Daniel Marson, a neuropsychologist at the University of Alabama at Birmingham who has studied the topic for 25 years.

“Financial capacity is probably the first higher-order functional capacity affected by neurodegenerative disorders and by normal aging,” he said. Using money competently requires complex thinking, from “something basic like using an ATM to things that are more complicated, like ‘How should I handle this call from a telemarketer?'” The Consequences of Declining Financial Capability : unsafe living conditions, impoverishment, homelessness, institutionalization, can be devastating.

Although the incidence of dementia has decreased in the United States and Europe, the aging of these populations means that more people will develop it.

Additionally, in a six-year study, Dr. Marson and colleagues found that older adults who received a diagnosis of mild cognitive impairment, often a precursor condition to dementia, also increasingly struggled. “There were diminished financial skills over time,” he said.

Other institutions have attempted to address the problem of declining decision-making power. Last year, the American Bar Association updated its “Assessment of Older Adults with Disabilities: A Manual for Lawyers.” The American Bar Association and the American Psychological Association have also published manuals for judges and psychologists.

The Financial Industry Regulatory Authority, or FINRA, has published online courses on financial exploitation of older adults and other vulnerable investors. Its rules allow a member firm to temporarily suspend transactions and disbursements when it believes there is exploitation. It also allows member firms to ask investors for a “trusted contact person” to consult in the event of suspected exploitation.

The IDA program is focusing on APS workers for now because “the typical agency is understaffed, under-resourced and under-staffed,” said Dr. Karlawish. California’s APS agencies handle about 30,000 cases involving older people each month, according to state data, and “are being asked to make capacity decisions that a chairman of a psychiatry department might struggle with,” he said. Dr Lachs.

California staff in the Zoom training session, politely asking Ms. White, like Ms. K, how she might respond to the bank manager’s suspicions, ultimately concluded that she did not need a professional job. It seemed that she understood her options.

Giving his nephew access to his savings account might not have been the smartest move. But the decision was his.

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