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Outline General Legal Terms Capacity Vs Competency 1:45 – 2:30 pm Presenter Disclosure Information Assessing Cognitive The following relationships exist related to this presentation: Impairment in the Elderly ►Edwin J. Olsen, MD, JD, MBA: No financial relationships to disclose. SPEAKER Edwin J. Olsen, MD, JD, MBA Off-Label/Investigational Discussion ►In accordance with pmiCME policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. Assessing Cognitive Impairment/Capacity Outline in the Elderly 1. General Concepts Edwin J. Olsen, MD, JD, MBA 2. Issues in Primary Care 3. DSM V—Neurocognitive Disorders • University of Miami, Miller School of Medicine 4. Evaluations Department of Psychiatry ([email protected]) 5. Testamentary Capacity • President, The Florida Veterans’ Medical & Legal Center, 6. Medical Professions Role Inc. 7. Physician Capacity • Co‐Director Miami VA Healthcare System, Medical/Legal 8. Driving Capacity Clinic 9. Permanency Planning • Veterans Advocacy Project Attorney, Florida International 10. Contested Wills University College of Law General Legal Terms Capacity vs Competency • Testamentary competency: legal concept of being capable of executing a will • Usually Ask: “Is this person Competent?” • Competency: legal definition defined by a • Should ask: “Does this person have the judge capacity to………….(specify) • Capacity: medical determination made by a • Competence is determined by a Judge doctor indicating that an individual • However, used interchangeably. understands relevant facts and appreciates potential out‐comes Civil Capacities Issues in Primary Care 1. To handle funds‐‐Fiduciary (VA Compensation • Identify early dementia—Mild Cognitive & Pensions— “Incompetent for VA Purposes”) Impairment (MCI); Depression 2. To make a will (Testamentary) • Interview and History: How patient presents 3. To Drive • Testing: Folstein Mini Mental Status; MoCA; 4. To consent to treatment (Informed Consent) MiniCog; Stroop Test; Telephone Interview for 5. To be married/divorced Cognitive Status(TICS) 6. To make a contract 7. Physician Capacity National Institute on Aging Cognitive Clinical Issues DSM‐5 Instruments • Neurocognitive disorders—Dementia, • 116 Instruments to Detect Cognitive Delirium, Amnestic, and Other Cognitive Disorders) Mild & Major Impairment in Older Adults • Domains Assessed • Dementia Subtypes: Alzheimer’s, vascular, • Time Lewy bodies, Parkinson's, Frontotemporal, • Cost TBI, HIV, substance/medication, Huntington's, • www.nia.gov/research/cognitive‐ Prion disease, Other medical condition, Multiple etiologies, Unspecified. instruments/search Mild Neurocognitive Disorder DSM V Mild Neurocognitive Disorder DSM V • A. Evidence of modest cognitive decline from and 2. Modest impairment in cognitive a previous level of performance in one or performance, preferably documented by more cognitive domains (complex attention, standardized neuropsychological testing, or in its executive function, learning and memory, absence, another quantified clinical assessment language, perceptual motor, or social B. Cognitive deficits do not interfere with cognition based on: capacity for independence in everyday activities. • 1. Concern of the individual, a knowledgeable C. Not exclusively in delirium informant, or the clinician that there has been D. Not explained by another Mental disorder (eg a mild decline in cognitive function: Major Depression, Schizophrenia) Due to Mild Alzheimer’s Due to Mild Alzheimer’s • A. Criteria are met for Mild NCD • Possible—no evidence of causative genetics • B. There is insidious onset and gradual • All 3 of following: 1. Clear evidence of decline progression of impairment in one or more in memory and learning. 2. Steadily cognitive domains progressive, gradual decline in cognition, • C. Criteria: Probable‐‐causative genetic without extended plateaus. 3. No evidence of mutation from genetic testing or family mixed etiology (absence of other history; neurodegenerative NCDs or CVA disease contributing to cognitive decline) Due to Mild Alzheimer’s Due to Mild Alzheimer’s • D. Disturbance is not better explained by CVA, • Alzheimer’s: impairment in memory and another neurodegenerative disease, the learning, sometimes deficits in executive effects of substance abuse, or another mental, function. Depression and/or apathy often neurological, or systemic disorder. seen • Culture‐Related—memory loss is considered normal in old age; face fewer cognitive demands in everyday life, or where very low educational levels pose greater challenges to objective cognitive assessment Major Depressive Disorder Depression Screens • Signs and Symptoms: 2 weeks period‐ • US Preventive Services Task Force (USPSTF) SIG:ECAPS (Suicide, Interest, Guilt, Energy, • January 28, JAMA—primary care practitioners Concentration, Appetite, Psychomotor, Sex) offer screening for all patients • Often difficult to separate from early • Patient Health Questionnaire (PHQ 2, PHQ9) dementia—Interview: Depression “I don’t • Hospital Anxiety & Depression Scales know” or won’t try; Dementia gives an • answer, although may not be correct. Geriatric Depression Scale Subtle Early Signs of Cognitive Subtle Early Signs of Cognitive Impairment Impairment • Shopping Sprees • Back Pain • Drinking Heavily • Risky Sexual Behavior • Forgetfulness • Exaggerated emotions • Excessive Internet Use • Problem Gambling • Binge eating and obesity • Smoking • Shop lifting • Not Taking Care of ones self National Alzheimer’s Association: Mild Costs Cognitive Impairment (MCI) • Decline in cognition (concentration, communication, memory and orientation). May also impact the person’s ability to conduct daily • activities in such areas as dressing, bathing and NIH Supported study found US dementia care eating meals. costs as high as $215 Billion in 2010 • MCI is often thought of as the period between normal cognition and when Alzheimer’s disease develops. • Others consider it to be the actual early stages of Alzheimer's, although not everyone with MCI will develop Alzheimer’s. Mild Cognitive Impairment (MCI) Mild Cognitive Impairment (MCI) • Originally: Only area an individual could demonstrate • Alzheimer's Association and National Institutes of impairment was memory Aging recommended revised definition of MCI in • Allowed for problems in other cognitive areas, such as 2012 reasoning and judgment. However, the person had to continue functioning quite well in daily life; if activities • Allows for mild impairment in ADLs, in addition to of daily living were impacted, the diagnosis would then the cognitive challenges. While it gives more likely be dementia, or specifically, the early stages of flexibility and perhaps is more accurate, it also Alzheimer's disease. may result in some people who were already • More recently not fitting in evaluations of those who were diagnosed with MCI, since many people with MCI diagnosed as having Alzheimer’s or another did indeed demonstrate a functional impairment. dementia now fitting the criteria for MCI instead. Mild Cognitive Impairment (MCI) Mild Cognitive Impairment (MCI) • Newly revised definition blurs the line • It’s estimated that about 20% of people over between MCI and Alzheimer’s, so some the age of 70 have MCI. researchers recommended that the term MCI • Cause unknown. Appears to have similar risk due to AD (Alzheimer’s disease) be used, factors to Alzheimer’s: age, education and unless it's clear that the MCI is related to such brain/body health factors as stroke, other potentially reversible causes diabetes, cholesterol, heart health and blood pressure. Difference Between MCI and Normal Difference MCI vs Alzheimer’s Age‐Related Memory Changes • MCI is a general term for mild impairments in • Normal to experience some occasional memory thought processes and memory, whereas gaps, such as not being able to remember someone’s name or where keys were put down. • Alzheimer’s is a specific disease in which “Benign Senescent Forgetfulness” memory and functioning continue to decline • A periodic delay in being able to access over time. memories is also typical. • Not normal: the experience of additional concerns in the areas of language, judgment and problem‐solving, or when the memory loss is more than just occasional. Treatment of MCI MCI References • • There is no medication approved for Alzheimer’s Memory Center. Mild Cognitive Impairment. http://www.amcneurology.com/blog/2009/12/02/mild‐cognitive‐impairment‐mci/ treatment of MCI at this time. Some • Journal of Alzheimer’s Disease. Effects of Varying Diagnostic Criteria on Prevalence physicians do opt to prescribe donepezil of Mild Cognitive Impairment in a Community Based Sample. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3146555/ (Aricept) • Morris, J. Archives of Neurology. February 6, 2012. Revised Criteria for Mild Cognitive Impairment May Compromise the Diagnosis of Alzheimer Disease • Other physicians recommend general risk‐ Dementia. http://archneur.ama‐assn.org/cgi/content/full/archneurol.2011.3152 • reduction strategies similar to what is Neurology. Longitudinal pattern of regional brain volume change differentiates normal aging from MCI. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690968/ recommended for Alzheimer’s, including • NYU Langone Medical Center. Mild Cognitive Impairment. maintaining healthy eating habits, an active http://www.med.nyu.edu/adc/forpatients/cognitiveimpair.html#what • University of California, San Francisco. Mild Cognitive Impairment. brain and regular social interaction. http://memory.ucsf.edu/education/diseases/mci
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