Clinical Geriatrics

To the Editor:
Thank you for your Psychiatry Rounds column in Clinical Geriatrics—always thoughtful and thought-provoking. I was especially interested in “Decision-Making Capacity.”1 You made many of the same points as Ganzini et al,2 which are increasingly important to be understood by all practitioners caring for elderly and care-dependent patients.

I would like to ask the following:

1. While the law “presumes legal competence” unless adjudicated otherwise, should clinicians presume clinical capacity in settings with a known prevalence of incapacity exceeding 50%,3 such as assisted living (60%), skilled nursing (58%), and dementia units (100%)? Or rather should they “suspend disbelief” and screen in those settings, as mandated, for example, by the Minimum Data Set 2.0 (Item B.4)?

2. Are you familiar with—and convinced by—studies correlating capacity with executive control function?4-6 In my clinical nursing home work, I have been quite impressed by the value of Royall’s CLOX-1 screen7 in detecting incipient incapacity.

3. I thought the “C” in Appelbaum and Grisso’s “UARC” criteria8 stood for choice, making a settled decision. Granted, ability to communicate is an important element in legal competence, but making the choice in the first place is a more fundamental component of decision-making capacity, as I had understood it. To illustrate, I have several aphasic patients who can still make choices (and convey them using assistive technology), whom I assess as having capacity, but others who equivocate and vacillate (to an extreme degree) or who avoid making decisions altogether, whom I assess as not having decision-making capacity.

Sincerely,

Duncan S. MacLean, MD, CMD
West Grove, PA

REFERENCES
1. Lantz MS. Decision-making capacity. Clinical Geriatrics 2006;14(2):15-18.
2. Ganzini L, Volicer L, Nelson WA, et al. Ten myths about decision-making capacity. J Am Med Dir Assoc 2004;5:263-267.
3. Royall DR, Cordes J, Polk M. Executive control and the comprehension of medical information by elderly retirees. Exp Aging Res 1997;23(4):301-313.
4. Holzer JC. Cognitive functions in the informed consent evaluation process: A pilot study. J Am Acad Psychiatry Law 1997;25(4):531-540.
5. Marson D. Executive dysfunction and loss of capacity to consent to medical treatment in patients with Alzheimer’s disease. Semin Clin Neuropsychiatry 1999;4(1):41-49.
6. Royall DR, Palmer R, Chiodo LK, Polk MJ. Executive control mediates memory’s association with change in instrumental activities of daily living: The Freedom House Study. J Am Geriatr Soc 2005;53(1):11-17.
7. Royall DR, Cordes JA, Polk M. CLOX: An executive clock drawing task. J Neurol Neurosurg Psychiatry 1998;64:588-594.
8. Appelbaum PS, Grisso T. Assessing patients’ capacities to consent to treatment. N Engl J Med 1988;319:1635-1638.

Dr. Lantz responds:
Dr. MacLean raises issues that are both thought-provoking and practical. While there are many settings, such as dementia special care units of nursing facilities, homes for the developmental disabled older adult and those with severe persistent mental illness, where the majority of persons may lack the capacity to make decisions, the uniform adherence to our standard of presumed competence is vital. As the ability to make decisions often declines over time, it becomes even more important to evaluate the individual’s capacity regarding the specific issue in question. This can be a tedious and time-consuming process, but also quite rewarding when it allows an individual to maintain integrity near the end of life.