U.S. Department of Veterans Affairs Public Access Author manuscript Clin Gerontol. Author manuscript; available in PMC 2017 June 09. Published in final edited form as: Clin Gerontol. 2017 ; 40(1): 1–2. doi:10.1080/07317115.2016.1238676.
VA Author Manuscript
Theory, Science, and Practice for Advancing Capacity Evaluation in Older Adults Jennifer Moye VA Boston Healthcare System and Harvard Medical School, Boston, Massachusetts, USA Fellow Clinical Gerontologists, welcome to issue 1 of 2017.
VA Author Manuscript
With this issue we celebrate two milestones—first, our special issue on capacity assessment and second, our 40th volume year. Clinical Gerontologist, under the founding leadership of Editor T.L. Brink has been a forum for research and clinical commentary regarding behavioral healthcare of older adults for more than 40 years. In 1977, when the journal started, the United States “baby boom” population was age 13–31! Now, baby boomers span ages 53–71 and drive population aging along with the fact of increasing longevity. Worldwide, population aging continues with growth across regions and especially in developing countries, with 26% of the world’s population projected to be 65+ by 2050 (United Nations, 2015). The demand for practitioners to be prepared to meet the needs of older adults is nothing if not secure—now we just have to ramp up the supply.
VA Author Manuscript
Since we are looking back, I will share that I do remember 24 years ago being quite daunted by a request to evaluate an older adult’s decision making capacity. In this case the older adult was on our acute medical unit and he wanted to go home against medical advice. The home situation raised concerns about his ability to care for himself and his home. Never had the tension between promoting autonomy and protecting from harm been so vividly set before me. Over the years I’ve done a fair amount of writing and research trying to wrap my mind around the complex issues that present themselves when capacity is in question. Periodically I’ve turned my attention elsewhere but capacity always draws me back, with its clinical and ethical complexities and its increasing frequency in our practice. We begin our special issue on capacity with a review of financial exploitation by Wood and Lichtenberg (2017). I suspect that most of our readers have been stunned and angered when they have encountered the sophisticated and devious approaches to defrauding an older family member or client. Wood and Lichtenberg provide a nice overview, weaving together the issue of financial capacity and contextual risk factors. Their article is followed by two original research articles from leading capacity researchers. First, we have a contribution from Dan Marson’s research group (Niccolai et al., 2017). Marson has been our scientific capacity sage for many years and we are excited to share his recent findings describing the prediction of change in financial capacity over 2 years in adults with MCI by measures of written arithmetic, confrontation naming, immediate visual memory, and visual attention. These findings are quite different from studies associating declines in consent capacity associated with memory, confrontation naming, and set shifting (Moye, Karel, Gurrera, & Azar, 2005) pointing to the unique characteristics of financial capacity. Next, we have a contribution by Barton Palmer and the UCSD capacity research group who have examined
Moye
Page 2
VA Author Manuscript
many aspects of capacity including research consent and issues that arise within psychiatric populations (Palmer et al, 2017). In this paper, 30% of older adults with Alzheimer’s disease were assessed to retain the capacity to consent to two research hypothetical projects—both with a relative high complexity and risk profile (phase 2 and phase 3 clinical trials). Not surprisingly, capacity was associated with level of cognitive impairment—but also with age and education. These findings again remind us of the need to not assume that persons with dementia lack capacity, but instead to consider a person’s ability as assessed specifically for the task at hand.
VA Author Manuscript
Our remaining papers are more clinical in nature, and in my opinion point to a direction that is needed in capacity education. We have good foundational frameworks and research studies (although many questions remain), now we have much to learn through case examples which illustrate specific issues in the minefield which is capacity. Page and Hinrichs’ (2017) clinical comment addresses the important issue of restoration of capacity in an interesting case where the older adult, treatment team, lawyers, evaluator, and judge saw the case differently. Hillman’s (2017) clinical comment also describes a case where disagreement ruled the day—this time disagreement between the older adult, treatment team, and family about the older adult’s sexual consent capacity. Both papers will surely hold your attention and include tables with details about measures and questions to ask that I hope will be useful to practitioners.
VA Author Manuscript
We have two additional papers where a new and emerging professional took the lead. It takes some guts and time investment to look back at our work and critically assess “what did I do, what happened next, was I right, and what can I do better next time?” Feng and colleagues (Feng, Murphy, & Mlinac, 2017) look back at 25 cases of independent living capacity evaluations in a home based primary care setting (HBPC). They summarize the challenges and ethical concerns they encountered and suggest ways forward. One of the challenges when someone lacks capacity to live independently is really working through whether all interventions to keep a person at home have been exhausted. About half the clients found to lack capacity were provided further support which resulted in them staying in home an average of 3 months more. We close the issue with a terrific paper by Prusaczyk and colleagues (2017) that stitches together the perspectives of emergency medicine, orthopaedic surgery, social work, and medical ethics when determining research consent capacity. They discuss the issues of timing, corrective feedback, plain language, and proxy consent in addressing research consent capacity. Their paper is a unique contribution in providing the viewpoints of these different disciplines. We hope this special issue on capacity enhances your theoretical, scientific and applied knowledge for these critically important evaluations.
References Feng MC, Murphy MR, Mlinac M. Independent Living Capacity Evaluation in Home-Based Primary Care: Considerations and Outcomes of a Quality Improvement Project. Clinical Gerontologist. 2017; 40(1):51–62. [PubMed: 28111494] Hillman J. Sexual Consent Capacity: Ethical Issues and Challenges in Long-Term Care. Clinical Gerontologist. 2017; 40(1):43–50. [PubMed: 28452627]
Clin Gerontol. Author manuscript; available in PMC 2017 June 09.
Moye
Page 3
VA Author Manuscript
Moye J, Karel MJ, Gurrera RJ, Azar AR. Neuropsychological predictors of decision making capacity over nine months in mild to moderate dementia. Journal of General Internal Medicine. 2005; 21:78– 83. DOI: 10.1111/j.1525-1497.2005.00288.x Niccolai LM, Triebel KL, Gerstenecker A, McPherson TO, Cutter GR, Martin RC, Marson DC. Neurocognitive Predictors of Declining Financial Capacity in Persons with Mild Cognitive Impairment. Clinical Gerontologist. 2017; 40(1):14–23. [PubMed: 28452629] Page KS, Hinrichs KLM. Swimming against the Tide: A Case Study on the Removal of Conservatorship and Guardianship. Clinical Gerontologist. 2017; 40(1):35–42. [PubMed: 28452626] Palmer BW, Harmell AL, Pinto LL, Dunn LB, Kim SYH, Golshan S, Jeste DV. Determinants of Capacity to Consent to Research on Alzheimer’s Disease. Clinical Gerontologist. 2017; 40(1):24– 34. [PubMed: 28154452] Prusaczyk B, Cherney SM, Carpenter CR, DuBois JM. Informed Consent to Research with Cognitively Impaired Adults: Transdisciplinary Challenges and Opportunities. Clinical Gerontologist. 2017; 40(1):63–73. [PubMed: 28452628] United Nations, Department of Economic and Social Affairs, Population Division. World population prospects: The 2015 revision. New York: United Nations; 2015. Wood S, Lichtenberg PA. Financial Capacity and Financial Exploitation of Older Adults: Research Findings, Policy Recommendations and Clinical Implications. Clinical Gerontologist. 2017; 40(1): 3–13. [PubMed: 28452630]
VA Author Manuscript VA Author Manuscript Clin Gerontol. Author manuscript; available in PMC 2017 June 09.
VA Author Manuscript
Theory, Science, and Practice for Advancing Capacity Evaluation in Older Adults Jennifer Moye VA Boston Healthcare System and Harvard Medical School, Boston, Massachusetts, USA Fellow Clinical Gerontologists, welcome to issue 1 of 2017.
VA Author Manuscript
With this issue we celebrate two milestones—first, our special issue on capacity assessment and second, our 40th volume year. Clinical Gerontologist, under the founding leadership of Editor T.L. Brink has been a forum for research and clinical commentary regarding behavioral healthcare of older adults for more than 40 years. In 1977, when the journal started, the United States “baby boom” population was age 13–31! Now, baby boomers span ages 53–71 and drive population aging along with the fact of increasing longevity. Worldwide, population aging continues with growth across regions and especially in developing countries, with 26% of the world’s population projected to be 65+ by 2050 (United Nations, 2015). The demand for practitioners to be prepared to meet the needs of older adults is nothing if not secure—now we just have to ramp up the supply.
VA Author Manuscript
Since we are looking back, I will share that I do remember 24 years ago being quite daunted by a request to evaluate an older adult’s decision making capacity. In this case the older adult was on our acute medical unit and he wanted to go home against medical advice. The home situation raised concerns about his ability to care for himself and his home. Never had the tension between promoting autonomy and protecting from harm been so vividly set before me. Over the years I’ve done a fair amount of writing and research trying to wrap my mind around the complex issues that present themselves when capacity is in question. Periodically I’ve turned my attention elsewhere but capacity always draws me back, with its clinical and ethical complexities and its increasing frequency in our practice. We begin our special issue on capacity with a review of financial exploitation by Wood and Lichtenberg (2017). I suspect that most of our readers have been stunned and angered when they have encountered the sophisticated and devious approaches to defrauding an older family member or client. Wood and Lichtenberg provide a nice overview, weaving together the issue of financial capacity and contextual risk factors. Their article is followed by two original research articles from leading capacity researchers. First, we have a contribution from Dan Marson’s research group (Niccolai et al., 2017). Marson has been our scientific capacity sage for many years and we are excited to share his recent findings describing the prediction of change in financial capacity over 2 years in adults with MCI by measures of written arithmetic, confrontation naming, immediate visual memory, and visual attention. These findings are quite different from studies associating declines in consent capacity associated with memory, confrontation naming, and set shifting (Moye, Karel, Gurrera, & Azar, 2005) pointing to the unique characteristics of financial capacity. Next, we have a contribution by Barton Palmer and the UCSD capacity research group who have examined
Moye
Page 2
VA Author Manuscript
many aspects of capacity including research consent and issues that arise within psychiatric populations (Palmer et al, 2017). In this paper, 30% of older adults with Alzheimer’s disease were assessed to retain the capacity to consent to two research hypothetical projects—both with a relative high complexity and risk profile (phase 2 and phase 3 clinical trials). Not surprisingly, capacity was associated with level of cognitive impairment—but also with age and education. These findings again remind us of the need to not assume that persons with dementia lack capacity, but instead to consider a person’s ability as assessed specifically for the task at hand.
VA Author Manuscript
Our remaining papers are more clinical in nature, and in my opinion point to a direction that is needed in capacity education. We have good foundational frameworks and research studies (although many questions remain), now we have much to learn through case examples which illustrate specific issues in the minefield which is capacity. Page and Hinrichs’ (2017) clinical comment addresses the important issue of restoration of capacity in an interesting case where the older adult, treatment team, lawyers, evaluator, and judge saw the case differently. Hillman’s (2017) clinical comment also describes a case where disagreement ruled the day—this time disagreement between the older adult, treatment team, and family about the older adult’s sexual consent capacity. Both papers will surely hold your attention and include tables with details about measures and questions to ask that I hope will be useful to practitioners.
VA Author Manuscript
We have two additional papers where a new and emerging professional took the lead. It takes some guts and time investment to look back at our work and critically assess “what did I do, what happened next, was I right, and what can I do better next time?” Feng and colleagues (Feng, Murphy, & Mlinac, 2017) look back at 25 cases of independent living capacity evaluations in a home based primary care setting (HBPC). They summarize the challenges and ethical concerns they encountered and suggest ways forward. One of the challenges when someone lacks capacity to live independently is really working through whether all interventions to keep a person at home have been exhausted. About half the clients found to lack capacity were provided further support which resulted in them staying in home an average of 3 months more. We close the issue with a terrific paper by Prusaczyk and colleagues (2017) that stitches together the perspectives of emergency medicine, orthopaedic surgery, social work, and medical ethics when determining research consent capacity. They discuss the issues of timing, corrective feedback, plain language, and proxy consent in addressing research consent capacity. Their paper is a unique contribution in providing the viewpoints of these different disciplines. We hope this special issue on capacity enhances your theoretical, scientific and applied knowledge for these critically important evaluations.
References Feng MC, Murphy MR, Mlinac M. Independent Living Capacity Evaluation in Home-Based Primary Care: Considerations and Outcomes of a Quality Improvement Project. Clinical Gerontologist. 2017; 40(1):51–62. [PubMed: 28111494] Hillman J. Sexual Consent Capacity: Ethical Issues and Challenges in Long-Term Care. Clinical Gerontologist. 2017; 40(1):43–50. [PubMed: 28452627]
Clin Gerontol. Author manuscript; available in PMC 2017 June 09.
Moye
Page 3
VA Author Manuscript
Moye J, Karel MJ, Gurrera RJ, Azar AR. Neuropsychological predictors of decision making capacity over nine months in mild to moderate dementia. Journal of General Internal Medicine. 2005; 21:78– 83. DOI: 10.1111/j.1525-1497.2005.00288.x Niccolai LM, Triebel KL, Gerstenecker A, McPherson TO, Cutter GR, Martin RC, Marson DC. Neurocognitive Predictors of Declining Financial Capacity in Persons with Mild Cognitive Impairment. Clinical Gerontologist. 2017; 40(1):14–23. [PubMed: 28452629] Page KS, Hinrichs KLM. Swimming against the Tide: A Case Study on the Removal of Conservatorship and Guardianship. Clinical Gerontologist. 2017; 40(1):35–42. [PubMed: 28452626] Palmer BW, Harmell AL, Pinto LL, Dunn LB, Kim SYH, Golshan S, Jeste DV. Determinants of Capacity to Consent to Research on Alzheimer’s Disease. Clinical Gerontologist. 2017; 40(1):24– 34. [PubMed: 28154452] Prusaczyk B, Cherney SM, Carpenter CR, DuBois JM. Informed Consent to Research with Cognitively Impaired Adults: Transdisciplinary Challenges and Opportunities. Clinical Gerontologist. 2017; 40(1):63–73. [PubMed: 28452628] United Nations, Department of Economic and Social Affairs, Population Division. World population prospects: The 2015 revision. New York: United Nations; 2015. Wood S, Lichtenberg PA. Financial Capacity and Financial Exploitation of Older Adults: Research Findings, Policy Recommendations and Clinical Implications. Clinical Gerontologist. 2017; 40(1): 3–13. [PubMed: 28452630]
VA Author Manuscript VA Author Manuscript Clin Gerontol. Author manuscript; available in PMC 2017 June 09.
