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During a recent Zoom conference call, four Adult Protective Services employees from California were trying to figure out if something suspicious was going on with an 82-year-old woman using a tool called the Decision-Making Ability Interview, or IDA. Mrs. K.
Adult Protective Services agencies in each state receive reports of possible neglect, self-neglect, abuse or exploitation of the elderly and other vulnerable adults. But agency workers are constantly faced with a vexing question: Does the adult in question have the capacity to make a decision about their medical care, living conditions, or finances, even if it’s not the decision the family, doctor, or financial advisor thinks they should make?
IDA It was developed by two geriatricians to help train Adult Protective Services staff on how to address this issue. The program helps them learn to use a structured interview procedure to gather information about a client’s decision-making ability. The two dozen California personnel who took the course had already completed 10 hours of individual online training; they were now role-playing their new interviewing skills in small groups, with facilitators.
A fictional character, Ms. K is played by Bess White, special projects manager at Weill Cornell Medicine. In the scenario, a bank manager expressed some doubts: Ms. K had $60,000 in a savings account, but her withdrawal amount increased sharply, from $600 a month to $600 a week. A younger man—his nephew, she said—had begun accompanying him to the bank, where the teller thought the man looked controlling and intimidating. An inspector who visited Ms. K at her home learned that her single credit card had expired and she had very little cash.
However, Ms. K denied that she was financially exploited; She said her niece lived with her and helped with the housework and made it to her doctor’s appointments. She used bank checks to do her grocery shopping.
In the exercise, one of the APS trainees found that Ms. K grasped the basic concept of financial exploitation. Ms. K said she heard about the scam on the news. And yes, she understood that a friend or relative could benefit in a similar way.
The interviewer then continued: “What would happen if someone took someone else’s money without permission?”
Ms. White, who played Mrs. K, replied, “I think one can take it and take it until there is nothing left.” But when the interviewer did more research to see if Ms. K understood that she might be at risk, she gave up. Saying that she trusts her niece, Ms. K; she didn’t want to upset him.
D., co-chair of geriatrics and palliative medicine at IDA, Weill Cornell Medicine. Mark Lachs and colleagues, and geriatrician and co-director of the Penn Memory Center Dr. Developed by Jason Karlawish. Dr. “People have the right to make bad decisions,” Lachs said in an interview. But he added that decision makers need to be able to understand the risks they face and the possible consequences.
“How can you walk into a 90-year-old brokerage and say, ‘I’ve had Treasury bonds for 50 years, but now I want to put my last $200,000 in Bitcoin’ – and no one raises an eyebrow?” said Dr. “We’re going to look back at this and say, ‘What were we thinking?’ we will say.”
In addition to applying the IDA to cases of financial neglect or abuse, California APS employees used it to assess a range of issues, including self-neglect, health and safety questions, refusal of physical care or medical treatment, and physical or psychological or sexual abuse. .
Dr. “It’s not intended to replace a psychiatrist, but it tells you when to contact a psychiatrist,” Lachs said. He added that clients whose IDA interviews reveal that they did not understand the risks or consequences should seek a full professional evaluation.
To date, nearly 500 APS employees in New York City, Massachusetts, and two California counties have taken the course and are certified. Kansas APS employees will undergo training this summer.
But Dr. Lachs and Karlawish think IDA could have wider uses. Trust and real estate lawyers and financial firms are already asking them this.
Hospital discharge planners can use IDA to assess whether a patient has the capacity to insist on going home rather than rehab. Wondering if the chain of assisted living facilities could help new residents understand the complex contracts they signed, Dr. He contacted Lachs.
Dr. Karlawish said the IDA interview tries to answer three key questions about a particular problem or risk: “Do you know what happened? Do you think this could happen to you? Can you come up with a plan to address this, can you reason and weigh the pros and cons?”
Depending on the complexity of a problem, people with diagnosed cognitive impairment or even dementia may still have enough understanding to deal with it.
Someone who demonstrates the three-part understanding during the IDA interview is likely capable of making a decision – including the decision not to resolve the issue. Someone who does not have this understanding needs a more comprehensive assessment, perhaps including consultation with family members or social service agencies. In extreme cases, it can lead to ultimate guardianship or guardianship.
A neuropsychologist at the University of Alabama at Birmingham, who has been researching the subject for 25 years, Dr. Daniel Marson says overcoming financial problems often serves as an early warning of incapacity.
“Financial capacity is probably the first high-level functional ability to be affected by neurodegenerative disorders and normal aging,” he said. Using money competently is from something basic like “using an ATM to ‘How should I handle this call from a telemarketer?’ It requires complex thinking, down to “more complex things like , institutionalization – can be devastating.
despite Dementia incidence decreased In the United States and Europe, the aging of these populations means that more individuals will develop it.
Also, in a six-year study, Dr. Marson and colleagues found that older adults diagnosed with mild cognitive impairment—usually a precursor to dementia—a condition. also struggled more and more. “There were financial skills that dwindled over time,” he said.
Other institutions have tried to address the problem of reduced decision-making ability. The American Bar Association last yearEvaluation of Disabled Older Adults: A Handbook for LawyersThe Bar Association and the American Psychological Association have also published handbooks for judges and psychologists.
The Financial Industry Regulatory Authority, or FINRA, has published online courses about the financial exploitation of older adults and other vulnerable investors. its rules allows a member firm to temporarily suspend transactions and payments when it believes that abuse has occurred. It also allows member firms to request a “trusted contact” from investors if abuse is suspected.
For now, the IDA program focuses on APS employees because “the typical office is understaffed, under-resourced and struggling,” said Dr. carlawish California APS agencies handle approximately 30,000 cases each month involving the elderly, according to state data, and Dr. “They’re being asked to make decisions about the capacity a psychiatry department head can have difficulty with,” Lachs said.
The California staff at the Zoom training session politely asked Ms. White—as Mrs. K—how she could respond to the bank manager’s doubts, eventually concluding that she didn’t need professional work. It turned out that he understood his options.
Allowing your niece to access her savings account may not be the smartest move. But the decision was his.
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