ADDRESSING CAPACITY
ISSUES: COMBINING THE
UNIQUE PERSPECTIVES OF
OCCUPATIONAL
THERAPISTS AND SOCIAL
WORKERS
Anne O’Loughlin Social Worker
Gemma Byrne Occupational Therapist
St. Mary’s Hospital Phoenix Park
CAPACITY
At present, however, there is no generally
applicable definition of capacity at common law
or in statute (LRC, 2006 Vulnerable Adults and
the Law par1.61)
 Indeed there is an inextricable link between the
law on capacity and human rights since if a
person is judged to lack legal decision- making
capacity, this results in the removal of autonomy
(LRC 2006 Vulnerable Adults and the Law:2:06)

A CONCEPTUAL MODEL OF ASSESSMENT
(MOYE ET AL, 2007 GERONTOLOGIST47(5))
Medical condition
 Cognition
 EVERYDAY FUNCTIONING care of self;
financial; medical; home and community life; civil
or legal
 INDIVIDUAL VALUES, PREFERENCES, AND
PATTERNS
 RISK OF HARM/LEVEL OF SUPERVISION
NEEDED
 Means to Enhance Capacity

CAPACITY- NOT JUST THE FUNCTIONING
OF THE MIND

Of central importance is the need to take a broad
view of ‘capacity,’ from the situated perspective of
the individual, paying attention to values as well
as facts...our decisions are made against a
backdrop of values...values creep in when we
decide to do things (Hughes, J. 2014 How We
Think About Dementia)
FAILURE TO ACCURATELY ASSESS
CAPACITY
Overestimating decision- making capacity may
cause persons to be left in harmful environments
 Underestimating capacity may inadvertently
limit a person’s rights when, in fact decisionmaking ability remains preserved (Naik, 2006
JEAN 18.4)
 Although a clinical capacity opinion is not a legal
finding, it often serves as important evidence in
legal proceedings.

MULTIDISCIPLINARY TEAMS

To move beyond specific disciplinary approaches
it is critical that each discipline educate each
other about their own perspectives in order to
reduce the risk of misunderstandings (Dong, 2005
JEAN 17.3).
Occupational Therapy and
Cognitive Assessments
Overview
Cognition-definition and overview
 Cognitive Screening Tools

MMSE
 MoCA
 RUDAS
 ACE-III
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Functional Assessments
Cognition
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Defined as the “mental processes associated with
attending, processing, storing, retrieving and
manipulating information.”
The brain is the director of what we do, we are
functional beings and it allows us to do all that
we wish and need to do.
Older age, neurological event and other
unforeseen circumstances can often impact on
our brain functioning. Cognitive deficits are
often the indicators of such problems occurring
within the brain.
Cognition
 Sensation

Information from sense organs to nervous
system; sight, hearing, touch, taste, smell
 Cognition

Ability to perceive, represent and organise
objects, events and their relationship to one
another in an appropriate way; mental
processes that allow us to recognise, learn,
remember and attend to changing information
around us.
 Perception

Processes involved in making sense of the
senses; the way we interpret the information
gathered and processed by the senses.
Executive
Skills
Praxis
Memory
Object Recognition
Visual & Spatial Perception
Attention
Sensory Registration
Applying cognition to function
When patients present to our service, these
cognitive deficits are often self-described (by
patient or carer) in terms of functional problems
e.g. forgetting to take medications, poor ability to
attend to the day (implications for important
appointments), leaving appliances switched on
when finished using them, poor attention to detail
when managing finances, falling more frequently
etc.


Accurate assessment of cognitive
functioning and/ or impairment is
increasingly important for clinicians
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Early diagnosis provides opportunity for medication
management and compensatory strategy training
Helps identify at-risk clients
Provide education to family and/or carers
Living wills for end of life care
Power of attorney
An effective cognitive assessment should
reveal whether there is reason to suspect
that parts of the brain are working less
effectively than they should be.
Cognitive Screening Tools
Mini-Mental State Exam (MMSE)
 Montreal Cognitive Assessment (MoCA)
 Rowland Universal Dementia Assessment Scale
(RUDAS)
 Addenbrooks Cognitive Assessment (ACE-III)

MMSE
Brief screening tool, quick, no training required
 30 questions; screens orientation,
attention/concentration, memory, language and
perception
 Scoring

27-30 –Normal
 21-26- Mild Cognitive Impairment
 11-20- Moderate Cognitive Impairment
 0-10 –Severe Cognitive Impairment

MMSE Limitations
Patients with high premorbid intelligence or
education show a ceiling effect thus leading to
false negatives
 Great age, limited education, foreign culture, and
sensory impairment can produce false positives.
 Consequently, MMSE score needs adjustment for
age and education
 It is now copyrighted so there is a cost to use
 It does not assess higher level executive
functioning skills
 Insensitive to MCI
 Misclassifies aphasic patients

MOCA
Initially designed as a brief screening tool for
mild cognitive impairment
 Evaluates multiple domains of cognitive
functioning
 Available free of charge and is a one page 30
point test that takes 10mins to administer
 Short-term memory, visuospatial, executive,
attention, concentration and working memory,
language and orientation
 A cut-off of 25 and below indicates cognitive
impairment
 Excellent sensitivity in identifying MCI and AD

RUDAS
Designed to detect dementia and monitor
cognitive functioning over time
 6 items- 12 domains- memory, visuospatial,
praxis, visuoconstructional, judgement and
language
 A score of less than 22 indicates the potential of
cognitive impairment
 Strong correlation with the MMSE
 Better diagnostic accuracy than MMSE
 Excellent test-retest and inter-rater reliability
 It evaluates executive function which is absent
from MMSE
 Not influenced by language, education or gender

ACE-III
Multi-domain assessment taking 12-20mins to
administer- free of charge
 5 cognitive domains with comparable
contribution to the total score of 100, higher
scores indicate better cognitive functioning
 Domains include attention/orientation, fluency,
language, memory, and visuospatial function.
 The inclusion of the clock drawing test assesses
further cognitive areas i.e. Perceptual ability
 Much research published- however more research
into the strengths and limitations

Functional Assessments
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Washing and Dressing assessments – PADL
Kitchen assessment – DADL
Home Visit
We are most concerned with the daily problems that
arise out of such cognitive impairments. Regardless of
how well or how poorly a person scores, its how well
they can function safely on a day-to-day basis- this is
the most important factor.
Remember!
A score doesn’t make a person!
 People can score poorly on standardised tests
however, remain able to function at a high level
at home due to well established routines, habits
and supports.
 Cognition can fluctuate depending on a number
of factors..
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Medications
Medical illness
Dehydration
Delirium
Sleep deprivation
Depression
IN SUMMARY…
Cognition is one of the many factors that a team
use to base clinical decisions
 The MDT are enabled to consider these results in
the overall evaluation of a client and their status
 Cognitive assessments are key instruments in
establishing strengths, weaknesses and guidance
for treatment
 No one assessment will tick all the boxes

Experience will often direct our assessment
choice
 Despite the worthwhile benefits of scoring
systems and correlations between assessments,
the key outcome we are striving for is optimum
functioning for the individual in the most
appropriate environment which enables such
participation.
 Determining a persons capacity to make a
decision needs to be a team assessment and
decision.

WHEN CLIENT SAYS “NO”
Yet, the moral responsibilities of the
professionals rarely end at the point when the
client says “no”. Honouring autonomy does not
preclude further understanding of the values
underlying an individual’s decision making or
help clarify a patient’s anxiety of what is at
stake.
 Understanding the patient’s values, continued
attempts to persuade the patient, and ongoing
conversations with the patient are ethically valid
choices (Dong and Gorbien, 2005 JEAN 17.3)

INTERPLAY BETWEEN CAPACITY AND
MISTREATMENT
The importance of the psychosocial realm in the
assessment and interpretation of capacity
emerges as critical in situations of abuse
 Issues of power and gender influence assessment
 The ability to maintain relational connections
may be more pivotal than autonomy and
independence for women (O’Connor et al, 2009
JEAN 21.2)

MOVING BEYOND CAPACITY: UNDUE
INFLUENCE
Undue influence is the substitution of one
person’s will for the true desires of another.
Fraud, duress, threats or other types of pressure
often accompany it. It occurs when one person
uses his or her role and power to exploit the
trust, dependency, and fear of another.
 Vulnerability: illness; cognitive impairment;
emotional impairment; deeply isolated; major life
transitions; bereaved ; close ties to the
perpetrator (Quinn, M. 2000 ‘Undoing Undue Influence’

JEAN 12:2)
SELF-NEGLECT
The fact that a patient is able to simply state
risks and benefits of an intervention does not
necessarily mean that he or she believes they
apply to their own situation (Appreciation)
 Older adults who self neglect lack the capacity to
make decisions (decisional capacity ) and the
capacity to execute decisions regarding their
health, safety and independent living (executive
capacity)(Naik et al, 2006 JEAN 18.4)

‘CAPACITY’
We should think very broadly when we are
making decisions for other people and when we
are making judgements about their abilities to
make decisions.
 We are amongst other things emotional,
evaluative and volitional creatures... and our
decision making reflects our complex make- up.
Judgements about the decision making of others
must allow enough space for this breadth of
consideration (Hughes, J. 2014 How We Think
About Dementia: 95)

‘CAPACITY’: IN THE FUTURE??
Person’s capacity to be construed functionally
(understand, retain, use or weigh information,
communicate)
 Importance of past and present will and
preferences; beliefs and values; and other factors
person would be likely to consider if he or she
were able to do so
 Consider views of others: carers, those interested
in welfare, healthcare professionals (Assisted
Decision-Making (Capacity) Bill 2013 S.3)
