During a recent conference call on Zoom, four California adult protection services operators, using a tool called Interview for Decisional Abilities, or IDA, were trying to figure out if something suspicious was happening to an 82-year-old woman they knew as the Mrs. K
Adult protective services agencies in every state receive reports of possible neglect, self-neglect, abuse, or exploitation of the elderly and other vulnerable adults. But temporary agency workers are constantly faced with a disturbing question: Does the adult in question have the ability to make a decision about their medical care, living conditions or finances, even if it is not the decision that the family, doctor or counselor financial do they think should be taken?
ida was developed by two geriatricians to help train adult protection service providers on how to manage this problem. The program helps them learn how to use a structured interview procedure to gather information about a client’s decision-making skills. The two dozen California staff members who attended the course had already completed 10 hours of individual online instruction; they were now practicing their new interviewing skills in small groups, role-playing with facilitators.
Ms. K, a fictional character, was played by Bess White, a special projects administrator at Weill Cornell Medicine. In the scenario, a bank manager had reported some suspicions: Ms. K had $ 60,000 in a savings account but her withdrawals had increased dramatically, from $ 600 a month to $ 600 a week. A man younger than her – her nephew of hers, said of her – had started accompanying her to the bank, where a cashier thought the man looked controlling and intimidating. An investigator who visited Ms. K at her home learned that her only credit card had expired and that she had little money.
But Ms K denied that she was being exploited financially; Her nephew lived with her, she said, and helped with the housework and rushed her to her doctor’s appointments. You used bank withdrawals to do your shopping.
In the exercise, one of the APS trainees had ascertained that Ms K had grasped the basic concept of financial exploitation. Ms. K had heard of news scams, she said. And yes, she understood that a friend or relative could take advantage of it in the same way.
Then the interviewer continued: “What do you think could happen if someone took another person’s money without their permission?”
Ms. White, playing Ms. K, replied: “I guess the person could pick it up and take it until there is nothing left.” But when the interviewer investigated further to see if Ms. K understood that she herself could have taken this risk, she hesitated. She was relying on her niece of hers, she said Ms. K; she didn’t want to upset him.
IDA was developed by Dr. Mark Lachen, co-director of geriatrics and palliative medicine at Weill Cornell Medicine, and his colleagues, and by Dr. Jason Karlawish, geriatrician and co-director of the Penn Memory Center. “People have the right to make bad decisions,” said Dr. Salmon said in an interview. But, he added, decision makers need to be able to understand the risks they run and the potential consequences.
“How can you walk into a brokerage office at 90 and say, ‘I’ve had Treasury bills for 50 years but now I want to put my last $ 200,000 in Bitcoin’ and nobody raises an eyebrow?” dott said the salmon. “We’ll look back and say, ‘What were we thinking?’”
In addition to applying the IDA to cases of financial negligence or abuse, California APS workers used it to assess a range of issues including self-neglect, health and safety concerns, denial of physical care or medical treatment. and physical or psychological or sexual abuse.
“It’s not meant to replace a psychiatrist, but it tells you when to contact a psychiatrist,” said Dr. said the salmon. Clients whose IDA interviews reveal an inability to grasp the risks or consequences should receive a comprehensive professional evaluation, she added.
To date, approximately 500 APS workers – in New York City, Massachusetts and two regions of California – have attended the course and received certification. Kansas APS workers will undergo training this summer.
But Docs Salch and Karlawish think IDA could have wider uses. Fiduciary and real estate lawyers and finance companies are already asking him.
Hospital discharge planners could use IDA to assess whether a patient has the ability to insist on going home instead of into rehab. A chain of care facilities contacted Dr. Salmon, wondering if IDA could help ensure the new residents understood the complicated contracts they were signing.
The IDA interview seeks to answer three fundamental questions about a particular problem or risk, said Dr. Karlawish said: “Do you recognize this is happening? Do you think this could happen to you? Can you come up with a plan to deal with it, reasoning and weighing the advantages and disadvantages? “
Depending on the complexity of a problem, people with diagnosed cognitive impairment or even dementia may still possess sufficient understanding to manage it.
Someone who demonstrates that three-part understanding during the IDA interview likely has the ability to make a decision, including a decision not to address the issue. Someone with no such understanding needs a more comprehensive assessment, possibly including consultation with family members or social service agencies. In extreme cases, it could lead to eventual protection or protection.
Finance management problems often serve as an early warning of failure, said Dr. Daniel Marson, a neuropsychologist at the University of Alabama at Birmingham, who has been studying the subject for 25 years.
“Financial capacity is probably the first higher-order functional capacity affected by neurodegenerative disorders and normal aging,” he said. Using money competently requires complex thinking, from “something as simple as using an ATM to more complicated things, like ‘How should I handle this call from a telemarketing salesperson?’” The consequences of diminished financial standing: conditions of unsafe life, impoverishment, homelessness, institutionalization – it can be devastating.
although the the incidence of dementia is decreasing in the United States and Europe, the aging of these populations means that more individuals will develop it.
Additionally, in a six-year study, Dr. Marson and colleagues found that older adults diagnosed with mild cognitive impairment – often a precursor condition of dementia – so he struggled more and more. “There have been diminished financial capabilities over time,” she said.
Other institutions have attempted to address the problem of diminished decision-making capacity. The American Bar Association updated its “Assessment of Seniors with Reduced Skills: A Handbook for Lawyers. ” The Bar Association and the American Psychological Association have also published manuals for judges and psychologists.
The Financial Industry Regulatory Authority, or FINRA, has published online courses on the financial exploitation of the elderly and other vulnerable investors. Its rules allow a member enterprise to temporarily suspend transactions and disbursements when it believes that exploitation is involved. It also allows member companies to ask investors for a “trusted contact person” to consult in the event of suspected exploitation.
The IDA program is focusing on APS workers for now because “the typical agency is understaffed, understaffed and struggling,” Dr. Karlaish said. California APS agencies handle about 30,000 cases involving seniors each month, according to state data, and “they are asked to make decisions about how well a psychiatry department chairman might struggle,” Dr. said the salmon
California staff during the Zoom training session, politely asking Ms. White – like Ms. K – how she could respond to the bank manager’s suspicions, eventually concluded that she didn’t need a professional job. She seemed to understand her options.
Giving your grandson access to his savings account may not have been the wisest move. But her decision was up to her.