Aging and Capacity

1. Aging and Capacity Timothy Lau, MD, FRCP(C ), MSc., Director of Undergraduate Education, Faculty of Medicine, Department of Psychiatry UNIVERSITY OF OTTAWA Geriatric Psychiatry ROYAL OTTAWA HOSPITAL

2. Overview • Aging • Cognitive changes with aging • Normal aging vs. MCI vs. AD • Capacity • Principles • Revised statutes • For treatment, admission to LTC, personal care • For finances, wills

3. Aging and Life Expectancy • Human Life Span = 125 years • Life Expectancy • (number of years a person can be expected to live) at birth: • Females 81.2 yrs • Males 75.4 years

4. Heterogeneity vs. Triumph of the human spirit

5. Challenges of Late Life • Sensory loss • Medical illness • Financial worries • Retirement • Dependency • Dying and death • Bereavement • Cognitive disorders

6. What cognitive changes take place with age? • Cognition refers to mental processes used for perceiving, remembering, and thinking. Most studies show that, in general, cognitive abilities are the greatest when people are in their 30s and 40s. • Cognitive abilities stay about the same until the late 50s or early 60s, at which point they begin to decline, but to only a small degree. • The effects of cognitive changes are not usually noticed until the 70s and beyond. • These statements are based on data from studies where averages were calculated for each age group. Within each age group, however, there are wide variations in cognitive ability. The information presented here represents general findings about age-related cognitive change. They do not necessarily happen to everyone.

7. What cognitive changes take place with age? • One study of intelligence over a lifetime found that by the age of 81, only 30-40% of study participants had a significant decline in mental ability. Two-thirds of people at this age had only a small amount of decline. And only certain cognitive abilities decline, while others may improve. • 4 areas to focus on: • Fluid and crystallized intelligence • Attention • Processing speed • Memory

8. Fluid vs. crystallized intelligence • Different aspects of cognition are affected in various ways over time. One measure of cognitive ability is intelligence. A commonly-used system of categorizing intelligence is into "fluid" and "crystallized" intelligence. • Fluid intelligence (also called "native mental ability") is the information processing system. It refers to the ability to think and reason. It includes the speed with which information can be analyzed, and also includes attention and memory capacity. • Crystallized intelligence is accumulated information and vocabulary acquired from school and everyday life. It also encompasses the application of skills and knowledge to solving problems.

9. Fluid vs. crystallized intelligence • Many studies have shown that fluid intelligence is more likely to decline with age than crystallized intelligence. In fact, crystallized intelligence may continue to improve with age. Many people continue to gain expertise and skills in particular areas throughout life. • It is theorized that much of the cognitive decline with age can be traced back to deficits in the information processing system (fluid intelligence). Tasks that use well-practiced skills or familiar information are generally not affected by age. However, complex tasks that require taking in new information and analyzing it may become more difficult. Many researchers attribute this to deficits that occur in attention, speed of processing, and memory.

10. Attention • Attention is necessary for information to be taken in to begin with. Attention is the ability to focus on certain bits of information and to decide whether and how much to process it further. It's possible to pay attention to only a limited amount of information at any one time. Certain changes in attentional ability have been reported with older age. • Some researchers have found that many older adults have increasing difficulty distinguishing between information that is relevant and information that is irrelevant to a particular task. They have difficulty focusing only on the necessary information, and are susceptible to becoming distracted. This may slow down the speed of performing a mental task and may compromise accuracy. • Some researchers have proposed that these attentional difficulties may be the result of a general overall slowing of information processing that has been observed as people age.

11. Processing speed • Mental processing and reaction time become slower with age. This slowing of information processing speed actually begins in young adulthood (the late 20s), although imperceptibly at first. By the time people are past 60 or older (depending on the individual), they will generally take longer to perform mental tasks than younger people. • On tests of intelligence that require the person to perform tasks within a short time frame, older adults often do worse than younger counterparts. In the past, this was considered to be a measure of decreased cognitive functioning. However, on intelligence tests with liberal time limits, older adults are often able to perform just as well as younger people. Therefore, it's now thought by some experts that older adults don't lose mental competence, it simply takes longer to process the necessary information.

12. Processing speed • One theory holds that the slowing of processing speed is the cause of many of the cognitive difficulties with aging. However, it’s not yet known what other factors may be responsible. It has been found that some mental processes are slowed more than others. Research continues to be conducted to figure out the exact role of slowed processing speed and to determine what other factors may be at work. • In addition to cognitive decline, slowed processing speed has also been linked to a decline in motor function. Older adults may have less dexterity and coordination than when they were younger. They may walk slower and take a longer time to react. • Some researchers have suggested that slower processing speed may also have a negative impact on some types of memory. Whether or not this is the reason, most people experience at least some degree of age-related decline in some types of memory ability.

13. Memory • Memory is a complex function that has been divided into different types. Only some of these are affected by age. Difficulties that occur with memory are usually small and vary widely from person to person, making generalizations difficult. • Further complicating the memory picture are the different methods by which different researchers categorize memory. However, it is widely believed that one type of memory, called working memory, is most affected by age. Working memory is the retention of information that must be manipulated or transformed in some way.

14. Memory • Conscious mental processing goes on in working memory. It requires taking in information from the environment and from memory stores and accomplishing a mental task. For example, a restaurant check comes to $36.43. This amount is kept in memory while figuring out which bills to use to pay the check, how much tip to leave, and how much change is due back. • Everyone has limits on how much they can keep in working memory at one time. As people get older, complex mental tasks can become more difficult if they require too much information to be held in memory in order to process it. • Some researchers postulate that the problem with working memory is related to reduced speed of information processing, which reduces the efficiency of working memory.

15. Memory • Some researchers postulate that the problem with working memory is related to reduced speed of information processing, which reduces the efficiency of working memory. • One popular method for categorizing memory divides it into "implicit" memory and "explicit" memory. Implicit memory is the retention of skills and reflexes that have been acquired, such as the procedures for driving a car. Implicit memory generally remains intact throughout life. Explicit memory is the conscious memory of facts and events. These memories are more vulnerable to age-related decline.

16. Memory • Older adults may have increasing difficulty with word retrieval. In other words, recalling the name of a familiar person or object, the "tip of the tongue" phenomenon. The reasons for this are not known. • One theory suggests that this also is due to slowed processing speed. As people get older, they've known more people, so searching a larger memory "database" for the right name takes longer. The information is not forgotten altogether. If someone says the name or word, it will be recognizable. • There may also be a physiologic explanation for this word-finding problem, having to do with atrophy of a brain structure called the prefrontal cortex.

17. Memory • In general, memory tasks that are complex and require manipulating a lot of new information quickly become more difficult with age. Facts, names, and events that are not often accessed may become more difficult to retrieve from memory. • However, knowledge that has been accumulated over a lifetime, which is repeatedly accessed and expanded, is generally retained. Well-practiced skills and abilities remain intact. And vocabulary usually continues to increase throughout life.

18. Memory • It's important to emphasize that the changes in cognition described here do not necessarily happen to everyone. There is wide variation among individuals. • Additionally, for those who do experience declines in cognitive functioning, they are usually not disabling. The degree of decline is small and should not interfere with normal day-to-day functioning. • There are many ways to compensate for the deficits or even to regain lost function. It may take longer for an older person to learn something new, but it's still possible to learn it. Memory difficulties can be gotten around by using calendars, lists, and other memory aids.

19. Cognitive changes with aging • Common “normal” complaints • Problems concentrating with distraction • Decreased ability to attend multiple tasks • Slower reaction time • Learning, storage and retrieval of recently learned information • Difficulty recalling names of some people • Delayed verbal memory for words is mildly decreased • Spatial memory problems

20. What physical changes happen to the brain? • The brain undergoes some physical changes with advancing age. It's likely that these physical changes account for at least some of the noticeable cognitive changes. The exact links has so far proved elusive between the physiologic changes of the brain and the cognitive and other effects. • The brain is composed of numerous structures, each composed of nerve cells (also called neurons) and supporting cells called glia. Nerve cells transmit electrical and chemical signals, and this transmission of signals between neurons underlies cognition.

21. What physical changes happen to the brain? • In addition to the work of these cells, brain functioning depends on a complex interaction between the brain regions. The cortex, which is the outer coating where higher mental activities occur, is divided into several lobes, which are further subdivided into regions. Physical changes that take place in the brain affect some areas while leaving others intact. • 4 Discussion points • Brain shrinkage • Lost connections • Plasticity • Theoretical links cell loss cell atrophy interconnective loss

22. Brain Shrinkage • Throughout adulthood, there is a gradual reduction in the weight and volume of the brain. This decline is about 2% per decade. Contrary to previously held beliefs, the decline does not accelerate after the age of 50, but continues at about the same pace from early adulthood on. The accumulative effects of this are generally not noticed until older age. • It has long been thought that the reason for brain shrinkage is the loss of neurons. Some past studies estimated that adults lose as many as 100,000 neurons a day. However, improved testing techniques have revealed that the actual loss of neurons is far less significant than previously thought. While some brain cells are lost, the reduction in brain volume is more a function of the neurons themselves shrinking in size, making them less effective messengers.

23. Brain Shrinkage • While the brain does shrink in size, it does not do so uniformly. Certain structures are more prone to shrinkage. For example, the hippocampus and the frontal lobes, two structures involved in memory, often become smaller. This is partly due to a loss of neurons and partly due to the atrophy of some neurons. Many other brain structures suffer no loss in size. • In the Lancet 2001, University College of London reported results from a small study with serial magnetic resonance imaging (serial MRI) to look at certain brain regions in a group with a genetic mutation that predisposed them to Alzheimers disease. Compared to controls at the end of the study there was significant atrophy in the medial temporal lobes. It is hoped that this kind of technique could be used to diagnose early stage or pre-clinical Alzheimers.

24. Lost connections • The complexity of the brain is due in part to the intricate system of interconnections between neurons in the different parts of the brain. Neurons communicate with one another via specialized chemicals called neurotransmitters, of which there are several. • Changes in this network of communication may account for some of the cognitive changes seen with age. Some of the connections may be lost, and new connections may not be made as readily. In addition, levels of two neurotransmitters (acetylcholine and dopamine) are thought to decline with age.

25. Plasticity • On the bright side, the brain has a great capacity for adaptation, modification, and repair. The term plasticity refers to the ability of the brain to modify its structure and function. • This capability continues throughout life. For one thing, there is a certain amount of redundancy in the brain. If one network of neurons is damaged or dies, another network can take over the function. • The death of neurons can also be compensated for by surrounding neurons sprouting new connections to take the place of the lost ones.

26. Plasticity • The brain is a dynamic, not a static, system. The neurons respond to mental stimulation and environmental factors. And there is the capacity to respond to age-related changes. • It appears likely that cognitive changes are noticed at a point when the compensatory mechanisms of the brain are unable to overcome physical changes taking place. • There may be strategies, either with medications, mental exercises, or something else, to enhance the brain's natural capacity for plasticity and thus forestall cognitive declines associated with aging.

27. Research • A portion of the frontal lobe, called the prefrontal cortex, is involved in monitoring and controlling thoughts and actions. The atrophy that occurs in this brain region may account for the word finding difficulties many older adults experience. It may also account for forgetting where the car keys were put or general absentmindedness. • The shrinkage of both the frontal lobe and the hippocampus are thought to be responsible for memory difficulties. • Compensation- PET study 20-30’s vs. 70-80’s. Older group did as well but used different areas PFC vs. visual association cortex.

28. Research • The long-held view that no new neurons form in the brain during adulthood has been proven incorrect. In fact, one brain region found to sprout new neurons throughout life is the hippocampus, the area linked to learning and memory. • Does this area grow new neurons in response to mental stimulation? The answer to this question is not yet known. However, it has been shown in studies with mice that those reared in a stimulating environment, containing toys, exercise apparatus, and opportunities for social interaction, generated new neurons at a greater rate than litter mates raised in standard cages. The mice with more cells also performed better on learning and memory tests involving negotiating mazes. • If these findings are also true for humans, then staying mentally and physically active would translate into improved memory and learning.

29. Aging & Capacity • 80% = “Normal” • 5% of these are supernormal • 75% “Age consistent memory changes” - have variable decline from their youth • About 20% are “abnormal” • 12% have Mild Cognitive Impairment • 8% have dementia • AD (1/2 to 2/3 cases of dementia) • Rest have Mixed, Vascular, Frontotemporal or Lewy Body Disease • Rarely - reversible dementias - tumor, NPH, etc.

30. Super-normal • Age-consistent loss • Mild Cognitive Impairment -no deterioration from young -average for their age -1 s.d < mean of age matched controls (MCI) Spectrum of Cognitive Decline Normal Aging Abnormal Aging • Beginning of Dementia • (MCI-DAT) • Dementia • (DAT) • Benign Forgetfulness • (MCI-MCI) • Any decline is exacerbated by: • depression • medication • medical illness • neurological illness Chertkow H, Bergman H, Schipper H et al. CJNS 2001; 28: Suppl. 1 – S28-S41

31. Natural history… Progression of AD Diagnosable dementia Loss of IADL’s (Instrumental Activities of Daily Living) Emergence of neuropsychiatric symptoms Nursing home placement Loss of basic ADL’s Death

32. Capacity and planning ahead • Ben has been married for 50 years. He always managed the family’s money. But since his stroke Ben can’t walk or talk. Shirley, his wife, feels overwhelmed. She never discussed with him what he wants. She’s worried about Ben’s health and unsure what decisions to make about his care. But, on top of that, she has no idea what bills should be paid or when they are due. • Eighty-year-old Louise lives alone. One night she fell in the kitchen and broke her hip. She spent one week in the hospital and two months in an assisted living facility. Even though her son lives across the country, he was able to pay her bills and handle her health care questions right away. That’s because several years ago, Louise and her son talked about what to do in case of a medical emergency.

33. On the other hand, because Ben always took care of family financial matters, he never talked about the details with Shirley. No one but Ben knew that his life insurance policy was in a box in the closet or that the car title and deed to the house were filed in his desk drawer. Ben never expected his wife would have to take over. His lack of planning has made a tough situation even tougher for Shirley. • Ben also did not make it clear what he would have wanted regarding his health and Shirley is unsure what decisions to make, fearful of making the wrong decision.

34. CONSENT Capacity • “No man is good enough to govern another man without that other's consent.” Abraham Lincoln (1809 - 1865) “Most human beings have an almost infinite capacity for taking things for granted.” Aldous Huxley (1894 - 1963)

35. Principles of Capacity • Presumption of capacity • Principle of least restrictive alternatives • Prior wishes when capable > best interests > desires of families/others • Definition of capacity

36. “Lawyers are the only persons in whom ignorance of the law is not punished.” Jeremy Bentham

37. Relevant Questions • When and how do we assess capacity? • How do we obtain valid consent? • Who’s responsibility is it? • Who can we go to if we have a question about this? • REVISED STATUTES: http://www.e-laws.gov.on.ca/DBLaws/Statutes • www.alzheimersottawa.org • http://www.ccboard.on.ca/ • http://www.health.gov.on.ca/english/public/forms/

38. Relevant Legislation • RSOs • Mental Health Act • Health Care Consent Act • Substitute Decision Act • Common Law Act • Highway Traffic Act • CCC • Fitness • Section 16: NCR • Civil Capacity MHA...

39. POA’s • In Ontario there are three kinds: • Continuing power of attorney for property: covers your financial affairs and allows you to name a person to act for you – especially if you become mentally incapable. • Non-continuing power of attorney for property: covers your financial affairs but can't be used if you become mentally incapable. You might need this if you want someone to look after your financial affairs if you're away from home for an extended period – or if you own a property with someone and want that person to handle the sale, especially if you're going to be away. • Power of attorney for personal care: allows you to appoint someone else to make your personal decisions – such as housing and health care – if you can't communicate. It's also called a health-care proxy and a durable power of attorney for health care.

40. MHA • Deals with • which hospitals in Ontario are Psych facilities • how and when someone may be brought there • how they may be admitted • how they may be kept • who may see the records • financial incapacity under the Act in a Psych facility • rights to patient information • CTO’s HCCA...

41. HCCA • Deals with • the rule that there must generally be informed, capable consent before tx or admission to a care facility • what to do in emergency situations where legally valid consent is N/A • how to determine capability for medical tx, admission to a NSG home or home for the aged, and personal assistance services once there • how to identify a SDM for an incapable person • how a SDM should make decisions • options available if a SDM makes decisions in an improper fashion 3 parts...

42. Health Care Consent Act • 3 Parts • Treatment: A health care practitioner is to administer a treatment only with valid consent • Admission to care facility: • under Charitable Institutions Act, Homes of the Aged Act & Rest Homes Act, Nursing Homes Act • in a S-1 facility need MHA • Personal Assistance Services: • hygiene, washing, dressing, grooming, eating, drinking, elimination, ambulation, positioning... Consent...

43. 1. Consent for each indiv. tx 2. Entire course of tx 3. Plan of tx that deals with one or more health problems or likely foreseeable problems given current condition. May allow for withholding or withdrawing tx. With the exception of certain emergency situations no tx w/o valid consent (10.1) (informed, capable, voluntary) The law allows the health practitioner proposing the tx to proceed in 3 ways…. HCCA: Tx and consent consent...

44. Elements of consent (11.1(1)) related to tx informed Informed (11.3) nature expected benefits material risks and ASEs alternative courses of action likely consequences of not having tx HCCA: Tx • given voluntarily • w/o misrepresentation/fraud • Expressed or implied (11.4) • written or vocal • Included consent (12) • allows for variations/change in setting presuming nature/risks/benefits are not significantly different Tx...

45. Defining treatment: • “Anything that is done for a therapeutic, preventive, palliative, diagnostic, cosmetic, or other health-related purpose. It includes a course of treatment or a plan of treatment.”2.1 HCCA. • Treatment Excludes • Assessing capacity • Assessment/Examination to know the nature of the condition • Taking Hx • Communicating a Dx • Admission to hospital or other facility • Provision of basic care (washing, dressing, hygiene, etc.) • A treatment that in the circumstances poses little or no risk of harm • anything prescribed by the regulations not constituting treatment Capacity...

46. Defining capacity... • A person is capable wrt tx, admission to a care facility, or a personal assistance service, if the person is able to: • UNDERSTAND the information that is relevant to making a decision • (cognitive ability) • APPRECIATE the reasonably foreseeable consequences of an action or inaction • applying the information in his/her own situation, assimilate and reach a decision: examples weighing the advantages and disadvantages

47. Capacity depends on... • Treatment: may be capable for some and not others • Time: capacity can change, particularly with treatment and status may need review.

48. Who can assess capacity? • For treatment • any health care professional • Placement and personal care • Evaluator: usually hospitals have discharge planners [DP’s] or case managers [CM’s] CCAC • OT/PT/SW • Nurse • MD • Audiologists and speech pathologists • psychologist SDMs...

49. Practical questions for consent to treatment • Does the person understand the condition for which the specific tx is being proposed? • Is the person able to explain the nature of the tx and understand the relevant info? • Is the person aware of the possible outcomes of tx, alternatives or lack of treatment? • Are the person’s expectations realistic? • Is the person able to make a decision and communicate a choice? • Is the person able to manipulate the information rationally?

50. Practical questions for consent to placement • Is the person aware of the problems that prompted the recommendation for admission? • Is the person able to explain how admission to a long term care facility may address these problems? • Is the person able to explain what happens if he or she chooses not to live in a LTC facility? • Does the person recognize the risks associated with his or her living situation? • Is the person able to discuss alternative ways he or she may manage independently? • Does the person understand the role other people such as family or other caregivers are playing in providing for his or her needs?