Balancing Adult Decisions

During a recent Zoom conference call, four Adult Immunization Service staff from California, using a tool called Decision-Making Interviews, or IDA, were trying to determine if something was wrong with an older woman. 82 they knew him as. Bi. K.

Adult Protection Services organizations in each state receive reports of potential neglect, neglect, abuse or exploitation of the elderly and other vulnerable adults. But agency staff are often faced with a deceptive question: Does the responsible adult have the power to make a decision about their medical care, living conditions or financial status – even if it is not a decision that the family, doctor, or financial adviser thinks should be made? ?

The IDA was developed by two pediatricians to help train Adult Immunization Service staff on how to handle the issue. The program helps them learn to use the interview process designed to gather information about a client’s decision-making ability. The two dozen California staff members taking the course had already completed 10 hours of personal online orders; they were now practicing their new interview skills in small groups, acting with facilitators.

Bi. K, the design character was played by Bess White, project specialist at Weill Cornell Medicine. In that case, the bank manager had reported some suspicion: Ms. K had $ 60,000 in a savings account but his withdrawal had increased dramatically, from $ 600 a month to $ 600 a week. The young man – his nephew, he said – had begun to escort her to the bank, where the spokesman thought the man appeared to be controlling and intimidating. The detective who visited Ms. K at home he discovered that his only credit card had expired and that he had little money.

But Ms. K denied financial exploitation; her nephew lived with her, she said, and helped with household chores and trips to the doctor’s appointment. He used bank money to buy their products.

In the exercise, one of the APS trainees had confirmed that Ms. K understood the basic concept of financial exploitation. Ms K had heard about the fraud from the news, she said. And yes, he understood that a friend or relative could also take advantage.

So the interviewee continued: “What do you think would happen if someone took someone else’s money without their permission?”

Bi. White, in place of Mrs. But when the respondent checked further to see if Ms. K understood that he himself could face this danger, he hesitated. Relying on her nephew, Ms. K said; he did not want to offend her.

The IDA was developed by Drs. Mark Lachs, co-chief of pediatrics and anti-depressants at Weill Cornell Medicine, and colleagues, and Drs. Jason Karlawish, pediatrician and co-director of the Penn Memorial Center. “People have the right to make bad decisions,” Drs. Lachs said in an interview. But, he added, decision-makers must be able to understand the risks they face and the possible consequences.

“How can you walk into a brokerage office at the age of 90 and say, ‘I’ve been with Treasury bills for 50 years but now I want to put my last $ 200,000 in Bitcoin’ – and no one is raising eyebrows?” Dr. Lachs said. “We’ll look back and say, ‘What were we thinking?'”

In addition to using the IDA for cases of neglect or misuse of funds, California APS staff were using it to assess a range of issues including self-care, health and safety questions, denial of physical or medical care, and physical or psychological abuse or sexual. .

“It does not make sense to replace a psychiatrist, but it does tell you when to contact a psychiatrist,” Drs. Lachs said. Clients whose IDA interviews indicate a lack of awareness of risks or consequences should receive a full professional evaluation, he added.

To date, about 500 APS employees – in New York City, Massachusetts and two states of California – have taken the course and received a certificate. Kansas APS staff will undergo training this summer.

But Dr. Lachs and Karlawish think IDA can be widely used. Loyalty and property lawyers and financial companies are already asking them about it.

Hospital discharge planners can use IDA to assess whether a patient is able to insist on returning home instead of being rehabilitated. A number of support centers contacted Dr. Lachs, wondering if the IDA could help ensure that new residents understand the complex contract they were signing.

The IDA interview attempts to answer three basic questions about a particular problem or danger, Drs. Karlawish stated: “Do you realize that this is happening? Do you think that could happen to you? Can you come up with a plan for dealing with it, pondering and weighing the pros and cons? ”

Depending on the complexity of the problem, people with cognitive impairment or even dementia may still have enough understanding to deal with it.

Someone who shows that understanding of the three parts during an IDA interview probably has the ability to make a decision – including the decision not to address the problem. The uninitiated may need more in-depth assessment, perhaps including consultation with family members or social service organizations. In the worst case scenario, it can lead to foster care or retention.

Financial problems are often used as an early warning of failure, said Dr. Daniel Marson, a neuroscientist at the University of Alabama in Birmingham who has studied the subject for 25 years.

“Financial capacity is probably the first high level of performance potential affected by neurodegenerative stress and normal aging,” he said. Spending money wisely requires complex ideas, ranging from “basic things like using an ATM to more complex things, such as ‘How do I make this phone from a mobile operator?'” , poverty, homelessness. , the establishment of an institution – can be very destructive.

Although the incidence of dementia has been declining in the United States and Europe, the aging of these people means that more people will develop it.

In addition, in a six-year study, Drs. Marson and colleagues found that older adults who were diagnosed with cognitive impairment – often the forerunner of dementia – also tried harder. “There was a decline in financial skills over time,” he said.

Some institutions have tried to address the issue of declining decision-making capacity. The U.S. Bar Association last year updated the “Evaluation of Decreased Adult Adults: A Book of Advocates.” The Law Society and the American Psychologists’ Association have also published books by judges and psychologists.

The Financial Sector Regulatory Authority, or FINRA, has published an online course on financial exploitation for vulnerable adults and other vulnerable investors. Its rules allow a member company to place a temporary restriction on transactions and payments when it believes that exploitation is involved. It also allows member companies to ask investors for a “trustworthy person” to consult in the event of suspected exploitation.

The IDA program targets APS staff at the moment because “a typical organization has fewer employees, has fewer resources and is struggling,” Drs. Karlawish said. California APS agencies deal with approximately 30,000 cases involving the elderly each month, according to government data, and are “asked to make decisions about the potential for mental health chairmanship,” Drs. Lachs said.

California staff at the Zoom training session, gently asking Ms. White – as Ms. K – how he could respond to the allegations of the bank manager, they finally concluded that he did not need to be professionally worked. It seemed that he understood his options.

Giving his nephew permission to access his savings account may not have been the wisest. But the decision was his.

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