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New tool helps evaluate older adults’ decision-making ability

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An elderly resident walks in a residential facility with the help of a nurse.

Geriatricians created the interview for decisional abilities to help social services workers determine whether further evaluation is required. Stephane de Sakutin/AFP via Getty Images

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There’s a new tool to help gauge the decision-making ability of older adults regarding a range of risks, from financial exploitation to self-neglect. The interview for decisional abilities, developed by geriatricians at Weill Cornell Medicine and the University of Pennsylvania, isn’t intended to replace a formal psychiatric evaluation, but to help adult protective services workers in the field determine whether a person is capable of making informed choices about their lives or whether further assessment is needed.

The system works to establish three things: whether a person has understanding that a given risk exists; appreciation that they themselves might be at risk; and reasoning about what could be done to mitigate the risk.

“It’s meant to indicate, as a screen, if you will, that something is amiss and we need to turf this upstairs a bit to really figure out what’s going on. Because many of the things that cause impaired decision-making ability, in older and younger people are treatable — a drug that’s having a cognitive side effect, thyroid disease, any number of things,” said system co-creator Dr. Mark Lachs, chief of geriatrics and palliative medicine at Weill Cornell Medicine and director of geriatrics at New York Presbyterian Healthcare System, in an interview with Marketplace’s David Brancaccio.

“I am in the business of honoring patient preferences — even if it means people discounting my medical advice, ranging from ‘take your insulin’ to ‘don’t smoke two packs of cigarettes a day at 86.’ And if people have the cognitive ability to make those decisions, they can,” Lachs said.

“But I will tell you that getting old can be hard, but getting old without money is really hard. And there’s a huge amount of data that suggests that these social forces in medicine — food insecurity, poverty — really overwhelm what I do is a physician. And my job becomes much harder when the horse has left the barn, if you will.”

The following is an edited transcript of the interview.

David Brancaccio: What you have is this interview for decisional abilities, IDA, and it can’t be too complex, right? The person is in the field.

Dr. Mark Lachs: Yeah, that’s exactly right. So the Cornell-Penn IDA is intended not to replace a formal psychiatric evaluation, but it’s intended to determine if there’s a concern, if there’s difficulty whereupon this could be kicked upstairs, if you will, for someone to make a formal assessment.

Brancaccio: So the first set of questions would be: Are you aware that people can completely rip an older person off?

Lachs: That is correct. So, in the training, we actually have a financial example in which an older man — widowed, lonely — has gotten involved in sort of a May-December romance. You know, “Do you realize that there’s a situation in which older people can have their money taken, and be preyed upon?” — “Oh yeah, I’ve heard of that. I saw that on ’60 Minutes’ or ’20/20” — he has a general understanding. “Do you think this could be happening to you?” — appreciation. “Well, I did notice that there have been withdrawals from my checking account. And I let my new girlfriend use my ATM card for groceries, but I’ve noticed, now, that larger amounts are disappearing” — so there, too, it’s a reasonable example that there’s a personal appreciation. And then reasoning would be the third step: “How do you think we could mitigate this?” — and the answer might be a trusted adult child or an attorney who could handle these matters. That’s a reasonable plan, as opposed to saying, “This person I’ve known for a few weeks loves me deeply, and I don’t need a plan because this is not happening to me.” And again, I reiterate that this is not meant to replace a very serious legal intervention, like guardianship or conservatorship, or getting a power of attorney. It’s meant to indicate, as a screen, if you will, that something is amiss and we need to turf this upstairs a bit to really figure out what’s going on. Because many of the things that cause impaired decision-making ability, in older and younger people are treatable. You know, a drug that’s having a cognitive side effect, thyroid disease, any number of things. And that’s what we geriatricians are in the business of ferreting out.

Brancaccio: You’ve written a book about the following, you’ve thought a lot about this. It’s not the adult protective services person’s job, or even your job as a geriatrician, to stop people from doing what they want with their resources — as long as their brain is working reasonably.

Lachs: That is correct. I am in the business of honoring patient preferences — even if it means people discounting my medical advice, ranging from “take your insulin” to “don’t smoke two packs of cigarettes a day at 86.” And if people have the cognitive ability to make those decisions, they can. Now, look, I’ve been accused [of] discriminating against older people; after all, younger people have a right to make decisions, why aren’t we going after them? I believe this tool might be useful in younger patients with other kinds of mental illness that’s impairing decision making ability. But I will tell you, David, that getting old can be hard, but getting old without money is really hard. And there’s a huge amount of data that suggests that these social forces in medicine — food insecurity, poverty — really overwhelm what I do is a physician. And my job becomes much harder when the horse has left the barn, if you will.

Brancaccio: On this IDA system that you and your colleague came up with, how long does it take to get your head around this?

Lachs: The training involves both a curriculum in which you asynchronously — that is, on your own time — take in the information, and then in a synchronous, live version on Zoom, you learn the technique, display what you’ve learned, role play, and then you bring it into the field and come back yet again to determine how you did. So this is not something you can learn in a few minutes. It is not something meant to replace a psychiatrist’s evaluation, if needed. It is not a simple tool, it’s not a depression or anxiety questionnaire you fill out. It’s a skill, a valuable skill. And the reports we’re getting from the folks who do this work is they feel it’s upped their game.

Brancaccio: So what do you figure, is it a couple of weeks of homework and then the live Zoom, something like that?

Lachs: Yeah, it’s 10 to 20 hours of training, and then two or three hours of Zoom class, reflection, going out using the tool and coming back. Really, a small investment to really protect the rights and dignity of older people.

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