Capacity to Do

I wrote   an  earlier   post about   hoarding  in  relation  to  the  Mental  Capacity  Act  (2005)  which  is  used  in  the  UK  to  assess  an  individual’s  ability  to make  a decision about  a  specific  course  of  action  if  there  is  an  indication  of  a  disturbance  of  the  mind  or  brain.

However, what  the  Act  does  not    describe adequately is  an  individual’s  executive  capacity i.e  the  ability  to act   on a  decision. This  has  been   identified  as  being  important      when  considering  areas  such as  hoarding  and  self  neglect (SCIE, 2011).

To clarify  what  is  meant  by  the  term. Naik et al (2008) describe  decisional capacity as

…“the  process of  making  decisions for  oneself or  extending that power  to  another  individual” p.27

In  contrast executive  capacity  is  described  as ;

“ the  process  of  putting  one’s  decision into  effect either  alone  or by  delegating those  responsibilities  to  another more physically  able  individual” p.27

 I  guess  in simple terms, executive  capacity  is concerns the   ability  to  walk  the  walk in  contrast  to  talking  the  talk (decisional capacity).

It  has  been  argued that when  assessing  capacity particularly in relation  to  self  neglect,   decision  making  capacity  is  often  given  more  attention  than  executive  capacity (SCIE, 2011).  However, some  people may  have  decisional  capacity  but   lack  the   ability  to  put   their decisions  into  action  due  to  executive  dysfunction.  Naik  et  al (2008) therefore  argue  is  important  for  professionals  assess both  decisional and  executive  capacity   when     planning  care  for   adults at  risk of  self  neglect.  The  same  authors  describe an “Articulate-Demonstrate “ approach  to  capacity  assessment. This   may  involve  a  combination  of  standardised    assessments including  psychometric and  OT  assessments  and  more  individualised observation  of clients'  day  to  day  functioning. The authors argue  that  OTs  and  Nurse  Practitioners  are  in a good position  to assess  abilities to  carry out  agreed  decisions  in  areas  such as  managing medication,  maintaining  personal  care   etc   with  or  without  additional  support.

In  relation  to  hoarding, research  has   identified  that  people who  hoard  are more  likely  to  have problems   in  executive  functioning  such as problems with  categorisation and  decision making, reduced  concentration  and  increased  impulsivity   ( eg Hartl et al 2004; McMillan  et al 2012). This  can result in problems such as accumulation of  excess  clutter and  behaviours  such  as  “churning” whereby  the  hoarding individual   picks  up  an  item   from  a  pile  and  cannot  decide  what  to   do  about  it so puts  it  on another  pile , meaning that  the  pile  of  clutter  just  moves   from  one  area  to  another.  (Tolin  et  al, 2014)

To  give  the  following  case example.

 I  have  been  working  with  an older  age   client    who  was  diagnosed  with  Alzheimer’s   disease  about  a  year previously and  presents   with moderate cognitive  impairment.  She  is  however  very   articulate  and is  keen  to maintain  her  independence .  She  has  always   lived  alone  and  is  fiercely independent . On  assessment   it  appears   that  she  has  had  long  standing  hoarding  traits,  but  these  have  worsened   due  to  recent   cognitive  decline. She  lives  alone  in  a  cluttered   studio flat  but  can  just  about  negotiate  her  way to  key  areas  of  the  flat  such as the  kitchen and  the  bathroom  sink  and  toilet  but  often  has  to  move  items  out  of  the  way  as  she  moves  around.

She  has  had  falls  and there  is an  ongoing  fire  risk  as  areas  on  her  floor  are  covered  with  piles  of  paper. She  recognises  that  there  is  a  risk  should  her  environment become  more  cluttered,   but  she  is    keen  to address  this  issue  herself.  Over the several  months  I  have  known  this  client,  I always  arrive  to  find  her  busily working  through  piles  of  paperwork  which  never  end  up getting  filed or  organised  in  a  systematic  way so  the  piles never  reduce just  move from  place  to place  ie “churning”. Although  she  has   been very  careful  in  the past about  ensuring  she  pays  bills  on  time,  she  has  started to experience difficulties  managing finances, for  example writing  out  a cheque for  a bill  but  forgetting  to post  it. Her  bathroom floor  is  full  of  clothes  that  were  taken  to  the  laundry but  not  put away, so they  have  subsequently  become  dirty  again and lie in piles  waiting  to be  washed  again. In  summary  she   now  struggles  to  carry  out goal directed actions  through a  series  of  stages.

In  discussing  the  situation   with the  client,   it  appears  that she  has  the  decisional  capacity to  understand  the  risks  associated  with the  clutter  in  the  flat.  However  she  lacks  the  executive  capacity to  manage the  build  up  of  clutter  without  support.

Having   become  more  aware of the  concept of  executive  functioning in  relation  to mental  capacity  relatively  recently, I  think  there  are  two  clinical main implications relating  to  OT   practice.

•     For  OTs  carrying  out  capacity  assessments (as  with  other  members  of the MDT),  executive  capacity  as  well as  decisional  capacity  should  be  highlighted when considering areas of  self  neglect  and  hoarding.
•      In  considering  the  role  of   OT  for hoarding,  there  is  potential  role for  OT  in  carrying out  standardised and   non-standardised  assessment  of  functional  abilities (executive capacity)   to  help clarify  an  individual’s  mental capacity regarding  actions  to  manage  hoarding.

As  always  any  thoughts  or  comments  are  welcome.

References

Hartl, T.L., Frost, R.O., Allen, G.J., Deckersbach, T., Steketee,G., Duffnay, S.R. & Savage, C.R. (2004). Actual and perceived memory deficits in individuals with compulsive hoarding. Depression and Anxiety,20, 59-69.

McMillan SG, Rees CS, Pestell C (2013) An  investigation of  executive  functioning, attention and  working  memory  in  compulsive  hoarding,  Behavioural  and  Cognitive 

Psychotherapy, 41, 610-625.

Naik, A.D., Lai,JM and  Dyer,CB (2008) Assessing  capacity in  suspected  cases  of  self  neglect. Geritrics, 63 (2), 24-31  accessed  online http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2847362/

Social Care  Institute  for  Excellence (SCIE). (2011) Adult  Service  CSIE Report  46 “Self neglect  and  adult safeguarding: findings  from  research” p-26-38 accessed  online http://www.scie.org.uk/publications/reports/report46.asp  

Tolin,DF; Frost, RO and Steketee, G. Buried  in Treasures: Help for  Compulsive Acquiring,  Saving,  and  Hoarding (2014) 2^nd  Ed. Oxford  University Press