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) 2nd
Ed. Oxford University Press
