R ights esponsibilities hetoric

Rights Responsibilities Rhetoric
Disclaimer
This speaker’s presentation represents the opinions of the author (s), and not necessarily those of the
Conference Organisers – the Guardianship Board of South Australia, the South Australian Public Advocate,
The Chief Psychiatrist, SA Health and the South Australian Public Trustee, or their organisations.
The contents are for general information only. They are not intended as professional advice – for that you
should consult a suitably qualified practitioner in the relevant field of law, mental health, guardianship,
advocacy, estate administration or trusteeship.
The Conference Organisers expressly disclaim all liability for any loss or damage arising from reliance upon any
information in these papers.
Copyright
©2009. Copyright in this material is retained by the author(s).
Permission to publish in this format has been granted to the Conference Organisers – the Guardianship Board
of South Australia, the South Australian Public Advocate, The Chief Psychiatrist, SA Health and the South
Australian Public Trustee.
Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under
the Copyright Act 1968, no part may be reproduced by any process without written permission from the author.
Organised by the SA Guardianship Board and the Chief Psychiatrist, SA Health in association with:
Neuropsychology & Mental
Capacity Assessments
Amie Foran – Royal Adelaide Hospital
Dr Rochelle Goodinson – Hampstead Rehab Centre
Julia Kuring – Repatriation General Hospital
Dr Elissa O’Connell – Hampstead Rehab Centre
Dr Emma Scamps – Brain Injury Rehab Service
Objectives
To increase participants’ ...
„ ...knowledge of the process of neuropsychological
assessment relevant to determination of decisionmaking capacity
„ ...knowledge of the specific cognitive functions
related to decision making ability
„ ...ability to utilise neuropsychological assessment
reports effectively
„ ...understanding of when referral to a
neuropsychologist may (or may not) be necessary
and/or useful
Clinical Psychology
„
Clinical psychologists are specialists in the assessment,
diagnosis and treatment of psychological problems and
mental illness
„
Referrals for:
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Depression (incl. bipolar disorder)
Anxiety disorders
Personality disorders
Psychosis
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Grief and loss
Traumatic events
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Adjustment (retirement/health problems/dementia)
„
Clinical Neuropsychology
„
Assessment, diagnosis and treatment of psychological
disorders associated with conditions affecting the CNS
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Understand brain/behaviour relationships
Identify cognitive strengths/weaknesses
Differential diagnosis
Strategies for rehabilitation
Education: consumers, families, carers, other health
professionals
Decision making capacity
Training
„
Qualifications
„
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Undergraduate degree in psychology (3yrs plus honours),
plus
Masters (2yrs), or clinical Doctorate (3yrs), or combined
Masters/PhD (4yrs) in Clinical Neuropsychology
State registered – but soon to be National
„
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Australian Psychological Society (APS)
APS College of Clinical Neuropsychologists
„
Membership restricted to psychologists who have completed
specialised training and supervised experience in the field.
Settings
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Paediatric
Rehabilitation
Neuroscience
Mental Health
Geriatric/Aged Care
Medico-Legal
Public vs Private Practice
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Public
Eligibility criteria
„ Waiting lists (longer)
„
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Private
Fees
„ Waiting lists (shorter)
„ Private Health Insurance (minimal)
„ No Medicare
„
Objectives
To…
„ ...increase participants’ knowledge of the process of
neuropsychological assessment relevant to
determination of decision-making capacity
„
...discuss the advantages of using
Neuropsychology in capacity assessments
Decision Making Capacity:
In a neuropsychological assessment of DMC:
„ The person has the ability to “understand and
appreciate (relevant) information” (Darzins et al. (2000). “Who can
decide?” p 2)
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That the person has received pertinent information
That they reasonably know risks, alternatives,
consequences of decision
Their choices depend on their personal values and goals
Decision Making Capacity Is Not:
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A bad decision
A decision with which we do not agree
Based solely on a person having a degree of
cognitive impairment or a mental illness
To the Neuropsychologist,
Decision-Making Capacity is Specific To:
„
The Domain
„ Financial, Life-style, Medical etc.
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The Decision
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For example, within Medical – consent to blood test versus
consent to complex surgery.
That Period of Time
Decision-Making Capacity is Specific:
This is why neuropsychologists request a specific
referral question
Rather than a referral for:
“Capacity assessment”
We prefer:
“Does this person have the capacity to appoint an
EPOA at this time?”
Neuropsychologists
„
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Have skill in the clinical interview and test
interpretation
Have experience in translating test results to
everyday function
Can integrate mood, personality and cognitive
factors which contribute to decision making
capacity
Have experience in differentiating
psychopathology from organic brain impairment
Neuropsychological Assessment
„
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Involves advanced training in the application and
interpretation of neuropsychological tests for a range of
disorders and contexts across the lifespan (paediatric to
geriatric)
Requires strong knowledge of brain structure, function
and dysfunction, and the effects of multiple factors on
cognitive, emotional and behavioural function
Uses a scientist-practitioner model and evidence-based
practice to take a hypothesis testing approach to
assessment
Neuropsychological Tests
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Are sensitive to impairment
Test performance is not based just on the endscore
“Norms” take into account the person's age,
education and gender
Comparison is made with pre-morbid
functioning
Neuropsychological Assessment Versus
Screening Tools
„
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Mini-Mental State Exam (MMSE), Frontal
Assessment Battery (FAB) etc. often used to
screen cognitive functioning
These tests use an end score, either out of 30
(for MMSE) or 18 (for FAB)
Some difficulties in interpretation can arise with
these scores
Neuropsychological Assessment Versus
Screening Tools
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What if English is their second language?
What if the person is of high pre-morbid intellect/ or ID?
What if they have had numerous screens (learning effects)?
What if they cannot use their hands to draw or write/ are
illiterate/ cannot see well and then the test is /28 (for MMSE).
What does 25/28 mean?
What does 27/30 mean for an 87 year old with Yr 7 education
who had learning difficulties at school?
What if their cognitive deficits lie in domains other than those
which these screens assess?
Advantages of Neuropsychological Assessment
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Objective, valid and reliable method of
comprehensively assessing many domains of
cognition
Can assess abilities related to decision making
Analyse task demands (handle a compensation/
lump sum payout vs. daily budget)
Advantages of Neuropsychological Assessment
„
Neuropsychological tests can provide specific
information about:
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Are these scores “normal” for age, ed, gender or do they
represent cognitive decline from premorbid?
Is their decision-making capacity likely to change?
What process is breaking down?
Can strategies be employed that may assist this person’s
ability to understand and appreciate the information?
Take Home Points
Neuropsychological assessment…
„ Is more than simply administering tests.
„
„
It is a process
Our training, background and highly
standardised tests enable us to play a valuable
role in the assessment of decision-making
capacity
Objective
„
To increase participants’…
… knowledge of the specific cognitive functions
related to decision making ability
Assessment of Capacity
Assessment is multi-layered
1. Background information
2. Interview with the individual (ideally seen over
more than one occasion)
3. Formal neuropsychological testing
4. Personality and values
1. Assessment: Background Information
Researching the individual;
„ Interview with relevant other’s (family, carers,
other staff)
„ Literature review/evidence-based research
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Reviewing medical files, brain scans
Contacting the GP, other specialists
2. Assessment: Interview With the
Individual
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Assists in determining the individual’s
awareness and insight into their abilities and
disabilities
As important as the test results themselves
Interview Questions
„
Is the individual;
Aware of the need for assessment?
„ Understand why other’s are concerned?
„ Able to acknowledge their functional and/or
cognitive limitations?
„ Realistic about the impact their deficits may have on
their safety?
„ Able to identify how they will minimise their safety
risks?
„
Interview Questions
Aware of their options? If not, are they open to
different options?
„ Able to see the dis/advantages of these options?
„
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Able to foresee the likely consequences of their
decision?
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Communicate their reasoning behind their decision?
(other factors?)
3. Aspects Of Functioning Important
To Assessment
1.
2.
3.
4.
5.
6.
7.
8.
9.
Insight
Orientation and Attention/Concentration
Working memory
Language
Arithmetic
Memory (short and long term)
Executive Functioning (initiate, reason, abstract,
problem solve, use judgement, form and apply
strategies, plan, think flexibly)
Emotions/Mood
Other factors
Attention & Concentration
„ Can the person take in the important
information?
„ Can they maintain their concentration for long
enough to think through the information?
„ Can they block out irrelevant information that
may interfere with their ability to make this
decision?
Language
„ Can the person understand the information
provided?
„ Can they generate and articulate their responses
in a way that effectively communicates their
wishes?
Memory
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Can they learn new information?
„
Can they retain information long enough to
consider all the relevant facts?
„
Is their decision consistent over time?
Executive functioning
„ Can they hold multiple-pieces of information in their
mind at the one time to compare and evaluate them?
„
Are they open to learning about different ideas or
options or are they overly rigid in their thinking?
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Can they engage in basic problem-solving & reasoning?
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Can they convert their intentions/verbalisations into
actions?
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Can they set goals, plan how to achieve it, monitor their
performance, and evaluate the consequences of their
behavior?
Emotions/mood
„ Is there uncontrollable fear or worry?
„
Do they have depressed mood? Does this lead
to non-compliance?
Is the person’s thinking disorganised?
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Are they hallucinating?
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4. Other Factors
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Values about guardianship: wants, preferences
for whom?
How decisions are made: alone or with others?
Goals and quality of life: what are the person’s
valued relationships, activities?
What are the individual's likes and dislikes,
hopes and fears?
What are their cultural and religious beliefs?
Take Home Points
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Given the comprehensive nature of the Ax and
importance of decision, the entire process for
a neuropsychological capacity assessment could
take several hours (eg., up to a full day or more,
in very complex cases)
The information gathered from the assessment
is interpreted and produced in a
neuropsychological report for the Tribunal
Objectives
To increase participants’ ...
„ … ability to utilise neuropsychological
assessment reports effectively
„ …understanding of the confounds of
neuropsychological capacity assessments, and
the collaboration with other professionals when
forming an opinion around mental capacity
The Neuropsychology Report
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Referral question
History
Presentation
Assessment results
Summary, conclusions and opinion
The report can provide a recommendation for the
tribunal around a person’s decision making capacity,
but the tribunal decides if a person is competent
The Audience
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The consumer
Acute medical and allied health professionals
Rehabilitation professionals
Carers
Family
The Tribunal
When To Use A Report
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The question of capacity needs to have been
addressed in the report for the report to be
appropriate for use in a GSB hearing
„
If the question of capacity has not been
addressed, it is not appropriate to send the
report to the GSB. A new referral to the
neuropsychologist is required
Confounds Of Neuropsychological
Assessment
Confounds can impact on the neuropsychological
assessment results and present challenges in
interpreting these results
Confounds
What are the common confounds to testing
and test interpretation:
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Non-standardized administration
Environmental factors
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Interruptions
Mood effects
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Fatigue
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Confounds
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Pain
Medication effects
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English as a Second Language
Difficulty estimating premorbid level of
functioning
Test-retest effects
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Effort
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Controlling For Confounds
„ Modify environment
„ Use appropriate interpreters
„ Use hearing devices
„ Develop rapport
Consultation With Others
„ Medical staff
„ Nurses
„ Carers
„ Allied
Health Professionals
„ Family and other interested parties
Take Home Points
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Specific referral questions enable
neuropsychology reports to be appropriate for
the GSB
Neuropsychology reports need to address the
issue of mental capacity for them to be
appropriate for use in a GSB hearing
Confounds to assessment are carefully
controlled for
Case Studies
Case Study 1 - Anna
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Background
79 year old
„ Lives alone with Domiciliary Care support (3x wk
showering)
„ 2 daughters live in UK
„ 2 friends have EPOA
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Anna
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Medical
Left parietal CVA 3 weeks prior to Ax
„ Previous right CVA with residual left homonymous
hemianopia & left hemiparesis
„ Pulmonary fibrosis (on home oxygen)
„ GORD
„ Anxiety/depression
„ Hypertension
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Anna – current issues
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Reduced mobility
Reduced upper limb functioning (L>R)
Reduced vision
SP recommended soft diet
Reduced memory
Concerns re planning/ problem solving
Treating team recommending RCF
Anna wanting to return home
Anna – formal NP Ax
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Premorbid : low average
Orientation : reduced, knew location
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Attention & working memory
„ low average, attended well over 1 hr session
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Language
„ markedly compromised word-finding & fluency
responses appropriate, followed instructions
Memory
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markedly reduced, subtle benefit from prompting
recalled conversation, incorporated previous info into
later responses, consistent over time
Anna – formal NP Ax
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Executive Functioning
„ Borderline
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good response to hypothetical emergency problemsolving scenario
identified goal, plan, and how to monitor
Emotions/Mood
„ elevated symptoms of depression, anxiety & stress
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identified her concerns & potential management
strategies, willing to consider treatment options
Anna – Interview
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Articulated her desire to return home and
treating team’s recommendation for RCF
Aware of physical & cognitive limitations &
potential safety risks; willing to accept help
Identified advantages of home & both
advantages and disadvantages of RCF without
prompting
With closed questions identified disadvantages
of home
Anna – Interview
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Could see likely consequences of home & RCF
Clear and consistent in reasons given for
decision
Willing to consider RCF if trial at home
unsuccessful
No evidence of tangential thoughts, disordered
thinking, perseveration or delusions
Recommendation - Anna
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Support needed for complex decision making
due to reduced cognitive abilities
Strategies to be considered:
Allow extra time
„ Summarise key points & repeat new info
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No clear evidence to suggest she was not
currently capable of making decisions in relation
to returning home or moving to an RCF (i.e.
must assume she does have capacity)
Case Study 2 - Bill
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Background
65 year old
„ Lives with his 89 year old mother
„ No children
„ Nil formal supports
„ Receives DSP
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Bill
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Medical
Current admission (2 months prior to Ax) dizziness,
confusion & wrist injury post fall. Auditory & visual
hallucinations noted during admission.
„ Prostatitis
„ ETOH abuse
„ Recurrent falls
„ Previous suicide attempts
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Bill – current issues
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Cognitive impairment ?ETOH related (ETOH abuse)
Pathological gambling
Depression with suicidal intent (increase in anti-depressant)
Learning disability in reading and writing
OT assessment
„ Unable to read bank statements/complete simple bank forms
„ Vulnerable to financial exploitation
Concerns re risk of losing savings/inheritance to gambling
Treating team recommending Administration order
Bill wants to retain control of his finances
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Bill – formal NP Ax
Premorbid : low average
Orientation : preserved
Attention & working memory
„ low average, variable attention over 80min session
Language
„ word-finding preserved, listening comprehension 4yrs:4m
„ responses relevant (but inconsistent), followed instructions
Memory
„ mildly reduced
„ recalled conversation, unable to incorporate previous info
into later responses, consistent in decision, inconsistent in
details provided re finances
Bill – formal NP Ax
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Executive Functioning
„ Extremely low verbal reasoning, rigid/concrete
„ poor response to hypothetical banking problem-solving
scenario
„ Identified goal (stick to budget) but unable to identify
reasonable plan or how to monitor performance of plan
Emotions/Mood
„ elevated symptoms of depression, anxiety & stress
„ willing to consider treatment options
Bill – Interview
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Articulated his desire to retain control of his finances
and aware of options of Public Trustee/family as
administrators
Aware he had spent a large sum of money in 12 month
period & risk of losing savings; unwilling to accept help
Identified disadvantages of Administrator without
prompting
With closed questions identified advantages of selfmanagement
Unable to acknowledge potential advantages of
Administrator or disadvantages of self-management
Bill – Interview
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Unable to see likely consequences of self-management
& Administrator
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Risk of over-spending vs limited access to money
Clear and consistent in his desire to retain control of his
finances
Inconsistent in details provided re his finances (e.g.
assets, debts, strategies to limit spending)
Unwilling to consider Administrator in any instance
Evidence of disordered thinking, rigidity
Recommendation - Bill
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Support needed for complex decision making due to
reduced cognitive abilities
Strategies to be considered:
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Allow extra time
Use clear, concrete information & examples
Suggest he is not currently capable of making decisions
in relation to managing his finances (self-management
vs Administrator); recommend application to GSB for
Administration order.
Objective
To increase participants’...
…understanding of when referral to a Clinical
Neuropsychologist may (or may not) be
necessary and/or useful.
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Conclusion
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Question time
Key Indicators for Referral
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Diagnostic formulation
Distinguishing the impact of different diagnoses
Extent of cognitive difficulties is unknown
History is unclear
Borderline cognitive status
Previous level of functioning is unknown
Key Indicators for Referral
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Presentation is inconsistent with behaviour or
functioning
Psychological confounds
Poor effort, malingering or symptom
exaggeration
Challenging behaviours
Legal issues (i.e. order may be contended)
Risks to consumer, staff and/or others
Do Not Refer to Neuropsychology
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Not medically stable
Not able to comprehend simple commands
Overtly confused or delirious
Intoxicated (note exceptions)
Recent changes to medication or planned
intervention that could change mentation,
Severe receptive language difficulties
Severely dysphasic (note exceptions)
Not compliant
Writing a Referral to
Neuropsychology
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Your/the referrer’s name and contact details
The consumer’s name, age and gender
The reason/s for referral
Specific referral question
„
The consumers’ primary diagnosis
Relevant medical and psychiatric history
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If an interpreter is required
„
Writing a Referral to
Neuropsychology
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Factors that may effect administration of pen
and paper tasks
Vision or hearing impairments
The presence of behaviours that will impede
testing (effort, aggression, etc)
Planned date of discharge, surgery, transfer,
tribunal hearing, and other information to assist
with planning
Summary
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Neuropsychologists are well qualified to conduct capacity
assessments
Neuropsychology assessments are comprehensive and time
consuming to reflect the significance of the opinion given
Neuropsychologists assess for domain and decision specific
mental capacity
The most appropriate referrals are often those that are
complex, diagnostically challenging or when there are
significant confounds present
Reports addressing specific referral questions will be most
appropriate for the GSB
Discussion
Organised by the SA Guardianship Board and the
Chief Psychiatrist, SA Health in association with
Rights Responsibilities Rhetoric
`