diminished mental capacity in the elderly

Assessment of Older Adults with Diminished Capacity: A Handbook for Lawyers v With the coming demographic avalanche of Boomers reaching their 60s and the over-80 popula-tion swelling, lawyers face a growing challenge: older clients with problems in decision-making capacity. Epidemiological studies in the elderly population have suggested that financial capacity is an “advanced” activity of daily living (ADL), also called an instrumental ADL or IADL (Wolinsky & Johnson, 1991). Over the past 10 years, the topic of treatment consent capacity in elderly persons has been receiving increasing research attention (Kim et al., 2002), yet the overall number of studies is still small. Here, we’ll discuss planning strategies that can protect your loved ones from incapacity of all kinds. Someone who pleads a “by reason of insanity” defense, if successful, will receive a “not guilty” verdict. In addition to considering a wider range of capacities, it will be important for researchers to characterize the nature of capacity impairment within a wider range of older patient groups. Coinciding with that increase, the number of Americans with Alzheimer’s (just one of the causes of diminished capacity) is predicted to climb from its 2015 total of 5.3 million to 7.8 million in 2030 and to 9.5 million in 2035, according to the Alzheimer’s Association. In future studies, researchers need to address issues of normative longitudinal change in financial capacity over the life course, the natural history of financial capacity loss in patients with dementia, and cognitive predictors of financial capacity. We review research efforts in two domains: medical decision-making capacity and financial capacity. The past 10 years has witnessed the emergence of capacity assessment in aging as a field of study, with a growing body of empirical studies, a promising first generation of capacity assessment instruments, and a small but growing cadre of scientific researchers. These studies also find that patients with dementia are impaired on consent abilities, and that as the dementia progresses, so too do the consent impairments. In Section 1(3), the Uniform Health-Care Decisions Act (National Conference of Commissioners on Uniform State Laws, 1993) defines consent capacity as “the ability to understand significant benefits, risks, and alternatives to proposed health care and to make and communicate a health-care decision.” As a capacity, treatment consent is distinctive for several reasons: (a) it arises in a medical and not a legal setting; (b) it generally involves a physician, psychologist, or other health care professional, and not a legal professional, as decision maker about capacity; and (c) these judgments are rarely subject to judicial review (Grisso, 2003). “Due to the nature of their client relationships, registrants are in a position to be among the first to recognize signs of diminished mental capacity or financial exploitation of older or vulnerable clients,” said Louis Morisset, CSA Chair and President and CEO of the Autorité des marchés financiers. In an earlier factor analytic study, consent capacity as a construct in AD was explained by two neuropsychologically mediated factors associated with verbal conceptualization and verbal memory (Dymek, Marson, & Harrell, 1999). Don’t Let Diminished Financial Capacity Put Your Elderly Loved Ones At Risk—Part 2. Martin is a 74-year-old former solicitor diagnosed with a form of dementia involving progressive loss of language, who wished to revoke the Enduring Power of Attorney (EPOA) in which he had previously appointed his ex-wife. Among these instruments are those produced by the MacArthur Group to assess capacity to consent to treatment (Grisso & Appelbaum, 1998b) and research (Appelbaum & Grisso, 2001), by Marson and colleagues to assess capacity to consent to treatment (Marson, Ingram, Cody, & Harrell, 1995) and financial decision making (Marson et al., 2000), as well as instruments to assess the capacity to live independently (guardianship; Anderer, 1997; Loeb, 1996). Could an incongruence between patient and clinician values about treatment decision making (see, e.g., Jahng, Martin, Golin, & DiMatteo, 2005) impact the outcome of capacity assessments? As noted in Table 1,<--CO?1--> situations requiring guardianship or conservatorship are resolved in a court of law, and they require a legal determination regarding competency. In our review of 16 studies (some with multiple publications), patient sample sizes ranged from 20 to 100 individuals (M = 41.44, SD = 22.54), as presented in Table 2. A diminished mental capacity plea is different from the similar “not guilty by reason of insanity” plea. (, Moye, J., Karel, M. J., Gurrera, R. J., Azar, A. R. (, National Conference of Commissioners on Uniform State Laws. This capacity comprises a domain so vast it can include almost all areas of functioning, and it may manifest itself in poorly understood behaviors such as “self-neglect” and with extreme unsanitary living conditions (Moye, 2003). (, Etchells, E., Darzins, P., Silberfeld, M., Singer, P. A., McKenny, J., Naglie, G., et al. For instance, a person who is sick and delirious might temporarily lose all the above capacities. As a result of these changes, capacity assessment, previously a relatively peripheral aspect of clinical or legal practice, has over the past 20 years become a generic, everyday issue that permeates different sectors of society. Know what a will or trust is and what it does. Behavioral Sciences and the Law.. Jahng, K. H., Martin, L. R., Golin, C. E., DiMatteo, M. R. (, Kim, S. Y. H., Caine, E. D., Currier, G. W., Leibovici, A., Ryan, J. M. (, Kim, S. Y. H., Karlawish, J. H. T., Caine, E. D. (, Krynski, M. D., Tymchuk, A. J., Ouslander, J. G. (, Markson, L. J., Kern, D. C., Annas, G. J., Glantz, L. H. (, Marson, D. C., Annis, S. M., McInturff, B., Bartolucci, A., Harrell, L. E. (, Marson, D. C., Chatterjee, A., Ingram, K. K., Harrell, L. E. (, Marson, D. C., Cody, H. A., Ingram, K. K., Harrell, L. E. (, Marson, D. C., Earnst, K., Jamil, F., Bartolucci, A., Harrell, L. E. (, Marson, D. C., Hawkins, L., McInturff, B., Harrell, L. E. (, Marson, D. C, Huthwaite, J., Hebert, K. (, Marson, D. C., Ingram, K. K., Cody, H. A., Harrell, L. E. (, Marson, D. C., McInturff, B., Hawkins, L., Bartolucci, A., Harrell, L. E. (, Marson, D. C, Sawrie, S., Snyder, S., McInturff, B., Stalvey, T., Boothe, A., et al. For example, studies might focus on capacity impairment within dementia subtypes (AD, PD, diffuse Lewy body disease, and frontal lobe dementia), and within other neuropsychiatric illnesses such as schizophrenia and profound depression. Having said that, and while recognizing that any investor may be socially vulnerable, this report focuses on issues more specific to older adults. NI = not indicated; CCTI = Capacity to Consent to Treatment Instrument; HCAI = Hopemont Capacity Assessment Interview; MacCAT-T = MacArthur Competency Assessment Tool for Treatment; CAT = Capacity Assessment Tool; UTD = Understanding Treatment Disclosures; ACE = Aid to Capacity Evaluation; TRAT = Thinking Rationally About Treatment. There are at least eight major capacity domains of relevance to older adults with neuropsychiatric illness, as presented in Table 1. The law requires that a person making or revising a will or trust must have “testamentary capacity.” That means that the maker must generally be able to: 1. They are meant to supplement but not supplant clinical judgment about capacity. Accordingly, studies are needed of the relationship between legal and clinical models of capacity, and of the relationship between clinical assessments and juridical actions (e.g., what kind of capacity assessments lead to optimal judicial orders). Know the “natural objects of his or her bounty” — in plain English, those most likely to receive his or her money or other property. A Boom in the Elderly Population With more and more Baby Boomers reaching retirement age each year, our country is undergoing an unprecedented demographic transformation that’s been dubbed “The Greying of America.” This population shift stands to affect many aspects of life, especially your relationships with aging par Thus, capacity assessment training should become a part of the clinical training of physicians, psychologists, and other health care professionals working with the elderly population (Karlawish & Schmitt, 2000; Marson, Sawrie, et al., 2000). These studies should also explore how clinicians from different disciplinary backgrounds may vary in their capacity assessment approach and outcomes. Two clinical areas that have received the most research attention are treatment consent capacity and financial capacity. E-mail: Search for other works by this author on: Journal of the American Geriatric Society, Journal of the American Geriatrics Society, Alzheimer Disease and Associated Disorders, Copyright 2007 by The Gerontological Society of America, Cross-national differences in the association between retirement and memory decline, Aging Narratives over 210 years (1810-2019), The Differential Impact of Retirement on Informal Caregiving, Volunteering, and Grandparenting: Results of a Three-Year Panel Study, Feeling Gratitude is Associated with Better Well-being across the Life Span: A Daily Diary Study during the COVID-19 Outbreak, Changes in self-estimated step-over ability among older adults: A 3-year follow-up study, The Journals of Gerontology, Series B (1995-present), About The Journals of Gerontology, Series B, About The Gerontological Society of America, American Bar Association Commission on Law and Aging and American Psychological Association, 2005, Marson, Chatterjee, Ingram, & Harrell, 1996, Moye, Gurrera, Karel, Edelstein, & O'Connell, 2006, Marson, McInturff, Hawkins, Bartolucci, & Harrell, 1997, National Conference of Commissioners on Uniform State Laws, 1993, Pruchno, Smyer, Rose, Hartman-Stein, & Laribee-Henderson, 1995, Carney, Neugroschl, Morrison, Marin, & Siu, 2001, Kim, Caine, Currier, Leibovici, & Ryan, 2001, Schmand, Gouwenberg, Smit, & Jonker, 1999, Wong, Clare, Holland, Watson, & Gunn, 2000, Marson, Annis, McInturff, Bartolucci, & Harrell, 1999, Marson, Earnst, Jamil, Bartolucci, & Harrell, 2000, Dymek, Atchison, Harrell, & Marson, 2001), Gurrera, Moye, Karel, Azar, & Armesto, 2006, Van Wielingen, Tuokko, Carmer, Mateer, & Hultsch, 2004, http://www.law.upenn.edu/bll/ulc/fnact99/1990s/uhcda93.pdf, Journal of Gerontology: Psychological Sciences, Receive exclusive offers and updates from Oxford Academic, Research Assistant Professor of Epidemiology, Board Certified or Board Eligible AP/CP Full-Time or Part-Time Pathologist, Broad; involves cognitive and procedural skills, Yes; when another party petitions for guardianship, or if elder abuse discovered, Yes; when another party petitions for conservatorship, or if elder exploitation discovered, Rarely; only in contested situations with conflict between family or health care professionals, Rarely; only in contested situations (often postmortem), Very rarely; only if brought for litigation, Extremely rarely; in most states voting rights remain even under plenary guardianship, Rarely; only if arises in context of guardianship, although registries of motor vehicles may suspend license without judicial review, Copyright © 2020 The Gerontological Society of America. dThe study also included a middle-aged comparison sample of adults with mental illness and learning disability. The IADLs are mediated by higher cognitive function and can be distinguished from “household” ADLs (e.g., preparing meals, shopping, doing housework) and “basic” ADLs (e.g., bathing, dressing, walking; see Wolinsky & Johnson). The emphasis on function has sparked efforts at developing standardized instruments to empirically measure skills in these domains. However, in such cases where there exists a previously appointed surrogate (such as a health care proxy), the authority of the surrogate springs into effect on the basis of a clinical finding of diminished capacity without judicial review. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. We offer summaries of research to illustrate the range, strengths, and limitations of existing research, and to serve as a basis for outlining an agenda for future research. The first is expressing a choice, which is the ability simply to convey a relatively consistent treatment choice. Someone who is victorious on a diminished mental capacity plea, however, will simply be convicted of a lesser offense. Capacity assessment of older adults will become increasingly important over the coming century. Further, in practice, many situations of diminished capacity are managed without any formal determination of incapacity or appointment of a surrogate. eThe study also included a comparison group with depression. Specifically, the recommendations call for: Educating professionals about capacity issues and on the assessment tools for determining mental capacity in older adults, such as the Department of Veterans Affairs guide "Assessment of Competency and Capacity of the Older Adult: A Practice Guideline for Psychologists.". There are steps you can take to prevent an elderly loved one from suffering from financial harm. The studies reviewed here represent researchers' initial efforts at empirically understanding financial capacity in dementia populations. Our society is undergoing a massive transfer of wealth from the World War II to the baby boomer generation (Havens & Schervish, 2003) within families that are increasingly blended and living at geographical distance. 2- Ibid. Patients with dementia also demonstrate a lack of awareness of declining financial abilities relative to patients without dementia (Cramer, Tuokko, Mateer, & Hultsch, 2004), with loss of awareness occurring first for more complex tasks (Van Wielingen, Tuokko, Carmer, Mateer, & Hultsch, 2004). American Bar Association Commission on Law and Aging and American Psychological Association., in press Judicial determination of capacity of older adults in guardianship proceedings. Capacity assessments are ultimately human judgments occurring in a social context. Treatment consent capacity in older populations is the most extensively researched of any of the civil capacities, although the overall number of studies is still small. At what point does decision making that is affected by a neuropsychiatric disease process no longer represent “competent” decision making? Older adults are often subjected to ageist beliefs, which include the erroneous notion that because people are older, they must have cognitive impairment, and should have someone else making their financial decisions for them. Diminished capacity occurs as a result of damage to the brain. ; Moye et al.) Neuropsychological studies of decisional capacity in dementia have provided important initial findings concerning the neurocognitive changes in the brain that presumably mediate loss of capacity, and that appear to strongly underlie the competency construct. (, Moye, J., Gurrera, R. J., Karel, M. J., Edelstein, B., O'Connell, C. (, Moye, J., Karel, M. J., Azar, A. R., Gurrera, R. J. ; Moye et al.). Planning Strategies to Protect Your Elderly Loved Ones from Incapacity In the first part of this series, I discussed the early warning signs of diminished financial capacity in the elderly. The development of objective instruments to measure capacity has been integral to the emergence of the capacity assessment field. Rates of impairment varied, depending on the instrument used. Despite its importance, there have been few working conceptual models of financial capacity. In the remainder of this article we summarize and analyze research in the two important clinical capacity domains that have received the most research attention to date: treatment consent capacity and financial capacity. Consulting with family members, friends or neighbors with knowledge of the older adult's functioning to help make a determination of his or her capacity. (, Wong, J. G., Clare, I. C. H., Holland, A. J., Watson, P. C., Gunn, M. (, Oxford University Press is a department of the University of Oxford. Compared with healthy control individuals, the consent capacity of individuals with dementia is reduced (Kim, Caine, Currier, Leibovici, & Ryan, 2001; Marson, Cody et al., 1995; Marson, Ingram, et al., 1995; Moye, Karel, Azar, & Gurrera, 2004a; Schmand, Gouwenberg, Smit, & Jonker, 1999; Stanley, 1988; Wong, Clare, Holland, Watson, & Gunn, 2000), particularly for understanding, reasoning, and appreciation (Marson, Cody, et al. COVID-19 resources for psychologists, health-care workers and the public. An important goal of clinical capacity assessment is to assist judges and other legal professionals in crafting legal interventions that are specifically tailored to the needs of individual clients, and that clearly identify needs for protection while simultaneously protecting rights in areas of preserved capacity. 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