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Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
© American Bar Association Commission on Law and Aging – American Psychological Association
1
Assessment of Older Adults with
Diminished Capacity:
A Handbook for Psychologists
American Bar Association/American Psychological
Association Assessment of Capacity in Older Adults
Project Working Group
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
© American Bar Association Commission on Law and Aging – American Psychological Association
2
About the American Bar Association Commission on Law and Aging
The mission of the American Bar Association (ABA) Commission on Law and Aging is to strengthen and secure the
legal rights, dignity, autonomy, quality of life, and quality of care of elders. It carries out this mission through
research, policy development, technical assistance, advocacy, education, and training. The ABA Commission
consists of a 15-member interdisciplinary body of experts in aging and law, including lawyers, judges, health and
social services professionals, academics, and advocates. With its professional staff, the ABA Commission examines
a wide range of law-related issues, including: legal services to older persons; health and long-term care; housing
needs; professional ethical issues; Social Security, Medicare, Medicaid, and other public benefit programs; planning
for incapacity; guardianship; elder abuse; health care decision-making; pain management and end-of-life care;
dispute resolution; and court-related needs of older persons with disabilities.
About the American Psychological Association
The American Psychological Association (APA) is the largest scientific and professional organization representing
psychology in the United States and is the world’s largest association of psychologists. Through its divisions in 53
subfields of psychology and affiliations with 59 state, territorial, and Canadian provincial associations, APA works
to advance psychology as a science, as a profession, and as a means of promoting health, education, and human
welfare. The APA Office on Aging coordinates the association’s activities pertaining to aging and geropsychology
(the field within psychology devoted to older adult issues). The Committee on Aging (CONA) is the committee
within the APA governance structure dedicated to aging issues. Its six expert geropsychologists are selected for
three-year terms. Together, the Office on Aging, CONA, and association members promote the health and wellbeing
of older adults and their families through expanded scientific understanding of adult development and aging and the
delivery of appropriate psychological services to older adults.
Disclaimer
The views expressed in this document have not been approved by the governing or policy-setting bodies of the
American Bar Association or the American Psychological Association and should not be construed as representing
policy of these organizations. Materials in this book were developed based on the consensus of a working group.
This document is not intended to establish a standard of practice against which clinical practice is to be
evaluated. Rather, it provides a framework that psychologists may find useful and effective in capacity
determination. Although the principles presented herein are intended to be generally relevant across all legal
jurisdictions, law and practice differ across state jurisdictions and sometimes even across county lines. Thus, this
book is intended to supplement (and cannot substitute for) a psychologist’s working knowledge of relevant
capacity law specific to his/her jurisdiction. This book focuses on issues in civil capacity determination in older
adults, not all aspects of capacity evaluation or all populations.
Copyright (c) 2008 by the American Bar Association and the American Psychological Association.
All rights reserved.
The ABA and the APA hereby grant permission for copies of the psychologist worksheet contained in this book to
be reproduced, in print or electronic form, for classroom use in an institution of higher learning, for use in clinical
practice, provided that the use is for non-commercial purposes only and acknowledges original publication by the
ABA and the APA. Requests to reproduce these materials in any other manner should be sent via e-mail to
[email protected]
10 Digit ISBN Number: 1-60442-234-3
13 Digit ISBN Number: 978-1-60442-234-4
ABA Product Code: 4280029
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
© American Bar Association Commission on Law and Aging – American Psychological Association
3
Table of Contents
Acknowledgements......................................................................................................................... 6
Executive Summary ........................................................................................................................ 7
I. The Importance of Psychological Assessment of Capacities ...................................................... 9
II. Legal Standards of Diminished Capacity................................................................................. 16
III. Conceptual Framework for Capacity Assessment .................................................................. 24
IV. Investigating the Referral and Planning Your Approach ....................................................... 30
V. General Approaches to Assessing the Older Adult.................................................................. 38
Capacity Worksheet for Psychologists ................................................................................... 48
VI. Assessing Specific Capacities................................................................................................. 52
Medical Consent ..................................................................................................................... 52
Functional Elements................................................................................................................ 53
Sexual Consent Capacity ........................................................................................................ 63
Financial Capacity .................................................................................................................. 72
Testamentary Capacity............................................................................................................ 82
Driving Capacity..................................................................................................................... 92
Independent Living ............................................................................................................... 102
VII. Undue Influence .................................................................................................................. 114
VIII. Working with Lawyers and Courts .................................................................................... 122
IX. Emerging Issues.................................................................................................................... 132
X. References............................................................................................................................. 137
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
© American Bar Association Commission on Law and Aging – American Psychological Association
4
Appendices
Available online at http://www.apa.org/pi/aging/programs/assessment/capacitypsychologist-handbook.pdf
Appendix A. Glossary................................................................................................................. 149
Appendix A. Glossary................................................................................................................. 150
Appendix B. Functional Assessment .......................................................................................... 157
Appendix C. Cognitive Assessment ........................................................................................... 164
Appendix D. Psychiatric and Emotional Assessment................................................................. 169
Appendix E. Values Assessment ................................................................................................ 171
Appendix F. Interventions to Address Diminished Capacity ..................................................... 173
Appendix G. Medical Conditions Affecting Capacity................................................................ 179
Appendix H. Temporary and Reversible Causes of Confusion.................................................. 183
Appendix I. Useful Web Sites .................................................................................................... 185
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
© American Bar Association Commission on Law and Aging – American Psychological Association
5
Acknowledgements
T
his book is the result of a collaborative effort of members of the American Bar Association
(ABA) Commission on Law and Aging and the American Psychological Association (APA).
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists is the third
work product of the ABA/APA Assessment of Capacity in Older Adults Project Working Group,
established in 2003 under the auspices of the interdisciplinary Task Force on Facilitating APA/ABA
Relations. The first work product, Assessment of Older Adults with Diminished Capacity: A Handbook for
Lawyers was published in 2005. The second product, Judicial Determination of Capacity of Older Adults
in Guardianship Proceedings: A Handbook for Judges was published in 2006. Copies of both handbooks
are available online at www.apa.org/pi/aging and www.abanet.org/aging.
Members of the ABA/APA Working Group for this project are: Barry Edelstein, PhD; Peter Lichtenberg,
PhD, ABPP; Daniel Marson, JD, PhD; Jennifer Moye, PhD; David Powers, PhD; Charles Sabatino, JD;
Aida Saldivar, PhD, ABPP; Erica Wood, JD; Stacey Wood, PhD; and Deborah DiGilio, MPH. Stacey
Wood, PhD, and Jennifer Moye, PhD, are the editors of the psychologist’s handbook.
Special contributors to this handbook include: Angela Jefferson, PhD (research consent capacity);
Michele Karel, PhD, and Brian Carpenter, PhD (values); Lori Stiegel, JD (elder abuse and undue
influence); and Susan Bernatz, PhD (undue influence). We thank Susie Hwang and Jamie Philpotts for
their superb editorial assistance.
This handbook was reviewed by an advisory panel of psychologists convened for this project: Norman
Abeles, PhD; Rebecca Allen, PhD; Adam M. Brickman, PhD; Michelle Braun, PhD; Brian D. Carpenter,
PhD; Gordon J. Chelune, PhD, ABPP (CN); Eric Y. Drogin, JD, PhD, ABPP; Colleen Fairbanks, PhD;
Michelle Dawn Gagnon, PsyD; Randy Georgemiller, PhD; Thomas Grisso, PhD; Irving Hellman, PhD;
Bret Hicken, PhD; Leon Hyer, PhD; Angela L. Jefferson, PhD; Sayaka Machizawa, PsyD; Joseph R.
Miles, MA; Barton W. Palmer, PhD; Sara Honn Qualls, PhD; Cheryl L. Shigaki, PhD, ABPP; and Martin
Zehr, PhD. The handbook also was reviewed by Barbara Soniat, PhD, Arthur R. Derse, MD, JD and
Kathleen Wilber, PhD, members of the ABA Commission on Law and Aging.
Finally, we thank the Borchard Foundation Center on Law and Aging for its financial support of this
project.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
© American Bar Association Commission on Law and Aging – American Psychological Association
6
Executive Summary
T
he ABA-APA Working Group on the Assessment of Capacity in Older Adults was established in
2003 under the auspices of the Task Force on Facilitating ABA-APA Relations. The workgroup
has produced two volumes thus far, a handbook for attorneys and a handbook for judges. The
current volume is designed for psychologists evaluating civil capacities of older adults.
Contemporary probate law encourages functional assessments that describe task-specific deficits rather
than global findings. With training in standardized cognitive and functional assessment, psychologists are
in an ideal position to provide such evaluations.
The specific goal of this handbook is to review psychological assessment of six civil capacities of
particular importance to older adults, namely, medical consent capacity, sexual consent capacity, financial
capacity, testamentary capacity, capacity to drive, and capacity to live independently. The handbook also
addresses the important topic of undue influence and introduces emerging areas of interest, such as the
capacity to mediate, the capacity to participate in research, and the capacity to vote.
The handbook begins with an Overview Chapter that discusses the history of the workgroup, scope of the
handbook, the increasing need for clinicians skilled in capacity assessment, as well as essential
definitions. In Chapter 2, critical legal definitions of civil capacities are delineated. The chapter
concludes by highlighting key differences between how the law views capacity and how psychologists
view capacity.
Chapter 3 lays out a nine part framework for conceptualizing capacity assessments. The framework
expands on Thomas Grisso’s conceptual model as it has evolved through discussion among working
group members. Nine conceptual elements for conducting a capacity assessment are:
(1) identifying the applicable legal standard(s)
(2) identifying and evaluating functional elements constituent to the capacity
(3) determining relevant medical and psychiatric diagnoses contributing to incapacity
(4) evaluating cognitive functioning
(5) considering psychiatric and/or emotional factors
(6) appreciating the individual’s values
(7) identifying risks related to the individual and situation
(8) considering means to enhance the individual’s capacity
(9) making a clinical judgment of capacity.
A worksheet highlighting each of the elements is included in the handbook.
The next two chapters, Chapter 4 and Chapter 5, move away from theoretical models and provide more
practical guidance to the clinician. Chapter 4 addresses important pre-assessment considerations including
understanding the “who”, “what”, “why”, and “when” of a particular capacity referral. In general,
capacity evaluations require a more extensive “pre-assessment” process; this chapter provides information
regarding what type of data should be collected prior to meeting the older adult. It further discusses the
various roles a psychologist may play as an expert in these types of cases. Chapter 5 provides an
overview of functional, cognitive, and behavioral assessment tools that may be used in capacity
evaluations, with the understanding that there is no “capacimeter” or standardized battery that will work
for all cases. The chapter concludes with suggestions for the integrating data, presenting results, and the
importance of articulating a specific capacity opinion. Brief case examples are provided here, as well as a
worksheet to assist clinicians in organizing the assessment process.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
© American Bar Association Commission on Law and Aging – American Psychological Association
7
Chapter 6 covers in depth the assessment of each of the six specific capacities (medical consent capacity,
sexual consent capacity, financial capacity, testamentary capacity, capacity to drive, and capacity to live
independently). Each section reviews up-to-date relevant clinical literature and relevant assessment tools,
walking through the nine-part framework in light of that specific capacity. An example report of a case is
given for each of the specific capacities.
Chapter 7 introduces the related but also distinct concept of undue influence to the reader. Undue
influence is a legal construct which refers to a dynamic in a confidential relationship where a stronger
party exploits their influence of a weaker party, often for financial gain. This chapter covers legal
definitions, clinical frameworks, and an assessment strategy for psychologists working with older adults
that are potentially at risk or the victims of undue influence. A case example is provided.
Chapter 8 provides psychologists with practical advice for working with attorneys and the courts on
matters related to capacity cases. This chapter will help psychologists connect with attorneys and be better
prepared to provide the type of information most relevant legal professionals. The chapter also provides
suggestions to the novice providing expert testimony in court and includes additional resources for those
practitioners wanting more than an overview.
In Chapter 9 emerging capacity areas are introduced. These include the capacity to consent to research,
the capacity to mediate, and the capacity to vote. These sections overview relevant literature but do not
provide case examples.
In summary, the handbook seeks to provide a relatively concise yet also comprehensive reference in the
area of civil capacity assessment of older adults by psychologists. Relevant literature, suggestions for
assessment tools, and case examples are provided throughout the handbook. The members of the
workgroup have enjoyed assembling this handbook and it is our hope that it will serve as a valuable
resource and tool for psychologists throughout the United States and elsewhere.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
© American Bar Association Commission on Law and Aging – American Psychological Association
8
I. The Importance of Psychological Assessment of Capacities
Robert Olsen is 89 years old and lives alone.
One day he calls 911 because he feels ill and
has fallen on the floor. The emergency
medical personnel transport him to the
hospital, noting that he is confused,
unbathed, and his home is dirty, with spoiled
food, urine, and feces in the house. They also
found medications in disarray and empty beer
bottles. Mr. Olsen is hospitalized for treatment
for acute renal failure with malnutrition and
dehydration. With medical intervention, his
cognition clears considerably. However, there
are residual problems with memory and
reasoning. A brain scan shows no acute
problems but a mild degree of
cerebrovascular disease. Mr. Olsen reports
anxiety in the hospital. He asks to be
discharged and assures the team he can
manage his medications, personal care, and
meals. He expresses discomfort with home
care services. Mr. Olsen values his
independence and wants to return to his
home of 63 years. The medical team asks the
psychologist “is he competent?”
•
•
•
•
•
•
•
•
•
•
•
•
Who do I talk to before the assessment?
Is an attorney always involved?
What does it mean to say someone lacks
capacity?
What is the family’s role?
What happens to the report?
Should I use a cognitive test battery—which
one?
Do I need to use objective capacity
measures—what are they?
How do I approach the patient?
How does the person’s history and values
figure in—what about the way he or she has
always lived or made decisions?
Do the choices reflect personal preferences
or cultural differences?
How do I integrate all the data to arrive at a
definitive capacity judgment?
How do I phrase my findings so they will be
understandable to the non-psychologist?
The purpose of this handbook is to provide a
resource to psychologists who are faced with
such questions as they assess various capacities
of older adults.
Scope of This Handbook
Clinical and legal professionals are
increasingly turning to psychologists for
opinions regarding the decision-making capacity
of older adults, such as the case of Mr. Olsen.
Often these complex cases require fine-grained
cognitive and functional evaluation that balances
promoting autonomy while protecting a
vulnerable adult from harm. Psychologists are
well-positioned to bring the critical skills of
standardized assessment and comprehensive
report writing to questions of diminished
capacity. However, few psychologists receive
formal training in capacity assessment of older
adults and may be hesitant to take on these types
of cases. The first time a psychologist is
confronted with such a task, many questions
may arise:
This handbook focuses on the assessment of
“civil” capacities in older adults in medical, long
term care, and private-practice settings. Six
capacity domains are presented: medical
consent, sexual consent, financial, testamentary,
driving, and independent living capacities. In
addition, the handbook discusses undue
influence and the relationship of capacity
assessment to legal interventions, such as
guardianship or conservatorship. This handbook
does not address capacities for criminal matters,
such as the capacity to stand trial, capacity to
represent oneself in a legal case, or capacity to
be executed. However, at times questions
regarding civil capacity arise in a criminal
setting, for example, when an individual has
perpetrated financial fraud against a vulnerable
older adult, and the prosecuting or defense
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
© American Bar Association Commission on Law and Aging – American Psychological Association
9
attorney is seeking information about the older
adult’s capacity to make financial decisions. The
capacity is still “civil,” although it is being
referred to the psychologist in a criminal matter.
This handbook is designed to address capacity
assessment generally across the United States,
but it is critical to be aware of the laws in one’s
own state. Some states may have provisions that
differ from those in this handbook.
For definitions of legal terms common in civil
capacity see Appendix A.
Purpose of Handbook
The purpose of the handbook is to promote
sound assessment of older adults, which lead to
appropriate interventions that balance promotion
of autonomy and protection from harm. This
handbook is not a practice guideline and is not
intended to establish a standard against which
clinical practice is to be evaluated. Rather, this
handbook provides a framework and assessment
examples that psychologists may find useful and
effective in capacity evaluation. This is a
handbook—with a goal of brevity and utility—
and is not meant to serve as an exhaustive text
on the matter of capacity assessment.
Working Group and Advisory Panel
The ABA/APA Working Group on the
Assessment of Capacity in Older Adults was
established in 2003 under the auspices of the
Task Force on Facilitating ABA/APA Relations.
The original working group was comprised of
three members of the American Bar Association
(ABA) Commission on Law and Aging and six
members of the American Psychological
Association (APA). When the working group
convened for the current project, two new
members were sought to replace two who had
departed. Individuals were recruited who had
expertise in the field (as evidenced through
clinical
work
and
scholarship),
with
consideration of enhancing gender and ethnic
diversity of the working group.
The working group developed an outline for
the book, selected editors, and assigned chapter
authors. Individual working group members then
developed chapters and revised them based on
extensive feedback from the group.
After an initial draft was completed, the
handbook was shared with an advisory panel of
22 psychologists as well as representatives from
the ABA Commission on Law and Aging.
Advisory panel members were selected based on
experience in the field of capacity assessment,
and to represent a range of clinical settings and
interest areas (e.g., geropsychology, forensic
psychology, neuropsychology, and rehabilitation
psychology). The advisory panel provided
feedback on each chapter, which was collated
and considered during conference calls by the
working group. When feedback was discrepant,
the working group made revisions to reflect the
diversity of opinions in the field. This handbook
is a product of the ABA/APA working group. It
has not been approved by the governing or
policy-setting bodies, and does not represent
policy of the ABA or APA.
American Bar Association and the
American Psychological Association
Collaboration
The ABA Commission on Law and Aging
and the APA have been collaborating to prepare
clinical and legal professionals to meet the needs
of the aging population. This educational
handbook is one product of the collaboration,
along with similar handbooks for lawyers and
judges. These collaborative projects arose
because psychologists within APA and legal
professionals within ABA were seeking more
information about capacity assessment of older
adults. In addition to educating the respective
memberships of these organizations, another
important goal is to improve the manner that
clinicians, lawyers, and judges communicate
with each other about capacity matters.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
© American Bar Association Commission on Law and Aging – American Psychological Association
10
The Handbook for Lawyers is at:
http://www.apa.org/pi/aging/capacity_lawyers_handbook.pdf
The Handbook for Judges is at:
http://www.apa.org/pi/aging/capacity_judges_handbook.pdf
Professional Competencies for
Capacity Evaluation
Some psychologists may ask: is it necessary
to be a forensic psychologist to do capacity
assessment
of
older
adults?
A
neuropsychologist?
A
geropsychologist?
Because questions of civil capacities arise in a
wide variety of settings and case particulars,
there is no one right answer.
Capacity assessment referrals can come
from a variety of sources and occur in a variety
of settings that influence the approach taken to
evaluation, and the professional competencies
needed. For example, a request for an
assessment of driving capacity may come from a
family member and not involve a lawyer in any
way. An assessment of capacity to make health
care decisions may be requested by a physician.
The knowledge base needed to address capacity
issues in a frail, medically complex older adult
living in a nursing home with many healthcare
and family system issues is different from the
knowledge base needed to assess a medically
healthy but psychiatrically ill older adult who is
referred by a court in a guardianship proceeding.
For example, with Mr. Olsen, the case would
benefit from a psychologist with a background
in geriatric syndromes, gero-neuropsychological
assessment, medical psychology, and aging
services.
A psychologist will need to investigate the
referral to determine if he or she has the
professional competence to address the referral
question based on education, training,
supervised experience, consultation, or study as
required by the Ethical Principles of
Psychologists and Code of Conduct (APA,
2002).
This handbook may aid psychologists in
their approach to capacity evaluation, but
psychologists who are new to the assessment of
capacity in older adults are encouraged to
consult with colleagues or pursue additional
education, training, and supervision in the area.
This handbook focuses on capacity
assessment of older adults, and presumes
general competencies in the assessment of older
adults, such as selection of appropriately agenormed and validated tests, adaptation of
assessment approaches, and knowledge of
syndromes of aging. Psychologists seeking
general resources about working with older
adults may refer to the Guidelines for
Psychological Practice with Older Adults (APA
2003,
at
http://www.apa.org/practice/guidelines/adult.pdf)
and other resources at the APA Office on Aging
Web site www.apa.org/pi/aging.
Cultural Considerations
Cultural issues are of special concern in
capacity assessment. With persons of diverse
cultural
background
and
experience,
consideration needs to be given to the role of
cultural variables in decision making. Cultural
variables such as language, immigrant status,
economical status, perceptions of institutions
such as hospitals, as well as perceptions of
disability and the role of family in care and
decision making, are important. Consistent with
the Ethical Principles of Psychologists and Code
of Conduct (APA, 2002) practitioners need to be
aware of test bias, test fairness, and cultural
equivalence. For additional guidance in working
with diverse populations refer to the Guidelines
on Multicultural Education, Training, Research,
Practice, and Organizational Change for
Psychologists
(APA,
2002
at
http://www.apa.org/pi/oema/resources/policy/multicu
ltural-guideline.pdf). The intersection of cultural
issues, values, and capacity assessment is further
discussed in relevant sections of this handbook
and in other sources (e.g., Qualls & Smyer,
2007).
Age Considerations
An evaluation of capacity may be utilized to
resolve critical disagreements about individual
decisions, and the need to offer protection versus
to promote autonomy. In a civil capacity
evaluation, these decisions may be about the
most personal matters in one’s life: what
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
© American Bar Association Commission on Law and Aging – American Psychological Association
11
procedures will be done to your body, where you
will live, who you are intimate with, how you
spend your money. All persons are presumed to
have capacity, and, when this is so, have the
“right to folly” – that is – have the right to make
“bad” decisions. The psychologist performing a
civil capacity evaluation is often addressing just
this issue: is this person making a decision we
disagree with, but one we must respect because
the person has capacity, or, because this person
lacks the capacity to make the decision, must we
step in to protect him or her. In these situations,
psychologists may need to guard against ageism
in themselves and others. An obvious point, but
one worth stating, is that age itself does not
imply diminished capacity or greater
“permission” to be protective or paternalistic.
Instead, an objective assessment of capacity,
including the risks of the situation, is required.
As will be discussed in later sections of the
book, consideration must be given to whether
the risks associated with the decision are new or
long-standing, and whether the risks are serious
and likely to happen.
The Need to Focus on Older Adults
Capacity assessment of older adults is
increasing. The older adult population will
double between 2000 and 2030, to 71.5 million
adults over the age of 65 (Wan, Sengupta,
Velkoff, & DeBarros, 2005). The fastest
growing group of older adults is the 85+ age
range, which is expected to grow from 4.2
million in 2000 to 12.9 million by 2020, an over
two hundred percent increase (Administration on
Aging, 2006). While most older adults do not
have dementia, older adults as a group are at
higher risk for cognitive impairment than
younger adults.
An estimated 5.2 million
Americans of all ages have Alzheimer's disease
in 2008. The number of people age 65 and over
with Alzheimer's disease is estimated to reach
7.7 million in 2030 (Alzheimer’s Association,
2008). These factors will result in an increasing
demand for assessment of the capacities of older
adults.
Evolution of the Field
Historically, evaluations of decisional
capacity have been made on the basis of a
clinical interview or general mental status
evaluation. Such clinical evaluations can be
unreliable (Markson, 1994; Marson, McInturff,
Hawkins, Bartolucci, & Harrell, 1997; Rutman
& Silberfeld, 1992). Personal values, experience
in the field, and ageism may influence a
clinician’s risk tolerance and his or her view of
an older adult’s decisional capacity (Clemens &
Hayes, 1997). Clinicians from theoretical
orientation and professional backgrounds may
differ in their evaluations of capacity. For
example, feedback from our own advisory panel
revealed differing opinions about the case of Mr.
Olsen.
While the use of standardized psychological
and neuropsychological tests may improve the
reliability of capacity assessment, validity may
still suffer. It can be unclear how to relate
general psychological assessment data (e.g.,
“impaired immediate memory”) to specific
capacity questions (“capacity to make a will”).
Clinicians focus on different cognitive abilities
in predicting capacity (Marson, Hawkins,
McInturff, & Harrell, 1997).
Forensic Assessment Instruments
A major advance in the field has been the
development of instruments to assess specific
functional abilities relevant to legal capacities,
what Thomas Grisso refers to as “forensic
assessment instruments.” Many of these
instruments are described in detail in his book
Evaluating Competencies, 2nd ed. (2003), as well
as in other sources (Moye, Gurrera, Karel,
Edelstein, & O’Connell, 2005; Qualls & Smyer,
2007; Sturman, 2005), and are summarized in
Appendix B of this handbook. For example, the
evaluation of Mr. Olsen would best be
accomplished by directly assessing functions
necessary to independent living.
Some specific capacity areas, such as
medical consent capacity, have seen a great deal
of instrument development, while others have
seen little to none, such as sexual consent
capacity and testamentary capacity. While these
instruments represent an extremely important
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
© American Bar Association Commission on Law and Aging – American Psychological Association
12
advancement of the field, most lack adequate
reliability, validity, and normative properties for
older adults. They are further discussed in
relevant sections of Chapter 6.
Capacity Research
Another important advance in the field has
been the emergence of the field of capacity as a
distinct field of legal, clinical, and behavioral
research (Marson & Ingram, 1996). The origins
of the field lie in a series of seminal articles
(Appelbaum, 1982; Appelbaum & Bateman,
1980; Appelbaum & Grisso, 1988; Appelbaum
& Roth, 1981; Meisel, Roth, & Lidz, 1977;
Roth, Meisel, & Lidz, 1977), and work by
Appelbaum and Grisso (Appelbaum et al., 1988;
Appelbaum & Grisso, 1995; Grisso, 1986;
Grisso & Applebaum, 1998), and of others
focusing on older adults (Fitten, Lusky, &
Hamann, 1990; Kim & Caine, 2002; Marson,
Chatterjee, Ingram, & Harrell, 1996; Marson,
Cody, Ingram, & Harrell, 1995; Moye & Karel,
1999; Sabatino, 1996; Smyer, Schaie, & Kapp,
1996; Stanley, Stanley, Guido, & Garvin, 1988;
Taub, Baker, Kline, & Sturr, 1987), which
advanced the theoretical and empirical basis of
the field of civil capacity assessment. However,
the body of capacity research dedicated to older
adults is modest and remains a rich area for
future research to guide this expanding and
complex area of clinical practice.
Why Are Evaluations of Capacity in
Older Adults Challenging?
Cases Involving Older Adults Are
Complex
When an older adult is referred to a
psychologist for an evaluation there often are
many layers of complexity to consider. Consider
the example of Robert Olsen: at first glance he
appears to have significant decisional and
functional impairments apparent from the facts
of his living situation. But what do we really
know about Mr. Olsen.
Does he have family or friends? What is
important to him? Why is he anxious? Is his
anxiety in need of treatment? Is he drinking in
excess or in a manner that conflicts with
medications? Does he know this? Are all his
doctors aware of what other doctors are
prescribing? Is the medication schedule simple
enough to follow? Is there a way to offer
supportive services to him that is less
threatening? Are his cardiac or pulmonary
conditions treated? Do the infarcts seen on the
brain scan translate to meaningful deficits? Has
his delirium resolved? Can any interventions
improve his functioning? Can he see and hear?
Is he depressed? Has someone close to him
died?
As we learn more about Mr. Olsen, the list
of questions may extend further. Clinical
evaluation of older adults is complex because
older adults are exceedingly complex—with a
lifetime of psychological, social, cultural, and
biological factors that contribute to the
individual’s specific strengths, weaknesses,
social system, lifestyle, and values. Because of
this it is important to develop knowledge and
skills in evaluating and treating older adults.
Capacity Assessment Is a New Practice
Area for Psychologists
At an earlier time, clinical capacity
determination was generally left to physicians.
The involvement of psychologists is more
recent. As such, some psychologists may be
unfamiliar with the meaning of the term capacity
or the wide range of interventions that may
apply to an older adult with decisional or
functional impairments. These include the
appointment of a guardian, conservator,
healthcare proxy, durable power of attorney, or
representative payee, as well as more social or
clinical interventions—for example, bill paying
programs through elder services.
Legal and social interventions for functional
impairments are described in Appendix F.
Psychologists are routinely trained in
psychological and cognitive assessment, but
rarely in the specifics of capacity assessment.
For example, the psychologist may be unsure of
what data are necessary to answer the question
“does this person have the capacity to manage
finances?”
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
© American Bar Association Commission on Law and Aging – American Psychological Association
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Confusion About the Term Capacity
Many psychologists may be more familiar
with the term competency rather than capacity.
Some recommend the term competency be used
only to refer to a legal finding, with the term
capacity to refer to clinical findings. While this
is an excellent practice as far as it goes, it only
goes so far, since many practitioners do not
abide by the distinction. In practice many
clinicians still refer to a patient’s “competency,”
leading to ongoing confusion. One approach to
avoid confusion is to simply adopt the phrase
“legal capacity” and “clinical capacity.”
Some use the term decision-making capacity
interchangeably with capacity, or to describe
capacity domains that are specifically and only
decisional in nature. That is, a distinction may
be drawn between decisional capacity (the
capacity to decide) versus executional capacity
(the capacity to implement a decision) (Collopy,
1988). For example, the capacity to make a
health care decision may only involve cognitive
processes of deciding, whereas the capacity to
manage finances may involve making decisions
and executing actions in concordance with
decisions (e.g., balancing a checkbook).
Importantly, the mere presence of physical
inability and loss of “executional capacity” does
not constitute incapacity, as the individual who
retains decisional capacity may direct another to
perform the task.
More on legal definitions of capacity is in
Chapter 2.
Another distinction may be drawn between
global capacity versus specific capacities. Both
clinical and legal professionals have used the
term “competency” to refer to a person’s global
ability to engage in a wide range of functions. It
has traditionally been thought of as
categorical—an individual either is competent or
is not. However, within the global application of
the term competency, there was little if any
consideration of: (a) the ability to successfully
perform specific functions; (b) intra-individual
variance in performance across functional
domains; or (c) potential methods of enhancing
an individual’s ability to perform a given
function or functions.
Currently, the emphasis is shifting in both
clinical and legal settings to the use of the term
capacities to allow a focus on the specific
functional capacities, and means of maximizing
those capacities. This shift can be seen in civil
law, particularly in guardianship1 and other
surrogate decision-making areas in a preference
for the term capacity.
Guardianship is a
relationship created by state law in which a court
gives one person or entity (the guardian) the
duty and power to make personal and/or
property decisions for another (the incapacitated
person) upon a court finding that an adult lacks
capacity to make decisions for him or herself.
When a petition for guardianship is filed,
psychologists may be asked to evaluate a
broader set of capacities—can this person be
independently responsible for his or her life?
However, this question still does not translate
into all-or-none “competency.” Psychologists
providing evaluations will offer a great deal to
the courts by assessing specific domains, and
identifying areas of retained strengths, which
will enable the judge to craft a “limited order,”
that is, to limit the authority of the guardian to
only those areas where the person needs
assistance
(American
Bar
Association
Commission on Law and Aging et al., 2006).
Confusion from Referring Parties
A national survey of 395 psychiatrists,
geriatricians, and geriatric psychologists
(Ganzini, Volicer, Nelson, & Derse, 2003),
noted that requests for capacity evaluation were
frequently associated with misunderstanding or
“myths” about capacity and the role of capacity
assessment. These myths include: equating legal
and clinical capacity; assuming a lack of
capacity when patients go against medical
advice; confusing involuntary civil commitment
with incapacity.
1
States use various terms for guardianship of
the person and guardianship of property. For
example, some use the term conservatorship
either generically or to indicate guardianship of
property. Check state law. This handbook refers
to guardianship generically as encompassing
authority over personal and/or property
decisions, unless otherwise indicated.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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These continuing myths mean the
psychologist often has to investigate, clarify, and
re-formulate a capacity evaluation request before
beginning the evaluation. Psychologists who are
new to capacity evaluation may find the ongoing
misunderstanding about capacity to increase
their own confusion. This may account for the
low reliability noted in assessment of capacity
(Marson et al., 1997), which is improved when
clinicians are educated about capacity (Marson,
Earnst, Jamil, Bartolucci, & Harell, 2000).
In the case of Mr. Olsen, the team asks for
an evaluation of “competency.” Does the team
mean capacity? Capacity for what? Is the team
interested in clinical or legal capacity? Is there
an intended course of action—such as pursuing a
guardianship or nursing home placement? Have
less restrictive alternatives been explored?
Multiple Roles
Although the referral question may be
“assess for capacity,” it is often up to the
evaluator to determine the specific role that he
or she will play in each case. In the case of Mr.
Olsen, the referring question may be to complete
an evaluation of his capacity to live
independently.
However, the psychologist may decide that
such an assessment should be delayed, if
possible, until after a rehabilitation stay in which
Mr. Olsen can regain function, can have his
anxiety treated, and to allow for the possibility
of developing in-home services that are
comfortable and appropriate for Mr. Olsen.
As illustrated in this case, the psychologist
must then balance the role of promoting selfdetermination, addressing the functional deficit,
and providing recommendations to clinical and
legal professionals involved with the person.
Special attention should be paid to means to
maximize the functional capacity of the
individual. Thus, a thoughtful evaluator may
find that an older adult who does not have the
capacity to perform a specific function at the
moment of evaluation may have insight and can
delegate to another with environmental, medical,
behavioral, or other interventions. These points
apply to prospective capacity evaluation—with a
person whose current and future capacity is in
question.
The role is different when the psychologist
is performing a retrospective evaluation of
capacity. These questions concern an opinion of
whether the psychologist thinks the person may
have had capacity to enter into a contract or
some other task in the past.
Undue Influence
Complicating the understanding of capacity
is the concept of “undue influence,” the focus of
chapter 7. Undue influence is a legal concept
that refers to a dynamic between an individual
and another person. It describes the intentional
use of social influence, deception, and
manipulation to gain control of the decision
making of another. For psychologists, undue
influence can be understood as a dynamic of a
relationship when a person uses a role and
power to exploit the trust, dependency, and fear
of another. The role and power permits the
person to gain control over the decision making
of the victim. In cases of undue influence, a
person may have full capacity. Alternatively,
there may be cognitive impairment that
increases susceptibility and dependence. In the
case of Mr. Olsen, although the psychologist is
to evaluate capacity, it will be useful to remain
mindful of potential issues of elder abuse and
neglect, “self-neglect,” and undue influence as
the psychologist investigates the social
circumstances surrounding the referral.
The next chapters will discuss legal
standards for various capacities and present a
general framework for capacity assessment. In
Chapter 6 specific capacity domains will be
discussed in detail. Remaining chapters deal
with undue influence, working with legal
professionals and the court, and emerging issues.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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II. Legal Standards of Diminished Capacity
This chapter describes legal approaches to
defining diminished capacity and incapacity.
Read in tandem with the next chapter on the
psychological
frameworks
for
capacity
assessment, the explanation highlights the
similarities and contrasts between the two
approaches to capacity.
Historically, the law’s approach to
incapacity reflects a long-standing paradox. On
the one hand, our legal system has always
recognized the situation-specific nature of
capacity, depending on the particular event or
transaction—such as capacity to make a will,
marry, enter into a contract, vote, drive a car,
stand trial in a criminal prosecution, and so on
(Parry, 1985). A finding of incapacity in any of
these matters could nullify or prevent a
particular legal act.
On the other hand, at least until very
recently, determinations of incapacity in the
context of guardianship or conservatorship
proceedings were routinely quite global,
absolute determinations of one’s ability to
manage property and personal affairs. A finding
of incapacity under guardianship law
traditionally justified intrusive curtailments of
personal autonomy and resulted in a virtually
complete loss of civil rights (Frolik, 1981;
Horstman, 1975).
In the last few decades, most states have
moved away from the all or nothing approach to
guardianship and moved toward a preference
for—or at least recognition of—a limited
guardianship model that appoints a guardian for
the person with incapacity only in those areas of
functioning in which capacity is shown to be
lacking. One result of this more finely tuned
approach to capacity assessment is a
fundamental change in terminology in the law.
Historically, it was common to use the term
“incompetency” to refer to the legal finding of
incapacity, and the term “incapacity” to refer to
the clinical finding. That distinction no longer
works, as most states have moved away from the
terminology of “incompetency” in favor of
function-specific “capacity” and “incapacity.”
Therefore, to avoid confusing the legal and
clinical concepts of capacity, we articulate the
distinction very simply as either “legal capacity”
or “clinical capacity.”
Starting Point: Consider state legal standards
for the specific transaction at hand. The
definition of “diminished capacity” will depend
on the type of transaction or decision under
consideration and the particular legal standard
of capacity used in the state.
Standards of Capacity for Specific
Legal Transactions
The starting point in the law is a
presumption that adults possess the capacity to
undertake any legal task they choose, unless
they have been adjudicated as incapacitated to
perform the task in the context of guardianship
or conservatorship, or where a party challenging
their capacity puts forward sufficient evidence
of incapacity in a legal proceeding to meet a
requisite burden of proof. The definition of
“diminished capacity” in everyday legal practice
depends on the type of transaction or decision
under consideration, as well as upon the
jurisdiction in which one is located (Walsh,
1994; Parry & Gilliam, 2002). Across
jurisdictions, legal capacity has multiple
definitions, set out in either state statutory and/or
case law.
For definitions of legal terms common in civil
capacity see Appendix A.
Examples of common transaction-specific
legal standards follow. Chapter 6 provides a
detailed review of the capacity domains relevant
to many of these legal standards.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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Testamentary Capacity
By far the most frequently litigated form of
capacity—the capacity to make a will—is
typically found to be present if the person
making the will—a testator—at the time of
executing a will, has the capacity to: (1) know
the natural objects of his or her bounty (or one’s
“generosity”); (2) to understand the nature and
extent of his or her property; and (3) to
interrelate these elements sufficiently to make a
disposition of property; (4) by means of a
testamentary
instrument.
(Mezzullo
&
Woolpert, 2004; Parry et al., 2002; Walsh,
1994). The terminology that the testator must be
of “sound mind” is still commonly used.
The legal “test” for testamentary capacity
does not require that the person be capable of
managing all of his or her affairs or making dayto-day business transactions. Nor must the
testator have capacity consistently over time.
Capacity is required on the day the will was
executed. Thus, a testator may lack testamentary
capacity before and/or after executing a will, but
if it is made during a “lucid interval,” the will
remains valid (Parry et al., 2002). Finally, even a
testator who generally possesses the elements of
testamentary capacity may have that capacity
negated by an “insane delusion” (i.e., irrational
perceptions of particular person or events”) if
the delusion materially affects the will.
Donative Capacity
The law addresses a number of specific
capacities related to finances. Capacity to make
a gift has been defined by courts to require an
understanding of the nature and purpose of the
gift, an understanding of the nature and extent of
property to be given, a knowledge of the natural
objects of the donor’s bounty, and an
understanding of the nature and effect of the gift.
A Legal Primer
American law is broadly divided into four areas:
• Constitutional law sets the basic framework for governmental powers, civil rights, and civil liberties.
• Statutes are enacted by elected legislatures, and set out provisions that may be quite broad in scope
or fairly detailed.
• Administrative rules, regulations, and policies, interpret and flesh out the statutes.
• Case law is the body of principles and rules arising from specific disputes heard in the courts. Judges
apply constitutional, statutory, and administrative law to individual conflicts, as well as the
principles derived from previous cases, to resolve cases and controversies.
Court decisions provide guidance in interpreting and applying existing law to the real world, while
sometimes creating new law. The aggregate of reported cases on a particular subject form a body of
jurisprudence referred to as common law doctrine. According to the principle of stare decisis, courts
adhere to decided cases or “precedent” unless the court finds a compelling reason to overrule it, thus
creating new precedent.
When lawyers and judges use the term "legal standard" for capacity, they mean the definition or test of
capacity as it exists in statutory law as interpreted by any existing administrative guidelines and case
law. For instance, a statutory definition of “testamentary capacity” may be clarified by will contests in
court. A definition of “incapacity” in guardianship law may be translated into practical terms by a court’s
evaluation form.
Statutes are written at the local, state, and federal levels. For most capacities in this book, and for adult
guardianship, the relevant laws are at the state level. State courts that address matters of civil capacity
or guardianship may be specialized family or probate courts, or they may be courts of general
jurisdiction in which a judge may be less familiar with the particular issues at stake.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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Some states use a higher standard for donative
capacity than for testamentary capacity,
requiring that the donor know the gift to be
irrevocable and that it would result in a
reduction in the donor’s assets or estate
(Mezzullo et al., 2004; Walsh, 1994). The
rationale for the higher standard is that the gift
takes effect in the present and not after the death
of the donor, so its consequences are potentially
greater.
The following capacities are discussed in
greater detail in Chapter 6
• Medical consent
• Sexual consent
• Financial
• Testamentary
• Driving
• Independent living
Contractual Capacity
In determining an individual’s capacity to
execute a contract, courts generally assess the
party’s ability to understand the nature and
effect of the act and the business being
transacted (Mezzullo et al., 2004; Walsh, 1994).
Accordingly, if the act or business being
transacted is highly complicated, a higher level
of understanding may be needed to understand
its nature and effect, in contrast to a very simple
contractual arrangement.
Capacity to Convey Real Property
To execute a deed, a grantor typically must
be able to understand the nature and effect of the
act at the time of the conveyance (i.e., transfer of
title) (Mezzullo & Woolpert, 2004).
Capacity to Execute a Durable
Power of Attorney
The standard of capacity for creating a
power of attorney has traditionally been based
on the capacity to contract. However, some
courts have also held that the standard is similar
to that for making a will (Regan & Gilfix, 2003).
Given the dramatic rise in the use of powers of
attorney for purposes of planning for incapacity
and their potential for financial abuse, it would
not be surprising to see an increase in litigation
over capacity to execute a durable power of
attorney and an attempt by courts to articulate
the test for capacity with greater detail.
An instructive contrasting approach is
offered by an Australian Office of the Public
Guardian, which instructs in its educational
materials that when making a general durable
power of attorney (called an enduring power of
attorney in Australia), the person must:
1. know the nature and extent of his or her
estate and finances;
2. understand that the power gives the agent
complete authority to deal with his or her
estate and finances in the same way that he
or she can personally do now;
3. know that in a power of attorney, he or she
may direct someone else (the agent) to act in
a particular way and that the authority can
be revoked at any time whilst he or she has
capacity;
4. understand that the authority is activated
without any formal procedure when he or
she loses capacity;
5. appreciate the very high level of trust he or
she is placing on the person appointed as
agent and understand that the agent is not
monitored in any way. If the agent is failing
in his or her responsibilities, this is usually
only dealt with after the fact in a judicial
proceeding (Office of the Public Advocate,
2003).
Capacity to Consent to Medical Care
Capacity to make a health care decision is
defined by statute in most states under their
advance directive laws. Typical of these legal
definitions is the following from the Uniform
Health Care Decisions Act:
“Capacity” means an individual’s ability
to understand the significant benefits,
risks, and alternatives to proposed health
care and to make and communicate a
health-care decision (Uniform HealthCare Decisions Act of 1993, 1994).
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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Decisional capacity in health care is rooted
in the concept of informed consent (Meisel,
1999; Furrow, Greaney, Johnson, Jost, &
Schwartz, 2000). Informed consent requires that
one’s consent to treatment be competent,
voluntary, and informed. The concept is based
on the principle that a patient has the right to
prevent unauthorized contact with his or her
person, and therefore a clinician has a duty to
disclose relevant information to the patient so
that he or she can make an informed decision
about treatment. The lack of informed consent is
often an issue in medical malpractice claims. It
is important to note that capacity is only one
element of the test of informed consent.
Thus, a person may have capacity to make a
treatment decision, but the treatment decision
lacks informed consent if it was either
involuntary or unknowing.
State advance directive laws generally
authorize physicians to evaluate and document a
patient’s decisional capacity for medical
treatment for purposes of triggering the authority
of a surrogate decision-maker without resort to
the courts.
Capacity to Execute a Health Care
Advance Directive
An individual’s capacity to execute an
advance directive for health care is different than
the capacity to make specific medical decisions.
As with durable powers of attorney for financial
matters, the test of capacity to execute a health
care power of attorney is generally parallel to
that of capacity to contract. And, because
adjudication of advance directive capacity issues
is almost non-existent, there is little specific
guidance beyond the contractual paradigm.
Accordingly, the psychological models of
capacity discussed in the next chapter help to
supplement these legal principles with
scientifically grounded road signs.
Capacity to Consent to Sexual Relations
Sexual consent law in most states has
developed in the context of criminal
prosecutions of individuals who have had sex
with someone allegedly incapable of consent
due to mental retardation. Older victims of
sexual assault who suffer from dementia or other
cognitive impairments will pose differing
clinical assessment challenges, but the legal
principles that have developed in the law are
essentially the same.
Generally, the law recognizes three factors
that must be analyzed in determining legally
sufficient consent: (1) knowledge of the relevant
facts relating to the decision to be made; (2) the
mental capacity to realize and rationally process
the risks and benefits of engaging in sexual
activity; and (3) voluntariness, meaning the
absence of coercion and the presence of a
realistic choice between engaging or refraining
from the activity. While the factors are fairly
uniform, the extent and means of demonstrating
these factors is not at all uniform. State courts
show significant variability, especially with
respect to definitions of mental capacity.
Most states define “mental capacity” to
mean that the person cannot understand the
nature of sexual conduct—that is, the person
does not know either the physiological aspects
of sex or the possible consequences of sexual
activity, such as pregnancy and the contraction
of sexually transmitted diseases. Some states
require an added element of appreciating the
moral dimension of the decision to engage in
sexual conduct, although actually following
those moral notions is not required. Thus, the
individual may need the capacity to appraise the
nature of the possible social stigma or taboo
associated with sexual intercourse outside of
marriage.
Regardless of the legal standard, an even
greater challenge is the lack of a clear standard
for the assessment process, i.e., the evaluative
criteria and tools to be used in the assessment of
capacity to consent to sexual relations.
Capacity to Drive
Capacity to drive a motor vehicle and
grounds for revoking the privilege are
established by state motor vehicle laws. While
variations in the law are common, the Uniform
Vehicle Code provides a fairly representative
norm. It provides that no license shall be issued
when the commissioner has good cause to
believe that a person “by reason of physical or
mental disability would not be able to operate a
motor vehicle with safety upon the highways.”
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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The tremendous variety of physical, mental,
and emotional impairments that can result in an
inability to operate a motor vehicle safely results
in substantial assessment variability, but
regardless of the nature or source of impairment,
the legal standard ultimately looks at its practical
impact on the individual’s ability to operate a
motor vehicle with reasonable and ordinary
control.
Capacity to Mediate
Mediation is increasingly being used as a
means of dispute resolution in a broad range of
issues that might otherwise go to court. With
respect to the capacity needed to engage in
mediation, the ADA Mediation Guidelines name
several factors to be considered by mediators:
The mediator should ascertain that a
party understands the nature of the
mediation process, who the parties are,
the role of the mediator, the parties’
relationship to the mediator, and the
issues at hand. The mediator should
determine whether the party can assess
options and make and keep an
agreement (Wood, 2001).
Other Legal Capacities
A host of other legal acts have specific
definitions of capacity articulated and honed by
statutes and courts in different jurisdictions. For
instance, lawyers may wrestle with client
capacity to marry, to stand trial, to sue and be
sued, or to vote.
diminished capacity to justify the appointment
of a guardian or conservator.
The law of guardianship has evolved
extensively from its English roots. Originally,
the law required a finding that the alleged
incapacitated person’s status was that of an
“idiot,” “lunatic,” “person of unsound mind,” or
“spendthrift.” Present day notions of incapacity
instead use a combination of more finely-tuned
medical and functional criteria. A common postWorld War II paradigm for the definition of
incapacity under guardianship laws was a twopronged test that required: (1) a finding of a
disabling condition, such as “mental illness,”
“mental disability,” “mental retardation,”
“mental condition,” “mental infirmity,” or
“mental deficiency;” and (2) a finding that such
condition causes an inability to adequately
manage one’s personal or financial affairs
(Sabatino & Basinger, 2000). Under this
definition, the disabling condition prong of the
test was quite broad. Many states included
“physical illness” or “physical disability” as a
sufficient disabling condition, and some opened
a very wide door by including “advanced age”
and the catch-all “or other cause.”
Such amorphous and discriminatory labels
invited overly subjective and arbitrary judicial
determinations. Over time, states sought to
refine both prongs of this test to make the
determination of incapacity less label-driven,
more specific, and more focused on how an
individual functions in society (American Bar
Association Commission on the Mentally
State Guardianship Laws Mix ‘n Match
Four Varying Tests of Incapacity:
Diminished Capacity in State
Guardianship Law
State guardianship and conservatorship laws
rely on broader and more encompassing
definitions of incapacity, a finding of which
permits the state to override an individual’s right
to make his or her own decisions and to appoint
someone (a guardian or conservator) to act as
the person’s surrogate decision-maker for some
or all of the person’s affairs. The criteria for a
finding of incapacity differ among the states, but
in all states, the law starts with the presumption
of capacity. The burden of proof is on the party
bringing the petition to establish sufficient
•
•
•
•
Disabling condition
Functional behavior (focusing on
essential needs)
Cognitive functioning
Necessity element or “least restrictive
alternative” criteria
Disabled and Commission on Legal Problems of
the Elderly, 1989; Anderer, 1990). For example,
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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many states have narrowed the qualifying
disabling conditions or eliminated them as a
criteria altogether on the rationale that diagnosis
does not equal disability. Likewise, the second
prong of the test—inability to manage one’s
affairs—has been honed by many states to focus
only on the ability to provide for one’s “essential
needs,” such as “inability to meet personal needs
for medical care, nutrition, clothing, shelter, or
safety” (Idaho Code, 1999; Minnesota Statues
Annotated, 1998, New Hampshire Revised
Statues Annotated, 1999).
In
more
recent
years,
“cognitive
functioning” tests have gained prominence in
many states to supplement or replace one or both
prongs of the traditional test. For example, in the
1997 Uniform Guardianship and Protective
Proceedings Act, a cognitive functioning test
replaces the disabling condition language in the
definition of incapacity:
“Incapacitated person” means an
individual who, for reasons other than
being a minor, is unable to receive and
evaluate information or make or
communicate decisions to such an extent
that the individual lacks the ability to
meet essential requirements for physical
health, safety, or self-care, even with
appropriate technological assistance
(Uniform Guardianship and Protective
Proceedings Act, 1997).
The three tests—disabling condition,
functional behavior, and cognitive functioning—
have been “mixed and matched” by states in a
variety of ways (Sabatino et al., 2000). Some
combine all three (Hurme & Wood, 2006). More
importantly, the majority of states have added
significant additional requirements as thresholds
for guardianship intervention—most commonly
a finding that the guardianship is “necessary” to
provide for the essential needs of the individual
(i.e., there are no other feasible options) or,
stated alternatively, that the imposition of a
guardianship is “the least restrictive alternative”
(Sabatino et al., 2000).
In addition to defining the elements of
diminished
capacity
for
purposes
of
guardianship, most state laws have finally
recognized that capacity is not always an all or
nothing phenomenon, and have enacted
language giving preference to “limited
guardianship” in which the guardian is assigned
only those duties and powers that the individual
is incapable of exercising. Thus, judges, as well
as lawyers who draft proposed court orders,
need to understand and identify those specific
areas in which the person cannot function and
requires assistance. Under the principle of the
least restrictive alternative, the objective is to
leave as much in the hands of the individual as
possible.
Undue Influence
Capacity assessment focuses on an
individual’s cognitive, functional, and decisional
abilities relative to the complexity and risk of
the legal transaction at hand. Undue influence
refers to a dynamic between an individual and
another person. It describes the bending of one
person’s will to the extent that the will of the
perpetrator is substituted for that of the victim.
Chapter 7 provides more detail about undue
influence with a case example.
Related to legal doctrines of fraud and
duress, undue influence may be alleged in legal
transactions, such as executing a will, entering a
contract, or conveying property to another, as
well as in cases of financial abuse, sexual abuse,
and even homicide. However, most typically,
financial exploitation is the driving force. While
diminished capacity may make one more
vulnerable to undue influence, it is not a
necessary component of the dynamic. Therefore,
undue influence can be present even when the
victim clearly possesses mental capacity.
Guidance for Lawyers and Judges
Although lawyers seldom receive formal
training in capacity assessment, they make
capacity judgments on a regular basis whether
they realize it or not. It is useful for
psychologists and other health professionals to
know something about the role lawyers and
judges play with respect to capacity
determinations.
The decision to provide any legal service to
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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a client contains within it the implicit
determination that the client has the capacity to
hire the lawyer and to complete the particular
legal transaction. In most cases, it is not a
difficult determination because there is no doubt
about legal capacity. Yet, as society ages, the
incidence of cases in which capacity is an issue
continues to increase substantially.
One source of guidance for lawyers has been
the ABA’s Model Rules of Professional Conduct
(MRPC). Revised in 2002, the Model Rules
acknowledge capacity assessment challenges,
and indeed, suggest a duty to make informal
capacity judgments in certain cases. Not all
states have adopted the Model Rules, but even
taking into account state variations, there is a
great deal of similarity in direction among the
state legal ethics rules. Model Rule 1.14: Clients
with Diminished Capacity, is most directly on
point. It recognizes, first, the goal of maintaining
a normal client-lawyer relationship even in the
face of diminished capacity; second, the
lawyer’s discretion to take protective action in
the face of diminished capacity; and third, the
discretion to reveal confidential information to
the limited extent necessary to protect the
client’s interests.
Part (b) of Rule 1.14 requires three criteria to
be met before the lawyer takes protective action:
•
•
•
the existence of diminished capacity;
a risk of substantial harm; and
an inability to act adequately in one’s own
interest.
Lawyers are familiar with assessing risk and
identifying what is in one’s interest, but usually
they are neither familiar with nor trained in
evaluating diminished capacity. Even though
taking protective action is permissive (“may”)
and not mandatory, inaction due to uncertainty
puts the lawyer uncomfortably between an
ethical rock and a hard place.
The Comment to new Rule 1.14 for the first
time gives some guidance in assessing capacity,
although the rule itself does not define capacity:
In determining the extent of the client’s
diminished capacity, the lawyer should
consider and balance such factors as: the
client’s ability to articulate reasoning
leading to a decision; variability of state
of mind and ability to appreciate
consequences of a decision; the
substantive fairness of a decision; and
the consistency of a decision with the
known long-term commitments and
values of the client. In appropriate
circumstances, the lawyer may seek
guidance
from
an
appropriate
diagnostician. (Comment 6 to MRPC
1.14, American Bar Association, 2002).
These qualitative factors blend quite
naturally with the normal client interview and the
counseling conversation. However, the Model
Rules do not provide any conceptual, clinical, or
practical explanation for the factors (National
Conference on Ethical Issues in Representing
Older Clients, 1994; Margulies, 1994). To fill in
the picture for lawyers and provide a more
systematic approach to the capacity assessment
process, the ABA Commission on Law and
Aging and the APA produced a handbook for
lawyers, entitled Assessment of Older Adults with
Diminished Capacity: A Handbook for Lawyers
(2005). The handbook does not lure lawyers into
the task of clinical assessment. Rather, it lays out
a systematic role for lawyers in capacity
screening at three levels:
1. “preliminary screening” of capacity, the goal
of which is merely to identify capacity “red
flags” and to make a decision whether
clinical consultation or referral is advisable;
2. using effective professional consultation or
referral effectively for formal assessment, if
needed; and
3. making the legal judgment that the level of
capacity is either sufficient or insufficient to
proceed with representation as requested.
Regardless of whether a clinical assessment
is utilized, the final responsibility rests on the
shoulders of the attorney to decide whether
representation can proceed as requested or not, or
whether in appropriate cases, protective action
under MRPC Rule 1.14(b) is merited.
In the context of guardianship proceedings,
most judges likewise lack a clinical background
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and are challenged by the demanding role of
making legal determinations about an
individual’s capacity—particularly because
evidence may be murky or insufficient—yet
fundamental rights hang in the balance. The
ABA Commission on Law and Aging and the
APA, with the National College of Probate
Judges (NCPJ), created a capacity handbook
specially designed for judges in these kinds of
cases, Judicial Determination of Capacity of
Older Adults in Guardianship Proceedings
(2006).
As with the lawyers’ handbook, the judges’
version does not propose to arm judges with
some kind of capacity test. Rather, it seeks to
provide a conceptual framework of capacity,
focusing on six areas (or “pillars of capacity”) in
which information should be collected and
examined: (1) medical condition; (2) cognition;
(3) everyday functioning; (4) values and
preferences; (5) the risk of harm and level of
supervision needed; and (6) opportunities to
enhance capacity. These elements are amplified
in the next chapter and framed within the
context of the applicable legal standard for the
capacity in question and clinical judgment. The
handbook also provides judges with several
practical tools: suggestions for communication
between judges and clinicians; strategies to
enhance the autonomy of the alleged
incapacitated person; help in identifying less
restrictive alternatives to full guardianship;
information about reversible causes of
impairment
Chapter 8 further discusses working with
lawyers and the courts
In working with lawyers or judges, it is
worthwhile for clinicians to learn whether they
are familiar with the above or similar resources,
because it can improve the quality and efficiency
of communication and collaboration between the
two disciplines.
Some Comparisons Between the Legal
and Clinical Models
As a bridge between the legal standards
discussed above and the conceptual framework
for clinicians in the next chapter, it is worth
noting three characteristics that put certain
similarities and differences between legal and
clinical approaches to capacity in relief.
Transactions or Domains
One is that the focus on particular
“transactions” in the law is parallel in many
respects to what psychologists would
characterize as functional “domains,” although
clinical domains are much more finely
articulated.
Binary versus Continuous
Two, the law tends to ask about capacity for
specific transactions in a binary fashion—i.e., is
capacity present or lacking—somewhat like an
on/off switch. Clinicians are more oriented
toward understanding capacities as variable
continuums in which there may be no bright line
between the presence or absence of capacity.
While the law is warming up to the variable
continuum notion, the transactional focus of the
legal question still pushes for a binary yes or no
answer.
Conceptual versus Operational
Third, legal definitions of transactional
capacity tend to follow a fairly simple
conceptual template: can the individual
understand the nature and effect of (fill in the
task) and perform whatever the essential
function is necessary to implement the task.
Thus, they tend to articulate tests that are sound
in principle but not necessarily helpful in parsing
the operational cognitive, behavioral, or
emotional abilities necessary to meet the
standard. Clinical assessment fills in that detail
but must be clearly linked to the relevant legal
standard.
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III. Conceptual Framework for Capacity Assessment
Psychologists bring several strengths to the
capacity assessment process, most notably but
not exclusively, skills in the use of standardized
assessment. The use of standardized assessment
is important because capacity assessments have
been criticized for being vague and subjective.
Comprehensive evaluation that incorporates
objective data is especially important in complex
cases. For some older adults there may be subtle
deficits in some areas and not others, a strong
desire on the part of the individual to retain
personal autonomy, significant risks in the
decisional outcomes, family conflict, team
disagreements, variable clinical status, undue
influence, and so forth. When assessing broad
capacities with cognitive and procedural
components, such as “the capacity to live
independently,” the task can be rather
overwhelming. It is not uncommon to feel
confused at times by the capacity assessment
task.
A clinical judgment about capacity of an
older adult is exactly that—a professional
clinical decision. There is no equation,
cookbook, or test battery for the assessment of
capacity. A one-size fits all approach is doomed
to failure because of the varying domains of
capacity, legal standards used to define specific
capacities, and the need to integrate multiple
sources of data in complex clinical situations. It
is, however, useful to have a framework of the
critical elements in capacity assessment, which
may function to guide the psychologist in the
assessment process.
This handbook will be based upon a ninepart framework for capacity assessment. The
framework represents an expansion of
psychologist Tom Grisso’s pioneering model for
legal capacity (1986) that included six elements:
causal, functional, contextual, interactive,
judgmental, and dispositional. The nine-part
framework used in this book expands on this
model in the context of clinical assessment of
older adults and the application of capacity
standards in state guardianship law.
A Framework for Capacity Assessment
1. Legal Standard
2. Functional Elements
3. Diagnosis
4. Cognitive Underpinnings
5. Psychiatric or Emotional Factors
6. Values
7. Risk Considerations
8. Steps to Enhance Capacity
9. Clinical Judgment of Capacity
This framework will be applied in a step by
step description of capacity assessment in
Chapter 5, and will be followed in each of the
case examples provided for various specific
capacities in Chapter 6.
Similarities with
Psychological Assessment
Inherent in this framework are many elements of
any comprehensive psychodiagnostic and/or
neuropsychological assessment, such as a
determination of the neurocognitive or
neuropsychiatric diagnosis, definition of the
cognitive strengths and weakness, functioning in
the environment, description of the individual’s
preferences
and
background,
and
recommendations for treatment. Some elements
are unique to capacity assessment—namely the
consideration of the legal standard for the
capacity in question, a risk analysis, and a
professional clinical judgment about decisionmaking capacity.
Development of the Framework
Readers may recognize elements of the
framework in this handbook from the ABAAPA-NCPJ Judges’ Handbook concerning
capacity in guardianship. The framework was
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expanded in this handbook for use by clinicians
to organize assessments for a variety of specific
capacities.
The conceptual framework,
illustrated in the scales figure below, was
developed by reviewing theoretical and legal
models for capacity as broadly conceived. First,
we considered Grisso’s (1986) model of legal
capacity, as well as a similar model in a VA
(1997) practice guideline for capacity
assessment by psychologists. Second, we
reviewed various legal frameworks for capacity
under guardianship, including state-by-state
comparison of legal standards for incapacity in
state
guardianship
law,
state-by-state
requirements for capacity evaluation in
guardianship, and national probate court
standards for capacity evaluation.
ultimately result in a person’s loss of a legally
recognized right to make a decision or perform a
task. For example, a clinical finding that a
person lacks testamentary capacity—lacks the
sufficient knowledge and judgment to
“competently” create or alter a will—means the
individual’s stated choices for that will are not
recognized in settlement of the estate. Therefore
any assessment regarding a matter of civil
capacity requires that the psychologist
familiarize him or herself with the legal
standard—most often by consulting with an
attorney. When working in a medical
organization, organizational policies and
procedures may further define these legal
standards and how they are applied in the
healthcare system. For psychologists new to the
capacity assessment task, legal standards may be
confusing. The language in legal standards may
not be consistent with clinical concepts, and may
be so vague as to not provide much clarification
for the clinical task. To locate legal standards, a
psychologist may consult statutory and case law
precedent within his or her state. Most likely, the
psychologist will then want to consult with an
attorney to discuss the legal standard and its
meanings from a legal perspective.
How do I find legal standards?
Discuss with an attorney, such as the
referring attorney, hospital counsel, or
colleague; see also Chapter 2.
Components of the Framework
Legal Standard
Clinical evaluations of capacity are
grounded in a clinician’s opinion about a
person’s ability to make a decision or perform a
task that has a specific definition in the law.
Therefore, the legal standard for the capacity in
question forms the foundation of a capacity
assessment. A finding of incapacity may
For example, a common set of legal
standards for medical consent capacity is the
ability to understand and appreciate diagnostic
and treatment information, reason about the risks
and benefits of treatment options, and express a
treatment choice. (These standards are further
described in Chapter 6, section 1). The statutory
or case law will not define exactly what
“appreciation” means, and how it should be
evaluated, but, if these are the factors in the
statutory framework, a clinical evaluation should
address each of these. As another example, the
Uniform
Guardianship
and
Protective
Proceedings Act, a model guardianship statute,
(National Conference of Commissioners on
Uniform State Laws, 1997) defines an
incapacitated individual as someone who is
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“unable to receive and evaluate information or
make or communicate decisions to such an
extent that the individual lacks the ability to
meet essential requirements for physical health,
safety, or self-care, even with appropriate
technological assistance.” Therefore, the
psychologist may want to build a test battery
that generally assesses the concepts of receiving
and evaluating information, and communicating
it, such as neuropsychological tests that assess
language, memory, executive functioning, or
functional and decisional capacity measures
tailored to target these standards.
Functional Elements
Functional assessment is a common
component of gerontological assessment, and
has been appreciated by clinicians (Scogin &
Perry, 1987) who categorize functioning into the
activities of daily living (ADLs) (e.g., grooming,
toileting, eating, transferring, dressing) and the
instrumental activities of daily living (IADLs)
(e.g., abilities to manage finances, health, and
functioning in the home and community). In the
context of capacity assessment, an assessment of
“everyday functioning” means some sort of
tailored evaluation—with interview questions
and, when possible direct assessment and
observation of the individual’s functioning—on
the specific task in question. For example, when
evaluating medical consent capacity, a broad
assessment of cognition would be followed by a
specific assessment of medical decision-making
capacity using a consent capacity instrument;
when evaluating capacities for financial
management, a broad assessment of cognition
would be followed by specific assessment of the
individual’s knowledge, skills, and judgment
relative to financial tasks relevant to the person’s
financial holdings and history, using a financial
capacity
instrument.
Neuropsychological
assessment may only assess cognition and may
not include specific standardized functional
assessment; therefore one difference between
capacity
assessment
and
most
neuropsychological assessment is this focus on
functioning, and the inclusion of some method to
assess the specific capacity in question using
direct assessment.
Diagnoses
Documentation of the medical diagnoses is a
key element in capacity determination as they
may be the causative factors explaining any
functional disability. Grisso refers to the
condition producing the disability as the “causal
factor” in his model of capacity assessment
(Grisso, 2003). With aging, a wide range of
neurological and psychiatric conditions may
influence capacity—for example, Alzheimer’s
disease or other forms of dementia, stroke,
Parkinson’s disease, traumatic brain injury,
schizophrenia, bipolar disorder, and more
(Dymek, Atchison, Harrell, & Marson, 2001;
Kim, Karlawish, & Caine, 2002). Some of these
conditions may be temporary and even
reversible if treated, including delirium,
depression, bipolar disorder, and psychotic
disorders, therefore in addition to identifying the
cause of the functional problem, it is important
to describe the prognosis and possibility of
improvement with time or treatment. The
identification of the causes of any cognitive or
behavioral impairment leads to an understanding
of the likely course of the problem, prognosis,
and identification of any treatments that may
help.
Because legal professionals are not
clinically trained, it is critical to spell out
information on prognosis in plain language—is
the condition likely to get better, get worse, or
stay the same, and if a change is likely to occur,
when might that be?
Cognitive Underpinnings
In Grisso’s model the “functional” element
encompasses all facets of the individual’s
thinking and functioning. In our framework for
clinical assessment we emphasize three elements
of functioning to be separately addressed in
clinical evaluation through interview or direct
objective measures: cognitive functioning,
psychiatric or emotional functioning, and
everyday functioning.
Many disorders that affect capacity do so
because they have a direct effect on cognitive
functioning, including insight and awareness of
deficits (e.g., dementia) (Gurrera, Moye, Karel,
Azar, & Armesto, 2006; Marson et al., 1996).
Some capacities, such as treatment or research
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consent are essentially cognitive or decisional in
nature. Other capacities, such as driving or
financial management, while they involve a
behavioral component, also rely heavily on
underlying cognitive functioning (Moye &
Marson, 2007). In terms of guardianship,
cognitive functioning is a component of
statutory standards for capacity in many states
(Sabatino & Basinger, 2000). For example, the
aforementioned UGPPA definition of incapacity
includes several elements of cognitive
functioning. Psychologists’ training and
background in comprehensive assessment of
cognitive domains is highly relevant to the
evolving concepts of capacity as being complex
and multifactorial, rather than an all-or-none
proposition.
Psychiatric or Emotional Factors
Just as the mere presence of a medical or
neurological disorder does not necessarily mean
capacity is impaired, the presence of a
psychiatric or emotional disturbance, such as
thought or mood disorder, does not imply
diminished capacity. An individual could have
symptoms of depression, anxiety, or psychotic
disorder and still be quite able to process
information. However, when psychiatric or
emotional disturbance is significant, such as
severe depression, paranoia, or disinhibition, it
may limit reasoning and judgment, and therefore
impair capacity (Grisso et al., 1995). Many
individuals with psychiatric or emotional
disturbance may improve with time and
treatment, and therefore it is especially critical in
the capacity report to recommend treatment
interventions and a time frame for reconsidering
capacity.
Values and Preferences
A person’s race, ethnicity, culture, gender,
sexual orientation, and religion may impact his
or her values and preferences (Blackhall,
Murphy, Frank, Michel, & Azen, 1995; Hornung
et al., 1998), and these lay the foundation for
decisions. Age, cohort, and life experience are
critical in forming values and preferences.
Sexual orientation may not only influence
values, but may have special implications in
surrogate decision making (who is the person’s
family and who is the person’s legally
recognized decision maker). Cultural beliefs and
practices may inform decisional preferences
including the manner in which decisions are
made (individual as decision maker versus
family). Therefore all of these factors are
crucial to consider in capacity assessment.
In this handbook we use the term “values” to
refer to an underlying set of beliefs, concerns,
and approaches that guide personal decisions,
where as we use “preferences” to refer to the
preferred option of various choices that is
informed by values. For example, a person may
value not being a burden on others, so may have
a treatment preference that results in less
caregiving burden. For ease, we will use the
term “values and preferences” to refer to both of
these factors.
Even when cognitive functioning may be
compromised, for instance by dementia, a
person may still be able to express important
deep-rooted values underlying their decisions
(Karel, Moye, Bank, & Azar, 2007). Further,
choices that are linked with lifetime values may
be rational for an individual even if outside the
norm. For example, a choice to live in what
many might consider substandard housing (e.g.,
a cabin in the woods without running water)
may reflect a long-standing preference to live in
such housing.
The extent to which an individual’s current
decisions are consistent with long-standing
values may be an indicator of capacity
(American Bar Association, 2002) although it
should be noted that values may change with
experience or may be significantly influenced by
family, social network, culture or religion, so a
change in values does not indicate a change in
capacity. In addition, knowledge of an
individual’s values helps to inform the plan of
care for the patient. It is especially important to
be cognizant of an individual’s values, and how
these may vary from those of the evaluator—as
capacity determinations should be based on the
capacity of the individual in question, and not a
mismatch in values between the patient and the
clinician. For example, choices to extend life, or
to decline life-sustaining treatments, may be at
odds with what an evaluator may choose for him
or herself in that situation, but reflect the
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individual patient’s values and beliefs. Values
considerations are also important in a broad
array of financial transactional capacities. Is the
choice to transfer assets to another through a
contract, home sale, or even marriage consistent
with the financial choices (and underlying
values which informed those) the person has
made in the past?
Risk of Harm and Level of
Supervision Needed
Many capacity evaluations are at heart a risk
assessment (Ruchinskas, 2005). Thus, the
evaluation of the person and his or her medical
conditions, cognitive and functional abilities,
personal values and preferences, all elements
that affect their day to day functioning, must be
analyzed in reference to the risk of the situation
at hand. Does the specific treatment or research
decision involve a high degree of risk? Is the
home situation isolated, unsafe, or proximal to
risks? Does the legal contract involve a great
risk to the individual’s assets? Is money
transferred in the will to an individual or
institution large in the context of total assets? An
analysis of risk is not merely a consideration of
the condition and its effects, but also takes into
account the environmental supports and
demands, or what Grisso (2003) terms the
“interactive” component. Strong social and
environmental supports may decrease the risk
while lack of supports may increase it. Thus, it is
at this point in the framework that a
consideration of the person’s social context is
made. The level of intervention or supervision
recommended as a result of the capacity
assessment must match the risk of harm to the
individual and the corresponding level of
supervision required to mitigate such risk, and
must include a full exploration of the least
restrictive alternatives (Sabatino & Basinger,
2000). Traditionally, capacity evaluation has
been primarily concerned with risks of harm to
oneself, and the state’s obligation to protect
those who are vulnerable. However, serious
risks to others (such as occur when unable to
drive a motor vehicle safely) may enter into
clinical judgments of capacity.
Means to Enhance Capacity
An essential component of a capacity
assessment is a consideration of what can be
done to maximize the person’s functioning.
Practical accommodations (such as vision aids,
medication
reminders)
and
medical,
psychosocial, or educational interventions (such
as physical or occupational therapy, counseling,
medications or training) may enhance capacity.
Many age-related cognitive and sensory declines
can be accommodated. If improvement of
capacity is possible with treatment for
underlying conditions, clinical recommendations
may guide the referral source, or if the
assessment is part of a court case, may guide the
judge in deciding when to re-hear the case.
Further,
clinical
recommendations
for
intervention may directly inform the individual’s
plan of care. Like all good psychological
assessment, capacity assessment is often an
opportunity for intervention. Of course, this
would not apply in a retrospective evaluation of
capacity in situations where intervention is not
an option (e.g., the person is deceased).
Clinical Judgment
As illustrated in the scales figure, the
fulcrum of a capacity assessment is the clinical
judgment. A capacity assessment is built upon
consideration of the legal standard for the
capacity in question. The more standardized and
structured assessment of the individual’s
diagnosis, cognitive, psychiatric, and everyday
functioning must be balanced with a
consideration of the individual’s values and
preferences, risk considerations, and the
possibility for enhancement of the apparent level
of capacity through treatments, aids, and
enhancements.
The conclusion section of the report
describes the findings of the assessment.
However, a mere description of the findings is
not enough; the psychologist must provide a
clear “yes or no” opinion about the capacity in
question. In some cases, the judgment is rather
obvious. For example, an individual may have
advanced dementia with severe impairment
across a range of functioning, and, therefore,
clearly lack capacity for the issue in question.
Or, an individual may have no or minimal
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impairments in assessed functional abilities and
clearly have capacity for the task in question.
However, the most challenging situation is
that of individuals whose capacity impairment is
not obvious—and these are the cases that
psychologists are most likely to be asked to
assess. These individuals in the “middle ground”
of capacity may have moderate impairments in
many areas, or significant impairment in some
areas but not others, or, significant impairment,
concerns about that are mitigated by
consideration
of
the
person’s values,
preferences, social supports, and risks.
In most situations the psychologist will need
to arrive at a “binary” or “dichotomous” answer
to the specific capacity question. An inherent
tension in arriving at this decision is that in
Clinical
Capacity
Capacity
Judgment
Has capacity
Has capacity
many situations capacity may be operating as
more of a continuous variable, yet the
psychologist must provide a dichotomous
answer, as illustrated in the figure. For many
psychologists, this sort of integration of data to
arrive at a dichotomous conclusion is a new and
uncomfortable role. The task is to consider all
the data and offer an opinion as to whether the
data, considered in context of values, risks, and
enhancements, lean more in favor of or against
the person’s capacity. In some situations, it may
help to further delineate the capacity task—e.g.,
the person has the capacity to make a simple
medical decision but not a complex or high-risk
one. There are situations in which the
psychologist may believe he or she cannot
provide a strict “yes or no” answer, and may say
the person has marginal capacity, if this can be
supported by the evidence. However, it is
important that a finding of “marginal capacity,”
rather than a yes/no finding, does not represent
discomfort with “sticking one’s neck out” and
offering a clear opinion. More explanation of
this process and examples appear in the
following chapters.
Diminished
capacity
Lacks
capacity
Lacks capacity
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IV. Investigating the Referral and Planning Your Approach
Capacity assessments require more attention
on the “pre-assessment” phase to determine
what is being assessed and how the assessment
should be planned. Therefore, a capacity
assessment starts long before the psychologist
sits down with the older adult. The goal of this
chapter is to help orient psychologists to the key
pre-assessment issues involved in an assessment
of capacity. Steps in this chapter are outlined in
the worksheet following Chapter 5.
Roles Psychologists Play in
Capacity Assessments
A large part of the orientation to the capacity
assessment process depends on the setting in
which the psychologist works and the role
played vis à vis the older adult and the system in
which the capacity question is arising. Capacity
assessments may arise through a wide range of
mechanisms. The context of the setting will
impact the procedure for the assessment. The
context of the case will determine who is the
“client” and the capacity in question.
Refer to Appendix A
for definition of the term client.
Medical Setting
Most hospitals have rules and regulations
that address informed consent in situations in
which the patient is clearly incapacitated and
there is an immediate threat of harm or risk of
death to the patient. However, there are other
situations of medical consent that are not
emergent, and for which a psychologist might be
asked to provide an opinion of capacity. Often
these arise when a patient is refusing medical
treatment; when a patient is agreeing with a
doctor’s recommendations, the doctor is less
likely to evaluate capacity.
For example, in what situations can a person
refuse a potentially life saving/sustaining
coronary artery bypass graft? What if that
individual is psychiatrically stable (at his or her
baseline) but has considerable anxiety or
paranoia? What if that individual is more acutely
psychotic? Can a person with diminished
cognitive functioning decide to stop dialysis?
What if the decision comes after several days off
dialysis in which a delirium is setting in? Can an
individual with disorganized reasoning due to
micro vascular insults refuse antihypertensive
medications or anticoagulation medications that
may prevent future infarcts? What if he or she
refuses even though he or she also states that it
is important to preserve mental capacity?
In these situations, if there is a clinical
finding of incapacity by a physician or another
professional authorized to determine capacity in
the state and in the hospital, it may permit the
individual’s healthcare proxy, agent under a
durable power of attorney for healthcare, and in
many states next of kin to consent to the medical
procedure. However, even this situation requires
some investigation and thinking through. What
if a daughter or son is the healthcare proxy and
consents to anticoagulation therapy, but is not
able to support the patient in monitoring blood
levels and adjusting medications? So, part of the
investigatory process is to think through the
outcomes of a potential yes or no finding on
capacity and determine the feasibility of various
solutions.
Long-term Care and
Rehabilitation Units
A psychologist may offer an opinion to a
medical team regarding a patient’s capacity to
make a medical decision while residing in a
long-term care setting. In these settings
psychologists are frequently asked to participate
in clinical decisions about a person’s capacity to
live independently, and in some cases to manage
finances.
In a rehabilitation or transitional setting,
these evaluations are especially key as they
significantly impact treatment and discharge
planning. Psychologists will need to comment
on the course of the illness as an individual’s
capacity may improve dramatically over a
period of time. In some cases, an individual has
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entered the hospital setting from a less than ideal
situation—such as a homeless shelter. The team
wants to know if the individual can be
discharged back to a homeless shelter in the
context of his or her current cognitive
functioning. A decision about the capacity to
live independently often does not have legal
ramifications. However, if a nursing home
placement is considered necessary, some
facilities require the appointment of a legally
authorized decision maker to consent to the
placement, prior to admission. Therefore the
opinion regarding the capacity to live
independently—in order to be discharged
home—can evolve to have tremendous
implications for the individual’s rights if
guardianship is sought.
setting if a crime against an older adult is
involved. In these cases, the psychologist may
work with law enforcement as part of the
investigational team. These cases may include
current or retrospective determination of
capacity and may require oral testimony in
court. The setting of the capacity evaluation
within a criminal proceeding can have
tremendous implications for the approach the
psychologist takes to confidentiality and
consent, as will be further described below.
Cases involving “criminal capacities” (e.g.,
whether an accused older adult has the capacity
for criminal responsibility) represents a different
area of clinical practice, typically by a
psychologist with specialized forensic training,
and are not within the scope of this handbook.
Guardianship Proceedings
Investigator
In some situations, it is clear from the outset
that the reason for the capacity evaluation is to
determine the need for a guardian. This may
happen in an inpatient or outpatient setting, or in
a setting unrelated to medical care. A petition for
guardianship requiring a capacity evaluation
may be brought by concerned family members,
social service agency, or adult protective
services. A psychologist’s role in this case is to
offer information as an expert to be used by the
court in making the determination. In some
cases, the capacity determination and
guardianship order may be contested, meaning
that there may be multiple experts involved.
Depending upon the state, there may be a form
required by the court to document the evaluation
and conclusions. In addition, a guardianship case
may occasionally require additional oral expert
testimony in court. The psychological evaluation
for guardianship also has the potential to identify
areas of retained functioning, and to therefore
recommend domains in which a guardianship
order may be limited. This means the individual
retains the rights to make decisions in that area.
Such statements provide opportunities for the
individual to retain rights, as well as a sense of
autonomy.
A psychologist may be hired by an older
adult’s attorney to provide opinion regarding
capacity issues. These consultations may or may
not require a report and are considered fact
finding for the attorney involved.
Criminal Proceedings
A psychologist may become involved in
evaluating civil capacities but within a criminal
Unexpected Case Arising in
Clinical Practice
Finally, there may be situations that arise
during routine clinical work that result in
questions of incapacity. For example, while
completing a clinical dementia work-up of a
patient, the psychologist learns that he or she has
made some very poor recent financial decisions
or been victim to financial exploitation. In these
cases, the psychologist may raise the issue of
diminished capacity, and the evaluation may
evolve to become a capacity evaluation (with
appropriate consent from the patient). If elder
abuse has occurred the psychologist will also
report to and involve adult protective services.
Key Questions to Orient Yourself
to the Case
What Functional Capacity Is in
Question?
Because it is the goal to craft a report that
describes the older adult’s specific strengths and
weaknesses, it is necessary to take time to
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ascertain exactly what domain is in question.
Answers to this question may include: medical
consent, financial abilities, independent living,
the ability to engage in binding contracts, the
ability to buy or sell property, testamentary
capacity, the capacity to drive, and the capacity
to consent to sexual activity. Capacity is an
evolving clinical and legal concept, so additional
domains may be identified in the future.
What Data Are Needed to Answer the
Functional Question?
Once the psychologist determines the
domain of capacity, it will suggest the type of
functional evaluation that may be needed. If the
capacity is largely decisional in nature, for
example, the ability to engage in a contract, the
testing will focus on specific decision-making
abilities relevant to contractual capacities and
related neurocognitive domains, such as
memory, executive function, and reasoning. If
the capacity involves performance aspects, such
as financial management to include check
writing, independent living to include household
chores, or driving, the testing will involve direct
assessment
and
observation
of
these
performance skills and related neurocognitive
functions, such as visual-spatial and executive
functions.
Who Is Bringing the Case to
Your Attention?
The answer to this question may include
health care professionals, attorneys, family
members, social service agencies, or adult
protective services. As the psychologist asks
about the background of the case, insights into
the most pressing matters and a list of potential
collateral interviewees may be developed.
What Level of Evidence Is Possible?
A related question is to consider the ideal set
of data versus the possible, and what this may
mean for the assessment outcome. For example,
when asked to evaluate capacity to drive, further
discussed in Chapter 6, an optimal evaluation
may include in-office cognitive testing and onroad driving evaluation. What if the psychologist
does not have the ability to refer the older adult
to an on-road test? What if financial capacities
are questioned but the older adult refuses to
participate in a comprehensive assessment of
financial abilities, although participates in
cognitive evaluation, and there is strong
evidence of financial exploitation? What if the
psychologist is asked to make a retrospective
determination of capacity, but has limited
records of cognitive and functional abilities?
In such cases, the psychologist needs to
determine if it is permissible to offer an opinion
about capacity with a less than ideal level of
evidence, in the context of the risks and benefits
to the older adult and others of not offering an
opinion. In these situations, the psychologist
should clearly indicate in the report any
limitations in the data that might exist.
Getting Oriented to the Case
What: What types of decisional or functional
processes are in question?
What data are needed?
Am I an appropriately qualified
evaluator?
Who: Who is the client?
What is the older adult’s background?
Who is requesting the evaluation?
Who are the interested parties?
Who sees the report?
Is the court or litigants involved?
When: How urgent is the request?
Is there a court date?
What is the time frame of interest?
Is the individual medically stable?
Where: In what context / setting does the
evaluation take place?
Why: Why now?
What is the history of the case?
Will a capacity evaluation resolve the
problem?
What Is the History of the Problem?
Usually, when a request for a capacity
evaluation is made, regardless of setting, some
crisis has arisen. It can be helpful to step back
and inquire about the older adult’s previous level
of functioning and the history of the complaint.
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For example in medical settings, has there been
a history of poor or marginal compliance that
has now become a more serious risk? In
financial domains, has the older adult had a
history of poor or eccentric financial
management, but now may be exploited by
fraud? In terms of independent living, does the
older adult have a history with social services
regarding difficulties with home management?
Is there a history of interpersonal difficulties?
These data can provide context that will help the
psychologist design the most appropriate
assessment and plan.
The psychologist will want to be particularly
attentive to the history of high-risk behaviors. A
referring party may be alarmed about the
potential for a high-risk behavior. The
psychologist will want to consider how serious
is the risk and how likely, given the history of
behaviors relevant to the capacity question. For
example, is the referring party simply worried
about the person “leaving the stove on,” but
there has been no effort to intervene (e.g.,
disable the stove); or has the person left the
stove on despite efforts to disable the stove and
there is evidence of fires or serious burns.
Obviously, the psychologist also will want to
know if any high-risk behaviors are quite new to
the person or have occurred over time, as these
may also point to an acute cause of confusion
that could be reversible.
Are the Courts Already Involved and/ or
Will They Be Involved in the Future?
Cases that arise in medical centers may
involve determining if an individual has the
ability to consent to treatment. In these cases
you will be providing clinical data to assist the
treatment providers. The report may never end
up in court.
However, if a psychologist is being brought
in to assist with a guardianship proceeding for
example, it could be prior to court involvement
or after courts are already involved. In the
former case, the referral may be in an
information gathering phase, trying to determine
if it is even necessary to pursue a guardianship.
If the court is currently involved, determine
what action is pending and ask for all relevant
court records to review on the case. If a court is
currently involved it is helpful to know the
timetable for the evaluation and report.
If Litigation Is Involved, Is It a Civil Matter
or Criminal Matter?
The vast majority of capacity cases come
about through the probate court concerning
matters of guardianship and estate. Cases
involving fraud or elder abuse may become
criminal prosecution of the perpetrator.
Therefore, the capacity may still concern a
“civil” issue, such as capacity to enter a contract,
but the context for the case is criminal. The
criminal context may bring to bear different
relevant standards. For example, the level of
proof may be “beyond a reasonable doubt” in
criminal matters.
What Is the Time Frame of Interest?
A psychologist may be asked to make a
retrospective evaluation of capacity—given the
data available, did the person have the capacity
to change a will? Or, a psychologist may be
asked to evaluate the person’s capacity in the
here and now. At times, a psychologist may also
be asked to project capacity into the future—
given what is known about the diagnostic cause
of diminished capacity, would capacity get
better, worse, or stay the same.
Who Are the Interested Parties or
“Players” Involved in the Case?
No matter what the context, there can be
widely varying opinions and motivations
surrounding the older adult’s capacity. Be
familiar with all of those with potential interest
in the case and try to assess the motivations of
the different participants. That may include
family members, attorneys, other experts,
physicians, and social workers. For example, in
a case of contested capacity involving an alleged
incapacitated person, there may be multiple
adult children involved, perhaps children from
multiple marriages, their attorneys and experts,
plus social services all with differing opinions
and motivations.
The court may very well include other
witnesses when making its determinations
regarding capacity. These witnesses may include
other experts, law enforcement, and others. The
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psychologist needs to be aware that the clinical
evidence that they provide may only be part of
the total evidence involved in the case. In other
situations, the psychological report may be the
only data upon which a legal determination of
capacity is made (e.g., most “routine”
guardianship hearings).
Will Answering the Question About
Capacity Resolve the Problem?
Sometimes thorny clinical problems are
initially posed as capacity issues, but the core
issue, such as a family systems issue, may not be
resolved with such an assessment. For example,
nursing home staff may ask a psychologist to
comment upon the capacity of someone who is
refusing personal care. Although indeed the
person may be so impaired as to be unable to
understand the consequences of refusing care
(e.g., bathing), a finding of incapacity will not
solve the problem. The staff needs to determine
how to deliver the care to the resistant patient.
Similarly, nursing home staff may have
unrealistic ideas about what a guardian can
offer. A guardian can provide key decisional
input but cannot monitor a person and compel
behavior from minute to minute.
Are There Less Restrictive Alternatives
That Might Resolve the Problem Without
a Capacity Evaluation?
Ideally, the clinician will work to put into
place the least restrictive alternative that
provides the older adult protection (if needed).
The older adult may have some mechanisms in
place that provide decisional support. These
mechanisms can include the use of advance
directives, healthcare proxy, a durable power of
attorney for finances and/or healthcare, or a
representative payee. For some of these
mechanisms, a capacity evaluation may still be
required, but with others, there may be a
solution that does not require going to that
length. With a highly functional family system
and some input from the older adult regarding
their wishes, it can be possible to avoid an
adversarial approach.
What Is the Urgency of the Request—
Is an Answer Needed Now?
Some capacity evaluation requests are very
urgent. For example, a person with diminished
cognitive abilities may be insisting on leaving
“against medical advice” (AMA) discharge
immediately, and the staff is unsure if the person
has the capacity to leave AMA or must be
prevented from going in some manner. In any
situation the psychologist will want to determine
if the individual is medically and psychiatrically
stable. In other situations, the psychologist may
determine the person is not stable, and the
capacity question can wait. For example, the
person will not come to harm if treatment is
delayed for a period of time. This will allow the
psychologist to work with the team to offer
interventions to maximize the individual’s
cognitive functioning prior to the capacity
assessment.
What Is the Older Adult’s Cultural
Background, Language Needs, and
Sensory Functioning?
As with any psychological assessment, the
psychologist will want to consider what
adaptations may need to be made in approaching
the older adult to maximize understanding.
Obviously, if the individual is a non-english
speaker, the evaluation must be done in the
individual’s language, using a translator if
necessary. Attention must then be paid to issues
of translation of measures and also of test bias.
Cultural factors influence more than the method
of assessment, but may also influence the
context in which the capacity question arose.
For example, if an older adult is refusing a
medical treatment, was the older adult provided
with sufficient information, and did he or she
understand it? Was there freedom to make a
decision that was informed and voluntary? Did
issues such as immigrant status, economical
status, culturally informed perceptions of illness
and the role of medical treatment influence the
older adult’s decision making? How does the
older adult wish for his or her family to be
involved in decisions?
In addition to cultural and language
concerns, potential sensory difficulties need to
be accommodated so that the older adult can see
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and hear relevant information during the
evaluation. In addition, it may be useful to
schedule shorter testing periods, and if more
lengthy testing is required, to do so over several
days.
To accommodate sensory loss, address:
Background noise
Seating position
Lighting
Large print materials
Hearing and visual aids
Speaking style and pace
Duration of testing sessions
See APA Guidelines for Psychological
Practice with Older Adults for more details
at www.apa.org/practice/adult.pdf
Am I Appropriately Qualified to Do the
Capacity Assessment?
At this point, the psychologist has amassed a
lot of information about what data are needed to
answer the capacity question and any mitigating
contextual factors. Next, the psychologist must
consider if he or she has the qualifications to do
the assessment (e.g., professional competencies
in the assessment of older adults). Further
qualifications may arise depending upon the
particulars of the case. For example, is a
bilingual psychologist needed? Will the
questions be better answered by an occupational
therapist? Is the situation so medically complex
that the capacity question may be better
answered by or in conjunction with a medical
doctor? Is the older adult’s underlying condition
one in which the psychologist has experience
assessing—different skills may be needed to
assess an individual with serious mental illness,
versus dementia or developmental disability.
Do I Have a Conflict of Interest?
If there is a conflict of interest between the
psychologist and patient, it should be identified,
and where appropriate, disclosed and/or
resolved. For instance, it is not advisable to do a
capacity assessment with an older adult known
through a therapeutic, personal, or professional
relationship because it would create a dual
relationship as described in the Ethical
Principles of Psychologists and Code of
Conduct (American Psychological Association,
2002).
Reviewing the Records
A thorough clinical assessment includes a
review of available medical records. However,
obtaining medical, legal, and other records
becomes even more important in capacity
assessments. The medical records are needed to
address the presence and type of medical
condition producing functional disability,
current medication regimens, the course of the
illness, and medical risk factors for cognitive
impairment. For example, a psychologist may be
able to obtain previous cognitive testing to use
as a baseline, neuroimaging information, a
description of the clinical course, information
regarding the use of assistive technologies, etc.
In guardianship cases, there may be
conflicting expert opinions regarding the need
for a guardian. Accessing previous assessments
and legal records can help the clinician to
organize the current assessment. In other types
of capacity cases, for example those regarding
financial capacity, it can be helpful to access
banking statements and other financial
information to determine if the older adult’s
report is accurate. For example, the older adult
states that they always pay their bills on time,
but there is objective evidence to the contrary.
Or the older adult confidently states monthly
income of $1,200 but records contradict that
information. Family members, social workers, or
private attorneys can be helpful in obtaining
such records.
Obtaining Informed Consent
Review the purpose of the evaluation, the
nature of the evaluation, and the evaluation
procedures with the older adult. Define the risks
for the person being assessed that include a loss
of decision-making rights, potential lack of
confidentiality, and the possible need for a
guardian or conservator. Also discuss any
possible benefits to the procedure that may
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include the gathering of helpful clinical
information that can be used in treatment
planning or as evidence in criminal matters on
the person’s behalf. Include a description of the
risks of not consenting. For example, in some
situations the psychologist may be responding to
a request to complete a court document
regarding the need for a guardian, and may need
to complete that regardless of whether or not the
person consents to a full evaluation. Therefore,
the psychologist might explain that the risks of
consenting include the loss of rights associated
with guardianship; the risks of refusing is that
the psychologist will be required to complete the
documentation without having obtained full
input from the patient.
After disclosing information—if necessary
in small “chunks” and with written support—ask
the older adult to state back the purpose of the
interview and risks and benefits involved. This
process may take several attempts and require
breaking the information down into simpler
pieces. The goal is to maximize understanding.
The consent process must consider who is
the client and who will see the report. For
example, in a court-ordered case, the report will
be used as evidence and viewed by all parties to
the case. In some states these capacity
declarations become public documents. It is the
psychologist’s job to ascertain who is the client
in each specific case and to ask the referring
person who will see the report. In situations
where the person being assessed is not the
psychologist’s “client,” informed consent
procedures must be modified to explain the
limits of confidentiality to the person being
assessed.
In the report, document the informed
consent process in detail, including how the
assessment was described to the individual, the
risks and benefits disclosed, and the extent of the
person’s understanding.
Of course an obvious question is whether
the individual for whom you are evaluating
capacity has the capacity to consent to the
assessment. In some cases the level of ability
needed to consent to the assessment is lower or
different than the ability being assessed. For
example, you may be evaluating the person’s
ability to manage a complex financial estate that
requires a higher level of understanding than
making a decision about whether to consent to
the capacity assessment process. Several
outcomes are possible, as summarized in the
table below.
Capacity Evaluation Consent Outcomes
Agreement to Evaluation
Capacity
to
Consent
Yes
No
Yes
Valid
Valid
Agreement Refusal
No
Incapable Incapable
Agreement Refusal
or Assent
The person may have capacity to consent to
the evaluation, and either agrees or refuses. In
this case, the person has provided a valid
agreement or refusal, and this can be
documented. Alternatively the person may not
have the capacity to consent to the evaluation,
and either agrees or refuses. If the person agrees,
he or she is generally said to have “assented”
and the assessment process goes forward. If the
person disagrees, and refuses to comply with an
interview, then the psychologist must document
why the person is believed to lack the capacity
to refuse the evaluation. In some situations, the
capacity evaluation stops there. In other
situations, where a capacity evaluation is court
ordered, the psychologist may be asked to
provide an opinion based on his or her
observations of the person.
Refer to Chapter 8
for a discussion of third party observers
Billing
Because capacity assessments can arise in
diverse settings, mechanisms for billing vary as
well. In settings where the primary goal of the
assessment is related to medical care, the
assessment may be billed to Medicare or private
insurance. However, when the referral is clearly
forensic in nature from the start, referred from
an attorney or court, billing of insurance is not
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appropriate. Thus, in forensic settings, it may be
the older adult, the attorney, or the court who
pay for the forensic evaluation. It is up to the
clinician to determine who is responsible for
payment and what the specific procedure will be
(i.e., payment of a retainer, etc.). Given the large
amount of pre-assessment work that often needs
to be done on these cases, it can be helpful for
the psychologist to ask for an upfront fee for
several hours to review records prior to giving
an opinion on the necessity and pros or cons of a
capacity evaluation.
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V. General Approaches to Assessing the Older Adult
General Principles
Clinical Interview
Capacity assessments with older adults differ
from regular clinical assessments in that they
focus on a specific capacity question. Therefore,
they require a functional assessment directed to
relevant legal standards. In keeping with good
clinical practice, tools employed in these
assessments should be normed for older
populations. Reference texts, such as the
Handbook
of
Normative
Data
for
Neuropsychological Assessment (Mitrushina,
Boone, Razani, & D’Elia, 2005) and a
Compendium of Neuropsychological Tests
(Strauss, Sherman, & Spreen, 2006) provide upto-date normative information on many general
cognitive tests for older adults.
Is there a “core assessment battery” for
capacity assessments? As the range of potential
capacity questions varies so widely, as do the
constituent functional and cognitive abilities, it
is not possible to have a “core assessment
battery.” Instead, a flexible battery based on
sound psychometric measures is required.
Whenever possible psychologists should use
functional tools that have been demonstrated to
be psychometrically sound and normed for older
adults.
Although psychologists bring important
abilities in the application of objective testing,
the clinical interview remains an essential part of
any capacity evaluation. However, the clinical
interview may take on a different role in
capacity assessments than it might in other
assessments. It can be useful to follow the
clinical framework introduced in Chapter 3 as
part of the capacity interview. For example, in
addition to performing a thorough psychiatric
diagnostic interview, the capacity interview is an
opportunity to gain information on the medical
and
cognitive
presentation,
everyday
functioning, individual values and preferences,
risk of harm, and means to enhance capacity that
impact most cases. The following sections
provide examples for how to modify the clinical
interview for capacity assessments.
See Appendix B for a list and description of
functional measures.
However, because capacity is an emerging
practice area, there are a limited number of such
tools available. Thus, psychologists will need to
seek other sources of data in some instances,
such as functional observations, collateral
interviews, and multidisciplinary team input
regarding function. The report for capacity
assessments should be drafted specifically for
this purpose and offer a clearly stated opinion
regarding capacity. Sample reports in Chapter 6
provide examples of how to convey an opinion.
Assessing Functional Elements During
the Clinical Interview
It is important to obtain functional
information through interviews with the patient,
and if appropriate, family and staff.
Discrepancies between older adult reports of
their IADLS and ADLs and collateral or
objective reports can be especially revealing. (Of
course, the psychologist would need to consider
whether a collateral has a conflict of interest in
describing functioning better or worse than it
actually is—especially in a criminal case). For
example, if being asked to assess financial
capacity, asking the older adult to list sources of
income,
bank
branches,
and
investments/retirement accounts to help
ascertain their abilities. It may be that the older
adult is able to handle simple financial
transactions, but needs assistance with complex
financial transactions.
Assessing the Diagnoses Producing
Functional or Decisional Disability
The clinical interview should include
questions to help determine if there is a medical,
psychiatric, or neurological condition impacting
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cognition. An interview might include a history
of the presenting problem, course, medical
history, psychiatric history, substance/alcohol
abuse, review of medications, and a review of
symptoms.
See Appendix F for a list of medical
conditions that can impact capacity.
Assessing Cognition During the
Clinical Interview
Although cognitive testing will provide the
standardized data to determine the presence or
absence of impaired cognition, interview data
can also provide a wealth of information
regarding the nature and extent of the
impairment. Many clinicians will begin with a
brief mental status screening using an interview
format or specific screening test to obtain a
ballpark estimate of level of functioning. The
screening test itself is limited in its ability to
predict capacity because of its lack of sensitivity
to executive functioning, but can be useful as a
starting point and to help in the selection of
assessment tools.
Behavioral evidence of memory and
executive dysfunction may be apparent during
the clinical interview and should be noted. In
terms of memory impairment, one can include a
discussion of current events or past important
events (e.g., sports, politics, major disasters). It
is also helpful to assess accuracy of
autobiographical information, including noting if
a temporal gradient is present (i.e., older adult is
able to accurately report some historical
information but not information from past year
or so). Based on interview data it is often
possible to determine if there is the presence of
errors in recent versus remote memory. In terms
of executive functioning, difficulties with
initiation, flexibility, impulsivity, and lability
throughout the discussion are noteworthy.
Insight into the current situation, and any
deficits is critical in being able to accept
assistance and delegate to others.
Values and Preferences
A person’s decisions should be understood
in the context of lifestyle or life patterns, values,
and preferences. Choices that are linked with
lifetime values might be considered “rational”
for an individual, even if outside the norm. For
example, some individuals choose not to involve
banks in any of their financial transactions, live
in marginal housing, or use their income to
support non-mainstream ideals. A person’s
values may arise from age, sexual orientation,
race, ethnicity, gender, culture, religion, or other
life experience that informs life perspective. For
example, previous experiences in assisting
others in end-of-life treatment decisions may
affect the approach taken to one’s own
decisions.
Knowledge of values is not only important
in informing capacity judgments, but also in the
guardianship plan. Core values may impact the
individual’s preference for who is named
guardian, as well as preferences concerning
medical decisions, financial decisions, and
living arrangements. What is needed are
questions that allow a deep understanding of the
reasons behind a person’s choices. For example:
1. Think about what is most important to you
in your life. What makes life meaningful or
good for you now?
2. Consider what is important to you in relation
to your health. What, if any, religious or
personal beliefs do you have about sickness,
health care decision-making, or dying?
3. What is your financial history? Are you in
any debt? Do you live week to week? Are
you able to plan ahead and save for the
future? How do you prefer to spend money?
4. Where are you living now? How long have
you been there? What makes a home a home
for you?
5. Who are the family and/or friends that live
in your community that are important to
you? What about those that live in another
community?
Other specific examples of questions to add
to clinical interviews appear in Chapter 6.
Objective Testing: Functional
Capacity assessments involve the integration
of data from cognitive and functional sources. In
the past, older adult and/or collateral reports
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were primarily employed to examine the
functional piece of the assessment. However,
those reports may be biased by lack of insight or
motivational issues. Newer approaches to
functional capacities include direct observation
of older adult’s abilities, the use of functional
measures abilities and functioning abilities, and
structured interviews. Direct assessment of
functional abilities can be performed by a
psychologist as well as many allied health
professionals. Occupational therapists have
special training in assessing everyday
functioning.
Capacity Assessment Tools
More recently, a number of clinicians and
researchers have developed assessment tools that
attempt to operationalize the legal standards for
specific capacities into direct functional
assessment instruments. The items and summary
scales are not meant to replace a full clinical
assessment, but may help the evaluator assess
specific functional areas relevant to the capacity
in question.
Medical Consent Capacity. Capacity to
consent to medical treatment has seen the most
instrument development, such as the MacArthur
Competence Assessment Tool - Treatment
(Grisso et al., 1998) and the Competency to
Consent to Treatment Instrument (Marson et al.,
1995). These are described in the medical
consent capacity section of Chapter 6 and in
Appendix B.
Sexual Consent Capacity. There are
currently no standardized tools to assess sexual
consent capacity.
Financial Capacity. Several tools exist for
the psychologist to assess financial capacity,
including the money management section of the
Independent Living Scales (Loeb, 1996), which
has norms for older adults, the Financial
Capacity Instrument (Griffith et al., 2003;
Marson et al., 2000), and the Hopemont
Capacity Assessment Interview (Staats &
Edelstein, 1995). These are described in the
financial capacity section of Chapter 6 and in
Appendix B.
Testamentary Capacity. There are
currently no standardized tools to assess
testamentary capacity.
Driving. The best “tool” for assessing
driving is targeted in-office testing followed by
simulator and on-road testing by a driving
professional. As described in Chapter 6, there
are some in-office tools that are important as
part of a comprehensive driving assessment.
Independent Living. In addition to
IADL/ADL tools, some instruments have been
developed to assess independent living in the
context of capacity questions, such as the
Independent Living Scales (Loeb, 1996) and the
Decision-making Interview for Guardianship
(Anderer, 1997). These are described in the
independent living capacity section of Chapter 6
and in Appendix B.
ADL/IADL Rating Scales
There are a wide variety of scales (see
Appendix B) developed to assess an older
adult’s level of functioning for “Activities of
Daily Living” (ADL) and “Instrumental
Activities of Daily Living” (IADL). These can
be useful in organizing and rating assessments of
functioning within specific functional domains.
Objective Testing: Cognitive
Psychologists may employ a variety of tasks
in the assessment of cognition. The “best” test
battery will depend on the context, the setting,
and the particulars of the case. The following
information is provided as a review to
psychologists with some task examples.
Cognitive tests are listed in Appendix C.
Attention
The older adult’s ability to attend to tasks is
an important first step in the completion of an
assessment. An inability to do so may be
indicative of a delirious state. Tasks such as
digit span or coding can help to determine a
baseline for attentional abilities.
Language
An ability to express a choice is a critical
component of capacity assessments. Complex
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medical and financial decisions require the
ability to read and comprehend written
documents. Speech production, language
comprehension, and written language skills are
all components of language assessment.
Impairments in object naming may be indicative
of a dementia process. Impairment in language
production or comprehension may be indicative
of an aphasia that may be secondary to a
vascular injury.
A language sample can be obtained by
asking an older adult to describe a scene.
Language comprehension can be assessed by
asking an older adult to follow commands.
Object naming may be assessed by presenting an
older adult with a line drawing and asking for
the name of the object. A writing sample can
indicate written language skills. The older adult
could also be asked to read a sample and answer
questions regarding the passage. If there is any
indication of a frank language disturbance (i.e.,
Broca’s aphasia), a more extensive formal
assessment of language using a languagespecific battery may be warranted.
Memory
Memory disorders can impair decisionmaking by influencing the older adult’s ability to
recall previously learned information, integrate
information across choice options, and learn new
information. Memory impairments are the
hallmark of dementia processes and as such
serve as a marker of potential impairment and
further decline. Free recall, cued recall, and
recognition are formats for memory assessment
in verbal and visual memory domains. Referrals
that include a history of traumatic brain injury
may need to add additional assessments of posttraumatic amnesia (PTA).
List learning tasks are especially sensitive to
mild cognitive impairment. A list learning task
will provide information regarding immediate
memory in the initial trials. After a delay, the
task will provide information regarding free
recall and possibly recognition abilities. These
tasks may also allow for observation of specific
memory errors, such as a tendency to
perseverate and/or confabulate. Story recall
memory tasks are useful because they provide
information regarding how older adults
remember information within a context. Visual
memory tasks can provide a perceptual
construction (drawing) sample, as well as an
assessment of visual memory abilities. Taken
together, the clinician can provide a profile of
strengths
and
weaknesses
and
make
recommendations for maximizing capacity. For
example, the psychologist may report that “the
older adult was impaired on tasks of verbal free
recall, but performed much better with a
recognition format. The older adult will perform
best if information is provided to her in a written
format.” Or, the psychologist may report
the older adult performed poorly on a
list learning task that included many
intrusions. On a story memory task, the
older adult tended to confabulate,
including many extraneous details.
Thus, the older adult is a poor historian,
has difficulty learning new information,
and has a tendency to “fill in the gaps,”
which potentially impacts decisional
capacity.
Visual-Perceptual
Perceptual disturbances can impair a
person’s capacity to drive and potentially impair
abilities to complete financial calculations. A
clinical assessment in such cases might include
tools that assess an older adult’s ability to copy
figures, decipher or match patterns, and/or
construct objects to samples.
Speed of Processing
Slowed speed of processing can result in
vulnerabilities to poor decision making,
especially in the context of coercive interactions.
A clinical assessment may include tools that
assess processing speed, such as Digit-Symbol
Coding from the WAIS, coding from the
RBANS, or Trails A from the trail-making test.
Executive Functioning
Executive functioning components, such as
the ability to plan, think flexibly, respond to
feedback, and inhibit impulsive responses are
critical to effective decision making. Some
common tools used in clinical geropsychology
settings, such as the MMSE, RBANS, and
COGNISTAT, EXIT25, provide limited
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information regarding executive functioning.
Thus, supplemental tests of executive function
should be employed whenever there is a
question regarding decision-making capacity.
Judgment and Reasoning
Tasks assessing judgment and reasoning can
be important auxiliary measures when
developing your opinion regarding an older
adult’s capacity. Tasks that assess abstract
reasoning like the Similarities subtest of the
WAIS tests can provide a helpful assessment of
thought processes. Judgment tasks like the
Kaplan Practical Problem Solving Task, or
reasoning from the COGNISTAT can provide a
sample of problem solving abilities. It can be
especially helpful to look at the distinction
between responses to these posed problems and
abilities to implement them. For example, when
posed the hypothetical problem “What would
you do if you saw smoke and fire in the home,”
the older adult may answer “run and put it out”
ignoring mobility issues.
Objective Testing: Psychopathology
A variety of objective measures of
psychopathology can be used to supplement
information obtained via the interview and
mental status examination. The objective
assessment of older adults can be challenging, as
individuals of this cohort are less familiar with
formal testing, many of the measures used to
assess psychopathology among younger adults
lack psychometric support with older adults, and
the
presentations
and
prevalence
of
psychopathology can be different in older than
younger adults (e.g., Cohen et al., 2000; Depp &
Jeste, 2004; Fisk & O’Riley, 2008; Kogan,
Edelstein, & McKee, 2000). One should limit
the use of objective measures to those that have
been created explicitly for older adults and have
psychometric support, and those that were
developed for younger adults and have
accumulated satisfactory psychometric support
with older adults. Two resources are Edelstein et
al. (2008), a review of instruments for the
assessment of selected disorders and problems
(i.e., anxiety, depression, personality, sleep,
suicide), and Segal, Coolidge, O’Riley & Heinz
(2006), a review of structured and semistructured interview instruments.
Lengthy,
comprehensive
assessment
instruments (e.g., MMPI) can be helpful, but
often exact the costs of fatigue and diminished
attention with older adults. This can be
particularly problematic with individuals whom
one already suspects may have compromised
cognitive skills. The use of more targeted
assessment instruments based on available
information and the initial interview results is
likely to prove more efficient and less taxing.
It is important to avoid placing too much
emphasis on psychiatric diagnostic categories
when attempting to appreciate the effects of
psychiatric and emotional factors on capacity.
Rather, the focus should ultimately be on the
potential influence of the psychiatric and
emotional symptoms on capacity. This influence
can occur through the patient’s cognitive
processes (e.g., delusional thinking, judgment,
insight), through diminished cognitive skills
(e.g., impaired attention, impaired working
memory), or through behaviors (e.g.,
disinhibition).
For example, an older adult with
schizophrenia might hold a delusion that his or
her physician is attempting to poison him or her
with the medication being offered. This delusion
may not influence the ability to express a choice,
the ability to understand information relevant to
his or her treatment, or the ability to reason with
relevant information. However, the delusion
could affect the ability to appreciate the
significance of the information provided about
the medication for his or her disorder and
treatment if he or she believed that the
medication would not improve his or her
condition. Moreover, it could influence the
person’s ability to appreciate the probable
consequences of the treatment option that is
being offered. That is, the patient believes that
the medicine being offered is poison that will
kill.
As another example, an older adult with
active Bipolar I disorder may have manic
episodes with racing thoughts, rapid speech,
decreased need for sleep, hypersexuality,
euphoria, and grandiosity. These symptoms
might influence capacity in any number of ways.
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Sleep deprivation associated with the disorder
could affect sustained attention and working
memory, and impact the ability to understand
information, appreciate the significance of
information, and reason with the relevant
information during a manic episode. Also, the
behaviors themselves, such as excessive
spending, could directly influence capacity—
such as the ability to manage a business.
The Role of Collateral Interviews
Clinicians accustomed to working with older
adults already know the value of conducting
collateral interviews in order to ascertain the
older adult’s insight and areas of concern. In the
capacity interview, these interviews take on
added importance as a source of potentially
objective data regarding the older adult’s
functional abilities. Multidisciplinary team
members may serve as collaterals. It is necessary
to obtain the older adult’s permission to
interview collaterals.
However, with any particular case, there
may be family members with strongly differing
opinions and motives regarding the outcome of
the assessment. For example, in cases involving
potential guardianship, there may be some
family members who oppose such an action and
others advocating for the protection. It is the
clinician’s role to ascertain the motives of the
family members involved in the case and the
implications for the collateral data. For example,
sometimes family members become concerned
regarding the financial management of a parent
if one child (often the caregiver) appears to be
benefiting financially from the arrangement.
Conversely, it is sometimes the in-home
caregiver who has the most information
regarding a decline that drives the proceedings
despite a lack of concern from out-of-state adult
children. In criminal matters, adult dependent
children or paid caregivers may be alleged
suspects in financial abuse cases, and thus have
motives to misrepresent the presentation.
Post Evaluation
How Will My Capacity Report Be Used?
A capacity report is subject to multiple uses.
It may be informational and advisory, it may
direct clinical action, or it could be used as
evidence in a court hearing or trial. During the
pre-assessment phase, the psychologist will
hopefully have determined who would be
serving as the client and where the report will be
submitted. However, it is possible for cases to
evolve and for the report to be subject to
additional uses. The report that was originally
meant to be used as informational may
ultimately end up as evidence in a judicial
setting. The capacity evaluation may also
inform a plan of care for the older adult, and
could specifically be used in a “guardianship
plan” developed by a guardian for the older
adult.
Do I Use a Special Form?
In some states, an additional legally
mandated form needs to be completed if the
report is for guardianship. These forms should
be completed in addition to a complete clinical
evaluation and can be submitted together.
Will I Provide Oral Testimony?
In most instances, a written report will be
sufficient. Occasionally, in a case of contested
capacity or in criminal matters, a psychologist
might be asked to provide oral testimony in the
court. Suggestions for preparation as an expert
witness are provided in Chapter 8.
How Do I Integrate the Information?
At the completion of the assessment, the
psychologist must now form an opinion
regarding an individual’s capacity. In doing so,
the psychologist will consider a wide range of
evidence, including functional skills relevant to
the capacity in question, cognitive functioning,
psychiatric functioning, medical diagnoses and
prognosis, the individual’s values, and
situational risks relevant to the capacity. This
requires a careful weighing of these factors in
order to arrive, if possible, at a clear yes/no
opinion regarding capacity. However, there will
occasionally be borderline cases in which
clinically the best judgment may be a finding of
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“marginal capacity.” Marginal capacity findings
have value as long as they are based on evidence
and not on the clinician's reluctance to offer a
clear opinion on the matter. A court (if involved)
will be able to consider a clinical finding of
marginal capacity in its overall calculus in
arriving at a legal capacity judgment.
In weighing the different sources of
evidence, it is best for the clinician to focus
initially on evidence regarding the functional
abilities constituent to the capacity, as this is the
evidence that is most capacity specific.
Secondary levels of evidence include cognitive
and psychiatric functioning, and medical
diagnosis and prognosis, which are each relevant
to capacity but not by themselves dispositive of
capacity issues. However, they obviously are
relevant to the clinical capacity judgment,
particularly in non-retrospective evaluations
where the underlying diagnostic issues may alter
the functional abilities and associated risks in the
future. As part of formulating a capacity
judgment, consideration should be given to the
individual’s values and their relation to his/her
behavior, and also to the specific risks inherent
to the capacity situation. It is also important to
describe available means of enhancing an
individual’s capacity, if such means are
available and feasible.
As an example, in the case of evaluating
treatment consent capacity, a clinician should
first evaluate the functional abilities constituent
to this capacity. These would be the patient’s
abilities to express a treatment choice, to
understand the treatment situation and options,
to reason about treatment choices and respective
risks/benefits, and to appreciate the personal
consequence of a treatment decision. The
clinician should then consider this functional
evidence in relation to the patient’s medical
conditions, prognoses, cognitive functioning
(e.g., neuropsychological test performance), and
psychiatric functioning (e.g., clinical interview
and psychiatric or personality testing
information). In formulating the judgment, all
this evidence should be considered in light of the
patient’s value system, and also in relation to the
relative risks/benefits of the treatment and social
situation. The clinician’s overall analysis and
judgment should be shaped by the individual’s
strong values (e.g., desire to avoid being a
burden to others) risk/benefit ratio of the
medical situation and proposed treatment (e.g., a
high risk surgery versus a low-risk biopsy).
The clinical findings and capacity judgment
made should be framed within the general
context of any applicable legal standards, in
order to ensure that the clinical findings are
closely linked to the decisional framework and
processes of the court. At the same time, in
stating clinical findings and judgments, the
clinician should be careful to not invade the
province of the court, and to clearly identify
his/her decision and findings as clinical and not
legal capacity matters.
How Do I Present Information
in a Report?
Each psychologist will use his or her own
format for report writing. Examples of reports—
and different formats—appear in Chapter 6. A
conclusion section of a capacity report will
likely address multiple issues.
Diagnostic Impressions. A psychologist
may begin a report conclusion by addressing the
diagnosis—much like in a typical clinical
referral. For example, it might include cognitive/
neuropsychologcal findings and personality
findings and conclude with a DSM “five axis”
format.
Capacity Opinion. The next section or
sections can present the clinician’s opinion of
the older adult’s psycholegal capacities. This
section should specifically address the capacity
at issue and, when possible, provide a clear
yes/no judgment regarding the opinion.
Recommendations. Finally, a clinician can
detail specific recommendations that may help
to optimize decision making and/or improve
clinical care.
Case Examples of Conclusions
The following case examples are to
demonstrate how one arrives at a specific
statement of capacity. These examples are
intended to illustrate key points in arriving at a
clinical judgment. These examples do not
represent a full report, which likely include
detailed information regarding the person’s
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history, clinical interview, standardized testing,
medical record, etc. More detailed examples are
provided in the specific capacity sections of
Chapter 6.
Case Example 1
The first example draws from a case where
the psychologist is being asked to give an
opinion regarding the older adult’s ability to
manage her finances in a retrospective
determination. The older adult has a history of
adequate knowledge and skills regarding her
financial transactions, but these have declined
significantly in recent years. The psychologist is
being asked about her ability to make a large
financial transaction in the recent past.
“It is this psychologist’s opinion that Ms.
Smith did not have the capacity to manage her
simple and complex finances independently, and
was not able to perform these financial tasks in
July 2007 until the present. Her current
diagnosis (dementia of the Alzheimer’s type,
moderate stage) and cognitive functioning
(severely impaired memory) suggests that her
memory loss has been present for at least 2-3
years. Further, Ms. Smith scored in the low
range on a task designed to assess her financial
ability. It is this examiner’s opinion that Ms.
Smith is not able to make small purchases, write
checks, or read or understand her bank
statements without assistance at present.
Further, she is not able to manage her complex
finances, balance her checkbook, or sign realestate agreements.”
Case Example 2
The next example presents a case of an older
adult’s ability to continue to manage his finances
in the face of clear cognitive decline. He has a
strong history of knowledge and skills in this
arena and as yet, no evidence of errors in
financial management. He has explicitly
delegated these responsibilities and can continue
to manage with support.
“It is this psychologist’s opinion that Mr.
Jones is able to manage his simple and complex
finances independently. His current diagnosis,
mild traumatic brain injury, has resulted in
moderately impaired memory and executive
functioning. However, he performed in the high
range on a functional assessment of financial
abilities. Mr. Jones has fairly well-preserved
abilities in terms of financial management
secondary to his background in accounting.
Further, Mr. Jones has on-line banking set up to
manage most of his monthly bills and direct
deposit of his assets. For more complex
transactions, such as managing his investment
portfolio, Mr. Jones may benefit from
assistance. The current protections in place,
with his son as POA and an investment advisor
to assist with his retirement income, appear
appropriate.”
Case Example 3
In this example, the older adult also presents
with clear moderate cognitive impairment.
However, the client does not have the strong
history of skills in this arena and there is
evidence of recent financial abuse. The example
illustrates how a psychologist may arrive at a
different clinical opinion when considering
objective data in light of the context and case
particulars.
“It is this psychologist’s opinion that Mr.
Roberts does not have capacity to manage
simple and complex finances independently. His
current diagnosis, vascular dementia, has
resulted in moderately impaired memory and
executive functioning. Mr. Roberts performed in
the moderate range on a functional assessment
of financial abilities, able to complete simple
calculations, but unable to do multiple step
transactions. Mr. Roberts has already been a
victim of fraud. He appeared to remember that
he had signed some type of document, but did
not appreciate its permanent nature and the
risks to his estate. Mr. Roberts is highly
susceptible to fraud and exploitation in his
current state and would benefit from a
conservator to protect his assets.”
Case Example 4
The case illustrates how a psychologist may
arrive at a decision when an older adult presents
with minimal impairment and has adequate
skills to manage transactions. The example
illustrates the consideration of test data in view
of the person’s history and values.
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It is this psychologist’s opinion that Ms.
Wright does have the capacity to manage her
simple and complex finances independently. Ms.
Wright’s daughter reported that Ms. Wright had
recently given $50,000 to a charity and
questioned her financial decision-making
abilities. Ms. Wright has a history of diabetes
and hypertension placing her at increased risk
for vascular dementia. She performed in the low
average range on tests of memory and executive
functioning. However, she performed in the high
range on a functional assessment of financial
abilities. She reported that she had given to this
charity for over 20 years. She was able to
describe the impact that this gift would have on
her standard of living (minimal). Thus, Ms.
Wright does not need formal protections in place
at the current time.”
inability to learn new information. His
performance improves when given repetitions
and cues, but he tends to “confabulate” or fill in
the gaps unintentionally.
In terms of executive functioning and
reasoning, because of Mr. Brown’s brain injury
to the frontal lobes, he has poor insight into his
limitations. He had difficulty solving everyday
problems and abstract problems. He had
difficulty with initiation. He will have trouble
thinking flexibly about a problem and may “get
stuck” on a particular solution. He may be
impulsive in his judgments.
Emotionally, Mr. Brown has reported
numerous symptoms of depression during the
clinical interview, and his mood was depressed.
He scored a 9 / 15 on the Geriatric Depression
Scale-short
form
indicating
moderate
depression.
Case Example 5
The final case example provides a possible
format for the presentation of evaluation data,
including diagnostic impressions, capacity
conclusions, and recommendations.
DSM-IV-TR Diagnosis:
Axis I
Dementia due to Head trauma;
Mood disorder due to a general
medical condition.
Axis II No diagnosis
Axis III Bilateral Visual Impairment
Axis IV Fraud victim legal action pending
Axis V GAF = 40
Diagnostic Impressions
The results of the clinical interview,
neuropsychological testing, and review of
medical records reveal neurocognitive patterns
consistent with a traumatic brain injury to the
frontal lobes of moderate to severe severity.
Cognitively, he has adequate attention.
Visual perceptual abilities were not assessed
due to bilateral visual impairment related to his
brain injury. His language production,
comprehension, and naming were within normal
limits.
Mr. Brown had deficits in memory, executive
functioning, and reasoning. Mr. Brown has no
memory of the event itself. This occurs because
the part of the brain involved in encoding (the
hippocampus region in the medial temporal
lobes) cannot encode the event secondary to
trauma. Second, Mr. Brown has minimal
retrograde amnesia, or a loss of memory for
past events. Third, Mr. Brown has posttraumatic amnesia lasting for several months
following the brain injury. Finally, Mr. Brown
has significant anterograde amnesia, or an
Capacity Conclusions
The results of functional testing previously
described, combined with reports of staff,
family, occupational therapy assessment, and
considered in light of the neuropsychological
testing support the following findings.
Financial Capacity: Given Mr. Brown’s
moderate to severe impairments in memory,
executive function, and on direct assessment of
financial capacities (money management scale
of the Independent Living Scales), it is the
examiner’s opinion that Mr. Brown does not
have capacity to manage simple or complex
finances independently.
Capacity to Manage His Person: Given Mr.
Brown’s moderate to severe impairments in
memory and executive function, and on direct
assessment of reasoning in independent living
tasks, it is this examiner’s opinion that Mr.
Brown is currently at significant risk for harm to
himself. He has limited insight into his abilities
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and his injuries. Mr. Brown needs the structure
of 24-hour care at the present time and for the
foreseeable future.
Recommendations
Mr. Brown has impairments in memory and
executive functioning that impact his simple and
complex decision making. He will continue to
need assistance for both personal and financial
decisions.
1. At this interview, depression was evident.
His treatment regimen for depression should
be reviewed and potentially adjusted.
2. Mr. Brown is now 12 months post injury.
Much of his recovery has already occurred,
so at this point a shift from treatment to
compensatory
training
should
be
considered.
3. Mr. Brown can still express preferences and
these should be honored when appropriate.
When stable, Mr. Brown would enjoy
visitors. He would enjoy visits with his dog,
if that is acceptable to the facility. Many
facilities have pet therapy available.
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Capacity Worksheet for Psychologists
Source: Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists by the ABA Commission on
Law and Aging and the American Psychological Association (2008). Please read and review the handbook prior to using the
worksheet.
Name: ________________________________
Date(s) of Evaluation: ___________________
Psychologist: ___________________________
Place of Evaluation: ____________________
A. Pre-Assessment Screening
Issue
What functional and decisional capacities are in
question:
Who is involved in this case:
Who is the older adult:
When does this evaluation need to be completed:
Where and how will the evaluation take place:
Why is this question being raised:
Is the patient medically stable:
B. Informed Consent
Understanding:
Questions to consider
What types of decisional or functional processes are in
question?
What data are needed?
Am I appropriately qualified to assess these?
Who is the client? Who are the interested parties?
Who is requesting the evaluation?
Who sees the report?
Is the court or litigants involved?
What is the person’s history, age, cultural background,
primary language, sensory functioning?
How urgent is the request?
Is there a court date?
What is the time frame of interest?
In what setting does the evaluation take place?
What accommodations are needed to maximize
performance?
Why now?
What is the history of the case?
Will a capacity evaluation resolve the problem?
Have all less restrictive alternatives and interventions
been exhausted?
Have all temporary and reversible causes of cognitive
confusion been assessed and treated?
Issues to disclose
Why is the evaluation requested?
Procedures involved in evaluation?
Potential risks?
Potential benefits?
Uses of the report?
Limits on privacy and confidentiality?
 Understands and consents
 Understands and refuses
 Questionable understanding but assents
 Questionable understanding but refuses
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C. Setting up the Assessment: Legal Standard and Functional Elements
What is the legal standard for the capacity in question?
What are the functional elements to consider?
D. Record Review
Medical records
Legal records
Diagnoses
Laboratory Tests
Imaging
Other Treatments
Medications
Documents filed in the court
Financial statements
HCP/POAHC documents
Other Records
E. Collateral Interviews
Family
Staff/ Professional Caregivers
Other
F. Accommodating and Enhancing Capacity During the Assessment
Assess recent events and losses, such as bereavement
Explore medical factors such as nutrition, medications, hydration
Select tests inconsideration of cultural and language issues; Administer tests in primary language
Select tests that are validated for the age of the person
Assess ability to read and accommodate reading difficulties
Adjust seating, lighting; Use visual and hearing aids
Consider fatigue; Take breaks; Use multiple testing sessions
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G. Assessment Data
Functional elements (list from 4B above):
 Objective Assessment
 Clinical Interview
Cognitive Underpinnings (possible domains):  Objective Assessment
 Clinical Interview
1. _______________________
Level of impairment:
Describe:
2. _______________________
Level of impairment:
Describe:
3. _______________________
Level of impairment:
Describe:
4. ______________________
Level of impairment:
Describe:
1. Sensory Acuity
2. Motor Activity and Speed of processing
3. Attention and Concentration
4. Working memory
5. Short term/recent memory and Learning
6. Long term memory
7. Understanding or Receptive Language
8. Communication or Expressive Language
9. Arithmetic
10. Verbal Reasoning
11. Visual-Spatial and Visuo-Constructional Reasoning
12. Executive Functioning
13. Other
Psychiatric/Emotional Factors (possible domains):
 Objective Assessment  Clinical Interview
1. Disorganized Thinking
2. Hallucinations
3. Delusions
4. Anxiety
5. Mania
6. Depressed Mood
7. Insight
8. Impulsivity
9. Noncompliance
10. Other
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Values
Possible Considerations
What is the older adult’s view of the situation?
Preferences for how decisions made? And by whom?
Preferences for living setting?
Goals including self assessment of quality of life?
Concerns, fears, preferences, religious views?
Preferences for spending and saving?
Impact of culture, age, sexual orientation, diversity?
Views about guardianship (if applicable)?
Risks
Possible Considerations
Is the risk new or old?
How serious is the risk?
How imminent is the risk?
What is the risk of harm to self? To others?
Are there concrete instances of failure?
How objective is the assessment of risk?
H. Findings
Diagnoses and Prognoses
Possible Considerations
What diagnoses account for the deficits?
Can conditions be treated?
Are deficits likely to get better, worse or stay the same?
When should the older adult be re-evaluated?
Capacity Framework
1) The functional abilities constituent to the
capacity;
Capacity Conclusions
 Has capacity for decision / task in question
 Lacks capacity for decision / task in question
2) Cognitive abilities, psychiatric/emotional
functioning, and medical diagnoses and prognosis,
as they relate to the functional abilities;
 Has marginal capacity for decision / task in question
(if the case is not being adjudicated, recommended
course of action)
3) The individual’s values, social network, and the
specific risks of the capacity situation.
Steps to Enhance Capacity
Would the Older Adult benefit from:
Education, training, or rehabilitation?
Mental health treatment?
Occupational, physical, or other therapy?
Home and/or social services?
Assistive devices or accommodations?
Medical treatment, operation or procedure?
Other?
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VI. Assessing Specific Capacities
This chapter presents six specific capacities:
medical consent, sexual consent, financial
capacity, testamentary capacity, driving, and
independent living. In each section we will
present the legal standards and discuss
functional, cognitive, psychiatric, and diagnostic
factors, as well as the role of values, risk, and
enhancing capacity. Each section includes a case
example. For each section one author took the
lead; therefore the case examples reflect the
approach of one clinician, although the working
group and our expert panel provided input.
Therefore, this chapter provides some diversity
of approaches to formatting a clinical approach
and related report.
Medical Consent
Introduction
The doctrine of informed consent requires
clinicians to obtain voluntary and competent
agreement to a medical intervention prior to
performing the intervention, and only after the
patient has been informed of the material risks,
benefits, and other facts of the condition and
procedure.
In the area of health care a variety of
capacities might be raised—such as the capacity
to consent to a specific medical treatment, the
capacity to manage one’s healthcare and
medications, and the capacity to appoint a
healthcare proxy (a decision maker for one’s
healthcare in the event of incapacity). This
chapter focuses on capacity to consent to
treatment, after brief comments on related
medical capacity issues below.
Capacity to Manage Health
The capacity to manage one’s health and
medications is an important area related to the
capacity to live independently (discussed later in
this chapter) and is little studied.
Capacity to Appoint a Health Care Proxy
As noted in Chapter 2, the capacity to
execute an advance directive for health care is
quite different than the capacity to make specific
medical decisions, thought to be parallel to the
capacity to contract. That is, it does not involve
understanding and consenting to medical
treatment but identifying a person to speak on
one’s behalf. This capacity sometimes arises in
conjunction with the capacity to consent to
treatment—particularly when a person is felt to
be too impaired to consent to a treatment or
procedure, and does not have a healthcare proxy
appointed. In these situations the question
sometimes arises whether the person still could
have the capacity to appoint a decision maker.
There is limited legal, conceptual, or empirical
data on this topic (Allen et al., 2003). As noted,
it is conceptually distinct from the capacity to
consent to treatment, which is the focus of this
section.
Extraordinary Medical Treatment
Many state laws and local hospital policies
limit the authority of guardians and healthcare
proxies to consent to extraordinary treatment,
such as decisions to withdraw life-sustaining
therapies (ventilation, artificial feeding and
hydration), commit for mental health treatment,
and consent to abortion, sterilization,
administration of psychotropic medications,
amputation, and electroconvulsive therapy.
Typically these treatments require review by
court or another oversight body (e.g., ethics
committee). If a clinician is being asked to
evaluate someone’s capacity to consent to or
refuse these treatments, and the question is being
raised about possible proxy consent, clinicians
should be familiar with any statutory
requirements and local hospital policies
regarding these situations.
This chapter will focus on the capacity to
consent to ordinary medical treatment.
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Legal Standard
Incapacity As Defined in Surrogate
Health Care Decision-Making Statutes
A variety of statutory frameworks exist for
defining incapacity in healthcare decision
making, including the health care power of
attorney and “living will,” surrogate consent,
and guardianship statutes. In these statutes,
surrogate health care decision-making authority
is triggered by a patient’s lack of capacity to
give informed consent for treatment.
For example, the Uniform Health-Care
Decisions Act (a model law defining incapacity
in the context of when a health care surrogate
decision maker may be appointed) defines
capacity as “the ability to understand significant
benefits, risks, and alternatives to proposed
health care and to make and communicate a
health-care decision” (Uniform Health-Care
Decisions Act, 1994). State-by-state citations for
living will and health care power of attorney
statutes can be viewed on the Web site of the
ABA Commission on Law and Aging at
http://www.abanet.org/aging.
Case Law Standards for
Capacity to Consent
In addition to statutes, incapacity is defined
in standards found in case law, used either
individually or conjointly as a so-called
“compound standard” (Berg, Appelbaum, Lidz,
& Parker, 2001; Grisso et al., 1998), as detailed
in the “functional” section below.
Substitute Judgment Mechanisms and
Less Restrictive Alternatives
When individuals are believed to lack the
capacity to make medical decisions, several
options are available. A previously appointed
health care proxy or durable power of attorney
may make decisions, and in over 35 states next
of kin may provide consent under defined
circumstances even if not previously so
appointed. In some cases, local policies allow
for surrogate consent by hospital medical
directors or ethics’ committees.
Functional Elements
The ability to consent to medical treatment
involves “functional” abilities that are cognitive
in nature. Generally, in describing the functional
elements of consent capacity, four case law
standards commonly recognized to convey
capacity are used, as described below.
1. Expressing a Choice
The standard of expressing a choice refers to
patients who are seen to lack capacity because
they cannot communicate a treatment choice, or
vacillate to such an extent in their choice that it
is seen to reflect a decisional impairment.
2. Understanding
The standard of understanding refers to the
ability to comprehend diagnostic and treatmentrelated information and has been recognized in
many states as fundamental to capacity.
3. Appreciation
The standard of appreciation has been
interpreted in different ways. It has been
described as the ability to relate treatment
information to one’s personal situation. The
standard of appreciation especially reflects the
ability to infer the possible benefits of treatment,
as well as accept or believe the diagnosis. This
standard has been related to the concepts of
insight and foresight.
4. Reasoning
The standard of reasoning involves the
ability to state rational explanations or to process
information in a logically or rationally consistent
manner.
Diagnostic Considerations
The capacity to consent to treatment has
been most widely studied in dementia, and to a
lesser extent in adults with psychotic disorders
(although these studies do not focus on older
adults). In mean comparisons with healthy
controls, consent capacity of individuals with
dementia is reduced compared to healthy
controls (Kim, et al., 2002; Marson et al., 1995;
Moye, Karel, Azar, & Gurrera, 2004a). Specific
abilities affected by dementia are the capacity to
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understand information and to weigh the risks
and benefits. In these same studies, the capacity
to personally appreciate the diagnosis and the
risks and benefits of treatment was sometimes
impaired in older adults with dementia.
In
control-comparison
studies
with
individuals with schizophrenia, results are
mixed, with some studies showing impairment
relative to controls and others not; however
these studies focus on younger adults with
schizophrenia (Grisso et al., 1995; Wong, Clare,
Holland, Watson, & Gunn, 2000). In general, the
pattern of decisional impairment associated with
schizophrenia is quite variable.
Adults in long-term care, without regard to
specific diagnosis, have been noted to have high
rates (44% - 69%) of medical consent capacity
impairment (Barton, Mallik, Orr, & Janofsky,
1996; Fitten et al. 1990; Pruchno, Smyer, Rose,
Hartman-Stein, & Lairbee-Henderson, 1995;
Royall, Cordes, & Polk, 1997). More research is
needed about consent impairments in other
diagnostic conditions.
Cognitive Underpinnings
The relationship of cognitive functions and
specific consent abilities has been studied in
older adults with dementia. Diminished consent
capacity has been associated with impairments
in
memory,
executive
functions,
and
comprehension. Specifically, difficulties in
understanding
diagnostic
and
treatment
information has been strongly related to
impaired memory, as well as impaired
conceptualization, and comprehension (Gurrera
et al., 2006; Marson et al., 1996; Marson et al.,
1995). Appreciation has been less robustly
related to cognitive functions than other consent
abilities, but, perhaps not surprisingly, has been
linked to impaired executive functions and
conceptualization.
Reasoning,
involving
contrasting risks and benefits and relating them
to personal preferences has been associated with
executive abilities, such as attention, mental
flexibility, and the ability to recall information
after a delay. Expressing a choice is a basic
consent ability, and has been related to auditory
comprehension and confrontation naming.
Psychiatric and Emotional Factors
Although the research literature suggests
that consent abilities do not form a strict
hierarchy (e.g., understanding is needed for
appreciation is needed for reasoning), the ability
to reason through risks and benefits appears to
be the most cognitively complex task, involving
remembering risks and benefits of various
options (or at least being able to refer to them on
paper), and weighing them against individual
values and preferences. For example, a person
might need to consider how much a specific
treatment might affect those areas important to
him or
her—avoiding
pain, avoiding
dependency, or being able to pursue a desired
activity. Because of the cognitive demands of
this task, especially for complex treatments, or
situations where there are multiple treatment
options, when symptoms of depression or
anxiety become severe, these psychiatric
symptoms may affect the ability to reason.
In contrast, while symptoms associated with
psychotic disorders may certainly affect a
person’s ability to understand and reason about
information, psychotic disorders may especially
impact “appreciation”—particularly when the
patient is delusional. That is, symptoms of
paranoid disorders may make it difficult to
accept a specific diagnosis or the possibility that
treatment will be beneficial.
Values
The position of a set of values and goals is
foundational
to
capacity
(President’s
Commission for the Study of Ethical Problems
in Medicine and Biomedical and Behavioral
Research, 1982). The idea here is that in the
process of choosing among treatment
alternatives a person is motivated by factors that
define quality of life for that person, or that are
broadly important in life—such as religious
values, a desire to preserve life, a strong need for
autonomy and independence, and a concern
about being a burden on others.
A related set of commentary on the issue of
values can be found in the ABA’s 2002 Model
Rules
of
Professional
Conduct
(http://www.abanet.org/cpr/mrpc). These rules
describe for lawyers the factors to be balanced in
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the determination of capacity—including “the
consistency of a decision with the known longterm commitments and values of the adult”
(ABA, 2002). In this comment the ABA
suggests that the consistency of a decision with
values may be one important indicator of a
person’s capacity. Of course, values and related
decisions also change over time—so fluctuating
statements of values do not necessarily indicate
incapacity. However, patients with dementia
may be able to express consistent values, even
when they are not fully able to engage in all the
technical aspects of consent (Karel et al., 2007).
A variety of specific “values” have been
identified as important to healthcare decision
making. Patients may consider whether various
treatment outcomes comprise states “worse than
death” or otherwise affect quality of life in
unacceptable ways (Ditto, Druley, Moore,
Danks, & Smucker, 1996; Lawton et al., 1999;
Pearlman et al., 1993); such values ratings are
predictive of treatment choices (Ditto et al.,
1996; Fischer, Alpert, Stoeckle, & Emanuel,
1997; Patrick et al., 1997; Schonwetter, Walker,
Solomon, Indurkhya, & Robinson, 1996).
Similarly, treatment choices can be made in
view of how they affect valued relationships.
Patients are often very concerned about the
impact of the illness and treatment on loved
ones, with many older adults in particular
expressing concern about becoming a burden to
their families (Karel & Gatz, 1996). Individuals
may differ in the extent to which they desire
control over treatment decisions, based on
generational, cultural, and personality factors.
Older cohorts and some cultural groups believe
decision making authority rests with the doctor
or the family.
Risk Considerations
A “sliding scale” for capacity has been
proposed when balancing risk considerations
and the threshold for intervention. A relatively
low level of capacity may be needed for a
relatively low risk procedure. For example, a
cognitively impaired patient in a nursing home
may be more likely to be viewed as having the
capacity to consent to a low-risk procedure, such
as a standard blood draw, as compared to a highrisk procedure, such as an invasive surgery like
coronary artery bypass graft. The evaluator will
want to consider the risks associated with the
procedure, and the risk associated with not doing
the procedure, as well as the likelihood of these
outcomes. In addition to these considerations,
the evaluator may consider the risk associated
with delaying a decision to consent to a medical
procedure. For example, it may be possible to
delay a hernia repair surgery if a person is
refusing that surgery, and it is felt that some
clinical intervention may enhance capacity (e.g.,
treating depression or anxiety; addressing causes
of delirium).
When known, it is useful to consider risks in
tandem with individual values. For example, if a
person is refusing a potentially life saving
procedure that could also lead to significant
functional impairment, ascertaining what is
known about the person’s values regarding
sustaining life versus quality of life is critical.
Some risk considerations become especially
challenging in the very old, particularly in
considering the risks and negative outcomes
associated with a procedure. For example,
surgery to correct a slowly progressing spinal
compression may carry more risks than the slow
progression over time for a very aged individual.
Therefore, the evaluator will need to carefully
consider the level of capacity needed to consent
to a treatment or procedure, in view of a careful
weighing of the risks of intervention versus nonintervention and how these risks compare to the
person’s values.
Steps to Enhance Capacity
As with any psychological evaluation, and
any capacity evaluation, the evaluator should
strive to maximize the person’s abilities during
assessment by addressing sensory deficits and,
when possible, evaluating the individual when
most alert and awake. Of course, medical
consent capacity evaluations may occur in acute
medical situations where it is not possible to
wait, for example, until the time of day when the
individual is functioning best.
Decision-making
capacity
evaluations
aiming to optimize decisional abilities should
utilize disclosure formats that are simplified and
guided to enhance understanding (Dunn & Jeste,
2001; Taub et al., 1987). These may closely
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mimic good doctor-patient dialogues in which
information is presented in a manner that
maximizes patient participation, as compared to
a test-like situation where a patient is required to
memorize
information.
Providing
the
information in writing, in short phrases, and,
with diagrams may enhance understanding of
the procedure. Capacity evaluations should not
neglect to consider the affect of framing, order,
and phrasing on the decision-making process.
Framing refers to whether risks are described as
the likelihood of negative outcome versus
positive outcome (e.g., “there is a 10% chance
you will die” versus “there is a 90% chance you
will live”). Further, evaluators might consider
the role of anxiety in decision-making. For
example, is the individual feeling overwhelmed
by the amount of medical information and
anxious about possible outcomes that he or she
is not processing information optimally?
Clinical Judgments of
Consent Capacity
In a seminal study, Marson et al., (1997)
found low agreement (kappa = .14) between five
physicians with different specialty training who
provided dichotomous ratings of consent
capacity in older adults with Alzheimer’s
disease. Agreement improved when physicians
were trained to evaluate specific legal standards
(kappa = .48), but there was still considerable
variability (Marson et al., 2000). It is unclear
what leads to different clinical judgments
between different clinicians, but some factors
have been suggested.
A wide range of characteristics has been
noted to influence clinical judgments in
diagnostic processes, such as gender (Roter &
Hall,
2004),
patient-physician
racial
concordance (Cooper et al., 2003), verbal and
nonverbal behaviors (Beck, Daughtridge, &
Sloane, 2002; Roter, Frankel, Hall, & Sluyter,
2006), and respect for or liking of patients
(Beach, Roter, Wang, Duggan, & Cooper, 2006;
Hall, Horgan, Stein, & Roter, 2002). Although
not yet studied in relation to capacity per se,
related research shows that biases and emotional
factors affect physician diagnostic judgment,
and may lead to diagnostic errors (Graber,
Franklin, & Gordon, 2005; Groopman, 2007).
With respect to particular medical decisions,
clinicians may evaluate a patient’s quality of life
differently, and often as less desirable, than does
the patient (Starr, Pearlmann, & Uhlmann, 1986;
Uhlmann, Pearlman, & Cain, 1988; Uhlmann &
Pearlmann, 1991), and physician proxies are
poor at predicting patient’s treatment
preferences (Uhlmann et al., 1991). In
evaluating capacity, clinicians may focus in on
different cognitive abilities thought to be key
(Earnst, Marson, & Harrell, 2000).
These findings point to the inherent nature
of clinical judgment as representing an
individualized decisional process, and one that
may be influenced by bias factors, particularly in
trying to understand the extent to which the risks
associated with consent or refusal of procedure
relates to the patient’s values, cognitive
functions, and decisional abilities.
In forming clinical judgments of consent
capacity it may be useful to consider the
diagnosis causing the consent impairment, the
level of impairment within key cognitive
abilities, such as memory, set shifting, naming,
conceptualization, and the extent to which these
translate to strengths or weaknesses in specific
consent abilities of understanding, appreciation,
reasoning, and expressing a choice. Many
clinicians find that when a consent capacity
evaluation is structured in this way, the process
of forming a clinical judgment is more evident
and defensible than a more unstructured clinical
interview or mental status evaluation. In
particular, it can be difficult to relate functioning
on general mental status variables (e.g.,
orientation to day) to consent if the evaluator has
not used some systematic approach to assessing
consent abilities.
Clinical Approaches to Assessing
Consent Capacity
Like any evaluation of civil capacities, the
evaluation should focus especially on the
relevant functional abilities.
Functional Assessment Instruments
In terms of assessing specific consent
abilities, the area of consent capacity has seen
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the most extensive instrument development in
comparison to other areas of civil capacity.
In addition to the nine instruments noted
here, there are several other vignette assessment
approaches described in the research literature
(e.g., Allen et al., 2003; Fitten et al., 1990; Fitten
et al., 1990; Schmand, Gowenberg, Smit, &
Jonker, 1999; Vellinga, Smit, van Leeuwen, van
Tilburg, & Jonker, 2004). The content of these
instruments is further described in Appendix B.
Some of these instruments use a standardized
vignette, others provide semi-structured
interview questions.
As shown in the table, the inter-rater
reliability is fair to good, however, test-retest
and internal consistency reliability have rarely
been studied, and normative data are scant.
Validity has been studied by comparing scores
obtained on these capacity instruments with
ratings by clinicians, experts, and scores on
neuropsychological tests. However, most
validity studies are based in relatively small
samples with limited replication. Not all of the
instruments are available for clinicians to use.
Summary of Psychometric Data Available for Consent Capacity Instruments
Name of Instrument
Abilities
Inter-rater
Reliability
Test-Retest
Reliability
Internal
Consist.
Reliability
Norms
N
Aid to Capacity Evaluation (Etchells et al., 1999)
UAR
.93
**
**
**
Assessment of the Capacity to Consent to Treatment
(Moye et al., 2008)
Capacity Assessment Tool (Carney, Neugroschl,
Morrison, Marin, & Siu, 2001)
Competency to Consent to Treatment Instrument
(Marson et al., 1995)
Competency Interview Schedule (Bean, Nishiasato,
Rector, & Glancy, 1994)
Decision-making Assessment Measure (Wong et al.,
2000)
Hopemont Capacity Assessment Interview (Staats et al.,
1995)
MacCarthur Competence Assessment Tool—T (Grisso &
Appelbaum, 1998)
Structured Interview for Competency (Tomoda et al.,
1997)
UARC
.90
**
.96
19
URC
**
**
**
**
UARC
.83-.96
**
**
15
UARC
.95
.79
.96
**
URC
K=.87
**
**
20
UARC
.93
.29
**
**
UARC
.59-.99
**
**
40
UARC
K> .60
**
**
**
** No
information identified. U=Understanding, R=Reasoning, A=Appreciation, C=Communicating a Choice
The MacCAT-T was based on three precursor instruments.
The use of these instruments offers a
standardized manner to assess each consent
ability (although not all assess all four abilities),
with fair to good inter-rater reliability. However,
given the limited data on other psychometric
properties (e.g., well-developed norms for older
adults with adequate representation across subgroups) some clinicians will find these do not
meet the Daubert standard of scientific
admissibility.
Nevertheless, the alternative is to use a more
subjective interview, which in comparison
would likely have reduced reliability relative to
the more standardized approaches of these
instruments. In selecting an instrument for
capacity assessment of older adults, clinicians
will want to consider if the instrument was
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developed for an older population, and for a
relevant treatment situation (e.g., the CIS was
developed for electroconvulsive therapy; the
HCAI was developed in a long-term care
setting).
Clinical Interview
As a general approach, to assess the ability
to state a choice, the clinician might ask: “Have
you decided whether to go along with your
doctor’s suggestions for treatment? Can you tell
me what your decision is?”
To assess the ability to understand
diagnostic and treatment information, the
clinician could say: “Tell me in your own words
what your understanding is of the nature of your
condition, the recommended treatments, the
benefits and risk of those treatments? How likely
are the benefits and risks to occur?”
To assess the ability to appreciate the
diagnosis and the possibility that treatments
could be beneficial, a possible set of questions is
“What do you really believe is wrong with your
health? Do you believe that you need some kind
of treatment? What is the treatment likely to do
for you? What do you believe will happen if you
are not treated? Do you believe the doctor is
trying to harm you?”
Finally, to evaluate the ability to reason
about treatment risks and benefits, the clinician
could ask: “What factors were important to you
in reaching the decision? How did you balance
those factors? Why does Treatment A seem
better than Treatment B? How will this
treatment affect the things or people who are
important to you?”
Values Tools are listed in Appendix E.
When considering values related to medical
treatment, there are a number of existing tools
available, such as the Values History (Doukas &
McCullough, 1991). One set of questions from
the Values Discussion Guide (Karel, Powell, &
Cantor, 2004) is:
1. First, think about what is most important
to you in your life. What makes life
meaningful or good for you now?
2. Now, think about what is important to
you in relation to your health. What, if
any, religious or personal beliefs do you
have about sickness, health care
decision-making, or dying?
3. Have you or other people you know
faced difficult medical treatment
decisions during times of serious
illness?
4. How did you feel about those situations
and any choices that were made?
5. Some people feel a time might come
when their life would no longer be
worth living. Can you imagine any
circumstances in which life would be so
unbearable for you that you would not
want medical treatments used to keep
you alive?
6. If your spokesperson ever has to make a
medical decision on your behalf, are
there certain people you would want
your spokesperson to talk to for advice
or support (family members, friends,
health care providers, clergy, other)?
7. Is there anyone you specifically would
NOT want involved in helping to make
health care decisions on your behalf?
8. How closely would you want your
spokesperson to follow your instructions
about care decisions, versus do what
they think is best for you at the time
decisions are made?
9. Should financial or other family
concerns enter into decisions about your
medical care? Please explain.
10. Are there other things you would like
your spokesperson to know about you, if
he or she were ever in a position to
make medical treatment decisions on
your behalf?
Thus, a full psychological evaluation,
including a clinical interview, cognitive testing,
psychodiagnostic assessment, can be combined
with a capacity-specific assessment of medical
consent capacity, as well as a values assessment
focusing on those values most relevant to
healthcare decision making. The following
example describes such an approach.
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Case Example
Psychological Evaluation:
Medical Consent Capacity
Mr. Savin is an 81-year-old male patient
referred for a psychological evaluation to
determine his decisional capacity to make
medical decisions for himself. The patient's
medical situation recently has become more
fragile and the treatment team is concerned that
patient may need a medical procedure performed
in the near future. The treatment team reports he
has been fairly compliant with treatment, but
appears to have a limited ability to understand
treatment information. His answers to questions
by the staff are at times odd, raising their
concerns further.
Informed Consent
Mr. Savin was explained the purpose of the
evaluation and that the results may be used to
assist in the team’s assessment of his ability to
make medical decisions independently. He was
warned that the capacity evaluation may result in
the appointment of another person to make
decisions for him. He appeared to understand the
purpose, risk, and benefits of the assessment and
consented to the evaluation.
Social History
Mr. Savin reported that he was raised in a
local community, one of seven children. He
described a positive upbringing with a close-knit
family. He was raised in the Catholic religion,
which he continues to practice. He reported that
he advanced through school without difficulty,
receiving average grades, leaving school in the
10th grade for work. He served in the Navy in
the post-WWII period.
He subsequently returned home and worked
for several years as a laborer. However, he has
not worked since the mid-1950s due to
psychiatric illness. He was never married and
does not have children. He has contact with two
brothers, but is generally not close to family or
friends.
Mr. Savin was psychiatrically hospitalized
in the mid 1950s for the first time in a state
psychiatric facility, where he states he received
“insulin treatments.” He was subsequently
psychiatrically hospitalized at the state
psychiatric hospital at least four times. He has
received ECT treatments in the past. After
several long-term stays in the state psychiatric
hospital, he eventually was placed in a
psychiatric group home, where he has remained
for the past 28 years.
Medical History
Mr. Savin was most recently medically
hospitalized for shortness of breath and
dehydration. He was subsequently transferred to
a rehabilitation unit for rehabilitative therapy
prior to a planned discharge most likely to a
more supervised environment, such as a nursing
home, due to his medical frailty.
Mr. Savin has a previous diagnosis of
schizophrenia (age of onset approximately 30),
cardiac disease, anemia, and gastro-esophgeal
reflux disease. He is status-post multiple
mycardial infarction with severe systolic
function, status-post coronary artery bypass graft
and mitral valve annuloplasty in 11/05, and has
hyperlipidemia, hypertension, and congestive
heart failure. There is no brain imaging on file.
Current Medications
Medication
Dosage/
Route/
Schedule
Indication
Epoetin Alfa
Recombinant Inj
40000
UNT/1ml SC
Anemia
Ferrous Sulfate
325mg tab
PO TID
Anemia
Furosemide PO
40mg tab PO
QAM
Congestive
Heart Failure
Lisinopril
2.5mg tab PO
Q Daily
Congestive
Heart Failure
Multivitamins
1 tablet PO Q
Daily
Supplement
to diet
Nitroglycerin SL
Sublingual
0.4mg tab
Q5MIN PRN
Chest Pain
Omeprazole Cap
20mg SA PO
Daily
30min prior to
eating
Gerd
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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Risperidone
1mg tab PO
QHS
Schizophrenia
Simvastatin
20mg tab PO
QHS
Hypercholesterol
Clinical Interview, Including
Psychiatric/Emotional Factors
and Values
Mr. Savin was casually dressed with fair
hygiene, demonstrated good eye contact,
relatively bright affect, and good interpersonal
engagement. Upon initial contact, he was sitting
in front of the nurses’ station with a blanket over
his head. When approached, Mr. Savin removed
the blanket and was pleasant, cooperative, and
willing to meet with this writer. When asked
why he had the blanket on his head, the patient
first replied with “it’s for mathematical
purposes.” Upon further inquiry, the patient
indicated that he did not feel secure without it
over him. He did not report believing someone
was out to hurt him, but instead suggested it
offered him a feeling of security.
His mood appeared normal and affect was
mildly restricted. His speech was normal in tone
and rate. He said he was not hearing voices, does
not feel that he is controlled by others, reported
no unusual or disturbing thoughts, and had no
indication of suicidal or homicidal ideas.
Regarding values, Mr. Savin indicated that
while he liked it at the rehabilitation hospital, he
wished to return to his foster home. He said that
he is not interested in completing advance
directives and instead wants the “doctors to
decide.” He stated that if they could not decide,
he would like the manager of his group home,
whom he calls his foster mother, to decide. He
stated that currently she makes financial
decisions for him.
Testing
Mr. Savin was assessed with a standardized
interview for consent capacity, the MacCAT-T,
and a standardized neuropsychological battery.
Because there was not a specific current medical
treatment facing the patient, the capacity
assessment interview was adapted to assess his
understanding, appreciation, and reasoning of
his cardiac illnesses. He displayed a high level
of motivation throughout the assessment and
adequate verbal comprehension. Results of this
testing are judged to be a valid indicator of his
current abilities.
Functional Assessment
Understanding. Mr. Savin was able to
demonstrate a general knowledge of his cardiac
condition, although there was also evidence of
some degree of impairment. He was able to
report on his cardiovascular issues and could
describe in general the procedures when surgery
is involved (i.e., patient is anesthetized, incisions
are made, etc). When current diagnostic
conditions and related treatments were described
to him, he paraphrased this information back to
the examiner.
Appreciation. When asked whether he had
any doubts about his medical conditions, he
described many of his problems as
“psychosomatic.” When queried, Mr. Savin
reported that he needed to “concentrate and
endure that responsibility on the sickness itself.”
He was impaired in his acknowledgement of
medical conditions and the benefits of treatment.
For example, when asked why someone would
need additional oxygen provided to him or her
(as he does) the patient responded, “You tell me
. . . I react to breathing.” Overall, Mr. Savin
could identify a number of his cardiac issues, but
had a tendency to minimize the personal
significance of the conditions and the benefits of
treatments.
Reasoning. When asked to describe the
risks and benefits of his medications for cardiac
illness and his cardiac surgeries he had
difficulty. He had difficulty identifying the risks
and benefits of surgery and instead deferred to
his psychiatrist. For example, Mr. Savin
indicated “there would be no risks or
complications if Dr. X. said to do it.” Mr. Savin
had difficulty comparing two ideas when
presented to him and could not weigh two
treatment ideas. His reasoning tended to be very
vague and moralistic. Oftentimes when queried
to clarify his answers, he responded with “it’s a
mathematical purpose,” and “it’s a better
deduction for myself personally.” Thus, it was
very difficult for him to justify his reasoning
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adequately as to why he would prefer not to
have certain procedures performed.
Expressing a Choice. When asked to describe
his choices for managing his cardiac illness he
repeatedly deferred to his psychiatrist. He
further reported that the best way a patient can
help himself is to “fully cooperate with whatever
the doctor says to do.” When the potential
serious risks of his cardiac illness and
importance of his treatments were reviewed, Mr.
Savin kept referring to a specific psychiatrist
stating “whatever he says or who he appoints . . .
I would do that.”
Summary
Mr. Savin is an 81-year-old male with a
history of multiple psychiatric and medical
problems.
I.
Schizophrenia
II. None
III. Cardiac illnesses
IV. Housing problems, limited social support
V. GAF current = 45
Cognitive Assessment
On
the
Repeatable
Battery
of
Neuropsychological Assessment Skills, as
shown in the table, Mr. Savin had moderate
impairment in immediate memory and severe
impairment in visual spatial abilities. Attention,
language, and delayed memory were in the low
average range. Additional executive testing
found moderate impairment on Trails B, and
moderate difficulty on the clock drawing task.
Decision-making Capacity. Regarding his
capacity to make medical decisions, it is the
opinion of this clinician that this patient lacks
the capacity to make medical decisions due to
his psychiatric condition and general cognitive
dysfunction. In terms of legal standards for
medical decision making, he has a general
understanding of medical information, but there
is some degree of impairment that may prevent
him from truly understanding the risks and
benefits involved. He has trouble appreciating
risks and benefits, defers to doctors excessively,
and has trouble reasoning about risks and
benefits because he is unable to compare two
ideas. He was willing to comply with the wishes
of particular doctors regardless of the risks
involved. His reasoning is vague and moralistic.
Mr. Savin clearly states on several occasions
that he does not like to make important decisions
and while he feels he is able to do so, he prefers
others to make them for him. He was unable to
express a specific treatment preference. While it
is the opinion of this clinician that the patient
could consent to very low-risk medical
procedures (i.e., having blood drawn), he lacks
the capacity to provide consent independently to
procedures where there are potentially more
serious risks, and the complexity of the
information is greater.
Ability
Tests
%ile
Range
Attention
Digit Span &
9%
Low
Coding
Visuospatial
Figure Copy & Line
Average
<1%
Orientation
Language
Picture Naming &
Impaired
9%
Semantic Fluency
Immediate
List Learning &
Memory
Story Learning
Delayed
List Recall/
Memory
Recognition, Story
Recall & Figure
Recall
Severely
Low
Average
5%
Moderately
Impaired
21%
Low
Average
Based on a clinical interview, standardized
capacity assessment, and cognitive testing, the
following conclusions are offered:
Cognitive
Functioning.
Regarding
his
cognition, he has adequate simple attention and
memory after a delay, but his working memory,
visual spatial skills, and executive function are
moderately to severely impaired. He appears to
have difficulty organizing verbal and visual
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information and becomes quickly overwhelmed.
He has difficulty switching between two
concepts. These deficits are consistent with his
long-standing diagnosis of schizophrenia.
Recommendations
1. Substitute decision maker. Based on the
results of this interview, it is recommended
that the treatment team work with Mr. Savin
to identify a possible healthcare proxy. He
has limited contact with his brothers, and
they may be appropriate to serve in this role.
Otherwise, it may be possible to appoint a
DPA or limited guardian for medical
decisions.
2. Dementia evaluation. Mr. Savin displays
cognitive
deficits
consistent
with
schizophrenia. Nevertheless, he has many
cardiac risk factors for vascular dementia.
The team may wish to consider a full
medical evaluation for dementia and
possible reversible causes of cognitive
impairment.
3. Financial capacity. Although it was not the
focus of this evaluation, results of the patient
interview and cognitive testing suggest that
Mr. Savin may have difficulty managing his
finances. According to the patient, his
psychiatric group home manager has
assisted with his finances. Given that he is
no longer living at the group home, and it is
uncertain that he will return, it may be
appropriate to explore if this arrangement
should continue, be formalized, or if another
fiduciary should be identified.
4. Presentation of information. Given Mr.
Savin’s tendency to become overwhelmed
by information, it will be important to
provide information about medical decisions
in simple, structured manner, limiting the
amount of information provided at any one
time.
5. Given Mr. Savin’s complex medical
problems and prognosis, it is important to
facilitate a discussion with him and possibly
family
members
to
facilitate
an
understanding of Mr. Savin’s preferences
and values regarding advanced illness
interventions.
6. Ongoing assessment and treatment of his
psychiatric symptoms is recommended.
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Sexual Consent Capacity
Introduction
Under American law, all individuals who
have reached the age of consent have the right,
and are assumed to have the capacity, to consent
to sexual relations. The age of consent varies
across states from 16 to 18 years of age. The
nature of sexual behaviors requiring consent can
range from touching to sexual intercourse. Longterm care facilities tend to be the primary venue
for the issue of sexual consent capacity to be
questioned. Sexual behavior between long-term
care residents is a complicated issue that can
create a tension between the desire of staff and
family members to protect potentially vulnerable
residents, and the desire of residents to meet
their sexual needs and assert their rights to
sexual relations. Long-term care staff are
particularly concerned with the diminished
capacity of residents to consent to sexual
relations (Lichtenberg & Strezepek, 1990) and
the propriety of resident sexual behavior
(Wallace, 2003).
Consent is the cardinal element in the
determination of the legality of sexual relations
(Stavis, 1991). Constitutional, civil, and criminal
law can each have relevance to the sexual
activities of long-term care residents (Stavis,
1991). Long-term care facilities, which are
licensed by their states, have a legal obligation
(state and constitutional) to protect its residents
from unreasonable harm (Lyden, 2007). There is
considerable variability in the statutory
definitions of capacity to consent to sexual
activity, ranging from very conservative to very
liberal tests (Lyden, 2007; Stavis & WalkerHirsch, 1999; Sundram & Stavis, 1993).
Unique aspects of sexual consent capacity
differentiate it from other forms of consent
capacity (Kennedy, 1999). For example, an
individual facing a medical treatment decision is
given information upon which a decision is to be
made. There are opportunities for one to discuss
this information with others and obtain advice
from one’s physician and significant others.
There are often opportunities to weigh the risks
and benefits of decisions with other individuals.
In contrast, the individual facing a decision
regarding sexual activities is often alone, with
the exception of the sexual partner(s), often
without the opportunity, or desire, to consult
with others, and in a situation that often requires
a relatively rapid response. Finally, there can be
no surrogate decision maker for sexual relations.
Considerably more attention has been paid to the
issue of sexual consent among intellectually
disabled individuals in both the legal and clinical
literatures, than to cognitively impaired older
adults. Kennedy (1999) has argued that the
sexual consent capacity standards applied to
individuals with intellectual or developmental
disabilities are applicable to individuals with
dementia. This literature may provide additional
information for the reader.
Legal Standard
There are no universally accepted criteria for
capacity to consent to sexual relations (Lyden,
2007). The legal standards and criteria for sexual
consent vary across states (Lyden, 2007; Stavis
et al., 1999). The most widely accepted criteria,
which are consistent with those applied to
consent to treatment, are: (1) knowledge of
relevant information, including risks and
benefits; (2) understanding or rational reasoning
that reveals a decision that is consistent with the
individual’s values (competence); and (3)
voluntariness (a stated choice without coercion)
(Grisso, 2003; Kennedy, 1999; Stavis, 1991;
Stavis et al., 1999; Sundram et al., 1993). In
light of the variation in standards across
jurisdictions, the reader is encouraged to read
relevant state law.
Functional Elements
Sexual consent is a complicated construct,
with knowledge, capacity, and voluntariness,
intertwined.
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1. Knowledge
This criterion requires that an individual be
able to demonstrate a basic knowledge of the
sexual activities in question, potential risks (e.g.,
pregnancy, sexually transmitted diseases) and
how to prevent them, the responsibilities of
pregnancy and parenthood, illegal sexual
activities (e.g., sexual assault, coercion, sexual
activities with incapacitated individuals, sexual
activities with under-age individuals), how to
determine whether sexual activities are not
desired by the partner, and appropriate times and
places for sexual activities. Several sexual
knowledge surveys that may be of use to the
clinician are listed by Lyden (2007).
2. Capacity
This criterion comprises the abilities of
decision-making capacity (Appelbaum et al.,
1988; Roth et al., 1977). They include the ability
to understand the options related to the sexual
behavior, appreciate the consequences of various
courses of action, and express a choice that is
based on a rational or logical consideration of
relevant knowledge, including the personal
benefits and risks of the sexual activity, and is
consistent with the individual’s values and
preferences.
3. Voluntariness
This criterion requires that an individual
have the ability to make a decision regarding
sexual activity that does not result from
coercion, unfair persuasion, or inducements
(Lyden, 2007; Moye, 2003). There are
differences across jurisdictions regarding what
constitutes illegal influence (Wertheimer, 2003).
Diagnostic Considerations
With the exception of mental retardation
(Kennedy & Niederbuhl, 2001), sexual consent
capacity has not been studied in relation to the
various
diagnostic
categories.
Though
individuals with intellectual or developmental
disabilities may share cognitive deficits with
individuals with dementia, the literatures are
distinct and have not yet been integrated. One
might presume that because sexual consent
shares many of the functional elements of
medical consent, and likely requires many of the
same cognitive skills, that the literature on the
effects of various psychiatric disorders on
medical consent could inform the judgment of
the clinician who is evaluating an individual for
sexual consent. For example, one might presume
that dementia or schizophrenia could diminish
capacity. Knowledge and voluntariness, which
are both important functional elements for
assessment, are less likely to be considered by
the clinician evaluating an individual for
medical consent. Thus, the parallel between
medical and sexual consent is not complete.
Cognitive Underpinnings
Though some empirical findings may inform
us about some of the cognitive skills required for
each of the three for sexual consent capacity
criteria, there is virtually no research evidence
that bears directly on the cognitive elements of
each of these criteria as they pertain to sexual
activities among older adults in long-term care
facilities. One would expect some of the
cognitive abilities required for the capacity to
consent to medical treatment to be relevant for
sexual consent capacity, particularly for the
elements of knowledge and understanding. In
light of the lack of empirical evidence, possible
abilities required for sexual consent capacity are
offered:
1. Cognitive Functions Related
to Knowledge
Possible cognitive abilities include attention,
semantic memory for basic biological
information regarding conception, pregnancy,
sexually transmitted diseases, methods of
preventing risks, social mores concerning sexual
behavior, and illegal sexual activities.
Autobiographical/episodic memory and higher
order cognitive abilities (e.g., executive
function) might be required to appreciate the
motives of a potential partner. Procedural
memory is necessary for utilizing devices for the
prevention of pregnancy and the spread of
sexually transmitted diseases.
2. Cognitive Functions Related
to Capacity
Possible
cognitive
abilities
include
attention, verbal comprehension of information
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presented by a potential partner, semantic
memory for presented information, historical
information that pertains to the current situation,
and information pertaining to the risks and
benefits of various sexual activities. These
abilities also may include abstraction and
executive functions required for the logical or
rational consideration of the benefits and risks of
the sexual activity, episodic memory for related
experiences, personal values, and preferences.
Finally, the ability to express a choice has been
related to auditory and confrontation naming, as
indicated in the preceding medical consent
section.
3. Cognitive Functions Related
to Voluntariness
Possible
cognitive
abilities
include
attention, abstraction, and executive functions
for the consideration of factors that could imply
coercion, unfair persuasion, or inappropriate
inducements. Semantic and episodic memory
may be required for contrasting the current
circumstances with those previously experienced
(directly or indirectly).
Psychiatric and Emotional Factors
As with the diagnostic factors, there is little
literature to offer guidance here. The cognitive
abilities that are likely required for sexual
consent are considerable. The complex ability to
weigh risks and benefits of sexual behavior is
perhaps the most vulnerable of the abilities.
Moderate to severe symptoms of depression and
anxiety could impact this ability. Sexual and
romantic relationships also bring their own set of
strong, potentially “troublesome,” emotions that
could interfere with the ability to rationally
weigh risks and benefits associated with sexual
behavior. Moreover, these emotions can leave
one more vulnerable to exploitation by a
potential partner. Fear of abandonment and
loneliness can also leave one more vulnerable.
Values
Community-dwelling older adults continue
to value and enjoy sexual relationships
throughout their lives (Masters & Johnson,
1966; Janus & Janus, 1993; Mathias, Lubben,
Atchison, & Schweitzer, 1997). This is the case
for nursing home residents as well (Lantz, 2004;
Richardson, 1995). Though sexual attitudes of
the general population about sexual expression
of older adults have moved in a positive
direction over the years, lesbian/gay/bisexual/
transgendered (LGBT) older adults face unique
legal and social issues in general, and regarding
their decision-making rights in particular. In
addition, the importance of sexuality likely
varies between individuals, as well as sexual
expression. One should not expect unique
gender role differences and family structures to
always be well understood by staff members,
some of whom may also not share attitudes with
the older adults. A recent MetLife study
revealed that a substantial percentage of LGBT
baby
boomers
are
concerned
about
discrimination as they age and are concerned
that they will not be treated with dignity and
respect by healthcare professionals.
Staff members of long-term care facilities do
not always place a high value on resident
personal choice for a variety of reasons,
sometimes this is for the sake of expedience, and
sometimes it is due to conflicting personal
values. In the latter case, sexual expression
among residents may not always be at the top of
the list of staff preferred resident behaviors.
Though many staff members believe that
residents have sexual needs, considerably fewer
believe that older adult resident discussions of
sexuality or maintaining an attractive self-image
are important (Lantz, 2004). Even the children
of older adult residents often oppose sexual
contact between their parents and other residents
(Lichtenberg et al., 1990).
Clinicians should consider their own level of
comfort in broaching topics related to sexuality,
their attitudes toward sexuality among older
adults, and the stereotypes and myths that might
influence their attitudes and comfort level.
Risks
The intimacy and sexual needs of long-term
care residents present a challenge to facility
staff, who must balance the risks of sexual
activity with the individual right to autonomy,
and the values, preferences, and sexual needs of
its residents. There can be personal risks for the
individual desiring sexual activity, and risks for
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residents without sexual consent capacity. Risks
to the resident include, for example,
exploitation, psychological or physical abuse,
sexually transmitted disease, pregnancy, social
rejection by staff or other residents, and even
harassment by family members of the sexual
partner. Risks for the facility can be
considerable, as a facility has the responsibility
of protecting its residents from unreasonable
harm resulting from sexual activity.
Rather than considering a single threshold
for consent capacity, sexual consent may be best
approached with attention to capacity for
decisions regarding particular types of sexual
activities. These could range, for example, from
kissing to sexual intercourse.
Steps to Enhance Capacity
Most of the abilities required for
demonstrating sexual consent capacity are
cognitive in nature. Sex education materials can
be provided when deficits in knowledge are
identified. Assistive devices can be provided for
sensory deficits and physical disabilities.
Depending upon the nature of memory deficits,
memory aids can be created. Problem solving
skills can be taught to augment an individual’s
ability to identify potential inappropriate or
coercive
situations,
generate
effective
approaches to addressing these situations, and
methods for selecting among the alternatives
generated. Rules of thumb, or heuristics, could
be taught for avoiding or escaping such
situations.
Clinical Judgment of Sexual
Consent Capacity
Sexual behavior varies along several
dimensions, including risk to the individual.
Thus, the determination of capacity need not
require a binary judgment. One should consider
clinical judgments that include outcomes that
vary along a dimension of potential risk to the
resident and the partner. Recommendations can
be made that would permit varying levels of
sexual contact, intimacy, and risk.
This judgment incorporates a particularly
complex set of interactive factors that include
knowledge and voluntariness, and numerous
other related historical and current factors noted
above. These factors, and the foundation
abilities of capacity, must all be integrated to
yield a judgment that balances the protection of
the resident, partner, and institution. Information
obtained from the interview of the resident, staff
members, and perhaps the potential partner, is
the most externally valid information available
given the typical circumstances. Cognitive
assessment can certainly inform and support
one’s conclusions, but ultimately one must be
convinced that the resident is capable of acting
with capacity in the moment. The more
functional the assessment, the more confident
one is likely to be with the final judgment.
Clinical Approaches to Assessing
Sexual Consent Capacity
The clinical assessment of consent capacity
is unlikely to receive judicial review unless the
case involves litigation (Moye at al., 2007). A
typical case might involve two nursing home
residents desiring sexual activities, with at least
one of the residents having questionable
capacity. Concern regarding vulnerability of one
of the residents could be expressed by staff
and/or family members, which leads to a request
to assess a resident regarding sexual consent
capacity. Another typical case might involve a
less cognitively impaired male approaching a
cognitively impaired women, with an attempt to
initiate sexual contact (Lichtenberg, 2007).
Long-term care staff may argue that the
individuals have a special relationship, only to
learn later that an impaired woman who had
been approached by a cognitively impaired man
thought that the man was her husband
(Lichtenberg, 2007). A third problem arises
when staff enter into sexual relations with
residents, which is clearly inappropriate and
should be addressed by facility policies. Finally,
as noted above, sexuality exists on a continuum,
ranging from hand holding or touching to sexual
intercourse. Preliminary information gathering
might include a review of resident records
regarding (reproductive ability, history of sexual
activity in the facility (including information
regarding past inappropriate or coerced
activities), evidence that the resident might be
vulnerable to undue influence or coercion,
cognitive functioning, and disorders that could
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impair cognitive functioning or limit or increase
sexual activity. Discussions with staff, and
family where relevant, regarding cognitive,
behavioral, and emotional functioning can be
helpful. Finally, formal assessment of the
resident’s cognitive and functional abilities
should be conducted. A staff member with
whom the resident feels comfortable (e.g., same
gender, personally familiar) might be enlisted to
explain the purpose and process of the
assessment (Lyden, 2007). The staff member
could remain for the assessment if the resident
feels more comfortable with that arrangement.
There are no generally accepted approaches
or criteria for the assessment of consent to
sexual activity. Stavis et al., (1999) suggest that
the following be considered by the examining
clinician, with the understanding that some
individuals with capacity to consent would not
meet all of these criteria:
Is an adult, as defined by state law;
demonstrates an awareness of person, time,
place, and event; possesses a basic knowledge of
sexual activities; possesses the skills to
participate safely in sexual activities; i.e.,
whether the person understands how and why to
effectively use an appropriate method of birth
control, and whether the person chooses to do
so; understands the physical and legal
responsibilities of pregnancy; is aware of
sexually transmittable diseases and how to avoid
them; demonstrates an awareness of legal
implications concerning wrongful sexual
behaviors
(e.g.,
sexual
assault,
inappropriateness of sex with minors,
exploitation, etc.); can identify when others’
rights are infringed; learns that ‘no’ from
another person means to stop (i.e., understands
that it is always inappropriate to have sex or
engage in other activities with someone who
says no or otherwise objects by words or
action)s; knows when sexual advances are
appropriate as to time and place (e.g., different
places and times may apply to dancing,
touching, sexual intercourse); does not allow his
or her own disability to be exploited by a
partner; knows when both parties are agreeing
to the same sexual activity; does not exploit
another person with a lower functioning who
might not be able to say no or defend oneself;
expresses understandable responses to life
experiences (i.e., can accurately report events);
can describe the decision-making process used
to make the choice to engage in sexual activity;
demonstrates the ability to differentiate truth
from fantasy and lies; possesses a reasoning
process that includes an expression of individual
values; can reasonably execute choices
associated with a judgmental process; is able to
identify and recognize the feelings expressed by
others, both verbally and nonverbally; expresses
emotions consistent with the actual or proposed
sexual situation; rejects unwanted advances or
intrusions to protect oneself from sexual
exploitation; identifies and uses private areas
for intimate behavior; is able to call for help or
report unwanted advances or abuse (Stavis et
al., 1999, p. 63-64).
Peter Lichtenberg offers the following
suggestions for assessing sexual consent
capacity:
1.
Patient’s awareness of the relationship:
a. Is the patient aware of who is initiating
sexual contact?
b. Does the patient believe that the other
person is a spouse and, thus, acquiesces
out of a delusional belief, or [is he/she]
cognizant of the other’s identity and
intent?
c. Can the patient state what level of
sexual intimacy [he/she] would be
comfortable with?
2.
Patient’s ability to avoid exploitation:
a. Is the behavior consistent with formerly
held beliefs/values?
b. Does the patient have the capacity to
say no to any uninvited sexual contact?
3.
Patient’s awareness of potential risks:
a. Does the patient realize that this
relationship may be time limited
(placement on unit is temporary)?
b. Can the patient describe how [he/she]
will react when the relationship ends?”
These authors note that while being able to
state the level of sexual activity or intimacy is
wanted is an important consideration, one must
also assess the ability to refuse or resist sexual
advances. Lichtenberg et al., also emphasized
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the importance of residents understanding that
the ending of a relationship might be one of the
potential risks of entering in to a sexual
relationship. Residents can leave facilities for a
variety of reasons (e.g., transfer due to illness),
thereby terminating the relationship.
Long-term care facilities should have
policies and procedures regarding sexual
relations that are consistent with state statutes,
and staff should receive in-service training to
develop a sensitivity to this issue (Lichtenberg,
2007). See the following for examples of an
institutional policy: www.hebrewhome.org/se.asp
or Center for Practical Bioethics (2006).
Psychologists are encouraged to become familiar
with the U.S. Code of Federal Regulations (42
CFR Part 483), which discusses the
requirements for states and long term care
facilities. In particular, the sections on resident
rights (483.10), resident behavior and facility
practices (483.13), quality of life (483.15), and
resident assessment (483.20) are relevant to the
sexual behavior of individual residents. These
regulations
can
be
found
at
http://www.access.gpo.gov/nara/cfr/waisidx_03/
42cfr483_03.html
Functional Assessment Instruments
There are no standardized instruments to
assess sexual consent capacity.
Case Example
Psychological Evaluation:
Consent to Sexual Activity
Ms. Smith is a 64-year-old woman living in
a nursing facility, who was referred for a routine
psychological evaluation and determination of
capacity to consent to sexual activity. The
resident desires a sexual relationship with
another resident, whom staff believe is
mistreating Ms. Smith. The staff is concerned
that Ms. Smith does not recall these episodes of
mistreatment and is concerned about her ability
to consent to sexual activities.
Informed Consent
The purpose of the capacity evaluation was
explained to Ms. Smith. The concern of staff
members was conveyed to Ms. Smith, as was the
possible consequence of finding her lacking
capacity to consent to sexual activity. She
indicated that she understood the rationale for
the evaluation and appreciated the staff’s
concern for her well-being. She felt confident
that she would be found to have capacity, but
admitted that her memory was oftentimes poor.
Social History
Ms. Smith attended school through the 10th
grade and worked as a saleswoman. She was
married three times and has one son by her
second marriage. Ms. Smith was in an
automobile accident about 20 years ago,
resulting in traumatic brain injury. No
documentation of the injury is contained in her
records.
Medical History
Ms. Smith’s records reveal a history of
depression, for which she was hospitalized
several years ago and was treated successfully
with an antidepressant. She has a history of
seizures dating back to her accident, although
her records indicate that they have been
completely controlled by medication. Ms. Smith
was transferred to the present facility one year
ago from another nursing facility where her
behavior became unmanageable. The major
complaint of staff at the other facility was verbal
outbursts and accusations made at staff. Since
arriving at the present facility she has adjusted
reasonably well and made several friends,
including the man with whom she has become
romantically involved. Her outbursts were
initially limited to times at which she wished to
be taken to the bathroom, and resulted when
staff did not comply immediately with her
requests. These outbursts were virtually
eliminated with a behavior management plan
implemented by nursing staff. Ms. Smith is
ambulatory with a wheelchair and is unable to
walk unassisted. She requires assistance with
activities of daily living. Ms. Smith complains
frequently of pain and requests pain medication,
in spite of the fact that she is receiving what
should be adequate pain medication. Ms. Smith
argues that the dosage is incorrect and
insufficient, and states that she was given larger
amounts of pain medication at the facility from
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Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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which she was transferred. Ms. Smith also
complains of discomfort in her stomach, which
may be due to dilation of her bowel duct and
which will likely be corrected with minor
surgery. She requests frequently that she be
taken to the bathroom to urinate. Medical causes
of the reported frequent need to urinate have
been ruled out. Staff members report that on
many occasions, Ms. Smith fails to urinate when
taken to the bathroom. Nevertheless, she is
receiving medication for an overactive bladder.
Ms. Smith’s current ICD diagnoses are
Essential Hypertension, Osteoporosis, Chronic
Airway Obstruction NEC, Epilepsy, and
Depressive Disorder NEC. No brain imaging
records are in her chart.
Staff interview:
Staff Interview
Nursing staff were interviewed about their
concerns regarding “mistreatment.” They
reported that they occasionally observed acts of
jealousy by Ms. Smith’s partner when she
attended to another male, and which was
followed by his grabbing her by the arm and
firmly telling her to stay away from the other
resident. The staff did not observe any verbal,
physical, or sexual abuse. Their concerns were
limited to a question of whether Mrs. Smith had
the capacity to engage in the sexual relationship
in the context of her known cognitive deficits.
Current Medications
Medication
Dosage/Route/Sche
dule
Indication
Acetaminophen
2325mg tabs PRN
po Q4hrs
Pain
Acetaminophen
with
Codeine
300mg tab pot id
Pain
Aspirin
325mg tab po qd
Hypertensi
on
Carbamazepine
3100mg tabs po bid
Seizures
Carbamazepine
200mg tab po qd
Seizures
Valsartan
80 mg tab po qd
Hypertensi
on
Gabapentin
600mg tab po tid
Pain
Ibuprofen
400mg pot id
Pain
Pirbuterol
0.2mg 2 puffs po qid
COPD
Mirtazapine
30mg tab po hs
Depression
Oxybutynin
5mg tab po qd
Overactive
Bladder
Phenobarbital
60mg tab po bid
Convulsion
s
Clinical Interview and
Behavioral Observations
Ms. Smith was approached in the recreation
room, where she was sitting in her wheelchair
watching television. She smiled and welcomed
this examiner. She was appropriately dressed in
jeans, blouse, and sneakers. She spoke slowly
and evidenced mild dysarthria. Her motor
activity
evidenced
mild
to
moderate
bradykinesia. She was oriented to person and
place, but not to time, reporting an incorrect date
and day of the week. Her mood was euthymic
and congruent with her current affect. Ms. Smith
denied suicidal and homicidal ideation,
delusions, and hallucinations. She denied
problems with sleeping and appetite. Ms. Smith
failed to state the correct reason that she was in
the hospital, indicating that she thought she was
here to check on her “bad temper.” She appeared
to be attentive and motivated throughout the
evaluation period.
Review of Medications
Ms. Smith’s medications were reviewed to
determine whether any could substantially affect
any of the cognitive skills that are considered
relevant for sexual consent capacity. Memory
was considered the most important of these in
light of Ms. Smith’s cognitive assessment
results. A review of her medications revealed
only one, carbamazepine, that might be
contributing
substantially
to
memory
impairment. However, the effects on memory
and fatigue typically pass over time. Valsartan,
her anti-hypertensive medication, can actually
improve word list recall. Ms. Smith had been
receiving this medication for several years.
Functional Capacity Assessment
Ms. Smith demonstrated satisfactory
knowledge of sexual activities, including
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Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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intercourse, understanding of the potential risks
and benefits of sexual behavior, and the
appropriate times and places for such behavior.
She demonstrated an understanding of how
condoms are used to prevent the spread of
sexually
transmitted
diseases
and
an
understanding of how they could be obtained by
her and properly used. Ms. Smith understood the
need for privacy for most forms of sexual
expression, and the fact that some staff members
were uncomfortable with public displays of
affection among residents. Ms. Smith
understood that she always has a choice of
whether to engage in sexual behavior and that
such behavior should be consistent with her
values and preferences. She demonstrated an
understanding that sexual behavior should be
free of coercion, unfair persuasion, or any
inducements by her or her partner. The question
of how Ms. Smith would weigh the benefits of
sexual
behavior
against
the
potential
inappropriate behavior (e.g., occasional yelling,
arm grabbing) of her partner, often due to
jealousy, was discussed. She expressed some
concern that her partner could become more
aggressive and indicated that if he did, she
would terminate the relationship. This response
must be considered in light of Ms. Smith
reporting that having a relationship with a man
was very important to her, and that she did not
feel she had many suitable men from which to
choose in the facility. Several potential scenarios
were presented to Ms. Smith to determine how
she would consider the elements of potential
situations that could involve sexual behavior,
weigh the risks and benefits in light of her
values, and make choices that were consistent
with these considerations.
Cognitive Assessment
Attention was assessed through an
examination of digit span forward from the
WAIS-III and the Attention subscale of the
Cognistat. Ms. Smith correctly repeated 7 digits
forward, which is .44 standard deviations above
the mean of 6.35 for adults ages 55-64. Ms.
Smith earned a score of 8 on the Cognistat
subscale, which is almost one standard deviation
above the mean for healthy adults of
approximately her age.
Memory was assessed with the Memory
subscale of the Cognistat and the Hopkins
Verbal Learning Test - Revised (HVLT-R). Ms.
Smith obtained a score of 4 on the Cognistat
Memory subscale, which is 10.7 standard
deviations below the mean of 11.5 for adults of
comparable age. The HVLT-R is a test of verbal
learning and short-term memory. Ms. Smith
recalled none of the initial 12 words following a
20-minute delay. Her total score of 21 is 1.5
standard deviations below the norm of 27.5
(sd=4.3) for healthy adults.
Ms. Smith’s memory for previously
acquired information regarding sexually
transmitted diseases and methods of preventing
risks was quite good. Ms. Smith’s recall of past
encounters with her potential partner was
problematic, as evidenced by her poor
performance on a delayed recall task and her
statements to staff that she did not recall her
potential partner treating her badly (e.g., yelling
at her, grabbing her arm) on previous days. It
was unclear from these reports whether Ms.
Smith was feigning poor recall so that she could
justify spending time with her potential partner.
Executive Function was assessed with the
Trails B, Similarities and Judgment subscales of
the Cognistat, and COWAT. Ms. Smith earned a
score of 5 on the Similarities subscale of the
Cognistat, which is almost two standard
deviations below the normative mean of 6.1. She
earned a score of 5 on the Judgment subscale,
which is approximately at the normative mean of
5.1. Ms. Smith named 10 unique animals on the
COWAT, which is 2.3 standard deviations
below the normative mean of 19.8. The poor
performance on the Trails B and COWAT, both
speeded tests, must be considered in light of Ms.
Smith’s bradykinesia.
Activities of Daily Living were assessed
with the Adult Functional Adaptive Behavior
Scale (AFABS) by a nurse familiar with Ms.
Smith. Moderate impairment in ambulation,
toileting, dressing, grooming, socialization,
managing money, managing health needs, and
memory were noted. Mild impairment was noted
in eating, environmental orientation, reality
orientation, receptive speech comprehension,
and expressive communication.
Psychiatric/Emotional Assessment
Depression was assessed using the Geriatric
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Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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Depression Scale- Short Form (GDS). Ms.
Smith obtained a score of 2, well below the
cutoff score of 5. She endorsed items regarding
problems with memory and lack of energy.
Summary
Ms. Smith is a 64-year-old female with a
history of depression and traumatic brain injury,
who has required nursing home placement for
over 20 years. The nursing facility staff are
concerned that she lacks capacity to consent to
sexual behavior, due primarily to her poor
memory. The following conclusions are offered
based on a clinical interview and psychological
testing:
Ms. Smith demonstrated adequate attention,
but moderate impairment in immediate memory
and severe impairment in delayed memory.
Remote autobiographical memory appeared
adequate. Staff reports of Ms. Smith’s memory
for recent incidents with her potential partner
suggest recent episodic memory impairment.
Ms. Smith’s own report of her memory
performance is consistent with this observation.
Depression was ruled out as a likely contributor
to memory impairment through consideration of
her scores on measures of depression and
attention. Her current medications are also
unlikely to be a major source of her memory
difficulties. Ms. Smith’s performance on the
tests of executive function was of limited value
in light of the potential influence of her
bradykinesia. However, functional assessment,
as noted below, revealed satisfactory reasoning,
planning, and problem solving.
Functional assessment of decision-making
capacity yielded evidence that she appreciated
that she always had a choice of engaging in
sexual behavior, that she could understand and
weigh the potential risks and benefits of such
behavior in light of her own values, and that she
could arrive at a decision that was consistent
with her reasoning and values.
Ms. Smith appears to have the knowledge
and many of the functional skills necessary for
making informed, well-reasoned decisions
regarding sexual behavior. However, her poor
delayed memory precludes her learning from
past
experiences.
This
is
particularly
problematic because her partner has allegedly
been seen mistreating Ms. Smith, and Ms. Smith
reports no recall of those episodes. Moreover,
Ms. Smith reports she fears her partner could
become aggressive. Since Ms. Smith cannot
recall past experiences with her partner, she
lacks the information that would be used to
avoid future aversive or physically dangerous
interactions. It is the opinion of this clinician
that Ms. Smith lacks the capacity to consent to
sexual behavior. There is no reason, however,
that Ms. Smith and her potential partner could
not visit with each other as long as the visits
occur in locations where staff can monitor their
behavior.
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Financial Capacity
Introduction
Legal Elements/Standards
Financial capacity is a medical-legal
construct that represents the ability to
independently manage one’s financial affairs in
a manner consistent with personal self-interest
and values (Marson & Hebert, 2008a). Financial
capacity, thus, involves not only performance
skills (e.g., counting coins/currency accurately,
completing a check register accurately, paying
bills), but also judgment skills that optimize
financial self-interest, and values that guide
personal financial choices. Financial experience
and skills can vary widely among cognitively
normal individuals and are associated with
factors of education and socioeconomic status.
From a legal standpoint, financial capacity
represents the financial skills sufficient for
handling one’s estate and financial affairs, and is
the basis for determinations of conservatorship
of the estate (or guardianship of the estate,
depending on the state legal jurisdiction).
Broadly construed, financial capacity also
conceptually encompasses more specific legal
capacities, such as contractual capacity, donative
capacity, and testamentary capacity. Thus,
financial capacity is an important area of
assessment in the civil legal system. (Marson et
al., 2008a).
From a clinical standpoint, financial
capacity is a highly cognitively mediated
capacity that is vulnerable to neurological,
psychiatric, and medical conditions that affect
cognition (such as dementia, stroke, traumatic
brain injury, and schizophrenia). In particular,
financial capacity issues arise frequently in the
context of older adults with cognitive loss and
dementia. Family members of such older adults
will often raise concerns about new problems
managing household finances, making poor
financial decisions, or being exploited/scammed.
Clinicians are increasingly being asked by
families, physicians, attorneys, and judges to
evaluate and offer clinical opinions regarding
financial capacity (Marson et al., 2008a).
For historical reasons, Anglo-American law
has traditionally treated an individual’s financial
capacity separately from the capacity to manage
personal
affairs.
Conservatorship
(or
guardianship of the estate) is a set of legal
procedures in which a court evaluates an
individual’s overall capacity to manage his/her
financial affairs and decides whether or not to
appoint a conservator to manage part or all of
them instead. Conservatorships can be limited or
plenary. The legal standard for conservatorship
varies across state jurisdictions, and historically
was often generally (vaguely) cast as the
capacity to manage in a reasonable manner all of
one’s financial affairs.
A better and far more specific criterion is set
forth in Section 410(2) of the Uniform
Guardianship and Protective Proceedings Act
(UGPPA), which states that a court may appoint
a conservator if the court determines that “the
individual is unable to manage property and
business affairs because of an impairment in the
ability to receive and evaluate information or
make decisions, even with the use of appropriate
technological assistance” and
the individual has property that will be
wasted or dissipated unless management
is provided or money is needed for the
support, care, education, health, and
welfare of the individual or of
individuals who are entitled to the
individual’s support and that protection
is necessary or desirable to obtain or
provide
money.
(Uniform
Law
Commissioners,
http://www.nccusl.org/Update/)
It is important for the practicing
psychologist to be familiar with the definition of
financial capacity in his/her state (Marson et al.,
2008a).
As discussed above, financial capacity also
conceptually encompasses specific types of legal
transactions, such as executing a contract
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Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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(contractual capacity), making a gift (donative
capacity), or making a will (testamentary
capacity). The legal standard for contractual
capacity is high and generally involves the
party’s ability “to understand the nature and
effect of the act and the business being
transacted” (Walsh et al., 1994; Mezzullo et al.,
2002).
In contrast, for reasons of public policy, the
legal standard for testamentary capacity is low.
Although requirements for testamentary capacity
vary across states, four criteria have been
identified. A testator must know what a will is,
have knowledge of his/her potential heirs, have
knowledge of the nature and extent of his/her
assets; and have a general plan of distribution of
assets to heirs. The absence of one or more of
these elements of testamentary capacity can
serve as grounds for a court to invalidate a will.
Testamentary capacity is treated separately, in
the next section of Chapter 6.
The standard for donative capacity, or the
capacity to give a gift can also vary across
jurisdictions. In some states, a comprehension
standard is applied similar to that used in
contractual matters: “the party contemplating
the donative transfer must understand the nature
and effect of the act of making a gift.” In other
jurisdictions, a lower standard equivalent to that
of testamentary capacity is applied.
schizophrenia may have adequate financial
performance skills but lack financial capacity
because he/she consistently makes poor
judgments about how to spend government
entitlement monies.
Marson and colleagues have proposed a
clinical model of financial capacity that
represents an initial effort at identifying
functional elements constituent to this capacity
(Griffith et al., 2003; Marson et al., 2000),
shown on the following page. The model
focuses on both performance and judgment
skills and conceptualizes financial capacity at
three increasingly complex levels.
1. Specific Abilities and Tasks
The first functional element is specific
financial abilities or tasks, each of which is
relevant to a particular domain of financial
activity. In the model, many general domains
can be further broken down into component
tasks or abilities that emphasize understanding
and pragmatic application of skills relevant to a
specific domain. For instance, the domain of
financial conceptual knowledge involves
understanding concepts, such as loans and
savings, and also using this information to select
advantageous interest rates. Similarly, bill
payment involves not only understanding what a
bill is and why it should be paid, but accurately
reviewing a bill and preparing it for mailing.
Functional Elements
Financial capacity is a complex, multidimensional construct representing a broad
range of conceptual, pragmatic, and judgmental
skills (Marson et al., 2005). Initial conceptual
formulations of financial capacity were limited
to unelaborated descriptions, such as “money
management skills” or “financial management
skills.” To date, some state statutory definitions
of financial capacity continue to maintain this
level of vagueness. However, recent clinical
studies have begun to model and empirically
investigate this capacity and its constituent
functional abilities.
As discussed above, in considering
functional abilities relevant to financial capacity,
a fundamental consideration involves the dual
performance and self-interest perspectives
discussed above. For example, a person with
2. General Domains
The second functional level is general
domains of financial activity, each of which are
clinically relevant to the independent
functioning of community-dwelling older adults.
In this model, core domains include basic
monetary skills, financial conceptual knowledge,
cash transactions, checkbook management, bank
statement management, financial judgment, bill
payment, knowledge of personal assets and
estate arrangements, and investment decision
making.
3. Overall Capacity
The third functional level is overall financial
capacity, or a global level. The global level of
the model considers overall financial capacity.
Clinicians are usually asked by families and the
courts to make clinical judgments concerning an
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Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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individual’s overall financial capacity. Such
global judgments involve an integration of
information concerning an individual’s task and
domain level performance, his/her judgment
skills, and informant reports of financial
abilities. Such global clinical judgments are
particularly relevant to conservatorship hearings.
The model has informed instrument
development and served as the basis for several
empirical studies of financial capacity in
dementia (Marson et al., 2000; Griffith et al.,
2003, Martin et al., 2008).
However, these studies notwithstanding,
there is not yet a clear consensus as to the
Conceptual Model of Financial Capacity:
Task Description
Difficulty
Domain 1 Basic Monetary Skills
Task 1a Naming Coins/Currency
Task 1b Coin/Currency relationships
Task 1c Counting coins/currency
Identify specific coins and currency
Indicate monetary values of coins/currency
Accurately count arrays of coins and currency
Simple
Simple
Simple
Domain 2 Financial Conceptual Knowledge
Task 2a Define financial concepts
Task 2b Apply financial concepts
Define simple financial concepts
Practical applications/computation using concepts
Complex
Complex
Domain 3 Cash Transactions
Task 3a 1 item grocery purchase
Task 3b 3 item grocery purchase
Task 3c Change/vending machine
Task 3d Tipping
Conduct 1 item transaction; verify change
Conduct 3 item transaction; verify change
Obtain change for vending machine; verify charge
Understand tipping convention; calculate tips
Simple
Complex
Complex
Complex
Domain 4 Checkbook Management
Task 4a Understand checkbook
Task 4b Use checkbook/register
Identify/explain parts of checkbook and register
Conduct simple transaction and pay by check
Simple
Complex
Domain 5 Bank Statement Management
Task 5a Understand bank statement
Task 5b Use bank statement
Identify/explain parts of a bank statement
Identify specific transactions on bank statement
Complex
Complex
Domain 6 Financial Judgment
Task 6a Detect mail fraud risk
Task 6b Detect telephone fraud risk
Detect/explain risks in mail fraud solicitation
Detect/explain risks in telephone fraud solicitation
Simple
Simple
Domain 7 Bill Payment
Task 7a Understand bills
Task 7b Prioritize bills
Task 7c Prepare bills for mailing
Explain meaning and purpose of bills
Identify overdue utility bill
Prepare bills, checks, envelopes for mailing
Simple
Simple
Complex
Domain 8 Knowledge of Assets/Estate
Indicate personal assets and estate arrangements
Simple
Domain 9 Investment Decision Making
Understand investment options; determine returns;
make and explain decision
Complex
Overall Financial Capacity
Overall functioning across tasks and domains
Complex
^ requires corroboration by informant
Reprinted with permission from Griffith, H.R., Belue, K., Sicola, A., Krzywanski, S., Zamrini, E., Harrell, L., & Marson, D. C.
(2003). Impaired financial abilities in mild cognitive impairment: A direct assessment approach. Neurology, 60, 449 - 457.
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functional elements that comprise financial
capacity. There is a significant need for both
neuropsychological and factor analytic studies to
identify component constructs and functional
elements for this capacity.
Diagnostic Considerations
Financial capacity is a multi-dimensional
and highly cognitive mediated capacity.
Accordingly, it is a capacity that is very
sensitive to medical conditions that affect
cognitive and behavioral functioning. Medical
conditions that impair financial capacity include
neurodegenerative disorders like Alzheimer’s
disease (AD) and Parkinson’s disease, severe
psychiatric disorders like schizophrenia and
bipolar disorder, substance abuse disorders, and
developmental disorders, such as mental
retardation and autism.
Existing empirical research in this area has
focused on changes in financial capacity
occurring in the context of Alzheimer’s disease
and related disorders. Patients with amnestic
mild cognitive impairment, the prodrome or
transitional stage to Alzheimer’s, already show
emerging deficits in higher order financial skills,
such as conceptual knowledge, bank statement
management and bill payment, and also in
overall financial capacity (Griffith et al., 2003).
Patients with mild Alzheimer’s disease have
emerging global impairment across almost all
financial tasks and most domains, while patients
with moderate Alzheimer’s disease have
advanced global impairment in all financial
areas (Marson et al., 2000). While financial
capacity is already impaired in patients with
mild Alzheimer’s disease, a recent longitudinal
study has also shown that there is rapid decline,
in both simple and complex financial tasks, in
mild Alzheimer’s disease patients over a oneyear period (Martin et al., 2008).
Cognitive Underpinnings
Due to the functional complexity of the
financial capacity construct, it is not surprising
that there are a wide variety of cognitive abilities
that inform financial capacity. Preliminary
conceptual work has suggested that financial
capacity is comprised of three types of
knowledge: declarative knowledge, procedural
knowledge, and judgmental abilities. A
preliminary neuropsychological study in older
adults has suggested that global financial
capacity is associated primarily with written
arithmetic abilities, and to a lesser extent with
memory and executive function skills, in
individuals across the demential spectrum:
cognitively normal older adults, patients with
amnestic mild cognitive impairment, and
patients with mild Alzheimer’s disease. Much
work remains to be done in explicating the
cognitive basis of financial capacity across
neurocognitive disorders.
Psychiatric and Emotional Factors
Psychiatric and emotional factors can often
play a significant role in the assessment of a
patient’s financial capacity. In some instances,
clinical depression or psychotic thinking may
affect an individual’s ability to carry out basic
financial tasks. More commonly, however, such
psychiatric conditions will adversely affect an
individual’s judgment in managing their
financial affairs. A protypical example would be
the dually diagnosed patient with schizophrenia
and a substance abuse disorder, who dissipates
his monthly entitlement check on illicit drugs
rather than paying for rent, utilities, and his
psychotropic medications.
Values
In assessing financial capacity, it is
important to obtain information regarding an
individual’s lifelong values and approach to
managing money and finances. As possible
examples, has an individual during her adult life
been scrupulous and detail oriented regarding
her finances, or has she adopted a laissez faire
approach and a dependence on others that has
sometimes led to financial difficulties? Such
information can help the psychologist determine
whether an individual’s recent problems
managing money represent a departure from her
premorbid baseline, or are simply an extension
of a prior “lifestyle” regarding the management
of money. This information in turn can inform
the interpretation of evidence and the outcome
of the capacity assessment.
It should be noted that a finding of intact
financial capacity is not necessarily inconsistent
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Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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with occasional bad or questionable financial
decision making, particularly if eccentric
decision making is a lifelong pattern.
Risk Considerations
The capacity to manage one’s own finances
is a core aspect of personal autonomy in our
society, on a par with autonomy to drive a motor
vehicle. Accordingly, the tension between
autonomy and protection is high with respect to
financial capacity: autonomy is highly desirable,
but the potential negative consequences for
individuals and families of failing capacity are
equally strong. Risks of failing financial
capacity include poor financial decisions,
unintentional self-impoverishment, victimization
and exploitation by others, and vulnerability to
undue influence.
In assessing financial capacity, an
assessment of the relative risks involved in a
situation is important. The divorced investment
banker with mild dementia who possesses a
large stock portfolio and multiple assets presents
a different risk profile than the married man with
mild dementia living on a fixed income and who
has a caring and involved family. Although
financial capacity may be impaired in both
situations, the outcome of the assessment and
the specific intervention(s) recommended can
differ substantially based on the risks presented.
Steps to Enhance Capacity
Because financial capacity is such a broad
construct, a cognitively or otherwise impaired
individual may have preserved financial skills as
well as areas of impairment. Supervision
regarding financial matters in the home setting
may extend and support functioning for a period
of time in areas, such as bill payment or
checkbook management. However, caution must
be exercised with respect to supporting
autonomy, insofar as a cognitively impaired
individual, despite periodic support, can
continue to be highly vulnerable to undue
influence and financial predation.
Clinical Judgments of
Financial Capacity
Unlike treatment consent capacity, there are
currently no published studies of clinician
judgments of financial capacity. In large part
this paucity reflects the absence of well-accepted
conceptual models and instruments for assessing
this capacity, and associated empirical research.
At the present time, judgments of financial
capacity are based on subjective clinical
judgment using interview information, capacity
remote neuropsychological tests, and in some
cases limited props examining basic monetary
and other skills or an objective functional
assessment instrument.
Judgments of overall financial capacity can
be framed using the categorical outcomes of
capable, marginally capable, and incapable.
Findings regarding specific financial domains
and tasks can be referenced as evidence for the
overall finding. The distinction between a
patient’s performance and judgment skills can
be incorporated into the clinician’s decisionmaking.
The potential outcome of marginally
capable (to manage financial affairs) is
important and implies limited capacity. It
suggests that an individual may retain financial
skills in some areas but not others. For example,
an elderly person with mild cognitive
impairment or early dementia may still be able
to perform some financial activities (e.g., handle
basic cash transactions, write small checks) but
not others (e.g., make investment decisions or
asset transfers). This clinical outcome may have
particular evidentiary relevance to state
conservatorship (guardianship of the estate)
proceedings, where courts in a majority of
jurisdictions have a legal judgment of limited
financial competency available to them.
Clinical Approaches to Assessing
Financial Capacity
As is true with other capacities, financial
capacity should be evaluated within the context
of a general evaluation of an individuals’
cognitive and emotional functioning. At present
there are two potential approaches to assessing
financial capacity: clinical interview and direct
performance instruments.
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Clinical Interview
The clinical interview is the traditional and
currently by far the most widely used method for
evaluating financial capacity. At the outset of an
interview with patients (and family members), it
is important that a clinician first determine the
patient’s prior or premorbid financial experience
and abilities. For example, it would be
inappropriate to assume that a person who on
testing demonstrates difficulty writing a check
has suffered decline in this area, if she has never
performed this task, and/or has traditionally
delegated this task to a spouse. Once premorbid
experience level is established, clinicians need to
identify the financial tasks and domains that
comprise the patient’s current financial
activities, and differentially consider those
required for independent living within the
community. The level of impairment on a
specific task or domain should be carefully
considered. Individuals who require only verbal
prompting to initiate or complete a financial task
(e.g., paying bills) are qualitatively different
from individuals who require actual hands-on
assistance and supervision in paying bills; both,
in turn, differ from individuals who are now
completely dependent on others to pay their
bills.
Some questions to add to a clinical interview
that specifically focus on issues relevant to
financial capacity are:
1. What is your financial history? Are you in
any debt? Do you live week to week? Are
you able to plan ahead and save for the
future?
2. Do you have enough money to provide for
yourself in your retirement?
3. Have you made a will?
4. How knowledgeable are you about financial
investments? What, if any, types of
investments do you currently have?
5. What are the things you like to spend money
on? In spending money, what are your
highest priorities?
6. Are there people or organizations to who
you generally make gifts or contributions?
7. How would you like to invest and manage
your money in the future? Do you want to
8.
9.
10.
11.
12.
13.
14.
15.
stick with what you know, or are you open
to new investment options?
Do you prefer higher-risk investments with a
possibility of higher return, or lower-risk
investments with a smaller, guaranteed
return?
If you needed help with your finances, who
would you like to help you? Who can you
trust to ensure your best interests?
How well does this person handle his or her
own finances? Is he/she in debt? Does
he/she have a good credit record? Is he/she
knowledgeable about financial investments?
Do you currently have or would you like to
obtain a financial advisor? Would this
person be a more objective spokesperson
than a relative or close friend?
Are there certain people with whom you
would like your spokesperson to discuss
financial decisions on your behalf (family,
financial advisors, other)?
Is there anyone you specifically would not
want to be involved in helping to make
financial decisions on your behalf?
How closely would you want your
spokesperson to follow your instructions
about financial decisions, versus what he or
she thinks is best for you at the time
decisions are made?
Are there other things you would like your
spokesperson to know about you, if he or
she were ever in a position to make financial
decisions on your behalf?
Functional Assessment Instruments
Performance-based instruments represent a
second approach to assessing financial capacity.
In contrast to clinical interview formats,
performance-based instruments are not subject
to reporter bias. Instead, individuals are asked to
perform a series of pragmatic tasks equivalent to
those performed in the home and community
environment. Performance-based measures are
standardized, quantifiable, repeatable, and norm
referenced, and thus results can be generalized
across patients and settings. These measures can
provide clinicians and the courts with objective
information regarding performance of specific
financial tasks that can be highly relevant to
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formulation of recommendations and treatment
strategies.
Weaknesses of performance-based measures
of financial capacity should also be noted.
Performance-based measures conducted in a
laboratory or clinical office setting cannot take
into account either the contextual cues or
distractions within the home environment that
may assist or interfere with a person’s abilities
to perform everyday financial tasks. These
instruments are more difficult and timeconsuming to administer. Given the multidimensional and pragmatic aspects of financial
capacity, the instruments will also require
specialized equipment and training which can
make them costly relative to clinical interview.
In comparison to the area of consent
capacity, financial capacity has seen only limited
instrument development to date. Measures of
limited financial skills can be found in a number
of broad-based IADL instruments, but there are
currently relatively few instruments dedicated to
the construct of financial capacity. Different
instruments are described in Appendix B.
Instruments to Assess Financial Capacity
Direct Assessment of Functional Status: One
subscale
Decision-making Interview for Guardianship: Four
vignettes assessing social judgment in financial
situations
Financial Capacity Instrument: Comprehensive
assessment of nine financial domains and overall
financial capacity
Hopemont Capacity Assessment Interview: Three
vignettes assessing social judgment in financial
situations
Independent Living Scales: One subscale
Case Example
I.
Background Information
Mr. Fields, a 75-year-old widowed
Caucasian male and construction business owner
with a 6th grade education, was referred as an
outpatient to the neuropsychology clinic by his
daughter, Ms. Daughter, and her attorney, Mr.
Legal, Esq., for evaluation of the patient’s
cognitive and emotional status, and capacities to
manage his business and financial affairs and to
make a will.
Mr. Fields reportedly has a three- to fiveyear history of memory problems, which
reportedly developed insidiously and have
gotten progressively worse. He reportedly has
not been previously evaluated for these
problems.
In interview, Mr. Fields stated that he does
not have any problems with his memory. He also
generally denied any other cognitive or
functional problems. He stated that he does not
have any help at home, but that his daughter
comes by sometimes to help him pay bills or to
bring him groceries. He denied problems with
his driving. Regarding mood or personality
changes, he reported that he is “doing fine” and
denied any symptoms of depression or anxiety.
Mr. Fields’s daughter, Ms. Daughter,
described a much more serious situation. Ms.
Daughter said that her father has had memory
problems for at least five years, and that his
memory has become noticeably worse over the
past three years. She said that she first noticed
something was different when she left her
accounting job in the family business in 1998
over some disagreements with her uncle James,
who co-owns the business with her father. She
said that her father did not seem to be taking up
for her, which was uncharacteristic of him. She
said that she later realized that her father was
forgetting about these disagreements and his role
in resolving them. Ms. Daughter reported that he
currently asks the same question repeatedly,
forgets conversations, and constantly misplaces
items. She said that he has more trouble
remembering people’s names. She said that he
has comprehension problems, but pretends to
understand people when they talk to him. She
reported that when they go to restaurants, he gets
lost on his way back from the restroom. She
reported that he has not driven since July 2000
when he had lung surgery. She said that just
prior to that, he complained to her about getting
lost while driving in a familiar area.
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Regarding functional changes, Ms. Daughter
reported that her father has no meaningful
activities around the home. He has had full-time
caregivers since July 2000. She noted that he
still cannot remember their names. She reported
that prior to these home health care
arrangements, her father was not bathing and
was wearing the same clothes every day. She
reported that she has handled all of her father’s
bill paying since October 2000. She said that she
also tries to supervise his business transactions.
Ms. Daughter reported that her father co-owns
an excavation business, Happy Valley
Construction, with his brother James. The
business is located in Columbus, Georgia. Mr.
Fields reportedly has a separate business where
he also buys, develops, and sells real estate. She
stated that her father has agreed on several
occasions to consult her before signing any
business documents, but then forgets to do this.
Ms. Daughter reported several poor business
decisions her father has made recently. She said
that in the past year he sold a piece of real estate
for $10,000 that was worth $250,000. She also
reported that he has made almost $500,000 in
loans to the family business over the past two
years, and that these loans have not been repaid.
She reported that her father initially loaned
$200,000 to Happy Valley in 1998, $90,000 of
which went to his nephew, who also works for
the company. She stated that there does not
appear to be a note for the loan to his nephew.
She reported that the remaining $300,000 was
loaned out in October 2000. Ms. Daughter said
that she has also recently discovered a buy/sell
agreement, signed by her father while she was
out of town, which states that if her father dies,
the company will go to her uncle James and the
money owed by the company to her father will
be forgiven. She noted that in this buy/sell
agreement, some property that belongs to her
father is listed instead as company property.
Regarding mood or personality changes, Ms.
Daughter reported that her father is more laid
back and even indifferent. She said that he used
to be very focused on and concerned about his
business affairs, but now does not seem
concerned about them. She denied symptoms of
anxiety or depression, but noted that he naps a
lot during the day. She also stated that he always
wants to eat because he forgets that he has
already eaten.
Social/Academic/Occupational History: Mr.
Fields reportedly was born and raised in
Columbus, Georgia. He reported that he had four
brothers and sisters. The patient’s father was a
farmer and iron smith. The patient was
reportedly married for 40 years when his wife
died in 1990. He reported that he has two
daughters and one son with a disability. He
currently lives alone.
Mr. Fields reportedly completed six years of
education. He reportedly buys and sells real
estate and co-owns an excavation business
called Happy Valley Construction Company.
Prior Medical History: Mr. Fields’s medical
history reportedly is significant for diabetes and
history of blood clots. Surgical history
reportedly includes four-way coronary artery
bypass graft (1989) and partial lung resection
(2000). The patient reportedly does not drink
alcohol and does not smoke. There is reportedly
no history of alcohol or other substance abuse.
Family medical history is reportedly positive
for myocardial infarction in his brother, stomach
cancer in his sister, skin cancer in his sister, and
possible Alzheimer’s disease in his mother.
Psychiatric History: Mr. Fields reportedly
has no history of mental health treatment. As
noted above, he reportedly has had no prior
evaluations for his memory problems.
Medications: Coumadin, Exelon, Tenormin,
ginkgo biloba, Ambien, Detrol, Claritin.
II. Behavioral Observations
Mr. Fields presented as a well-groomed,
nicely dressed 75-year-old Caucasian man. He
was accompanied to the evaluation by his
daughter.
In interview, the patient’s speech was fluent
and reasonably goal-directed but lacked
spontaneity. Responses were impoverished.
Comprehension appeared generally intact.
Affect was mildly constricted, and mood was
pleasant but irritable. Insight was judged to be
very poor. There was no indication or report of
formal hallucinations or delusions, or of a
thought or perceptual disorder. There was no
indication or report of suicidal ideation, plan, or
intent.
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During testing, Mr. Fields was alert and
pleasant but would quickly become irritable and
uncooperative with testing. He exhibited mild
performance anxiety. He displayed task
frustration by abandoning or avoiding tasks. He
showed no response to encouragement from the
psychometric technician. He displayed inability
to complete some tasks due to comprehension
problems. He made a few perseverative and
intrusion errors. He required constant redirection
to task. He showed a complete lack of testtaking strategies.
Mr. Fields was irritable and at times
uncooperative during the testing. At one point,
he refused to continue testing and started to
leave, but was persuaded by his daughter to
continue. Because of his reluctance to
participate, and the examiner’s concern that he
would prematurely terminate the testing, only an
abbreviated test battery could be administered.
Nevertheless, sufficient information was
obtained to respond fully to the referral
questions. Overall, the patient appeared to put
forth variable but acceptable effort during the
testing. Much of his reluctance to participate
related to tasks that he appeared unable to
perform. Overall, the current test results are an
accurate representation of Mr. Fields’s current
levels of cognitive and emotional functioning,
and of his current financial abilities.
III. Tests Administered
California Verbal Learning Test - II (CVLT-II)
Clinical Interview
Cognitive Competency
Executive Clock Drawing Task (CLOX)
Financial Capacity Instrument
Geriatric Depression Scale (GDS)
Mattis Dementia Rating Scale (DRS)
Token Test
Trails A and B
WAB Auditory Comprehension
Wide Range Achievement Test-3(reading subtest)
IV. Impressions and Summary
Neuropsychological Findings
1. Probable dementia, currently moderate
(DRS=89/144, CDR= 2.0).
The neuropsychological test results were
consistent with probable moderate dementia.
Evidence for this impression included severe
impairment on a dementia screening instrument
and impairments in high-load verbal learning,
recall, and recognition memory (severe to
profound), simple short-term verbal recall
(severe), orientation to time (severe), orientation
to
place
(severe),
simple
auditory
comprehension (severe), reading abilities
(moderate), visuospatial construction of a clock
drawing (mild), simple visuomotor tracking
(mild), propositional auditory comprehension
(moderate), and spontaneous construction of a
clock drawing (severe). The patient was unable
to complete a measure of visuomotor
tracking/set flexibility. In addition, the patient’s
daughter reported that he has had progressive
memory and other cognitive problems for as
long as five years.
Functional testing and interview data were
also consistent with moderate dementia. Mr.
Fields was severely impaired on a cognitive
measure of everyday problem solving abilities.
On a functional measure of financial capacity,
the patient showed intact performance only on
simple tasks of naming coins/currency,
coin/currency relationships, and single and
multi-item grocery purchases. He demonstrated
significant impairment on tests of counting
coins/currency,
understanding
financial
concepts, making change for a vending machine,
tipping, conceptual understanding of a
checkbook/register, pragmatic use of a
checkbook/register, conceptual understanding of
a bank statement, use of a bank statement,
detection of telephone fraud, conceptual
understanding of bills, identifying and
prioritizing bills, and knowledge of his personal
financial assets and activities. In addition, the
patient’s daughter indicated that he has home
health care aides around the clock. She reported
that prior to these arrangements, the patient was
not bathing and wore the same clothes every
day. She said that he currently has no
meaningful activities around the home.
2. Possible Alzheimer’s disease.
Mr. Fields’s neurocognitive profile was
consistent with possible Alzheimer’s disease.
High-load verbal learning, recall, and
recognition memory were moderately to
severely impaired and he was unable to benefit
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from semantic or recognition cueing. He showed
0% recall after a short delay, which is consistent
with the rapid decay of information over delay
seen in Alzheimer’s disease. In addition, he had
0% short-term recall of verbal items from the
memory subtest of the DRS. Characteristic
impairments on measures of executive function
(simple visuomotor tracking, propositional
auditory comprehension, and spontaneous
construction of a clock drawing) and inability to
complete a measure of visuomotor tracking/set
flexibility. Due to the patient’s reluctance to
cooperate, a more comprehensive evaluation of
memory, attention, expressive language, and
verbal intellectual abilities was not possible.
Clinical course was consistent with
Alzheimer’s disease. Mr. Fields’s cognitive
difficulties reportedly have slowly progressed
over the past five years. He also has a family
history of possible Alzheimer’s disease.
In the examiner’s judgment, it is highly
probable that Mr. Fields has Alzheimer’s
disease. However, he needs a neurological workup for dementia before the clinical diagnosis can
established conclusively.
Capacity Findings
1. Probable current incapacity to manage
business-related and everyday financial affairs.
History, interview, and test data indicated
that Mr. Fields is currently incapable of
managing his financial affairs and making
business-related decisions. In interview, Mr.
Fields demonstrated inaccurate knowledge of his
financial and business affairs. For example, the
patient indicated that he goes into work at his
excavation
business
every
day,
even
occasionally running construction equipment,
whereas the patient’s daughter reported that he is
retired and that his brother operates and manages
the business on his own. She reported that her
father continues to manage his own finances, but
makes poor business decisions (e.g., recently
sold some property for 10% of what it was
worth). She reported that her father has agreed
several times not to sign anything without letting
her review it first, but then forgets to consult her.
She said that he has also made several large
loans to his business recently, but seems
generally unaware of these loans and the fact
that they are not being repaid.
Functional testing of financial abilities
revealed overall severe impairment in financial
capacity. On testing, Mr. Fields demonstrated
intact performance on tasks of naming
coins/currency, coin/currency relationships, and
single and multi-item cash purchases. However,
he was impaired on tests of counting
coins/currency,
understanding
financial
concepts, making change for a vending machine,
tipping, conceptual understanding of a
checkbook, use of a checkbook, conceptual
understanding of a bank statement, use of a bank
statement, detection of telephone fraud,
conceptual understanding of bills, identifying
and prioritizing bills, and knowledge of personal
financial activities.
Taken together, these findings indicate that
Mr. Fields is no longer capable of managing any
aspect of his business and financial affairs.
2. Probable vulnerability to undue influence.
Early on in their disease course, patients
with Alzheimer’s disease and related dementias
become increasingly vulnerable to the influence
of others. It is possible that Mr. Fields’s reported
recent poor business decisions may reflect such
a vulnerability. For example, during testing Mr.
Fields failed to detect a telephone credit card
scam situation and agreed to provide his credit
card number over the phone to an unknown
caller.
V. Recommendations
1. We recommend that Mr. Fields be referred
to the Memory Disorders Clinic for a full
neurological and dementia evaluation.
2. Continued
pharmacotherapy
with
cholinesterase inhibitors appears to be
appropriate.
3. Mr. Fields and his family should consider
legally securing his business, financial, and
personal affairs as soon as possible. Mr.
Fields could potentially benefit from formal
conservatorship. Given his level of dementia
and
functional
impairments,
formal
guardianship should also be considered.
4. Mr. Fields’s cognitive and emotional status
should continue to be closely monitored.
This evaluation would provide a useful
baseline if follow-up testing were indicated.
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Testamentary Capacity
Introduction
Under Anglo-American law, the right of
testation refers to the freedom to choose how
one’s property and other possessions will be
disposed of following death. In order for a will
to be valid, the testator (person making the will)
must have testamentary capacity at the time that
the will is executed. Testamentary capacity is,
thus, a legal construct that represents that level
of mental capacity necessary to execute a valid
will. If testamentary capacity is absent, then the
will is void and fails. For reasons of public
policy supporting the orderly probating of wills
and distribution of assets to heirs, courts have
traditionally applied a low legal threshold for
finding testamentary capacity (Marson &
Hebert, 2008b).
Conceptually testamentary capacity falls
within the broader concept of financial capacity,
but for reasons of history and tradition
testamentary capacity continues to receive
distinct attention within the legal system. Each
state jurisdiction, through its statutes and case
law, sets forth legal elements or criteria for
testamentary capacity. Although requirements
for testamentary capacity vary across states, four
criteria have generally been identified. A testator
must know what a will is; have knowledge of
his/her potential heirs; have knowledge of the
nature and extent of his/her assets; and have a
general plan of distribution of assets to heirs.
The absence of one or more of these elements of
testamentary capacity can serve as grounds for a
court to invalidate a will. As discussed further
below, a will can also fail if the testator has an
insane delusion that specifically and materially
affects the testator’s creation or amendment of a
will. Finally, a will is often challenged on the
conceptually separate ground that it was the
product of undue influence on the testator
exerted by a family member or third party (see
separate chapter on undue influence in this
book). (Marson et al., 2008b).
As testamentary capacity represents a legal
construct closely associated with the testator’s
mental status, clinicians are often asked to
evaluate testamentary capacity and offer clinical
testimony in legal proceedings. Such evaluations
are sometimes conducted contemporaneously
with a will’s execution, but more often occur
retrospectively following the incapacity or death
of a testator and probating of the will. In recent
years there has been an increase in will contests
in the probate courts, with associated claims of
impaired testamentary capacity and also undue
influence (Marson et al., 2008b).
Legal Elements/Standards
Although requirements for testamentary
capacity vary across states, four criteria have
generally been identified. A testator must have
(1) knowledge of what a will is; (2) knowledge
of that class of individuals that represents the
testator’s potential heirs (“natural objects of
one’s bounty”); (3) knowledge of the nature and
extent of one’s assets; and (4) a general plan of
distribution of assets to heirs.
The absence of one or more of these
elements can serve as grounds for a court to
invalidate a will due to lack of testamentary
capacity. However, the way in which courts
weigh legal elements of testamentary capacity in
determining the validity of a will varies across
states. Some states require that the testator meet
only one of the criteria for a will to be valid.
Other states require that the testator not only
understand a will and demonstrate memory of all
property and potential heirs, but also hold this
information in mind while developing a plan for
disposition of assets. Accordingly, the reader is
strongly encouraged to review the relevant law
on testamentary capacity specific to his/her state
jurisdiction (Marson et al., 2008b).
As discussed in the section below, the
functional elements of testamentary capacity are
almost entirely cognitive. To exercise
testamentory capacity, however, one must
communicate and work with an attorney, which
introduces a professional relationship and some
element of social discourse into the exercise of
this capacity.
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Functional Elements
In the case of testamentary capacity, the
functional elements are best understood as
reflections of the underlying legal elements.
Testamentary capacity is analogous to consent
capacity insofar as it is a highly verbal mediated
capacity with no pragmatic skills or demands
other than a signature on the legal document.
Thus the functional elements inherent to
testamentary capacity would include the
cognitive abilities to generally describe what a
will is, to recall and name potential heirs
(objects of bounty), to describe generally the
nature and extent of assets includable within a
person’s will, and to outline very generally a
potential plan of distribution of assets to heirs.
Cognitive Underpinnings
Given the “purely” cognitive basis of the
testamentary capacity construct, it will be
important over time to identify discrete
cognitive functions that inform each of the legal
(and functional) elements. Marson and
colleagues have done some initial conceptual
work in this area (Marson, Huthwaite, & Hebert,
2004), but true delineation of these cognitive
sources awaits empirical confirmation.
1. Cognitive Functions Related to
Understanding the Nature of a Will
This element requires a testator to
understand the purposes and consequences of a
will, and to express these verbally or in some
other adequate form to an attorney or judge.
Possible cognitive functions involved may
include semantic memory regarding terms such
as death, property and inheritance, verbal
abstraction and comprehension abilities, and
sufficient language abilities to express the
testator’s understanding. A testator’s signature
on a legal document by itself does not
demonstrate understanding, as a signature is an
automatic procedural behavior not dependent
upon higher level cognition (Greiffenstein,
1996).
2. Cognitive Functions Related to
Knowing the Nature and Extent of
Property
The second legal element of testamentary
capacity requires that the testator remember the
nature and extent of his or her property to be
disposed. As reported earlier, some states differ
in their interpretation of this (Walsh et al.,
1997). Possible cognitive functions involved
here would include semantic memory
concerning assets and ownership, historical
memory and short-term memory enabling recall
of long-term and more recently acquired assets
and property, and comprehension of the value
attached to different assets and property. If the
testator has recently purchased new possessions
prior to his or her execution of a will, then
impairment in short-term memory (the hallmark
sign of early Alzheimer’s disease) can
significantly impact his or her recall of these
items. Testators also must be able to form
working estimates of value for key pieces of
property that reasonably approximate their true
value; it is likely that executive function abilities
play a role here (Marson et al., 2004).
3. Cognitive Functions Related to
Knowing the Objects of One’s Bounty
This legal element requires that the testator
be cognizant of those individuals who represent
his natural heirs, or other heirs who can place a
reasonable claim on the estate. Autobiographical
memory would appear to be a prominent
cognitive ability associated with this element. As
dementias like Alzheimer’s disease progress,
testators may be increasingly unable to recall
family members and acquaintances, leading
ultimately to failures to recognize these
individuals in photographs or even when
presented in person (Marson et al., 2004).
4. Cognitive Functions Related to a Plan
for Distribution of Assets
This final legal element of testamentary
capacity requires that the testator be able to
express a basic plan for distributing his assets to
his intended heirs. Insofar as this element
integrates the first three elements in a
supraordinate fashion, the proposed cognitive
basis for this element arguably represents an
integration of the cognitive abilities underlying
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the other three elements. Accordingly, executive
function abilities are implied as the testator must
demonstrate a projective understanding of how
future dispositions of specific property to
specific heirs will occur (Marson et al., 2004).
Psychiatric and Emotional Factors
Related to Testamentary Capacity
Severe
psychiatric
disorders
like
schizophrenia and bipolar disorder can affect
testamentary capacity in different respects. In
some cases, the level of emotional disturbance
may be sufficient to affect the individual’s
cognitive understanding of one or more of the
legal elements. However, even if an individual
with psychiatric illness can meet the legal
elements for testamentary capacity, the will can
still fail if the psychiatric illness is specific to the
testamentary disposition. Thus, if a testator
refuses to include a child in a will due to a
psychiatric delusion that the child is stealing
from her or trying to injure her, that could be
properly challenged under the insane delusion
doctrine outlined above. The notion here is that
but for the specific delusion, the testator would
be including the child in a will that would meet
the requirements for probate (Marson et al.,
2008b).
Diagnostic Considerations
As a cognitively mediated capacity,
testamentary capacity is sensitive to a variety of
medical conditions that affect cognitive and
behavioral functioning. Medical conditions that
impair
testamentary
capacity
include
neurodegenerative disorders like Alzheimer’s
disease and Parkinson’s disease, acquired
neurological injuries like traumatic brain injury,
and developmental disorders, such as mental
retardation and autism. In addition, as discussed
above, severe psychiatric disorders like
schizophrenia and bipolar disorder can affect
testamentary capacity in different respects.
There is very little empirical research to date
in the area of testamentary capacity, and none
specific to the effects of different diagnostic
conditions on testamentary capacity. This
remains an area where considerable valuable
research can be done.
Values
The capacity to distribute assets and other
personal possessions following death is an
important right and valued aspect of personal
autonomy in our society. For reasons of public
policy, courts invoke a low legal threshold for
upholding wills and permitting legal transfer of
property after death. Thus, the values and
interests of the testator are given considerable
weight by courts. In assessing testamentary
capacity, as in financial capacity, it is important
to obtain information regarding an individual’s
lifelong values about money, personal property,
and finances. In this regard, important
information can be ascertained by reviewing
prior wills of a testator, which will reflect the
application of his/her values to the assignment of
property to designated heirs. A testator’s radical
departure from prior testamentary value patterns
in a new will, known legally as an “unnatural
will,” may lead a court to consider whether a
testator is suffering from diminished capacity or
from coercion through the effects of undue
influence. As an example, one of the authors
was involved in a case where the testator, a
woman, had predicated prior wills firmly on the
principle of keeping the federal tax
consequences of any will as limited as possible.
In later life, after developing a dementia and
falling under the influence of an unscrupulous
family friend and neighbor, her wills
demonstrated a total disregard for tax
consequences, but a remarkable attention to the
financial needs and benefits of the neighbor.
This will was challenged on grounds both of
impaired testamentary capacity and undue
influence, and the change in the testator’s value
assumptions underlying the new will became a
key argument for the party challenging the
validity of that will.
Risk Assessment
The financial stakes are very high with
respect to will transfers of assets, which can
involve substantial monetary amounts. The
number of will contests has increased
significantly in the past 20 years, due to factors
such as the increase in blended families and
associated conflicts in family agendas, and the
enormous transfer of wealth currently occurring
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between the World War II generation and the
Baby Boomer generation (estimated at anywhere
between $6 trillion and $16 trillion). The low
legal threshold applied for upholding
testamentary capacity has as its inevitable
counterpart the increased risk that a cognitively
impaired testator will make an inappropriate or
unintended disposition, or be subjected to undue
influence in which testamentary intent is
supplanted by the will of the influencer. As a
practical matter, it is crucial that family
members take steps to ensure that a cognitively
impaired
older
adult
family
member
(prototypically, the widow who insists on living
alone and resists any outside help) is supported
and protected in her financial and testamentary
activities. This can be a delicate matter for
families, but, in general, a level of concern is
justified given the rampant financial exploitation
of older adults that is occurring nationwide.
Steps to Enhance Capacity
Due to its cognitive basis and relatively
modest cognitive demands, testamentary
capacity is a capacity that can be readily
supported or enhanced. All of the elements of
testamentary capacity can be discussed ahead of
time with the testator, and relevant material such
as potential heirs or assets/possessions can be
rehearsed prior to will execution. As part of such
support efforts, it is important to ensure
throughout the process that the testator is acting
in a voluntary way and is not subject to direct or
indirect coercion or influence.
An assessment of the patient’s awareness of
cognitive deficits can be an important part of the
task of enhancing capacity. There is an ethical
imperative to preserve and support autonomous
decisions of the patient wherever possible. An
individual’s awareness is often critical to how
well he or she might be able to compensate for
cognitive deficits. That is, those individuals with
a significant lack of awareness will not see any
need to try and compensate for deficits, whereas
those individuals with awareness will be open to
compensatory strategies. Thus the clinician
should investigate the patient’s awareness of
deficits and openness to potential compensatory
strategies. In their 1997 practice guideline on
capacity assessment for psychologists in the
Veterans Affairs system, the authors noted the
importance of assessing awareness of deficits
(U.S. Department of Veterans Affairs, 1997).
Clinical Judgments of
Testamentary Capacity
Similar to financial capacity, there are
currently no published studies of clinician
judgments of financial capacity known to the
authors. There are also no empirically validated
assessment instruments currently available. A
testamentary capacity information collection
form was developed by attorney Baird Brown
and co-authors (Walsh et al. 1994). At the
present time, judgments of testamentary capacity
are based on subjective clinical judgment and
experience using patient and collateral interview
information, inventories of patient assets and
potential heirs, and more or less structured
evaluations of cognitive and psychiatric
functioning. Valuable recommendations for
conducting clinical assessments of testamentary
capacity has been offered by forensic
psychiatrists (Spar & Garb, 1992; Shulman et
al., 2007).
Judgments of testamentary capacity can be
framed using the categorical outcomes of
capable and incapable, and in certain instances
marginally capable. The evidence regarding
each legal (functional) element should be
detailed, including comparisons of the testator’s
belief and knowledge with actual externally
confirmed accounts of heirs and asset
possession. The potential outcome of marginally
capable may be important in some cases of
prospective assessment where the testator’s
capacity is borderline as a result of cognitive,
psychiatric, or other medical conditions, but
nonetheless may be supportable in various ways.
Clinical Approaches to Assessing
Testamentary Capacity
Clinical consultation regarding testamentary
capacity can substantially inform the way in
which attorneys and judges understand and
determine legal issues of testamentary capacity.
The roles of clinicians in cases of testamentary
capacity include informal consulting with
attorneys about adults with questionable
capacity, contemporaneous clinical evaluations
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of testamentary capacity prior to will execution,
and retrospective evaluations of testamentary
capacity in cases involving a now deceased or
incapable testator, discussed in turn below
Functional Assessment Instruments
There are no empirically validated
standardized instruments to assess testamentary
capacity.
Consultation Regarding
Testamentary Capacity
An attorney may choose to consult with a
clinician prior to, or instead of, seeking a formal
clinical assessment. In this situation, the
clinician provides an informal opinion regarding
testamentary capacity based solely on adult
observations and information provided by the
attorney. The clinician may also identify
concerns or issues that the attorney may have
overlooked, as well as suggest strategies for
enhancing testamentary capacity. Clinical
consultation may assuage an attorney’s concern
regarding an adult’s testamentary capacity, or
justify pursuing a formal clinical evaluation of
testamentary capacity.
Contemporaneous Clinical Evaluation of
Testamentary Capacity
In certain circumstances the testator, or
his/her attorney or family member, may request
that a clinician assess the testator’s testamentary
capacity prior to will execution. Two scenarios
are common to such a referral. The attorney may
have concerns about testamentary capacity and
desire clinical expertise and input on the issue
before proceeding further. Alternatively, in cases
of ongoing or anticipated family conflict, the
attorney may seek to preempt a future will contest
by having an assessment of testamentary capacity
conducted as part of the will execution.
Contemporaneous
evaluations
of
testamentary capacity are multi-faceted and
involve (1) collecting relevant data regarding the
testator’s assets, potential heirs, and general
cognitive and everyday functioning from
collateral sources (i.e., a spouse, other family
members, and friends), (2) conducting a
comprehensive mental status examination of the
testator to identify cognitive and psychiatric
impairments
that
may
interfere
with
testamentary capacity, and (3) completing a
thorough clinical interview of the testator that
assesses testamentary capacity according to the
above legal criteria. Spar and Garb have
proposed a valuable semi-structured interview
approach that clinicians can use to structure an
interview regarding testamentary capacity (Spar
et al., 1992) (see also Shulman et al., 2007).
Because the validity of a will is dependent upon
the testator’s capacity at the specific time that
the will is executed, clinicians should conduct
evaluations of testamentary capacity as close to
the time of will execution as possible (Marson et
al., 2008b).
Retrospective Evaluation of
Testamentary Capacity
Although contemporaneous assessment of
testamentary capacity is highly desirable,
retrospective evaluations probably represent the
majority of these forensic assessments.
Retrospective evaluations arise after the death or
incompetency of a testator, when potential heirs
or other parties contest a will on grounds that the
testator lacked testamentary capacity at the time
that the will was executed. Retrospective
evaluations of testamentary capacity are based
upon a thorough record review and information
obtained from the testator’s family, friends,
business associates, and other involved
professionals
(often
through
deposition
testimony). Primary attention is given to
gathering
evidence
of
mental
status,
neurobehavioral, and everyday functional skills
occurring as close as possible to the date that the
will was executed. Relevant personal records
include the testator’s business records,
checkbook and other financial documents, and
personal documents (e.g., letters, diaries, family
films or videos, etc.). Medical records can yield
particularly useful information, including mental
status, behavioral observations, diagnosis, level
of impairment, dementia stage (if applicable),
and psychological test results. Clinicians may
also find it beneficial to interview the testator’s
surviving family, friends, business associates,
and other involved professionals regarding the
testator’s cognitive and functional abilities at the
time that the will was executed.
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Ultimately, the clinician must assemble all
of this information and retrospectively determine
whether or not the testator clinically had
testamentary capacity at the prior relevant legal
time point(s). In some cases it may not be
possible to render such a judgment, if there is
insufficient evidence of the testator’s cognitive,
emotional,
and
functional
abilities
contemporaneous with the prior will execution.
With respect to both contemporaneous and
retrospective
forensic
evaluations
of
testamentary capacity, it is important to
emphasize that the clinician’s opinions regarding
testamentary
capacity
represent
clinical
judgments that the court may consider and
weigh in arriving at a dispositive legal judgment
of testamentary capacity (Marson et al., 2008b).
5.
6.
Recommended Steps in Conducting a
Retrospective Evaluation of
Testamentary Capacity
1
Identify the operative legal standard for
testamentary capacity in your state
jurisdiction. For example, in Michigan there
are three criteria (Persinger v. Holst, 2001
Michigan Court of Appeals):
a. to comprehend the nature and extent
of his or her property,
b. to recall the objects of his or her
bounty, and
c. to determine and understand the
distribution of his or her property.
2. Organize medical, legal, and other records
relevant to the capacity issue. Creating a
chronological timeline reflecting important
medical and lay contacts, and relevant legal
transactions, is essential to organizing the
information an expert is asked to review.
3. Where possible, contact and speak with
individuals who knew the decedent testator
and can offer informed lay judgments about
mental status at the time of will execution.
4. Obtain information about the attorneys
involved in the will execution. Who was the
attorney and what history did he or she have
with the adult? Was there a single discussion
about the will between the adult and
attorney or multiple discussions? Did the
7.
8.
attorney make notes at the time the will was
created or changed?
Assess for the presence and severity of a
mental disorder at the time of will execution.
With older adults, the most often disputed
wills are those that were made or modified
when an individual had a memory disorder
or a diagnosed dementia. Is there evidence,
through medical records, of a mental
disorder that might affect cognitive and
emotional abilities related to the elements of
testamentary capacity? In some cases, there
may be specific neuropsychological test
information that will shed light on mental
capacity relevant to testamentary capacity.
In cases of dementia, seek to determine the
stage of dementia as it can significantly
inform the clinical judgment of testamentary
capacity. The Clinical Dementia Rating
(CDR) (Morris, 1993) represents one such
dementia staging tool. Because the legal
threshold for testamentary capacity is low,
an individual with mild dementia may still
be capable of making a new will, whereas a
patient with more advanced dementia may
no longer recognize the objects of his
bounty, or know the nature and extent of his
property. However, as discussed throughout
this handbook, every capacity matter is
individual-specific and, irrespective of
dementia stage, requires an analysis of the
individual’s mental status and condition in
relation to the particular jurisdictional
elements for testamentary capacity.
Assess testamentary capacity by determining
whether there is clinical and other evidence
in the record supporting the critical legal
elements of this capacity. In some cases
there may be insufficient evidence in the
record to support a clinical judgment of
testamentary capacity.
In addition to offering a capacity judgment,
a psychologist or other expert is often wellpositioned to offer a retrospective opinion
regarding the possible role of undue
influence in will procurement. Most will
contest cases will involve an associated,
alternative legal claim of undue influence,
with the contention that even if the testator
possessed residual testamentary capacity, it
was supplanted by the actions of a third
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party influencer. Undue influence
discussed in more detail in Chapter 7.
is
Case Study of Prospective Assessment
of Testamentary Capacity
I.
Referral and Background Information
Ms. Milton was referred as an outpatient to
the Clinical Neuropsychology Laboratory by Dr.
Psychiatrist for evaluation of testamentary
capacity.
History of Present Illness: Ms. Milton has
been followed by Dr. Psychiatrist for treatment of
anxiety and depression. She has decided to make
changes in her will and wants to ensure that the
new will will not be challenged. Dr. Psychiatrist
recommended that she have a formal evaluation to
assess testamentary capacity, and referred her to
the Clinical Neuropsychology Laboratory.
In interview with the examiners, Ms. Milton
denied significant changes in cognitive
functioning. She acknowledged occasionally
losing her train of thought, but denied memory
loss that interferes with her daily life. She also
denied difficulties with language, visuospatial,
motor, or sensory function.
Ms. Milton denied significant changes in her
daily functioning and in her emotional state. She
reported that she cooks, does chores, and babysits
her granddaughter. She denied depression and
stated that she was feeling pretty good. Ms. Milton
acknowledged anxiety regarding the sale of the
family business.
In the interview, Ms. Milton responded
appropriately and knowledgeably to questions
regarding testamentary capacity. She defined a
will as the “distribution of property of a person
who is deceased according to their wishes.” She
provided a comprehensive description of her
property and assets, which appeared informed and
accurate. Ms. Milton also provided a complete list
of her immediate descendants and potential
beneficiaries of her will. She described her
planned division of her estate into four equal
shares for her husband, son, daughter, and her
granddaughter (daughter’s child). She indicated
that she was not planning to include her grandson
(son’s child) in the will, but provided a clear and
reasonable explanation. She stated that her
decision was based upon her relationship with this
child.
The patient’s daughter, Ms. Daughter,
reported a similar situation concerning her
mother’s health. She denied changes in her
mother’s memory, language, visuospatial, motor,
and sensory function. She reported that her mother
shows good judgment in everyday activities. Ms.
Daughter stated that her mother picks up her
granddaughter from preschool every day and has
no problems with babysitting her. Ms. Daughter
also indicated that there has been no change in her
mother’s activities around the house and she
continues to cook, perform small chores, read, and
manage her checkbook. She reported that her
mother does not currently appear to be depressed.
Prior Medical History: The patient’s medical
and surgical history is reportedly positive for
tuberculosis and removal of the upper lobe of her
right lung (age 16), hysterectomy (1970),
cholecystectomy, breast cancer with right radical
mastectomy (12-14 years ago; there has been no
recurrence); and hospitalization for acute
bronchitis (19xx). Ms. Milton also reported
bladder
incontinence,
kidney
problems,
diverticulitis, ulcers (which she attributed to stress
regarding her children and her business), and
multiple hospitalizations for tachycardia. She
reported breaking her wrist in the early 19xxs. She
indicated that she had an adverse reaction to the
anesthesia and “died on the table.” Ms. Milton
reported respiratory difficulty since that time. She
also reported initial memory difficulties that
resolved over time. Family history is reportedly
positive for cancer (father), ulcers (father), and
circulatory problems (mother). The patient’s
mother reportedly experienced cognitive changes
following a limb amputation.
Psychiatric History: Ms. Milton’s history is
positive for inpatient and outpatient psychiatric
treatment. She reported seeking treatment for
depression following her hysterectomy and the
illness of her parents (approximately 1970). Ms.
Milton indicated additional treatment for
depression following her father’s death in the mid1970s. In 19xx she reportedly intentionally
overdosed on sleeping pills, came close to dying,
and was hospitalized for psychiatric treatment.
She reported approximately five inpatient
hospitalizations,
including
treatment
for
depression and dependence on sleeping pills and
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pain medication. Ms. Milton reportedly saw Dr.
Shrink for many years in the 1980s and early
1990s. She has seen Dr. Psychiatrist for
depression associated with her hospitalization in
1996, family difficulties, and dependence on
prescription medications.
Medications: Verapamil, Atenolol, Propulsid.
Social/Academic/ Occupational History: Ms.
Milton is an only child who inherited the family
funeral home. Her husband managed the business
after her father died. Her son, Mr. Son, is currently
managing the business, although her husband
remains active in the business. Ms. Milton’s
daughter also works in the family business. Ms.
Milton has been approached about selling the
funeral home and there has been some family
disagreement regarding the sale. The patient
reported anxiety regarding the sale and distress
that her children do not get along well. Ms. Milton
also described a close relationship with her
granddaughter (Ms. Daughter’s daughter) and
reported frequent contact with her. She stated that
she does not often see her grandson (Mr. Son’s
son) and indicated some conflict with her
daughter-in-law.
Ms. Milton reportedly completed 12 years of
education with an overall grade average of “A.”
She is the owner of her family business.
II. Behavioral Observations
Ms. Milton presented as a nicely dressed and
well-groomed 66-year-old Caucasian female. She
was accompanied to the evaluation by her
daughter.
In the interview, speech was goal oriented and
responsive, but mildly slurred with strained and
hypernasal vocal quality. These speech difficulties
are probably attributable to dentures and Ms.
Milton’s history of respiratory difficulty. Affect
was full. Mood was pleasant, but somewhat
serious and anxious. The patient appeared candid
and forthright.
In the testing, Ms. Milton was alert and
pleasant. Some mild performance anxiety was
noted, but the patient responded appropriately to
encouragement
and
handled
frustration
appropriately. No expressive or receptive
language difficulties were noted. There was no
loss of task, cognitive rigidity, or spoiling. There
were a few perseverations and intrusions.
Ms. Milton appeared to put forth a good effort
throughout the testing. The current results appear
to be a valid representation of her current level of
cognitive and emotional functioning.
III. Tests Administered
Aphasia Series
Apraxia Series
Beck Depression Inventory
Benton Visual Form Discrimination Test (VFDT)
Boston Naming Test (BNT)
California Verbal Learning Test (CVLT)
Cognitive Competency
Construction Series
Dementia Rating Scale (DRS)
Financial Capacity Instrument (FCI)
Neurodiagnostic Interview
Premorbid Verbal IQ Estimate (Barona)
Shanan Sentence Completion Test (SSCT)
Trails
Visual Series
Wechsler Memory Scale-Revised (WMS-R)
Wechsler Adult Intelligence Scale-Revised
(WAIS-R)
IV. Summary of Test Results
Orientation: Ms. Milton was fully oriented to
person, place, and time.
Attention and Concentration: General
attention and concentration was in the low average
range for age group (23th %ile). Simple
visuomotor tracking was in the low average range
for age, sex, and educational level (27th %ile).
Auditory attention was in the high average range
for digits forward (83th %ile) and in the mildly
impaired range for digits backward (9th %ile).
Visual attention was in the low average range for
forward sequencing (17th %ile) and backward
sequencing (21th %ile).
Language: Spontaneous speech was mildly
slurred with strained and hypernasal vocal quality.
Confrontation naming was in the average range
for age (44th %ile).
Simple auditory comprehension was intact.
Reading comprehension was generally intact
relative to a neurologically intact geriatric sample.
Memory Function: Short-term verbal memory
fell in the high average range for age group (81st
percentile). Delayed recall (30-minute) for verbal
material was also in the high average range (75th
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percentile), with 81% retention of learned verbal
material.
Short-term visual memory was in the average
range for age group (68th percentile). Delayed
recall (30-minute) for visual material was in the
moderately impaired range for age group (1st
percentile), with no retention of learned visual
material. Ms. Milton appeared to have difficulty in
recognizing which visual patterns she was
required to reproduce.
High-load verbal acquisition was in the mildly
impaired range (4th percentile). Short-term recall
(5 minute span) and delayed recall (20 minute
span) were in the low average range. Semantic
cueing enhanced recall from mildly impaired to
intact performance. There were a few
perseverations and intrusions. Recognition
memory was intact.
Visuospatial Function: Simple visual field
perception was intact. Visual form discrimination
was in the mildly impaired range with peripheral
and rotation errors.
Visuospatial construction for simple and
complex geometric figures was intact. Block
construction fell in the average range for age
(25%ile).
Fine Motor Functioning: Bimanual motor
planning was intact. Simple and complex
ideomotor hand functioning was intact bilaterally.
Intelligence
and
Higher
Cognitive
Functioning: The patient obtained a WAIS-R
Verbal IQ of 105, which placed her current level
of verbal intellectual functioning in the average
range for age (63rd percentile). This score was
comparable to a premorbid estimate of 106
(Barona).
The patient obtained a WAIS-R Performance
IQ of 93, which placed her current level of
nonverbal intellectual functioning in the average
range for age (32nd percentile). This score was
somewhat lower than expected from a premorbid
estimate of 104 (Barona).
The patient obtained a WAIS-R Full Scale IQ
of 100, which placed her current level of
intellectual functioning in the average range for
age (50th percentile). This score was comparable
to a premorbid estimate of 105 (Barona).
Mental Flexibility and Executive Function:
On a test of visuomotor tracking and set
flexibility, the patient performed in the mildly
impaired range (7th percentile). The patient’s
spontaneous clock drawing indicated possible
very mild impairment in executive functioning.
Ms. Milton had slight difficulty in placing the
clock hands and distributing numbers around the
clock face.
Social Comprehension and Judgment: On a
cognitive measure of everyday problem solving,
Ms. Milton demonstrated mildly impaired
functioning, relative to a neurologically intact
geriatric sample. Incorrect responses reflected
some insensitivity to threats to personal safety.
General conceptual comprehension was in the
high average range (85th percentile).
Financial Capacity: On a measurement of
financial capacity, Ms. Milton demonstrated mild
impairment in small cash transactions, relative to a
neurologically intact geriatric sample. Financial
judgment was in the low-average range. Basic
monetary skills, financial conceptual knowledge,
checkbook management, and bank statement
management were intact.
Personality Functioning: On a self-report
inventory of depressive symptomatology, Ms.
Milton endorsed symptoms of self-criticism,
concern about physical appearance, decreased
motivation, fatigue, and somatic concerns.
Overall, her responses did not indicate the
presence of significant depression.
On a semi-projective sentence completion
test, Ms. Milton demonstrated coping mechanisms
that were primarily active (When she saw that
others did better than she: “she decided to try
harder”; When she was attacked she: “fought
back”). Responses reflected a variable self
concept (People think I: “am fat”; She often thinks
she is: “very happy”). Ms. Milton’s responses also
indicated aims and frustrations that were primarily
externally directed.
V. Impression
1. Generally intact cognitive and emotional
functioning for age, education, and
occupational attainment (DRS = 140/144),
with isolated cognitive deficits.
The neuropsychological test results
indicated
generally
intact
cognitive
functioning. The patient’s performance
indicated intact functioning across domains of
language, short-term memory, visuospatial
construction, fine motor functioning, and
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intellectual functioning. There were isolated
mild deficits in high-load verbal acquisition,
visual form discrimination, and mental
flexibility, moderate impairment in delayed
visual memory, and possible decline in
attention/concentration. Ms. Milton also
demonstrated some mild deficits in functional
abilities indicating some insensitivity to
threats to personal safety, and difficulties with
small cash transactions and financial
judgment.
The interview and psychological testing
also revealed adequate emotional functioning.
Ms. Milton denied depression during
interview and on a self-report inventory. She
acknowledged anxiety surrounding the sale of
her business, but this did not appear to be
affecting her overall functioning.
2. Probable intact testamentary capacity.
The patient demonstrated sufficient
specific knowledge of the testamentary
process to indicate current capacity to make a
will. She provided an adequate description of
the function of a will. She produced a
reasonable account of her property and listed
those relations whose interests would be
affected by her will. She produced coherent
and adequate reasons for the inclusion and
exclusion of relations in her will.
The
neuropsychological
and
psychological testing also supported the
patient’s testamentary capacity. The patient
demonstrated intact functioning on a dementia
screen and overall intact cognitive
functioning. There were isolated cognitive
deficits, but they did not suggest a dementing
process and should not interfere with the
patient’s ability to prepare a will. There was
also no evidence of psychiatric problems
sufficient to interfere with the patient’s
testamentary capacity.
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Driving Capacity
Introduction
Regarding Americans and driving, Marshall
McLuhan in 1964 said, “The car has become an
article of dress without which we feel uncertain,
unclad, and incomplete” (McLuhan, 1964). As
this quote indicates, driving is a central and
longstanding characteristic of American culture.
On average, nationwide, drivers learner’s
permits are allowed starting at age 14 with a
provisional license by age 16, followed with a
full license by age 18. Once a full license is
attained the Department of Motor Vehicles
(DMV),2 or other designated state motor vehicle
department, does not take away an individual’s
drivers license upon reaching a certain age.
Although there is variability across states in
older driver re-licensing laws, the license to
drive is generally dependent on a person’s
mental and/or physical condition and ability to
follow traffic laws and rules, regardless of age.
(http://www.agingsociety.org/agingsociety/links/
driverLicense.html).
A person’s cognitive and physical ability to
drive is usually questioned when there is a
recent history of a stroke, brain injury, presence
of a progressive dementia, history of increased
citations, and development of epilepsy or other
neurological conditions that could negatively
affect driving ability. For instance, in California,
a reexamination of driving ability can be
prompted by reports made by professionals, such
as physicians, emergency technicians, and peace
officers who become aware of an individual
having a physical or mental condition associated
with loss of consciousness or control or
behaviors suggestive of unsafe driving.
Laws vary by state in terms of who can
make a report. In some states physicians and
surgeons are required to notify the state’s motor
vehicle department of certain conditions and
2
States differ in the name of the agency that regulates
driving. In this handbook the term “Department of
Motor Vehicles” or “DMV” will be used to apply to
any such state agency.
disorders, and it is up to their discretion to report
other conditions that could impact an
individual’s ability to drive. In other states,
health care providers are not allowed to contact
state agencies with private health information.
Whether or not psychologists are mandated or
allowed reporters also will vary from state to
state. In most states, family and peers can file
reports to the state motor vehicle department if
they believe that a person is no longer safe to
drive. In summary, some state motor vehicle
departments allow for both professionals and
non-professionals to notify them of individuals
whose driving privileges need to be reexamined.
It is up to the discretion of the DMV or other
designated state motor vehicle department to
determine what action will be taken. Readers are
referred to their state DMV for further
information on notification process and
regulations.
Increasingly, psychologists are being asked
to partake in the evaluation of an older
individual’s capacity to drive and to assess the
various components that contribute to driving.
The license to drive is dependent on both
physical and mental abilities that affect the
ability to follow traffic laws and rules.
Therefore, an evaluation should assess: (1) a
person’s physical ability to drive; (2) cognitive
ability to understand not just driving rules, but
how to properly drive a car; (3) cognitive ability
to implement knowledge of driving-related
information; and (4) psychiatric,substance use,
and emotional factors that contribute to driving.
It is essential to know if an individual has a
history of risk-taking behavior, aggressive
driving, and use of drugs or medications that
could affect driving (Schultheis, 2007).
Additionally, anxiety about driving, as well as
overconfidence in one’s driving abilities can
impact
driving
capacity.
Ideally,
a
comprehensive driving evaluation should
include a medical evaluation, complete
psychological evaluation, and driver specialist
evaluation.
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A psychologists role may vary depending on
the setting.
A psychologist may make a
recommendation after reviewing the driver
specialist evaluation, or the driver specialist may
make a recommendation after reviewing the
psychological test results, or a physician may
utilize both the psychological test results and the
driver specialist evaluation results to provide a
recommendation.
and to discern a safe from a dangerous driving
situation. Additionally, functional visual field
declines with age and has been found to
correlate with crash data in older drivers
(Owsley et al., 1998). Clearly, visual acuity
plays an essential role in driving capacity.
Psychologists should therefore inquire about last
eye examination, medical conditions that could
affect vision (e.g., diabetes), and refer to an eye
clinic if necessary.
Legal Elements/Standards
Capacity to drive a motor vehicle and
grounds for revoking the privilege are
established by state motor vehicle laws. While
variations in the law are common, the Uniform
Vehicle Code provides a fairly representative
norm. It provides that no license shall be issued
when the commissioner has good cause to
believe that a person “by reason of physical or
mental disability would not be able to operate a
motor vehicle with safety upon the highways”
(National Committee on Uniform Traffic Laws
and Ordinances, 2000).
The tremendous variety of physical, mental,
and emotional impairments that can result in an
inability to operate a motor vehicle safely results
in substantial assessment variability, but
regardless of the nature or source of impairment,
the legal standard ultimately looks at its practical
impact on the individual’s ability to operate a
motor vehicle with reasonable and ordinary
control.
Functional Elements of Driving
Capacity
Driving capacity involves more than a
person’s knowledge about driving and cognitive
abilities to participate in the driving task, but
also the individual’s ability to participate in
driving despite potential physical frailty or other
limited abilities.
1. Visual Acuity
Has it become difficult for the person to read
signs, estimate distance, or differentiate a pole
from a person standing at the intersection
preparing to cross? Visual acuity is necessary in
order to be able to navigate and not get lost, to
be aware of changes in one’s route (e.g., detours,
construction, etc.), to be aware of speed signs,
2. Flexibility and Strength
Injuries, decreased activity, and various
medical conditions (e.g., arthritis) could
potentially affect a person’s flexibility and
strength. Neck and shoulder pain or lack of
flexibility could limit a driver’s ability to swivel
and glance over their shoulder to quickly check
their blind spot before changing lanes.
Decreased strength or sensation in hands could
change a driver’s ability to hold onto and control
the steering wheel considerably during both
routine and emergency driving situations.
Decreased sensation, strength, and coordination
in legs and feet could potentially result in
difficulties using the brakes, the accelerator, and
the clutch, especially during unexpected
situations.
3. Reaction Time
Reaction time is known to slow with age and
may impact driving abilities. For example,
reaction time can impact driving by slowing
response time when faced with an expected
situation (e.g., a ball rolling out in front of the
car), to determine what the necessary driving
response should be (e.g., brake, swerve, slow
down), to plan the action (e.g., step on brake,
turn steering wheel, take right foot off of the
accelerator), and to implement it. Changes in
visual acuity, flexibility, strength, as well as
normal changes in processing speed associated
with aging will all affect a driver’s reaction time.
Older adults with mobility issues or certain
neurological conditions are at heightened risk
for slowed reaction time.
4. Knowledge
An individual needs to demonstrate
knowledge of the rules of the road and the
potential consequences of not obeying the rules
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(e.g., tickets, incarceration, and injury to self or
others). A driver should be able to demonstrate
knowledge of basic automobile functions and
what to do in emergent situations (e.g., driving
in rain versus snow, which way to turn in a skid,
why is tire pressure important).
5. Appreciation of Medical Diagnosis
An individual needs to appreciate how
medial conditions may impact driving ability.
The person should be able to identify, if viable,
potential ways to safely compensate for
foreseeable weaknesses.
6. Judgment
A driver needs to demonstrate judgment in
driving situations. Ascertaining abilities to
handle hypothetical situations, such as “What
would he or she do if there was a flat tire? How
does he or she handle frustration while on the
road and that of other drivers?” may yield
helpful insights.
7. Driving Efficacy
Assessing the person’s level of confidence
in his or her own driving ability can provide
valuable information regarding functional
driving capacity. One might ask about
confidence level in terms of vision in the day or
night, comfort with freeway driving, strength
and ability to make sharp turns, and/or to
respond to situations requiring a rapid response.
Diagnostic Considerations
Various medical conditions could potentially
affect driving ability. These include, but are not
limited to: musculoskeletal disorders, sensory
disorders, arthritis, dementia, psychiatric
disorders, stroke, sleep apnea, and substance
use. Dementia, for instance, can impair memory,
as well as attention, visual spatial abilities,
language abilities, and judgment. Additionally,
medical conditions that are associated with
abrupt changes in cognition, such as epilepsy,
diabetes, or heart disease, can place an
individual at higher risk for a motor vehicle
accident (Waller, 1980). A close review of
medications is critical as many prescription
drugs can be sedating and impair driving ability.
Medications known to impair driving include:
opioids,
benzodiazepines,
antidepressants,
hypnotics,
antipsychotics,
antihistamines,
glaucoma
agents,
nonsteroidal
antiinflammatory drugs, and muscle relaxants (Carr,
2000). Medical and psychological diagnosis,
along with medications used to treat these
conditions, need to be a component of the
driving capacity evaluation, but do not
necessarily automatically negate an individual’s
ability to drive.
Cognitive Underpinnings
There is a well-developed domain of
research to draw upon in terms of cognitive
underpinnings of driving abilities. Consistent
evidence has supported the notion that driving
performance in older adults is related to visual
attention and processing speed (Lee, Lee, &
Cameron, 2003; Roenker, Cissell, Ball, Wadley,
& Edwards, 2003). Changes in functional visual
field, that area from which a person can attain
visual information in a quick glance (Sanders,
1970) has received particular interest. The
useful-field-of-view (UFOV) test is a measure
commonly used to assess functional visual field
by testing visual processing speed and visual
attention during higher order processing tasks.
Studies have found a relationship between
performance on UFOV tests and future at-fault
motor vehicle accidents (Owsley et al., 1998;
Ball et al., 2006). The size of the functional
visual field has been found to be affected by
visual sensory function, delays in processing
ability, difficulties with divided attention, and
inability to ignore distracters (Owsley, Ball, &
Keeton, 1995; Ball, Roenkel, & Bruni, 1990). It
is therefore considered a key cognitive
component to driving ability.
Other important cognitive mechanisms
associated with driving difficulties include
impaired memory, impaired visual acuity,
decline in peripheral vision, and decreased
ability to perform two tasks simultaneously
(McGwin, Chapman, & Owsley, 2000; Bravo &
Nakayama, 1992; McPeek & Nakayama, 1995).
Cognitive abilities can be negatively
impacted by substance abuse, as well as a
variety of medical conditions and medications,
and the impairments can range from mild to
severe, and can be progressive, permanent, or
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reversible (e.g., medication side-effects). It is
therefore essential to assess cognition and attain
a thorough history to identify potential variables
that could be impacting cognitive abilities
associated to driving.
Psychiatric and Emotional Factors
There are various psychiatric and emotional
factors that can affect driving abilities.
Symptoms related to psychosis, such as
delusions, hallucinations, and disorganized
thinking, can potentially lead to risky driving
behavior due to the person misinterpreting their
environment and behaving erratically. Anxiety
and medications to treat anxiety can both
influence a person’s physical and mental ability
to drive. For instance, anxiety can increase
muscle tension, distort the environmental data
that the driver attends to, and lead to poor
decisions
regarding
necessary
driving
maneuvers (e.g., I am in the far left lane and I
need to make a right turn on this street?).
Medications for anxiety can cause a dangerous
level of muscle relaxation that can impede the
ability to drive or cause sedation. Depression
can lead to fatigue, decreased sleep, and
problems focusing and making decisions, all of
which can have negative effects on driving
ability. Additionally, being sleep deprived can
lead to increased risk for motor vehicle accidents
due to drowsiness. Medications to address sleep
deprivation may also negatively affect driving
ability if taken incorrectly.
Abuse of prescription and non-prescription
drugs may go undetected. Pain medicine, for
instance, can be abused and influence driving
ability. Use of amphetamines or other stimulants
should also be considered. The abuse of alcohol
is obviously a major concern for driving. Older
adults are more likely to be on prescription
medications and if these are combined with
alcohol it could alter cognition and increase the
effects of alcohol to a greater degree than
drinking alcohol alone, making driving more
dangerous. The effects of long-term heavy
alcohol use, such as cerebellar degeneration,
polyneuropathy, amblyopia, and alcohol
dementia, can begin to develop or become
intensified, and gradually increase impairments
in driving. Clearly, a thorough assessment of
mental health problems and substance use is
necessary to identify potential driving
complications.
Values
Society’s value on driving and independence
can cloud not just the adult’s judgment but that
of the clinician who is trying to be benevolent.
From a psychological perspective driving
represents independence and vitality. Socially,
an individual that drives has a broader scope of
social and financial resources, and can be more
active in the community. Driving can be a
source of self-esteem, as people may equate the
need to be driven to being a burden or being
useless. For some, the inability to drive can be
perceived as an enormous loss in life and can
greatly influence their view of self and can lead
to increased mental health problems (Marottoli
et al., 1997).
Driving cessation in older adults has been
associated with depression and diminished outof-home activities, as well as increased caregiver
stress (Foley, Harley, Heimovitz, Guralnik, &
Brock, 2002; Marottoli et al., 1997; Marottoli et
al. 2000; Azad, Byszewksi, Amos, & Molnar,
2002). Individuals who have to stop driving
report that an inability to participate in leisure
activities is the domain most impacted by loss of
the driver’s license (Azad et al., 2002). It is
therefore important for clinicians to monitor a
person’s reaction and identify sources of support
if driving abilities are suspended. Working with
the adult and the family or friends (if available)
to identify feasible transportation options is
essential in order to decrease caregiver burden
and to promote as much continued independence
for the adult as possible.
The value placed on driving will also
depend on where the individual lives.
Communities vary, and those individuals who
live in areas with good public transportation may
be more comfortable with the idea of giving up
driving than someone who is completely reliant
on their car for everyday necessities and
socializing.
A number of technologies may support older
adults who continue to drive. These
developments may include automatic braking
systems to minimize unnecessary accelerating,
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navigation systems, climate controls to keep the
driver alert, and a system that goes beyond the
car by using a Global Positioning System (GPS)
with an Intelligent Transportation System (ITS)
to send information to vehicles when a
pedestrian is nearby. Driving safety must be
evaluated within the context of the owner’s
current vehicle.
Notably, many older drivers show concern
and insight into driving habits and self regulate
by driving only during the daytime, driving
slower, or limiting driving to shorter or nonhighway distances. Actively involving the
elderly adult in planning for future driving
limitations and cessation may help to reduce the
negative effects that a sudden and mandatory
loss of driving privilege could have. For more
information on advance care planning for
driving changes see the Alzheimer’s Association
Web site at : http://www.alz.org/living_with_alzheimers_driving.asp
Risks
An example of the grave social and
personal dangers that at-risk drivers pose is the
July 16, 2003, case in Santa Monica, California,
in which an 87-year-old driver drove his car into
a crowded farmer’s market, killing 10 people
and injuring 63 more. Police investigations
indicated that the driver hit the gas pedal instead
of the brake and that the car was actually
stopped by the body of a victim that was trapped
underneath the car (www.cnn.com/2004/LAW/01/05/farmer.market.crash).
Drivers age 16-20, followed by those age
21-34, have the highest rates of traffic fatalities.
As a group, drivers age 65 and older drive fewer
miles than other age groups, but pose the next
greater risk for injury or fatality in motor vehicle
accidents. Among older adults, the risk for
driving injury and fatality increases with age.
Dellinger, Sehgal, Sleet, and BarrettConnor (2001) found that among elderly drivers
who had stopped driving within the past five
years, the majority did it for medical reasons.
Interestingly, however, those who stopped
driving had fewer medical problems than those
who continued to drive, suggesting that
accumulation of medical problems alone is not
the determining factor in the decision to stop
driving and that perhaps overall health or
functional ability played a greater role in the
decision. Okonkwo, Crowe, Wadley, Ball (2008)
examined self-regulation of driving for older
adults with varying functional abilities and
found that a significant portion of high-risk
drivers did not restrict their driving. Their
findings point to the probability that for many
older individuals, the value of driving outweighs
the potential risks of unsafe driving due to
decreased functional abilities.
Clearly, there are many variables that go
into the life-altering decision to stop driving.
The significant benefits and risks of continued
versus cessation of driving need to be well
thought-out when considering a decision to limit
or stop driving for older adults who are
experiencing medical, physical, and functional
declines that are adversely affecting driving.
Steps to Enhance Driving Capacity
Several options are available for individuals
who present with limited driving capacity. For
instance, if the concern is primarily physical
limitations due to hemiplegia or weakness, a car
can be modified to accommodate the driver
(e.g., creating a left foot accelerator or a car that
can be driven with just the use of one’s hands).
A review of treatable or reversible conditions
affecting driving capacity, such as a mood
disorder or medications, should also be
conducted. Another possibility is to limit the
license to driving a certain route or only under
certain conditions. In some cases, extended
driver’s training with a Driver Rehabilitation
Specialist (DRS) or refresher courses for older
drivers (e.g., AARP Driver Safety Program,
http://www.aarp.org/families/driver_safety/)
may also be an option. Studies have found also
that training in speed-of-processing, as assessed
by the useful-field-of-view (UFOV) test,
correlated with improvements in driving on
simulator measures and during driving
evaluation (Roenker et al., 2003).
Clinical Judgment of Driving Capacity
Clinical judgment of driving capacity will
include the safety of the driver and the
community, as well as the psychological benefits
and risks of permanent loss of driver’s license
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and/or continued driving. Clinical judgment may
include consideration as to whether the
individual needs to stop driving immediately or
perhaps helping the person prepare for an
eventual transition from driver to non-driver.
There may be times when findings from a
psychological evaluation clearly indicate
impairment in all or most cognitive areas
essential to driving. In this case, the psychologist
can recommend to the physician and DRS that
driving not be pursued. However, on other
occasions a clinician may recommend that the
physician and the DRS team proceed with
caution, gather more data, or discourage the
adult from pursuing driving. The clinician needs
to keep in mind that the purpose of the
psychological component of the evaluation is
not to absolutely determine driving capacity, but
to provide input and recommendations to the
physician and DRS.
Clinical Approaches to Assessing
Driving Capacity
A comprehensive assessment of driving
capacity can be composed of three parts:
medical exam, psychological evaluation, and
driving evaluation. The use of stand alone
psychological testing is not recommended to
determine driving capacity. Psychologists should
make every effort to collaborate with physicians
and driver specialists whenever participating in a
driving capacity evaluation.
Medical Exam
The first step in a driving capacity
evaluation should be a medical exam. This is
necessary to rule out potential medical
conditions that could impair driving ability. In
most states physicians are legally mandated to
report cases that involve medical conditions that
could affect driving. Therefore, a prior report
regarding the examinee’s questionable driving
ability due to a medical condition may already
be documented. In the DMV’s reexamination
process, an individual can be asked to present
medical information related to their driving
ability and should therefore be prepared to
present medical documentation supporting their
desire to re-instate a license to drive.
Psychological Evaluation
The purpose of the psychological evaluation
is to enhance the physician and driver
specialists’ knowledge of the adult’s cognitive
and emotional functioning and how these may
detrimentally affect driving ability. This
information can be used to identify areas of
strength and weakness that can also be useful if
the adult is referred for driver’s training. A
psychological evaluation can consist of a clinical
interview,
cognitive
measures,
and
personality/behavioral measures.
Clinical Interview: The clinical interview
will help to establish rapport and can be used to
gather information related to the adult’s
premorbid driving style, history of driving
citations, and their awareness of current medical
and physical circumstances that could affect
their driving ability. The clinical interview can
be used to gather information on how the adult
anticipates how he or she will resolve
unexpected driving situations.
During the clinical interview gathering
information from available family and friends
can also shed light on the adult’s driving habits.
Although collateral information is important, the
clinician needs to keep in mind that it can also
be biased and that occasionally family and
friends may underreport or misinterpret the
adult’s driving behaviors (Hunt, 1993).
Personality/Behavioral Measures: Assessing
anxiety and depression is important as these are
treatable conditions that can contribute to
delayed responses, distraction, and errors when
driving. These can be assessed, for instance,
with the Beck Depression Inventory, Beck
Anxiety Inventory, and Geriatric Depression
Scale.
Cognitive Measures: A psychological
battery for assessing driving capacity may
include measures to assess mental status,
attention, working memory, divided attention,
information processing speed, executive
functions, visual spatial abilities, visual
perception, inhibition, and language. Tests of
visuospatial abilities are the most related to
different driving measures (Reger, Welsh,
Watson, Cholerton, Baker, & Craft, 2004).
Psychological batteries that serve as a
component of an evaluation of driving capacity
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may include a wide range of instruments
depending upon the particulars of the referral.
Some examples include: Mini Mental State
Examination; Dementia Rating Scale; Trail
Making Test Parts A and B; Cancellation Task;
WAIS Digit Symbol, Digit Span, Information,
Picture Arrangement, and Block Design
subtests; Simple or Choice/Complex Reaction
Time; Motor-Free Visual Perceptual Test;
PASAT; WASI Matrix Reasoning; WMS-III
Logical Memory, Facial Recognition, Visual
Reproduction subtests; Benton Visual Retention
Test; RBANS; Stroop; Rey-Complex Figure;
Word Fluency; Boston Naming Test; Porteous
Maze; Right/Left Orientation; Cognistat;
Independent Living Scale; and Driving
Judgment Situations (Reger et al., 2004;
Schultheis, 2007; Pasino & Kahan, 2001).
Specialized Driving Tests: Other measures
that are more specialized for assessment of
driving include Cognitive Behavioral Driving
Test, DriveABLE Screen, and Useful Field of
View (UFOV), a measure of processing speed
and spatial attention used to predict driving
performance (Schultheis, 2007). Performance on
these cognitive measures can provide useful
information regarding a person’s ability to
visually scan and track information, to attend to
the driving task, to shift set/multitask, to
problem solve, and to reason through driving
situations.
It should be noted that correlations between
neuropsychological tests and on-road tests are
variable (Reger et al., 2004; Schultheis, 2007) so
although the results of psychological cognitive
testing is important, it is essential to keep in
mind that their ability to predict actual driving
ability is limited.
Another limitation to the application of
psychological measures in assessing ability to
drive is that there is no well-defined appropriate
cut off for driving (Reger et al., 2004). Unless an
individual displays a significant impairment
(e.g., left visual field cut or neglect), it is left up
to clinical judgment to determine how poorly
and on what measures an individual can perform
in order to support or not support the reinstatement of a driver’s license.
In essence, psychological testing can assess
various components of driving, but correlations
between test results and driving are not well
established, cut off scores that predict impaired
driving are not standardized, and psychological
testing does not test all of the abilities required
for driving simultaneously in an in vivo
situation. Therefore, it is not recommended that
they be the sole determining factor in assessing
an individual’s ability to drive.
Driver Specialist Evaluation
The final component of a thorough driving
capacity evaluation is the driver specialist
evaluation. This entails evaluating the
examinee’s actual driving ability through virtual
driving tests, as well as behind the wheel testing.
The Association for Driver Rehabilitation
Specialists (ADED) has a national listing of
agencies offering driving evaluations that can be
viewed online at www.driver-ed.org, or contact
them toll free at 1-800-290-2344. Driver
Rehabilitation Specialists (DRS) must meet
certain requirements and are generally licensed
kinesthesiologists,
licensed
occupational
therapists, registered physical therapists, or state
approved driving instructors or driver education
teachers. The purpose of their evaluation is to
determine current level of driving ability and,
under certain circumstances, to determine if
driver training or classroom education would be
beneficial (NMEDA & ADED Model Practices
for Driver Rehabilitation for Individuals with
Disabilities, May 2002).
Findings from a
psychological evaluation can be useful during
this component of the driving capacity
evaluation because it can provide information to
the DRS regarding strengths and weaknesses of
the potential driver.
Case Examples
The following two cases were selected to
demonstrate the possible variability in
psychological testing and how findings can be
communicated to drivers’ training programs and
physicians. Both individuals were referred by
their physician for neuropsychological testing
and a driver’s evaluation, if appropriate, to
assess driving ability and for driving
recommendations. They were both seeking to reinstate their driver’s license after sustaining a
brain injury that led to a physician report to the
DMV.
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Case 1
Psychology Component
Case 1 is a 65-year-old female diagnosed
with traumatic brain injury, seizure disorder, and
depression with history of alcohol and drug
abuse. She was evaluated for driving capacity 18
months after discharge from an inpatient
hospital. Psychological testing revealed the
following:
Test
MMSE
Trails A
Trails B
RBANS:
Immediate Memory
Visual Construction
Language
Attention
Delayed Memory
Total Test RBANS
WASI Matrix Reasoning
NCSE Abstract Reasoning
ILS Health & Safety
Driving Judgment Situations
Observed
Performance
Average
Impaired
Impaired
Low Average
Average
Average
Borderline
Low Average
Low Average
Borderline
Average
Mild Impairment
Average
In terms of Neurobehavioral Functioning
she showed none to little: faulty orientation,
disinhibition,
impaired
initiation,
agitation/irritability,
behavior
dyscontrol,
blunted affect, emotional lability, bizarre
thinking, inaccurate insight, or suicidality. She
demonstrated borderline fatigability, anxiety,
and depression.
The psychological evaluation resulted in
diagnosis of Alcohol Abuse and Cognitive
Disorder, NOS. In the discussion, significant
difficulties with visual scanning and shifting set
were noted, as well as mild difficulties with
problem solving. Longstanding and probable
ongoing alcohol abuse was considered to be
contributing to her current testing profile.
Caution in pursuing driving was recommended
due to cognitive issues.
Driver Specialist Component
Her clinical driving evaluation was
conducted 14 months after the psychological
evaluation. A specially trained occupational
therapist conducted the evaluation. It consisted
of gathering history regarding her health and
medications, identifying her driving goals,
driving history, vehicle she was interested in
driving, mobility factors, assessing cognition, as
well as evaluating her vision, perception, and
physical status. The evaluation also looked at
activities of daily living status, current
transportation, and wheelchair necessity. It
assessed variables related to communication and
behaviors that could influence her readiness to
drive.
Under medical history, it was noted she had
a history of seizure disorder, brain injury, left
sided weakness, depression, and alcohol use. It
was indicated she reported not using alcohol in
12 months and being seizure free for 18 months.
Use of an antidepressant, anticonvulsant, and
pain medication was noted. In regards to her
activities of daily living it was stated she was
independent with all self care tasks. She did not
use a wheelchair and was independent for all
mobility. Factors that were identified as
influencing her readiness to drive included
physical limitations, psychosocial factors,
cognitive limitations, and difficulty following
multiple directions.
Under vision, it was noted that she required
corrective lenses for driving but not for reading.
Her peripheral vision was intact. Occulomotor
convergence was normal. Occulomotor range of
motion was full range with jerky tracking for
both eyes. Perception tests identified left-right
confusion. In assessing her physical ability of
upper and lower extremities to drive a car (i.e.,
proprioception, strength, range of motion, motor
control, and tone), she performed within normal
limits, except for motor control of lower
extremities which was rated as limited. Range of
motion for her neck was within normal limits.
On tests of right foot reaction time for simple
(i.e., red and green) and complex (i.e., green,
yellow, and red) scenarios, she demonstrated
overshooting and hesitation.
The findings of the DRS determined that she
had questionable driving potential and a
recommendation of 6 driving lessons was made.
Concerns included delayed visual processing,
frequent need for repetition of instructions,
decreased smooth coordinated control of lower
extremities, and overshooting and delayed
reaction time of right foot.
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During the driving simulation she
demonstrated good control of the vehicle but
was unable to find her way back to the training
site and was unable to consistently follow rules
of the road. Only three driving lessons were
completed due to the driver demonstrating
problems with short-term memory and visual
processing. The final recommendation was that
she not drive.
Case 2
Psychology Component
Case 2 is a 68-year-old male who, at time of
discharge, was diagnosed with traumatic brain
injury, high blood pressure, and dislocation of
the left shoulder. He was evaluated six months
after discharge from an inpatient hospital.
History was positive for cocaine use, but he had
not used any substances for over five years.
Psychological testing revealed the following:
Test
MMSE
Trails A
Trails B
RBANS:
Immediate Memory
Visual Construction
Language
Attention
Delayed Memory
Total Test RBANS
WASI Matrix Reasoning
NCSE Abstract Reasoning
ILS Health & Safety
Driving Judgment Situations
Observed
Performance
Average
Average
Average
Average
Average
Average
Borderline
Average
Low Average
Average
Average
Average
Average
In terms of neurobehavioral functioning he
showed none to little: faulty orientation,
disinhibition,
impaired
initiation,
agitation/irritability,
behavior
dyscontrol,
blunted affect, emotional lability, fatigability,
bizarre thinking, inaccurate insight, or
suicidality. He demonstrated borderline anxiety
and depression.
The psychological evaluation resulted in a
diagnosis of status post traumatic brain injury
with improving cognitive status. The findings
indicated average functioning, with presence of
anxiety and low mood related to changes in
work status that was affecting his attention. He
was described as missing details, but noted to be
generally
cognitively
intact
and
the
recommendation was to proceed with drivers
training.
Driver Specialist Component
His clinical driving evaluation was
conducted by a specially trained occupational
therapist. It consisted of gathering of history
regarding his health and medications, identifying
adult’s driving goal, driving history, vehicle he
was interested in driving, mobility factors,
assessing cognition, as well as evaluating his
vision, perception, and physical status. The
evaluation also looked at activities of daily
living status, current transportation, and
wheelchair necessity. It assessed variables
related to communication and behaviors that
could influence his readiness to drive.
Under vision, it was noted he required
corrective lenses for reading but not for driving.
His peripheral vision was intact for both eyes.
Occulomotor
convergence
was
normal.
Occulomotor range of motion was full range for
both eyes with slight ptosis and slightly ectopic
right eye being identified. Perception tests were
normal. In assessing his physical ability to drive
a car, limited gross strength and limited range of
motion of left shoulder was noted. Range of
motion for his neck, as well as upper extremity
and lower extremity functions were within
normal limits. His reaction time for right foot
was measured for simple (i.e., red and green)
and complex (i.e., green, yellow, and red)
scenarios, and was deemed to be satisfactory.
During the driving simulation he was
assessed in the program car with modified
equipment. He demonstrated good control of the
vehicle and good safety habits. He was able to
adjust the speed of the car and its position even
when at freeway speeds.
Overall the driving specialist evaluation
found him to have adequate visual processing,
good problem solving for driving scenarios,
good reaction time, and mild difficulty with
information retrieval. The recommendation was
that he be referred to the DMV for a formal road
test. Shortly thereafter he was formally cleared
medically for driving and a formal notification
was given to the DMV.
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Conclusion
A driving capacity evaluation entails a
collaborative effort between physicians,
psychologists, and DRS. Although driving itself
can become a routine and over-learned activity,
the fact is that the environment in which it
occurs is fluid and with limited predictability.
The foundation for driving is physical: a driver
needs to have sufficient physical ability to
maneuver an automobile, not just during routine
daily driving, but also in sudden, unexpected
situations. The next step is brain function and
emotional state. A driver needs to recall and use
good judgment, not just about day-to-day rules
of the road, but about unusual circumstances that
can arise. Anxiety, depression, anger,
prescription and non-prescription drugs, and
cognitive impairments can all influence physical
reactions and driving judgment, particularly in
unanticipated conditions. And finally, the
product is the integration of physical ability,
cognitive ability, and emotional state into an
actual safe driving experience in both mundane
and unexpected driving conditions. As the
American population ages, psychologists’
involvement in driving capacity evaluations is
likely to increase and it will be important to be
aware of what the assessment entails and to
collaborate with other professionals in order to
ensure both the safety of older adults and other
drivers on the road.
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Independent Living
Introduction
In much of the dominant American culture,
adulthood is often marked by an individual’s
ability to move out of a parent’s home and live
independently. A person who lives on his or her
own is thought of as self-sufficient, accountable
for one’s own welfare, and worthy to enjoy a
certain degree of freedom within the home.
Illness and financial circumstances, however,
can interfere with a person’s ability to live
independently. The need for functional support
may increase as people age, due to functional
limitations associated with physical ailments that
may accompany aging. Familiarity with a
neighborhood or environment may become more
important for safety and socialization, and the
cultural emphasis on self-autonomy may result
in a concern for becoming a burden to others.
The development of a medical illness that
results in changes in a person’s ability to care for
him or herself can lead to hospitalization. A
gradual decline in physical abilities can
eventually limit a person from being able to
perform activities of daily living (ADLs)
necessary for survival, as well as instrumental
activities of daily living (IADLs) (i.e.,
management of healthcare, finances, the home,
etc.). The same is true for the development of
memory problems that can lead a person to
forget about soup on the stove, to take
medication, or how to get to the grocery store
and back. The development or exacerbation of
mental health problems related to a thought
disorder or mood disorder can also affect a
person’s ability to live independently. An
individual can become homeless for many
reasons, including mental health problems,
substance abuse issues, and cognitive deficits. In
general, when a person’s ability to care for him
or herself comes into question, an evaluation to
determine independent living capacity should be
considered.
Evaluations for capacity to determine
independent living are often done by
psychologists. They may be the sole evaluator or
part of a team of professionals. These
assessments use various measures to determine
cognitive abilities, decision-making abilities,
physical/functional abilities, and whether or not
the factors are reversible. In some cases, these
evaluations are done in the context of
determining whether the individual needs a
guardian of person. In other cases, these
evaluations remain in more of a clinical realm,
focusing on helping to determine the appropriate
discharge location that matches the person’s
needs. In any case, these evaluations are often
among the most difficult because they concern
such a fundamental value—independence—and
because the range of skills and abilities that are
potentially relevant is so vast.
Legal Elements/Standards
In most states, there is unlikely to be a
specific standard for “the capacity to live
independently.” Instead, the most relevant legal
standards for the capacity to live independently
are likely those which are defined in
guardianship law. In Chapter 2, it was noted that
state statutes for incapacity under guardianship
vary widely, but that many cite one or more of
four “tests”:
1. The presence of a disabling condition;
2. A functional element—sometimes defined
as the inability to meet essential needs to
live independently;
3. A problem with cognition;
4. A necessity component—that is that
guardianship is necessary because less
restrictive alternatives have failed.
A list of such less restrictive alternatives is
provided in Appendix F.
As an example, the Uniform Guardianship
and Protective Proceedings Act (UGPPA; a
model act that states may use when revising
guardianship statutes) defines an incapacitated
individual as someone who is
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unable to receive and evaluate
information or make or communicate
decisions [cognitive element] to the
extent that the individual lacks the
ability to meet essential requirements for
physical health, safety, or self-care
[functional
element],
even
with
appropriate technological assistance
[necessity element] [bracketed notes
added] (National Conference of
Commissioners on Uniform State Laws,
1997).
The most recent UGPPA standard does not
include diagnostic or causal elements, although
most state statutes do. The framework of this
handbook includes a diagnostic component
because it establishes the causal condition
behind the functional deficits, and informs the
choice of treatments, the course of the disorder,
and the prognosis for improvement.
In some states, legal guidance relevant to
independent living may be provided in the adult
protective services (APS) statutes. Some
psychologists may be familiar with these as the
statutes that define “elder abuse” or “adult
abuse” and address reporting to APS, whether
mandatory or voluntary. Adult protective
services investigates allegations of elder or adult
abuse and provides services to individuals that
are at risk for abuse, neglect, or exploitation.
Recently the ABA Commission on Law and
Aging analyzed all state laws and concluded that
the threshold criteria for APS intervention can
be organized into the following five categories:
age, condition, function, living situation, and
services received. Each of these categories
incorporates an array of concepts. The ABA
Commission has grouped the diverse statutory
terminology into subcategories. For example, the
APS statutes that have a “condition” criterion
may refer to these subcategories: mental or
physical impairment, mental or physical illness,
dementia, or substance abuse. The APS statutes
that have a “function” criterion include these
subcategories:
1. Lacking the ability to make, communicate,
or implement decisions.
2. Lacking the ability to understand the risks
and consequences of behavior.
3. Being dependent on others.
4. Requiring care, treatment, or custody for
own welfare or welfare of others.
5. Restricted ability to carry out ADLs.
6. Unable to care for or manage ones’ self or
property.
7. Unable to delegate responsibility.
8. Unable to perform or obtain services.
9. Unable to protect self.
An individual who is living independently
but who is determined to be unable to care for
him or herself may be self-neglecting. While the
complicated and evolving concept of selfneglect is beyond the scope of this handbook, it
is important that psychologists are aware that
many APS laws address self-neglect, and that a
report to APS about a self-neglecting individual
may be required by state law or, even if not
required, may be appropriate under the
circumstances. A report to APS may result in
additional interventions, monitoring, or support
for the individual.
For further information, readers are
encouraged see the ABA Commission’s analysis
of state APS laws by visiting its Web site at
www.abanet.org/aging.
In summary, in preparing to evaluate
capacity to live independently, familiarity with
guardianship statutes, APS statutes, and other
law related to the capacity to live independently
and, broadly, to care for one’s person is
important. However, such law and legal
guidance regarding the task of living
independently can be so broad that they may not
provide much specific direction to the
psychologist.
In this handbook we propose that a
psychological evaluation relevant to the capacity
to live independently needs to determine if an
individual is a significant danger to her or
himself due to limited functional abilities, or due
to cognitive or psychiatric disturbances, and also
cannot accept or appropriately use assistance
that would allow him or her to live
independently. These functional, cognitive, and
psychiatric issues are further detailed in the next
sections.
Functional Element
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A common framework in gerontologic
literature for everyday functioning is the
ADL/IADL framework. There is no exact
agreement on the specific areas considered
ADLs and IADLs—but generally the ADLs are
“basic” to personal care (eating, bathing,
toileting, etc.), whereas the IADLs are “higher
level” abilities, such as financial management,
household management. As described in
Appendix B, there are a number of useful tests
for rating ADLs and IADLs.
An assessment of ADLs and IADLs,
however, is insufficient to evaluate the capacity
to live independently, because it is more of a
categorization of important activities, and does
not consider the cognitive and judgment skills
related to these. In a seminal survey of clinical
and legal professionals involved in guardianship,
key abilities essential to independent living were
defined and q-sorted (Anderten, 1979). A
number ADLs/IADLs were identified (such as
diet, hygiene, maintain household, use
transportation), but also key judgmental abilities
(such as the ability to handle emergencies and
compensate for deficits). This emphasis on
cognition is also reflected in another study that
aimed to identify the key functional elements for
independent living under guardianship using a
social cognitive framework (Anderer, 1997). In
this framework, the key judgmental factors are
the ability to identify a problem, generate
alternative solutions, make the decision,
implement the solutions, and verify the solution.
In this handbook, we propose a three-part
framework for the functional elements
associated with independent living. This
framework was developed from consideration of
the above cited studies, as well as from a
rehabilitation perspective in which the goal is for
individuals to be as independent as possible
despite limited physical and cognitive abilities.
We propose that the assessment of capacity to
live independently, therefore, requires the
integration of understanding what is required to
live independently, the functional ability to
apply one’s knowledge (“application”), and the
ability to problem solve and appreciate
consequences of potential choices (“judgment”).
This framework reflects legal standards
found in guardianship laws that emphasize
cognitive and functional components, as well as
cognitive,
functional,
and
judgmental
components of independent living cited in APS
laws. It allows the clinician to conceptualize and
evaluate how cognitive factors, physical deficits,
and maladaptive behaviors could be interfering
with the patient’s ability to live on their own.
1. Understanding
Does the adult understand the day-to-day
requirements of taking care of self and home?
For instance, does he understand that bills need
to be paid in order to keep utilities running?
Does she know how much their income consists
of and does she keep track of banking to ensure
checks do not bounce? Does he understand that
grocery shopping needs to be done regularly in
order to have sufficient food in the house? Is she
aware of kitchen safety to prevent fires? Does he
understand weekly chores versus daily chores?
Does she understand how their medical
problems may affect the ability to maintain a
home and health? In general, what is the adult’s
understanding of the basic requirements
necessary to live independently and can he or
she foresee possible problems related to
performing or not performing tasks?
2. Application
If the adult has an understanding of general
requirements of living independently, is the
individual able to either perform the tasks
required for managing home and health or direct
another person to assist them? For example, an
adult with history of stroke with residual rightsided hemiplegia may not be able to write
checks necessary for paying bills, but can this
person direct someone to do it and to balance the
checkbook? Can the person clean the kitchen
and dishes sufficiently to prevent contamination
of food by bacteria and/or pests? If there are
pets, does the individual feed and clean up after
them? How does the person maintain personal
hygiene? In essence, are there physical or
cognitive limitations and if so can the adult
problem solve around them in order to continue
to maintain health and the home?
In general an assessment of the person’s
ability to perform activities of daily living, such
as dressing themselves, toileting, bathing,
transferring, and mobility, is essential.
Difficulties in any of these areas can potentially
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lead to deterioration of the individual’s hygiene,
health, and self-esteem. What is more key,
however, is not if the person can or cannot do
the task, but if not, does the person recognize the
need to have the task done (insight), and will he
or she accept help for that need?
3. Judgment
Does the presence of a cognitive disorder,
emotional disorder, or thought disorder affect
the person’s judgment as it relates to care of self
or the home? In some cases an individual may
understand the requirements for independent
living, and be willing to do those or accept help
for those, but exercise poor judgment in doing
those consistently, in avoiding high-risk
behaviors when alone, or in responding to
emergency situations that arise. An example of
when this would become a concern follows: a
woman suffers from depression and therefore
experiences depressed mood, anhedonia,
decreased motivation, poor appetite, and
hypersomnia. Her symptoms prevent her from
“caring” about her health and her home and she
is, therefore, not motivated to perform the tasks
herself or to seek assistance from someone else.
In this case, her ability to functionally care for
herself and her home and to live independently
is severely affected by an emotional disorder.
She may not be able to accurately foresee the
potential consequences of not performing dayto-day tasks related to her personal survival and
her home.
Diagnostic Considerations
In older adults, the most common disorder
likely to affect the capacity to live independently
is dementia. Innumerable studies have
documented the relationship between the
severity of dementia and the performance of
functional abilities key to independent living
(Tatemichi, Desmond, Stern, Paik, & Bagiella,
1994; Hill, Backman & Fatiglioni, 1995).
The
best
symptom
predictors
of
institutionalization of individuals with dementia
have been excessive night-time activity,
immobility or difficulty walking, and
incontinence (Hope, Keene, Gedling, Fairburn,
& Jacoby, 1999), along with caregiver factors.
For example, institutionalization of a cognitively
impaired older adult is less likely to occur when
the caregiver is provided respite through family
assistance with overnight help and ADLs
(Gaugler et al., 2000). While dementia is the
greatest risk factor for institutionalization of
older adults, medical burden was the most
salient variable for non-demented older persons
(Bharucha, Panday, Shen, Dodge, & Ganguli,
2004).
In addition to cognitive impairments, other
factors identified in the literature that are
associated with decline in functional status in
older adults who live in the community are
depression, disease burden, increased or
decreased body mass index, lower extremity
functional limitation, low frequency of social
contacts, low level of physical activity, no
alcohol use compared to moderate use, poor
self-perceived health, smoking, and vision
impairments (Stuck, Walthert, Nikolaus, Bula,
Hohmann, & Beck, 1999).
Just as dementia can be the result of a
variety of different medical conditions, reduced
functional ability can also result from a variety
of medical problems (e.g., hip fractures,
amputations,
neurological
conditions).
Clinicians, therefore, need to assess a broad
scope of possible diagnostic factors that can
contribute to a decline in functional status and to
what degree these are affecting the person’s
ability to perform ADLs and IADLs.
Another factor to consider is the effect of
medications on higher order functioning. Older
adults are more sensitive to the direct effects and
side effects of medications due to slower
metabolisms and are at greater risk of drug
interactions due to often being prescribed
multiple medications.
Cognitive Underpinnings
Living independently does not require that
an individual be cognitively intact, but if
cognitive deficits are present, it does require a
determination as to what extent they will affect
the person’s ability to live alone and what, if
any, adjustments should be considered to the
individual’s environment to enhance cognitive
strengths. Cognitive factors that can trigger an
evaluation of capacity for living independently
include, but are not limited to: language deficits,
memory deficits, impulsivity, and poor insight.
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In order to understand the day-to-day
requirements of living alone an individual would
need to demonstrate the ability to attend to what
needs to be done (i.e., be alert enough to know
that things need to be done and to actively plan
to do them). Further, an individual would need
to know where he or she is, what he or she is
doing, and what is the essential purpose of the
task at hand. Episodic memory will be helpful to
assist the person in recalling when events
occurred and which ones did not. Informational
memory will help the person understand what
items are within the home, what needs to be
replaced, and what precautions need to be taken.
Cognitive deficits could also affect a
person’s ability to apply knowledge and use
good judgment. For instance, deficits in
executive functioning could lead to impulsivity,
disinhibition, decreased initiation, or poor
planning that could lead to a person putting him
or her self in danger. Language deficits could
affect a person’s ability to read labels on food
and medications, to communicate with others, or
to understand what others say. In addition to
limiting the person’s ability to effectively
interpret language-related elements in their
environment, it could make it challenging for an
adult to direct another person to perform tasks or
assist with their personal care. Visuospatial and
memory deficits could affect a person’s ability
to manage medications (Richardson et al., 1995),
while visuospatial problem solving and memory
have been found to affect money management
skills, as well as overall safety (Richardson et
al., 1995). Attention deficits have been
correlated with balance, falls, and ADL function
(Hyndman & Ashburn, 2003).
Clinicians should be aware that an
assessment that focuses only on cognitive
abilities may not be sufficient to predict
functioning and capacity to live independently.
A literature review conducted by Royall et al.
(2007) found that, although executive function
measures were strongly related to higher order
cognitive capacities (e.g., medical and financial
decision-making), and that screening measures,
such as the Mattis Dementia Rating Scale and
Mini-Mental State Exam, were strongly related
to disability and functional status, cognition was
found to be weakly-to-moderately associated to
variations in functional status. These findings
suggest that assessment for independent living
capacity should incorporate both cognitive and
functional assessments in order to get a more
accurate understanding of the person’s impaired
activities.
Psychiatric and Emotional Factors
Severe depression can strongly limit a
person’s motivation for self-care, and by
extension, care of the home. Anxiety is not often
a cause of difficulty for independent living,
although significant anxiety symptoms may
impact the person’s abilities to accept help, or to
leave the home when necessary to obtain
required goods or services that promote the care
of the home or person. Hoarding may be
associated with obsessive compulsive features
and can cause difficulty with independent living.
Symptoms of psychotic disorder are often
associated with difficulties with independent
living. For instance, negative symptoms have
been linked to competence in performing ADLs
and ratings of mental health (Meeks & Walker,
1990). Obviously, self-neglect is a negative
symptom of schizophrenia and, therefore,
impacts the individual’s ability to provide for the
care of his or her person. Like severe anxiety or
PTSD, paranoia could cause a person to be
uncomfortable with or to reject help.
Hallucinations may make it difficult for the
person to accurately assess and resolve problems
in their day to day living situation. Substanceuse disorders may be associated with inadequate
care of oneself or one’s home.
Values
The evaluation of the capacity to live
independently is laden with values issues. Often
individuals have strongly held values related to
remaining independent. Further, society’s value
on living independently can cloud not just the
older adult’s judgment but that of the clinician
who may impose his or her value system on the
adult. It is also essential that the clinician be
aware of the ethnocentric views that they are
bringing to the assessment. For instance, in
assessing an adult from a collectivistic-minded
society (e.g., Asian or Latino) a clinician will
need to take into consideration that the person
may not be accustomed to being totally self-
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reliant and that immediate and extended family
may have previously provided a great deal of
support. The value of living independently may
differ for this person from that of someone who
has always had the expectation of being
completely self-sufficient and is not accustomed
to needing assistance from others.
It will be important to become familiar with
a person’s culture, religion, and belief system to
accurately assess if the older adult’s behaviors
and judgments are consistent with longstanding
practices. For instance, does the individual have
the expectation that family will perform certain
tasks and therefore lack the initiative or fail to
consider the task as something that he or she
needs to do for themselves? For example, in
certain cultures women are responsible for the
home but not for making decisions or financial
transactions. In this case, a clinical judgment
concerning a woman’s financial abilities from
this culture could be misinformed because she
would not anticipate needing to pay bills or
perform other tasks outside of her general
responsibilities.
Risks
When weighing the functional data for
independent living, the clinician will consider
not only the person’s values, but the risks. These
include estimating the risk to the individual
should she or he remain living independently
and without a guardian (should the case be
considered for guardianship) and the benefits to
the person of a supervised living situation. In
addition, the risk of imposing a restrictive
supervised environment on an older adult which
results in the loss of the enjoyment and
autonomy must be weighed. Obviously, the most
useful source of data for considering these risks
is the history of highly undesirable outcomes for
the person because of his or her difficulty with
self care. When weighing the risks, it is
important to consider the seriousness of the risk,
the likelihood of the risk, and whether any and
all supports that will enhance this individual’s
capacity to remain independent have been tried.
Steps to Enhance Capacity
There is a huge array of social, medical, and
legal interventions that may assist a person in
living independently. These are described in
Appendix F, and will vary to some extent
according to the local Area Agency on Aging,
the individual’s Medicare or other insurance
coverage, and the state elder care framework.
The level of assistance that a person requires
will depend on various factors, such as cognitive
deficits, physical deficits, and medical problems.
For instance if someone is mildly physically
impaired and the primary deficit is memory,
various technological tools may be used to
compensate for the memory problems (e.g.,
using a pager to remind to take medications, to
remind about appointments, etc.). Memory
books can also be incorporated if the person can
be trained to remember to use them. Individuals
can also benefit from notes with instructions or
reminders posted strategically around the home
(e.g., on medicine cabinet, near front door, on
refrigerator). If family or friends or other
community agencies are available to check in on
the adult throughout the day, they can also help
to enhance the adult’s ability to continue to live
independently by taking care of the things that
the adult cannot do physically or checking in to
ensure that they have performed daily activities
and responsibilities. If no family or friends are
available to assist the adult in their current
home, home health aid, chore services, Meals on
Wheels, and other home services may be
available. A move to an assisted living and/or
transitional living centers may provide the
person the opportunity to remain largely
independent.
Collaboration with speech therapists and/or
cognitive rehabilitation specialists, as well as
occupational therapists and physical therapists
for adults with cognitive decline and/or physical
impairments, can be crucial in assisting them to
identify areas of potential improvement.
Clinical Judgment of Capacity for
Living Independently
Once the evaluation is completed the
clinician will need to integrate the data and
come to a clinical decision about the adult’s
capacity for living independently. It is important
for the clinician to consider the adult’s culture
and support system. Premorbid lifestyle choices
should also be considered. For instance, in the
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case of an individual who was living in shelters
or on the street prior to hospitalization and
would like to continue to do so, it may be
difficult for the clinician (as well as family or
other staff) to accept this as an acceptable way to
live. For some individuals, however, it is
preferable to be homeless and free on the streets
than to be in a nursing home where there are
rules to follow. This judgment, however, has to
be considered in view of any changes in the
individual’s level of vulnerability and therefore
potential risk. A person may have previously
been homeless, but this may no longer be
feasible, despite longstanding values, if the
person has suffered a medical incident (e.g.,
stroke, amputation) that greatly changes
functional abilities. The threshold for capacity to
live independently will vary if the person is to
live in his or her home or in a shelter; if there are
family or friends that can check in on the person
or not; if there is only one medication once a day
versus multiple medications for life-threatening
conditions. The clinical judgment of capacity for
living independently is exceedingly difficult. It
must integrate all of the assessment data and
come to a determination that balances a respect
for the individual’s autonomy and cultural
values, as well as consider the legal standards
and social requirements that safeguard not just
the individual but communities, as an unsafe
individual could potentially cause harm not just
to him or herself, but to others and their
property.
Clinical Approaches to Assessing
Capacity for Living Independently
Clinical approaches to assessing such a
broad capacity will likely utilize a wide array of
traditional cognitive measures, as well as
behavioral, psychiatric, and functional measures.
Incorporating both subjective (i.e., what adult
self-reports he or she can do) and objective (i.e.,
performance-based or direct observation)
assessments
of
functional
abilities
is
recommended because they can significantly
vary from each other (Glass, 1998). An example
of an approach and battery that incorporates the
above dimensions follows: a review of medical
records, clinical interview, Neurobehavioral
Cognitive Status Examination (NCSE) (a.k.a.,
Cognistat), Repeatable Battery for the
Assessment of Neuropsychological Status
(RBANS), Wechsler Memory Scale—third
edition (WMS-III), Wechsler Abbreviated Scale
of Intelligence (WASI), Independent Living
Scale (ILS), observation/data collection of in
vivo decision-making activities, Geriatric
Depression Scale (GDS), and review of
medical/pharmacological
evaluation
to
determine if cognitive factors (e.g., confusion)
are reversible. Assessment of substance use and
misuse of prescription medications can be
conducted in order to determine if these are
present and potentially affect judgment. This is
not an exhaustive list, but rather a list of
potential measures that might be incorporated
into the evaluation of an older person’s capacity
to live independently.
Review of Medical Records
Whenever possible, a review of medical
records should be considered as it can provide
the clinician with a plethora of information
about the adult’s medical diagnosis and
treatments, as well as behaviors. A review of
outpatient medical records, for instance, may
reveal either consistency in attending
appointments or missing many appointments. It
can reveal information about the adult’s medical
progress and compliance (or poor compliance)
with treatments and medications. Most
importantly it can be used to get an accurate
detail of the person’s medical diagnosis and
medication regimen. Records may also show if
the patient was previously referred to, or seen
by, mental health services. If the patient has
received mental health services, reviewing those
records will also be beneficial. The clinician can
then use this information to corroborate
information given by the adult, as well as to
determine if medical or psychological conditions
or medications and their side-effects could affect
cognition, judgment, and/or physical abilities
that would affect the ability to live
independently.
The Clinical Interview
The clinical interview will help to establish
rapport, as well as to provide the clinician with
data regarding the adult’s premorbid lifestyle
choices, cultural values, and awareness of
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current medical and physical circumstances that
could affect the ability to care for him or herself
and live independently. The clinical interview
can also provide information on how the adult
anticipates he or she will resolve problems.
Although the clinical interview can provide
crucial information, its interpretation can be
subjective, so objective data collection to
support
the
clinical
interpretation
is
recommended.
Some questions to add to a clinical interview
that specifically focus on issues relevant to the
capacity to live independently are:
1. Where are you living now? How long have
you been there?
2. Does anyone live there with you? If not, do
you have any fears or concerns about living
alone?
3. Does anyone visit on a regular basis?
4. What family and/or friends live in your
community who are important to you?
5. What is most important to you about where
you live? What makes it “home”?
6. What kind of personal activities do you
enjoy doing at home?
7. Are there community activities in which you
enjoy participating?
8. What
do
you
like
about
your
house/apartment?
9. What do you not like about your
house/apartment? What does not work well
for you and why?
10. Do you feel that you can manage the
house/apartment on your own? Have you
noticed any changes in your abilities to
manage?
11. Are there areas of your life that you feel you
may need some assistance managing? For
instance, do you have any trouble with
housekeeping, yard work, preparing meals,
shopping, driving, using the telephone, the
mail, your health, taking medications,
managing your money, or paying bills on
your own?
12. Is there someone helping you with any of
these things? If so, how long have they been
assisting you?
13. If you needed help, who would you like to
help you? Is there anyone that you would be
wary of? Why?
14. Have you had any safety concerns at home?
For instance, have you ever accidentally left
the stove or oven on, fallen and been unable
to get up by yourself, left your doors
unlocked, or invited a stranger into your
home?
15. Where would you like to live in the future?
16. Have you ever considered moving to a place
where there would be more help for you,
such as senior housing, assisted living, or a
nursing home? How do you feel about that?
What fears or concerns do you have?
Functional Assessment
Functional evaluation includes observation
and direct assessment of the adult in day-to-day
activities, as well as administration of functional
assessment instruments. For instance, for an
adult that is hospitalized, feedback from nurses
who work with him or her daily can provide
information about how the person is functioning
within the hospital. Is he forgetting to use a
walker? Is she impulsively getting out of bed
and falling? Is he wandering outside the room?
For an individual who lives in the community,
feedback from neighbors, family, and friends
can be helpful in getting a broader picture of the
individual. For example, they can indicate if
they’ve noticed changes in behaviors, increased
need for assistance, or changes in memory?
They can corroborate information provided by
the adult. A functional assessment is important
for an individual that will be living alone
because although an adult may know what needs
to be done (e.g., take medicine daily), he or she
may lack the ability to actually perform the
behavior or direct care due to underappreciated
cognitive or physical difficulties.
Functional Assessment Instruments
One useful measure of functional ability is
the “Independent Living Scales” (ILS). This
instrument evaluates an individual’s memory
and orientation, knowledge about how to
manage
money,
manage
home
and
transportation, knowledge about health and
safety, and social adjustment. For instance, in
the memory section it asks respondents to
remember an appointment, while in the health
and safety section it asks examinees to
demonstrate how they would call an ambulance.
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In the managing money section basic skills, such
as the ability to count coins, write checks, and
read a bill, are assessed. In the home and
transportation sections the adult is asked to find
information in a phone book, to write a check,
and to discuss precautions a person can take
while bathing. Responses are given 0, 1, or 2
points and totaled within each subtest to create a
profile. The scores can fall within one of three
areas: dependent, moderately independent, and
independent. This measure helps the clinician
identify areas in which the adult may require
assistance.
Additional functional instruments are
described in Appendix B.
Cognitive Assessment
Objective testing to determine cognitive
abilities and how these may affect decision
making and the ability to live independently can
be completed with brief assessment instruments
such as the NCSE or RBANS. The NCSE allows
a
clinician
to
assess
orientation,
attention/concentration,
language
abilities,
construction
abilities,
memory,
abstract
reasoning, and judgment. The NCSE has
separate norms for individuals over age 65 and
is available in various languages. The RBANS
assesses for learning and memory for both
immediate visual and verbal information,
attention, language, visuospatial abilities, and
delayed memory. The RBANS has norms for
ages 20-89. These brief assessment instruments
can administered in 15 to 45 minutes and
additional measures, such as instruments to
assess executive function, can be included with
these tools to make the assessment more
comprehensive.
A more extensive neuropsychological
battery may include a WMS-III, the WASI, and
additional measures of executive functioning.
The combination of these measures can provide
a clinician with an idea of baseline abilities,
areas of cognitive deficits, and areas of cognitive
strength. Together with functional assessment
these tools provide insight into how cognition
may impact a person’s ability to perform the
day-to-day
tasks
required
for
living
independently. These are described in Appendix
C.
Psychiatric and Emotional Assessment
Measures to assess mood disorders can be
incorporated into the evaluation to determine
how much they may be contributing to behavior
and decision making. Examples include the
Beck Depression Inventory, Beck Anxiety
Inventory, and Geriatric Depression Scale.
These are described in Appendix D.
Case Example
Introduction to Psychological Evaluation
for Independent
Living Capacity
Mr. Cruz is a 63-year-old never-married
monolingual English speaking Latino male who
suffered a left occipital-parietal stroke with
subsequent right-sided upper and lower
extremity weakness, memory deficits, as well as
visuospatial and language deficits. Premorbid
medical history included prior occipital and
cerebellar infarcts, mild diffuse atrophy with
periventricular white matter changes, a diagnosis
of
dementia,
hypertension,
hypercholesterolemia,
and
polycysthemia
secondary to tobacco use.
A routine psychological evaluation was
done with the patient at time of admission. On
admission he presented with severe expressive
aphasia, and deficits in visual spatial processing,
reading, writing, attention, and memory. He
made significant improvements in various
cognitive and physical areas so his attending
physician referred him for a psychological
evaluation to determine capacity to live
independently after inpatient rehabilitation
therapy was completed.
Informed Consent
Mr. Cruz was informed that the purpose of
the evaluation was to gather information about
his capacity to live independently. The benefits
and risks of the evaluation were discussed with
him, specifically that we would get a better
understanding of his functional status and it
would help the team with discharge planning,
but that it might show that he cannot live
independently and would need to reside in a
supervised living situation. He was further
advised that if the findings indicated he did not
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have capacity to live independently, the results
of the evaluation could possibly be used to
support a guardianship petition.
It is important to discuss the purpose, as
well as risks and benefits of an independent
living capacity evaluation in order to get
informed consent, but also because the results
can be life altering. It is also a way to show
respect, empower the patient, and engage them
in the process. Clinically, advising patients that
their capacity is being questioned often results in
less resistance to testing and generally leads to a
good therapeutic alliance that is based on trust.
Mr. Cruz agreed to participate in the evaluation.
Social History
Mr. Cruz was born in the Midwest and
moved to the West Coast during his twenties. He
completed high school and worked in the fitness
industry. His career had focused on weight
lifting and working as a trainer.
Premorbid history of mental health problems
was denied. He reported smoking one-and-a-half
packs of cigarettes per day for 48 years and
remote history of steroid use. No other substance
use history was indicated.
Evaluation Procedure
Clinical Interview, Cognistat, ILS Managing
Home and Health and Safety subtests, and
portions of Guide to Capacity Questionnaire. He
was observed in physical therapy, occupational
therapy, and speech therapy over a two-week
period to assess functional abilities.
Behavioral Observations
Mr. Cruz was awake, alert, and fully
oriented. His demeanor towards the evaluation
was cooperative and forthcoming with mild
underlying resistance. He was noted to make
general statements about his abilities and then
self correct. For instance, he stated he could
walk as well as anyone in the hospital and then
self-corrected stating that was probably an
exaggeration, as he still needed to improve his
ambulation abilities. Right-sided weakness was
significantly improved from time of admission
but coordination deficits were still present. He
was noted to use his right hand for writing and
pointing at items throughout the evaluation.
Psychotic thought process was not present.
Emotionally, patient shared that he was nervous
as he knew he was being evaluated. Affect was
full range and mood was euthymic with mild
underlying anxiety. It was noted that patient
reported being thirsty and dizzy and was
concerned about being hypoglycemic.
Cognistat
Mr. Cruz’ performance was in the average
range for orientation, attention, language
abilities, calculations, and reasoning abilities. It
was noted that impulsivity led to errors but he
was able to self correct. For instance, he said it
was September 1995 and when asked if that was
correct he immediately stated it was wrong.
Language comprehension, repetition, and
naming were within normal limits. Mr. Cruz was
also able to describe a picture of a boy fishing.
He was able to do simple calculations of
addition, division, and subtraction. Abstract
thought process was within normal limits and
significantly improved from time of admission.
Judgment was also within normal limits. His
performance for visuoconstructional tasks and
memory tasks was severely impaired. He was
unable to replicate various block constructions
or copy a geometric design. He was able to learn
four words but after a brief delay required
multiple choice, cuing to remember three words
and was unable to identify the fourth word.
Overall executive functioning was impaired. On
Trails 1 his performance was slow but accurate
(10th percentile). However, he was unable to
complete Trails B, which requires him to switch
between two patterns. This task was
discontinued at three minutes. Mr. Cruz repeated
the same error: an inability to switch between
the patterns, despite numerous repetitions of task
demands. These results suggest that Mr. Cruz
will have difficulty when trying to complete two
tasks at the same time, especially as task
complexity increases.
Independent Living Scales
On the Managing Home and Transportation
subtest Mr. Cruz was unable to do four items
due to visuospatial deficits. He got 16 out of 22
possible points (73%). In general, he was able to
discuss accurate ways of managing public
transportation and getting information via
telephone, as well as appropriate times to
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contact his landlord. On the Health and Safety
subtest he attained a standard score of 42,
placing him in the moderately dependent range.
He was able to discuss reasonable actions to take
in various emergency situations related to signs
of a heart attack, taking care of body,
unintentional weight loss, bleeding, and loss of
hearing and vision. He had difficulty
comprehending several questions and therefore
gave fair to poor responses. For instance, when
asked what he would do if he couldn’t hear most
conversations he replied, “I guess I wasn’t
meant to hear it.” When it was re-worded as,
“What if you had hearing loss?” he replied, “Get
hearing checked. It could be dangerous ....” He
lost points for responses that were impulsive and
was noted to self-correct his impulsivity on at
least one question by stating, “that would be an
extreme response.”
Clinical Interview
Mr. Cruz began the evaluation by discussing
his
understanding
of
discharge
recommendations, rehabilitation progress, and
medical problems. He shared that we were in a
rehabilitation hospital for people who had
“seizures . . . aneurysms.” He was able to state
that he had problems with memory, ambulation,
and vision secondary to an “aneurysm.” Mr.
Cruz was able to discuss his visual field cut. He
was not able to name his medications, but was
able to reliably state what they were not for
(e.g., seizures, pain, and diabetes). He was
unsure if he was taking a blood thinner, but
affirmed that he was taking medicine to control
his blood pressure.
In discussing his discharge plans, patient
shared that he wanted to go home and live
independently and that he understood that he
needed help with his medications. Upon further
query, patient was able to discuss other possible
complications he could experience due to his
current deficits. For instance, Mr. Cruz agreed
that he would not be able to pay bills due to his
visual problems and difficulties with writing. He
agreed that he could have problems shopping
and cooking as well, due to his visual deficits.
Therapy Observations
Mr. Cruz was observed in therapies over a
two-week period. Level of agitation observed at
time of admission had decreased as his abilities
improved. He was noted to follow directions,
participate, and cooperate with limits set by
therapists. His recall for events that occurred in
therapies was variable, as was his recall for
environmental information. For instance, on one
occasion he was found sitting next to another
patient’s bed and erroneously saying it was his
bed; he was actually assigned to a bed on the
other side of the room. Therapists noted that his
memory deficits, as well as premorbid
personality style, limited carry-over for
strategies taught. At time of discharge he was
able to ambulate independently but could still
not navigate around the unit or from the unit to
the therapy gyms without getting lost.
Impressions and Recommendations
Mr. Cruz is a 63-year-old single male who is
status post left occipital-parietal ischemic stroke
with
subsequent
right-sided
weakness,
visuospatial deficits, graphomotor deficits, and
memory problems. His history is negative for
mental health problems and suggestive of a
determined, independent individual. Premorbid
personality and lifestyle are likely to lead to
attempt to present in better light and to overstate
his abilities, however, upon query he is likely to
correct himself.
Attention, language, and reasoning abilities
improved since admission two weeks prior,
however, he continues to present with deficits in
vision and memory. Mr. Cruz expresses
awareness of memory deficits, as well as his
right visual field cut. His insight into his own
medical condition seems fair to good as
indicated by his ability to discuss his various
medical treatments. His awareness of his
memory problems, however, appears to cause
increased anxiety that leads him to second guess
some of his responses and seek reassurance from
others.
He expressed understanding of potential
dangers of returning to live alone and based on
his functional abilities he would be a significant
danger to himself if he were to return to live
independently. Mr. Cruz agrees and is agreeable
to being discharged to a nursing facility while he
continues to recover from his stroke and to reassess his ability to live independently in the
future.
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Although financial capacity was not a focus
of this evaluation, his visual deficits will most
likely interfere with his ability to manage his
finances. It is suggested social work assist the
patient to identify an individual that can assist
him with finances or explore other options.
In conclusion, at this time, Mr. Cruz has
capacity to make and communicate decisions,
and limited ability to implement decisions made.
He has capacity to understand the risks and
consequences of his behavior. His ability to
complete ADLs, to manage himself or his
property, to protect himself, and perform or
obtain services, however, is limited. He is likely
to be dependent on others to a great degree and
requires care and treatment for his own welfare.
Mr. Cruz overall does not have capacity to live
independently at this time due to functional
deficits related to cognition, sensory deficits,
and memory deficits that could result in him
putting himself or others at risk for harm.
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VII. Undue Influence
To this point, the handbook has focused on a
conceptual framework and assessment tools for
understanding decisional capacity. Psychologists
working with older adults may come across a
related but distinct area of law, that of undue
influence. In Chapter 2, relevant legal
definitions are given to describe undue
influence. The goal of the current chapter is to
review critical elements of the legal definitions,
further describe the dynamic of undue influence,
introduce clinical frameworks for thinking about
undue influence, provide suggestions for
assessment, and give a clinical case example. It
should be noted that little empirical research
exists to guide clinicians in their assessment of
undue influence. At present a number of
theoretical frameworks are used to understand
undue influence and to present the data in court.
We will begin by briefly reviewing relevant
legal definitions.
Legal Standards of Undue Influence
The Restatement of Contracts, an
authoritative secondary legal source, defines
undue influence as follows:
Undue influence is unfair persuasion of
a party who is under the domination of
the person exercising the persuasion or
who by virtue of the relation between
them is justified in assuming that that
person will not act in a manner
inconsistent
with
his
welfare
(“Restatement (Second) of Contracts,”
1981).
The doctrine is akin to doctrines of fraud
and duress and may be alleged in legal
transactions, such as executing a will, entering a
contract, or conveying property to another, as
well as cases of financial abuse, sexual abuse,
and even homicide. Other definitions stress the
psychological component of undue influence,
the intentional and improper use of power or
trust in a way that deprives a person of free will
and substitutes another’s objective.
Consent to a contract, transaction, or
relationship, or to conduct, is voidable if the
consent is obtained through undue influence
(Black’s Law Dictionary, 2004). While
diminished capacity may make one more
vulnerable to undue influence, it is not a
necessary component of the dynamic. Therefore,
undue influence can be present even when the
victim clearly possesses mental capacity. Much
of the law of undue influence is forged in statespecific case law that exhibits a great deal of
variability in defining undue influence, so the
law of each state must be consulted.
Evaluations to examine the potential
presence of undue influence require
knowledge of several concepts:
Capacity: Broadly refers to an individual’s
ability to receive and evaluate information
and make and express a decision.
Financial Exploitation: A type of elder
abuse, involving the improper use or theft of
another’s assets.
Undue Influence: When exploiters, whether
family, acquaintances, or strangers, use their
power to deceptively gain control over the
decision making of a victim. Often involves
financial exploitation.
Undue Influence in Relationships
Based on Trust and Confidence
Keeping in mind the wide variability across
states, courts often require two elements to be
proven in a case of undue influence involving a
contract: (1) a special relationship between the
parties based on confidence and trust; and (2)
intentional and improper influence or persuasion
of the weaker party by the stronger.
Psychologists performing assessments of
undue influence must therefore determine if a
confidential relationship exists that would
provide the opportunity for undue influence to
occur. More descriptively, undue influence
occurs when a person uses his or her role and
power to exploit the trust, dependency, and fear
of another. Perpetrators of undue influence use
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this power to deceptively gain control over the
decision making of the second person (Singer,
1993). Psychologists working with the older
adults on cases regarding financial capacity need
to be knowledgeable about undue influence and
integrate that knowledge into every stage of the
assessment process.
Psychological Frameworks for
Understanding Undue Influence
Undue influence is an emerging area of
study for psychologists and, to date, there is
little published research to draw upon. Here we
introduce several models, but draw upon
common elements in our discussion. We present
four models that have been used to understand
undue influence in older adults. Margaret
Singer, PhD, an early noted expert in this field
originally developed her model regarding undue
influence out of her work with cult victims.
Subsequent clinical models, such as the Brandle/
Heisler/ Steigel Model, Blum’s “IDEAL” model,
and Bernatz’s “SCAM” model draw heavily on
the work of Singer and her collaborator,
Abraham Nievod, PhD, JD.
Singer’s framework emphasized social
influence conditions that the suspect crafts
unknowingly to the victim. These conditions
included creating isolation, fostering a siege
mentality, inducing dependency, promoting a
sense of powerlessness, manipulating fears and
vulnerabilities, and keeping the victim unaware
and uninformed.
Undue Influence “IDEAL” Protocol
Isolation
Dependency
Emotional manipulation and/or
Exploitation of a vulnerability
Acquiescence; and
Loss
Bennett Blum, MD, a psychiatrist, expanded
on Singer’s model to create a model to
understand undue influence emphasizing the
social conditions prevalent in cases of undue
influence situations. Dr. Blum’s “IDEAL”
model is organized around five main categorical
headings and several subdivisions. These
headings include isolation from family and
friends; dependency on the perpetrator;
emotional manipulation of the victim;
acquiescence of the victim due to the previous
factors; and financial loss. Dr. Blum created a
practical and qualitative tool, the “Undue
Influence Worksheet,” used by some lawyers,
court investigators, law enforcement personnel
and adult protective services workers. The Blum
Worksheet is essentially a data collection tool,
organized around the five main categorical
headings and several subdivisions. Its aim is to
help clarify for the user whether excessive
manipulation is present. The data then must be
evaluated in light of local statutes and case law
defining undue influence.
A third clinical framework has been
developed by clinical and forensic psychologist
Susan I. Bernatz, PhD. The “SCAM” model
builds on Singer’s and Blum’s work in which
social influence conditions are emphasized, yet
also includes factors that contribute to the
victim’s “susceptibility” and addresses the
perpetrators “active procurement” of the legal or
financial transaction(s). The “SCAM” model
views undue influence as an inter-relational
concept between the victim and the perpetrator
and incorporates four main categories that
include: susceptibility factors of the victim; a
confidential and trusting relationship between
the victim and perpetrator; active procurement
of the legal and financial transactions by the
perpetrator; and, monetary loss of the victim.
There are additional subcategories for
susceptibility and confidential relationship.
Additional factors that fall under the
susceptibility category include: medical and
psychological factors that contribute to impaired
cognition and lack of capacity of the victim;
dependency on the perpetrator, which is often a
by-product of impaired functional ability and
capacity of the victim; isolation of the victim,
which includes physical or emotional isolation;
and, the victim’s knowledge and previous habits.
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Undue Influence SCAM Model
Susceptibility
Confidential Relationship
Active Procurement
Monetary Loss
Undue influence is a type of elder abuse.
Older women who are White and live alone are
often considered to be the most likely victims of
financial elder abuse that is reported (National
Center for Elder Abuse, 1998). A widely-cited
profile of a target for financial abuse is generally
a White woman over 75 years of age who is
living alone (Rush & Lank, 2000; Tueth, 2000).
Additionally, the victim’s ability to resist undue
influence has been noted to be lessened when
the person or victim is dependent on the
caretaker or influencer. Spar et al., (1992) noted
that any debilitating mental or physical illness
resulting in dependence on caretakers will
increase susceptibility to undue influence.
Dependency can include physical dependence,
such as food preparation, assistance with
medications, helping with bill paying,
checkbook
management,
reading
bank
statements, or taking the victim to the
physician’s office. Emotional dependence can
include emotional support and encouragement,
and information dependence can include
dependence on information, such as financial or
legal advice.
In the SCAM model the vulnerable or
susceptible individual also develops a
confidential and trusting relationship with the
perpetrator. The victim’s trust is gained through
various tactics of persuasion, manipulation, and
deception. Some of these tactics come in the
form of social influence techniques, such as
liking and reciprocity (Regan et al., 1971), and
authority (Milgram, 1963), and at other times the
strategy may be to just keep the victim unaware
and uninformed about the legal or financial
transactions. These weapons of influence are
utilized by the perpetrator to heighten the
victim’s reliance and dependence on the
perpetrator. For example, a common method of
persuasion that a suspect may exploit is that of
reciprocity. The suspect may perform caretaking
duties for the victim, such as driving to doctors’
appointments, filling prescriptions, or cooking
meals. The victim often feels that he or she
“owes” the perpetrator something. The victim is,
thus, often taken advantage of by the person who
gains from the victim’s indebtedness. Influence
becomes “undue” when the perpetrator exploits
the victim’s dependency and trust for personal
financial gain. It is this trust and dependency
that gives the perpetrator the ability to steal the
victim’s assets.
There are many potential “indicators” of
undue influence to bear in mind. These factors
include both demographics that increase risk and
behavior changes such as: White women over
the age of 75 years of age, recently widowed
men and women, individuals who are
geographically isolated, and individuals who
have had a significant or unexplained emotional
change, such as a marked depression and or
insidious memory loss or other cognitive
deficits. In terms of behavioral changes, a
comparison of the victim’s past spending habits
with current habits is critical to assess. For
example, the victim that has lived modestly
throughout life but now begins to make large
purchases and/or give large amounts of money
and gifts to a new “best friend” may be a victim
of undue influence. Financial transactions that
are uncharacteristic of the victim may be another
marker of undue influence. For example, bank
records indicating many ATM transactions that
are not possible for a homebound older adult
could be suspect, as would be an older adult
allegedly performing on-line bank transactions
but who does not own a computer. The purpose
of these transactions may be to transfer funds
into “joint-accounts” that the victim and suspect
are both signors on, but is controlled by the
alleged influencer. Additional indicators may
include changes in the victim’s will or trust that
are not consistent with a previous disposition,
and the absence of any third party advisers.
Upon questioning the victim it is often
determined that the suspect has been initiating
all of the aspects of the financial and or legal
transactions, including providing transportation
to the bank, hiring a notary or an attorney,
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printing out forms, etc. This type of active
procurement can be used as evidence of undue
influence.
Summary of Clinical Models
In Chapter 2, we provide a summary of
Summary of Undue Influence Models
Singer/Nievod Model
Factors:
1. Isolation
2. Dependency
3. Creating Siege
Mentality
4. Sense of
Powerlessness
5. Sense of
Fear/Vulnerability
6. Staying Unaware
Blum IDEAL Model
Factors:
1. Isolation
2. Dependency
3. Emotional
manipulation and/or
Exploitation of a
vulnerability
4. Acquiescence
5. Loss
The Brandle/Heisler/Stiegel model describes
perpetrator behavior in cases of undue influence.
Although psychologists will primarily be asked
to assess older victims, knowledge regarding the
alleged influencer can be useful in determining
the potential presence of undue influence. The
influencer is often in the home close to the
victim and may even be interviewed by the
psychologist as a collateral source.
In the Brandle/Heisler/Stiegel model, the
influencer is described as a predator who targets
isolated elders, often in places such as
supermarkets and drug stores, and “grooms” the
person through an initial show of friendship and
caring. Once trust has been established, the
influencer will use a variety of tactics to increase
their power and control and diminish the control
of the older adults, including isolation, fear,
shame, with intermittent acts of kindness. At the
same time, the alleged influencer will work to
keep the victim unaware of their intent and the
loss of assets.
Brandle/Heisler/Stiegel
Model
Elements:
Goal:
1. Susceptibility
• Financial Exploitation
2. Confidential
Typical Perpetrator
Relationship
Tactics:
3. Active Procurement 1. Isolate from others
4. Monetary Loss
and information
2. Create fear
3. Prey on
vulnerabilities
4. Create dependency
5. Create lack of faith in
own abilities
6. Induce shame and
secrecy
7. Perform intermittent
acts of kindness
8. Keep unaware
Bernatz SCAM Model
potential risk factors identified by the courts in
cases of undue influence, including opportunity,
motive,
unnaturalness
of
transaction,
susceptibility, and the use of unnatural devices.
In this chapter, we have emphasized clinical
factors that psychologists can assess and
potentially describe in a report provided to the
courts as evidence. The frameworks presented
differ in their specifics, but there are some
important common elements to keep in mind
while conducting an assessment. These include
factors that increase susceptibility of the victim,
the presence of a confidential relationship, a
mechanism for fraud to occur, and monetary
transfers that benefit the alleged influencer.
Writing About Undue Influence in
Your Report
Undue influence evaluations include all of
the information that goes into a capacity
assessment (purpose of evaluation, history of
problem, medical, social, occupational history,
neuropsychological testing, discussion of results,
and financial capacity findings), as well as a
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discussion of the factors that have contributed to
the older adult’s susceptibility to undue
influence. Copious records are gathered in these
cases to develop a timeline of events and to
factually support the expert’s opinion. These
records may include medical, law enforcement,
legal and financial, deposition testimony, estate
planning documents, interviews with the victim,
and collateral informants.
Case Example
Ms. Johnson is an 86-year-old female referred
for a neuropsychological evaluation to determine
her decisional capacity to make financial
decisions for herself and to determine relevant
factors that may have contributed to Ms.
Johnson’s susceptibility to undue influence and
inability to resist fraud in the time frame in
question.
Presenting Problem
Ms. Johnson is an 86-year-old widowed
female currently residing in her home. She owns
her home and given its proximity to the ocean, it
is worth over $2 million. The case was initially
brought to APS due to a potential case of
physical and financial elder abuse. The primary
referral questions were to assess Ms. Johnson’s
ability to complete financial transactions and to
assess whether or not she was susceptible to
undue influence. The APS report documented
the following concerns: the victim had made
recent changes to her will and trust. However,
she had carried a diagnosis of dementia since
early 2003. Furthermore, APS reported that Ms.
Johnson prepared a cassette tape that discussed
her final wishes—to have an autopsy of her
body and an accounting of her estate upon her
passing. Her housekeeper was the reporter in
this case and handed over the tape to law
enforcement.
This request for autopsy was in direct
opposition to her previous wishes as set forth in
a Durable Power of Attorney over Health Care
written in 2003. Further, she had voiced to
friends that she thought the alleged influencer
was “trying to kill her.” At the same time, the
victim seemed powerless to escape from the
confidential relationship, as she had become
completely dependent upon suspect. Interviews
with neighbors indicated that the alleged
influencer had moved in with the victim shortly
after the loss of her husband and provided
welcomed companionship. The victim and
alleged influencer appeared to have met at a
church that they both have belonged to for years.
At first the two were seen as close friends, even
traveling together on vacation. Over time, the
relationship became increasingly exploitive.
Financial records indicated that the victim had
paid for the alleged influencer’s living expenses
for the past five years and had given her
$800,000 in payments by check and account
transfers. In summary, the victim was at risk for
financial and physical harm. Based on the above
information
a
medical
workup
and
neuropsychological evaluation were conducted.
Informed Consent
Ms. Johnson was explained the purpose of
the evaluation and that the results may be used
by this examiner in court in prosecution and
litigation involving financial decision making
and undue influence. She appeared to understand
the purpose, risk, and benefits of the assessment
and consented to the evaluation.
Social History
Ms. Johnson reported that she was raised in
a local community, in a close family with
several siblings who are all now deceased. She
reported that she attended high school and junior
college without difficulty. She was married to
her husband for over forty years although had no
children from this union. She enjoyed working
as an office manager for a local company for
over 25 years, but then retired and enjoyed
traveling with her husband.
Medical History
Ms. Johnson carries a history of multiple
cancers, and is post p surgery and chemotherapy
in 2002. Additionally, she has a history of
hyperlipidemia,
hypertension,
macular
degeneration and depression (1993-2005).
Current Medications
Restoril
Actonel
Clonidine
7.5 1 qhs prn
35 1 TAB
HCL .1 mg. qd
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Neuroimaging was performed in 2003 and
the CT findings revealed an old lacunar infarct
in the left cerebellar hemisphere and mild
microvascular ischemia in the left frontal lobe.
Additionally, Ms. Johnson was seen by a
neurologist in July of 2003 where her
performance on the MMSE was 24/30. At this
time she was placed on Aricept, although she
stopped taking the medication. Ms. Johnson did
not have any follow-up visits with the
neurologist. Ms. Johnson is completely
dependent on the alleged influencer, who has
hired caregivers to take care of her in her home.
Ms. Johnson needs assistance with dressing,
showering, meal preparation and clean up, home
maintenance, bill paying, transportation, and
medical advocacy and support.
Clinical Interview
This examiner met with Ms. Johnson in her
home. She was casually dressed, well coiffed,
and presented with good hygiene. She was
pleasant and cooperative and her mood appeared
to be slightly blunted and her affect mildly
restricted. At times she appeared anxious, asking
if the alleged influencer was in the home and
checking the time. She displayed consistent
motivation throughout the evaluation and results
of this testing are judged to be a valid indicator
of her current ability.
During the clinical interview Ms. Johnson
was a poor historian and unable to provide
global or detailed histories with regard to her
medical conditions or her finances and estate
planning. When asked if she had any previous
history of surgeries she remarked, “not that I
know of.” Ms. Johnson was also deficient in her
financial knowledge. She could not recall where
she did her banking, what the name of her
brokerage institution was, or what was the
purpose of a trust. Ms. Johnson did acknowledge
that in early 2004 she began to give the suspect
an “allowance” of $500 a week in exchange for
the suspect’s care-giving duties and assistance
with managing her finances. She denied ever
giving the suspect any financial gifts or loans.
Cognitive Testing
On the Repeatable Battery for the
Assessment of Neuropsychological Skills
(RBANS) she had the following results:
Ability
Attention
VisualSpatial
Language
Immediate
Memory
Delayed
Memory
Percentile
58%
< 1%
Range
Average
Severely Impaired
8%
0.1%
Borderline
Impaired
0.1%
Impaired
Additional executive testing found severe
impairment on Trails B, although average ability
on the clock drawing task. Functional testing in
the area of money management on the
Independent Living Scale (ILS) placed her
performance in the impaired range or requiring
supervision in the area of money management.
When asked to name one thing she could do to
keep from being cheated out of her money she
replied, “I have no idea, I don’t know how to
stop it.”
An assessment of mood using the Geriatric
Depression Scale was consistent with the
presence of significant depression (18/30). In
addition, the client reported symptoms
consistent with an anxiety disorder, including
feeling fearful, on edge, and reported that she
worried all the time about the alleged influencer.
Summary
Ms. Johnson is an 83-year-old female with a
history of multiple medical surgeries who is
currently living at home with 24-hour, 7-day a
week care. Concerns about her current financial
decisions and the possibility of her being a
victim of elder physical and financial abuse have
been raised. Specifically, it is alleged that she
may have been the victim of undue influence.
Based on clinical interview and cognitive
testing, the following conclusions are offered:
Regarding her cognition she has adequate
attention, however her short- and long-term
verbal memory, executive functioning, and
visual spatial abilities are impaired. She was
impoverished in her ability to adequately explain
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her current finances or perform simple and
complex financial tasks (write out two checks
and reconcile the amount with a balance
previously given to her) and to perform a simple
two-step operational math problem (if her
medical insurance company pays for 20% of her
medical bill of $350, what does she owe). She
was also unable to describe what the purpose of
a trust or will.
Regarding her capacity to make financial
decisions it is this clinician’s opinion that Ms.
Johnson lacks the capacity to make financial
decisions given her cognitive dysfunction and
probable dementia diagnosis. She has a deficient
understanding of the nature and consequences of
her financial decisions. Ms. Johnson is unable to
manage her checkbook, understand her bank and
brokerage account statements, conceptually
understands the legal vehicle of a trust or will
and is unable to enter into either buy/sell
agreements with regards to her stock portfolio or
contractual agreements regarding her real estate.
Furthermore, it is also this clinician’s
opinion that Ms. Johnson has been susceptible to
undue influence for several years beginning with
the loss of her husband in early 2002. This
clinician’s opinion is based on a review of
medical, law enforcement, legal and financial
records; estate planning documents included in
this case record; cognitive testing and interview
with Ms. Johnson; interview with her caregiver,
and with friends of Ms. Johnson’s for 15 years;
deposition testimony from her caregiver, estate
planning attorney, and the alleged perpetrator;
and a review of the deposition video of the
perpetrator.
There are numerous factors that contributed
to Ms. Johnson’s susceptibility that include: her
psychological and medical conditions, (history
of depression 1993-2005), cognitive deficits,
dementia syndrome, depression and anxiety, and
medical conditions, which included a history of
cancer). Further, Ms. Johnson has been
dependent on the alleged influencer for all of her
IADLS, including medical and financial
assistance. The alleged influencer is aware of
Ms. Johnson’s difficulties but did not provide
Ms. Johnson with any third-party advisers to
help in the management of her estate or to
provide Ms. Johnson with a system of checks
and balances. Additionally, Ms. Johnson
changed her disposition plan to her will in the
time in question to benefit the alleged influencer
and these changes were significantly different
from Ms. Johnson’s previous plans and wishes
that appeared to benefit several foundations, and
friends, as well as the alleged influencer. The
alleged influencer initiated the transactions and
was solely responsible for transferring the large
amount of assets into an account that she held
jointly with Ms. Johnson.
Furthermore, Ms. Johnson instilled her trust
and confidence to the alleged influencer. Ms.
Johnson was befriended by the victim at a
church that they both had belonged to for
numerous years. The alleged influencer initially
began to assist Ms. Johnson with some of her
care-giving needs and much-needed social
support after the death of her husband. Due to
the victim’s infirmities and isolation from others
Ms. Johnson became more dependent on the
alleged influencer, which eventually led to the
suspect paying the victim’s bills, reconciling her
bank account, and eventually obtaining a
Durable Power of Attorney over the victim’s
finances. Eventually, the alleged influencer also
moved in with the victim and opened many new
bank accounts with both her and the victim as
co-signors. The victim was unaware of the new
accounts that had been opened. According to the
detective’s report and the forensic handwriting
analysis, Ms. Johnson did not write any of the
checks that were written to the alleged
influencer. Unfortunately, Ms. Johnson’s trust,
dependency, and vulnerabilities appeared to
have been exploited for the alleged influencer’s
financial gain.
Recommendations
1. Financial and physical protection of Ms.
Johnson. Based on the results of this
evaluation, it is recommended that Ms.
Johnson be appointed a temporary
conservator to oversee her health care and
finances and represent Ms. Johnson until
this investigation and litigation is over.
2. Dementia work-up. Results of this
evaluation reveal that Ms. Johnson has an
insidious memory decline and cognitive
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testing consistent with a dementia syndrome.
A full medical evaluation for dementia and
reversible causes of cognitive impairment
are recommended.
3. Ms. Johnson is currently on medications that
have the potential to impair cognition. A
medication evaluation is recommended.
4. Ms.
Johnson
evidenced
significant
depression and anxiety symptoms during the
evaluation, and further treatment is
recommended. Ms. Johnson may benefit
from a thorough mental health work-up,
including
psychopharmacological
and
psychosocial interventions.
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VIII. Working with Lawyers and Courts
Psychologists engaged in capacity assessment
may receive referrals from lawyers for
evaluations, and will respond to court orders for
clinical evaluation in guardianship proceedings.
This chapter will examine key factors in
working with lawyers, including consultations,
requests for formal assessments, client consent,
information needed, and use of the report. Next,
the chapter will describe how psychologists can
best work with the court in the context of a
guardianship proceeding.
Accepting Referrals From a Lawyer
When and Why a Lawyer Might Seek
Your Help
Capacity evaluations can be valuable to
lawyers and their clients because they furnish
objective cognitive and behavioral data and
professional expertise. The potential uses of
clinical opinion on client capacity include:
• Determination of whether a prospective client
has sufficient legal capacity to enter into a
lawyer-client relationship;
• Determination of whether a client has
capacity to undertake a specific legal
transaction;
• Evidence in a guardianship proceeding;
• Expert testimony in a deposition or
courtroom hearing;
• Clarification of the areas of diminished
capacity, as well as retained strengths;
• Affirmation of the client’s capacity;
• Expert opinion on conclusions of other
psychological evaluations, including those
submitted by opposing counsel;
• Justification of the attorney’s concerns about
capacity to disbelieving clients and family
members;
• Expert advice on strategies to compensate for
identified mental deficits;
• Indication of the need for protective action by
the attorney; and
• Recommendations concerning any follow-up
testing.
How to Connect with Lawyers
Lawyer referrals for capacity consultation or
assessment can enhance your practice and
sharpen your expertise. Legal rules of ethics on
clients with diminished capacity allow the
lawyer to find an “appropriate diagnostician,”
but do not specify who is “appropriate” nor how
to identify such a practitioner. Psychologists can
help to make the connection—reaching out and
developing referral resources so that a lawyer
will know where to turn when the need arises.
One starting point is the local Area Agency
on Aging for the county, city, or multi-county
area of your practice. Under the Older
Americans Act, Area Agencies on Aging are
responsible for planning and funding a wide
range of services for older persons. They
typically provide extensive information and
referral services, and it would behoove a
psychologist whose practice focuses on older
people to seek out and meet with the nearest
Area Agency on Aging. Such agencies
frequently are in close touch with local elder law
attorneys. To find your local Area Agency on
Aging, contact the Eldercare Locator at 1-800677-1116, or online at www.eldercare.gov.
State bar associations have sections on aging
or disability; a list is available from the ABA
Commission
on
Law
and
Aging
(www.abanet.org/aging/resources/statemap.shtm
l). Some local bar associations have sections or
committees as well. In addition, the National
Academy of Elder Law Attorneys has members
throughout the country, and a number of state
chapters (www.naela.com). In areas without a
bar committee on aging or a NAELA chapter,
interested psychologists could contact the local
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probate or mental health section of the bar
association. An offer to make a presentation on
capacity assessment often will be welcomed by
state or local bar groups.
Also, get to know local legal services staff.
Some legal services or legal aid programs have a
designated attorney or paralegal serving elders.
Often these programs are funded through the
Area Agencies on Aging with Older Americans
Act funds. Finally, each state has a “protection
and advocacy agency” designated under federal
law to provide legal representation and other
advocacy services to people with disabilities.
Connections with this state office may be useful,
as well (http://www.napas.org/).
Consultation: A lawyer’s conversation with
a clinician to discuss concerns about the
client’s presentation. Usually client is not
identified and consultation does not require
client consent.
Referral: A formal referral to a clinician for
evaluation, which may or may not result in a
written report. Requires client consent.
Informal Consultation with a Lawyer
It is important to distinguish informal
consultations that a lawyer might seek with a
psychologist from formal referrals for
assessments.
Sometimes—instead
of
or
preliminary to seeking a formal assessment—a
lawyer may seek an informal private
consultation to discuss and clarify specific
capacity issues before proceeding further with
Uses of informal consultation
•
•
•
•
Clinical interpretation of problem
Informal clinical opinion on capacity
Suggestions for enhancing capacity
Additional questions to ask client
If client is not identified, no consent
necessary, and lawyer pays fee.
representation. In such a consultation, the lawyer
can discuss client communications and
reactions, as well as the legal transaction for
which capacity is required. The lawyer can seek
an informal opinion on the question of
capacity—and on the question of whether a
formal assessment is necessary. The clinician
can raise questions the lawyer might have
overlooked, allay or reframe the lawyer’s
concerns, and suggest strategies for enhancing
client capacity.
A preliminary up-front consultation on
capacity can bring a lot of “bang for the buck”—
in some cases saving the lawyer and the client a
great deal of time, money, and angst if it avoids
an unnecessary formal assessment. Or it may
provide reassurance that a formal assessment is
indeed the right step, as well as an indication
about what kind of assessment might be optimal.
In such an informal consultation, the client
may or may not be identified. If the client is
identified in the consultation—or if your
community is small enough that the lawyer
would know who the client is— ethical
considerations on client consent come into play,
just as they would for a formal assessment (see
below). However, if the client is not identified,
the question of consent for the assessment does
not arise. The consultation is simply professional
advice to the lawyer, paid for by the lawyer—
simplifying the process greatly.
Referrals for Formal Assessment
An attorney may feel compelled by capacity
concerns, litigation strategy, or other case
circumstances to seek an independent formal
capacity evaluation by a psychologist or other
clinician. Such a decision is significant because it
necessarily involves disclosure to the client of an
attorney’s concerns or litigation strategy, and
requires a client’s consent. It represents a
significant step by the attorney that can impact
the attorney-client relationship in both positive
and negative ways.
Be aware that a formal assessment is not
without danger for the lawyer, as there is a risk of
potential adverse use of the assessment against
the lawyer’s client. Though the report may be
protected under psychologist-patient privilege
and attorney-client privilege when the client
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refuses to consent to disclosure, these privileges
are variable under state law and subject to a host
of exceptions and interpretations. Their
protection from discovery in civil litigation is
not absolute (Powell & Link, 1994; Ludington,
1962). Thus, it should be emphasized that the
clinical evaluation need not result in a formal
written report. The lawyer may instruct the
psychologist to conduct the evaluation, and then
to call the lawyer with preliminary, unwritten
conclusions, after which the lawyer can state
whether or not the psychologist should commit
the opinion to writing. Thus, it is important for a
psychologist to clarify with the lawyer
beforehand whether a written report is desired.
Client Consents Needed in Referral From
Lawyers
If a lawyer seeks to refer a client to a
psychologist for a formal capacity assessment,
there are several hurdles of consent. It can be a
tricky process, since consent requires some level
of capacity, and capacity is at issue.
Lawyers are bound by ethical rules to get the
consent of the client for a clinical referral. As a
practical matter, there can be no referral unless
the client at some level agrees to have an
appointment with a clinician and to participate in
the interview and the selected assessment tests.
Once the client has made contact with the
psychologist or other clinician, the assessor will
need to ensure there is sufficient informed
consent to conduct the evaluation (see Chapter
4).
Finally, the clinician then must get the
client’s consent to provide the test results to the
lawyer under the privacy requirements of the
Health Insurance Portability and Accountability
Act (HIPAA, 1996).
What Information Do You Need from the
Lawyer?
To be most responsive to the lawyer’s
request for a capacity assessment, a psychologist
or other clinician needs full information. This is
best set out in a well-tailored referral letter from
the lawyer, which should include at least:
•
•
•
background information about the client
and the circumstances;
the reason for the referral—the legal issue
at hand; and
the relevant legal standard of capacity.
As noted in the Veterans Administration’s
Assessment of Competency and Capacity of the
Older Adult: A Practice Guideline for
Psychologists,
There is always a specific reason why
the psychologist is being consulted, and
it is often not clearly stated. The
psychologist must also understand the
circumstances under which the person is
allegedly unable to function under legal
standards for competency. What specific
areas of skill and function are at issue?
In what circumstances and places do
they occur? What other resources does
the patient have to assist him/her in this
matter? Why is the question being asked
now? Was there a critical incident? Are
there any major changes (e.g., surgery,
relocation), which have had or might
have a significant impact on this
individual’s ability to make decisions?
(U.S. Department Veterans Affairs,
1997, p. 29).
If the referral letter from the lawyer does not
include these elements, the clinician should seek
the information.
It is important for the clinician to
communicate with the lawyer orally, as well as
receiving a written request, to make sure there is
a clear understanding of the purpose for the
referral and the elements outlined in the referral
letter, as noted in the checklist on this page. The
aim is to ensure a complete and well-targeted
assessment that is worth the money spent.
Having to fill in gaps or ambiguities afterwards
is both costly and an inefficient use of
everyone’s time.
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Information Needed from Lawyer
1. Client background: name, age, gender,
residence, ethnicity, and primary
language if not English.
2. Reason client contacted lawyer; date of
contact; whether new or old client.
3. Purpose of referral: assessment of
capacity to do what? Nature of the legal
task to be performed, broken down as
much as possible into its elemental
components.
4. Relevant legal standard for capacity to
perform the task in question.
lawyer-client relationship. Thus, the lawyer can
use the assessment report as valuable—often
conclusive—evidence, but still needs to “look
behind” the report and make an independent
judgment taking all factors into account. Ideally,
the lawyer will use the capacity assessment in
his or her own evaluation, including the steps
outlined in the ABA-APA capacity assessment
Handbook for Lawyers (ABA Commission on
Law and Aging et al., 2005, pp.13 - 26).
Once the lawyer has used the psychologist’s
report in making a legal judgment about the
capacity of a client, the report is subject to
multiple applications. The lawyer may:
•
•
5. Medical and functional information
known: medical history, treating
physicians, current known disabilities;
any mental health factors involved;
lawyers observations of client
functioning; need for accommodations.
•
6. Living situation; family make-up and
contacts; social network.
•
7. Environmental/social factors that the
lawyer believes may affect capacity.
8. Client’s values and preference to the
extent known; client’s perception of
problem.
9. Whether a phone consultation is
wanted prior to the written report.
How Will the Lawyer Use
Your Report?
Ultimately, the judgment about the client’s
capacity for the legal transaction at hand is the
lawyer’s to make. While the results of a clinical
assessment generally will be a determining
factor, client capacity to accomplish a legal task
is a legal decision and an inherent part of the
•
Maintain it in the file as evidence to support
the lawyer’s determination about capacity;
Use it as formal evidence in a judicial
proceeding;
Use it to help frame judicial orders for a
limited guardianship or conservatorship in
which the individual retains powers in areas
of retained capacity;
Take protective action as allowed under the
ethical rules for lawyers who have clients
with diminished capacity and who are at risk
of harm; or
Recommend to the client and family
appropriate
clinical
interventions,
placements or changes in lifestyle, based on
the report, before pursuing any legal
transactions.
Are Third Party Observers of Evaluations
a Good Idea?
Sometimes the lawyer may request to be
present during a formal evaluation, or demand
that a third party be present to observe the
testing. The lawyer’s aim is to ensure that the
test and questions are fair to the client and that
the test procedures are accurately administered.
The presence of third party observers in
psychological
evaluations
has
been
controversial; and the topic has triggered
position papers by professional organizations
and court decisions.
The American Psychological Association
Standards for Educational and Psychological
Testing (APA 1999) as well as other
professional sources (Anastasi 1988; McSweeny
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et al 1998; APA CPTA Guidelines, 2007)
indicate that the testing environment must be
free of distractions. The presence of a third party
observer may affect the client’s performance and
introduce a variable that deviates from the
standard testing procedure. Standardized test
manuals (e.g., WAIS-III Technical Manual,
1997) state that such observers should be
excluded from the testing environment. The
presence of a third party observer “may
represent a threat to the validity and reliability of
the data generated by an examination conducted
under these circumstances, and may compromise
the valid use of normative data in interpreting
test scores” (NAN, 1999). APA’s Statement on
Third Party Observers in Psychological Testing
and Assessment (2007) provides further
information, including situations in which a third
party’s presence may enhance validity (e.g.,
translator, caregivers in some situations).
The U.S. Supreme Court has stated that the
presence of an attorney during an evaluation
“could contribute little and might seriously
disrupt the examination” (Estelle v. Smith, 451
U.S. 454, 470 n. 14, 1981). However, it should
be noted that case law on third party observation
varies. For example, in Florida a recent criminal
case, Maraman v State of Florida (980 So.2s
1096 (2008), held that a defendant who raised an
insanity defense to murder charge was entitled to
have an examination by a clinical psychologist
videotaped. The court referred to the state’s
“liberal policy governing the attendance of third
persons at examinations in adversarial settings”
and found that “a person who is required to
submit to a mental examination in an adversarial
proceeding or setting is entitled to have the
examination attended by her attorney and a court
reporter or videographer, subject to the court’s
authority to limit attendance for good cause. “
If an attorney request third party
observation, it is important for the clinician to
make the lawyer aware of the potential for
altered test results, and the statements by
national clinical organizations. If the attorney
insists on the observation, the psychologist may
decline to conduct the evaluation, could alter
testing procedures to minimize the intrusion, or
consider other options outlined in the APA
statement.
Working with the Court in Judicial
Proceedings, Including Guardianship
In addition to receiving referrals from
lawyers, psychologists sometimes are involved
in court proceedings. Psychologists may give
depositions or be called to testify in court as an
expert in capacity assessment in a range of
judicial settings, including adult guardianship
cases.
Psychologists in Court
Capacity can become a key focus in
litigation—for example, in a will contest when
the capacity of the testator is at issue; in a
dispute about medical treatment in which the
ability to give informed consent is questioned; or
in civil litigation in which contractual capacity is
a factor. Psychologists can make important
contributions, providing essential evidence in
such cases. Judges will frequently rely on the
statement of a psychologist in making tough
decisions about the capacity of an individual to
perform a specific task. Whether giving a sworn
deposition or being called to court as an expert
witness, psychologists should be prepared to
establish their qualifications in capacity
evaluation. In court, you may be examined by
the opposing attorney about your credentials, the
depth and currency of your knowledge, the
evaluation of the individual, and your opinion as
to capacity. Be prepared! An excellent reference
is Brodsky (1991), Testifying in Court:
Guidelines and Maxims for the Expert Witness,
as well as additional resources by Brodsky
(Brodsky, 1991; 2004). He explains:
For the past 20 years I have been leading
workshops for mental health professionals
about testifying in court. What I have
learned is that for some potential expert
witnesses, the prospect of ever testifying in
court is frightening. For other witnesses, a
particular kind of case is difficult . . . . For
still other expert witnesses, testifying is a
time of professional mastery, occasionally
elation, a chance to explain and defend their
knowledge in a public forum.
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Brodsky gives 62 maxims to help potential
expert witnesses prepare and to respond to crossexamination. For example:
•
•
•
•
•
•
“Review current literature on the topic
about which you will testify.” The
references in this handbook should be a
good start.
“Witnesses often feel like aliens in the
courtroom. The solution is to be present
often and to develop a sense of place
identity.” He advises going into the empty
courtroom alone and sitting for a while or
sitting in on other trials.
“Meet with the attorney prior to the direct
examination and be involved in preparing
the questions.”
“Prepare a list of professionally relevant
and complete qualifying questions for the
attorney to use in the opening of the direct
examination.” If challenged, “comfortably
agree with accurate challenges to your
credentials. Offer narrative explanations
only when they are non-defensive and
unforced.”
What if you make a mistake? “After a
disaster during testimony, correct the error
as soon as you can. If you cannot, let it
go.”
You may get a question about “examiner
effects”—the influences a psychological
examiner has on a client. “Crossexaminations about examiner effects call
for the witness to explain how training and
standardized procedures diminish such
effects.”
Brodsky and similar sources give additional
tips for expert witnesses to help you amplify the
Be Prepared to Testify in Court
•
•
•
•
.
Review relevant literature.
Become familiar with the courtroom.
Work with the attorney prior to direct
examination.
Don’t be defensive.
points in your evaluation and give the court an
accurate picture of the strengths and weaknesses
of the alleged incapacitated person.
Guardianship Proceedings
The remainder of this section concerns the
role of psychologists in evaluating an alleged
incapacitated
individual
in
an
adult
guardianship proceeding. Such proceedings will
become increasingly more frequent in the
coming years as t as the aging of the population
and the number of old-old increases, and the
number of individuals with Alzheimer's disease
rises, and the population of younger adults with
intellectual disabilities rises.
What Is “Incapacity” in Guardianship
Law? Guardianship is a relationship created by
state law in which a court gives one person or
entity (the guardian) the duty and power to make
personal and/or property decisions for another
(the ward or incapacitated person). The
appointment of a guardian occurs when a judge
decides an adult individual lacks capacity to
make decisions on his or her own behalf (Quinn,
2005). Each state has an adult guardianship
statute providing for a specific process and
procedural protections for the alleged
incapacitated individual. State terminology
varies. Under the Uniform Guardianship and
Protective Proceedings Act and a growing
number of state laws, a “guardian” makes
personal decisions concerning health care, living
arrangement,
and
lifestyle;
while
a
“conservator” makes financial and property
decisions—but some states use different terms.
For example, the law might refer to a “guardian
of the person” and “guardian of property”—or a
“conservator” might encompass both, as in
California. (See Glossary at Appendix A.)
Each state law sets out a definition of
incapacity. As outlined in Chapter 3, these
definitions have changed over time, moving
from medical labels—often including archaic
discriminatory terms such as “senility” and
“imbecility”—toward a four-pronged approach
including: (1) medical condition; (2) cognitive
impairment; (3) functional ability; and (4) risk of
harm. State laws combine various of these
elements as guidance for judges in determining
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the capacity of an adult against whom a petition
for guardianship has been brought.
Statutes in the vast majority of states
provide for a clinical examination as evidence of
incapacity, and some 31 state laws specifically
include a psychologist in the range of clinical
experts (Teaster, Wood, Schmidt & Lawrence,
2007; see chart of Hurme et al., 2006). (Other
examiners named by state statutes include
physicians,
psychiatrists,
mental
health
professionals, social workers, nurses and “other
qualified professionals.”) In approximately 30
states a clinical examination is required, while
some 15 states leave this to the discretion of the
judge, and the remainder of states give no
statutory direction (Mayhew, 2005; Moye,
Wood, Edelstein, Armesto, Harrison, Bower &
Wood, 2007; Moye, Butz, Marson, & Wood,
2007).
The Uniform Guardianship and Protective
Proceedings Act, which serves as a model for
state legislation, calls for examination by “a
physician, psychologist, or other individual
appointed by the court who is qualified to
evaluate the respondent’s alleged impairment.”
(Uniform
Guardianship
and
Protective
Proceedings Act, 1997). A growing number of
states
provide
for
a
comprehensive,
interdisciplinary team approach—such as an
evaluation by a physician, psychologist, and
social worker.
What Can a Guardianship Capacity
Evaluation Include? Clinical evaluation is
critical to the judge’s determination of capacity
and appointment of a guardian. However,
historically assessments frequently have been
limited. Sometimes a clinician simply and
briefly states a conclusion about capacity, rather
than offering a detailed and nuanced description
of the findings. Indeed, a 2006 study examined
clinical evidence of guardianship in three states,
rating evaluations on diagnosis, prognosis,
cognitive or psychiatric symptoms, functional
abilities, values or preferences, and social
system. The study found that many of these
elements often were missing; and over 28% of
the files included conclusory comments without
supporting statements or documentation (Moye
et al., 2007). Such a conclusory letter may be of
little value to the judge in fashioning a
guardianship order (Bulcroft, Kielkopf, & Tripp,
1991; Dudley & Goins, 2003; Moye, et al,
2007). Without a clear picture of the individual,
the judge will be working in the dark in trying to
make an informed, fair, and tailored decision
about the person’s capacity and the intervention
necessary.
The practice of submitting a conclusory or
“short shrift” statement may be due to lack of
direction from statute or from the court as to the
format, content, and scope of the assessment—
or lack of conceptual models and instruments for
assessing capacity in guardianship. If clinicians
provide information on all of the nine elements
in the model set out in Chapter 3 in reports
submitted to court in guardianship proceedings,
the quality of information judges have before
them will be greatly enhanced.
In addition, clinicians should be aware of
any statutory guidance concerning the
information needed in a clinical assessment.
Statutes in 23 states offer such guidance
(Mayhew, 2005). Court rules and court orders
also may specify the elements of an evaluation.
The court also may direct the clinician to
indicate whether the individual can attend the
hearing, and if so, what accommodations should
be considered. The individual has a right to be
present, and the court must provide reasonable
accommodations under the Americans with
Disabilities Act. About half of the state laws and
Uniform Act require that the person be present
unless good cause is shown (for more
information refer to your state statute). Often
people may want their “day in court” and feel
Doing a capacity assessment for
guardianship? Check three sources of
guidance:
1. The nine-element model set out in
Chapter 3;
2. Any statutory provisions or court rules on
assessment elements; and
3. The court’s or party’s request for
assessment.
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more satisfaction from the hearing if they are
present and involved, whether a guardian is
appointed or not. Additionally, presence in court
allows the judge an opportunity to observe the
individual. The person may or may not become a
witness in the case. However, a medical
condition may prevent presence—or the person
may not wish to come.
It is useful when the psychologist’s report:
•
•
•
Makes the judge aware of any possible
reversible causes of impairment—such as
delirium, depression, or the effects of
medications.
Indicates any possible mitigating factors
that might be masquerading as
impairment—such as hearing loss, grief,
malnutrition, or educational or cultural
barriers.
Indicates any possible less restrictive
alternatives to guardianship. For example,
perhaps the individual maintains the
ability to execute a health care advance
directive or a financial power of attorney.
Consider any less restrictive alternatives, see
Appendix F.
Is the Evaluation Request from Court or
From Parties to the Proceeding? The role of
the psychologist may differ depending on
whether the evaluation is ordered by the court or
is requested by the petitioner or the respondent.
The court may order an evaluation at any
stage of the proceeding, if additional clinical
input is needed. Many courts have specific
forms for the evaluator to complete. The form
may or may not lend itself to inclusion of all of
the handbook elements and the additional
information helpful to the judge. A cover letter
or a more extensive attachment may be
permitted, allowing for further specificity. The
ABA-APA “Model Clinical Evaluation Report”
is a tool that may be helpful to clinicians in
completing the report (available in the ABAAPA judges handbook: www.apa.org/pi/aging).
For the court-ordered evaluation payment may
come from the estate of the alleged incapacitated
person, from the court budget—or in specific
instances may be covered by Medicare,
Medicaid or private insurance.
The psychologist needs to consider the
consent of the individual for the evaluation.
State law may address the right to refuse to
participate in an evaluation. As with attorney
referrals, practically, there can be no evaluation
unless the individual at some level agrees to
participate in the interview and the assessment
tests. The clinician could wait for a time in
which the person is stabilized, explain the
assessment, and seek at least an “assent.”
A different scenario arises if one of the
parties—the petitioner or the respondent—
requests a statement for the guardianship
petition or hearing, or requests the release of a
letter or statement previously prepared from an
evaluation prior to the petition. The party may
supply the psychologist with the court form for
clinical statements—or simply may request a
letter or statement to be attached to the petition
or submitted to the court. The clinician should
seek to include the same elements discussed
above, offering a thorough capacity analysis.
The clinician would have similar concerns in
seeking the individual’s consent. If the request is
for release of an earlier report or statement,
consider whether it is still timely and accurate or
needs to be supplemented with more current
information.
What does a limited order look like?
What does a guardianship plan look like?
For examples, refer to the ABA-APA
Handbook for Judges at:
http://www.apa.org/pi/aging/capacity_judges_handbook.pdf
It is important for psychologists to
understand that HIPAA (1996) differs depending
on whether the evaluation is ordered by the court
or requested by the petitioner. If a court orders
the evaluation, there are no barriers under
HIPAA in providing the results to the judge,
since under federal regulations, a “covered
entity,” including a psychologist, may disclose
protected health information to comply with a
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court order, as long as the disclosure is limited
to the protected health information expressly
authorized by the order (45 C.F.R.
164.512(e)(1)(i)) (You do not have to disclose
your informal psychotherapy notes). The
psychologist needs to explain to the individual
that patient-therapist confidentiality does not
apply when a court orders the evaluation.
However, if the information is requested by the
petitioner, HIPAA protections come into play,
and any disclosure would require the
authorization of the individual.
How Will the Court and Guardian Use
Your Report? Your evaluation report
frequently will be the key piece of evidence on
which the judge will rely in making a decision
about the capacity of the individual and the need
for appointment of a guardian. Judges typically
don’t have training in mental health or
psychology, and look to expert advice on which
to base their judicial opinion. Because
guardianship removes fundamental rights it is
incumbent on psychologists to offer an informed
and thorough assessment.
In addition to determining whether a
guardian is needed, the judge decides the scope
of the guardianship order. A full or “plenary”
guardianship transfers all rights and powers of
the individual to the court-appointed guardian,
reducing the person to the status of a child—
except for any remaining rights preserved by
statute. A “limited” guardianship transfers
rights and powers only in those areas in which
the judge determines the person lacks capacity.
The principle underlying limited guardianship is
that there is no “bright line” of capacity—that
incapacity need not be all or nothing.
In 1982, the Uniform Guardianship and
Protective Proceedings Act included limited
guardianship provisions, giving a major boost to
adoption of the concept in state law. Today
virtually all state guardianship statutes include
provisions for limiting or tailoring the court
order—in some cases stating a preference for
limited
guardianship
over
plenary
guardianship—and most include language
acknowledging the importance of “maximizing
self-determination and independence” of the
individual.
Such language on limited guardianship,
however, is difficult to put into practice. A 1994
study found that nationwide the overall rate for
use of limited guardianships (excluding one
high-use state) was about 5% (Center for Social
Gerontology, 1994)—and while there are no
recent statistics, usage appears low. Limited
guardianship requires that the judge tailor each
order to fit the specific areas of ability of the
individual. A legal scholar postulated that:
Judges are not like baseball umpires, calling
strikes and balls or merely labeling someone
competent or incompetent. Rather, the better
analogy is that of a craftsman who carves
staffs from tree branches. Although the end
result—a wood staff—is similar, the process
of creation is distinct to each staff. Just as
the good wood-carver knows that within
each tree branch there is a unique staff that
can be “released” by the acts of the carver,
so, too, a good judge understands that,
within the facts surrounding each
guardianship petition, there is an outcome
that will best serve the needs of the
incapacitated person, if only the judge and
the litigants can find it (Frolik, 2002).
Your evaluation report is the key tool that
may enable a judge to craft such a nuanced
order. Ultimately, the shape and extent of the
guardianship order—and the resulting retention
or removal of individual rights—hinges on the
quality of information provided by the clinician
and others who testify to the individual’s
abilities.
After the judge’s determination and order, a
psychologist’s evaluation report may have an
additional use—in guiding a plan to be followed
by the court-appointed guardian.
A guardianship plan is a forward-looking
document submitted by a guardian to the court
describing the proposed care of the individual
and reporting on past care. Guardianship plans
provide a baseline inventory that enables the
court to measure the guardian’s future
performance. Some state statutes include
requirements for guardianship plans. In other
cases, court practice may provide for the filing
of such plans. A 2005 AARP survey showed
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that close to 35% of responding guardianship
experts said their court requires guardians to file
forward-looking plans (Karp & Wood, 2006).
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IX. Emerging Issues
The past ten years has witnessed a tremendous
growth in the attention to capacity issues as they
affect older populations. While this book has
focused on six of the more common reasons for
referrals for civil capacity assessment of older
adults, a number of other areas represent
“emerging issues” in capacity assessment that
are receiving increasing attention in the
scientific, legal, and clinical literature.
Capacity to Participate in Mediation
“Dispute resolution” encompasses a broad
range of processes designed to assist parties in
resolving differences. While court adjudication
is one form of dispute resolution, it also
encompasses other alternatives such as
arbitration, mediation, conciliation, and use of
ombudsman programs. Dispute resolution is a
broad-based, rapidly growing movement
touching all sectors of society, including
government, business, labor, schools, consumer
affairs, and the family.
Mediation—one prominent form of dispute
resolution—is a process in which a trained
For more on dispute resolution, see the
ABA Section on Dispute Resolution
www.abanet.org/dispute/home.html and the
Association for Conflict Resolution
www.acrnet.org
neutral facilitator assists disputants in framing
issues in dispute, enhances communication
between parties, helps parties develop possible
solutions, and aids them in reaching mutually
acceptable agreements (Nolan-Haley, 1992; see
also www.mediate.com). The process is
voluntary, involving a willingness of the parties
to “come to the table” with a mediator present,
and to discuss the issues. The goal in mediation
is less “to win” than to reach a negotiated
agreement that reflects the interests of the parties
involved. The solutions are crafted by the parties
themselves, and can be more creative and more
suited to individual needs than might be possible
through court litigation or the third party
decisions of an arbitrator. Because the parties
have an “ownership” in the agreement, they may
have a sense of empowerment from their
involvement and may be more likely to abide by
the terms of the agreement. Yet there can be
risks that inappropriate use of mediation could
stifle an individual’s rights under law.
There are hundreds of community mediation
programs, court-annexed mediation programs,
and mediation practitioners throughout the
nation. Elder mediation is a growing field in
which meditative techniques are applied to
conflicts in areas such as adult guardianship,
bioethics,
housing,
consumer
affairs,
intergenerational differences, disability disputes
and long-term care conflicts (Wood, 2001). The
benefits of mediation in such contexts can be
significant, as mediation can offer a convenient,
timely, inexpensive, and empowering approach
toward solving difficult problems.
Sometimes issues of capacity arise in elder
mediation settings. Mediation is premised on the
notion that the disputing parties understand the
problem at issue and the process for resolution.
The mediator must determine whether the
parties have capacity to participate in the
process, always beginning with a presumption of
capacity. According to the Americans with
Disabilities Act (ADA) Mediation Guidelines,
the mediator should determine a party’s capacity
“on a case by case basis,” if and when a question
arises concerning ability to engage in the process
and ability to “give voluntary and informed
consent to any agreement reached.” The
Guidelines name several factors in the
determination: “The mediator should ascertain
that a party understands the nature of the
mediation process, who the parties are, the role
of the mediator, the parties’ relationship to the
mediator, and the issues at hand.” The
Guidelines caution that this determination
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should not “rely solely on a party’s medical
condition or diagnosis” and that “an adjudication
of legal incapacity is not necessarily
determinative of capacity to mediate”
(Americans with Disabilities Act Mediation
Guidelines, 2000).
Mediation experts Coy and Hedeen (1998)
name eight “minimal requirements” for
participation in community mediation, including
the ability to: (1) see how specific issues are
related and connected to each other; (2) focus on
one issue at a time; (3) understand cause and
effect, match events and consequences; (4) take
responsibility for one’s own actions; (5)
conceive of and respond to common measures of
time in the context of scheduling; (6)
comprehend the nature of a behavioral
commitment; (7) identify desired outcomes; and
(8) understand the mediator’s role.
Determining capacity of parties in
mediation, just as in other contexts, can be
difficult and ambiguous. Coy and Hedeen
suggest that mediators should not be hasty in
making judgments about lack of capacity, and
submit that the dangers of “rushing too quickly
to judgment” must be balanced with the integrity
of the mediation process. They caution against
overly strict screening criteria and “raising the
bar too high” so as to exclude parties from the
opportunities of mediation. The real question
might not be “can the party mediate” but “can
the party mediate with support?” Mediators need
to consider critical accommodations, such as
including a support person for a person with
possible diminished capacity; changing the time,
length, or setting of the mediation session;
allowing for frequent breaks; and checking
understanding with paraphrasing.
If a mediator determines that a party is
simply unable to participate and adhere to an
agreement, the next question is whether a
surrogate can participate on behalf of the
individual (Karp et al., 1997). The knotty
problem of capacity to mediate was highlighted
in the First National Symposium on Ethical
Standards for Elder Mediation in 2007
(Montgomery County Mediation Center et al.,
2007) and resulted in significant debate.
At some point a mediator may need
guidance on assessing mediation capacity, and
may turn to a psychologist. Psychologists must
understand the nature of mediation, and provide
an evaluation—either informal or formal—about
the person’s ability to understand the process
and issues at hand, make and abide by an
agreement. Also, psychologists will need to
differentiate the capacity to mediate from
conflict avoidance, culturally-based behaviors,
or other factors not related to capacity. There are
few screening tools to assess capacity to
mediate, but there are resources that might
provide some initial guideposts for consideration
(Coy et al., 1998; Karp et al., 1997). Interested
psychologists may wish to identify mediators or
mediation programs in advance and develop a
working relationship.
Capacity to Consent to Participate in
Research Studies
Psychologists may be asked to evaluate an
individual’s capacity to consent to a research
project, particularly those that emphasize the
inclusion of patients with neurological
conditions, such as Alzheimer’s disease, or
psychiatric diagnoses, such as schizophrenia, all
of which may involve some clinically relevant
cognitive impairment. However, these types of
issues could arise as part of a variety of studies
that include older adults as participants,
including those with any potential cognitive
impairment.
Capacity to provide informed consent for
research participation depends on the complexity
of the study in question. That is, a person may
have capacity to make an informed decision
about a simple low-risk study, such as one that
requires a paper and pencil interview, but not
have sufficient capacity to make an informed
decision about a study involving more complex
procedures, such as surgery. As a result,
psychologists may be called on to evaluate
prospective enrollees in research involving
potentially invasive procedures, such as a
lumbar puncture in a clinical trial. In most cases,
the Institutional Review Board responsible for
overseeing the research study will provide
guidance on how to handle the consenting
procedures
for
“decisionally
impaired”
participants; however, these procedures do not
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provide much direction in terms of defining
decisional impairment, so that the specifics of
that determination may be left up to the
psychologist.
Two recent reviews describe instruments for
medical and research consent capacity, such as
the MacArthur Competence Assessment Tool CR (Dunn, Nowrangi, Palmer, Jeste, & Saks,
2006;
Sturman,
2005).
However,
for
psychologists, it is important to understand that
capacity to consent to research participation
differs from treatment capacity in several
fundamental ways. First, and perhaps most
significant, the research study is not for the
participant’s personal medical benefit. Rather, it
is intended to advance knowledge and science.
In contrast, treatment is always meant to benefit
the individual’s medical status. Second, there
may be a conflict of interest within the research
setting that is not present in the treatment
setting. Specifically, the principal investigator of
the research study may benefit from increased
numbers of study enrollees, whereas this conflict
is not likely to occur in a treatment situation.
Third, federal regulations mandate what must be
disclosed when obtaining informed consent for
research participation, and these regulations,
which are monitored by the study’s local
Institutional Review Board, vary depending on
the level of risk involved in the research study.
If the psychologist is called upon to make a
determination about decisional capacity in a
research context, it is important that he or she be
knowledgeable about relations between capacity
to make an informed decision about research
participation and cognitive functioning. Older
adults with clinically relevant cognitive
impairment, such as Alzheimer’s disease, have a
reduced ability to provide informed consent for
participating in research (Karlawish, Casarett, &
James, 2002; Kim, Caine, Currier, Leibovici, &
Ryan, 2001). A recent study suggests that older
individuals with mild cognitive impairment, a
syndrome
with
circumscribed
cognitive
impairment but relatively preserved instrumental
activities of daily living (such as medication
management), may have more difficulties
providing informed consent for complicated
clinical trials than cognitively normal older
adults (Jefferson, et al., 2008). However, it is
important to remember that decisional capacity
is situation-specific, and cognitive impairment
or a neurological diagnosis does not mean that a
person automatically has impaired research
consent capacity (Marson, Schmitt, Ingram, &
Harrell,
1994).
Among
patients
with
schizophrenia, psychiatric symptoms are
generally not predictive of decisional capacity
(Palmer & Salva, 2007). In bipolar disorder,
manic symptoms may decrease the capacity to
consent to research (Misra, Socherman, Park,
Hauser, & Ganzini, 2008; Palmer, Dunn, Depp,
Eyler, & Jeste, 2007). Future research in this
area will increase our understanding of the
cognitive correlates of research consent capacity
across the cognitive aging spectrum and improve
specific assessment tools.
In the event that a cognitively impaired
individual is unable to provide informed
consent, a legally authorized representative may
be able to do so. However, the authority of a
health care proxy or guardian to consent to
research participation is not clearly defined in
law. In some states, if the research holds
therapeutic benefit, the health care proxy or
guardian may be authorized to provide surrogate
consent. For example, Utah’s healthcare power
of attorney statute (§ 75-2a-1106) an individual
may make an advance health care directive in
which the principal can authorize the agent to
consent to participation in medical research. In
some states, guardians may be required to seek
specific court approval for participation in
research. This area of law is likely to evolve.
Capacity to Vote
While voting is a fundamental right
protected by both federal and state constitutions,
it is balanced in law by a need to protect the
integrity of the electoral process. State
constitutions, election laws, and guardianship
laws all contribute to a complex matrix of voting
rights
for
individuals
with
cognitive
impairments. States have authority to regulate
the election process, including defining who is
eligible to vote (Hurme & Applebaum, 2007).
Federal election law allows states to
disenfranchise persons “by reason of mental
incapacity” (42 U.S.C. & 1973 gg-6 (a) (3) (B)
(2000) primarily to protect the electoral process
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from fraud and incompetent voting. The clear
majority of states have no disenfranchisement
provision for persons with a category of mental
impairment or disability (Hurme et al., 2007).
Specific state elections laws vary widely in their
descriptions of these provisions. In a few states,
including Massachusetts, the right to vote is
automatically revoked if an individual is placed
by probate courts as “under guardianship.” In
other states, the right to vote may be addressed
during guardianship proceedings. Because the
right to vote can not be delegated, an individual
under guardianship law either has the right to
vote or has lost it (Hurme et al., 2007).
The guardianship reform movement has
resulted in changes to most state laws that now
encourage the crafting of limited versus full
guardianships where it is at all possible (see
Chapter 2). Fortunately, these reforms are now
being adopted for voting rights. For example, a
growing number of states have specific
provisions that persons under full or limited
guardianships retain all legal and civil rights not
specifically taken away (Hurme et al., 2007).
For psychologists involved in guardianship
proceedings, there is an opportunity to protect
civil rights by explicitly addressing the client’s
ability to vote, despite other areas of weakness.
The assessment of voting abilities is
controversial and was one of the topics of a
recent symposium entitled Facilitating Voting
As People Age: Implications of Cognitive
Impairment, held in March 2007 at the
University of the Pacific McGeorge School of
Law.
The recommendations of the symposium
included a statement on capacity to vote. The
recommendation emphasized that capacity to
vote should be presumed, regardless of
guardianship status, and that state laws “should
explicitly state that the right to vote is retained
except by court order” in accordance with
procedural standards. The recommendation set
out a capacity standard as follows: “If state law
permits exclusion of a person from voting on the
basis of incapacity, a person should be
determined to lack capacity only if the person
cannot communicate with or without
accommodations a specific desire to participate
in the voting process.” This relatively low
standard presumes the capacity to vote, and is in
accordance with a key court determination
holding that a state bar to voting by reason of
cognitive impairment must only be enforced
through a specific judicial finding of an
individual’s inability to understand the nature
and effect of voting. (Doe v Rowe, 156 F. Supp.
2d 35, D. Me., 2001.)
There has been some work on tools to assess
ability to vote (e.g., the Competence Assessment
Tool for Voting (CAT-V) (Applebaum, 2007).
These tools are intended to be used when a court
specifically addresses the right to vote (e.g., in a
guardianship hearing regarding an individual
person) and should not be employed as
screening mechanisms at polling booths or in
long-term care facilities (Sabatino et al., 2007).
Future Directions
Capacity assessment of older adults will
become increasingly common in the coming
years. The convergence of several factors—
increasing longevity, the increased numbers of
adults in the United States reaching old age,
along with the increasing prevalence
neurocognitive conditions associated with aging,
and the tremendous intergenerational transfer of
wealth will make capacity assessment a
prominent public concern.
Psychologists’ expertise in standardized
cognitive and functional assessment will be
critical in enhancing the accuracy and
comprehensiveness
of
these
important
assessments that assist clinical and legal
professionals in balancing the need to promote
autonomy of older adults with the need to
protect and provide for those who are
vulnerable.
An emerging body of scientific literature has
been useful in enhancing the empirical basis of
these assessments, while a promising “first
generation” of capacity assessment instruments
may help to direct evaluators to more domain
relevant assessment.
Nevertheless, many areas of civil capacity
assessment of older adults remain largely
unexamined (e.g., sexual consent), particularly
in ways that are readily transferable to clinical
assessment in the here and now. Psychologists’
expertise in research is needed to advance the
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
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135
field. Many domains of capacity, and the related
concept of undue influence, would benefit from
studies that focus on development of assessment
instruments, as well as related work to define the
clinical risk factors associated with capacity loss
within neurocognitive or neuropsychiatric
conditions.
While additional research is critical to
enhancing the empirical basis of this evolving
field, clinical capacity opinions will of course
remain a professional judgment, informed by the
scientific literature and the clinical expertise of
the evaluator. As such, ongoing education and
training regarding these assessments will
continue to be needed.
Capacity is an evolving and complex
psycho-legal construct with clinical, ethical, and
legal dimensions. Vigorous interdisciplinary
collaboration between clinical, legal, and public
policy professionals will continue to be vital to
advancing the field of capacity assessment,
protecting rights, and furthering the accuracy
and utility of capacity assessment in resolving
important issues of autonomy and protection for
the growing population of older adults.
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Appendices
Available online at http://www.apa.org/pi/aging/programs/assessment/capacity-psychologisthandbook.pdf
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Appendix A. Glossary
Psychologists may be unfamiliar with legal terms that often arise in connection with capacity assessment
of elders. This glossary gives the basics. However, many terms vary considerably among the states. While
the glossary is a starting point, it is important to consult state law. Black’s Law Dictionary and the
National Guardianship Association’s “Guardianship Terminology” (www.guardianship.org) were helpful
in developing the list below.
Adult protective services (APS)
Those services provided to ensure the safety and well-being of elders and adults with disabilities,
who are in danger of being mistreated or neglected, are unable to take care of themselves or
protect themselves from harm, and have no one to assist them. Interventions provided by adult
protective services agencies include, but are not limited to, receiving reports of adult abuse,
exploitation, or neglect, investigating these reports, case planning, monitoring and evaluation—
and arranging for the provision of medical, social, economic, legal, housing, law enforcement or
other protective, emergency, or supportive services.
Alternatives to guardianship
Various legal tools, social services, and government programs that may delay or prevent the
appointment of a guardian and preserve autonomy for individuals not at risk to serious harm to
themselves/others or exploitation. Examples of legal tools include health care advance directives,
durable financial powers of attorney, and trusts. Government programs might include Social
Security representative payment and VA fiduciary appointments. Social services could include
nursing care, home health aides, case management, homemaker services, and congregate or
home-delivered meals.
Autonomy
Self-direction or self-governance. The APA Ethics Code refers to the principle of “Respect for
People’s Rights and Dignity,” including respecting rights and dignity of all people, including the
rights of individuals to privacy, confidentiality, and self-determination.
Advance directive
A written instruction guiding health care and/or appointing an agent to make decisions about care
in the event that an individual loses the capacity for informed consent and is unable to
communicate his/her desires at a future date.
Advocacy
In law, the act of assisting, defending, or pleading for another. In psychology, advocacy has been
considered more clinically, for example, when a geropsychologist advocates on behalf of a
patient to receive elder services. The APA Ethics Code refers to the principle of “Justice,”
including recognizing that fairness and justice entitle all persons to access to and benefit from the
contributions of psychology and to equal quality in the processes, procedures, and services being
conducted by psychologists.
Beneficence
An ethical principle regarding doing good for others, including intervening to positively benefit
another individual and prevent harm.
Best interests
A standard of surrogate decision-making based on what a reasonable person would consider the
optimal decision or arrangement for an incapacitated person, taking into account the least
intrusive and most normalizing approach possible given the individual’s needs—as opposed to a
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“substituted judgment” standard of decision-making based on the incapacitated person’s known
values or preferences.
Capacity
Generally, an individual’s physical or mental ability; a legal status presumed to apply to all
adults. Capacity is difficult to define globally, and, therefore, is generally defined in law in
reference to a specific task (e.g., capacity to execute a will). The word capacity was used formerly
to reflect a clinical opinion on which a legal decision about “competency” might be based, but is
now used to refer to the legal status as well as the clinical judgment. When used by legal
practitioners, the element of understanding is often referenced. For example, capacity may be
used to refer to the ability to understand the nature and the effects of one’s acts.
Case law
The aggregate of reported courts cases as forming a body of jurisprudence. The law of a
particular subject in a particular jurisdiction, as evidenced or formed by the decisions of judges in
court cases, as opposed to statutes, regulations, or other sources of law.
Civil capacities
Those capacities regarding the management of personal affairs, including parental capacities (i.e.,
child custody), personal decisions, financial decisions, consent to health care treatments, and
consent to research, as distinct from capacity as it may be defined in a criminal context, for
example “capacity to stand trial.”
Civil commitment
Civil commitment (or “mental commitment”) is a process in which a judge decides whether a
person who is alleged to be mentally ill should be required to go to a psychiatric hospital or
accept other mental health treatment. Such a legal judgment may follow a clinical decision to
involuntarily hospitalize an individual. Typically the clinical decisions must be followed by a
legal review within a short time period set out by law. Civil commitment is generally based on
whether the person is in danger of harm to self or others, and derives from the state’s police
power. Importantly, civil commitment does not change the person’s legal status concerning
capacity and does not result in the appointment of a guardian. In contrast, a judge’s decision in
guardianship derives from the state’s “parens patriae” responsibility to protect vulnerable
individuals.
Client
In the legal system, a person who employs or retains an attorney to represent the person in court,
or to advise, assist, or defend the person in legal proceedings and act on his or her behalf in any
legal business. One of the key elements in the lawyer-client relationship is confidentiality.
According to ethical rules, with limited exceptions, a lawyer may not reveal information relating
to the representation of a client unless the client gives informed consent. However, as provided by
the ABA Model Rules of Professional Conduct, when representing a client with diminished
capacity, a lawyer may take protective action, including revealing information about the client,
but only to the extent reasonably necessary to protect the client’s interests (Model Rule 1.14(c)).
Common law
A body of law based on rulings by courts, as opposed to statutory law. It is also called “case law.”
Competency
A legal status presumed to apply to all adults. This term previously was widely used to denote a
legal status, but recently the term “capacity” generally is used instead (see “Capacity”above). The
words competent and competency are sometimes still used in clinical settings, although it may be
helpful for psychologists to redefine their use to team members as “capacity to do x.”
Conservator
A person (family, friend, or paid professional), agency, or institution appointed by the court to
make financial decisions (e.g., management of assets, businesses, making contracts, making wills,
making gifts) for another who is determined by a judge to be unable to make such decisions. In
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some states, a conservator is called a “guardian of the property.” In a few states, “conservator”
refers generally to a guardian for adults.
Court
A governmental body of judges who hear cases, adjudicate disputes, and administer justice. In
many states guardianship hearings are held in a probate court, while in other states guardianship
may be in a general jurisdiction court, which hears all types of cases, including civil and criminal
matters.
Criminal capacities
Those capacities related to criminal charges and proceedings, including competency to waive
silence/counsel (Miranda), plead guilty, dismiss counsel/conduct one’s own defense, stand trial,
criminal responsibility (not guilty by reason of insanity), and execution (as opposed to “civil
capacities” above).
Deposition
Evidence given under oath and recorded for use in court at a later date. A psychologist may be
asked to give a statement under oath about an individual’s capacity, rather than or in addition to
appearing in court to testify. (See “discovery” below.)
Diminished capacity
A lessened ability to understand the nature of one’s acts in one or more domains. A person may
have capacity in some domains but not in others. A judge may find that a person has diminished
capacity and appoint a guardian whose authority is limited in scope to those areas in which a
person lacks capacity. Since capacity is not global in nature but task specific, some guardianship
reform recommendations urge that the term “diminished capacity” be used generally instead of
the term “incapacity.”
Discovery
An investigation conducted before trial of facts and documents in possession of the opposing
party. Discovery allows one party to question other parties, and sometimes witnesses. It also
allows one party to force the others to produce requested documents or other evidence.
Due process
Constitutional guarantees that the government will act fairly and with adequate process (such as
notice, opportunity to be heard, right to confront, and cross-examine witnesses) if it attempts to
deprive a person of life, liberty, or property.
Durable power of attorney (DPA)
A legal instrument used to delegate authority to another. The person who signs (“executes”) a
power of attorney is called the “principal,” and the person to whom authority is delegated is
called the “agent.” A “durable” power of attorney enables the agent to act for the principal even
after the principal loses capacity to make decisions, and is effective until revoked by the principal
or until the principal’s death. A durable power of attorney generally refers to financial decisions,
and can be an effective alternative to guardianship, allowing an individual to plan for the control
of his or her affairs in the event of incapacity.
Elder abuse
Any knowing, intentional, or negligent act by a caregiver or any other person that causes harm or
a serious risk of harm to a vulnerable adult. The laws vary from state to state, but broadly defined,
abuse may be: physical abuse, emotional abuse, sexual abuse, exploitation, neglect, or
abandonment. Elder abuse may be domestic (occurring in the elder’s home or in the home of a
caregiver) or institutional (occurring in a residential facility). A psychologist may receive a
request to evaluate capacity in a case in which elder abuse has been identified. In addition,
psychologists may uncover elder abuse during the course of a capacity evaluation.
Estate
All real and personal property owned by a person—for example, bank accounts and a home.
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Expert testimony
Testimony relating to a scientific, technical, or professional matter by experts—persons qualified
by their training, skill, or familiarity with the subject matter. Psychologists may be called to give
expert testimony on a person’s capacity in court. A person who gives expert testimony is an
expert witness. Expert testimony may be given in writing or orally in the court, but the term
usually refers to oral testimony.
Fiduciary
A person who has assumed a special relationship to another person or his/her property, such as a
trustee, administrator, executor, lawyer, guardian, or conservator. Thus, a fiduciary is a general
term to apply to many categories of decision-making and management arrangements. A fiduciary
must exercise the highest degree of care and accountability to maintain and preserve the person’s
rights and/or property within the fiduciary’s charge.
Financial capacity
Decision making regarding a number of financial tasks, such as general financial management of
assets and debts, writing checks, paying bills, knowing and using currency and coin, making
contracts, writing wills.
Forensic assessment instrument (FAI)
A term coined by Grisso (1986) to describe instruments that provide standardized, quantitative
methods with which to observe and describe behaviors of direct relevance to the law’s questions
about human capacities.
Guardian
A person (family, friend, or paid professional), agency, or institution appointed by the court to
make personal decisions for another. In some states, the term “guardian of the person” is used to
differentiate a guardian from a conservator or guardian or property. However, sometimes the term
“guardian” is used to refer to management of both personal and property decisions. A guardian’s
authority is often limited in some ways by statutes (e.g., a guardian by statute may not be able to
consent to ECT without special court permission) and can also be limited by the judge regarding
specific tasks or decisions based on the retained functional strengths of the person. (See “limited
guardianship/conservatorship” below.)
Guardian ad litem
A person, often an attorney, appointed by the court to represent the best interests of an alleged
incapacitated person during a guardianship proceeding, and/or who investigates the circumstances
surrounding the request for guardianship and makes recommendations to the court. Duties of a
guardian ad litem (GAL) vary substantially by state, Thus, GAL duties may include acting on
behalf of the individual and/or acting on behalf of the court. If a GAL is involved in a case, the
psychologist may wish to clarify whose interest the GAL is representing.
Guardianship
A legal mechanism established by a court after a hearing that empowers one party to make
financial or personal decisions or both (e.g., regarding a wide range of decisions—health care,
where to live, where to travel, money management, business arrangements, lawsuits) for another
individual, whom a judge determines lacks capacity to make such decisions.
Guardianship of person
A legal mechanism establish by a court after a hearing that empowers one party to make personal
decisions (see “guardian”) for another whom a judge determines lacks capacity to make such
decisions.
Guardianship of estate
A legal mechanism establish by a court after a hearing that empowers one party to make financial
decisions for another, whom a judges determines lacks capacity to make such decisions. In many
states guardian of the estate (or guardian of the property) is termed a “conservator.”
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Health care proxy
A person (“proxy” or “agent,” usually a family member or friend) appointed by another
individual (principal) to make health care decisions for the principal if and when he or she
becomes incapable of making such decisions. The proxy’s authority may be unspecified (to make
all decisions in accordance with the principal’s best interests) or may be specified (to make
decisions in accordance with instructions). A health care proxy can also include a person who has
the authority to make health care decisions on behalf of another through state law—often a family
member or a guardian. (That is, under some state laws, a person may be recognized as a legally
authorized proxy by virtue of his or her relationship to the patient in cases where a person did not
previously execute an advance directive or other such document.)
Incapacity
A legal status determined in a court whereby an individual is judged to lack sufficient ability to
make specific personal or financial decisions for him or herself. (This term formerly was used to
reflect a clinical opinion, but now is being used in legal settings instead of the term
“incompetency.”) Under the Uniform Guardianship and Protective Proceedings Act, an
incapacitated person means an individual who “for reasons other than being a minor is unable to
receive and evaluate information or make or communicate decisions to such an extent that the
individual lacks the ability to meet essential requirements for physical health, safety, or self-care,
even with appropriate technological assistance.”
Informed consent
Agreement to a treatment or other intervention that is based on adequate knowledge of the
condition and alternatives (is informed), is not coerced (is voluntary), by a person who has
capacity for such decisions. Informed consent is the process by which a fully informed patient can
participate in choices about health care. It originates from the legal and ethical right the patient
has to direct what happens to her body and from the ethical duty of the physician to involve the
patient in his or her health care.
Jurisdiction
The legal authority of a court to hear and decide a case. Also, the geographic area over which the
court has authority to decide cases
Least restrictive alternative
The least intrusive service or treatment that can effectively and safely address a person’s needs
and stated preferences. Also, “least restrictive alternative” is a constitutional principle providing
that the government may not pursue a legitimate purpose (such as protecting an individual who
lacks capacity) through means that broadly stifle rights when the purpose can be achieved more
narrowly. When there is a deprivation of rights and liberties for safety and protection, the less
drastic means possible must be used.
Legally authorized representative
An individual or judicial or other body authorized under applicable law to consent to specified
actions or decisions on behalf of an individual who lacks capacity to give such consent. A legally
authorized representative could include, for example, a guardian, or an agent under a power of
attorney. However, under specific statutory or regulatory frameworks, it may include other named
decision-makers and may be focused on particular decisions. For instance, a legally authorized
representative under Medicare can enroll individuals in Medicare plans. A legally authorized
representative in some mental health systems can make mental health decisions on behalf of
individuals with mental illness or intellectual disabilities.
Limited guardianship/conservatorship
A court order in which a guardian or conservator is given power and authority to make decisions
only in those areas or domains in which an individual lacks ability to make such decisions—as
opposed to a “plenary order” in which all rights and legal authorities are transferred from an
incapacitated person to a guardian.
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Litigation
A controversy before a court, often called a “lawsuit.” If the controversy is not settled by
agreement between the parties it is heard and decided by a judge or jury in a court. Litigation is
one way of resolving disputes. “Alternative dispute resolution” methods, such as arbitration or
mediation, offer avenues of settling controversies other than decisions by a judge or jury.
Parens patriae
A legal concept deriving from ancient English law in which the state as “parent” has a duty to
protect individuals who cannot protect themselves. The state may intervene via guardianship over
children, mentally ill, mentally retarded, and other vulnerable individuals.
Petitioner
A person or agency who makes a request to court. In the context of guardianship, the person who
files the petition alleging that an individual lacks capacity and requires a guardian.
Plenary guardianship
A guardianship order in which full rights and authority for making personal and financial
decisions is transferred from the individual who lacks capacity to make such decisions to the
guardian appointed by the court. A plenary guardianship order may be contrasted with a “limited
order” in which only some rights and duties are transferred.
Representative payee
An individual appointed by a benefit provider (e.g., the VA, Social Security Administration, state
agencies) when the provider questions the benefit recipient’s ability to manage the funds. The
payee receives and has responsibility only for the funds distributed by that provider. Importantly,
the determination of the recipient’s need for a payee is within the discretion of the agency, and
does not alter the individual’s legal status for decisions beyond the handling of the benefits.
Respondent
Person named as the subject of a guardianship petition who is alleged to be incapacitated to make
either some or all necessary personal or financial decisions. Also may be called “alleged
incapacitated person” or “proposed ward.”
Standard of proof
The extent of evidence that must be presented in a trial in order to win. Different cases require
different standards of proof depending on what is at stake—proof beyond a reasonable doubt
(criminal cases), by clear and convincing evidence, or a preponderance of the evidence. In many
states, determination of incapacity in guardianship cases must be by clear and convincing
evidence.
Statutory law
A statute is a law passed by a legislature—as opposed to case law, determined by judges in case
decisions that become precedent for future cases. Statutory law is the body of legislation, as in
state or federal codes.
Substituted judgment
The standard of surrogate decision-making that requires decisions in accordance with an
individual’s known values or preferences, as opposed to the “best interests” standard based on
what a reasonable person would deem best under the circumstances. Requires a guardian or other
decision-maker to “step into the shoes” of the incapacitated person.
Testamentary capacity
Capacity to execute a will.
Testator
A person who makes a will.
Trust
A legal instrument in which the owner of real or personal property (the trustor or settler) gives
ownership of the property to a trustee to hold and to manage for the benefit of a third party (the
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beneficiary). A trust can be a useful device for planning for the financial security of an
incapacitated individual.
Undue influence
Influence or coercion by someone who intentionally uses his or her role and power to deceive and
exploit the trust, dependency, and fear of another, gaining decision-making control of another. An
individual who is stronger or more powerful gets a weaker individual to do something that the
weaker person would not have done otherwise. The stronger person uses various techniques or
manipulations over time to gain power and compliance.
Uniform laws
Model laws drafted by the Uniform Law Commissioners for potential adoption by state
legislatures on subjects where uniformity is desirable and practicable. For example, there is a
Uniform Guardianship and Protective Proceedings Act and a Uniform Power of Attorney Act.
Uniformity between states helps when matters such as guardianship cross state lines Uniform
laws also are instructive in providing a potential model for useful and effective law.
Ward
Person for whom a guardian is appointed. The term generally is no longer used in recent
legislation. Other terms include: incapacitated person, disabled person, protected person,
conservatee.
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Appendix B. Functional Assessment
Functioning can be assessed through informal means, such as observing the individual, and asking the
individual, family, and staff questions, or through formal testing. Historically, functioning as been
formally assessed through ADL and IADL rating scales. These scales are valuable but are not focused on
functional assessment for the purpose of capacity evaluation – which is more closely tied with legal
definitions of capacity.
A number of instruments have been designed specifically to assess capacities. Such tools have recently
been developed, since the 1990s, and are summarized below. They are called “tools” because it is not
possible to have an exact “test” of capacity. Capacity is a professional, clinical, and, ultimately, legal
judgment. Since some of these tests are newly developed, not all meet the “Daubert standard” of scientific
admissibility. Refer to the articles and test manuals for specific information on test properties.
1. Adult Functional Adaptive Behavior Scale (AFABS)
Primary Reference: Pierce, P.S. (1989). Adult functional adaptive behavior scale (AFABS): Manual of
directions. Togus, ME: Author.
Area Assessed: Functional Abilities for Independent Living
Description: The Adult Functional Adaptive Behavior Scale (AFABS) was developed to assist in the
assessment of ADL and IADL functions in the elderly to evaluate their capacity for personal
responsibility and the matching of a client to a placement setting. The AFABS consists of 14 items. Six
items rate ADLs: eating, ambulation, toileting, dressing, grooming, and managing (keeping clean)
personal area. Two items tap IADLs: managing money and managing health needs. Six items tap
cognitive and social functioning: socialization, environmental orientation (ranging from able to locate
room up through able to travel independently in the community), reality orientation (aware of person,
place, time, and current events), receptive speech communication, expressive communication, and
memory. Items are rated on four levels: 0.0 representing a lack of the capacity, 0.5 representing some
capacity with assistance, 1.0 representing some capacity without assistance, and 1.5 representing
independent functioning in that area. Individual scores are summed to receive a total score in adaptive
functioning. The AFABS assesses adaptive functioning through interviewing an informant wellacquainted with the functioning of the individual in question. The informant data is combined with the
examiner’s observation of and interaction with the client to arrive at final ratings. The AFABS is designed
for relatively easy and brief administration (approximately 15 minutes). The author recommends it be
administered only by professionals experienced in psychological and functional assessment, specifically a
psychologist, occupational therapist, or psychometrician, although research with the AFABS has also
utilized psychiatric nurses and social workers trained in its administration.
2. Aid to Capacity Evaluation (ACE)
Primary Reference: Etchells et al., (1999). Assessment of patients’ capacity to consent to treatment.
Journal of General Internal Medicine, 14, 27-34.
Area Assessed: Medical Decision Making
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The ACE is a semi-structured assessment interview that addresses seven facets of capacity for an actual
medical decision: the ability to understand (a) the medical problem; (b) the treatment; (c) the alternatives
to treatment; (d) the option of refusing treatment; (e) the ability to perceive consequences of accepting
treatment; (f) refusing treatment; and, (g) the ability to make a decision not substantially based on
hallucinations, delusions, or depression. These reflect legal standards in Ontario, Canada, but also
correspond to U.S. legal standards. Questions in the areas a-d assess the decisional ability of
understanding. Questions in areas e and f appear to tap reasoning, and in area g diminished appreciation
based on patently false beliefs (e.g., “Do you think we are trying to harm you?”).
3. Assessment of Capacity to Consent to Treatment (ACCT)
Primary Reference: Moye et al., (2008). Assessment of capacity to consent to treatment: Current research,
the “ACCT” approach, future directions. Clinical Gerontologist, 37, 37-59.
Area Assessed: Medical Decision Making
The ACCT is a standardized assessment interview that begins by assessing a patient’s values relevant to
medical treatment, including preferred activities, relationships, means of making decisions, and views on
quality of life. Then, a series of questions is used to ask about understanding, appreciation, reasoning, and
expressing a choice. The ACCT can use a standardized vignette in which case standardized scoring
criteria may be used to rate the vignette. Three vignettes are available. Inter-rater reliability was .90 and
internal consistency reliability was .96 in a sample of 40 patients and 19 controls.
4. Capacity Assessment Tool (CAT)
Primary Reference: Carney et al., (2001). The development and piloting of a capacity assessment tool. 12
J. Clinical Ethics 17-23.
Area Assessed: Medical Decision Making
Description: The CAT proposes to evaluate capacity based on six abilities: communication,
understanding choices, comprehension of risks and benefits, insight, decision/choice process, and
judgment. It uses a structured interview format to assess capacity to choose between two options in an
actual treatment situation; as such, it does not use a hypothetical vignette.
5. Capacity to Consent to Treatment Interview (CCTI)
Primary Reference: Marson et al., (1995). Assessing the competency of patients with Alzheimer’s disease
under different legal standards. 52 Arch. Neurol. 949-954.
Area Assessed: Medical Decision Making
Description: The CCTI is based on two clinical vignettes; a neoplasm condition and a cardiac condition.
Information about each condition and related treatment alternatives is presented at a fifth to sixth grade
reading level with low syntactic complexity. Vignettes are presented orally and in writing; participants are
then presented questions to assess their decisional abilities in terms of understanding, appreciation,
reasoning, and expression of choice.
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6. Competency Interview Schedule (CIS)
Primary Reference: Bean et al. (1996). The assessment of competence to make a treatment decision: An
empirical approach, 41 Can. J. Psych. 85-92.
Area Assessed: Medical Decision Making
Description: The CIS is a 15-item interview designed to assess consent capacity for electro-convulsive
therapy (ECT). Patients referred for ECT receive information about their diagnosis and treatment
alternatives by the treating clinician, and the CIS then assesses decisional abilities based on responses to
the 15 items
7. Decision Assessment Measure
Primary Reference: Wong et al. (2000). The capacity of people with a “mental disability” to make a
health care decision. 30 Psych. Med. 295-306.
Area Assessed: Medical Decision Making
Description: Wong et al., working in England, developed a measure that references incapacity criteria in
England and Wales (understanding, reasoning, and communicating a choice), based on methodology by
Grisso et al. (1995). Their instrument also assesses the ability to retain material because it is one of the
legal standards for capacity in England and Wales (though not in the United States.). A standardized
vignette regarding blood drawing is used to assess paraphrased recall, recognition, and non-verbal
demonstration of understanding (pointing to the correct information on a sheet with both correct
information and distracter/incorrect information).
8. Decision-Making Instrument for Guardianship (DIG)
Primary Reference: Anderer, S.J. (1997). Developing an instrument to evaluate the capacity of elderly
persons to make personal care and financial decisions. Unpublished doctoral dissertation, Allegheny
University of Health Sciences.
Area Assessed: Self care, Home care, Financial, (Guardianship)
Description: The Decision-Making Instrument for Guardianship (DIG) was developed to evaluate the
abilities of individuals to make decisions in everyday situations often the subject of guardianship
proceedings. The instrument consists of eight vignettes describing situations involving problems in eight
areas: hygiene, nutrition, health care, residence, property acquisition, routine money management in
property acquisition, major expenses in property acquisition, and property disposition. Examinees are
read a brief vignette describing these situations in the second person. Detailed scoring criteria are used to
assign points for aspects of problem solving, including defining the problem, generating alternatives,
consequential thinking, and complex/comparative thinking. The DIG is carefully standardized. Standard
instructions, vignettes, questions, and prompts are provided in the manual. In addition, detailed scoring
criteria are provided. Sheets with simplified lists of salient points of each vignette, provided in large type
are provided, help to standardize vignette administration and emphasize the assessment of problem
solving and not reading comprehension or memory. Vignettes are kept simple, easy to understand, and are
brief.
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9. Direct Assessment of Functional Status (DAFS)
Primary Reference: Loewenstein et al. (1989). A new scale for the assessment of functional status in
Alzheimer’s disease and related disorders. 44 J. Gerontology: Psych. Sci. 114-121.
Area Assessed: Functional Abilities for Independent Living
Description: The Direct Assessment of Functional Status (DAFS) was designed to assess functional
abilities in individuals with dementing illnesses. The scale assesses seven areas: time orientation (16
points), communication abilities (including telephone and mail; 17 points), transportation (requiring
reading of road signs; 13 points), financial skills (including identifying and counting currency, writing a
check and balancing a checkbook; 21 points), shopping skills (involving grocery shopping; 16 points),
eating skills (10 points), dressing and grooming skills (13 points). The composite functional score has a
maximum of 93 points, exclusive of the driving subscale, which is considered optional. The DAFS
requires that the patient attempt to actually perform each item (e.g., is given a telephone and asked to dial
the operator). The entire assessment is estimated to require 30-35 minutes to complete. Any
psychometrically trained administrator can administer the scale. The DAFS has been used for staging
functional impairment in dementia, from one to three, in a group of 205 individuals with probable
Alzheimer’s disease.
10. Financial Capacity Instrument (FCI)
Primary Reference: Marson et al. (2000). Assessment of financial capacity in patients with Alzheimer’s
disease: A prototype instrument. 57 Arch. Neurol. 877-884.
Area Assessed: Financial
Description: The Financial Capacity Instrument (FCI) was designed to assess everyday financial activities
and abilities. The instrument assesses six domains of financial activity: basic monetary skills, financial
conceptual knowledge, cash transactions, checkbook management, bank statement management, and
financial judgment. The FCI is reported to require between 30 minutes to 50 minutes to administer,
depending on the cognitive level of the examinee. The FCI uses an explicit protocol for administration
and scoring.
11. Hopemont Capacity Assessment Interview (HCAI)
Primary Reference: Edelstein et al. (1993). Assessment of capacity to make financial and medical
decisions (paper presented at Toronto meeting of the American Psychological Association, Aug. 1993).
Area Assessed: Financial, Medical Decision Making
Description: The Hopemont Capacity Assessment Interview (HCAI) is a semi-structured interview in two
sections. The first section is for assessing capacity to make medical decisions. The second section is for
assessing capacity to make financial decisions and will be discussed here. In the interview the examinee is
first presented with concepts of choice, cost, and benefits and these concepts are reviewed with the
examinee through questions and answers. The examinee is then presented medical or financial scenarios.
For each scenario the individual is asked basic questions about what he or she has heard, and then are
asked to explain costs and benefits, to make a choice, and to explain the reasoning behind that choice. The
HCAI uses a semi-structured format. General instructions are provided. Specific standardized
introductions, scenarios, and follow-up questions are on the rating form.
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12. Hopkins Competency Assessment Test (HCAT)
Primary Reference: Janofsky, McCarthy, & Folstein. (1992). The Hopkins competence assessment test: A
brief method for evaluating patients’ capacity to give informed consent. Hospital and Community
Psychiatry, 43, 132-135.
Area Assessed: Informed consent and advance directives.
Description: The HCAT is a brief instrument with six items with a total score of 0-10 that assess a
patient’s general understanding of informed consent and advance directives. Inter-rater reliability was .95.
13. Independent Living Scales (ILS)
Primary Reference: Loeb, P.A. (1996). Independent Living Scales. San Antonio:
Corporation.
Psychological
Areas Assessed: Care of home, Health care, Financial (Guardianship)
Description: The Independent Living Scales (ILS) is an individually administered instrument developed
to assess abilities of the elderly associated with caring for oneself and/or for one’s property. The early
version of the ILS was called the Community Competence Scale (CCS). The CCS was constructed
specifically to be consistent with legal definitions, objectives, and uses, in order to enhance its value for
expert testimony about capacities of the elderly in legal guardianship cases. The ILS consists of 70 items
in five subscales: Memory/Orientation, Managing Money, Managing Home and Transportation, Health
and Safety, and Social Adjustment. The five subscales may be summed to obtain an overall score, which
is meant to reflect the individual’s capacity to function independently overall. Two factors may be derived
from items across the five subscales: Problem Solving and Performance/Information. The ILS has
extensive information on norms, reliability, and validity.
14. MacArthur Competence Assessment Tool - Treatment (MacCAT-T)
Primary Reference: Grisso et al. (1998). Assessing Competence to Consent to Treatment. New York:
Oxford.
Area Assessed: Medical Decision Making
Description: The MacCAT-T utilizes a semi-structured interview to guide the clinician through an
assessment of the capacity to make an actual treatment decision. It does not use a standardized vignette.
Patients receive information about their condition, including the name of the disorder, its features and
course, then are asked to “Please describe to me your understanding of what I just said.” Incorrect or
omitted information is cued with a prompt (e.g., “What is the condition called?”), and if still incorrect or
omitted, presented again. A similar disclosure occurs for the treatments, including the risks and benefits
of each treatment alternative. Next, patients are asked if they have any reason to doubt the information
and to describe that. They are then asked to express a choice and to answer several questions that
explicate their reasoning process, including comparative and consequential reasoning and logical
consistency. The MacCAT was based on three pre-cursor instruments, POD, TRAT, and the UTD that
looked in detail at appreciation, reasoning, and understanding respectively.
15. Multidimensional Functional Assessment Questionnaire (MFAQ)
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Primary Reference: Center for the Study of Aging and Human Development. (1978). Multidimensional
functional assessment: The OARS methodology. Durham, NC: Duke University.
Area Assessed: Functional Abilities for Independent Living
Description: The Multidimensional Functional Assessment Questionnaire (MFAQ) was developed to
provide a reliable and valid method for characterizing elderly individuals and for describing elderly
populations. The MFAQ supersedes the nearly identical Community Survey Questionnaire (CSQ, a
predecessor which also was developed by the Duke Center). Both instruments frequently have been called
the “OARS,” in reference to the program that developed the instrument throughout the 1970s. The MFAQ
or the CSQ was already in use by well over 50 service centers, researchers, or practitioners nationally
when the MFAQ was published (1978). Part A provides information in five areas of functioning,
including activities of daily living. The Activities of Daily Living (ADL) dimension assesses 14 functions
including both instrumental and physical ADLs. Instrumental ADLs are: use telephone, use
transportation, shopping, prepare meals, do housework, take medicine, handle money. Physical ADLs are:
eat, dress oneself, care for own appearance, walk, get in/out of bed, bath, getting to bathroom, continence.
Part B of the MFAQ assesses the individual’s utilization of services, that is, whether and to what extent
the examinee has received assistance from various community programs, agencies, relatives, or friends,
especially within the latest six months. Questioning also includes the examinee’s perceived need for the
various services.
16. Philadelphia Geriatric Center Multilevel Assessment Inventory (MAI)
Primary Reference: Powell, Lawton, & Moss. (undated). Philadelphia geriatric center multilevel
assessment instrument: Manual for full-length MAI. Philadelphia, PA: Author.
Area Assessed: Functional Abilities for Independent Living
Description: The Philadelphia Geriatric Center Multilevel Assessment Inventory (MAI) was designed to
assess characteristics of the elderly relevant for determining their needs for services and placement in
residential settings. The MAI is a structured interview procedure that obtains descriptive information
about an elderly respondent related to seven domains. Each of the domains (except one) is sampled by
interview questions in two or more subclasses, which the authors call sub-indexes. The full-length MAI
consists of 165 items; the middle length MAI has 38 items, and the short-form has 24 items. The domains
assessed are physical health, cognitive, activities of daily living, time use, personal adjustment, social
interaction, and perceived environment. The MAI manual provides considerable structure for the process
of the interview, sequence and content of questions, and scoring. It describes criteria for 1 to 5 rating of
each of the domains, but these criteria are not tied specifically to item scores. The manual discusses
general considerations for interviewing elderly individuals and dealing with special problems of test
administration with this population (e.g., dealing with limited hearing or vision).
17. Structured Interview for Competency
Primary Reference: Tomoda, Yasumiya, Sumiyama, Tankada, Hayakawa, & Kimimori. (1997).
Reliability and validity of structured interview for competency incompetency assessment testing and
ranking inventory. Journal of Clinical Psychology, 53, 443-450.
Area Assessed: Medical Decision Making
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Description: The SIC or SICIATRI (see full reference) is a 12-item interview, with a 0-36 total score.
There are explanations, probes, and anchor points for administration and scoring. Scores are converted to
ranks to rank an individual’s capacity.
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Appendix C. Cognitive Assessment
This section provides an overview of cognitive functioning and neuropsychological assessment, and is
based on information available in key clinical references and the consensus of the working group. This
appendix is not intended as a comprehensive or exhaustive discussion of cognitive or neuropsychological
testing.
Cognitive Screening
Cognitive screening tests are useful for giving a general level of overall cognitive impairment. They may
be used as an overall screening to determine whether additional testing is needed. They may also be used
for individuals with more severe levels of impairment who cannot complete other tests.
Acronym
BIMC
Cognistat
MLDT
Screening Test Name
Blessed Information
Memory Concentration
Test
The Neurobehavioral
Cognitive Status
Examination
MacNeill Lichtenberg
Decision Tree
MMSE
Mini Mental State
Examination
MoCA
Montreal Cognitive
Assessment
MSQ
Mental Status
Questionnaire
7MS
The Seven Minute Screen
SLUMS
The Saint Louis University
Mental Status Examination
SPMSQ
Short Portable Mental
Status Questionnaire
TICS
Telephone Interview for
Cognitive Status
Screening Test Description
33-point scale with subtests of orientation, personal information,
current events, recall, and concentration. There is a short version
with six items.
This screening test examines language, memory, arithmetic,
attention, judgment, and reasoning.
This decision tree combines the use of brief screening measures
(Benton’s Temporal Orientation Test and the Animal Naming test)
with questions about environmental demand and a 3-item screen to
rule out depression.
30-point screening instrument that assesses orientation, immediate
registration of three words, attention and calculation, short-term
recall of three words, language, and visual construction.
30-point cognitive screening instrument that assesses
visualspatial/executive, naming, memory, attention, language,
abstraction, delayed recall, and orientation to time.
http://www.mocatest.org/
10-item, 10-point scale assessing orientation to place, time, person,
and current events. It has low to modest sensitivity for detecting
neurological illness.
This screening instrument combines four tests, each with separate
scores of various ranges: recall, verbal fluency, orientation, and clock
drawing.
11-item scale to detect mild cognitive impairment and dementia
includes orientation, word memory, arithmetic, naming, clock
drawing, story memory. http://medschool.slu.edu/agingsuccessfully/
pdfsurveys/slumsexam_05.pdf
10-point scale scored as a sum of errors on subtests of orientation,
location, personal information, current events, and counting
backwards. High scores (8-10) equals severe impairment. Race and
age corrections to scores are available.
11-item scale developed for situations where in-person cognitive
screening is impractical, although it can be administered face to face.
Norms for English-speaking adults, ages 60-98 years.
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Neuropsychological Testing
A neuropsychological evaluation typically assesses various areas called “domains” with neuroanatomic
correlates (see table below). Some of these areas are assessed through observation of the client’s
presentation and communication during a clinical interview. Most are assessed through tests that have
standard instructions, standard scoring, and are referenced to adults of similar age and education to
provide performance range that is “norm-referenced.”
There are a number of neuropsychological “batteries” that assess, either briefly or in great depth, a wide
range of domains using various “subtests.” Like with any test or battery, the examiner will need to
consider whether the assessment instrument has adequate reliability, validity, and normative properties for
the population of the individual being assessed. Examples of neuropsychological batteries are:
Halstead-Reitan Neuropsychological Battery
Kaufman Short Neuropsychological Assessment
Luria-Nebraska Neuropsychological Battery
Microcog
Repeatable Battery for the Assessment of Neuropsychological Status
Wechsler Adult Intelligence Scale—III
A flexible battery, tailored to the specific capacity question, may draw from the above batteries and
specific neuropsychological tests noted in the table below.
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Common Neuropsychological Domains
Domain
Appearance
Description
• Grooming, weight, interaction
with others
Sensory Acuity
• Ability to hear, see, smell, touch
Motor Activity
• Motor activity (active, agitated,
slowed)
• Motor skills (gross and fine)
detection of visual, auditory,
tactile stimuli
Attention
• Attend to a stimulus
• Concentrate on a stimulus over
brief time periods
Memory
• Working memory: attend to
verbal or visual material over
short time periods; hold two
ideas in mind
• Short-term/recent memory and
learning: ability to encode, store,
and retrieve information
Relevance to Capacity
• Appearance, orientation, and
interaction indicate general mental
condition and may reveal problems
with judgment
• Sensory deficits impact functioning
in the environment
• Sensory deficits may make
performance on
neuropsychological tests worse
and, therefore, should be
considered in interpreting scores
• Motor deficits impact functioning
in the environment
• Motor deficits may make
performance on
neuropsychological tests worse and
therefore should be considered in
interpreting scores
Possible Methods of Assessment
• Observation
•
•
•
Observation
Structured hearing tests
Structured vision tests
•
•
•
•
•
Observation
Finger Tapping
Grooved Pegboard
Finger Oscillation Test
Tactual Performance Test
• Basic function necessary for
processing information
•
•
•
•
•
•
•
Digit Span Forward and Backward
Working Memory (from the WMS-III)
Paced Auditory Serial Attention Test (PASAT)
Visual Search and Attention Test (VSAT)
Visual Attention (from the Dementia Rating Scale (DRS))
Trails A of the Trail Making Test
Continuous Performance Test
• Some memory is important for all
decision making. Although
memory aids can be used,
individuals must be able to hold
ideas in mind (“working memory”)
• Memory is especially important for
functioning at home and
•
Memory Assessment Batteries (from the WMS-III or the
Memory Assessment Scales (MAS))
Auditory Verbal Learning Test
Recognition (from the DRS)
Fuld Object Memory Evaluation
California Verbal Learning Test (CVLT)
•
•
•
•
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• Long-term memory: remember
information from the past
remembering to perform critical
activities (e.g., take medications)
and be safe (e.g., turn off stove)
•
•
Hopkins Verbal Learning Test (HVLT)
Rey Auditory Verbal Learning Test
Communication
(also called
expressive
language)
• Express self in words or writing
• State choices
• Basic function necessary to convey
choices in decision making
•
•
•
•
•
Communication during testing
Controlled Oral Word Association Test (commonly called
the verbal fluency)
Boston Diagnostic Aphasia Examination (BDAE)
Multilingual Aphasia Examination
Boston Naming Test (BNT)
Understanding
(also called
receptive
language)
• Understand written, spoken, or
visual information
•
•
•
Understanding during testing
Boston Diagnostic Aphasia Examination (BDAE)
Multilingual Aphasia Examination
Arithmetic or
Mathematical
skills
•
•
•
Arithmetic subtest of WAIS-III
Reasoning
•
•
•
Verbal subtests from the WAIS-III, such as Similarities,
Comprehension
Proverbs
Visual-Spatial and
VisuoConstructional
Reasoning
• Important when making decisions,
especially regarding new problems
or new treatments
• Critical to understanding the
options
Understand basic quantities
• Important for financial decision
making
Make simple calculations
• Important for day to day financial
tasks
Compare two choices
• Critical in almost all decision
making
Reason logically about outcomes
• Visual-spatial perception
• Visual problem solving
• Important for functioning in the
home and community
• Essential for driving
•
•
•
•
•
•
•
•
•
Performance subtests from WAIS-III, such as Block
Design, Object Assembly, Matrix Reasoning
Hooper Visual Organization Test
Visual Form Discrimination Test
Clock Drawing
Rey-Osterrieth Complex Figure
Line Bisection
Bender Visual Motor Gestalt Test
Tactual Performance Test
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Executive
Functioning
• Plan for the future
• Demonstrate judgment
• Inhibit inappropriate responses
• Essential for most decision making
• Important to avoid undue influence
•
•
•
•
•
•
•
Similarities (from the WAIS-III)
Trails B of the Trail Making Test (TMT)
Wisconsin Card Sorting Test
Stroop Color Word Test
Delis-Kaplan Executive Function System (DKEFS)
Mazes
Tower of London
Insight
• Acknowledge deficits
• Acknowledge the potential
benefit of intervention
• Accept help
• Often considered a part of
“executive function”
• Critical to the use of less restrictive
alternatives
• An individual needs to be able to
recognize they have a deficit and
be willing to accept help in order to
use home services
•
•
Interview
Comparing observed deficits with the individual’s reports
of deficits
Informant reports
•
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Appendix D. Psychiatric and Emotional Assessment
This section provides an overview of psychiatric and emotional assessment, and is based on information
available in key clinical references and the consensus of the working group. This appendix is not intended
as a comprehensive or exhaustive discussion of psychiatric and emotional assessment. Tests of emotional
and personality functioning can provide a more objective means to assess the range and severity of
emotional or personal dysfunction.
1. Mood and Symptoms of Depression, Anxiety, and Psychoses
Definition: These scales assess the individual’s degree of depressed or anxious mood, and associated
symptoms, such as insomnia, fatigue, low energy, low appetite, loss of interest or pleasure, irritability,
feelings of helplessness, worthlessness, hopelessness, or suicidal ideation. Some scales will also assess
the degree of hallucinations, delusions, and suspicious or hostile thought processes.
Test Examples:
• Geriatric Depression Scale (GDS)
• Cornell Scale for Depression in Dementia
• Dementia Mood Assessment Scale (DMAS)
• Beck Depression Inventory (BDI)
• Beck Anxiety Inventory (BAI)
• Padua Inventory (PI)
• Fear Survey Schedule -II - Older Adult (FSS-II-OA)
• Geriatric Anxiety Inventory (GAI)
• Center for Epidemiological Studies Depression Scale (CES-D)
• Hospital Anxiety and Depression Scale (HADS)
• Worry Scale (WS)
• Beck Hopelessness Inventory (BHI)
• Geriatric Suicidal Ideation Scale (GSIS)
2. Personality
Definition: Personality inventories are occasionally used in capacity assessment to explore unusual ways
of interacting with others and looking at reality that may be impacting sound decision making.
Test Examples:
• Millon Clinical Multiaxial Inventory-III (MCMI-III)
• Minnesota Multiphasic Personality Inventory – 2 (MMPI)
• Revised NEO Personality Inventory (NEO-PI-R)
• Personality Assessment Inventory (PAI)
3. Tests of Effort, Motivation, or Response Style
These measures, also referred to as validity tests, are structured in such a way to detect inconsistent or
unlikely response patterns indicative of attempts to exaggerate cognitive problems. They serve as one
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type of evidence permitting the clinician to judge the validity of the overall cognitive testing. Generally
they detect test-taking response patterns that deviate from chance responding or from norms for
established cognitively-impaired clinical populations like those with Alzheimer’s disease. If the tests are
positive, they suggest an intentional (or in some cases subconscious) test-taking approach to exaggerate
deficits. It remains a clinical judgment as to how to interpret the clinical meaning of the test-taking
bias/exaggeration. In some cases, they may reflect malingering for monetary secondary gain, whereas in
others they may indicate a factitious disorder or sometimes a somatoform disorder. Tests of validity may
be used when the examiner is concerned that the individual has a reason to gain from “faking bad” on the
test, such as in disability claims. Older adults who are receiving capacity evaluation are most likely to be
giving maximal effort to perform at their highest level in which case formal tests of validity are probably
not indicated.
Definition: Validity tests are structured in such a way to detect inconsistent or unlikely response patterns
indicative of attempts to misrepresent psychopathology or cognitive dysfunction.
Test Examples:
• Test of Memory Malingering (TOMM)
• Structured Inventory of Malingered Symptomatology (SIMS)
• Miller Forensic Assessment of Symptoms Test (M-FAST)
• Assessment of Depression Inventory (ADI)
• California Verbal Leaning Tests (CVLT-II)
• The Word Test
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Appendix E. Values Assessment
A number of tools and instruments have been developed to assess values related to health care. Most have
been developed to assist in advance care planning for medical decisions, as well as for use in long-term
care settings.
General References
Hammes, B.J., & Briggs, L.A. (2005). Initiating, facilitating, and honoring conversations about future
medical care. In J. K. Doka, B. Jennings, & C.A. Corr (Eds.), Ethical dilemmas at the end of life (pp. 125138). Washington, DC: Hospice Foundation of America.
Kane, R. A. (2000). Values and preferences. In R. L. Kane & R. A. Kane (Eds.), Assessing older persons:
Measures, meanings, and practice implications. (pp. 237-260). Oxford: Oxford University Press.
Karel, M.J. (2000). The assessment of values in medical decision making. Journal of Aging Studies, 14,
403-422.
Compassion and Choices (http://www.compassionandchoices.org/)
Instruments
1. Five Wishes
Primary reference: Commission on Aging with Dignity (1998). Five wishes. Tallahassee, FL:
Commission on Aging with Dignity. http://www.agingwithdignity.org/5wishes.html
Five Wishes advance directive that includes sections on naming a healthcare proxy and describing
preferences for healthcare interventions, personal care, and family involvement.
2. Preferences for Everyday Living Inventory (PELI)
Primary Reference: Carpenter, B. D., Van Haitsma, K., Ruckdeschel, K., & Lawton, M. P.
(2000). The psychosocial preferences of older adults: A pilot examination of content and structure. The
Gerontologist, 40, 335-348.
Detailed assessment of psychosocial preferences for activities, daily routines, environmental features, and
other aspects of day to day living.
3. Values History
Primary Reference: Doukas, D. J., & McCullough, L. B. (1991). The values history: The evaluation of the
patient’s values and advance directives. The Journal of Family Practice, 32, 145-153.
Description: Self-report instrument that includes a section on broad values associated with quality of life
and a section on directives regarding specific medical interventions.
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4. Values and Preferences Scale (VPS)
Primary Reference: Whitlatch, C. J., Feinberg, L. F., & Tucke, S. S. (2005). Measuring the values and
preferences for everyday care of persons with cognitive impairment and their family caregivers. The
Gerontologist, 45, 370-380.
A 24-item scale that assesses everyday care values and preferences of people with cognitive impairment,
addressing domains of personal autonomy, environment, and social network.
5. Your Life, Your Choices
Primary Reference: Pearlman, R., Starks, H., Cain, K., Rosengreen, D., & Patrick, D. (1998). Your life,
your choices—Planning for future medical decisions: How to prepare a personalized living will.
Springfield, VA: U.S. Department of Commerce, National Technical Information Service.
http://www.rihlp.org/pubs/Your_life_your_choices.pdf
Comprehensive workbook that includes exercises for discerning and communicating values, beliefs, and
preferences related to medical care, including “who should speak for me,” “what makes your life worth
living,” and “personal and spiritual beliefs.”
6. Your Values and Your Health Care Decisions: A Values Discussion Guide
Primary Reference: Karel, M.J., Powell, J., & Cantor, M. (2004). Using a values discussion guide to
facilitate communication in advance care planning. Patient Education and Counseling, 55, 22-31.
Ten questions to facilitate a conversation about key values relevant for health care decision making.
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Appendix F. Interventions to Address Diminished Capacity
The following list was based on a checklist of less restrictive alternatives to guardianship by Professor
Joan O’Sullivan, University of Maryland School of Law. This list details a wide range of legal and social
interventions that can be used to assist someone with functional or decisional compromise instead of
guardianship.
If the person needs medical treatment, but is not able to consent:
Health Care Advance Directive
Any written statement a competent individual has made concerning future health care decisions. The
two typical forms of advance directive are the living will and the health care power of attorney.
Surrogate decision making by an authorized legal representative, a relative, or a close friend
In many states, the next of kin are authorized to make some or all medical treatment decisions in the
absence of a health care advance directive or appointed guardian.
If the problem involves litigation against or by the disabled person:
Appointment of Guardian ad litem
The court in which litigation is proceeding has authority to appoint a guardian ad litem solely for the
purpose of representing the best interests of the individual in the litigation.
If the problem involves a family dispute:
Mediation
Referring a case to mediation before a hearing offers a personal, confidential, and less intimidating
setting than the courtroom, as well as an opportunity for exploring underlying issues privately.
If the person needs help with financial issues:
Bill paying services
Also called money management services, these assist persons with diminished capacity through check
depositing, check writing, checkbook balancing, bill paying, insurance claim preparation and filing, tax
and public benefit preparation, and counseling.
Utility company third party notification
Most utility companies permit customers to designate a third party to be notified by the utility company
if bills are not paid on time.
Shared bank accounts (with family member)
The use of joint bank accounts is a common strategy for providing assistance with financial
management needs. However, if the joint ownership arrangement reaches most of the individual’s
income or assets, it also poses risk in its potential for theft, self-dealing, unintended survivorship, and
exposure to the joint owner’s creditors. A more secure arrangement is a multiple-party account with the
family member or friend designated as agent for purposes of access to the account.
Durable Power of Attorney for finances
This legal tool enables a principal to give legal authority, as broadly or as narrowly as desired, to an
agent or attorney in fact to act on behalf of the principal, commencing either upon incapacity or
commencing immediately and continuing in the event of incapacity. Its creation requires sufficient
capacity to understand and establish such an arrangement.
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Trusts
Trusts can be established to serve many purposes, but an important one is the lifetime management of
property of one who is or who may become incapacitated. They are especially useful where there is a
substantial amount of property at stake and professional management is desired. Special or
supplemental needs trusts and pooled income trusts are recognized under federal Medicaid and Social
Security laws as permissible vehicles for managing the funds of persons with disability who depend on
government programs for their care needs.
Representative Payee
A person or organization authorized to receive and manage public benefits on behalf of an individual.
Social Security, Supplemental Security Income (SSI), veterans’ benefits, civil service and railroad
pensions, and some state programs provide for appointment of a “rep payee.” Each program has its
own statutory authorization and rules for eligibility, implementation, and monitoring.
Adult protective services
The term protective services encompasses a broad range of services. It includes various social services
voluntarily received by seniors in need of support (e.g., homemaker or chore services, nutrition
programs). It also includes interventions for persons who may be abused, neglected, or exploited, and
which may lead to some form of guardianship.
If the person is living in an unsafe environment:
Senior shared housing programs
In shared housing programs, several people live together in a group home or apartment with shared
common areas. Congregate housing refers to complexes with separate apartments (including kitchen),
some housekeeping services, and some shared meals. Many congregate care facilities are subsidized
under federal housing programs. Personal care and health oversight are usually not part of the facility’s
services, but they may be provided through other community social services.
Adult foster care
Adult foster care is a social service that places an older person, who is in need of a modest amount of
daily assistance, into a family home. The program is similar to foster care programs for children. The
cost varies and may be covered in part by the state social services program.
Community residential care
These are small supportive housing facilities that provide a room, meals, help with activities of daily
living, and protective supervision to individuals who cannot live independently, but who do not need
institutional care.
Assisted living
Assisted living facilities provide an apartment, meals, help with activities of daily living, and
supervision to individuals who cannot live independently, but who do not need institutional care.
Nursing home
Nursing homes provide skilled nursing care and services for residents who require medical or nursing
care; or rehabilitation services for injured, disabled, or sick persons.
Continuing Care Retirement Communities (CCRCs)
Continuing Care Retirement Communities, also called life care communities, usually require the
payment of a large entry fee, plus monthly fees thereafter. The facility may be a single building or a
campus with separate independent living, assisted living, and nursing care. Residents move from one
housing choice to another as their needs change. While usually very expensive, many guarantee
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lifetime care with long-term contracts that detail the housing and care obligations, as well as its costs.
If the person needs help with activities of daily living or supervision:
Care management
This is provided by a social worker or health care professional, who evaluates, plans, locates,
coordinates, and monitors services for an older person and the family.
Home health services
If the person needs medical care or professional therapy on a part-time or intermittent basis, a visiting
nurse or home health aide from a home health agency may meet that need. Some services may be
covered by Medicare or Medicaid, private insurance, or state programs
Home care services
Homemaker or chore services can provide help with housework, laundry, ironing, and cooking.
Personal care attendants or personal assistants may assist an impaired person in performing activities
of daily living, (i.e., eating, dressing, bathing, toileting, and transferring), or with other activities
instrumental to daily functioning.
Adult day care services
These are community-based group programs designed to meet the needs of functionally and/or
cognitively impaired adults through an individual plan of care. Health, social, and other related support
services are provided in a structured, protective setting, usually during normal business hours. Some
programs may offer services in the evenings and on weekends.
Respite care programs
“Respite” refers to short-term, temporary care provided to people with disabilities in order that their
families can take a break from the daily routine of caregiving. Services may involve overnight care for
some period of time.
Meals on Wheels
Volunteers deliver nutritious lunchtime meals to the homes of people who can no longer prepare
balanced meals for themselves. The volunteers also provide daily social contact with elders to ensure
that everything is okay.
Transportation services
Because many elders cannot afford a special transit service, and are too frail to ride the bus, senior
transportation services volunteers drive clients to and from medical, dental, or other necessary
appointments, and remain with them throughout the visit.
Food and prescription drug deliveries
Either volunteer-based or commercially-based delivery services for food or prescription drugs, may
assist those who are unable to leave their home regularly.
Medication reminder systems
This may include a weekly pill organizer box, or another pill distribution system, or telephone reminder
calls.
Telephone reassurance programs
These services use volunteer to provide a daily telephone call to older persons living alone.
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Emergency call system (“lifeline )
Usually includes equipment added to the telephone line, plus a wireless signal button worn by the older
adult. Trained responders provide emergency assistance in the event of a medical emergency in the
home, such as a fall.
Home visitors and pets on wheels
Elder service agencies and other volunteer agencies may match elders with home visitors, including
visiting pets, which provide social interaction and a form of monitoring.
Daily checks on the person by mail carriers
Many mail carriers, if notified that an elder at risk is living at an address, will monitor the home to
insure that mail has been picked up daily, and if not, notify a designated individual.
Housing modification
A home may be modified or renovated to enhance safety and the use of technology in the home. For
example, grab bars, ramps, night wandering alarms, medication prompt systems, and home-telehealth
monitors may be added.
If the person has a psychological or medical condition impacting capacity
Alcohol or other substances intoxification
Detoxification; supplement diet or other intake needs.
Altered blood pressure
Treat underlying cause of blood pressure anomaly with medication or other treatment.
Altered low blood sugar
Management of blood sugar through diet or medication.
Anxiety
Treatment with medications and/or psychotherapy; support groups.
Bereavement; Recent death of a spouse or loved one
Support; counseling by therapist or clergy; support group; medications to assist in short-term problems
(e.g., sleep, depression).
Bipolar disorder
Treatment with medications and/or psychotherapy; support groups.
Brain tumor
Medical treatment as indicated, such as surgery, radiation, and medication.
Delirium
Obtain standard labs; obtain brain scan if indicated; assess vitals; treat underlying cause; monitor and
reassess over time.
Dementia
Treatment with medications for dementia; simplify environment; provide multiple clues within
environment; use step-by-step communication.
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Depression
Treatment with medications and/or psychotherapy; add pleasurable activities to day; ECT if indicated;
support groups.
Developmental disability
Education and training.
Head injury
Treatments for acute effects (e.g., bleed, pressure, swelling) as necessary; monitoring over time;
rehabilitative speech, physical, occupational therapies.
Infection (e.g., urinary, influenza, pneumonia, meningitis)
Treat underlying infection with antibiotic or other treatment.
Insomnia
Sleep hygiene practices (e.g., limit caffeine, light exercise, limit naps); medications.
Liver or kidney disease
Treatment of underlying illness with medication, dialysis, surgery.
Loneliness
Social and recreational activities; support groups.
Malnutrition or dehydration
IV fluids; fluid/food by mouth; food supplements; possible food by feeding tube.
Mania
Treatment with medications and/or psychotherapy; support groups.
Medications and sudden medication withdrawal
Review of medications by clinical pharmacist or specialist; slow one-by-one tapers or changes of
medications.
Poor heart or lung function (e.g., hypoxia)
Treatment of underlying condition with medication, surgery, supplemental oxygen.
Post surgical confusion (usually related to anesthesia or pain medicines)
Monitoring and reassessment over time; try alternative medications and treatments for pain
management.
Depression and anxiety
Psychotherapy, support, counseling by therapist or clergy; support group; medications to treat
symptoms.
Schizophrenia; hallucinations or delusions
Treatment with medications for schizophrenia; simplify environment; provide support.
Transfer trauma (a recent move that has the individual disoriented)
Monitoring over time; re-orientation to environment.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
©American Bar Association Commission on Law and Aging – American Psychological Association
177
Transient ischemic attacks (TIA)
Treatment of risk factors to prevent future recurrence.
Urinary or fecal retention
Treat underlying cause of retention through medication or surgery.
Vitamin deficiency; Imbalances in electrolytes and blood levels
Vitamin or electrolyte supplement; balanced diet; diet supplements.
If communication is difficult
Difficulty hearing
Use hearing amplifiers; have hearing evaluated; provide hearing aids; write information down; repeat
information; slow down speech; speak clearly and distinctly.
Difficulty seeing
Use magnifying glass; have sight evaluated; provide glasses; provide spoken information; repeat
information; ensure sufficient lighting; use large print; have access to Braille materials.
Difficulty understanding English
Use translator.
Low educational or reading level; illiterate
Provide information in simple language without “talking down”; provide information in multiple
formats.
Religious, cultural, or ethnic background
Sensitivity to religious, cultural, and ethnic traditions; inquire about views and needs; involve
professional from similar background.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
©American Bar Association Commission on Law and Aging – American Psychological Association
178
Appendix G. Medical Conditions Affecting Capacity3
Dementia is a general term for a medical condition characterized by a loss of memory and functioning.
Primary degenerative dementias are those with disease processes that result in a deteriorating course,
including Alzheimer’s disease, Lewy Body Dementia, and Frontal Dementia (each associated with a type
of abnormal brain cell).
Condition
Etiology
Symptoms
Treatability
Alcoholic Dementia
A fairly common form
Memory loss, problem- Alcohol dementia is
partially reversible, if there
of dementia, caused by solving difficulty, and
is long-term sobriety—
long-term abuse of
impairments in
cessation of use. There is
alcohol, usually for 20
visuospatial function
years or more. Alcohol are commonly found in evidence to suggest that
some damaged brain tissue
is a neurotoxin that
patients with alcohol
may regenerate following
passes the blood-brain
dementia.
extended sobriety, leading
barrier.
to modest improvements in
thinking and function.
Alzheimer’s disease
(“AD”)
Most common type of
dementia, caused by a
progressive brain
disease involving
protein deposits in
brain and disruption of
neurotransmitter
systems.
Bipolar Disorder or
A psychiatric illness
characterized by
alternating periods of
mania and depression.
Manic Depression
Initial short-term
memory loss, followed
by problems in
language and
communication,
orientation to time and
place, everyday
problem solving, and
eventually recognition
of people and everyday
objects. In the early
stages, an individual
may retain some
decisional and
functional abilities.
May affect functional
and decisional abilities
in the manic stage or
when the depressed
stage is severe.
Progressive and
irreversible, resulting
ultimately in a terminal
state. Medications may
improve symptoms and
cause a temporary
brightening of function in
the earlier stages.
Can be treated with
medications, but requires a
strong commitment to
treatment on the part of the
individual. Varies over
time; periodic reevaluation is needed.
3
This list is meant to define terms as used in this book, and is not meant to define terms more universally. The
glossary uses definitions from the Diagnostic and Statistical Manual of Mental Disorders, where available, and
where not, definitions are based on the consensus of the working group.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
©American Bar Association Commission on Law and Aging – American Psychological Association
179
Condition
Coma
Source
A state of temporary
or permanent
unconsciousness.
Delirium
A temporary
confusional state with
a wide variety of
causes, such as
dehydration, poor
nutrition, multiple
medication use,
medication reaction,
anesthesia, metabolic
imbalances, and
infections.
Frontal or Frontotemporal
Dementia
Broad category of
dementia caused by
brain diseases or small
strokes that affect the
frontal lobes of the
brain.
(Pick’s disease is one
example)
Jacob-Creutzfeldt Disease
A rare type of
progressive dementia
affecting humans that
is related to “mad
cow” disease.
Symptoms
Minimally responsive
or unresponsive,
unable to
communicate
decisions and needs a
substitute decision
maker.
Substantially impaired
attention and
significant decisional
and functional
impairments across
many domains. May
be difficult to
distinguish from the
confusion and
inattention
characteristic of
dementia.
Problems with
personality and
behavior are often the
first changes, followed
by problems in
organization,
judgment, insight,
motivation, and the
ability to engage in
goal-oriented
behavior.
The disease usually
has a rapid course,
with death occurring
within two years of
initial symptoms.
These include fatigue,
mental slowing,
depression, bizarre
ideations, confusion,
and motor
disturbances,
including muscular
jerking, leading finally
to a vegetative state
and death.
Treatability
Often temporary;
regular re-evaluation
required.
Often temporary and
reversible. If untreated
may proceed to a
dementia. It is
important to rule out
delirium before
diagnosing dementia.
To do so, a good
understanding of the
history and course of
functional decline, as
well as a full medical
work-up, are
necessary.
Early in their disease,
patients may have
areas of retained
functional ability, but
as disease progresses
they can rapidly lose
all decisional capacity.
There is no treatment
currently and the
disease is relentlessly
progressive.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
©American Bar Association Commission on Law and Aging – American Psychological Association
180
Condition
Diffuse Lewy Body
Dementia (DLB)
Source
A type of dementia on
the Parkinson disease
spectrum.
Major Depression
A very common
psychiatric illness.
Developmental Disorders
(“DD”), including Mental
Retardation (“MR”)
Brain-related
conditions that begin
at birth or childhood
(before age 18) and
continue throughout
adult life. MR
concerns low-level
intellectual
functioning with
functional deficits that
can be found across
many kinds of DD,
including autism,
Down syndrome, and
cerebral palsy.
Progressive brain
disease that initially
affects motor function,
but in many cases
proceeds to dementia.
Parkinson’s Disease (PD)
Symptoms
DLB involves mental
changes that precede
or co-occur with motor
changes. Visual
hallucinations are
common, as are
fluctuations in mental
capacity.
Sad or disinterested
mood, poor appetite,
energy, sleep, and
concentration, feelings
of hopelessness,
helplessness, and
suicidality. In severe
cases, poor hygiene,
hallucinations,
delusions, and
impaired decisional
and functional
abilities.
Functioning tends to
be stable over time but
lower than normal
peers. MR is most
commonly mild. Some
conditions such as
Downs syndrome may
develop a supervening
dementia later in life,
causing decline in
already limited
decisional and
functional abilities.
Treatability
This disease is
progressive and there
are no known
treatments. Parkinson
medications are often
of limited use.
PD presents initially
with problems with
tremors and physical
movement, followed
by problems with
expression and
thinking, and leading
sometimes to dementia
after a number of
years.
PD is progressive, but
motor symptoms can
be treated for many
years. Eventually,
medications become
ineffective and most
physical and mental
capacities are lost.
Evaluation of capacity
must avoid confusion
of physical for
cognitive impairment.
Treatable and
reversible, although in
some resistant cases
electroconvulsive
therapy (ECT) is
needed.
Not reversible, but
everyday functioning
can be improved with
a wide range of
supports,
interventions, and less
restrictive alternatives.
Individuals with DD
have a wide range of
decisional and
functional abilities
and, thus, require
careful assessment by
skilled clinicians.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
©American Bar Association Commission on Law and Aging – American Psychological Association
181
Condition
Persistent Vegetative State
(PSV)
Source
A state of minimal or
no responsiveness
following emergence
from coma.
Schizophrenia
A chronic brain-based
psychiatric illness
Stroke or Cerebral Vascular
A significant bleeding
in the brain, or a
blockage of oxygen to
the brain.
Accident (“CVA”)
Traumatic Brain Injury
(“TBI”)
A blow to the head
that usually involves
loss of consciousness.
Vascular Cognitive
Impairment
Multiple infarcts that
cause cognitive
impairment
Vascular Dementia (“VaD”)
Multiple strokes that
accumulate and cause
dementia.
Symptoms
Patient is mute and
immobile with an
absence of all higher
mental activity.
Cannot communicate
decisions and requires
a substitute decision
maker for all areas.
Hallucinations and
delusions; poor
judgment, insight,
planning, personal
hygiene, interpersonal
skills. May range from
mild to severe. Impact
on functional and
decisional abilities is
variable.
May affect just one
part of the brain, so
individuals should be
carefully assessed to
determine their
functional and
decisional abilities.
Treatability
Cases of PSV usually
lead to death within a
year’s time.
Many symptoms can
be successfully treated
with medication.
Capacity loss may
occur when patients go
off their medications.
Some level of
recovery and
improved function
over the first year;
thus a temporary
guardianship might be
considered if the
stroke is recent.
Usually show recovery
Individuals with mild
and moderate TBI may of thinking and
functional abilities
appear superficially
the same as before the over the first year;
thus a temporary
accident, but have
guardianship should
persisting problems
be considered if the
with motivation,
injury is recent.
judgment, and
organization. Those
with severe TBI may
have profound
problems with
everyday functioning.
Functional strengths
May remain stable
and weaknesses may
over time if underlying
vary, depending on the cerebrovascular or
extent and location of
heart disease is
the strokes.
successfully managed.
May worsen if
Functional strengths
cerebrovascular
and weaknesses may
vary, depending on the disease continues to
cause progressive
extent and location of
impairment.
the strokes.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
©American Bar Association Commission on Law and Aging – American Psychological Association
182
Appendix H. Temporary and Reversible Causes of Confusion
In evaluating capacity, remain mindful of possible temporary or reversible causes of confusion. If any of
these are present:
Î Provide appropriate treatment or accommodations.
Î Re-assess capacity after treatment or accommodation.
Common Medical Causes
Causes of Delirium
Look for:
Drugs4
Electrolytes
Lack of Drugs, Water, Food
Infection or Intoxification
Reduced Sensory Input
Intracranial Causes
Urinary Retention/Fecal Impaction
Myocardial
Other Causes of Confusion
Liver or kidney disease
Vitamin deficiency
Post surgical state
Consider how long the problem has been going on?
Were standard lab tests and vitals done?
> 6 meds or > 3 new meds or use of drugs that cause confusion
Low sodium, blood sugar, calcium, etc.
Pain, malnutrition, dehydration
Sepsis, urinary track infection, pneumonia; alcohol, metals, solvents
Impaired vision, hearing, nerve conduction
Subdural hematoma, meningitis, seizure, brain tumor
Drugs, constipation
Heart Attack, heart failure, arrhythmia
Hepatitis, diabetes, renal failure
Folate, nicotinic acid, thiamine, vitamin B12
Anesthesia, pain
Common Psychosocial Causes
Was a careful case history taken?
Depression is a common cause of confusion and is mistaken for dementia or delirium
Transfer trauma (a recent move that has the individual disoriented)
Recent death of a spouse or loved one
Recent stressful event
Insomnia
Common Miscommunication Problems
Could the older adult see, hear, and understand questions?
Difficulty understanding English
Decisions impacted by religious, cultural, or ethnic background
Low educational or reading level; illiterate
Difficulty hearing or seeing
4
The Delirium mnemonic is adapted from the work of Rudolph, J.L., and Marcantonio, E.R.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
©American Bar Association Commission on Law and Aging – American Psychological Association
183
Medications That May Commonly Cause Confusion
Class
Uses
Examples of More Problematic Medicines
Anticholinergic
Block the action of the
neurotransmitter
acetylcholine
Antidepressants
Depression
AntiParkinson drugs
Antipsychotics
Parkinson’s disease
symptoms
Hallucinations, Delusions
Barbiturates
Sleep and Anxiety
Benzodiazepines
Sleep and Anxiety
Histamine-2 (H2) Blockers
Block the action of
gastric acid secretion
Pain
Chlordiazepoxide, Diazepam, Flurazepam,
Nitrazepam
Cimetidine, Famotidine, Nizatidine,
Ranitidine
Ibuprofen, Indomethacin
Pain
Morphine, Propoxyphene, Meperidine
Inflammation, Pulmonary
disease
Predisone, Dexamethasone, Methylprednisolone
Nonsteroidal antinflammatory drugs (NSAIDs)
Opioids
Steroids
Distinguishing Delirium from Dementia
Characteristics
Atropine, Scopolamine, and many Antihistamines
such as Chlorpheniramin,
Cyproheptadine, Dexchlorpheniramine,
Diphenhydramine, Hydroxyzine, Promethazine
Amitriptyline, Doxepin
Levodopa (L-dopa or Sinemet), Bromocriptine
Chlorpromazine, Haloperidol, Thioridazine
Thiothixene
Phenobarbital, Secobarbital
Delirium
Dementia
Onset
Acute
Insidious
Course
Fluctuating
Stable and deteriorating
Duration
Hours to weeks, sometimes longer
Months to years
Attention
Poor
Usually normal
Perception
Hallucinations and misperceptions
Usually normal
Consciousness and orientation
Clouded; disoriented
Clear until late stages
Memory
Poor memory after 1 minute or
more
Poor memory after 15 minutes or
more, but may be okay in shorter
time periods
Note: The most critical factors in distinguishing a temporary cause of impairment from dementia are:
comes on rather suddenly, fluctuates between good and bad, problems with attention.
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
©American Bar Association Commission on Law and Aging – American Psychological Association
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Appendix I. Useful Web Sites
Administration on Aging
For Professionals: http://www.aoa.gov/prof/prof.asp
How to Find Help: http://www.aoa.gov/eldfam/How_To_Find/How_To_Find.asph
Alzheimer’s Association
http://www.alz.org
AARP
http://www.aarp.org
American Bar Association Commission on Law and Aging
http://www.abanet.org/aging
American Psychological Association
Office on Aging: http://www.apa.org/pi/aging
Guidelines for Psychological Practice with Older Adults: http://www.apa.org/practice/guidelines/adult.pdf
Benefits Check Up (Web-based service to screen for benefits programs for older adults)
http://www.benefitscheckup.org/
Center for Disease Control
http:/www.cdc.gov/aging
Centers for Medicaid & Medicare Services
http://www.cms.hhs.gov
First Gov for Seniors (Federal clearinghouse)
http://www.firstgov.gov/Topics/Seniors.shtml
Geriatrics at Your Fingertips
http://www.geriatricsatyourfingertips.org/
(Free registration required)
Medicare
http://www.medicare.gov
National Academy of Elder Law Attorneys
http://www.naela.com/
National Association of Area Agencies on Aging
http://www.n4a.org/
Older Driver Safety Project
http://www.n4a.org/older_driver_safety/materials.cfm
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
©American Bar Association Commission on Law and Aging – American Psychological Association
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National Association of Professional Geriatric Care Managers
http://www.caremanager.org/
National Association of State Units on Aging
http://www.nasua.org/
National Center for State Courts
http://www.ncsconline.org/
National College of Probate Judges
http://www.ncpj.org/
National Council on Aging
http://www.ncoa.org
National Disability Rights Network
http://www.napas.org/
National Guardianship Association
http://www.guardianship.org/
National Highway Traffic Safety Organization
Older Drivers Program
http://www.nhtsa.dot.gov/portal/site/nhtsa/menuitem.31176b9b03647a189ca8e410dba046a0/
National Institute on Mental Health
Older Adults and Mental Health
http://www.nimh.nih.gov/health/topics/older-adults-and-mental-health/index.shtml
National Institute on Aging
http://www.nia.nih.gov/
Social Security Administration
http://www.socialsecurity.gov
Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists
©American Bar Association Commission on Law and Aging – American Psychological Association
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