Published in UAB Insight, Summer 2007
Objective tools to assess decision-making capacity
The estimates are sobering: In the next 40 years, the number of people worldwide with Alzheimer’s disease will quadruple, reaching 85 million by 2050. These individuals face a host of challenges in addition to the deterioration of everyday functional capabilities. The ability to manage personal finances is a critical skill that often is lost to age-related dementias.
“The impairment and eventual loss of financial competency are devastating and not uncommon consequences of Alzheimer’s disease and related dementias,” says UAB Alzheimer’s Disease Center Director Daniel J. Marson, JD, PhD, an attorney and clinical psychologist with specialty training in neuropsychology and geropsychology. “Financial exploitation of cognitively impaired elderly persons is already rampant, will continue to grow along with an aging population, and has enormous adverse consequences for patients and their families.”
Physicians, psychologists, and other clinicians are increasingly asked to evaluate patients’ financial capacity, Marson says. “Most clinicians are not trained in this area and may feel ill-prepared to provide objective assessments. Such judgments have important legal and ethical implications, and clinicians must address the conflict between an individual’s right to autonomy and their need for protection. Capacity determinations can seriously restrict or remove an individual’s freedom to make financial decisions, but these steps may be necessary to safeguard patients and families from exploitation.”
Objective Tools
Marson and colleagues have developed a set of objective measures to assess financial capacity in patients with a range of conditions from mild cognitive impairment to Alzheimer’s disease. “Financial capacity encompasses many types of knowledge and specific skills,” he says. “Each has significance to independent functioning.”
Marson and his team developed assessment tools, including a psychometric instrument for direct performance assessment and a 25-minute clinical interview. The tools assess different domains of financial ability relevant to community function, including basic monetary skills (the ability to name, quantify, and count coins and currency); conceptual knowledge (understanding the definition of a loan or taxes); cash transactions; checkbook and bank statement management; financial judgment; bill payment; and knowledge of personal assets and estate arrangements.
Studies using these instruments show that small declines in financial capacity begin in patients with mild cognitive impairment. “As patients progress to mild and moderate Alzheimer’s, cognitive decline accelerates and impairments in financial skills become substantial and widespread,” Marson says. “I recommend that people diagnosed with mild cognitive impairment, along with their families, proactively engage in financial and estate planning in anticipation of the significant and rapid loss of abilities that occurs with Alzheimer’s disease.”
Marson notes decisions about diminished financial capacity are not always made in the courtroom. “More often determinations are made by physicians and psychologists working with the elderly, and are usually adhered to by patients and families. These decisions have an enormous human impact. Our center offers new tools that bring objectivity and scientific rigor to issues of financial capacity and other medical-legal capacities.”
For more information
Dr. Daniel Marson
1.800.UAB.MIST
mist@uabmc.edu
Marson is New Director of UAB’s Alzheimer’s Disease Center
UAB's interdisciplinary Alzheimer's Disease Center (ADC) coordinates diagnosis, treatment, research, and education about a disease that its new director, Daniel C. Marson, JD, PhD, says could grow to tidal wave proportions in coming decades.
"The ADC is well-recognized as an important resource for diagnosis and treatment of Alzheimer's disease in Alabama and our region. The center is seeking greater balance between basic and clinical studies, and current research efforts include AD issues in African Americans, cross-dementia studies of AD and Parkinson's disease, and mouse models of AD," he says.
It is an exciting time nationally in AD research. Neuroimaging now can accurately display amyloid distribution and load in the brain, and investigators are identifying new genetic components of AD. UAB's ADC is participating in two key national studies of AD funded by the National Institute on Aging: the Alzheimer's Disease Cooperative Study, a consortium of AD centers that carry out clinical trials, and the Alzheimer's Disease Neuroimaging Initiative, a study investigating brain changes over time using neuroimaging.
"Our goal is identifying the disease process earlier and intervening before it substantially affects the brain. I am optimistic that we will find ways to identify and modify key biological processes before they cause the dementia we know as AD."