Capacity to Manage Finances Health Considerations: Cognition and Executive Functioning

1. Capacity to Manage FinancesHealth Considerations: Cognition and Executive Functioning Lawrence J. Kerzner MD, FACP, AGSF Director, Geriatric Medicine Division Hennepin County Medical Center Lawrence.Kerzner@hcmed.org JUNE 12, 2014

2. Canary in the coal mine Financial capacity is among the first to decline in individuals with emerging cognitive impairments Affects housing, independence, health, well being ~$2.6 billion – annual loss by survivors of elder financial abuse .

4. New York Times

5. New York Times

7. 1. What are the relationships between different type of capacity for decision making among vulnerable adults? 2. What illnesses and situations can impair capacity for financial decision making? When should these be suspected? 3. To what extent can cognitive assessment tools inform understanding about capacity to manage finances?

8. Health States of Elders Healthy, Robust, Successful Aging Usual Frail Cognitive impairment End of life

9. 2013 MN Vulnerable Adult Definition excerpt • possesses a physical or mental infirmity or other physical, mental, or emotional dysfunction: • that impairs the individual's ability to provide adequately for the individual's own care without assistance, including the provision of food, shelter, clothing, health care, or supervision; and • because of the dysfunction or infirmity and the need for care or services, the individual has an impaired ability to protect the individual's self from maltreatment. • "care or services" means care or services for the health, safety, welfare, or maintenance of an individual.

10. MN Financial Exploitation 2013 acquires possession or control of, or an interest in, funds or property of a vulnerable adult through the use of undue influence, harassment, duress, deception, or fraud….

11. Assessment of testamentary capacity and vulnerability to undue influence Shulman KI et al AM J Psychiatry 2007;164(5):722-727

12. Types of Capacity Financial Testamentary Consent to medical care Consent to participation in research Everyday decision making capacity Driving Own guns?

13. Financial Capacity “ability to independently manage one’s finances in a manner consistent with personal self interest”

14. Financial Medical Verbal Discretepoints in time Specific decisions Lifetime Conceptualize Pragmatic/procedural Judgment Highly vulnerable to illness Impairment occurs early, individuals/family members may be unaware

15. Tasks related to financial capacity Identifying and counting money Conducting cash transactions Paying bills, checkbook management Understanding debt and loans Judgment to conduct financial activities (mail, telephone fraud) Avoid financial abuse

16. Testamentary Capacity 1. Knowledge what a will is • Knowledge of the class of individuals that represents potential heirs (“natural objects of one’s bounty”) • Knowledge of the nature and extent of one’s assets 4. General plan of distribution of assets to heirs.

17. Testamentary CapacityCapacity to form a will Choice Appreciation of consequences Rational reasons expressed clearly, consistently

18. Biomedical Ethics Principles Actualized Through Medical Decision Making Autonomy: Informed consent – informed refusal Capacity to decide Beneficence – Non maleficence Justice Fidelity

19. Consent to Medical Care and Treatment:Focus on Autonomy 1. Nature, purpose of what is proposed 2. Risks 3. Benefits 4. Alternatives including no treatment 5. Recuperative 6. Any other information requested

20. Increasing complexity • Communicate a choice 2. Understand information about proposed diagnostic tests / treatments 3. Appreciate the context, underlying values and current medical situation 4. Use of reason to make a decision

21. Capacity to participate in research Voluntary, competent, informed, understanding Reason to do the research Purpose Experiment Risks Anticipated benefits

22. Right to withdraw Alternatives to participation Confidentiality Safeguards to minimize risk People with cognitive impairment Guardians, formal decision makers

23. Finances, Testamentary, Medical, Research Capacity

24. Day to day capacity Finances Medication Meal Preparation

25. Driving Cognitive function Physical function Task specific Context - time of day, distance, speed Guns Might capacity for driving or cooking serve a template?

26. Geriatric patients, firearms and physicians. Kapp MB. Annals Intern Med 2013;159:421-422 Cognitive or emotional deficits Deteriorating behavioral symptoms Foreseeable risk to themselves or others (if armed) Physician should consider recommending to family members or functional equivalent Removed from home or unloaded stored lock and key

27. How might various health conditions and health states affect financial capacity?

28. Health States of Seniors Healthy, Robust, Successful Aging Usual Frail Cognitive impairment End of life

30. De-afferentationOlympics of Geriatric Care

31. What illness or conditions adversely affect thinking, cognition, decision making abilities Developmental - Acquired Dementia and related disorders Stroke Acute and chronic medical illnesses Medications Severe psychiatric illness (get elder physicians talk data too)

32. Epidemiology of Alzheimer’s Disease >5 million people US 11-16 million by 2050 17 million world wide Annual incidence (what % develop it) 60-70 1% develop yearly ≥ 85 ~ 7% Prevalence (what % have it) 65-69 1% ≥ 65 5% People live years with the disease, % who have it doubles every 5 years after age 65 75-84 18% ≥ 85 30-50%

33. Dementia in Elderly 60-70% Alzheimer’s disease women > men 15-30% Other: Vascular (VaD) Lewy Body (DLB) Frontotemporal (FTD) 2 - 5% Drugs, metabolic, subdural, NPH, Parkinson’s

34. Estimated > 50% with dementia have not been diagnosed by a physician many with mild, some with moderate disease Undiagnosed patients may account for 50-60% of dementia in primary care populations studied How prevalent are more subtle cognitive impairments?

35. Mild Cognitive Impairment (MCI) 3-53% over 65 have this 2 X prevalence of dementia 1-2% /year in general populationdevelop AD 10-15 % per year with Amnestic MCI convert to AD some change back to normal. 5-10 X likelihood of developing dementia.

37. Chertkow H. et al. CMAJ 2008;178:1273-1285. Diagnosis and treatment of dementia: 3. Mild cognitive impairment and cognitive impairment without dementia.

38. Financial Capacity “The ability to independently manage one’s finances in a manner consistent with personal self interest” Lifetime of conceptualizations, pragmatic/procedural, judgment skills Knowledge, performance, judgment on an ongoing basis Highly vulnerable to cognitive changes

40. Footprints of possible financial impairment 1. Change in appearance or poor hygiene 2. Recent loss or spouse or partner who may have been managing finances 3. New family members or caregivers who may be accompanying person to office visits 4. Medical condition potentially affecting functional capacity or cognition

41. Direct reports from patients families or caregivers New difficulty with common financial skills calculating change writing checks organizing financial documents managing assets

42. Forgetting to pay utility bills or rent Concern or confusion about “missing funds” in bank accounts Reports of erratic, unusual, or uncharacteristic purchases or gifts Accusations of persons stealing or mismanaging money

43. Cognitive areas Personality Intellect Memory Spatial Organization Language Level of Consciousness Regulation of Attention - Executive Function Arousal

44. Functional anatomy of executive processes involved in dual-task performance. Adcock AR et al. Proc Nat AcadSci 2000 ;97(7):3667-3572 The allocation of attentional resources among competing tasks.

45. Regulation of Attention

46. Abnormal Regulation of Attention

47. Diagnosis of Dementia Decline in cognitive abilities sufficient to interfere with social or occupational functioning affecting at least two areas of cognition: Memory Executive function Language (Aphasia) Spatial organization (Apraxia) Sensory integration (Agnosia) (not caused by other illnesses, psychiatric illness, delirium)

48. Mild Cognitive Impairment - MCI Memory difficult or other cognitive impairments without impairments in social or occupational functioning

49. Executive function – intimately linked to all of the brain

50. Executive function Plan Initiate Sequence Monitor Stop complex behavior