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Assessing Competency to Manage One’s Own Affairs

Assessing Competency to Manage One’s Own Affairs. Bonnie Sachs, M.S. Forensic Neuropsychology Summer 2006. It is not wealth one asks for, but just enough to preserve one’s dignity, to work unhampered, to be generous, frank, and independent … - W. Somerset Maugham, 1915.

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Assessing Competency to Manage One’s Own Affairs

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  1. Assessing Competency to Manage One’s Own Affairs Bonnie Sachs, M.S. Forensic Neuropsychology Summer 2006

  2. It is not wealth one asks for, but just enough to preserve one’s dignity, to work unhampered, to be generous, frank, and independent… -W. Somerset Maugham, 1915

  3. How Does One Define Independence? • Driving ability • Decisions about their well-being (MDM) • Financial Autonomy (FC) -Larrabee, 2005

  4. Why is Financial Capacity Important? • “Financial capacity is a vital aspect of individual autonomy in our society” (Larrabee, 2005) • Loss of FC has serious consequences for patient and family: • Psychological consequences include loss of control, depression (Moye, 1996) • Family consequences include endangering own or other’s assets (long-term care, inheritance) • Elder abuse and exploitation • Guardianship issues

  5. Financial Questions • Had some difficulty calculating a tip at a restaurant? • Gotten confused when reviewing your bank or credit card statement? • Forgotten a stamp, return address, or signature on a check when mailing your bills? • Been confused when presented with investment options or choices (stocks, bonds, etc)?

  6. Then you may have diminished financial capacity…

  7. Financial Capacity • FC is a continuum that is made up of a wide range of abilities • It is considered an Advanced / Complex ADL: • Requires higher cognitive function • Medical decision making, managing finances

  8. Basic Identifying coins/currency Conducting cash transactions Managing a checkbook Reading a bank statement Verifying assets/ownership of property Complex Understand/apply tipping convention Paying with a check Prepare bills, checks, envelopes for mailing Understand risks and benefits of investments Financial Capacity

  9. Case Example 1 • Mr. M is a 72 year old man with Moderate AD (MMSE score = 20). On assessment, he has trouble identifying coins, naming their value, and paying for an item with correct change in the supermarket. He does not recognize his bank statement or checkbook as his own, and has been a victim of telephone fraud on a two occasions. He has also forgotten to pay his rent and water bills for his apartment. • Capable or not?

  10. Case Example 2 • Mrs. A is an 81 year old woman diagnosed with Mild AD (MMSE score=23).Her son and daughter-in-law claim that she has paid bills twice in one month, forgotten to pay her electric bill and had services turned off, and frequently needs help when reviewing her bank records. Additionally, she invested $10,000 of her savings into a risky stock and lost money on the investment. They also point out that she gets lost frequently and often misplaces objects around the house. • Capable or not?

  11. Trick question… • Partially or marginally capable is acceptable… • Persons can be capable for some tasks (i.e. counting money, paying at stores, identifying and understanding a checkbook) and incapable at others (writing and addressing checks, making investments, detecting mail fraud)

  12. How is Financial Capacity Assessed? • Prior Financial Capacity Form (PFCF) & Current Financial Capacity Form (CFCF) • PFCF assesses for individual differences in prior financial experience • CFCF assesses current financial functioning • 8 conceptual domains, 20 items total • Informant and patient response forms available -Wadley et al., 2003

  13. PFCF & CFCF • Knowledge is assessed by questions, not demonstration • Example Question: “Basic money skills include knowing the names of coins and paper money and being able to count money. Do you have these basic money skills?” • Answer:A) No, B) Yes, or C)Yes, but with help • Results of a study with AD to come… -Wadley et al., 2003

  14. Direct assessment of 20 tasks which forms 9 domains (old version = 6 domains). Tasks are rated as simple or complex Also includes a global FC rating Authors derived cutoffs for capable, marginally capable, and incapable 9 Domains: Basic monetary skill Financial conceptual knowledge Cash transactions Checkbook management Bank statement management Financial judgment Bill payment Knowledge of assets Investment decision making Financial Capacity Instrument (FCI) -Marson et al., 2000

  15. Financial Capacity Instrument • The FCI appears to be the “instrument of choice” for assessing FC, although there is clearly a dearth of available empirical research on the conceptualization of FC and its measurement • One caveat of the FCI is that it doesn’t thoroughly account for lifetime financial capacity or experience

  16. FC & Dementia • Mild AD (MMSE 20-23) • Generally, performance was intact on simpler tasks than more complex • Using a cut-score, 50% of patients were capable on Domains 1, 2, & 3, 30% on Domains 4 & 5, and less than 15% capable on Domains 6 and above. • Hierarchy of abilities for Mild AD patients

  17. FC & Dementia • Moderate AD (MMSE 10-20) • Patients with this level of dementia displayed high rates of incapable outcomes on virtually all domains of the FCI • The range was 90-100%.

  18. Mild AD: Mild AD patients are at risk for impairment in most financial abilities, especially complex ones. Areas of preserved autonomy should be carefully evaluated/monitored. Moderate AD: These patients are at great risk for loss of all financial activities. Although each patient is an individual, it is likely that most patients with moderate AD are unable to manage their own financial affairs. Author Comments about Dementia & FC Larrabee, 2005; Marson et al., 2000

  19. An Aside… • Using the PFCF & CFCF, patients and caregivers did not differ on PFCF ratings, but did differ on CFCF ratings • AD patients almost always overestimated their abilities, while caregivers equally underestimated and overestimated patients’ performance. • For global ratings, almost of half of the AD caregivers misclassified patients’ abilities. -Wadley et al., 2003

  20. FC & MCI • MCI state presumed to not reflect functional changes… • However, one study found that for Domains 2, 5, & 7, Controls > than MCI • MCI > Mild AD on Domains 1, 2, 3, 4, 5, 7, & 9. • For overall FC ratings, Control > MCI > Mild AD. • These results suggest mild, but significant, decline in financial abilities is a functional change present in MCI. Griffith et al., 2003

  21. FC & Serious Mental Illness • Even less research than on AD/MCI • Generally, impairments are found even in discrete financial skills such as counting change and paying bills • As opposed to losing skills at some point, many with SMI/Schizophrenia never acquire financial management skills • As a results, many may need representative payees to manage money for rent, food, etc. Patterson et al., 2001; Marson et al., 2005

  22. Questions?

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