Difficulties With Elder Decision-Making

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Is Dad Okay?

In our consulting practice, we often come across the problem of aging parents and elders who are losing capacity for decision-making, but are not completely incapacitated. We call this “the grey area” between perfectly normal and impaired. The frightening thing about having a loved one in “the grey area” is that no one knows for sure just how impaired the elder actually is, and the elder may be getting into danger. This is a regular problem in persons who have dementia, whether it has been formally diagnosed or not. Doctors call it “cognitive decline” or “mild impairment”. It is a tinderbox of problems for families, as loss of capacity gives rise to many of the family conflicts we see.

Families argue among one another that Mom or Dad is “just fine” or that no one should tell the parent what to do, because they have the “right” to decide everything for themselves. Others may argue that the parent can’t remember anything anymore, and how come everyone is in denial. You get the picture. Maybe it’s your picture.

How do you know if your elderly aging parent is too impaired to make money or health decisions? There are objective ways to find out. These objective ways work better than a 5 minute doctor’s visit, and better than a family member’s untrained and unprofessional opinion. They involve psychological testing. Psychological testing is a special kind of assessment that must be done by a licensed psychologist. Not even an M.D. is trained to do psychological testing, which is very specialized. It goes far beyond the “mini mental status exam”, which can be administered by just about anyone, and is used often by healthcare providers to get a fast read on how oriented a person is to who and where they are. The weakness of the mini mental status exam is that it takes about 20 minutes to administer, has just 27 questions, and it does not even address the issue of a person’s ability to make decisions. Rather, it is a very cursory look at a person’s short and long term memory. It was never designed solely as a comprehensive diagnostic tool. Its purpose is to get a quick assessment of orientation and memory ability. For licensed psychologists, it is unethical to use a single test to make a diagnosis or to decide, on that alone, if a person is incapacitated or not.

Want to get a good, thorough idea of how impaired your elder is or isn’t? We recommend the following steps:

  • 1.Have your elder visit the regular doctor, and accompany him or her. Mention to the doctor the problems you are noticing with your aging parent’s memory or cognitive decline. Be specific. You can do this with our without your elder present, depending on your relationship and how you feel about discussing this in front of your parent.
  • 2.Ask for a referral for a competency assessment. The doctor will need to understand why this is necessary. Medicare will pay for a very limited psychological assessment, which may not be sufficient to find out what you need to know. You may have to pay out of pocket for the complete kind of testing.
  • 3.Your elderly aging parent needs to cooperate with undergoing testing. The testing for capacity at a basic level, at least, will take a minimum of two hours, and will also require and interview with your loved one, separate from the testing. These should be done on different days, as your elder may be fine one day and unable to answer questions the next. The testing psychologist needs to see him or her more than once.
  • 4.Take the results of the testing seriously. Psychological testing instruments used to determine capacity have been used and researched by psychologists over time. These instruments, also researched by universities, have been found to be reliable and valid for widespread use.

Full neuropsychological test batteries, used for diagnosing brain injury or getting a very complete picture of cognitive impairment, are available. They take at least a full day to administer. Such a grueling amount of testing may not be necessary to find out if a person has capacity to make decisions. Simpler alternatives exist. However, if a guardianship is going to be requested, a full test battery (series) may be necessary to present in court. Otherwise, we suggest using the simplest method that can be ethically considered complete, for testing capacity.

What do you do if your elder won’t sit still for testing, or just refuses? Without objective testing, you have to rely on behavior of your elder to signal when it’s time for him or her to yield to others for decision-making. If family members are getting concerned, you can be sure there is a problem. Ask your parent’s doctor for advice. Write a letter to the doctor if necessary, spelling out the specific things that worry you, and seek the doctor’s help to keep your parent out of danger. Loss of capacity for decision-making is usually gradual, and can fool people. We think testing, when possible, can remove doubt.

For a detailed discussion about decision-making for dangerous older drivers, see The Boomer’s Guide to Aging Parents, How to Handle a Dangerous Older Driver, and in the same series, How to Handle Money for Aging Loved Ones, available at AgingParents.com.

 2009 By Carolyn L. Rosenblatt, R. N., Attorney at Law and Dr. Mikol S. Davis, Psychologist


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