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Impact of Dementia on Impact of Dementia on Capacity to Manage Finances and Capacity to Manage Finances and
Prevention of Financial ExploitationPrevention of Financial Exploitation
Daniel Marson, J.D., Ph.D.Daniel Marson, J.D., Ph.D.Professor of NeurologyProfessor of Neurology
Director, Alzheimer’s Disease CenterDirector, Alzheimer’s Disease Center
Department of NeurologyDepartment of Neurology
University of Alabama at BirminghamUniversity of Alabama at Birmingham
[email protected]@uab.edu
The Aging Population, Alzheimer’s and Other Dementias:The Aging Population, Alzheimer’s and Other Dementias:
Law and Public PolicyLaw and Public PolicyNational Health Law and Policy Resource CenterNational Health Law and Policy Resource Center
University of Iowa, Iowa City, IowaUniversity of Iowa, Iowa City, Iowa
March 1, 2012March 1, 2012
DisclosureDisclosure Financial Capacity Instrument (FCI)Financial Capacity Instrument (FCI)
Semi-Structured Clinical Interview for Financial Semi-Structured Clinical Interview for Financial
Capacity (SCIFC)Capacity (SCIFC)
Owned by UAB Research FoundationOwned by UAB Research Foundation
Inventor Dr. MarsonInventor Dr. Marson
No royalty incomeNo royalty income
No relationships with pharmaceutical companiesNo relationships with pharmaceutical companies
Outline 1: Outline 1: Dementia and Financial CapacityDementia and Financial Capacity
Capacity Assessment in an Aging SocietyCapacity Assessment in an Aging Society
Dementia and Functional Change Dementia and Functional Change
What is Financial Capacity?What is Financial Capacity?
Warning Signs of Diminished Financial CapacityWarning Signs of Diminished Financial Capacity
Research on Financial Capacity in MCI and ADResearch on Financial Capacity in MCI and AD
Financial Capacity and the Alzheimer BrainFinancial Capacity and the Alzheimer Brain
Outline 2: Outline 2: Prevention of Financial ExploitationPrevention of Financial Exploitation
The $18.1 Trillion Problem The $18.1 Trillion Problem
Contractual/Transactional Approaches to PreventionContractual/Transactional Approaches to Prevention
Familial Approaches to PreventionFamilial Approaches to Prevention
Legislative Approaches to PreventionLegislative Approaches to Prevention
Capacity AssessmentCapacity Assessmentin an Aging Societyin an Aging Society
Definitions—Oxford Universal Dictionary
CapacityCapacity ~1480 ~1480 [selected definitions][selected definitions]
Mental receiving power; ability to take in impressions, ideas, Mental receiving power; ability to take in impressions, ideas, knowledge. 1485 knowledge. 1485
Active power of mind, talent. 1485 Active power of mind, talent. 1485 The power, ability, or faculty for anything in particular. 1647The power, ability, or faculty for anything in particular. 1647 Law. Legal qualification. 1480 Law. Legal qualification. 1480
Definitions—Oxford Universal Dictionary
CompetentCompetent ~1483 ~1483 [selected definitions][selected definitions]
Law. Legally qualified or sufficient. 1483Law. Legally qualified or sufficient. 1483
CompetenceCompetence ~1594 ~1594 [selected definitions][selected definitions]
Sufficiency of qualification, capacity. 1700Sufficiency of qualification, capacity. 1700 Especially law—legal capacity. 1708Especially law—legal capacity. 1708
“As our society ages, clinical assessment of higher order As our society ages, clinical assessment of higher order functional capacities has become increasingly important. functional capacities has become increasingly important.
In areas like financial capacity, medical decision making In areas like financial capacity, medical decision making capacity, medication compliance, and driving, society has capacity, medication compliance, and driving, society has a strong interest in accurately discriminating intact from a strong interest in accurately discriminating intact from impaired functioning.” impaired functioning.”
Marson et al. (2000) Marson et al. (2000) Archives of Neurology, Archives of Neurology, 57: 877-84457: 877-844
Capacity Assessment and AgingCapacity Assessment and Aging
Unprecedented aging societyUnprecedented aging society
Older population vulnerable to cognitive disorders affecting Older population vulnerable to cognitive disorders affecting
decision-making abilitydecision-making ability
Persons with diminished capacity vulnerable to poor Persons with diminished capacity vulnerable to poor
decision-making and exploitationdecision-making and exploitation
Capacity Assessment and AgingCapacity Assessment and Aging Individualistic societyIndividualistic society
Intergenerational transfer of wealth--$16B - $18BIntergenerational transfer of wealth--$16B - $18B
Breakdown of traditional family structureBreakdown of traditional family structure
Family disputes over care of elderlyFamily disputes over care of elderly control of health care & financial decisionscontrol of health care & financial decisions use of estate and inheritance use of estate and inheritance
Civil Capacities/Competencies
Financial capacity: Financial capacity: manage financial affairs manage financial affairs
Treatment consent capacity: Treatment consent capacity: make medical decisionsmake medical decisions
Research consent capacity: Research consent capacity: research participationresearch participation
Testamentary capacity: Testamentary capacity: make a will make a will
Driving capacity: Driving capacity: operate a motor vehicleoperate a motor vehicle
Voting capacity: Voting capacity: capacity to cast a ballot in electioncapacity to cast a ballot in election
Capacity to live independently: Capacity to live independently: global global
Multiple Professions Must Deal With Multiple Professions Must Deal With Older Adult Capacity IssuesOlder Adult Capacity Issues
Clinicians: Clinicians: can patient consent to treatment?can patient consent to treatment?
Researchers: Researchers: can subject participate in research?can subject participate in research?
Attorneys: Attorneys: can client enter into a contract? make a will? can client enter into a contract? make a will?
Accountants: Accountants: can client contract for services? understand tax return?can client contract for services? understand tax return?
Real estate: Real estate: can client enter into listing agreement?can client enter into listing agreement? c contract of sale?ontract of sale?
Brokers: Brokers: can client enter into financial service contract?can client enter into financial service contract?
understand different forms of risk/return? enter understand different forms of risk/return? enter
into simple into simple or complex investment vehicles?or complex investment vehicles?
Adult protective: Adult protective: can client manage finances and own affairs? can client manage finances and own affairs?
does client need protection?does client need protection?
Dementia Dementia and and
Functional Change Functional Change
Pathological Time-line for ADPathological Time-line for AD
Cognitive Signs of Emerging DementiaCognitive Signs of Emerging Dementia
Short term memory lossShort term memory loss
DisorientationDisorientation
Communication problemsCommunication problems
Comprehension problemsComprehension problems
Lack of mental flexibility, inability to planLack of mental flexibility, inability to plan
Calculation problemsCalculation problemsAssessment of Older Adults with Diminished Capacity: A Handbook for Lawyers, p. 14-15
CLOX 1: Normal Older Control
CLOX 1: Mild Cognitive Impairment
CLOX 1: Mild Alzheimer’s Disease
Emotional/Behavioral Signs Emotional/Behavioral Signs of Diminished Capacityof Diminished Capacity
Significant emotional distressSignificant emotional distress
Emotional labilityEmotional lability
Social inappropriatenessSocial inappropriateness
DelusionsDelusions
HallucinationsHallucinations
Poor grooming/hygienePoor grooming/hygiene
Assessment of Older Adults with Diminished Capacity: A Handbook for Lawyers, pp. 15-16
Instrumental Activities of Daily LivingInstrumental Activities of Daily Living Instrumental activities of daily living are more complex Instrumental activities of daily living are more complex
activities that are not essential to self-care, but that enable the activities that are not essential to self-care, but that enable the individual individual to live independently within a communityto live independently within a community
Light housework Light housework
Preparing meals and cleanupPreparing meals and cleanup
Shopping for groceries or clothes Shopping for groceries or clothes
Using the telephone Using the telephone
Using transportation (community mobility)Using transportation (community mobility)
Taking medications Taking medications
Health management and maintenance Health management and maintenance
Managing moneyManaging money
Activities of Daily LivingActivities of Daily Living Activities of daily living (ADLs) are "the things we normally do in daily living Activities of daily living (ADLs) are "the things we normally do in daily living
including any daily activity we perform for including any daily activity we perform for self-careself-care (such as feeding (such as feeding
ourselves, bathing, dressing, grooming), work, homemaking, and leisure."ourselves, bathing, dressing, grooming), work, homemaking, and leisure." ~MedicineNet.com Medical Dictionary~MedicineNet.com Medical Dictionary
Bathing Bathing
GroomingGrooming
Dressing and undressing Dressing and undressing
Eating Eating
Transferring from bed to chair, and back Transferring from bed to chair, and back
Voluntarily control of urinary and fecal discharge Voluntarily control of urinary and fecal discharge
Using the toilet Using the toilet
Walking (not bedridden)Walking (not bedridden)
IADLs As Early Functional MarkersIADLs As Early Functional Markers in Dementia Research in Dementia Research
IADLs are cognitively complex activities vulnerable to IADLs are cognitively complex activities vulnerable to
cognitive aging, MCI, and dementiacognitive aging, MCI, and dementia
IADLs like financial capacity show significant impairment IADLs like financial capacity show significant impairment
in MCI and the very earliest stages of ADin MCI and the very earliest stages of AD
Are diagnostically important markers for research on Are diagnostically important markers for research on
progression in MCIprogression in MCI and and conversion to dementiaconversion to dementia
Functional Change in DementiaFunctional Change in Dementia
Mrs. Ethel C 69 year old white femaleMrs. Ethel C 69 year old white female
MMSE = 22/30 DRS = 120/144 Diagnosis = mild ADMMSE = 22/30 DRS = 120/144 Diagnosis = mild AD PremorbidPremorbid: : “Ethel handled the family bank account for most of “Ethel handled the family bank account for most of
our married life with little help from me--and balanced the our married life with little help from me--and balanced the
checkbook.”checkbook.”
CurrentCurrent: : “Approximately 2 years back she could no longer “Approximately 2 years back she could no longer
handle the family bank account--this happened very quickly--she handle the family bank account--this happened very quickly--she
failed to make deposits and enter the checks she had written—failed to make deposits and enter the checks she had written—
she now has no worry about finances.” she now has no worry about finances.”
Financial CapacityFinancial Capacity
““everyday use of money will be highly everyday use of money will be highly correlated with general success in correlated with general success in independent living” independent living”
Melton et al. (1987) Melton et al. (1987) Psychological Evaluations for the Courts, Psychological Evaluations for the Courts, p. 249p. 249
An Important ConstructAn Important Construct
economic: economic: maintaining household and financial independencemaintaining household and financial independence
psychologicalpsychological critical to self-perception of independencecritical to self-perception of independence
clinical:clinical: marker of MCI and early dementia?marker of MCI and early dementia?
legal:legal: financial competency and conservatorship financial competency and conservatorship
elder abuse/undue influenceelder abuse/undue influence
Defining Financial Capacity:Defining Financial Capacity:Two Key PerspectivesTwo Key Perspectives
Performance Perspective:Performance Perspective:
FC as the ability to carry out financial activitiesFC as the ability to carry out financial activities
Handle money, understand concepts, pay bills, etc. Handle money, understand concepts, pay bills, etc.
Emphasizes role of Emphasizes role of performanceperformance..
Best Interest Perspective:Best Interest Perspective:
FC as ability to identify and protect financial self-interest FC as ability to identify and protect financial self-interest
Emphasizes role of Emphasizes role of judgmentjudgment..
““the capacity to manage money and the capacity to manage money and financial assets in ways that meet a financial assets in ways that meet a person’s needs and which are consistent person’s needs and which are consistent with his/her values and self-interest”with his/her values and self-interest”
D. Marson October, 2007D. Marson October, 2007
Conceptual Model of Conceptual Model of Financial CapacityFinancial Capacity
Conceptual Model of FCConceptual Model of FC
Clinically informedClinically informed
Focus on functional abilities relevant to FCFocus on functional abilities relevant to FC
Three levels:Three levels:
TasksTasks——specific financial abilitiesspecific financial abilities
DomainsDomains——broad financial activities that each have clinical broad financial activities that each have clinical
relevance to independence (eg., managing checkbook)relevance to independence (eg., managing checkbook)
GlobalGlobal——overall financial capacityoverall financial capacity
Financial Tasks Financial Tasks
Naming coins/currency Naming coins/currency Coin/currency relationshipsCoin/currency relationships Count coins/currency Count coins/currency Understanding conceptsUnderstanding concepts Applying conceptsApplying concepts Conduct cash transactionsConduct cash transactions Making change for vendingMaking change for vending Tipping in a restaurantTipping in a restaurant
Understanding checkbookUnderstanding checkbook Using checkbook/registerUsing checkbook/register Understanding bank statementUnderstanding bank statement Using a bank statementUsing a bank statement Awareness of mail fraudAwareness of mail fraud Awareness of telephone fraudAwareness of telephone fraud Prioritizing billsPrioritizing bills Preparing bills for mailingPreparing bills for mailing Making investment decisionMaking investment decision
Financial DomainsFinancial Domains Domain 1 Basic Monetary SkillsDomain 1 Basic Monetary Skills
Domain 2 Financial Conceptual KnowledgeDomain 2 Financial Conceptual Knowledge
Domain 3 Cash TransactionsDomain 3 Cash Transactions
Domain 4 Checkbook ManagementDomain 4 Checkbook Management
Domain 5 Bank Statement ManagementDomain 5 Bank Statement Management
Domain 6 Financial JudgmentDomain 6 Financial Judgment
Domain 7 Bill PaymentDomain 7 Bill Payment
Domain 8 Knowledge of Personal Assets/EstateDomain 8 Knowledge of Personal Assets/Estate
Domain 9 Investment Decision MakingDomain 9 Investment Decision Making
Tasks by DomainTasks by Domain
Domain 1 Basic Monetary SkillsDomain 1 Basic Monetary Skills Task 1a Naming coins/currency Task 1a Naming coins/currency SimpleSimple Task 1b Coins/currency relationshipsTask 1b Coins/currency relationships ComplexComplex Task 1c Counting coins/currency Task 1c Counting coins/currency SimpleSimple
Domain 2 Financial Conceptual KnowledgeDomain 2 Financial Conceptual Knowledge Task 2a Define financial conceptsTask 2a Define financial concepts ComplexComplex Task 2b Apply financial conceptsTask 2b Apply financial concepts ComplexComplex
Tasks by DomainTasks by Domain
Domain 3 Cash TransactionsDomain 3 Cash Transactions Task 3a 1 item grocery purchase Task 3a 1 item grocery purchase SimpleSimple Task 3b 3 item grocery purchase Task 3b 3 item grocery purchase Simple Simple Task 3c Change/vending machine Task 3c Change/vending machine ComplexComplex
Task 3d Tipping Task 3d Tipping ComplexComplex
Domain 4 Checkbook ManagementDomain 4 Checkbook Management Task 4a Understand checkbook/registerTask 4a Understand checkbook/register ComplexComplex
Task 4b Use checkbook/register Task 4b Use checkbook/register ComplexComplex
Tasks by DomainTasks by Domain
Domain 5 Bank Statement ManagementDomain 5 Bank Statement Management Task 5a Understand bank statement Task 5a Understand bank statement ComplexComplex
Task 5b Use bank statementTask 5b Use bank statement ComplexComplex
Domain 6 Financial JudgmentDomain 6 Financial Judgment Task 6a Detect mail fraud riskTask 6a Detect mail fraud risk SimpleSimple
Task 6c Identify telephone fraudTask 6c Identify telephone fraud Simple Simple
Tasks by DomainTasks by Domain
Domain 7 Bill PaymentDomain 7 Bill Payment Task 7a Understand billsTask 7a Understand bills SimpleSimple
Task 7b Prioritize billsTask 7b Prioritize bills SimpleSimple
Task 7c Prepare bills for mailingTask 7c Prepare bills for mailing ComplexComplex
Domain 8 Knowledge of Personal Assets/EstateDomain 8 Knowledge of Personal Assets/Estate
Domain 9 Investment Decision MakingDomain 9 Investment Decision Making
Warning Signs of Diminished Warning Signs of Diminished Financial CapacityFinancial Capacity
Slide provided by Dr. Marson, JD, PhD and UAB
Martin et al. (2003). Loss of calculation abilities in mild and moderate AD. Archives of Neurology. 60: 1585-1589.
Responding to Responding to Warning Signs of Diminished Warning Signs of Diminished
Financial CapacityFinancial Capacity
Financial Capacity in MCI and AD:Financial Capacity in MCI and AD:
Clinical Interview Assessment Clinical Interview Assessment
Clinical Interview AssessmentClinical Interview Assessment
Potentially very useful approachPotentially very useful approach
Combine clinical interview + direct testing of skillsCombine clinical interview + direct testing of skills
Interview both patient and caregiverInterview both patient and caregiver
Allows for clinical judgmentAllows for clinical judgment
Categorical judgments: Categorical judgments: capable marginally capable incapablecapable marginally capable incapable
Disadvantages:Disadvantages: Requires trained clinicianRequires trained clinician
Time intensive for the clinician (~25 minutes)Time intensive for the clinician (~25 minutes)
Clinical subjectivity in evaluating performanceClinical subjectivity in evaluating performance
Semi-Structured Clinical Interview Semi-Structured Clinical Interview for Financial Capacity (SCIFC)for Financial Capacity (SCIFC)
25-30 minute clinical interview 25-30 minute clinical interview
Based on conceptual modelBased on conceptual model
Semi-structured: preserves clinical autonomySemi-structured: preserves clinical autonomy
Interview format with some props:Interview format with some props:
Includes interview of collateral sourcesIncludes interview of collateral sources
Assesses 8 domains and global financial capacityAssesses 8 domains and global financial capacity
Judgment rating for each domain and global: Judgment rating for each domain and global: capable capable
marginally capablemarginally capable
incapableincapable
Order of Financial Domains on SCIFCOrder of Financial Domains on SCIFC
Domain 2 Financial Conceptual KnowledgeDomain 2 Financial Conceptual Knowledge
Domain 1 Basic Monetary SkillsDomain 1 Basic Monetary Skills
Domain 3 Cash TransactionsDomain 3 Cash Transactions
Domain 4 Checkbook ManagementDomain 4 Checkbook Management
Domain 5 Bank Statement ManagementDomain 5 Bank Statement Management
Domain 6 Financial JudgmentDomain 6 Financial Judgment
Domain 7 Bill PaymentDomain 7 Bill Payment
Domain 8 Knowledge of Personal Assets/EstateDomain 8 Knowledge of Personal Assets/Estate
Excerpted Domains on SCIFCExcerpted Domains on SCIFC
Domain 2 Financial Conceptual KnowledgeDomain 2 Financial Conceptual Knowledge
Domain 1 Basic Monetary SkillsDomain 1 Basic Monetary Skills
Domain 3 Cash TransactionsDomain 3 Cash Transactions
Domain 4 Checkbook ManagementDomain 4 Checkbook Management
Domain 5 Bank Statement ManagementDomain 5 Bank Statement Management
Domain 6 Financial JudgmentDomain 6 Financial Judgment
Domain 7 Bill PaymentDomain 7 Bill Payment
Domain 8 Knowledge of Personal Assets/EstateDomain 8 Knowledge of Personal Assets/Estate
Who Is Ms. Y?
59 years old59 years old
African-AmericanAfrican-American
MarriedMarried
14 years of education14 years of education
RN and director of adult day careRN and director of adult day care
Financial Capacity Financial Capacity Training Video #1—040Training Video #1—040
Ms. YMs. Y
Who Is Mr. X?
74 years old74 years old
CaucasianCaucasian
MarriedMarried
9 years of education9 years of education
RetiredRetired
Last occupation: Last occupation:
architectural design construction supervisorarchitectural design construction supervisor
Financial Capacity Financial Capacity Training Video #2—298Training Video #2—298
Mr. XMr. X
Who Is Mr. Z?
73 years old73 years old
CaucasianCaucasian
MarriedMarried
14 years of education14 years of education
RetiredRetired
Last occupation: Last occupation:
nursing assistant at VA hospitalnursing assistant at VA hospital
Financial Capacity Financial Capacity Training Video #3—326Training Video #3—326
Mr. ZMr. Z
Research Findings UsingResearch Findings Using
SCIFC Clinical InterviewSCIFC Clinical Interview
SCIFC Study Sample at BaselineSCIFC Study Sample at Baseline
Controls Controls MCI MCI Mild AD Mild AD Mod ADMod AD
pp N=75N=75 N=58 N=58 N=97 N=97 N=31 N=31
AgeAge 66.1 (7.7)66.1 (7.7) 68.068.0 (8.3)(8.3) 72.4 (8.4)72.4 (8.4) 75.3 (8.4)75.3 (8.4).0001.0001
EducEduc 14.3 (1.6)14.3 (1.6) 13.7 (2.0)13.7 (2.0) 13.4 (2.1)13.4 (2.1) 11.1 (3.7) .000111.1 (3.7) .0001
Gender Gender (m/f)(m/f) 24 / 51 24 / 51 18 / 4018 / 40 52 / 45 52 / 45 10 / 21 10 / 21 .007.007
RaceRace 65 W, 10AA65 W, 10AA 44 W, 14 AA 44 W, 14 AA 85 W, 12 AA85 W, 12 AA 23 W, 8 AA23 W, 8 AA .12.12
MMSEMMSE 29.3 (1.0)29.3 (1.0) 28.2 (1.9)28.2 (1.9) 24.0 (3.1)24.0 (3.1) 16.4 (4.2)16.4 (4.2) .0001.0001
Physician CollaboratorsPhysician Collaborators
Britt Anderson, M.D. Britt Anderson, M.D. NeurologyNeurology
Patricia Goode, M.D. Patricia Goode, M.D. Geriatric MedicineGeriatric Medicine
Cleveland Kinney, M.D.Cleveland Kinney, M.D. Geriatric PsychiatryGeriatric Psychiatry
Anthony Nicholas, M.D.Anthony Nicholas, M.D. NeurologyNeurology
Terri Steele, M.D.Terri Steele, M.D. Geriatric PsychiatryGeriatric Psychiatry
Physician Capacity JudgmentsPhysician Capacity Judgments
• Study recruited 261 participantsStudy recruited 261 participants
• Study physicians made Study physicians made 11,11811,118 financial capacity judgments financial capacity judgments
• Each physician made an average of 2,224 judgmentsEach physician made an average of 2,224 judgments
• 627 ratings missing of 11,745 possible: 627 ratings missing of 11,745 possible: 94.7% completion rate94.7% completion rate
• Attests to effort/commitment of study physicians and staffAttests to effort/commitment of study physicians and staff
Basic Monetary Skills:Basic Monetary Skills:Judgment Outcomes By Percentage and GroupJudgment Outcomes By Percentage and Group
98 10092
66
0102030405060708090
100
Control MCI Mild AD Mod AD
Perc
en
tag
e
Capable
Marginal
Incapable
Control, MCI, mild AD differ from mod AD at p < .01 using GEEControl, MCI, mild AD differ from mod AD at p < .01 using GEE
Jts = 353 Jts = 282 Jts = 475 Jts = 155
Checkbook Management:Checkbook Management:Judgment Outcomes By Percentage and GroupJudgment Outcomes By Percentage and Group
9585
32
10
0102030405060708090
100
Control MCI Mild AD Mod AD
Per
cen
tag
e
Capable
Marginal
Incapable
Control differ from MCI at p = .06 Control differ from MCI at p = .06 Control, MCI differ from mild AD and mod AD at p < .01Control, MCI differ from mild AD and mod AD at p < .01
Mild AD differ from mod AD at p < .01Mild AD differ from mod AD at p < .01
Jts = 356 Jts = 267 Jts = 446 Jts = 144
Bank Statement Management:Bank Statement Management:Judgment Outcomes By Percentage and GroupJudgment Outcomes By Percentage and Group
93
72
33
4
0102030405060708090
100
Control MCI Mild AD Mod AD
Per
cen
tag
e
Capable
Marginal
Incapable
All groups differ at p < .01 using GEEAll groups differ at p < .01 using GEE
Jts = 357 Jts = 269 Jts = 435 Jts = 137
Global Financial Capacity:Global Financial Capacity:Judgment Outcomes By Percentage and GroupJudgment Outcomes By Percentage and Group
95
82
26
4
0102030405060708090
100
Control MCI Mild AD Mod AD
Per
cen
tag
e
Capable
Marginal
Incapable
All groups differ at p < .01 using GEEAll groups differ at p < .01 using GEE
Jts = 333 Jts = 282 Jts = 476 Jts = 155
Financial Capacity andFinancial Capacity and
the Alzheimer’s Disease Brainthe Alzheimer’s Disease Brain
Normal Brain AD BrainNormal Brain AD Brain
Loss of Brain Tissue in Alzheimer’s Disease
Normal Aging
Mild CognitiveImpairment
Alzheimer’s Disease
Conceptual Model of Declining Financial Capacity in aMCI and AD
Angular Gyrus and Financial CapacityAngular Gyrus and Financial Capacity
Results of VBM Analysis of Financial Capacity Instrument Scores in Patients with Amnestic MCI
(A) The cluster with maxima at coordinates 54, 48, and 44 on the glass brain projection (P=.08 corrected) (the second cluster was not significant after correction).
(B) The maxima of the above coordinates projected onto T1 MRI scans in each dimension for comparison.
Journal of the American Geriatrics Society, 58:265–274, 2010
Perhaps some day we will be able Perhaps some day we will be able to use MRI scansto use MRI scans
to help identify older persons to help identify older persons at risk for loss of financial capacity?at risk for loss of financial capacity?
““To those seniors and especially elderly veterans like myself, I want to To those seniors and especially elderly veterans like myself, I want to tell you this: You are not alone and you have nothing to be ashamed of. tell you this: You are not alone and you have nothing to be ashamed of.
If elder abuse happened to me, it can happen to anyone.” If elder abuse happened to me, it can happen to anyone.”
Mickey Rooney Mickey Rooney Testimony to Senate Special Committee on Aging, March 2, 2011 Testimony to Senate Special Committee on Aging, March 2, 2011
Outline 2: Outline 2: Prevention of Financial ExploitationPrevention of Financial Exploitation
The $18.1 Trillion Problem Facing UsThe $18.1 Trillion Problem Facing Us
Contractual/Transactional Approaches to PreventionContractual/Transactional Approaches to Prevention
Familial Approaches to PreventionFamilial Approaches to Prevention
Legislative Approaches to PreventionLegislative Approaches to Prevention
The $18.1 Trillion Problem The $18.1 Trillion Problem
% U.S. Households Across Age Group% U.S. Households Across Age Group
23.2 23.3 19.212.8
21.2
0102030405060708090
100
< 35 Years 35-44Years
45-54Years
55-64Years
65+ Years
Pe
rce
nta
ge
Adapted from D. Laibson, Age of Reason Lecture, June 2011 Morningstar Conference Adapted from D. Laibson, Age of Reason Lecture, June 2011 Morningstar Conference
% U.S. Household % U.S. Household WealthWealth Across Age Group Across Age Group
4.714.4
24.1 22.8
34
0102030405060708090
100
< 35 Years 35-44Years
45-54Years
55-64Years
65+ Years
Pe
rce
nta
ge
Adapted from D. Laibson, Age of Reason Lecture, June 2011 Morningstar Conference Adapted from D. Laibson, Age of Reason Lecture, June 2011 Morningstar Conference
All U.S. Households Balance Sheet[Federal Reserve Flow of Funds—2009]
Total = $53.1 TrillionTotal = $53.1 Trillion
From D. Laibson, Age of Reason Lecture, June 2011 Morningstar Conference From D. Laibson, Age of Reason Lecture, June 2011 Morningstar Conference
U.S. Household Wealth U.S. Household Wealth Across Age Groups Across Age Groups (in $ Trillion Dollars)(in $ Trillion Dollars)
53.1
2.57.6
12.8 12.118.1
0
10
20
30
40
50
All Ages < 35Years
35-44Years
45-54Years
55-64Years
65+ Years
$ T
rillio
n D
olla
rs
Adapted from D. Laibson, Age of Reason Lecture, June 2011 Morningstar ConferenceAdapted from D. Laibson, Age of Reason Lecture, June 2011 Morningstar Conference
$18.1 Trillion is at Risk$18.1 Trillion is at Risk Normal cognitive aging = the brain over age 65Normal cognitive aging = the brain over age 65
Age related improvement:Age related improvement:
Experiential pattern recognitionExperiential pattern recognition
““Wisdom”Wisdom”
Age related declines in multiple cognitive functions:Age related declines in multiple cognitive functions:
Short term memory capacityShort term memory capacity
Processing speedProcessing speed
Executive/planning abilitiesExecutive/planning abilities
Numeracy and arithmetic skillsNumeracy and arithmetic skills
““Fluid intelligence”Fluid intelligence”
Vulnerability to poor decisions and exploitationVulnerability to poor decisions and exploitation
“If the chance of getting a disease is 10 percent, how many people out of 1,000 would be expected to get the disease?”
78 78 76 74 7267
5851
0102030405060708090
100
% W
ith
Co
rre
ct
An
sw
er
Adapted from D. Laibson, Age of Reason Lecture, June 2011 Morningstar ConferenceAdapted from D. Laibson, Age of Reason Lecture, June 2011 Morningstar Conference
Normal Cognitive Aging and Financial CapacityNormal Cognitive Aging and Financial Capacity
We have focused on impact of prodromal (MCI) and clinical We have focused on impact of prodromal (MCI) and clinical
dementia (AD) on financial capacitydementia (AD) on financial capacity
But in terms of overall impact, But in terms of overall impact, normal cognitive agingnormal cognitive aging is the is the
greatest threat to financial capacity in the elderly:greatest threat to financial capacity in the elderly:
2009: 2009: 39.6 million elderly in U.S. 5.2 million with AD over 6539.6 million elderly in U.S. 5.2 million with AD over 65
2030: 2030: 72.1 million elderly in U.S. 7.7 million with AD over 6572.1 million elderly in U.S. 7.7 million with AD over 65
--www.aoa.gov/aoaroot/aging_statistics/index.aspx--accessed 29Feb2012--2011 Alzheimer’s Disease Facts and Figures, Alzheimer’s Association, p. 19
Prevention of Prevention of Financial Catastrophes Financial Catastrophes
and Exploitation in Older Adultsand Exploitation in Older Adults
Time MagazineSeptember 3, 2001
Approaches to Prevention: Approaches to Prevention: Contractual/Transactional Contractual/Transactional
Beyond the Durable Power of Attorney for Finances Beyond the Durable Power of Attorney for Finances
which authorizes a proxy to act financially for grantorwhich authorizes a proxy to act financially for grantor
Explicit advance planning for diminished capacity as part Explicit advance planning for diminished capacity as part
of specific banking, trust, investment transactionsof specific banking, trust, investment transactions
““Diminished Capacity” clauses?Diminished Capacity” clauses?
Explicitly recognize possibility of future diminished capacityExplicitly recognize possibility of future diminished capacity
Authorize financial institution to contact designated familyAuthorize financial institution to contact designated family
Set forth an agreed general plan of action Set forth an agreed general plan of action
Provide secure path of communication/action for institutions Provide secure path of communication/action for institutions
Approaches to Prevention: Approaches to Prevention: LegislativeLegislative
Increasing recognition that diminished financial capacity Increasing recognition that diminished financial capacity
is an inherent aspect of aging–both normal and is an inherent aspect of aging–both normal and
abnormal cognitive agingabnormal cognitive aging
Legislatures may wish to enact special protections for Legislatures may wish to enact special protections for
older adults as consumers and contracting partiesolder adults as consumers and contracting parties
Should there be a designated time period in which an Should there be a designated time period in which an
older adult and his/her family may unilaterally cancel older adult and his/her family may unilaterally cancel
without penalty incurred contractual obligations?without penalty incurred contractual obligations?
Could potentially reduce scam transaction activity?Could potentially reduce scam transaction activity?
Approaches to Prevention: Approaches to Prevention: FamilialFamilial
The best source of protection for a financially vulnerable The best source of protection for a financially vulnerable
elder is usually an aware and caring familyelder is usually an aware and caring family
““Family awareness” programs about financial Family awareness” programs about financial
vulnerability of older loved ones?vulnerability of older loved ones?
Modeled after drug awareness programs in teens? Modeled after drug awareness programs in teens?
Templates for family conversations on these difficulty Templates for family conversations on these difficulty
topics, and for developing appropriate protectionstopics, and for developing appropriate protections
Involvement of local banks, brokers, and other financial Involvement of local banks, brokers, and other financial
professionals? professionals?
CollaboratorsCollaborators
UAB Department of NeurologyUAB Department of NeurologyRoy Martin, Ph.D.Roy Martin, Ph.D.
Randall Griffith, Ph.D. Randall Griffith, Ph.D.
Kristin Triebel, Psy. D.Kristin Triebel, Psy. D.
Ozioma Okonkwo, Ph.DOzioma Okonkwo, Ph.D
Lindy Harrell, M.D., Ph.D. Lindy Harrell, M.D., Ph.D.
John Brockington, M.D.John Brockington, M.D.
David Clark, M.D.David Clark, M.D.
Richard Powers, M.D. Richard Powers, M.D.
Katherine Belue, B.S.Katherine Belue, B.S.
UAB Department of Biostats UAB Department of Biostats Alfred Bartolucci, Ph.D.Alfred Bartolucci, Ph.D.
UAB Dept of EducationUAB Dept of Education
Scott Snyder, Ph.DScott Snyder, Ph.D..
UAB Dept of PsychologyUAB Dept of Psychology
Virginia Wadley, Ph.D.Virginia Wadley, Ph.D.
UCSD Department of UCSD Department of BiostatisticsBiostatistics
Rema Raman, PhDRema Raman, PhD
Ron Thomas, PhDRon Thomas, PhD
NIH SupportNIH Support
Studies of Financial Capacity in Alzheimer’s Disease Studies of Financial Capacity in Alzheimer’s Disease (1 R01 MH55247)(1 R01 MH55247)
Alzheimer’s Disease Research Center Alzheimer’s Disease Research Center (1P50 AG16582)(1P50 AG16582)
A Longitudinal Study of Loss of Financial Capacity in A Longitudinal Study of Loss of Financial Capacity in Alzheimer’s Disease Alzheimer’s Disease (ADRC Project 2)(ADRC Project 2)
Functional Change in Mild Cognitive Impairment Functional Change in Mild Cognitive Impairment (1 R01 (1 R01 AG021927AG021927))
Questions?Questions?
Financial Capacity in MCI and AD:Financial Capacity in MCI and AD:
Psychometric Testing Psychometric Testing
Psychometric Assessment of FCPsychometric Assessment of FC
Direct assessmentDirect assessment of performance in a controlled setting of performance in a controlled setting
Standardized, objective scoring, norm referencedStandardized, objective scoring, norm referenced
Finely grained measurementFinely grained measurement versus vague informant report versus vague informant report
VerifyVerify patient and family report of financial abilities patient and family report of financial abilities
Useful clinical addition to traditional NP test batteryUseful clinical addition to traditional NP test battery
Disadvantages:Disadvantages:
May lack ecological validity—difficult to replicate community setting in clinicMay lack ecological validity—difficult to replicate community setting in clinic
Requires trained administrator and are time consumingRequires trained administrator and are time consuming
Tests of financial capacity not commonly availableTests of financial capacity not commonly available
Financial Capacity Instrument (FCI-9)Financial Capacity Instrument (FCI-9)
Standardized measure with scoring system and normsStandardized measure with scoring system and norms
Directly tests performance on:Directly tests performance on:
18 financial tasks18 financial tasks
9 financial domains9 financial domains
global (overall) financial capacityglobal (overall) financial capacity
Needs a trained administratorNeeds a trained administrator
Takes about an hour to administer to dementia patientsTakes about an hour to administer to dementia patients
FCI Video:FCI Video:
Domain 7—Bill PaymentDomain 7—Bill Payment
Task 7a: Understanding BillsTask 7a: Understanding Bills
Task 7b: Prioritizing BillsTask 7b: Prioritizing Bills
Task 7c: Preparation of Bills for PaymentTask 7c: Preparation of Bills for Payment
Research Findings Using Research Findings Using Financial Capacity InstrumentFinancial Capacity Instrument
FCI Study SampleFCI Study Sample
ControlsControls MCIMCI Mild AD Mild AD pp
NN 2626 3030 3434
AgeAge 66.2 (7.7)66.2 (7.7) 67.6 (8.9)67.6 (8.9) 73.4 (8.4)73.4 (8.4) .05.05
EducEduc 14.5 (2.4)14.5 (2.4) 14.6 (2.3)14.6 (2.3) 14.6 (2.7)14.6 (2.7) nsns
RaceRace 73% W73% W 77% W77% W 94%W 94%W nsns
GenderGender 69% F 69% F 57% F 57% F 60% F60% F nsns
MMSEMMSE 29.2 (1.1)29.2 (1.1) 28.5 (1.2)28.5 (1.2) 24.0 (2.9)24.0 (2.9) <.001<.001
DRSDRS 137.1 (4.6)137.1 (4.6) 130.9 (5.7)130.9 (5.7) 113.9 (10.2)113.9 (10.2) <.001<.001
CDR CDR sum boxsum box 0.0 (0.1) 0.0 (0.1) 1.0 (0.8)1.0 (0.8) 5.1 (1.3)5.1 (1.3) <.001<.001
Group Differences on FCI Total ScoreGroup Differences on FCI Total Score
282263
247
203
0
50
100
150
200
250
300
Domains 1-7
Raw
Sco
re Max Score
Control
MCI
Mild AD
C > MCI > AD
p = .0001
Task 7c: Preparing Bills for PaymentTask 7c: Preparing Bills for Payment
2723.9
21.9
13
0
5
10
15
20
25
30
Preparing Bills for Payment
Raw
Sco
re
Max Score
Control
MCI
Mild AD
C, MCI > ADC, MCI > AD
p = .0001p = .0001
Controls=36, MCI=35, Mild AD=53
Task 7c: Preparing Bills for PaymentTask 7c: Preparing Bills for Payment Time Time (in seconds)(in seconds)
300
115.9
150.9
208.6
0
50
100
150
200
250
300
Preparing Bills for Payment (time in seconds)
Raw
Sco
re Max Score
Control
MCI
Mild AD
C < MCI < ADC < MCI < AD
p = .0001
Controls=36, MCI=35, Mild AD=53
Raw Score/Time DissociationRaw Score/Time Dissociation
MCI patients can perform many financial tasks about as MCI patients can perform many financial tasks about as
well as controlswell as controls
But it often takes MCI patients significantly longer to But it often takes MCI patients significantly longer to
complete these tasks complete these tasks
Tasks are no longer as automatic and routineTasks are no longer as automatic and routine
At some point increasing task time = impairmentAt some point increasing task time = impairment