The THHB September 2017 Dispatch
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70s & Beyond | Senior Nutrition
 
Q&A: What You Can Do if You’re Worried About "Incompetence"

Q: My 87 year old father lives alone. His house has become increasingly dirty, but he refuses to get help, even though I’m sure he needs it. I’m worried that he’s becoming incompetent, but he doesn’t want to go see the doctor. What can I do?

Q&A: What You Can Do if You're Worried About "Incompetence"

A: This situation does come up a fair bit with aging parents and relatives. I’m sorry to say there usually are no easy solutions. But there are definitely things you can and should do, and it’s better to act sooner rather than later.

Let’s review what you can do. I’ll also explain what I’ve learned about “incompetence” over the years, and how doctors usually play a role in the evaluation of such seniors. I’ll offer a few thoughts on how seniors and families can plan ahead, to avoid facing this kind of dilemma. And then last but not least, I share a few thoughts on taking care of yourself as you go through this.

What’s probably going on with your father

The usual concern, for a person of this age, is that the senior has developed a dementia such as Alzheimer’s disease.

This is a pretty reasonable concern, since an estimated 30% of people aged 85+ have dementia. And of course, if the senior seems to be doing worse than before, when it comes to activities that require mental organization (such as keeping a house reasonably clean), that further increases the chance that some kind of brain deterioration is causing problems.

But, we should never start by assuming a senior has developed dementia!

The main thing you wrote above is that you’re worried about a dirty house and a refusal to get help. This could be due to thinking problems. But it could also be due to pain and mobility problems, combined with a common reluctance to accept assistance.

Still, I have to admit that in most similar cases that I’ve encountered, the senior does have cognitive impairment. And we do usually find it’s substantial enough and irreversible enough to qualify as dementia.

Now, even if he does have dementia, that doesn’t mean we can’t improve his thinking. I often find that by adjusting medications or the senior’s situation, we can optimize the brain function and help the person manage better, despite the underlying dementia. We also occasionally find that a senior with dementia is also delirious from an illness or other health problem, which can make the thinking worse than usual.

So, getting him the right medical evaluation and optimization is key. You might even be able to get him to the doctor not by saying “You need to be checked for dementia,” but by saying “We need the doctor to help you feel your best and be your best, since that helps you keep living at home as you want to.” (It’s important to frame your suggestions as ways to help your father acheive his health and life goals.

Of course, these are all things we find out after the senior has been medically evaluated, and by someone who knows how to assess dementia symptoms correctly.

Part of your frustration is that your father doesn’t want to go see a doctor. So you’re stuck: worried that something’s wrong, worried that your father has become incompetent, and unsure as to how to move forward since your father is refusing to cooperate. Let’s talk about your options for doing something, despite your father’s reluctance.

How to get help in helping your father

Start by asking yourself whether you think your father really might have lost mental insight and abilities, as opposed to simply making choices that you disagree with.

If you think he really is cognitively impaired, then you probably should consider pushing things a little more, to get him the help he seems to need.

I would also encourage you to make a list of specific concerns and red flags. You can use the “Quick Start Guide to Checking Older Parents” or a similar checklist, to help you identify specific problems that need attention.

How to know if a senior is “incompetent”?

Now, you’re getting help because presumably you want to help your father with his goals, which for most seniors include maintaining independence, dignity, and quality of life.

But you also mentioned a worry that he is becoming “incompetent.” This is an important question to address, and families often ask me to weigh in on this. What I tell them is that as a doctor, I can’t say whether the person is incompetent. Instead, my role is to help assess a senior’s capacity to make medical decisions, and to identify underlying medical problems that might temporarily or permanently affect decision-making.

You should know that the term “incompetence” is generally used to refer to a legal determination. In other words, it’s up to courts, not doctors, to say whether someone is incompetent. This is governed by state law so different states have different criteria. But overall, if someone is found in court to be incompetent, they often will be assigned a guardian or conservator to manage decisions on their behalf.

To decide whether a senior is legally competent, the court will need to know about the senior’s capacity to manage certain major types of decisions. These might include:

  • Medical consent capacity
  • Sexual consent capacity
  • Financial capacity
  • Testametary capacity
  • Capacity to drive
  • Capacity to live independently

The tricky thing about capacity is that it can certainly change depending on the day and situation. For instance, a person who is sick and delirious might temporarily lose all the above capacities. A bad depression could also affect capacity for some time. People with dementia or other forms of cognitive impairment are also prone to have their mental capacities fluctuate somewhat, depending on the day and whether their brains are functioning at their best.

So how do doctors and psychologists weigh in on capacity? The truth is that it’s pretty variable, and it’s also an area of law and clinical practice that is evolving.

For the best information on how clinicians should address issues related to capacity in seniors, I recommend this resource, which was created as joint effort between the American Psychological Association and the American Bar Association.

Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists

Obviously, as it’s written for clinicians rather than for the public, it’s rather long and technical. But if you really want to understand this topic, that’s the best info I’ve found.

But bear in mind that although the handbook above describes best recommended practices, many clinicians may practice a little differently, often due to lack of time or training.

For instance, because medical problems often interfere with a senior’s mental capacities, doctors are routinely asked to weigh in. In principle, when asked about a senior’s capacity, a doctor should first want to know “Capacity to do what, or decide what?” And then the doctor should write a statement specific to that question, providing documentation supporting the doctor’s conclusion.

But that’s not how things often work in the real world. In practice, I’ve often been asked just to say whether a senior “has capacity” with no additional specifications. I’ve also seen many doctors write vague statements saying “Mr. So-and-so has lost his mental capacities.”

How valid are such statements? I don’t really know, and suspect it depends on the jurisdiction and the purpose to which the doctor’s note is used. For instance, some seniors have trusts or other services that require a “doctor’s note,” and these may have different standards compared to the courts.

How to plan ahead to avoid these problems

The very best approach, of course, is for an older person to have previously planned for this situation. By this, I don’t mean simply completing paperwork in order to designate a relative or friend as durable power of attorney (Lasting Power of Attorney, LPA, in the UK) for health, and also for finances.

Don’t get me wrong, planning ahead with such power of attorney paperwork is very important and very helpful.

However, such power of attorneys don’t quite address the situation that all seniors should plan for: the possibility that they’ll be cognitively slipping and unable — or unwilling — to admit it and let others assist as needed.

I have only rarely seen seniors prepared for this, even though every senior has a pretty substantial chance of developing Alzheimer’s or another dementia provided they live long enough.  (Remember, about 30% of those aged 85+ have dementia, and it goes up to about 50% of those aged 90+.)

Being a doctor, rather than a lawyer, I’m not even entirely sure what the best way IS to prepare. The best situations I’ve seen were when a senior

  • Created a trust,
  • Designated a trustee or fiduciary to take over when needed,
  • Specified what conditions would trigger trustee take-over, and
  • Specified what the care priorities should be in the event that the senior couldn’t make decisions.

But again: I am not a lawyer and this is not legal advice. The expert advice consistently is to plan ahead, plan ahead, plan ahead.

To that I would add:

  1. Hope for the best
  2. Plan for the likely (eg eventual severe dementia if you’ve been diagnosed with mild dementia)
  3. Plan for the quite possible (a fall in which you break a hip, eventually developing dementia, etc)

Your father did not plan for this situation. However, as you help him work through the current situation, keep the above planning principles in mind! You’ll almost certainly have more to plan for, especially if he does end up diagnosed with dementia (which means you or someone else will need to make decisions at some point).

Don’t forget to take care of yourself!

As I said at the beginning, this kind of situation is hard to sort through.

It’s messy, and complicated, and stressful, and also tends to bring out whatever family tensions tend to come out when families face problems.

So. If you are worried about an elderly father who lives at home alone and might be “incompetent,” you can’t just focus on helping your father. You also must focus on equipping yourself to handle what is likely to be a stressful and messy time for the next several months to years. Investing a little time — and possibly a little money — in this will pay off for your father, for you, and for those around you.

The basics of this include making sure you get enough sleep, regular exercise, nutritious food, activities that refresh the soul, and all the other things that are good for humans.

I would also recommend cultivating a mindfulness practice, if you don’t already have one. I have heard good things about the free guided meditations by Tara Brach, or you can try an app such as Headspace. The key is to do at least 10 minutes every day.

Last but not least, you’ll need support from friends and family. It’s also usually helpful to get support from others facing similar challenges with aging parents; you can find these in-person and online.  (The most active caregiver forum I’ve found is at AgingCare.com.) You’ll connect with people in similar situations, who will provide helpful suggestions and will completely understand when you need to vent your frustrations.

Good luck!!

Credits:

by Leslie Kernisan, MD MPH, Better Health While Aging

 
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