Wealth and Capacity; Who Gets to Decide?

Earlier this week, Dr. Nancy Hoffman, neuropsychologist and I (Geriatrician in the Greater San Francisco Bay Area) presented a talk about undue influence and how to address financial elder abuse. Today, I read that Sumner Redstone, 92, is ousting long time CEO/directors of his $40 billion dollar empire (including CBS and Viacom) and his estranged daughter (and VP of Viacom) is taking control. There seems to be a lot of legal action and uncertainty about the next steps for these businesses.

This is a case that could much more simply be decided by a geriatric assessment of current medical issues and medications, followed by gero-neuropsychological testing to determine capacity and issues of undue influence. Strangely enough, it is likely that such huge fortunes are involved that hinder Mr. Redstone having the assessment and care needed support his medical and psychological needs. Put another way, everyone has an angle when large amounts of money are concerned. Click here for link to article.

He may have capacity, he may be aware of mismanagement in his company and want to set things a right. Commonly at that age, he may have a decline of executive function, or the capacity to understand risks and benefits of interventions, whether they be financial or medical. For those with substantial assets, frail health and care dependency are at higher risk for financial elder abuse. He may be isolated and those close to him can tell him things, such as, "They want to take your money and control you, I am here to help you." Even without dementia, an elder can be a victim of undue influence, or the elder can be swayed to use assets for the benefit of the perpetrator over the victims needs and desires. Typically, it is the family member who abuses the elder (think of Brooke Astor), but it could be anyone from the neighbor, to the contractor cold calling, to caregivers angling to get married (think of Steven Hawking) to the lawyer, minister, or charity.

In the assessment of the elder, first must be the review for the effect of medications such as confusing meds such as Xanax or sedating meds such as Seroquel (Click here for more info on medications), that can affect the elders thinking ability, or medical issues that would diminish judgment. Click here to learn more. Often the assessment of dementia goes little farther than the Mini-Mental Status Exam (MMSE). This is inadequate to determine capacity or lack thereof. It is a screen. However, an elder could have a perfect score of 30 and not have capacity (from loss of judgment and risk assessment); or may have a score of 20 (the usual cut off is 24 for dementia) and understand the risk and the benefits and still have capacity. Gero-Neuropsychological testing is the answer. Done properly, employing the Iowa Gambler's Task (specific for determining risk assessment ability) when needed will demonstrate the elders abilities to understand risk/benefits and communicate a reasoned response.

Even for elders of modest means, taking away their ability to determine their future is too important to leave to a screen (MMSE) or the assessment of a lawyer. Neuropsychological testing and the Geriatric Assessment are the gold standard to preserve independence, or protect the vulnerable.