Good Manners Do Not Equal Capacity

imagesCAW6PLLHI have a patient who has fairly advanced dementia. She has trouble speaking, but she still knows what day it is. When people come to visit, she recognizes them and makes appropriate comments, though usually in very short sentences. She can still play bridge, though her skill at that game has greatly diminished. When friends come to visit, they acknowledge that she’s bedridden and ill, but say, “Her mind seems fine.” It’s not. Her “capacity,” that is, her ability to take in information, analyze it, and make decisions, is severely compromised. A scammer called her a couple years ago and she gave her complete bank account information and let him withdraw $1,000. When you discuss complicated medical options with her, she cannot understand the treatments, much less the pros and cons of each. She needs a fiduciary to pay her bills. Her daughter has medical power of attorney for her. Still, many people might think she’s reasonably OK, if old and ailing.

In addition to doing geriatric house calls in the San Francisco Bay Area, I also testify in court cases involving geriatric patients. In both those contexts, I find that everyone seems to think they can diagnose the presence, the absence, or the severity of dementia: general practitioners, judge, attorneys, social service workers, accountants, and family members. Most people do not understand that even if a person knows the day and who’s president, their mental function may still be severely compromised.

As humans, we’re used to relying upon social cues. So if someone’s expression seems alert, and they can navigate a social situation, many assume that person is fine. Someone with early dementia, especially vascular dementia of frontal-temporal dementia, may “pass” in a casual setting but be completely unable to manage their finances, cook, drive safely or care for themselves.

I had a 63-year-old patient who had alcoholic dementia. If everything was presented to him on paper, he seemed to be able to make reasoned decisions. Yet he could not remember that he had been in the hospital several times in the past month. He could not remember abusing alcohol, or passing out at the wheel of a car. He could not make reasoned decisions because he could not remember what happened to him in the past. Yet because he seemed socially appropriate, I had to cajole the attending neuro-psychologist to take a second look at his case.

Remember that self-reported abilities and good manners do not mean a person has all the mental tools necessary to run an adult life. If you have any concerns or suspicions that your elder’s abilities have become seriously compromised, get them in for a full “Gero-Neuropsychological Testing.” It’s important that the person doing the testing understand the issues of the elderly. Not every psychologist or psychiatrist has this training. Make sure you ask.