ASSESSING GERIATRIC COMPETENCY

The following few decades are likely to bring increasing calls for consultation and expert testimony on geriatric competency.  With advanced technology in medicine, the length of our life extends every year.  It is not uncommon to see the aging group of seniors in their eighties and above.  The ability to qualify the cognitive and behavioral changes of aging is still in dispute in many courts and legal debates. This article reviews some situations when assessment of geriatric competency might become an issue.

Conservatorship Issues

At times, frustrated patients and family members cannot agree on treatment issues, on priority of actions and financial affairs.  Power of attorney is not useful in cases of major disagreements within the family.  While conservatorship sounds more frightening, it is sometimes a life-saving measure, which brings peace and important balance within the family.  Family members are usually appointed as conservators. When the projected conservator refuses to perform the duty

or is highly opposed by a proposed conservatee, other “neutral” candidates can be selected from outside the family.  Other legal specifics may influence the choice of a conservator, but usually close family members would fulfill well the role of a conservator for the person and his estate. 

Driving Competency

Special concerns are related to competency of driving a vehicle. It is common to see seniors complaining about a suspended or revoked driver’s license. Statistically speaking, crash rates per miles driven are higher in the elderly than in other age groups.  Driving skills tend to deteriorate with age and it is partially related to the normal processes of aging.  Visual fields and visual acuity tend to diminish. Concentration and attention may slowly decrease, reaction time increases.  The combination of these may substantially impair driving abilities.  Furthermore, side effects of medications represent a separate risk. 

No definitive cognitive test or driving test is available to accurately measure the risk of accidents. A combination of tests for attention, concentration, reaction time and cognitive functioning give the most comprehensive assessment. 

Dementing processes such as Alzheimer’s disease bring an additional challenge for driving habits.  California Code of Regulations and Section 510 of the Health and Safety Code require reporting of dementia to the DMV.  In response, the DMV will examine driving competency at Driver Safety Offices located in Fullerton, Laguna Hills and Westminster. 

It is important to maintain the balance in the risk vs. the benefit of driving and be concerned about possible consequences of any imbalances.  The safety of our families and the joy of driving should be thought of constantly when we sit behind the wheel.

Will Contests

Another very important type of assessment is usually related to mental competency to sign a will or susceptibility to undue influence at the time the will was signed. While there are many grounds upon which the validity of a will can be challenged, the most common points for contest from a competency stand point would be:

1) Testator (the person signing the will) lacked the testamentary capacity to sign the will or codicil (amendment to an existing will).

2) Testator was not able to tolerate the challenge and was susceptible to undue influence.

If it is proven that the testator lacked testamentary capacity, the entire will is invalidated. If undue influence is proven, the part of the will affected by the influencing person is invalidated.

Forensic expertise may be needed at the time of signing a new will when there is doubt about the proposed beneficiary or testator’s competency.

This issue can also be raised post-mortem, a few years after testator’s death.  At times, the will is contested by an unhappy potential beneficiary asking for a settlement or compensation.

Many legal terms have been applied in decisions regarding geriatric competency: “testamentary capacity”, “lucid intervals”, and “undue influence”. It is still the obligation of the medical field to clarify the understanding of aging processes.  Medicine has been directed for generations toward finding the truth about illness or normal processes of aging.  It can serve us again with objectivity and impartial expertise in many legal situations.

SHOULD YOU HAVE ANY QUESTIONS PLEASE CALL:

(949) 462-9114

Alex D. Michelson, M.D.

Forensic Psychiatry at UCLA School of Medicine

SUICIDE AS A PSYCHIATRIC EMERGENCY

            In our lives, various situations may represent substantial crisis or emergency.  Loss of marriage, bankruptcy, terminal illnesses are on the list among the most difficult situations.  For many centuries, suicide has been one of the most sorrowful and critical tragedies in human lives.  Each year, suicide takes away approximately 30, 000 people in the United States.  The number of attempted suicides when death was prevented is 8 to 10 times higher.  The total suicide rate has remained fairly constant over the years and is currently 12 per 100,000. 

            Suicide is ranked as the ninth overall cause of death in this country after heart disease, cancer, cardiovascular disease, COPD, accidents, pneumonia/influenza, diabetes mellitus, and HIV virus.  State by state analysis of suicide in the last decade among people between the ages of 15 and 44 revealed that New Jersey has the lowest rate of suicide for both sexes.  Nevada,

New Mexico and Wyoming had the highest rates.  The prime suicide site of the world is the Golden Gate Bridge in San Francisco, with more than 800 suicides since the bridge opened in 1937. 

            Let’s review step by step factors associated with the risk of suicide. 

• SEX:    Men commit suicide more than 3 times as often as do women.  Women, however, are four times more likely to attempt suicide than are men. 
• AGE:    Suicide rates increase with age.  Among men, suicides peak after the age of 45.  Among women the greatest number of completed suicides occur after the age of 55.  Rate of 40 per 100,000 population occur in men ages 65 and older.  Older people are less often attempting suicide than younger people.  However, they are more successful completing it.  Suicide is the third leading cause of death in the 15 to 24 year old age group, after accidents and homicides. 
• RACE:   Two of every three suicides are white males.  Among young people who live in inner cities, and certain Native Americans and Inuit groups, suicide rates have exceeded the national rate.  Suicide rates among immigrants are higher than in the native born population. 
• MARITAL STATUS:   Marriage reinforced by children seems to significantly diminish the risk of suicide.  Among married people, the suicide rate is 10-11 per 100, 000.
• OCCUPATION:  Employment in general protects against suicide.  Among occupational rankings, professionals including physicians have traditionally been considered to be at the greatest risk for suicide.  The higher a person’s social status, the greater the risk of suicide.  But a fall in social status also increases the risk. 

• CLIMATE:      No seasonal correlation with suicide has been found.  Suicides increase slightly in spring and fall, but contrary to popular belief, not during December and holiday periods.  I personally see some challenges of the holiday season for people with limited family support and interaction.  However, it is still my belief that the holiday season is the best part of the year. 

The different risk factors described in this article are based on a substantial amount of statistical information.  These factors though should not be utilized alone in suicide risk assessment. Taking into consideration the individual characteristics of a person gives a comprehensive approach to this issue.  Most of the time, mental health professionals assess suicide risk.  You may contact Dr. Michelson’s office at (949)  462-9114 to discuss your concerns or questions.

The majority of suicide committers tend to suffer from depressive disorders and substance abuse. By reducing the rate of depression and substance abuse in the community we decrease the incidence of suicide and subsequently frustration, guilt and despair among surviving friends, family and significant others.            

Alex D. Michelson, M.D.

Clinical Psychiatry

Offices In Laguna Hills, California

“Life Comfort versus Depression”

Historically, mood disorders have occupied a prominent part in medicine and numerous scholars have written about depression over the years. It is not surprising that people are very much aware of depression as a phenomenon. Quite a few people have asked me about specifics of depression with respect to age, gender and suicide potential. Those inquiries triggered  interest in writing this article and summarizing some important aspects of clinical depression.

Let me focus first on the causes of depression, which indeed can be very different and complex. The most common life situations that account for depression are loss of a spouse, multiple physical illnesses, social isolation, and low socio-economic status.  It is interesting that 50% of my patients deny depressive feelings and are referred for treatment due to social withdrawal and decreased activity.  Depressed people tend to have a good understanding of their problems.  At times, they overemphasize symptoms, their disorder, and their life problems.  On one hand, it makes some facilitation for treatment because of good compliance with medications and therapy.  On the other hand, it is difficult at times to convince such patients that improvement is possible.  Patience and compliance with therapy usually give positive results in over 90% of cases.  Nevertheless, we are aware that the risk for depression is 15% in a lifetime.  Up to 65% of depressed individuals contemplate suicide, and 10%-15% commit suicide.  Therapists are encouraged to ask depressed patients about suicidal thinking. This practice does not increase the risk for suicide. 

Depressed mood and loss of interest in hobbies or pleasurable activities would be the key symptoms for depression.  Other symptoms such as decreased appetite, insomnia, poor concentration and indecisiveness may also be part of the picture. Anxiety is present in 90% of all cases. Cognitive decline in depression has a sudden onset as opposed to dementing processes.  In dementia, deterioration of cognitive functioning is more gradual.

Dynamically, it is common to see pain of “loss” directed toward oneself among depressed patients. Many of them live for somebody else and in those situations tend to experience multiple setbacks in relationships by not receiving empathy and compassion.  Disappointments in life generate desperate sadness, and depressive feelings. 

Biological predispositions have also been described in literature.  Lately, in clinical practice, we have noticed a tendency of stopping estrogen / progesterone replacement medications among female patients. Discontinuation of this therapy exacerbates depressive symptoms.  Although we are aware of increased incidence of mood disorders in post-partum and perimenopausal periods, future evaluation of sex steroids with respect to mood stabilization is warranted. 

Many therapies and medications are currently available to improve our life and target depression. Yet, some people are still suffering from depressive symptoms and delay treatment. We believe that life comfort should be considered in every individual of either gender and in all age groups regardless of cultural backgrounds and socioeconomic status.

Alex Michelson, M.D.

Clinical and Medical-Legal Psychiatry

Offices in Laguna Hills, California

Phone: (949) 462-9114