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Bonnie Olsen, Ph.D. Clinical Professor of MedicineElder Abuse Forensic Center
Program In GeriatricsUniversity of California, Irvine
Bonnie Olsen, Ph.D. Clinical Professor of MedicineElder Abuse Forensic Center
Program In GeriatricsUniversity of California, Irvine
Assessing Vulnerability, Capacity & Undue Influence
in Elder Abuse
Assessing Vulnerability, Capacity & Undue Influence
in Elder Abuse
Topics:Topics:
Normal aging Conditions contributing to vulnerability Conceptual framework for evaluation of
vulnerability and capacity Components of assessment Forms of undue influence
Normal aging Conditions contributing to vulnerability Conceptual framework for evaluation of
vulnerability and capacity Components of assessment Forms of undue influence
Age-related Cognitive ChangeAge-related Cognitive Change
• Expect little change in memory before 70• Then only slight decline -
encoding vs. retrieval • General intellectual skills persist• Speed, flexibility & multi-tasking decline
slightly• Compensated by wisdom & experience
• Expect little change in memory before 70• Then only slight decline -
encoding vs. retrieval • General intellectual skills persist• Speed, flexibility & multi-tasking decline
slightly• Compensated by wisdom & experience
Conditions Leading to Vulnerability
Conditions Leading to Vulnerability
• Dementia, cognitive impairment• Psychiatric disorders • Depression, Anxiety• Loneliness, Isolation, Grief• Disability• Substance abuse (Rx, OTC,OTB)
• Dementia, cognitive impairment• Psychiatric disorders • Depression, Anxiety• Loneliness, Isolation, Grief• Disability• Substance abuse (Rx, OTC,OTB)
DementiaDementia
Degenerative Impairment in memory and
at least one other cognitive domain
Effects IADL functioning
Degenerative Impairment in memory and
at least one other cognitive domain
Effects IADL functioning
Prevalence of Dementia:Prevalence of Dementia:
65 year old = > 5 % 75 year old = > 15 % 85 year old = > 45%
65 year old = > 5 % 75 year old = > 15 % 85 year old = > 45%
DEMENTIADEMENTIA
Differentiating types: Most distinct early in disease
process More similar as it progresses Important if it informs:
Treatment Prognosis Caregiving needs Vulnerability to abuse
Differentiating types: Most distinct early in disease
process More similar as it progresses Important if it informs:
Treatment Prognosis Caregiving needs Vulnerability to abuse
DementiaDementia
2%8%
30%
60%
Alzheimer's Disease
Vascular Dementia
Other DegenerativeDementiaOther Causes
2%8%
30%
60%
Alzheimer's Disease
Vascular Dementia
Other DegenerativeDementiaOther Causes
Diagnostic Distribution
DementiaDementia
ALZHEIMER’S DISEASE:
Typical onset in 70’s - 80’s Early onset - mid 50’s Memory first symptom (encoding deficit) Lack of insight Impairment in functional skills: IADL’s Lack of content to speech Agitation and Anxiety Common
ALZHEIMER’S DISEASE:
Typical onset in 70’s - 80’s Early onset - mid 50’s Memory first symptom (encoding deficit) Lack of insight Impairment in functional skills: IADL’s Lack of content to speech Agitation and Anxiety Common
DementiaDementia
Diagnosis of Alzheimer’s disease:
Neurological Exam normal MRI shows atrophy SPECT scan biparietal decreased
perfusion Neuropsychological test impairment in multiple
domains
Diagnosis of Alzheimer’s disease:
Neurological Exam normal MRI shows atrophy SPECT scan biparietal decreased
perfusion Neuropsychological test impairment in multiple
domains
DementiaDementiaVASCULAR DEMENTIA:
Also called microvascular disease, multi-infarct dementia
Impairment in frontal/subcortical circuits Look for risk factors (heart, diabetes, HTN) Subtle decline in speed of processing Memory due to poor retrieval Other retrieval problems - word finding Usually some insight Emotional lability/depression Usually personality preserved
VASCULAR DEMENTIA:
Also called microvascular disease, multi-infarct dementia
Impairment in frontal/subcortical circuits Look for risk factors (heart, diabetes, HTN) Subtle decline in speed of processing Memory due to poor retrieval Other retrieval problems - word finding Usually some insight Emotional lability/depression Usually personality preserved
DementiaDementiaLewy Body Dementia:
Onset in 70’s, faster course Initial symptoms include:
- change in personality (delusions)- visual hallucinations- impaired visuospatial skills
(pentagons)- fluctuating attention- motor impairment - parkinsonism
Lewy Body Dementia:
Onset in 70’s, faster course Initial symptoms include:
- change in personality (delusions)- visual hallucinations- impaired visuospatial skills
(pentagons)- fluctuating attention- motor impairment - parkinsonism
DementiaDementiaFrontotemporal Dementia:
Also Picks Disease Initial symptoms before 65 yrs. First symptom in self-regulation/executive
function Lack of personal awareness Impaired interpersonal conduct Lack of insight Memory NOT impaired initially
Frontotemporal Dementia:
Also Picks Disease Initial symptoms before 65 yrs. First symptom in self-regulation/executive
function Lack of personal awareness Impaired interpersonal conduct Lack of insight Memory NOT impaired initially
DeliriumDelirium
Reversible Due to metabolic or physiologic cause Common etiologies:
Infection Toxicity Anesthesia Medication Dehydration
Reversible Due to metabolic or physiologic cause Common etiologies:
Infection Toxicity Anesthesia Medication Dehydration
DeliriumDelirium Disturbance of consciousness, arousal Fluctuates over time Develops quickly (hours, days) Change in other cognitive functions Can coexist with dementia, depression,
anxiety
Disturbance of consciousness, arousal Fluctuates over time Develops quickly (hours, days) Change in other cognitive functions Can coexist with dementia, depression,
anxiety
DepressionDepression
Depressed mood Loss of pleasure or interest Weight loss or gain Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or guilt Decreased concentration Recurrent thoughts of death or suicide
Depressed mood Loss of pleasure or interest Weight loss or gain Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or guilt Decreased concentration Recurrent thoughts of death or suicide
Diagnostic Criterion:
DepressionDepression
Fewer mood symptoms (sadness) Fewer ideational symptoms (guilt,
suicidality) More somatic complaints (pain, GI) More cognitive impairment
(attention, memory, indecisiveness) More delusional symptoms
Fewer mood symptoms (sadness) Fewer ideational symptoms (guilt,
suicidality) More somatic complaints (pain, GI) More cognitive impairment
(attention, memory, indecisiveness) More delusional symptoms
Symptoms in Older Adults:
DepressionDepression Major Depression: 1– 2% of geriatric
population, lower than in other age groups. Minor Depression: approx. 16% of geriatric
population, higher than other age groups. Depression in the general population is 3
times as common in women than men. May be reversed in geriatric population.
Suicide rate highest for elderly men than any other group.
Major Depression: 1– 2% of geriatric population, lower than in other age groups.
Minor Depression: approx. 16% of geriatric population, higher than other age groups.
Depression in the general population is 3 times as common in women than men. May be reversed in geriatric population.
Suicide rate highest for elderly men than any other group.
DepressionDepression
Depression and anxiety often coexist Often complicated by
dementia/cognitive decline Lower threshold for treatment Treat as syndrome
Depression and anxiety often coexist Often complicated by
dementia/cognitive decline Lower threshold for treatment Treat as syndrome
Unique to older populations:
DepressionDepression
Associated with medical conditions: Diabetes Stroke Heart attack Cancer
Associated with medical conditions: Diabetes Stroke Heart attack Cancer
Incidence Frequent symptom in geriatric population Rarely diagnosed or treated directly in
geriatric population
Incidence Frequent symptom in geriatric population Rarely diagnosed or treated directly in
geriatric population
ANXIETY
Anxiety SymptomsAnxiety Symptoms
Cognitive: worry, poor concentration
Somatic: fatigue, muscle tension, poor
sleep Emotional:
restlessness, irritability
Cognitive: worry, poor concentration
Somatic: fatigue, muscle tension, poor
sleep Emotional:
restlessness, irritability
The Conceptual BasisThe Conceptual Basis
Evaluating Vulnerability and Capacity
Evaluating Vulnerability and Capacity
Four Concepts Are Critical To Understanding Abuse
Four Concepts Are Critical To Understanding Abuse
Autonomy
Vulnerability
Capacity
Undue Influence
Autonomy
Vulnerability
Capacity
Undue Influence
AUTONOMY:
TO GOVERN ONE’S SELF.
Autonomy Is The Highest Principle
in Legal, Psychological and Medical
Issues
AUTONOMY:
TO GOVERN ONE’S SELF.
Autonomy Is The Highest Principle
in Legal, Psychological and Medical
Issues
AUTONOMY: YOU HAVE THE
RIGHT TO MAKE YOUR OWN DECISIONS,
GOOD OR BAD,
STUPID OR SMART,
WHETHER OTHERS AGREE OR NOT,
if you have the CAPACITY to make them
& you are not
UNDULY INFLUENCED.
AUTONOMY: YOU HAVE THE
RIGHT TO MAKE YOUR OWN DECISIONS,
GOOD OR BAD,
STUPID OR SMART,
WHETHER OTHERS AGREE OR NOT,
if you have the CAPACITY to make them
& you are not
UNDULY INFLUENCED.
Vulnerability:Any Condition Severe Enough That Another Person Could Use It To Unduly Influence You or Take Advantage of You.
Vulnerability:Any Condition Severe Enough That Another Person Could Use It To Unduly Influence You or Take Advantage of You.
Most Vulnerable Conditions Are Diagnosable Disorders Most Vulnerable Conditions Are Diagnosable Disorders
Can lead to lack of capacity
Capacity: The Legal Definition
Varies From State to StateDepends upon the kind of
transaction involved
Most Involve Two Things
Capacity: The Legal Definition
Varies From State to StateDepends upon the kind of
transaction involved
Most Involve Two Things
Key Phrase in California Probate Code 812
The Person Must “Understand and Appreciate”
Key Phrase in California Probate Code 812
The Person Must “Understand and Appreciate”
“Understand” can be assessed by having person re-state key facts regarding decision or act or process information adequately.
“Appreciate” requires ability to relate information to one’s own circumstance, to identify consequences to self and others of the decision, to weigh risks against benefits for self.
“Understand” can be assessed by having person re-state key facts regarding decision or act or process information adequately.
“Appreciate” requires ability to relate information to one’s own circumstance, to identify consequences to self and others of the decision, to weigh risks against benefits for self.
Capacity Is Not Absolute:
It Is Relative To The Complexity Of The Decision To Be Made
You can have capacity to make one kind of decision but not another.
Capacity Is Not Absolute:
It Is Relative To The Complexity Of The Decision To Be Made
You can have capacity to make one kind of decision but not another.
Capacity Relates To Being Able To Make a “Decision”
Capacity Relates To Being Able To Make a “Decision”
What’s a “Decision”?
the rational evaluation of alternatives understanding the implications of the
choices choosing the one that is best for
oneself
What’s a “Decision”?
the rational evaluation of alternatives understanding the implications of the
choices choosing the one that is best for
oneself
Issue: How Much Capacity
Is “Enough” Capacity?
Issue: How Much Capacity
Is “Enough” Capacity?
Well….what are you trying to decide?
Well….what are you trying to decide?
Legal/Medical Decisions Of Different LevelsTestamentary capacity
Marriage
Contractual capacity
Having surgery
Participation in research.
Legal/Medical Decisions Of Different LevelsTestamentary capacity
Marriage
Contractual capacity
Having surgery
Participation in research.
Capacity Is Not The Same As Diagnosis
Capacity Is Not The Same As Diagnosis
Diagnosis (dementia, mental retardation, psychosis) does not tell you the person’s capacity.
Capacity must be individually assessed.
Diagnosis (dementia, mental retardation, psychosis) does not tell you the person’s capacity.
Capacity must be individually assessed.
Capacity Is Not The Same As IQCapacity Is Not The Same As IQ
IQ measures acquired knowledge and abilities.
Regardless of IQ, capacity still has to be tested.
IQ measures acquired knowledge and abilities.
Regardless of IQ, capacity still has to be tested.
Capacity Is Not Equivalent To Physical Changes In The BrainCapacity Is Not Equivalent To
Physical Changes In The Brain
Brain scans neither prove
nor disprove capacity.
Provide good correlative evidence
Brain scans neither prove
nor disprove capacity.
Provide good correlative evidence
Conditions That Contribute To Vulnerability:
Conditions That Contribute To Vulnerability:
• Dementia, Cognitive impairment• Psychotic disorders• Depression, Anxiety• Disability • Loneliness, Grief, Isolation• Substances (Rx, OTC,OTB)
• Dementia, Cognitive impairment• Psychotic disorders• Depression, Anxiety• Disability • Loneliness, Grief, Isolation• Substances (Rx, OTC,OTB)
Assessing Capacity:
A Three-Step Process
Assessing Capacity:
A Three-Step Process
Four Conditions That Impair Capacity Under The Law
Four Conditions That Impair Capacity Under The Law
Cognitive Impairment
Severe Mood Disturbance
Perceptual Distortion
Thought Processing Defects
Cognitive Impairment
Severe Mood Disturbance
Perceptual Distortion
Thought Processing Defects
Step One: Can The Person Process Information And
Think Logically In General?
Step One: Can The Person Process Information And
Think Logically In General?
(Does the machinery work?)
You have to actually test for it. Common mistake is to assume person is OK.
(Does the machinery work?)
You have to actually test for it. Common mistake is to assume person is OK.
Processing Information For Capacity Purposes Requires At A Minimum
Processing Information For Capacity Purposes Requires At A Minimum
1. Attention, concentration
2. Orientation, Short-term memory
3. Retrieval of long-term memory
4. Language: comprehension and expression
5. Visual-spatial abilities
6. Reasoning
1. Attention, concentration
2. Orientation, Short-term memory
3. Retrieval of long-term memory
4. Language: comprehension and expression
5. Visual-spatial abilities
6. Reasoning
Why are some things remembered and not others ?
Why are some things remembered and not others ?
Recall old memories but NOT new(long term vs. short term)
Recall emotional events but not ordinary
Recall big picture but not details
Recall old memories but NOT new(long term vs. short term)
Recall emotional events but not ordinary
Recall big picture but not details
Can The Person Think Logically, Rationally and Abstractly?
Can The Person Think Logically, Rationally and Abstractly?
“Executive Functions”
logic organizeconsequences planjudgment
alternativesinsight reason
“Executive Functions”
logic organizeconsequences planjudgment
alternativesinsight reason
Step Two: Assess for Other Deficits
Step Two: Assess for Other Deficits
Mood disorders
(depression & anxiety) Perceptual disturbances
(hallucinations) Thought disorders
(delusions)
Mood disorders
(depression & anxiety) Perceptual disturbances
(hallucinations) Thought disorders
(delusions)
Step Three : The InterviewAppreciating This DecisionStep Three : The InterviewAppreciating This Decision
• Reasons for the decision
• Consequences of the decision
• Benefits and risks of the decision
• Alternatives considered
• Consistency of the decision
Undue Influence
exerting inappropriate influence
over a vulnerable person in order
to change his/her decision or
behavior.
Undue Influence
exerting inappropriate influence
over a vulnerable person in order
to change his/her decision or
behavior.
Undue InfluenceUndue Influence
The perpetrator’s “will” is substituted for the “will” of the victim
Victim acts subject to the will or purposes of the perpetrator
Victim agrees to give the perpetrator money or property
The perpetrator’s “will” is substituted for the “will” of the victim
Victim acts subject to the will or purposes of the perpetrator
Victim agrees to give the perpetrator money or property
Assessment of Undue InfluenceAssessment of Undue Influence
Examine the dynamic interplay between the victim and the perpetrator
Medical diagnosis, mental illness, cognitive impairment is not necessary
Affected by mental capacity, medical issues and environmental factors
Manipulation, coercion, compulsion or restraint occurs as a direct result of the relationship
Examine the dynamic interplay between the victim and the perpetrator
Medical diagnosis, mental illness, cognitive impairment is not necessary
Affected by mental capacity, medical issues and environmental factors
Manipulation, coercion, compulsion or restraint occurs as a direct result of the relationship
Five Common Forms of Undue Influence:It’s WICKED!
Five Common Forms of Undue Influence:It’s WICKED!
Withholding information, not disclosing.
Intimidating, threatening, coercing.
Charming, Kissing up, getting overly close.
Exploitive: acting while person is most vulnerable.
Deceiving, making false promises.
Withholding information, not disclosing.
Intimidating, threatening, coercing.
Charming, Kissing up, getting overly close.
Exploitive: acting while person is most vulnerable.
Deceiving, making false promises.
Questions?Questions?