Financial incapacity may signal worsening dementia

Loss of financial skills can be a warning sign of the onset of dementia in older Americans. When should friends and family step in?

Many Americans have struggled with the thorny issue of taking the car keys from an aging parent or grandparent. But how do you know when to take away the checkbook?

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The Financial Capacity Instrument, a tool developed at UAB, measures a patient's capacity across 20 tasks, including counting coins and currency.

Physicians need to help patients and families dealing with Alzheimer’s disease and its pre-cursor, mild cognitive impairment (MCI), recognize when an older patient is losing the ability to manage their own financial affairs, say researchers at the University of Alabama at Birmingham and the University of California at San Francisco in commentary published Feb. 16, 2011, in the Journal of the American Medical Association.

“Financial capacity is essential for an individual to function independently in our society,” says study co-author Daniel Marson, J.D., Ph.D., professor of neurology and director of the UAB Alzheimer’s Disease Center. “Diagnosis of cognitive impairment generally, and MCI and Alzheimer’s disease specifically, should signal likely financial impairment and prompt physicians to encourage patients and families to seek financial and legal advance planning.”

The commentary from Marson and colleagues is part of JAMA’s “Care of the Aging Patient: From Evidence to Action” series that provides evidence-based clinical guidance to physicians.  Patients with MCI typically still are functioning in the community with focal memory or other cognitive impairments but are beginning to show initial signs of functional decline. Since 2000, Marson and his group have published a number of empirical studies detailing impairments of financial skills in patients with Alzheimer’s disease.

In 2009, Marson and his group published a major paper on declining financial capacity in MCI and progression to Alzheimer’s, which involved a tool developed at UAB called the Financial Capacity Instrument. The FCI measures capacity across 20 tasks, including understanding a bank statement, balancing a checkbook, paying bills, preparing bills for mailing and counting coins and currency.

“Declining financial capacity is a good barometer for progression of both MCI and Alzheimer’s disease,” said Marson, “Our previous research has shown that a decline in checkbook-management skills can be a harbinger of a patient’s progression from MCI to early Alzheimer’s dementia. Emerging impairments in financial skills and judgment often are the first functional changes demonstrated by patients with incipient dementia.”

In the JAMA paper, the authors suggest that timely identification and informal assessment of financial impairment by clinicians often can lead to the establishment of effective financial protections for affected patients and limit the economic and legal hardships that often accompany financial incapacity. They offer guidance on recognizing possible impaired financial capacity and signs of financial abuse.

Marson says it’s important for families, caregivers and health-care professionals to be vigilant about changes in an older patient’s financial abilities to avoid potential catastrophic financial losses due to poor decision-making, fraud and other forms of exploitation.

He and his co-authors suggest that caregivers oversee a patient’s checking transactions, contact the patient’s bank to detect irregularities such as bills being paid twice or become co-signers on a checking account so that joint signatures are required for checks above a certain amount. Online banking and bill-payment services are additional options for families.

Marson collaborated with lead author Eric Widera, M.D., Veronika Steenpass, M.D., and Rebecca Sudore, M.D., from the division of geriatrics at the University of California at San Francisco, on the commentary.

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