Financial Skills Are Often the First to Go When Cognition Issues Arise

When Helen Clark brought her father-in-law, then 83, to the doctor last year, she knew his mind was slowing, but a mental status exam confirmed it. He knew the year, where he lived and the name of the president. But when the doctor asked him to count backward from 100, subtracting seven from each number — 100, 93, 86, 79 — a look of confusion washed over his face.

Studies show that the ability to perform simple math problems, as well as handling financial matters, are typically one of the first set of skills to decline in diseases of the mind, like Alzheimer’s, and Ms. Clark’s father-in-law, who suffered from mild dementia, was no exception. Research has also shown that even cognitively normal people may reach a point where financial decision-making becomes more challenging.

“A person can appear to have their wherewithal cognitively, but not have the ability to understand money in the same way anymore,” said Ms. Clark, a retired registered nurse and family therapist in Cottonwood, Calif.
The issue looms large, particularly as the number of older people continues to rapidly expand: There are 44.7 million people 65 and older, representing 14 percent of the population, according to the most recent census data, but, within 10 years, they will swell to an estimated 66 million. This group collectively holds trillions of dollars in wealth, but are often left to manage their own finances, even as they become increasingly vulnerable. About half of adults in their 80s either have dementia, or at least some cognitive impairment without dementia, researchers said.

“If you can detect emerging financial impairment early, you can also step in early and protect the person,” said Daniel Marson, a neuropsychologist and director of the Alzheimer’s Disease Center at the University of Alabama at Birmingham. “It may be if you step in two months from now, they won’t be in a position to make a poor decision or be exploited a year from now.”

For Ms. Clark’s father-in-law, Francis Taylor, the intervention came too late. At 80 years old, he married a woman 17 years his junior, who, over their three-year union, according to the family, cashed $40,000 in blank checks sent by his credit-card issuer and emptied the contents of his $123,000 annuity, leaving him with little more than a giant tax bill.

Mr. Taylor, a former diesel mechanic and Korean War veteran, gave his wife permission to make two annuity withdrawals over the phone. But his wife, who couldn’t be reached for comment, made 20 more withdrawals on her own by using her husband’s Social Security number and other identifying information, and signing papers to direct money into a joint account, according to documents provided by Ms. Clark. After an internal investigation, MetLife, the annuity provider, concluded that it had followed proper procedures.

Preventing these situations is often difficult. Knowing exactly when to get involved can be fraught, whether you are an adult child or a trusted adviser. There are a series of early warning signs of financial decline, which Dr. Marson identified in a recent study, which is being submitted for publication and was funded by the National Endowment for Financial Education and the National Institute on Aging.

The signs, while perhaps not surprising, are subtle, making them easy to miss: It may become more difficult for people to identify the risks in a particular investment, and they may focus too much on the benefits. Completing various tasks on a financial to-do list may start to take longer, such as preparing bills for the mail. Everyday math may become more laborious or prone to errors, whether that’s figuring out a tip in a restaurant or doing a calculation that requires two steps. Financial concepts, like medical deductibles and minimum balances required in savings accounts, may also become harder to grasp. Naturally, these behaviors should represent a significant change: If a person was never adept with personal finances, this won’t serve as much of an indicator.

Dr. Marson said he identified these warnings signs as part of a study of 138 older adults over time who were initially deemed “cognitively normal” by a panel of four doctors when they joined the study (and after at least one annual follow-up visit). Participants were also timed as they completed financial tasks in a lab. Twenty-three members of the group later received a diagnosis of mild cognitive impairment, but when the researchers went back and looked at the original results of the financial capacity test — when the group members were deemed cognitively normal — there were already subtle signs of slowing and financial decline.

“The group that would later decline already had some emerging signs,” Dr. Marson said, though they weren’t glaring.

While many people continue to handle their finances with ease well into their later years, even people with healthy brains tend to experience cognitive decline. According to one study, which analyzed participants’ propensity to make financial mistakes, a person’s financial decision-making ability peaks at age 53, or, more generally, in their 50s. This is the sweet spot, the paper said, because they have substantial amounts of experience but they have had only modest declines in their ability to solve new problems.

There is a general tendency for our ability to solve new problems — known as fluid intelligence — to slowly decline over time, starting as early as age 20. But this is at least partly offset by our growing experiences and wisdom, known as crystallized intelligence.

David Laibson, an economics professor at Harvard and co-author of the research, said he believed that crystallized intelligence tended to plateau when people reached their 70s. That plateau, accompanied with declining fluid intelligence, might explain why older consumers made more financial mistakes than middle-age ones in his study.

“At that point, vulnerability increases,” Professor Laibson said. “Our nation’s wealth is disproportionately held by older adults, and they are exactly the group, particularly as they reach their 80s and 90s, that are most vulnerable. But our system has the fewest protections for those people.”

He said he wishes all 65-year-olds would start by simplifying their financial lives, reducing the money clutter to just a few mutual funds at a reputable institution.

Then there are the boilerplate tools, including wills, revocable living trusts, durable financial power of attorney, and health care directives. Financial institutions often want their own powers of attorney filled out, so it helps to put them in place before you need them. If ready access to more credit isn’t important, advisers suggested freezing elders’ credit files, so criminals cannot attempt to open accounts in their names. Automate bill payments.

If adult children suspect a parent needs watching over, they can also ask financial institutions to send duplicate statements or notices if a parent misses a long-term care insurance payment, for example. Monitoring can also easily be done from afar with online access to accounts, but that sort of access can be disastrous in the wrong hands. If the person does not have trusted family members or friends, a licensed fiduciary can be a good alternative to monitor accounts, said Carolyn Rosenblatt, an elder lawyer and author who counsels families on aging-related issues.

Another financial adviser asks his clients to assemble what he calls a protective tribe, or a handful of people who are willing to step in and assist if and when the need arises. “The protective tribe is important because senior abuse is often committed by a close relative or trusted professional,” said Jean-Luc Bourdon, a certified public accountant who specializes in financial planning in Santa Barbara, Calif. “A tribe is needed to have checks and balances.”

Many estate planning lawyers and financial planners ask their clients to name a person they can contact if they suspect their cognitive skills may be on the decline. Sometimes called “a letter of diminishing capacity,” the document typically authorizes the adviser to raise the issue with a trusted individual the client names.

Bob Rall, a financial planner in Merritt Island, Fla., said it came in handy when a widow with modest assets asked if he could send her $50,000 so she could host an 80th birthday party. “I immediately called her daughter, who the client had previously given me the authorization to speak with,” he said. “After a discussion, we decided to send her mom $15,000. She still had a pretty nice party.”

For many families, there isn’t much margin for error. Ms. Clark’s father-in-law still has the equity in his home; she intervened just as his wife was completing the paperwork for a reverse mortgage.

“Although this is tragic for my father-in-law,” Ms. Clark said, “what I am even more concerned about is the lack of accountability when fraud occurs across the board for elders in this position.”

When Siblings Clash about a Parent’s Care

As aging parents lose their independence and begin to rely on family for more support, the amount of conflict between adult children can increase. Dealing with a parent’s care can rekindle sibling rivalries that have lain dormant for years—even decades. This discord can tear families apart, and spoil some of the last opportunities children have to build meaningful, positive memories with their parents.

The Causes of Conflict Between Siblings

Family dynamics are infinitely complex, but two underlying themes run through most sibling disputes about their parent’s care– injustice and inheritance.

When one sibling shoulders a disproportionate burden of Mom or Dad’s care, that sense of unfairness can foster resentment. Often, by virtue of distance, the siblings who live further away are “off the hook” when it comes to caring for an aging parent, while the nearest siblings are obliged to take on a caregiving role. When the caregiving sibling asks for help from other siblings, the other siblings often don’t fully appreciate, or choose to ignore, how much help their parent needs, and how much work one sibling is doing.

Playing on an ancient idiom, Mark Twain once said, “The lack of money is the root of all evil.” If that’s the case, our deflated economy may contribute to more sibling clashes over a parent’s finances: The average American household’s net worth has declined 40% since 2007. This means that less fortunate siblings must divide an even smaller inheritance, naturally increasing the likelihood of conflict. It’s easy to condemn the sibling who seems preoccupied with money, but this sibling may only be hoping to remedy a difficult, or even desperate, financial situation, or to feed a family or catch up on a mortgage. In a perfect world, each of us is selfless and not motivated by money, but we live in a far from perfect world where money is indispensable.

A Perfect Storm
Money and caregiving are stressful flashpoints on their own, but when both areas of contention are in the mix, they can create a perfect storm of animosity between siblings. When family dynamics are already tense because one sibling feels unjustly overburdened with a parent’s care, the “x-factor” of money can compound the conflict and create an all-out schism. For example, a sibling who provides most of a parent’s care may feel entitled to a greater share of an inheritance. In other cases, siblings who are more distant or uninvolved may believe that the caregiving sibling is spending too much money on a parent’s care. Sometimes, the children of aging parents will even resist plans for professional care in order to “protect” an inheritance.

Tips for Improving Communication with Your Siblings
There are no easy answers to settle disputes between siblings who are butting heads over a parent’s care, but maintaining (or rebuilding) communication is crucial.

The Family Meeting
Ideally, siblings can identify and correct issues before they become irreconcilable. The key is good communication, and a tried and true strategy to facilitate the exchange of ideas is the family meeting. At a family meeting, there should be frank and open discussion about a parent’s care needs. Each sibling’s role and obligations should be established, and future plans should be made. But if the question of where to hold a family meeting leads to a bitter argument in and of itself, the friction may have gotten past the point when a family meeting can help.

An Outside Voice: Advisors, Counsels and Mediators
Sometimes a neutral third-party can calm feuding siblings. An elder care advocate,  who work directly with families as they plan a parent’s care, have defused many disputes between siblings over lengthy conference calls. Family counselors can also help to bridge the differences between siblings, assuming they still talk to one another. If things have become really heated, a family mediator specializing in senior care issues may be able to break through the ill will and help build consensus and find middle-ground.

The High Road
Ultimately, the only person we can change is ourselves. No matter how much we try to reason with a disagreeable sibling, we may not succeed. While advocating for what’s best for our parent, it’s wise to “let go” of anger or resentment towards a sibling who has been unhelpful or hurtful, and to strive for the undeniable peace that comes from acceptance and forgiveness; neither stifling our impulse to call out an uncooperative brother or sister, nor allowing ourselves to be consumed with anger.

Mediating Family Disputes Over Dementia

The importance of mediation is increasingly recognized in resolving family disagreements among siblings concerning the best interests of parents affected by dementia such as Alzheimer’s disease.

When an individual suffers from dementia, behavior changes often create frightening and dangerous circumstances. Unsafe driving, confusions about medications, uncharacteristic emotional or physical spousal abuse, or wandering away from home are not unusual occurrences.

Legitimate safety concerns arise, both for the individual suffering with the dementia as well as for caregivers and others who could be affected. Change can be legally complicated and emotionally difficult.

If family members are unable or unwilling to make lifestyle changes to manage the behaviors that arise from dementia, at a certain point the police and Office of Aging sometimes get involved. When an older person becomes such a responsibility for a public agency, a guardianship action often results.

This can lead to involuntary placement in a licensed, and secure, long-term care facility, which might not be the family’s preferred option. Sometimes the threat of such outside intervention is enough to focus family members on the need to make tough decisions.

When family disagreements are played out in court proceedings, a judge must decide who would be the better guardian for a parent no longer able to act independently. The need for a guardianship appointment is most common when an adult with dementia has failed when competent to execute a power of attorney document to appoint an agent to act for them.

A guardianship can also be necessary if no backup agent was appointed to succeed the only appointed agent whose status changes and who becomes unable to serve in the role.

Senate Bill 568 has been proposed as legislation amending state law regarding how guardianship matters are managed by Orphans Courts in Pennsylvania. The legislation introduces the terms arbitration and mediation for the first time as options in relation to a guardianship process. However, elder mediation has existed for many years in some localities.

The Good Shepherd Mediation Program of Philadelphia was established in 1984 and offers both mediation services for families, as well as training for professionals interested in providing elder mediation services. Typical elder mediation issues include living arrangements, driving, property maintenance, care issues, and finances.

Depending on the circumstances of a family conflict, a mediation session might include three generations of a family, religious advisers, friends, neighbors, service providers and financial and legal advisers.

Mediation differs from arbitration, in which a neutral party or panel hears a dispute between parties and renders an opinion that could have legal significance. Mediation is a dispute-resolution process which participants must approach voluntarily and work through in good faith.

A successful mediation hears the wishes of the older adult and encourages family members to work through their different perspectives. Ideally, a mutually agreeable resolution about a necessary decision results from the process of gathering information and considering options.

A mediator might need to help a family work through sibling rivalries and minimize the current relevance of previous family conflicts and pain.

Decisions about older persons with dementia are difficult. When one spouse seems to equate self-worth with the ability to be a caregiver of the other, this can translate to a denial of a need for change. Sometimes a child who has not been present to observe the decline of a parent with dementia has difficulty processing the significance of their parent’s decline as reported by a sibling.

Mediation can be useful to resolve emotional disagreements about dementia, avoiding hard feelings which can permanently divide families.

Circumstances of dementia can create additional stress when family members’ disagreement results in tensions that cause relationships to suffer. These tensions, general logistics, and time pressures lead to families avoiding important and difficult conversations.

Not discussing the impact of dementia contributes to a failure to recognize or react to the new reality caused by progressive dementia, and delays important decisions. At least one of the parents might eventually lack the capacity to participate in decision-making about care.

If your family is experiencing the onset of dementia, it is important to attempt to get legal affairs in order immediately. If a consensus cannot be reached about the need to appoint an agent or who should be appointed, mediation might be useful to resolve this impasse. Even if the preparation of legal documents can be completed without mediation, mediation of lifestyle issues could be beneficial. 


How An Adam Sandler Movie Is Helping Dementia Patients

For 94-year-old Louise Irving, who suffers from dementia, waking up every day to a video with a familiar face and a familiar voice seems to spark a flicker of recognition.

"Good morning, merry sunshine, how did you wake so soon?" Irving's daughter, Tamara Rusoff-Hoen, sings in a video playing from a laptop wheeled to her mother's nursing home bedside.

As the five-minute video plays, with stories of happy memories and get-togethers, Irving beams a bright smile before repeating the traditional family send-off.

"Kiss, kiss ... I love you."

Such prerecorded messages from family members are part of an apparently unique pilot program at the Hebrew Home at Riverdale aimed at helping victims of Alzheimer's disease and other forms of dementia break through the morning fog of forgetfulness that can often cause them agitation and fear.

It's an idea borrowed from an unlikely place: the 2004 Adam Sandler movie "50 First Dates," in which a brain-injured woman played by Drew Barrymore loses her memory every day and a suitor played by Sandler uses videos to remind her about him.

"It was fluff, but it made me think, 'How could that translate to our residents with memory loss?'" says Charlotte Dell, director of social services at the home.

"We're looking to see if we can set a positive tone for the day" without using drugs, she says. "What better way to start the day than to see the face and hear the voice of someone you love wishing you a wonderful morning?"

As in the movie, every day is a new day, and the video becomes part of the morning routine. Relatives who take part are urged to say good morning, use memory-triggering personal anecdotes and remind the residents that attendants will be helping them get dressed and ready for the day.

Alzheimer's disease and other dementias afflict a growing number of Americans as baby boomers age and people live longer. The Alzheimer's Association says more than 5 million Americans have Alzheimer's.

The personal morning video appears to be a new wrinkle in dementia caretaking.

"Memory tools like videos and photos get a lot of use, but to have a couple of minutes with a loved one as a way to start out the day, I haven't heard of anything quite like that," says Ruth Drew, director of family and information services for the association.

Robert Abrams, a geriatric psychiatrist at NewYork-Presbyterian Hospital, called the program "both innovative and thoughtful."

"You've got a group of people with dementia who don't really grasp the nature and purpose of their surroundings or the circumstances that compelled them to be there," Abrams says. "Consequently, they're alone and at sea and feel frightened and even abandoned by family."

Experts caution, however, that Alzheimer's patients vary widely, and techniques that may work beautifully for one might not work for another.

The program at the Hebrew Home is limited to residents in the early and moderate stages of dementia who are likely to recognize the people in the video and understand what they say.

"Do we know for sure that they know, this is my daughter, this is my son? No," Dell says. "But they recognize them as somebody they care about and love."

The program is starting with residents who are known to staff as difficult in the morning and who refuse care, a description that Rusoff-Hoen acknowledges fits her mother.

"Some of her agitation comes from, 'Who the heck are these people? Why am I here?'" she says.

Although Rusoff-Hoen, who lives a couple of hours away in Ghent, visits her mother three days a week, she said the video program helps fill in the gaps. "I am there with my mom, loving her and wishing her a wonderful day and helping her to feel better because there's not a lot I can do for her," Rosoff-Hoen said.

The Hebrew Home plans to evaluate the program after this month and may expand it to more of the several hundred residents in its memory-care "neighborhoods." Dell says anecdotal evidence from the staff is "very positive."

Irving's son-in-law, Mihai Radulescu, also made a video for her. In it, he kids her about being "a delinquent" because she once worked for a bootlegger.

On the recording, he repeatedly reminds Irving, "I know where you are. ... I will always find you," because she has expressed a deep fear of being lost.

Other videos include a woman reminding her mother, in Spanish, to eat and take her medications, then tearing up at the end and saying, "I love you, Mom."

On another video, a man encourages his mother, saying, "You used to tell me that attitude is everything. ... You said that it's best to start off on the sunny side of the street."