Financial Capacity in Older Adults a Review of Clinical Assessment Approaches and Considerations

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• HHS Author Manuscripts
• PMC2714907

J Am Geriatr Soc. Author manuscript; available in PMC 2010 May 1.

Published in final edited class equally:

PMCID: PMC2714907

NIHMSID: NIHMS102048

Clinical Interview Assessment of Fiscal Capacity in Older Adults with Mild Cognitive Impairment and Alzheimer's Disease

Daniel C. Marson, J.D., Ph.D.,^{i, 2} Roy C. Martin, Ph.D.,^{1, 2} Virginia Wadley, Ph.D.,^{2, 3} H. Randall Griffith, Ph.D.,^{1, ii} Scott Snyder, Ph.D.,⁴ Patricia S. Goode, Yard.D.,^{three, v} F. Cleveland Kinney, M.D.,^{2, 6} Anthony P. Nicholas, One thousand.D., Ph.D.,^{1, 2} Terri Steele, M.D.,⁶ Britt Anderson, M.D.,⁷ Edward Zamrini, Chiliad.D.,^eight Rema Raman, Ph.D.,⁹ Alfred Bartolucci, Ph.D.,^{2, 10} and Lindy E. Harrell, Ph.D., Thou.D.^{i, 2, 5}

Daniel C. Marson

^aneSection of Neurology, Academy of Alabama at Birmingham (UAB), Birmingham, Alabama 35233-7340

²Alzheimer'due south Disease Research Center, Department of Neurology, UAB, Birmingham, Alabama

Roy C. Martin

¹Department of Neurology, University of Alabama at Birmingham (UAB), Birmingham, Alabama 35233-7340

^twoAlzheimer's Disease Inquiry Center, Department of Neurology, UAB, Birmingham, Alabama

Virginia Wadley

^twoAlzheimer'south Disease Research Center, Department of Neurology, UAB, Birmingham, Alabama

ⁱⁱⁱDivision of Gerontology, Geriatrics and Palliative Intendance, Department of Medicine, UAB, Birmingham, Alabama

H. Randall Griffith

^oneSection of Neurology, University of Alabama at Birmingham (UAB), Birmingham, Alabama 35233-7340

^twoAlzheimer'due south Illness Research Center, Department of Neurology, UAB, Birmingham, Alabama

Scott Snyder

^ivSection of Education, UAB, Birmingham, Alabama

Patricia South. Goode

³Division of Gerontology, Geriatrics and Palliative Intendance, Section of Medicine, UAB, Birmingham, Alabama

⁵Birmingham Veterans Affairs Medical Center, Birmingham, Alabama

F. Cleveland Kinney

ⁱⁱAlzheimer's Disease Research Heart, Section of Neurology, UAB, Birmingham, Alabama

^{half dozen}Department of Psychiatry and Behavioral Neurobiology, UAB, Birmingham, Alabama

Anthony P. Nicholas

¹Department of Neurology, University of Alabama at Birmingham (UAB), Birmingham, Alabama 35233-7340

^twoAlzheimer's Disease Inquiry Heart, Section of Neurology, UAB, Birmingham, Alabama

Terri Steele

⁶Department of Psychiatry and Behavioral Neurobiology, UAB, Birmingham, Alabama

Britt Anderson

^sevenUniversity of Waterloo, Department of Psychology, Centre for Theoretical Neuroscience, Waterloo, Canada

Edward Zamrini

^viiiSection of Neurology, University of Utah Health Sciences, Common salt Lake City, Utah

Rema Raman

^nineDepartment of Family Medicine and Neuroscience, Academy of California San Diego, San Diego, California

Alfred Bartolucci

²Alzheimer's Disease Research Center, Department of Neurology, UAB, Birmingham, Alabama

^xSection of Biostatistics, UAB, Birmingham, Alabama

Lindy E. Harrell

¹Department of Neurology, University of Alabama at Birmingham (UAB), Birmingham, Alabama 35233-7340

²Alzheimer's Illness Inquiry Middle, Department of Neurology, UAB, Birmingham, Alabama

^vBirmingham Veterans Diplomacy Medical Eye, Birmingham, Alabama

Abstruse

Objectives

To investigate financial capacity in patients with mild cognitive impairment (MCI) and Alzheimer'southward disease (Ad) using a clinician interview approach.

Setting

Tertiary care medical center.

Participants

Good for you older adults (N=75), patients with amnestic MCI (N=58), mild Advertizing (N=97), and moderate AD (N=31).

Measurements

The investigators and five study physicians adult a conceptually based, semi-structured clinical interview for evaluating seven core fiscal domains and overall fiscal chapters (Semi-Structured Clinical Interview for Fiscal Chapters; SCIFC). For each participant, a physician fabricated chapters judgments (capable, marginally capable, or incapable) for each fiscal domain and for overall capacity.

Results

Study physicians fabricated a total of over 11,000 capacity judgments across the written report sample (N=261). Very adept inter-rater agreement was obtained for the SCIFC judgments. Increasing proportions of marginal and incapable judgment ratings were associated with increasing disease severity across the iv study groups. For overall financial capacity, 95 percent of doc judgments for older controls were rated as capable, as compared to only 82% for patients with MCI, 26% for patients with balmy AD, and four% for patients with moderate AD.

Conclusion

Financial capacity in cognitively impaired older adults can exist reliably evaluated past physicians using a relatively brief, semi-structured clinical interview. Financial capacity shows mild impairment in MCI, emerging global impairment in mild AD, and advanced global impairment in moderate Advertisement. MCI patients and their families should proactively engage in financial and legal planning given these patients' risk of developing AD and accelerated loss of financial abilities.

Keywords: fiscal chapters, competency, clinical assessment, balmy cognitive damage, Alzheimer's illness

INTRODUCTION

As our society ages, increasing numbers of older adults will experience impairment of higher social club functional abilities as a upshot of Alzheimer'south affliction and related disorders (AD). In areas such as medical determination-making, driving, managing finances, and making testamentary dispositions, families and society as a whole have a strong involvement in distinguishing intact from impaired performance^{1 – 4}. Clinical assessment of such central functional capacities by physicians and other wellness care practitioners is an of import but ofttimes disregarded aspect of geriatric do.

Amid college society abilities, the capacity to manage fiscal diplomacy has item significance to independent functioning of older adults^{five , vi}. Financial capacity comprises a broad range of conceptual, businesslike, and judgment abilities, ranging from basic skills similar counting coins and currency, to more complex skills such equally paying bills, managing a checkbook, and exercising financial judgment⁷. Similar to driving and mobility, it is a core aspect of individual autonomy in our society and represents a cognitively complex set of knowledge and skills vulnerable to cognitive aging and dementia ^{5 , 8 – xi}.

Impairment of financial abilities occurs in patients with Advertizement and to a lesser extent in patients with balmy cognitive impairment (MCI)⁵. Using a psychometric mensurate of fiscal capacity, our group has previously institute that patients with amnestic MCI demonstrate mild impairments in fiscal abilities such equally conceptual knowledge, bill payment, and bank statement direction¹². In contrast, patients with mild AD show impairments across a range of both simple and complex financial abilities⁵, and these abilities bear witness further rapid decline over a one year period¹³. Patients with moderate Advertizing, in turn, demonstrate astringent and global damage in all financial skills¹³. This progressive loss of fiscal skills in older patients with MCI and Advert mirrors the problems of financial judgment, exploitation, and elder abuse that plague the elderly population and that are targets of public policy measures¹⁴.

The financial capacity of older adults is also a growing clinical issue for physicians and other health care professionals¹⁵. Families frequently await to health care providers to address bug of declining financial skills and decision-making in their loved ones. These clinical judgments, while not legal adjudications, have important ethical and legal implications, equally they often result in restriction or removal of a patient's freedom to manage their financial affairs⁷. These judgments are as well challenging to make, equally physicians and other clinicians have had little or no education or training in financial capacity cess². In contrast to areas such as medical-conclusion-making capacity, there are no published studies of clinician assessment of financial capacity. In addition, in that location are few if any clinician-administered instruments available with which to assess financial capacity. The availability of such instruments could improve clinical intendance and promote both autonomy and protection of older adults.

The present report examined assessment of financial capacity in older adults using a clinician-administered interview (Semi-Structured Clinical Interview for Fiscal Capacity) (SCIFC). Nosotros depict the development of the SCIFC as an cess tool and and so nowadays data concerning its reliability and validity in a clinical sample representing the dementia spectrum (cognitively good for you older controls, and patients with MCI, balmy AD, and moderate AD).

METHODS

Conceptual Model of Financial Capacity

Fiscal capacity involves a wide range of declarative, procedural, and judgment-based knowledge and skills⁷. Nosotros previously accept developed a conceptual model that views financial chapters at three levels: specific financial abilities (task level) such equally counting coins/currency or prioritizing bills for payment; broader areas of financial activity each having clinical relevance for contained functioning (domain level) such every bit conducting cash transactions or exercising financial judgment; and overall fiscal capacity (global level). This conceptual model is discussed in more detail elsewhere^{v , 7 , 16}.

Evolution of a Clinician Cess Measure

The SCIFC was adult as a clinician-oriented, semi-structured interview singled-out from existing standardized psychometric capacity measures^{v , 17 , 18} which are quantified and crave trained technicians for administration. Primary considerations were to develop a relatively cursory interview assessing a range of financial domains and affording the clinician both construction and autonomy. The SCIFC was developed by the investigators (D.C.One thousand., V.West., and S.S.) and five study physicians (B.A., P.1000., C.Chiliad., A.P.Northward., and T.Due south.). Phases of evolution included : (1) identifying and discussing constituent skills and abilities related to the financial domains of the conceptual model⁵; (ii) generating and refining test items for each domain; (three) creation of a 25-infinitesimal, semi-structured interview based on examination item selection; (4) identification of core items and also optional supplemental examination items for each domain; (5) evolution of administration and scoring procedures; and (vi) piloting and terminal revision of the interview. Table ane presents a schematic of the SCIFC instrument and its cadre items.

Table 1

Schematic of the Semi-Structured Clinical Interview for Financial Capacity (SCIFC)

	Item Description
Domain 1 Basic Monetary Skills
Core Questions:
1. Naming coins/currency	Identify specific coins and currency
ii. Coin/currency relationships	Place relative worth of coins/currency
3. Counting coins/currency	Accurately count coins and currency
Domain 2 Financial Conceptual Knowledge
Core Questions
i. Ascertain term coin	Ascertain a variety of financial concepts
2. Define ways people obtain money
three. Ascertain term loan
Domain three Cash Transactions
Core Questions
1. Place item price	Identify cost of single item from cost tag
ii. one detail grocery buy	One particular transaction; verify alter
iii. Addition of sales tax	Explain boosted charge regarding purchase
Domain 4 Checkbook Direction
Core Questions
1. Understand checkbook	Ascertain cheque
two. Apply checkbook	False transaction; pay past check
3. Use checkbook register	Simulated register entry and balancing
Domain 5 Bank Argument Management
Cadre Questions
1. Place banking concern statement	Explicate purpose of depository financial institution statement
2. Identify banking company statement residue	Summate bank argument residuum
3. Place deposit	Identify monthly checkbook deposit
4. Identify balance differences	Identify residual differences
Domain six Financial Judgment
Core Questions
1. Observe telephone fraud risk	Detect and explain hazard
2. Decide appropriate value	Explain how to determine worth of automobile
3. Advertising auto	Indicate how to advertise automobile
4. Receiving payment	Explicate how to obtain appropriate payment
Domain 7 Bill Payment
Core Questions
1. Understand bills	Explain pregnant and purpose of bills
ii. Identify pecker amount	Identify coin owed on bill
iii. Questioning amount of bills	Explain how to question amount of beak
four. Unpaid bills	Explain consequence of unpaid bills
Domain 8 Knowledge of Personal Avails and Estate Arrangements
Core Questions
1. Income	Place source of income
2. Avails and will/trust	Place valuables and will/trust
Overall Fiscal Chapters	Functioning across all skills and domains

The SCIFC contains both verbally administered items (question/respond) and too performance items using financial stimuli and other testing materials materials. Some illustrative items from the SCIFC and its domains are presented below:

Domain one: Basic Monetary Skills
•	"Please identify these coins and currency"
Domain 2: Financial Conceptual Knowledge
•	"What is money?"
Domain 3: Greenbacks Transactions
•	"Please give me the exact corporeality of money needed to buy this box of tissues"
Domain 4: Checkbook Management
•	"What is a check?"
Domain 5: Bank Statement Management
•	What are some of the ways John Doe spent coin during this month?
Domain 6: Fiscal Judgment
•	"How could y'all be sure the price for the car is off-white? "
Domain seven: Nib Payment
•	"If you had a question almost this beak, what would you do?"
Domain eight: Cognition of Personal Financial Assets and Estate Arrangements
•	"Practise you have a will or a living trust?"

The terminal version of the SCIFC interview comprised seven core domains (Domains ane–7) and one experimental domain (Domain 8). The clinician straight judges performance on the core domains, while Domain viii (Knowledge of Assets and Estate) likewise requires the clinician to obtain corroborating information from a reliable informant. Because informant availability and study accuracy were variable beyond study participants, nosotros treated Domain 8 every bit experimental. Clinicians follow general scoring criteria for individual core and supplemental items within each domain, but retain autonomy regarding domain and overall capacity judgments. The SCIFC elicits a total of nine capacity judgments (i for each domain and for overall financial capacity). In making a judgment, a clinician assigns one of three possible outcomes (capable, marginally capable, or incapable) based upon their assessment and clinical judgment. This judgment outcome classification has been used successfully in prior fiscal capacity^{v , 13} and other capacity research^{19 , 20}.

Study Participants

Participants consisted of 75 healthy older controls, 58 patients with amnestic MCI, 97 balmy Advertisement patients, and 31 moderate Advert patients. All participants were recruited through the Alzheimer'due south Disease Enquiry Center (ADRC) at the University of Alabama at Birmingham (UAB) and were part of an associated NIH enquiry projection (Financial Capacity Project; 1R01MH55247).

Salubrious community dwelling older adults were clinically evaluated past a neurologist and neuropsychologist to ensure the absence of medical, neurologic, and psychiatric weather affecting noesis. Controls in this study received a Clinical Dementia Rating (CDR)²¹ staging scores and completed standardized tests of mental condition (Mini-Mental State Examination; MMSE²²), and global cognitive status (Dementia Rating Scale; DRS²³). Controls were characterized equally cognitively normal in the UAB ADRC diagnostic clinical consensus conference.

Patients with amnestic MCI were recruited through the Memory Disorders Dispensary at UAB and were well-characterized based upon the medical, neurologic, psychiatric, and neuropsychological screening described above. Diagnosis of amnestic MCI was made in ADRC diagnostic consensus briefing using original Mayo criteria²⁴.

Patients with likely AD were likewise recruited from the Memory Disorders Clinic and their dementia was well characterized based on the above screening procedures. Diagnosis of probable Advertising was made in the ADRC diagnostic consensus conference using NINCDS-ADRDA criteria²⁵. Dementia severity (balmy- moderate) was assigned in consensus conference and was based both on clinical information and CDR score²¹.

Informed consent was obtained from all participants and their caregivers. This report was approved by the UAB Institutional Review Board.

Study Physicians

As discussed higher up, v UAB physicians (ii geriatric psychiatrists, one geriatrician, and ii neurologists) served every bit study collaborators and assisted with both evolution of the SCIFC and its awarding in the written report. Each physician had extensive clinical experience with geriatric and dementia cess, and besides with competency cess in clinical settings. Each doc was board certified in their specialty. Physicians were blinded to participant diagnosis at the time of their interview.

Procedures for SCIFC Administration and Scoring

Using the SCIFC, each report physician evaluated the capacity of each participant using a alive interview/videotape review methodology successfully employed in prior studies²⁶. Specifically, each study participant was directly interviewed with the SCIFC past i study physician. The interview was videotaped, and the other four physicians each independently reviewed the videotaped interview. In this way, all study physicians evaluated each written report participant, while at the same time avoiding potential confounds involved with multiple medico assessments of the aforementioned participant. The interviewing physician was randomly assigned to forestall any systematic interviewing bias.

Statistical Analyses

Demographic and Clinical Variables

Group differences in terms of age, education, DRS-2 total score, CDR sum of boxes, and Mini-Mental Country Exam (MMSE²²) score were analyzed employing ANOVA with Tukey'south Studentized Range (HSD) test. Analyses of the distribution of CDR staging, gender, and ethnicity group differences were performed with chi-foursquare.

Estimates of Physician Judgment Agreement

Physician judgment agreement was defined at 2 levels. Splendid judgment agreement was defined as 100% or "verbal" agreement for a specific capacity outcome for a participant on an SCIFC variable. As a hypothetical case, all five physicians hold that Participant Ten is capable on Domain 1. Very good judgment agreement was defined equally 80%+ agreement for a specific chapters effect for a participant on an SCIFC variable. As a hypothetical instance, four (or five) of the five physicians concord that Participant Y is marginally capable on Domain vi. We used the 80%+ judgment understanding level as the ground for evaluating judgment reliability in the study. This arroyo to estimating understanding was chosen for ease of interpretation and to avert unstable and artificially lowered statistical estimates of agreement due to restricted range of the capacity judgment information across groups.

Comparing of Chapters Judgment Outcomes Across Groups

Group differences in financial capacity outcomes on the SCIFC variables (with doctor judgments inside the same patient treated equally a cluster) were analyzed using a Generalized Estimating Equations (GEE) approach for ordinal data²⁷. GEE is an extension of the full general linear model and is used to analyze clustered data in which the multiple scores from the aforementioned patient are probable to be correlated. The GEE method accounts for the correlation amongst observations from the same participant and provides more efficient and less biased regression parameters than the stock-still ordinal logistic regression method. The GEE analyses were carried out using SAS (version nine.2) PROC GENMOD procedure.

For each SCIFC variable, a separate GEE analysis was conducted for participants in each of the four groups. In each model, the SCIFC judgment score, classified as an ordinal variable (capable/marginally capable/incapable) served every bit the dependent variable and group (Control/MCI/Mild AD/Moderate AD) was entered every bit the predictor variable. Each model adjusted for age and didactics, and the Holm's adjustment was used to conform for multiple comparisons. A p value of .01 was employed equally the criterion for statistical significance.

Information Exclusion: Prior/Premorbid Financial Feel

Because individual fiscal feel can vary across individuals^five, nosotros deemed for lack of fiscal skills and feel. The Prior/Premorbid Fiscal Chapters Form (PFCF)⁵, a measure that rates the level of prior (command) or premorbid (MCI or AD patient) feel across each SCIFC domain, was administered separately to participants and their informants (i.e., family fellow member). We used the PFCF results to exclude data of participants defective experience on specific SCIFC variables. These procedures resulted in the exclusion of 1 control from Bank Statement Management assay. In the MCI group the following domain related exclusions occurred: Financial Concepts (n=1), Checkbook Management (n=4), Bank Statement Management (n=3). In the mild AD group, the following exclusions occurred: Financial Concepts (n=2), Checkbook Direction (n=vi), Bank Argument (n=viii), Financial Judgment (n=half dozen), Neb Payment (north=iv). In the moderate AD group, the following exclusions were identified: Checkbook Management (north=two), Bank Statement (north=3), Financial Judgment (n=2), and Bill Payment (north=2).

RESULTS

Demographic and Mental Status Variables

Results are set along in Table 2. Controls and MCI patients were younger than balmy Advertisement patients, who in plough were younger than moderate Ad patients. The control group had higher didactics levels than the mild and moderate Advertising patients. The MCI and mild Advertizement group had similar levels of didactics, with both having higher teaching levels than the moderate Advertizing group. More than men than women composed the balmy Ad group. The groups did not significantly differ in the proportion of Caucasians and African-Americans. The MMSE and DRS-2 total scores were worse for the mild and moderate AD patients compared to MCI patients and controls.

Table 2

Demographic variables of study participants

	Controls	MCI	Mild AD	Moderate Advertisement
	N = 75	Northward = 58	N = 97	N = 31
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	F	p value
Age (years) b,c,d,due east	66.1 (seven.7)	68.0 (8.3)	72.4 (viii.4)	75.3 (viii.4)	xiv.three	< .001
Education (years) b,c,e,f	fourteen.3 (1.6)	13.7 (2.0)	13.iv (ii.1)	11.ane (3.vii)	15.five	< .001
Gender (m/f) c,d,e,f	24 / 51	eighteen / 40	52 / 45	10 / 21	12.ii*	< .007
Race **
Caucasian	65	44	85	23	eight.three *	0.21
African American	9	14	11	8
Other	ane	0	one	0
MMSE b,c,d,eastward,f	29.3 (1.0)	28.two (1.9)	24.0 (3.i)	16.four (iv.2)	196.9	< .001
DRS Full Score
(max = 144) a,b,c,d,e,f	138.vii (3.viii)	131.iii (vii.4)	114.0 (12.1)	90.7 (nineteen.6)	178.five	< .001
CDR Staging, n
0.0	lxx	8	00	00
0.5	04	48	17	00
one.0	00	2	80	10
2.0	00	00	00	18
3.0	00	00	00	ane
CDR sum of boxes a,b,c,d,e,f
Max = 18, mean (SD)	0 (.2)	ane.ii (1.iii)	v.0 (1.8)	ix.eight (iii.iv)	290.7	< .001

Physician Capacity Judgments

A total of xi,118 individual capacity judgments were fabricated by the v physicians beyond the nine SCIFC domains and overall sample (n=261). Each physician made an boilerplate of 2,224 capacity judgments, attesting to their effort and commitment. A total of 627 ratings were non obtained (missing information) out of 11,745 possible ratings [5 physicians ×261 participants ×ix SCIFC variables]. This represented a 94.7% judgment upshot completion rate.

Doctor Judgment Agreement

Tabular array 3 presents SCIFC inter-rater judgment findings using the exact (100%) and 80%+ understanding levels. Every bit previously described, the standard for evaluating judgment agreement was set up at 80%+ agreement. For participants as a whole, adequate inter-rater understanding was establish for all domains and for overall capacity. For overall capacity, eighty%+ agreement was obtained in 78% of cases (203 of 261 participants). At the total group level and across the cadre domains, 80%+ agreement levels ranged from a loftier of 95% of cases (Basic Monetary Skills) to a depression of 76% (Financial Judgment). As discussed above, the reliability level for experimental Domain 8 (Knowledge of Personal Assets/Estate Arrangements) was lower due in role to missing corroborating informant written report.

Table 3

Observed Inter-Rater Judgment Agreement for the Five Physicians Using the SCIFC

Domain	Controls N= 79		MCI Northward = 58		Mild AD Northward = 97		Moderate Advertisement N = 31		Total Northward = 261
	100% Interrater Understanding	80%+ Interrater Agreement	100% Interrater Agreement	eighty%+ Interrater Agreement	100% Interrater Agreement	80%+ Interrater Agreement	100% Interrater Agreement	80%+ Interrater Agreement	100% Interrater Agreement	fourscore%+ Interrater Agreement
D1Basic Monetary Skills Observed	73/75	75/75	57/58	58/58	87/97	91/97	xx/31	25/31	237/261	249/261
Percentage Understanding	97%	100%	98%	100%	90%	92%	66%	81%	91%	95%
D2Financial Concepts Observed	71/75	74/75	56/57	57/57	68/95	81/95	12/31	23/31	207/258	235/258
Percentage Agreement	95%	99%	98%	100%	72%	86%	39%	74%	eighty%	91%
D3 Cash Transactions Observed	73/75	74/75	57/58	58/58	72/97	83/97	17/31	29/31	219/261	244/261
Percentage Agreement	97%	99%	99%	100%	74%	86%	55%	94%	84%	93%
D4 Checkbook Management Observed	69/75	75/75	44/54	50/54	58/91	74/91	23/29	24/29	194/249	223/249
Percentage Understanding	92%	100%	81%	93%	64%	81%	79%	83%	75%	xc%
D5 Bank Statement Mgmt Observed	68/74	71/74	34/55	44/55	43/89	61/89	20/28	23/28	165/246	199/246
Percentage Agreement	92%	96%	62%	80%	48%	68%	71%	82%	67%	fourscore%
D6 Financial Judgment Observed	60/75	67/75	36/58	47/58	35/97	67/97	11/29	17/29	142/256	196/256
Per centum Agreement	80%	89%	62%	81%	36%	69%	38%	59%	55%	76%
D7 Bill Payment Observed	72/75	73/75	51/58	54/58	55/93	71/93	15/29	twenty/29	193/255	218/255
Percentage Agreement	96%	97%	88%	93%	59%	76%	52%	69%	75%	85%
D8 Assets/Estate Organization Observed	63/75	68/75	41/58	51/58	35/97	58/97	2/31	12/31	141/261	189/261
Percentage Understanding	84%	91%	71%	88%	36%	60%	6%	39%	54%	72%
D1–7 Full Score Observed	64/75	68/75	37/58	51/58	35/97	67/97	17/31	26/31	153/261	203/261
Percentage Agreement	85%	91%	64%	90%	36%	69%	55%	84%	59%	78%

Beyond study groups, hateful 80%+ judgment agreement for the seven core domains was 97% of control cases, versus 92% of MCI cases, eighty% of mild Ad cases, and 77% of moderate Advert cases. For overall capacity, eighty%+ understanding was obtained in 91% of control cases, 90% of MCI cases, 69% of mild AD cases, and 84% of moderate Advertisement cases. The lower agreement level for the mild AD grouping is interesting and is discussed further below.

For all SCIFC variables combined beyond all groups, 80%+ agreement was obtained in 85% of cases (1966 of 2308 cases).

Chapters Judgment Outcomes Across Groups

Table 4 presents md capacity judgment outcomes (capable, marginally capable, or incapable) across SCIFC variables and groups. Between group differences (p<.01) were found for all domains and overall capacity, with increasing proportions of impairment (marginally capable and incapable outcomes) on the SCIFC variables associated with increasing disease severity.

Tabular array four

Group Differences in SCIFC Judgment Outcomes beyond All Doctor Raters

	Controls North = 75			MCI N = 58			Balmy AD N = 97			Moderate AD N = 31
	Capable	Marginally Capable	Incapable	Capable	Marginally Capable	Incapable	Capable	Marginally Capable	Incapable	Capable	Marginally Capable	Incapable
D1 Basic Monetary Skills c,d,east,f	344 (98%)	8	1	281 (99%)	1	0	435 (92%)	27	xiii	102 (66%)	xviii	35
D2 Fiscal Cognition b,c,d,e,f	348 (99%)	5	0	280 (99%)	1	0	379 (82%)	72	11	77 (50%)	49	29
D3 Cash Transactions b,c,d,e,f	341 (97%)	12	0	273 (97%)	9	0	333 (70%)	92	50	fifty (32%)	49	56
D4 Checkbook Mgmt b,c,d,e	339 (95%)	15	2	226 (85%)	27	14	144 (32%)	82	220	15 (10%)	14	115
D5 Bank Statement Mgmt a,b,c,d,e,f	333 (93%)	22	two	193 (72%)	65	11	145 (33%)	128	162	6 (iv%)	xv	116
D6 Fiscal Judgment b,c,d,e,f	306 (92%)	27	0	234 (83%)	41	7	215 (47%)	126	119	27 (xix%)	48	70
D7 Bill Payment b,c,d,e,f	326 (98%)	vii	0	262 (93%)	xvi	4	294 (65%)	105	56	32 (22%)	49	64
D8 Knowledge Assets/Estate b,c,d,e,f	319 (96%)	xiii	1	256 (91%)	25	1	296 (62%)	141	38	44 (28%)	71	40
Overall Fiscal Chapters a,b,c,d,e,f	315 (95%)	eighteen (05%)	0 (0%)	231 (82%)	44 (sixteen%)	7 (2%)	125 (26%)	175 (37%)	176 (37%)	six (4%)	32 (21%)	117 (75%)

Relative to controls, MCI patients were impaired on Depository financial institution Statement Management and on overall financial capacity. In improver, trends emerged on Checkbook Management (p=.060) and Financial Judgment (p=.062). Relative to controls and MCI patients, balmy Advertising patients were impaired on all domains (except Basic Monetary Skills) and on overall fiscal capacity. Relative to controls and MCI patients, moderate AD patients were impaired on all SCIFC variables. In add-on, relative to mild Advertising patients, moderate AD patients were dumb on all domains (except Checkbook Direction and Nib Payment), and on overall financial capacity.

Examination of judgment outcomes by group revealed that for overall fiscal chapters, controls were rated as capable in 95% of judgments (encounter Table 4 and Figure 1). At the domain level, controls had every bit high equally 99% capable judgments (Financial Concepts), with a low of 92% (Financial Judgment). Marginally capable outcomes constituted betwixt two% and 8% of judgments, while incapable outcomes represented less than 1%.

Judgment Outcomes by Pct and Group for Selected SCIFC Variables

In contrast, judgments for MCI patients reflected the emergence of mild impairments in fiscal capacity (Table 4 and Figure one). While MCI patients were rated as capable in at to the lowest degree 93% of judgments on four domains (Bones Budgetary Skills, Financial Concepts, Cash Transactions, and Nib Payment), they performed less well on domains of Checkbook Direction (85% capable judgments) and Financial Judgment (83%), and showed a statistically significant arrears on Bank Statement Direction (72% capable and 24% marginally capable judgments). In addition, a arrears emerged for overall fiscal capacity, with only 82% of judgments for MCI patients rated capable, and some other 16% rated marginally capable. These findings suggest emerging financial deficits in MCI patients.

Mild AD patients demonstrated global deficits in financial chapters (Table 4 and Figure 1). For overall financial capacity, only 26% of judgments were rated capable (37% marginally capable and 37% incapable judgments), reflecting a marked loss of financial skills relative to controls and MCI patients. At the domain level, at that place were 70% or less capable judgments on five domains, with less than fifty% capable judgments for iii circuitous domains (Checkbook Management, Banking concern Statement Management, and Financial Judgment).

The moderate Advertizing group demonstrated advanced global impairment on the SCIFC variables. For overall fiscal chapters, only 4% of judgments were rated capable. At the domain level, there was less than 50% capable judgment ratings on half dozen of seven core domains, and less than 25% capable outcomes on four complex domains (Checkbook Management, Bank Statement Management, Financial Judgment, and Bill Payment).

DISCUSSION

In our aging social club, physicians and other clinicians are increasingly asked to accost issues of financial capacity in older adults with cerebral impairment and dementia. However, clinicians have lacked the preparation, experience, and clinical tools for undertaking these important assessments^{28 , 29}. The present study used a clinician-based interview to assess financial capacity in older adults representing the dementia spectrum. Using this interview, experienced physicians reliably distinguished the financial skills of cognitively normal older adults, patients with amnestic MCI, and patients with balmy and moderate Advert.

The present study found that the SCIFC achieved very good levels of judgment consistency in a sample representing the dementia continuum. Beyond the seven core financial domains, the mean level of adequate judgment understanding (fourscore%+) occurred in 97% of cases for older controls, 92% of cases for MCI, 80% of cases for mild Advertizement, and 77% of cases for moderate AD. For overall financial capacity, acceptable agreement occurred in 91% of control cases, 90% of MCI cases, 84% of moderate Advert cases, and 69% of mild AD cases. The agreement level was somewhat lower for mild Advertizement patients, every bit this grouping with its mixture of deficits and preserved skills by and large presents the greatest ambivalence for physician raters^thirty. As a reflection of this, medico ratings of overall chapters were effectively dichotomous for the control and MCI groups (almost entirely capable vs. marginally capable outcomes), dichotomous for moderate Advertisement patients (marginally capable vs. incapable outcomes), but fully trichotomous for mild Advertising patients (relatively equal proportions of capable, marginally capable, and incapable outcomes).

The SCIFC demonstrated construct validity past discriminating judgment outcomes across the four groups, with increasing impairment of financial skills (higher proportions of marginal and incapable outcomes) corresponding to dementia stage and increasing illness severity. MCI patients demonstrated impairments on the Bank Statement Management domain and on overall fiscal capacity, with trends for the domains of Fiscal Judgment and Checkbook Direction. Thus, equally judged by experienced physicians, some patients with MCI showed balmy impairments on more complex financial domains and on overall financial capacity. These findings replicate several findings from our group's prior psychometric study of financial chapters in MCI¹². The clinical implication is that upon receiving a diagnosis of amnestic MCI, patients and their families should proactively appoint in fiscal and legal planning, in apprehension of possibly developing Advertising and respective increased loss of fiscal abilities.

Compared to both older controls and MCI patients, mild AD patients demonstrated significant impairments on all financial domains (with the exception of Basic Budgetary Skills) and on overall financial capacity. The findings likewise replicate findings from our prior psychometric study of financial chapters¹³ indicating that in mild AD there is emerging global impairment of financial skills. In comparison to mild Advertizement patients, moderate AD patients showed impairment on all SCIFC variables (except maybe Checkbook Management). These findings were indicative of advanced, global impairment of financial skills found at the moderate dementia stage¹³.

The present written report has several limitations. Beginning, the study physicians served in dual roles of assisting with musical instrument development and of rating the capacity of report participants. Their collaborative efforts in instrument development may have inflated judgment reliability levels to some caste. Future studies should examine SCIFC rater agreement using non-study related physicians, and also other clinician disciplines (eg., clinical psychologists, nurses, social workers), in club to strengthen the generalizability of current findings regarding the SCIFC'south reliability and validity, and evaluate its broader utility in clinical settings. Many decorated physicians may not exist able to conduct a 25 infinitesimal interview themselves, whereas one of their clinical staff could. In our judgment, the SCIFC has the potential to exist used finer by a range of clinical staff with varying experience levels, if such clinicians are provided with an administration protocol and appropriate grooming.

2nd, although physician capacity outcomes varied equally predictable across disease severity, they were non evaluated in terms of an external validity criterion. This makes it difficult to assess how well the SCIFC performance corresponds to actual "existent world" financial capacity outcomes. Currently there is non an accepted gold standard for evaluating clinical judgments of financial chapters, or other capacities for that matter. MCI and Advertising patient cocky written report, and also family unit report, of financial chapters accept not ever proven to be a reliable criterion^{31 , 32}. Psychometric testing of financial capacity in a laboratory setting is a possible external criterion^{31 , 32}, just is also limited past issues of ecological validity and psychometric norming techniques. The consequence of establishing external validity in capacity studies is of import, as it affects the ultimate conviction that can exist extended to use of capacity measures in clinical practise.

Third, the number of physician raters was express to five. However, each doctor had feel in geriatric assessment, had various training backgrounds (due east.thousand., geriatrics, psychiatry, neurology), and had clinical experience making chapters judgments. In prior research^{26 , 30} we have institute that using five physicians with varied specialty backgrounds supports a stable consensus judgment consequence, and provides a stronger modal central tendency than a smaller number.

Quaternary, the interview/videotaping format limited the ability of the iv reviewing clinicians to fully utilise their own clinical skills and knowledge to the case. All the same, videotaping was essential methodologically to avoid confounds and logistical challenges associated with multiple clinician interviews of the same participant. Finally, the report sample, although relatively large, was obtained from a unmarried clinical setting with limited generalization of findings.

Our study provides initial support for the value of a semi-structured, interview arroyo for assessing financial capacity in older adults with cognitive impairment and dementia. This approach provides the structure necessary for attaining reliable and valid assessments, but besides permits the clinical flexibility needed for individualized assessments of patients in clinical care settings^{2 , 33}. The clinician is able to draw upon their feel and intuition in making these of import clinical decisions³⁴. The SCIFC besides has the advantage of being derived from a conceptual model of financial capacity³⁵ with clinically relevant fiscal domains. A domain-based approach allows the clinician to pre-select areas of assessment, and also to make up one's mind areas of contained role and preserved autonomy versus areas of deficit requiring supervision or direct intervention. Finally, as noted higher up, additional study of the SCIFC instrument and approach is needed to extend and strengthen the electric current findings of reliability and validity, in item studies in naturalistic clinical settings involving both physician and non-physician clinicians.

Acknowledgment

Funding Sources: Supported by research grants MH55247 (National Institute of Mental Wellness) and AG024525, AG021927, P50AG16582 (National Institute on Crumbling)

The authors give thanks the staff of the Neuropsychology Laboratory for their aid with testing participants. The authors also express item gratitude to Dr. Jonathan Williams of the Department of Pharmacology at Oxford University, England for his valuable statistical communication and consultation.

Office of the Sponsor: The funding source had no role in the design or behave of the study, data direction or analysis, or manuscript preparation

Footnotes

Portions of this paper were presented at the 10^th International Briefing on Alzheimer's Affliction held in Madrid, Kingdom of spain on July 15–20, 2006.

The capacity assessment measure out used in this study is copyrighted and owned by the UAB Enquiry Foundation. None of the authors or the UAB Enquiry Foundation receives royalty or other income regarding this instrument.

Conflict of Interest: The editor in master has reviewed the conflict of interest checklist provided past the authors and has determined that the authors have no fiscal or any other kind of personal conflicts with this paper.

Fiscal Disclosures: No relationships reported.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714907/