Competence: Competency Testing
Something that many caregivers come up against when caring for an older person is the question of competence. Particularly in the "in-between" stage when we may see clear signs that the elder is not making wise or safe decisions, but doctors and other family members may not agree. How do you get an objective assessment of someone's competence?
In these circumstances we must work with the legal definition of competence, which is the ability to understand and manage one's own affairs. Someone may be competent to manage their personal affairs, such as what to wear, what to eat, and where to live, but be unable to manage their financial or medical affairs. Others may not be able to competently do any of these things, so there are "degrees" of competence or incompetence. This doesn't make things any easier.
It is common for family doctors and other healthcare providers to use the Mini Mental State Exam to assess a patient's memory. This quick 27 question is designed to quickly give the examiner a general idea of someone's orientation to who and where they are and of their short and long term memory. The Mini Mental test is not designed to evaluate someone's capacity for decision-making.
In fact, it is not uncommon for someone to score relatively well on the Mini Mental exam while being obviously mentally ill or otherwise unable to make logical decisions or understand the consequences of poor decisions.
While you may be quite sure that your senior is not "competent," this is a determination that you, as a lay person, cannot legally make. It falls to the professionals to assess competence.
If the symptoms or behavior are fairly obvious a basic competency exam can usually be made by a physician such as a psychiatrist. For more subtle cases, or when you are preparing for a guardianship proceeding, many people (and competency courts) prefer to use the expertise of a neuropsychologist.
Neuropsychologists are licensed psychology professionals. Most have a doctorate degree (PhD) with extensive training in brain-behavior relationships. A neuropsychologist will do a thorough interview and administer a battery of tests, mostly pencil and paper, designed to evaluate someone's motor skills, attention, language abilities, memory, reasoning, perception, and speed of mental processing.
The neuropsychologist's goal is to use specific tests, 1) to establish a diagnosis if disability is identified; 2) to identify the areas of disfunction; 3) to define the degree of disability, whether full or partial, and 4) to assist in identifying the best plan for the future.
A full battery of neuropsychological tests can take a full 8 hour day to complete. Many neuropsychologists will split this testing into two or more sessions. This is less exhausting and allows a better assessment of possible "good" days and "bad" days. Less intensive testing may be sufficient for your needs, but expect that even basic testing will require at least two hours. An experienced neuropsychologist can advise you about the kind of testing that would probably be most useful.
If you believe that having your elder competency tested would be a good idea, of if you must have it done for a guardianship proceeding, ask your senior's primary care physician, psychiatrist, or your guardianship attorney for a referral.
Medicare may not cover the full cost of a complete battery of tests. Be prepared to ask any professional ahead of time about their experience with Medicare coverage. An experienced neuropsychologist will be able to predict with accuracy what will be covered and how much you will have to pay out of pocket.
Be aware also that your elder will have to cooperate with the tester. If your elder is uncooperative you cannot force participation. We have found that many older folks are more willing to participate in "neurological" testing than are willing to voluntarily see a psychiatrist.