Medico legal assessments in neurodegenerative conditions Dr Nora Breen

The podcast provides a comprehensive overview of neuropsychology, its importance, and applications particularly concerning assessment in individuals with neurodegenerative conditions. The speaker begins by outlining the field of neuropsychology, defining it as the study of the relationship between brain function, cognition, and behavior. They emphasize the importance of understanding various neurological disorders, discussing how neuropsychologists are uniquely trained in neuroanatomy and neuropathology, enabling them to assess the cognitive and behavioral problems resulting from neurological illnesses and injuries.

Following this foundational explanation, the speaker delves into when neuropsychological assessments are particularly pertinent for patients with neurodegenerative conditions. They highlight how these assessments can clarify diagnoses where there might be ambiguities, such as distinguishing between different forms of dementia, including Alzheimer’s disease and depression, which can present similarly in terms of cognitive decline. The lecture details the process of neuropsychological assessments, which typically extend over two to three hours and involve both clinical interviews and standardized testing aimed at gauging various cognitive functions, such as attention, memory, and executive functioning.

The speaker further explains the significance of these assessments in developing treatment plans and monitoring cognitive changes over time. They elucidate how neuropsychologists contribute to determining the capacity of patients to make decisions, particularly in medico-legal contexts. This includes areas such as financial decision-making and the ability to assign power of attorney, which often arise in discussions regarding end-of-life planning and guardianship. The speaker underscores that a diagnosis of dementia does not inherently equate to a loss of capacity, making individual assessments crucial to understanding each patient's abilities and limitations.

Additionally, the lecture addresses the specific capacity assessments conducted by neuropsychologists, which are tailored to the context of the decision in question. The speaker stresses that capacity is decision-specific and can fluctuate based on various factors, including the progression of a neurodegenerative condition and the individual’s insight into their own cognitive health. They explain the five areas assessed during these evaluations: understanding relevant information, weighing consequences, communicating decisions, and how these insights evolve in the context of patient care.

Concrete case examples illustrate the lecture, highlighting scenarios faced by neuropsychologists. One case describes a 92-year-old woman whose power of attorney came into question due to concerns about her being influenced by another resident in her care facility. The other case discusses an 80-year-old former accountant whose cognitive decline manifested in financial management issues, leading to the involvement of a neuropsychologist to assess his capacity amidst family dynamics. These practical illustrations serve to reinforce the complexities of capacity assessments and their implications for patient welfare.

In conclusion, the speaker reiterates the key takeaways: dementia does not automatically imply a lack of capacity, capacity assessments must be specific and contextual, and the variability of cognitive function necessitates periodic reassessment. Overall, the lecture emphasizes the critical role neuropsychologists play in navigating the intersection of cognitive health, legal capacity, and family dynamics in the context of neurodegenerative diseases.

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Okay, so just to go through what I'm going to be covering in the session today,

I'd like to just briefly talk to you about what neuropsychology is.

I know some of you will be very familiar with neuropsychologists and what we

can offer, but just to cover that in case there's anyone who's not familiar with what we do.

Then I'll talk about when a neuropsychology assessment is useful in patients

with neurodegenerative conditions.

And then I'll talk about medico-legal assessments of capacity.

And I'll focus on sort of the main areas of capacity that we see as neuropsychologists

and cover things like financial capacity and power of attorney,

enduring guardianship,

testamentary capacity, and capacity regarding employment.

And then I'll also talk about when to refer a patient for a neuropsychology

medico-legal assessment. Thank you.

So just very briefly to let you know who I am, so I've been here with Macquarie,

Health Neuropsychology for 15 years.

I do some medico-legal work with a company in Sydney and Canberra.

I've been doing that for the last few years and I was for a good part of my

career at the Neuropsychology Unit at Royal Prince Alfred Hospital where I was

head of the Neuropsychology Unit before I left there.

Okay so just in a

general sense what is neuropsychology so

a clinical neuropsychologist specializes in

the relationship understanding the relationship between

the brain cognitive function and behavior

so we have our training in neuroanatomy and neuropathology and brain function

And we specialize in the understanding of disorders and syndromes of cognition

and behavior that result from neurological illness and injury.

And we also specialize in understanding the effects of other factors on cognition and behavior.

So, for example, depression and how someone with depression,

their cognitive profile can mimic someone with an early dementia.

But we have good ways of distinguishing between those underlying disorders.

Okay, so in terms of what a neuropsychologist actually does,

we conduct assessments using standardized and sensitive tests so we get a good

understanding of the person's cognitive and behavioral function.

We assist with diagnosis, we provide detailed cognitive profiles,

we look at the person's strengths and weaknesses, and we provide strategies,

recommendations, and education, both for the individual and for their families.

In terms of who is referred to a neuropsychologist, we see a range of people

with different underlying conditions, as you can see from the diagram,

but the bulk of the patients that I see and that most neuropsychologists see

are people who have neurological conditions, including neurodegenerative conditions,

and that's what will be the focus of the talk.

So, in terms of what a neuropsychology assessment actually involves when you

refer someone to see a neuropsychologist, it's with the understanding it will

be a lengthy assessment. It's usually two to three hours face-to-face.

It involves a clinical interview and then the standardized testing.

And with the testing, we are looking at all aspects of their brain function and their behavior.

So we're looking at things like their orientation, their attention and concentration,

their learning and memory, their visuospatial skills, language skills,

executive function, so problem solving, reasoning, and so on, and their mood.

So then after the assessment, the neuropsychologist scores up all the testing that's done,

analyzes the test results, looks at the cognitive profile, obtains further history

if necessary, sometimes the person doesn't come with a family member and we

often need to get further history from the appropriate person,

then we write up the report and make the recommendations.

Okay, so in terms of neuropsychology assessments in patients with neurodegenerative conditions,

the way that neuropsychology is useful in these individuals is for diagnosis.

So, for example, as I mentioned, people come to see us because they're worried

about a change in cognition, particularly memory problems, and they might have been to see their GP.

They might have done very well on a mini mental or a cognitive screening test,

but there are issues at work and they're very worried that things are not as good as they should be.

And that would be a good reason to refer them for a neuropsychology assessment.

To get a detailed history, particularly in a high-functioning person,

we can see even a small decline from the level that we would expect them to be performing at.

We also see people where it's clear they have a neurodegenerative condition,

but which neurodegenerative condition it is needs to be determined.

And so distinguishing, for example, Alzheimer's disease from depression or Alzheimer's

disease from vascular dementia or Lewy body, dementia with Lewy bodies or frontotemporal dementia.

Of course, it's important to understand which type of neurodegenerative condition

they have because there's different treatments, courses and expectations for

that individual and their families.

Neuropsychologists can also monitor cognitive and behavioural changes over time.

So that's a good reason to refer someone for an assessment if you want a baseline

and then you want to follow them over time.

Maybe you're looking at whether a treatment has worked and whether their cognition

has remained stable or there have been improvements or decline.

So the neuropsychologist can help the person and their family understand the

changes that occur with their particular neurodegenerative condition,

changes in cognition, changes in behaviour, changes in personality.

Neuropsychologists can contribute to treatment plans. So for people who have

young onset dementia under the age of 65, neuropsychology reports can be very

helpful for an NDIS application to gain appropriate funding.

We can assist with recommending strategies in daily life, recommending support

services, and guidance about employment.

And moving more onto the focus of today, neuropsychologists can provide opinions

regarding capacity and decision-making.

And this is the medico-legal aspect of assessments in patients with different forms of dementia.

Okay, so I guess there are a couple of sort of main points that I thought it

would be important to make.

One is that a diagnosis of dementia doesn't automatically mean that the person lacks capacity.

Sometimes that's what the family think, that he's got a diagnosis of Alzheimer's

disease now, so I think we need to enact the power of attorney and so on.

But actually that issue of capacity needs to be assessed sort of independently

of whether they have that diagnosis or not.

Obviously capacity can change as the disease progresses, so it's not sort of a set and forget.

They might have capacity at one point, you know, in the mild to moderate range

of a dementia. They might lack capacity as the dementia goes on.

Another type of dementia, another individual might actually lack capacity quite

early on in the course of the dementia, perhaps because they lack insight.

So it's very individual.

Another issue is that capacity is decision specific.

So, when individuals get referred for a capacity assessment,

it needs to determine, it needs to be specific about what are we looking at

here. Is it financial capacity?

Is it capacity to make their own health decisions?

Is it capacity to make a will or change a will?

Is it capacity in terms of their work performance? So capacity and these medical

legal assessments of capacity, it's not a blanket, it's not capacity as sort of a blanket term.

It's very decision specific.

So, the assessments that we do, a medico-legal capacity assessment,

we do the normal interview that we would do with someone getting their background,

getting an understanding of what cognitive problems they're having.

But then we also do a very specific capacity assessment, and that depends on the type of capacity.

So, for example, a financial capacity assessment, we go through with them their

understanding of their financial situation or their assets,

what bank accounts they have, what bills are paid.

Like, it's a very detailed but very specific interview and assessment.

And then we do the neuropsychology testing as well.

And we're looking at understanding, we're looking at getting an understanding

of that specific area of capacity,

their level of insight regarding any cognitive decline they have,

and what their cognitive function is like, and specifically what their decision-making

skills are like, what their reasoning

skills are like, and what their learning and memory is like, too.

These types of assessments often involve a separate interview with a family

member and we do that separately so we can determine how accurate they have been.

And sometimes we need to talk to multiple family members because sometimes family

members have differing opinions about what the situation is.

So it's quite an involved assessment.

So, in terms of what we're looking for in these assessments,

looking at capacity in a medico-legal context, we're looking at these five particular areas.

We're looking at, do they understand the facts involved?

Can they understand the main choices they have regarding the capacity,

the decision-specific capacity?

Can they weigh up the consequences of the choices? Can they understand how the

consequences affect them?

And can they communicate their decision?

So sometimes the family are not happy about a particular decision that the person

might have made. But in fact, if they have capacity to make that decision,

they can make that decision.

Okay, so when would you refer an individual with dementia for one of these assessments?

And these are the type of situations where people get referred for this type of assessment.

Often it is the family, they might have a new diagnosis of a neurodegenerative

condition and the family are

wanting to get them to set up a power of attorney or enduring guardian.

And they're wanting to be sure that they have capacity to make that decision.

So to think about who their options are and who the best person or people would be in those positions.

Sometimes it's because the power of attorney and enduring guardian have already

been set up, but the family are now concerned that they need to be enacted,

the enduring power of attorney. So they come for that reason.

Sometimes an individual wants to change a will or instruct a lawyer,

and the family are concerned that they don't have capacity to instruct a lawyer.

So we would see someone for that type of assessment.

You might refer someone because it's become clear that they're becoming very vulnerable.

We often see people who've been exploited and been victim of financial scams

and then the family become aware that actually maybe that person is not managing

their finances well and they haven't realised that large amounts of money have been taken away.

Sometimes it's a good idea to refer to a neuropsychologist for an objective

assessment when the family dynamics are very complex.

An objective assessment can help the family move forward and decide what the best way forward is.

Sometimes the family are worried about coercion

that maybe someone is being pressured to change their

will or you know coercion in

sort of other financial means and it

needs to be determined whether they actually have capacity to do that or not

and then we also see people with these performance issues at work and that can

become medico-legal and really it's to determine if someone has an early stage

of a neurodegenerative condition,

they have often have a high-level job with a lot of responsibility,

perhaps mistakes have been made and it's needing to determine whether they have

capacity to continue working at the level they have been working.

Okay, so in terms of, just I thought I'd give a couple of case examples of the

sorts of people that we see.

These are two real cases that I've just seen recently, actually.

One was a 92-year-old woman who had

a diagnosis of mild Alzheimer's disease

and she'd gone into

residential care after having a fall and she'd been there about six months when

I saw her and she had appointed her two children as her power of attorney and

enduring guardian and they were already managing her finances and helping her

make sort of health decisions they helped her,

make the decision about the residential care

home once she was

in the home the two Two children became very worried

about another resident who seemed to be monopolising

their mother and providing her with a lot of information about a solicitor that

they used and were talking to her a lot about her financial situation and her will.

And this woman had a very large

estate and there was a lot of money

and assets and things tied up in her will

so the children were worried

that their mother could be coerced into talking to a lawyer and perhaps changing

her will and so they organized an assessment for her to look at her level of

cognitive impairment and whether she had capacity to change her will and instruct a lawyer.

The second case I saw recently, it was an 80-year-old man who was previously

an accountant, and he came to me already with a diagnosis of mixed Alzheimer's

disease and vascular dementia.

And his wife actually had become concerned because she said he just seemed to

be a bit confused about the financial situation.

Bills weren't being paid on time. They were getting reminder notices,

which they never had in the past.

He seemed to be having trouble using the computer and internet banking,

but he was quite secretive and he'd always done it.

So she wasn't quite sure how much trouble he was having.

And then he got caught up in a financial scam and that's when she became worried and she wanted to,

she had, they had appointed each other as their power of attorney and she wanted

to enact the power of attorney, and he absolutely did not want to hand that over to her.

He felt that he was still capable and competent, and so he came for an assessment

of his financial capacity as well as a neuropsychology assessment.

So they're the sorts of people who would benefit from the type of medical legal

assessment, capacity assessment that neuropsychologists can offer.

Okay, so the key takeaways.

I guess the main takeaways are that a diagnosis of dementia does not mean the person lacks capacity.

That capacity depends on their ability to reason and make decisions regarding a specific area.

The nature and degree of cognitive impairment

is very important in terms of determining if someone

has capacity and also their level

of insight just a

reminder that capacity is decision specific so if you refer someone for a capacity

assessment the neuropsychologist will be asking is this about what type of capacity

are you looking for is this about financial capacity Is it about can they make

personal and accommodation decisions, health decisions?

Is it about their will? Is it about employment?

The capacity is decision-specific.

And that capacity can change over time in these individuals with neurodegenerative

conditions and having a baseline,

an initial assessment of capacity, that can be reviewed over time because that capacity can change.

Thank you.