Awareness of financial skills in dementia

Self-awareness for financial decision-making abilities in healthy adults

Objective

Decades of research have established how to measure metacognition (i.e., awareness of one’s cognitive abilities), whereas relatively little is known about how to assess the integrity of financial awareness (FA; awareness of one’s financial abilities), a related construct with practical implications for vulnerable older adults. The current study’s goal was to apply established metacognitive frameworks to identify an objective measure of FA.

Methods

Metacognitive ratings were integrated into two financial decision making (FDM) assessments in order to derive two types of FA metrics: absolute accuracy (calibration) and relative accuracy (resolution) in each FDM task. Associations between each FA metric, demographic variables, FDM performances, and metamemory were examined.

Design & setting

Cross-sectional, community-based, prospective study.

Participants

93 individuals with mean age = 59 years (SD = 15.12); mean education = 15.70 (SD = 2.39); 60% females.

Measures

FA was calculated using the Financial Competency Assessment Inventory (FCAI) and Decision Making Competence Assessment Tool, Finance Module (DMC-F), and memory awareness was calculated using an objective metamemory test.

Results

None of the FA metrics was associated with age, education or gender. FCAI calibration was inversely associated with FDM, and positively correlated with DMC-F calibration and metamemory calibration. None of the FA metrics for DMC-F was associated with metamemory.

Conclusions

Mirroring findings from metamemory studies, overconfidence in FDM was associated with lower FDM accuracy in healthy adults. Moreover, calibration scores on the FCAI and metamemory were related, suggesting that FA taps into metacognitive abilities. Our findings provide preliminary evidence for how to measure FA in both clinical and research contexts.

The Screening Utility and Ecological Validity of the Neuropsychological Assessment Battery Bill Payment Subtest in Older Adults with and without Dementia

Objective

The Neuropsychological Assessment Battery Bill Payment subtest has shown strong diagnostic accuracy in dementia due to Alzheimer’s disease (AD) versus non-AD. Its relationship to mild cognitive impairment (MCI) or all-cause dementia has not been fully examined nor has its ecological validity as a proxy of financial independence.

Method

We describe 270 women (63%) and men (age = 72 ± 8.39) who completed Bill Payment during outpatient neuropsychological evaluation. Seventy-one were cognitively normal (CN), 160 had MCI, and 39 had Dementia. Two hundred fourteen were independent in money management, 31 were assisted (had oversight/some help), and 25 were dependent (relied on others). Receiver operating characteristic (ROC) curves tested Bill Payment’s utility as a dementia screen. Kruskal–Wallis tests examined whether Bill Payment differed by levels of financial independence.

Results

At a cutoff of 17, Bill Payment had strong sensitivity (0.87) and specificity (0.80) for dementia versus CN cases. A cutoff of 15 distinguished dementia from MCI (Sn = 0.64, Sp = 0.85), whereas a cutoff of 16 distinguished dementia from functionally unimpaired cases (MCI + CN) with greater sensitivity and similar specificity (Sn = 0.74, Sp = 0.81). Sensitivity attenuated in MCI versus CN cases (Sn = 0.46, Sp = 0.83). Those who were independent in money management had higher scores than assisted and dependent cases (p ≤ 0.046). Assisted and dependent cases were no different (p > 0.05).

Conclusions

Bill Payment is a valid screen of all-cause dementia. Lower Bill Payment scores may mark subtle functional decline beyond cognitive impairment alone. Specifically, results provide preliminary evidence of Bill Payment’s ecological validity as a measure related to financial independence. It may prove useful when impaired financial abilities are suspected but unreported.

Assessment of financial decision making: an informant scale

Older adults with cognitive impairment are a population at great risk for financial exploitation. At-risk older adults often have difficulty reporting on their own financial abilities. Collecting information from trusted others is vital for professionals investigating the financial exploitation older adults. There are few reliable, valid, and standardized informant-report measures of financial capacity, and none that assess decisional abilities for an ongoing, real-world financial transaction. The present study sought to examine the psychometric properties of a new informant-report scale of financial decisional abilities in older adults. One hundred fifty participants were recruited to complete the Family and Friends and Interview regarding a known older adult's financial decisional abilities. A factor analysis identified two subscales. The full scale had adequate sensitivity and specificity to detect an informant's current concerns regarding financial exploitation. The Family and Friends Scale is a useful tool for collecting informant-report regarding an older adult's ability to make financial transactions.

Systematic Review of Measurement Property Evidence for 8 Financial Management Instruments in Populations With Acquired Cognitive Impairment

OBJECTIVES

To critically appraise the measurement property evidence (ie, psychometric) for 8 observation-based financial management assessment instruments.

DATA SOURCES

Seven databases were searched in May 2015.

STUDY SELECTION

Two reviewers used an independent decision-agreement process to select studies of measurement property evidence relevant to populations with adulthood acquired cognitive impairment, appraise the quality of the evidence, and extract data. Twenty-one articles were selected.

DATA EXTRACTION

This review used the COnsensus-based Standards for the selection of health Measurement Instruments review guidelines and 4-point tool to appraise evidence. After appraising the methodologic quality, the adequacy of results and volume of evidence per instrument were synthesized. Measurement property evidence with high risk of bias was excluded from the synthesis.

DATA SYNTHESIS

The volume of measurement property evidence per instrument is low; most instruments had 1 to 3 included studies. Many included studies had poor methodologic quality per measurement property evidence area examined. Six of the 8 instruments reviewed had supporting construct validity/hypothesis-testing evidence of fair methodologic quality. There is a dearth of acceptable quality content validity, reliability, and responsiveness evidence for all 8 instruments.

CONCLUSIONS

Rehabilitation practitioners assess financial management functions in adults with acquired cognitive impairments. However, there is limited published evidence to support using any of the reviewed instruments. Practitioners should exercise caution when interpreting the results of these instruments. This review highlights the importance of appraising the quality of measurement property evidence before examining the adequacy of the results and synthesizing the evidence.

Instruments for evaluating financial management capacity among the elderly: an integrative literature review

Abstract Objective: To identify tools available in literature for assessing the financial management capacity of elderly persons with and without cognitive deficit or impairment. Methods: An integrative literature review was performed. Scientific publications indexed in the PubMed, LILACS (Latin American and Caribbean Health Sciences Literature), Psychology Index and Cochrane Library databases by November 2015 were evaluated. Results: Of the 609 articles obtained from the databases, 29 were considered eligible for this review, and involved 11 instruments for the evaluation of financial management capacity, the most cited of which was the Financial Capacity Instrument (FCI). Conclusion: There are several scales and instruments available which are used to investigate both daily and instrumental activities of daily living, which allow the independence and effective functioning of the elderly on a day to day basis to be verified. Non-Brazilian literature also describes specific instruments for the assessment of financial management capacity. However, no references to a specific scale that evaluates this construct and which has been validated and adapted for the Brazilian population were identified.

Assistive technology for memory support in dementia

BACKGROUND

The sustained interest in electronic assistive technology in dementia care has been fuelled by the urgent need to develop useful approaches to help support people with dementia at home. Also the low costs and wide availability of electronic devices make it more feasible to use electronic devices for the benefit of disabled persons. Information Communication Technology (ICT) devices designed to support people with dementia are usually referred to as Assistive Technology (AT) or Electronic Assistive Technology (EAT). By using AT in this review we refer to electronic assistive devices. A range of AT devices has been developed to support people with dementia and their carers to manage their daily activities and to enhance safety, for example electronic pill boxes, picture phones, or mobile tracking devices. Many are commercially available. However, the usefulness and user-friendliness of these devices are often poorly evaluated. Although reviews of (electronic) memory aids do exist, a systematic review of studies focusing on the efficacy of AT for memory support in people with dementia is lacking. Such a review would guide people with dementia and their informal and professional carers in selecting appropriate AT devices.

OBJECTIVES

Primary objectiveTo assess the efficacy of AT for memory support in people with dementia in terms of daily performance of personal and instrumental activities of daily living (ADL), level of dependency, and admission to long-term care. Secondary objectiveTo assess the impact of AT on: users (autonomy, usefulness and user-friendliness, adoption of AT); cognitive function and neuropsychiatric symptoms; need for informal and formal care; perceived quality of life; informal carer burden, self-esteem and feelings of competence; formal carer work satisfaction, workload and feelings of competence; and adverse events.

SEARCH METHODS

We searched ALOIS, the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), on 10 November 2016. ALOIS is maintained by the Information Specialists of the CDCIG and contains studies in the areas of dementia prevention, dementia treatment and cognitive enhancement in healthy people. We also searched the following list of databases, adapting the search strategy as necessary: Centre for Reviews and Dissemination (CRD) Databases, up to May 2016; The Collection of Computer Science Bibliographies; DBLP Computer Science Bibliography; HCI Bibliography: Human-Computer Interaction Resources; and AgeInfo, all to June 2016; PiCarta; Inspec; Springer Link Lecture Notes; Social Care Online; and IEEE Computer Society Digital Library, all to October 2016; J-STAGE: Japan Science and Technology Information Aggregator, Electronic; and Networked Computer Science Technical Reference Library (NCSTRL), both to November 2016; Computing Research Repository (CoRR) up to December 2016; and OT seeker; and ADEAR, both to February 2017. In addition, we searched Google Scholar and OpenSIGLE for grey literature.

SELECTION CRITERIA

We intended to review randomised controlled trials (RCTs) and clustered randomised trials with blinded assessment of outcomes that evaluated an electronic assistive device used with the single aim of supporting memory function in people diagnosed with dementia. The control interventions could either be 'care (or treatment) as usual' or non-technological psychosocial interventions (including interventions that use non-electronic assistive devices) also specifically aimed at supporting memory. Outcome measures included activities of daily living, level of dependency, clinical and care-related outcomes (for example admission to long-term care), perceived quality of life and well-being, and adverse events resulting from the use of AT; as well as the effects of AT on carers.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all titles and abstracts identified by the search.

MAIN RESULTS

We identified no studies which met the inclusion criteria.

AUTHORS' CONCLUSIONS

This review highlights the current lack of high-quality evidence to determine whether AT is effective in supporting people with dementia to manage their memory problems.

Executive Dysfunction Following Critical Illness: Exploring Risk Factors and Management Options in Geriatric Populations

Cognitive impairment is a common occurrence that has been shown to occur in over 50 % of patients following critical illness. This impairment occurs across a range of domains including attention, memory, processing speed, and executive dysfunction. In this article, we will discuss the pathophysiology behind cognitive impairment including hypoxemia and cytokines. Secondly, we will describe the risk factors for cognitive impairment including age, length of stay, and delirium. Lastly, we will review emerging data related to the use of cognitive rehabilitation, formation of postintensive care clinics in qualifying patients, and potential neuropharmacologic therapy. While our chapter focuses on cognitive impairment generally, it places a particular emphasis on executive dysfunction, not because impairment occurs solely in this domain but because impairments of an executive nature may be uniquely debilitating.

[In Process Citation]

The accelerated aging of the Canadian population is a recognized fact and leads to an increasing number of seniors with cognitive impairments (Curateur public du Québec, 2010a). This has a definite impact on health professionals who have to assess their competency to live independently and manage their finances. This decision, which has important consequences for the person, must be based on an objective and rigorous assessment. The purpose of this paper is to analyse the available tools, both in the scientific literature and in clinical settings, to better document the various components to assess seniors' competency to live independently and manage their finances. The goal is to help practitioners who work with older people with cognitive impairments to accurately assess their ability to manage themselves and their property. A review of the relevant literature and training available, as well as three group consultations, showed that there is no consensus about the tools used to assess the capacity to take care of oneself and one's property. Additional studies are thus needed to fill the gap in knowledge about specific tools used to assess competency.

'She's usually quicker than the calculator': financial management and decision-making in couples living with dementia

This article explores how married couples managed their finances and made financial decisions when one spouse had dementia, drawing comparisons with the approaches used prior to the illness. More specifically, the article examines the role of social factors in influencing the involvement of people with dementia in financial management and decision-making, particularly whether a gender dynamic adopted earlier in a marriage similarly influenced a gendered approach following dementia. The research formed part of a larger study of everyday decision-making by couples living with dementia which explored the role of non-cognitive factors in influencing whether people with dementia were involved in decision-making processes. Twenty-one married couples living at home took part; the recently-diagnosed were excluded. Qualitative methods -including participant observation and interviews - were used to examine the couples' fiscal management and decision-making-processes, the perceptions of people with dementia and their spouses about their current financial abilities and whether any support provided by spouse-carers influenced their partners' financial capacity. The fieldwork was undertaken in the North of England between June 2010 and May 2011. Thematic analysis of the data showed that social factors influenced the perceived capacity of people with dementia and the financial practices adopted by the couples. In particular, gender influenced whether people with dementia were involved in financial decisions. The research demonstrated that non-cognitive factors need to be taken into account when assessing and facilitating the capacity of people with dementia. In addition, as people with dementia were somewhat marginalised in decisions about designating financial authority (Lasting Power of Attorney), spouse-carers may need guidance on how to undertake advance care planning and how to support their relatives with dementia in major decision-making, particularly when there are communication difficulties.

Dementia Risk and Financial Decision Making by Older Households: The Impact of Information

The knowledge and reasoning ability needed to manage one's finances is a form of human capital. Alzheimer's disease and other dementias cause progressive declines in cognition that lead to a complete loss of functional capacities. In this paper we analyze the impact of information about cognitive decline on the choice of household financial decision-maker. Using longitudinal data on older married couples in a novel application of survival analysis, we find that as the financial decision maker's cognition declines, the management of finances is eventually turned over to his cognitively intact spouse, often well after difficulties handling money have already emerged. However, a memory disease diagnosis increases the hazard of switching the financial respondent by over 200 percent for couples who control their retirement accounts, like 401(k) accounts, relative to those who passively receive retirement income. This finding is consistent with a model of the value of information: households with the most to gain financially from preparation are most responsive to information about cognitive decline.

Poor decision making is a consequence of cognitive decline among older persons without Alzheimer's disease or mild cognitive impairment

OBJECTIVE

Decision making is an important determinant of health and well-being across the lifespan but is critical in aging, when many influential decisions are made just as cognitive function declines. Increasing evidence suggests that older adults, even those without dementia, often make poor decisions and are selectively vulnerable to scams. To date, however, the factors associated with poor decision making in old age are unknown. The objective of this study was to test the hypothesis that poor decision making is a consequence of cognitive decline among older persons without Alzheimer's disease or mild cognitive impairment.

METHODS

Participants were 420 non-demented persons from the Memory and Aging Project, a longitudinal, clinical-pathologic cohort study of aging in the Chicago metropolitan area. All underwent repeated cognitive evaluations and subsequently completed assessments of decision making and susceptibility to scams. Decision making was measured using 12 items from a previously established performance-based measure and a self-report measure of susceptibility to scams.

RESULTS

Cognitive function data were collected over an average of 5.5 years prior to the decision making assessment. Regression analyses were used to examine whether the prior rate of cognitive decline predicted the level of decision making and susceptibility to scams; analyses controlled for age, sex, education, and starting level of cognition. Among 420 persons without dementia, more rapid cognitive decline predicted poorer decision making and increased susceptibility to scams (p's<0.001). Further, the relations between cognitive decline, decision making and scams persisted in analyses restricted to persons without any cognitive impairment (i.e., no dementia or even mild cognitive impairment).

CONCLUSIONS

Poor decision making is a consequence of cognitive decline among older persons without Alzheimer's disease or mild cognitive impairment, those widely considered "cognitively healthy." These findings suggest that even very subtle age-related changes in cognition have detrimental effects on judgment.

Delirium: an emerging frontier in the management of critically ill children

Delirium is a syndrome of acute brain dysfunction that commonly occurs in critically ill adults and most certainly is prevalent in critically ill children all over the world. The dearth of information about the incidence, prevalence, and severity of pediatric delirium stems from the simple fact that there have not been well-validated instruments for routine delirium diagnosis at the bedside. This article reviewed the emerging solutions to this problem, including description of a new pediatric tool called the pCAM-ICU. In adults, delirium is responsible for significant increases in both morbidity and mortality in critically ill patients. The advent of new tools for use in critically ill children will allow the epidemiology of this form of acute brain dysfunction to be studied adequately, will allow clinical management algorithms to be developed and implemented following testing, and will present the necessary incorporation of delirium as an outcome measure for future clinical trials in pediatric critical care medicine.

Awareness of social and emotional functioning in people with early-stage dementia and implications for carers

OBJECTIVES

This study explores the extent to which awareness of social and emotional function is reduced in early-stage dementia and whether this relates to the quality of life of the person with dementia (PwD), the quality of the relationship between the PwD and carer and carer stress.

METHOD

Ninety-seven participants with a diagnosis of Alzheimer's, vascular or mixed dementia rated their social functioning using the Socio-Emotional Questionnaire (SEQ). Carers provided parallel ratings, allowing calculation of discrepancy scores used to index awareness. Neuropsychiatric symptoms, PwD quality of life, the perceived quality of the relationship for both partners and carer stress were also measured.

RESULTS

Factor analysis of the SEQ indicated three domains of social functioning: emotional recognition and empathy (ERE), social relationships (SR) and prosocial behaviour (PB). For PwD unawareness was related to cognitive dysfunction and psychiatric disturbance, but not to quality of life or quality of relationship. Lower awareness was associated with greater carer stress and poorer perceived quality of relationship.

CONCLUSION

Lack of awareness of social functioning had important implications for relationship quality and levels of carer stress.

Finances in the older patient with cognitive impairment: "He didn't want me to take over"

Financial capacity can be defined as the ability to independently manage one's financial affairs in a manner consistent with personal self-interest. Financial capacity is essential for an individual to function independently in society; however, Alzheimer disease and other progressive dementias eventually lead to a complete loss of financial capacity. Many patients with cognitive impairment and their families seek guidance from their primary care clinician for help with financial impairment, yet most clinicians do not understand their role or know how to help. We review the prevalence and impact of diminished financial capacity in older adults with cognitive impairment. We also articulate the role of the primary care clinician, which includes (1) educating older adult patients and their families about the need for advance financial planning; (2) recognizing signs of possible impaired financial capacity; (3) assessing financial impairments in cognitively impaired adults; (4) recommending interventions to help patients maintain financial independence; and (5) knowing when and to whom to make medical and legal referrals. Clearly delineating the clinician's role regarding identification of financial impairment could establish for patients and families effective financial protections and limit the economic, psychological, and legal hardships of financial incapacity on patients with dementia and their families.

Delirium: an emerging frontier in the management of critically ill children

The objectives of this article are (1) to introduce pediatric delirium and provide understanding of acute brain dysfunction with its classification and clinical presentations (2) to understand how delirium is diagnosed and discuss current modes of delirium diagnosis in the critically ill adult population and translation to pediatrics (3) to understand the prevalence and prognostic significance of delirium in the adult and pediatric critically ill population (4) to discuss the pathophysiology of delirium as currently understood, and (5) to provide general management guidelines for delirium.

Assessment of decision-making capacity in older adults: an emerging area of practice and research

The convergence of the aging of our society, the increase in blended families, and an enormous intergenerational transfer of wealth has greatly expanded the incidence and importance of capacity assessment of older adults. In this article we discuss the emergence of capacity assessment as a distinct field of study. We review research efforts in two domains: medical decision-making capacity and financial capacity. Existing research in these two areas provides a first pass at many key questions related to capacity assessment, but additional studies that replicate, extend, and improve on this research are urgently needed. An agenda for future is detailed that recommends studies of a wide range of capacity constructs, focusing on clinical markers of diminished capacity, methods to improve clinical assessment, and the many intersections of law and clinical practice.

The use of everyday technology by people with dementia living alone: mapping out the difficulties

While the technological development available to society is taking quantum leaps, we have little knowledge of how people with mild dementia manage to cope with familiar technology at home, such as television and electronic household machines, or new technology, such as remote controls, cell phones and computers. As this technology represents a potential problem area, the aim of this qualitative, exploratory study was to identify and characterize difficulties with and hindrances to using everyday technology, as they appeared in data, for persons with early stage dementia. Eight participants with dementia were included in an extensive data collection consisting of repeated interviews and observations made in the home; the data were analyzed adopting a constant comparative approach. The results exhibit a taxonomy of difficulties in four domains, encompassing conditions that interfere with the use of the technology, deficiencies in knowledge and in the communication between users and their technology, and limitations in the use of instructions. Typically, difficulties appeared in complex combinations. They arose when familiar technology was being used, and not only when new technology was to be used. This raised concerns about the need these people have for support in home and in society. Further research is needed to validate the findings.

An integrated biopsychosocial approach to understanding awareness deficits in Alzheimer's disease and brain injury

Considerable emphasis has been placed upon cognitive neuropsychological explanations of awareness disorders in brain injury and Alzheimer's disease (AD), with relatively few models acknowledging the role of psychosocial factors. The present paper explores clinical presentations of unawareness in brain injury and AD, reviews the evidence for the influence of psychosocial factors alongside neuropsychological changes, and considers a number of key issues that theoretical models need to address, before going on to discuss some recently-developed models that offer the potential for developing a comprehensive biopsychosocial account. Building on these developments, we present a framework designed to assist clinicians to identify the specific factors contributing to an individual's presentation of unawareness, and illustrate its application with a case example.

Interpreting patient/informant discrepancies of reported cognitive symptoms in MS

Although numerous studies have shown that brain-damaged patients tend to underestimate neuropsychological (NP) impairment when self-ratings are compared to informant ratings, the meaning of such discrepancies is not well studied in multiple sclerosis (MS). We compared patient self- and informant-report questionnaire ratings of NP functioning in 122 MS patients and 37 age- and education-matched normal controls. In addition to completing the Multiple Sclerosis Neuropsychological Questionnaire (MSNQ), participants underwent NP testing and assessment of depression, personality, and neuropsychiatric symptoms. Based on the normal distribution of discrepancy scores, patients were classified according to whether they overestimated or underestimated their cognitive ability, relative to informant ratings. ANOVAs comparing test scores derived from overestimators, underestimators, and accurate estimators were significant for multiple measures of cognitive function, depression, personality, and neuropsychiatric symptoms. Overestimators were characterized by less depression and conscientiousness, and greater degrees of cognitive impairment, euphoric behavioral disinhibition, and unemployment as compared to underestimators. We conclude that patient/informant discrepancy scores on the MSNQ are associated with the aforementioned neuropsychiatric features, and that the MSNQ has potential utility for predicting euphoria and disinhibition syndromes in MS.