The wills of older people: risk factors for undue influence.

BACKGROUND: As people live longer, there is increasing potential for mental disorders to interfere with testamentary distribution and render older people more vulnerable to "undue influence" when they are making a will. Accordingly, clinicians dealing with the mental disorders of older people will be called upon increasingly to advise the courts about a person's vulnerability to undue influence. METHOD: A Subcommittee of the IPA Task Force on Testamentary Capacity and Undue Influence undertook to establish consensus on the definition of undue influence and the provision of guidelines for expert assessment of risk factors for undue influence. RESULTS: International jurisdictions differ in their approach to the notion of undue influence. Despite differences in legal systems, from a clinical perspective, the subcommittee identified some common "red flags" which might alert the expert to risk of undue influence. These include: (i) social or environmental risk factors such as dependency, isolation, family conflict and recent bereavement; (ii) psychological and physical risk factors such as physical disability, deathbed wills, sexual bargaining, personality disorders, substance abuse and mental disorders including dementia, delirium, mood and paranoid disorders; and (iii) legal risk factors such as unnatural provisions in a will, or provisions not in keeping with previous wishes of the person making the will, and the instigation or procurement of a will by a beneficiary. CONCLUSION: This review provides some guidance for experts who are requested by the courts to provide an opinion on the risk of undue influence. Whilst international jurisdictions require different thresholds of proof for a finding of undue influence, there is good international consensus on the clinical indicators for the concept.

Stigma by association and Alzheimer's disease.

Although it is widely assumed that persons with Alzheimer's disease (AD) are victims of stigmatization, little is known about courtesy stigma or stigma by association and AD. Phone interviews were conducted with 61 caregivers of persons with AD in order to assess four dimensions of stigma by association--interpersonal interaction, concealment, structural discrimination and access to social roles. The participants perceived a minimal amount of stigma directed towards themselves but a considerable percentage reported perceptions of stigma regarding the person with AD. Additionally, participants reported high levels of structural discrimination towards the person with AD and towards themselves. It was found that stigma by association related to AD is especially high in dimensions affecting the delivery of services and the lives of the person with AD.

[How do physicians actually write guardianship certificates for elderly patients?].

UNLABELLED: Physicians participate in the legal process of appointing guardianship by writing medical certificates concerning guardianship. There are no instructions or clear-cut methods to examine how to determine a person's ability to handle his own affairs (estate and body), or to evaluate his ability to express his opinion concerning guardianship. There are, however, a number of ways to examine and analyze the subject. Our paper presents findings from 16 randomly collected medical certificates from diverse sources (13 different institutions, physicians from various specialties), for which the courts decision is known. We checked to see if the medical certificates relate to and fulfill basic medico-legal and clinical points referred to in the professional literature. RESULTS: We found that full demographic details were recorded in only one certificate (6.2%), the identity of the solicitor of the certificate was mentioned in 3 cases (18.7%) and the source/s of information in 6 cases (37.5%). Results of complete cognitive/mental examination (mental status) were mentioned in 4 cases (25%), psychiatric diagnoses in 12 cases (75%), level of severity in 9 cases (56.2%), reference to a temporary phenomenon in one case, and evaluation of basic daily functioning in 2 cases (12.5%). None of the cases included more complex daily functioning evaluations (instrumental). Similarly, none of the certificates mentioned whether or not legal criteria were used to evaluate the subjects ability to handle his estate or body or his ability to express his opinion concerning guardianship. On the other hand, formal reference to the ability to handle affairs (in 7 cases [43.7%] distinction between estate and body) and to express an opinion concerning guardianship was noted in 15 cases (93.75%). The length of the medical certificate averaged 13.8 lines (standard deviation 10.1, range 4-41); 13 of the certificates were written in public forums with an average length of 9.9 lines (standard deviation 4.6, range 4-20 lines), as opposed to 31 lines (standard deviation 9.5, range 22-41) for the private sector. Our findings suggest that the medical certificates were lacking in clinical facets examined, especially the medico-legal aspects. Despite these shortcomings, the courts accepted the overwhelming majority of the documents (15/16, 93.7%), perhaps because most of the certificates included formal reference to specific legal questions raised in the court (ability to handle affairs, ability to express opinion concerning guardianship). In our opinion, these findings, if validated in larger groups and in more courts, require multi-system re-evaluation of the subject of writing medical certificates for legal guardianship of the elderly.

Social worker estimations of life span in terminal cancer patients.

The objective of this study was to evaluate the accuracy of the social worker estimation (SWE) of the length of survival of patients who were seen at the end stage of their terminal illness, in home-based palliative care treatment. Estimates were filled out on a form every 2 weeks during the time of the visits until the patient's discharge or death. The wording used by the social worker was the 'average survival period'. Survival was measured from the time of each survival prognostication until death from any cause. Both SWE and actual survival were categorized into 12 weeks. Then, 29 estimates were analyzed using the SPSS statistical software package. The mean and median actual survivals of the total cohort were 6.5 and 5.1 weeks, respectively. The minimum and maximum weeks of actual survival were 0.1 and 23.1, respectively. The mean and median differences between SWE and actual survival were 2.1 and 1.6 weeks, respectively (range: 18.7, minimum and maximum differences of -7.3 and 11.4 weeks, respectively). The Pearson correlation coefficient between actual survival and SWE was 0.827 (P<0.001). Overall, 59% (17/29) were correctly assigned by social worker to the correct survival categories. Our study suggests that the oncology social worker can be a valuable resource for information about the patient's prognosis of life span.

Process and organizational characteristics of memory clinics in Israel: a national survey.

A survey was conducted to describe the characteristics and activities of memory clinics in Israel. A structured questionnaire was mailed to 25 memory clinics, accompanied by a cover letter and a returning envelope. The questionnaire included items regarding: (a) administrative structure of the clinic (the period and place of operation, number of staff and their professions); (b) patients' characteristics (monthly number of patients, sources of referral and eligibility criteria); (c) assessment methods used (history, cognitive screening instruments, functional status assessment, neuroimaging and laboratory tests); (d) the assessment process (length of assessment, family involvement); and (e) outcomes of the assessment process. Twelve questionnaires were returned, yielding a 52% response rate. Overall, there was agreement regarding the general operating characteristics of the clinics. The majority was based on an interdisciplinary team including a physician, a nurse and a social worker. The mean number of new monthly patients attending the clinics was 24 (range 7-70), and the main source of referral was the Sick Funds. Mostly all clinics used the Mini Mental State Examination as a screening instrument and performed psychological, physical, neurological, and laboratory examinations. Medication treatment was the main outcome reported by the clinics. In a country like Israel, where geriatric psychiatry services are still developing, there is an increasing need to expand the number and type of services provided by memory clinics.

Comparison of a clock drawing test in elderly schizophrenia and Alzheimer's disease patients: a preliminary study.

The objective of this study was to compare between the quantitative and qualitative aspects of a clock drawing test in elderly schizophrenic and Alzheimer's disease (AD) patients. Three independent raters performed a retrospective analysis of the clock drawing item from the Cambridge Cognitive Examination (CAMCOG), in long-term open wards of a public psychiatric hospital and an outpatient psychogeriatric clinic. The study group comprised 21 elderly schizophrenic patients ('graduates') and 21 AD patients matched for gender and education, and cognitive impairment confirmed by a Folstein mini-mental state examination (MMSE) score of 18-23. The Clock Drawing Interpretation Scale (CDIS) was the measure used. Schizophrenic patients were significantly younger than AD patients (63.5 versus 81.3 years, p<0.0001), however, similar concerning gender, education, MMSE and CAMCOG scores. CDIS scores were not correlated with age in eight group. Inter-rater reliability was high (range 0.84-0.97). No significant differences between patient groups were found in mean CDIS total scores. A CDIS specific item analysis revealed that schizophrenic patients were significantly less impaired than AD patients on three out of 20 items: Number 7 (most symbols are aligned in a clockwise or a rightward direction). Number 8 (all symbols are totally within a closure figure), and Number 13 (numbers do not go beyond 12). Although schizophrenic patients and AD patients had similar total scores on the clock drawing test, they differed on specific test items related to spatial/planning deficit and preservation.

A comparison between demographic and clinical characteristics of younger and older elderly new referrals to an out-patient psychogeriatric service.

We compared the demographic and clinical characteristics of 37 subjects under and 41 subjects over 75 years of age who were consecutive new referrals to an out-patient psychogeriatric service in order to examine if an age-related dichotomy emerges in this population. Even though the groups were similar in most demographic (gender, education, years in Israel, family status) and some clinical aspects (number of physical diagnoses, medications taken) they differed significantly in some other clinical variables. "Functional" disorders, independence in performing household activities and Activities of Daily Living (ADL) and more recommendations for ambulatory follow-up were more prominent in the younger group. This profile has much in common with elderly patients newly referred to the general mental health services. The older group had more "organic" disorders, significant need for assistance in household activities and ADL, and more recommendations for follow-up in day-care centers, a profile more characteristic of patients who are treated in memory/dementia clinics. Thus, from a services organizational point of view, it is possible to subdivide out-patient elderly individuals with cognitive and emotional disturbances into separate groups, each with its own characteristics and needs.

Clock drawing test: correlation with linear measurements of CT studies in demented patients.

OBJECTIVES: To investigate a presumed correlation between clock drawing ratings and linear measurements of computerized tomography (CT) studies in demented patients. DESIGN: Blinded evaluations of clock drawing tests and CT studies of elderly dementia patients were conducted by a geriatric psychiatrist and a neuroradiologist. SUBJECTS: Fifty-one community-dwelling elderly subjects meeting the criteria for DSM-IV diagnosis of dementia (Alzheimer's type dementia: N=31; vascular dementia: N=15; "mixed" type dementia: N=5). MATERIALS: Mini-Mental State Examination (MMSE), Cambridge Cognitive Examination (CAMCOG), Clinical Dementia Rating (CDR). CAMCOG derived scored clock drawings were evaluated using adaptations of Shulman et al.'s and Freedman et al.'s methods. CT studies were evaluated using six different linear measurements of brain atrophy described in the literature. RESULTS: Of the CT linear measurements, only the Cerebro-Ventricular Index-2 (CVI-2; bicaudate index) significantly correlated with clock drawing ratings (CAMCOG's clock r=-0.407, p=0.003; Shulman's method r=0.357, p=0.01, Freedman's method r=-0.413, p=0.003) in the dementia group. There was no significant correlation between CVI-2 with demographic (age), cognitive (MMSE, CAMCOG) and clinical (duration of illness, CDR) ratings. Alzheimer's patients generally maintained a significant correlation between CVI-2 and clock drawings, but vascular dementia patients did not; CVI-2 also correlated significantly with the Praxis subtest of the CAMCOG in dementia and Alzheimer's patients but not in the vascular dementia group. Similarly, multiple stepwise regression analysis showed that only CVI-2 but not the other radiological measures studied, was selected as the significant variable to correlated with clock drawing test ratings in the dementia group and Alzheimer's patients. Partial correlation analysis controlling for demographic and clinical variables shows that controlled variables had no significant effect on the relationship between clock drawing ratings and CVI-2. CONCLUSION: A single and easy to perform measure of caudate atrophy correlates specifically and consistently with impairments revealed in the clock drawing test and with a Praxis subtest, suggesting possible caudate involvement with clock drawings in dementia in general and of the Alzheimer's type in particular.

The Cambridge Cognitive Examination (CAMCOG): validation of the Hebrew version in elderly demented patients.

BACKGROUND AND PURPOSE: The CAMCOG is the second most popular cognitive testing instrument in use by Israeli clinicians. The present study examines the reliability and validity of a Hebrew version of the CAMCOG in a group of dementia sufferers in a clinical setting. METHOD: Study participants included 36 dementia sufferers and 19 control non-demented, depressed elderly subjects, consecutive referrals to an outpatient psychogeriatric service and an 'open' ward of a psychiatric hospital. Operational clinical criteria for dementia and its subtypes and for the various forms of depression were used as the 'gold' standards. The CAMCOG was translated into Hebrew and then back to English. Seven items needed modifications for local usage. RESULTS: Interrater and test-retest scores calculated as exact agreement rates ranged from good to excellent for all items, although test-retest reliability scores were generally lower than interrater scores. Kappa statistics ranged from good to excellent for all but one item in the interrater scores and for two items in the test-retest scores. A strong convergent validity was found with the MMSE score (r=0.89, p<0.01). The 79/80 cutoff point provided moderate sensitivity (57.9%), excellent specificity (97.2%) and a strong predictive value (83.6%). CONCLUSION: The Hebrew version of the CAMCOG was found to be an appropriate instrument to discriminate between demented and non-demented depressed controls in a clinical setting. In light of the demographic, cultural and linguistic heterogeneity of the Israeli elderly population, further studies should examine the psychometric characteristics of the CAMCOG in a more varied sample and also using other cutoff points in order to establish if an increase in its discriminatory power is obtainable.

Agreement between spouses and children in descriptions of personality change in Alzheimer's disease.

The purpose of the present study was to evaluate the agreement among spouses and children in their describing the current and past personality of patients with Alzheimer's disease (AD) and to determine the relations between their descriptions and selected demographic and clinical variables. The subjects were 22 dementia out-patients who fulfilled the DSM-III-R criteria for uncomplicated dementia of the Alzheimer's type and the NINCDS-ADRDA criteria for AD. Spouses and children of these patients were separately administered Brooks and McKinlay's personality inventory consisting of 18 pairs of adjectives that characterize the extremes of a behavioral dimension, and were asked to judge where the subject's demeanor fell on a five-point scale, varying from +2 to -2, in which zero was regarded as neutral. Spouses and children reported marked changes in most measured behavioral dimensions following the onset of AD. Spouses identified significant changes on 14/18 items and children on 13/18 items. Spouses and children agreed on practically all items concerning personality attributes before the onset of illness, and on 16/18 items after it. Changes in personality were not correlated with the studied demographic characteristics of patients, spouses and children, nor with the cognitive deficits and illness duration of the patients.

'Yes' ifs, ands or buts: examining performance and correlates of the repetition task in the mini-mental state examination.

The aim of this study was to examine whether the type of sentence used in the repetition task included in the Mini-Mental State Examination (MMSE) affected performance in a group of 79 demented and 19 non-demented Hebrew-speaking elderly persons. The cognitive functioning of the participants was assessed using the MMSE and CAMCOG examinations. The performance of the repetition task was evaluated by using three sentences: the literal translation of the English language expression used in the original MMSE; a well-known Hebrew proverb consisting of monosyllabic words and rhythmic effects; and another well-known Hebrew proverb without such attributes. Only a third of the participants successfully repeated the literally translated expression. It showed low predictive value and was highly affected by education. The well-known Hebrew monosyllabic proverb showed moderate predictive value but no discriminatory ability. The other well-known Hebrew proverb performed the best. The translation of the repetition task in the MMSE to other languages is problematic. Strict adherence to the original language proved to be the least desirable choice.

Supportive telephone outreach as an interventional strategy for elderly patients in a period of crisis.

During the Gulf War in 1991 a telephone-based support system was established for elderly patients living at home in Israel. The study population involved 93 elderly patients (mean age 74), who had recently been discharged from hospital and were chosen for supervision by the Home-Care Unit of the Tel Aviv Sourasky Medical Center, Israel. Two different teams were involved with the telephone support calls: secretarial staff (nonprofessional team) and social workers (professional team). The research examined the characteristics of the study population and also included a comparison between the two groups of patients receiving the psycho-social support. The latter indicated that better results of outcome indices were achieved by the professional team. Further, this study demonstrated the feasibility of telephone-support outreach as an interventional strategy for psycho-social support for elderly patients at a time of crisis.

How do cognitively impaired elderly patients define "testament": reliability and validity of the testament definition scale.

The testament definition scale (TDS) is a specifically designed six-item scale aimed at measuring the respondent's capacity to define "testament." We assessed the reliability and validity of this new short scale in 31 community-dwelling cognitively impaired elderly patients. Interrater reliability for the six items ranged from .87 to .97. The interrater reliability for the total score was .77. Significant correlations were found between the TDS score and the Mini-Mental State Examination (MMSE) and the Cambridge Cognitive Examination scores (r = .71 and .72 respectively, p = .001). Criterion validity yielded significantly different means for subjects with MMSE scores of 24-30 and 0-23: mean 3.9 and 1.6 respectively (t(20) = 4.7, p = .001). Using a cutoff point of 0-2 vs. 3+, 79% of the subjects were correctly classified as severely cognitively impaired, with only 8.3% false positives, and a positive predictive value of 94%. Thus, TDS was found both reliable and valid. This scale, however, is not synonymous with testamentary capacity. The discussion deals with the methodological limitations of this study, and highlights the practical as well as the theoretical relevance of TDS. Future studies are warranted to elucidate the relationships between TDS and existing legal requirements of testamentary capacity.

Examining the reliability and validity of the Hebrew version of the Mini Mental State Examination.

The Mini Mental State Examination is used worldwide for the screening and diagnosis of dementia. The aim of the present study was to examine the reliability and validity of the Hebrew version of the Mini Mental State Examination. The Hebrew version of the Mini Mental State Examination was administered to 36 demented and 19 non-demented elderly persons. Test-retest reliability scores were calculated as exact agreement rates, and ranged from good to excellent for all the items. Strong convergent validity, as measured by the correlation between the MMSE and the CAM-COG (r = 0.94), was found. Good predictive value was observed as over three-quarters of the participants were correctly classified as demented or non-demented. The Hebrew version of the MMSE was found to be a useful and valid instrument for the determination of dementia in the elderly population.

Accuracy of recall memory in elderly patients in response to telephone support calls.

During the Gulf War, 93 elderly patients (mean age 74 years) received telephone-based support calls from a hospital-based home care facility. Accuracy of memory recall of these telephone support calls was assessed 6 weeks after the termination of the war by means of a postal questionnaire. The relative accuracy of the recall memory of these patients or their caregivers to the telephone calls received exhibited a sensitivity of 75%, a specificity of 78%, a positive predictive value of 60% and a negative predictive value of 88%. Patients who had received four calls demonstrated better memory recall than those receiving less than four. Thus, relying upon patient's memory alone may be insufficient for evaluating survey data in the elderly. In addition, we found that only patients who correctly remembered receiving four individual telephone support calls tended to exhibit a decrease in the anxiety level. This study emphasizes the importance of repeated interventional telephone calls as a method of increasing recall accuracy and decreasing anxiety in aged patients.

Effects of trihexyphenidyl on MMSE and CAMCOG scores of medicated elderly patients with schizophrenia.

The purpose of this study was to assess the effects of an anticholinergic (trihexyphenidyl) antiparkinsonian medication on the Mini-Mental State Examination (MMSE) and the Cambridge Cognitive Examination (CAMCOG) scores in long-term institutionalized elderly patients with schizophrenia. Seventeen schizophrenic (DSM-III-R) inpatients on long-term medication who had received trihexyphenidyl for at least 6 consecutive months were compared for MMSE scores, CAMCOG scores, and other demographic and clinical variables with 14 patients not receiving any anticholinergic agent for the same time period. Results showed that age, years of education, illness duration, length of current hospital stay, the Manchester Scale scores, and chlorpromazine daily equivalent dose in mg were not different in the two groups compared. Extrapyramidal signs such as tremor, rigidity, and bradykinesia were more frequent in trihexyphenidyl receivers. The scores of MMSE (p < .007) and CAMCOG (p < .005) and CAMCOG subscales of orientation (p < .03), language (p < .01), and memory (p < .002) were significantly lower among trihexyphenidyl receivers, as was the Social and Occupational Functioning Assessment Scale score (p < .05). In addition, the MMSE and CAMCOG scores were significantly lower for patients receiving 10 mg of trihexyphenidyl a day compared with those receiving 5 mg/day and nonusers. It is suggested that trihexyphenidyl in usual clinical doses may impair total MMSE and CAMCOG scores as well as some of the CAMCOG subscales in this patient population. However, only a prospective study, preferably double-blind and controlled, with measures of change will validate this conclusion.