What’s the test for determining capacity?

[threshhold]

I’m a little concerned about a family friend who has been diagnosed with dementia. His short term memory is quite poor but he lives independently (with family support) and seems to function reasonably well. He enjoys watching films, communicated sending text messages and has clear recall
of people and things - just gets stuck mostly on short term memory issues. His son is an attorney on his LPA but his son seems desperate to get financial control - has talked of ‘downsizing’ his father’s house and taking control over where his father lives. His father has said he does not want to move (and has told me the same on multiple occasions). Obviously at some point, a move will be necessary but right now, our friend is clear of his wishes although there’s no doubt it sounds as though his son is applying subtle pressure.

The son took his father to the GP last week and I’m just wondering what the threshold is for a GP to state someone doesn’t have capacity? Could the son realistically get LPA at this stage?

Capacity depends on the decision, it isn't really a yes or no.

But the situation you describe is hard. If the person has dementia then any move will be discombobulating, so the question is whether to do it earlier while the person can still maybe manage to adjust, or leave it as long as possible.

My understanding is that people retain their rights to make bad decisions but they must understand the potential consequences.

With my DPs we have spent two years going at their pace, but it has meant at times considerable fire fighting which could have been avoided if we had been able to be more proactive.

To be honest and with the benefit of hindsight, DSis and I should have encouraged our parents to downsize and move much earlier - or at least tried harder to start the conversation when DF was diagnosed with Alzheimers.

Barriers to that approach were our lack of understanding of how utterly and completely awful Alzheimers can be, my DM's complete denial of the diagnosis and continued pretence that everything was ok when it wasn't, and my DF's inability even to remember that he had Alzheimers!

If the son is shouldering what will be an increasing burden of care and responsibility as his DF continues to decline, then I can understand why he is encouraging a move sooner rather than later.

Your friend is currently as well as he will ever be, and will continue to decline. Planning for the future is sensible.

The mental capacity act is the law that governs.

If the son already has LPA (finance or health or both?) then the father clearly wants the son to act in his behalf when he can’t for himself. The question becomes when does the father lose capacity for making a decision and when does the LPA kick in. That’s what the MCA governs and there is a 4 step ‘proof’ if you like. Everyone must be deemed to have capacity unless they are proven not to via the mental capacity act and that must be clearly documented.

otherwise within retained capacity, everyone can make an unwise decision even if others disagree with it.

As the first response says, capacity isn't a one size fits all measurement. Somebody can have the capacity to decide what they want for dinner, if they want to take a medication or if they want to move into a care home. It they may fall somewhere between these three. So the GP won't give a yes/no answer to the question, and may recommend a referral to adult social services.

There is a disorder of mind or brain, so it is possible that mental capacity for some decisions is affected some of the time.

I wonder what the family support that allows this gentleman to continue to live in his own home looks like?

If he were asked ‘where do you want to live’ I’m sure he would say ‘I’d like to stay in his house’. Suppose his son were not able to visit any more (eg psychiatric breakdown, or had a stroke himself) what would he say then? Would he recognise and be able to describe what his son does to help him? Does he consider that help essential, or just a nice visit that sometimes includes a bit of help? Is he able to describe how he would manage whatever the son does without him? What risks would that involve? What does the son think he is doing, and what would he be worried about if he didn’t go over and do it any more?

It’s not rocket science, but it’s also not straightforward. And I wouldn’t be too quick to assume the son wants financial control in a negative sense. I work with vulnerable older people and eg battling with literally constant scam calls to the landline, or the endless ‘just five pounds a month will save this puppy’ adverts on daytime tv, or scammers knocking on the door, is a worry. People with dementia may end up with multiple direct debits they have no idea they started.

I don’t see much wrong with the proposal actually, it’s often for the best even if the person doesn’t agree. It’s hard for older people to accept change and far too many of them don’t downsize when they really should which ultimately makes their lives more difficult longer term.

my understanding is having capacity is having the ability to understand the consequences of actions / inactions and decisions. It's usually determined by a GP but many GPs don't have sufficient training specifically in this to understand how to establish it. A clinical neuropsychologist who focussed in this area would be better trained to establish it.

Four steps

1. ability to understand the information presented ie. housing options and why family think moving would be a good idea
2. retain the information (might be an issue if short term memory is poor)
3. weigh the information (you can't do this if you can't remember the options you are meant to be choosing between)
4. communicate the decision.

As someone who has recently had to overrule wishes about residence know that for the vast majority of families /carers this isn't an easy thing to do. (Elderly Person I Care For - EPICF)

In my case EPICF wouldn't accept factual information about what was happening at home (cooker being left on etc) and kept dismissing it as lies/ exaggeration (in fact I was very careful to never exaggerate the truth was shocking enoughh). When presenting options it rapidly became apparent they couldn't actually remember the first of the two you presented.

So there was no way for them to weigh a decision as they had dismissed most of the factual information as lies and then forgotten the first option!

Their friends were initially unsupportive of me and stirred up discontent in EPICF. In the end my fellow attorney and I offered to arrange for an independent capacity assessment (we both assess capacity in our professional roles but felt the need to cover our backs). In the event EPICF decided that they weren't going to insist on that as being told they didn't have capacity was too depressing. This was all fairly unpleasant.

Same friend then expressed great suprise when the dementia diagnosis was made public (despite me telling them for ages that EPICF was impaired) and tried to tell me it must be wrong.

I am well aware that outsiders can provide useful checks and balances and that elder abuse does happen. But more commonly I'd say the insiders simply have a better picture of what is going on.

My story has a happy ending. EPICF is very happy in their new residential placement and has told me so and how safe and free from worry they are. I'm also no longer on the verge of a breakdown trying to balance all their stuff with my own job and life.

Downsizing now would probably be a good idea, before it's too late for him to manage.

My mum was adamant that she wasn't moving (from a 3 bed house to a small 2 bed bungalow). She eventually agreed and a few years later, it is a good job she did as her mobility has now declined, she is having regular falls and can't manage stairs. She would not have been able to use the bathroom or bedroom in the old house and wouldn't have been safe upstairs, even with a stairlift to get her up there. Plus the upkeep would be too much now.

The son may be 'desperate' to get financial control because his father is incapable of dealing with his finances. My mother had dementia and it was one of the first things my mother lost the ability to do. So bills went unpaid and I had to step in as her attorney. As a family friend you cannot know how able the father is, people with dementia can still be able to do some things well and other things hardly at all.

People with dementia always want to stay in their own home because it is familiar. They express this wish far beyond the time when it is safe and for them to do so, my mother was still saying it when I had to move her to a care home for her own safety.

Personally I wouldn't 'downsize' someone with dementia, because they are likely to need a care home at some point and that means the hassle of two property sales and two moves for the person. But there may be circumstances for this family which make it a feasible option.

Not the point, I know, but my DM (with dementia) moved to a care home before the DoL requirement was enforced, so despite an informal SW visit arranged by the care home first, nobody had officially checked that her liberty was being wrongly curtailed.

Roll on nearly 8 years, and I was actually at Wimbledon when I had a phone call from an ‘independent social worker’ who said that she and a psychologist or psychiatrist would be visiting DM to ascertain that she needed to be in the sort of care home she couldn’t just walk out of.

Well, good luck with that, I said, since DM was long past the stage of being able to hold any sort of intelligible conversation.

Some weeks later the SW phoned to tell me that she and the psych. were satisfied that the placement was in order.

‘Thank you, but she died 3 weeks ago.’

I actually felt a bit sorry for her, she was evidently appalled!

The son may be 'desperate' to get financial control because his father is incapable of dealing with his finances.

Yes. As a family friend you can have no idea how badly the man is affected by his dementia. The son is doubtless doing his best to help his father.

My mother had dementia and it was one of the first things my mother lost the ability to do. So bills went unpaid and I had to step in as her attorney.

This may well be happening, too.
Again, you have no idea about the loss of the man's abilities.

As a family friend you cannot know how able the father is, people with dementia can still be able to do some things well and other things hardly at all.

Exactly.
You sound very judgemental @threshhold and as though you suspect the man's son of depriving him of his liberty and his money.

Until you've been a carer for someone with dementia, please stop making assumptions.

My experience with my DM was that she was very good at disguising/playing down her cognitive decline. With anyone other than a few very close family members she brushed it off as 'just muddling my words, just a bit tired etc or pretended to be 'joking' if she said things that seemed odd. For a long time I know that many people saw me as over-reacting/controlling when I tried to encourage her to consider her options for accommodation/paid helpers/managing her finances/shopping etc. She was very convincing when she told them she was managing perfectly well on her own, with just a bit of help from me when I 'popped in' occasionally and she didn't see what all the fuss was about. What they didn't see was that 'popping in' was actually a 3-4 hour round trip that I was doing several times a week to sort medication, take her food, empty bins, clean, check post/text messages to her, take her to medical appointments, 'help' her to make phone calls etc. Or the multiple phone calls every day about what she should eat/how to use appliances/when am I visiting next etc, sometimes in the middle of the night. It wasn't until I took a step back and didn't answer the phone every time if I was busy, and cut back visits to once a week that anyone else realised what I was doing to enable her to be 'managing perfectly well by myself'. When you're not in the thick of it yourself I think it's also very easy to underestimate how time consuming some of these supposedly small tasks to help elderly relatives are. A 5 minute job of ordering medication will take an hour, because DM wants me to do it with her (not for her) and insists that we have to check every box she has, count remaining tablets and check the printed prescription sheet several times before we can tick the boxes online and make the order. A 10min trip to the GP takes hours, because she wants to get changed, go to the loo, check the contents of her bag, check the appointment text etc before we go and then something will happen (eg a phone call) that disturbs her and she has to start the process again- if I try to push her to leave quickly she will just sit down and say we obviously don't have time so we'll just have to rearrange for another day. It's not her fault, but she will tell everyone she gets herself ready (which is true, I don't have to physically put her clothes on etc) so all she needs me to do is pick her up and take her there. So I can see why other people who have not done this think 'Poor DM, her daughter makes such a fuss about taking her anywhere.'

Obviously at some point, a move will be necessary but right now, our friend is clear of his wishes although there’s no doubt it sounds as though his son is applying subtle pressure.

Far better to move now, while your friend is still in relatively good mental health.

OP, with kindness, it seems to me like you haven't had experience of a close relation with dementia?

He may present well to you, he may insist everything is fine, and that he absolutely wants to stay in his current home - but the reality that his son and family are dealing with is probably very different.

My friend's mother who had dementia was being fleeced by a conman. They didn't discover this until they managed to enact the financial POA, and her mother's "friend" mysteriously disappeared once the money was stopped. She lost thousands of pounds to him.