Annals of Long Term Care

**sub**Overview of Factors Which Predict an Individual’s Ability to Control Personal Finances and Select Living Situations**endsub**
After older patients receive medical care, agencies are often reluctant to allow them to return to their homes if the patients are thought to be unsafe in their environment. Sanitation, spoiled food, unkempt houses, and fear that they will wander or that they will not receive sufficient care are some of the many concerns that prevent older patients from living alone. “What we’re faced with are what factors should be measured in determining whether somebody is competent to make one’s own decision about a living situation, what cognitive deficits might influence this determination, when does the safety of those around the patient influence this decision,” said Leo M. Cooney, Jr., MD, Professor of Geriatric Medicine and Chief of  the Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT.

Referring to the 14th century English concept of parents patria, the innate authority and responsibility of a benevolent society to intervene in order to protect people who cannot protect themselves, Dr. Cooney posed a vital question pertaining to this issue: When does the authority and responsibility of society to protect people overrule the patient’s autonomy?

Some of the important functional activities that are at risk when an older person is living at home alone include taking medication properly, preparing meals, and getting sufficient nourishment.  Other anxieties stem from the fear that an older person will be taken advantage of, that he or she will not accept help from and trust people who are offering assistance (such as visiting nurses), that the person will not be able to make the distinction between a trustworthy and non-trustworthy individual, or that the person will engage in unsafe activity, such as burning pots and pans or starting fires.

When older people are thought to be incompetent, they are often considered to be unable to live alone. According to Dr. Cooney, incompetence occurs when people, because of lack of capacity to contemplate and weigh choices rationally, cannot adequately care for themselves or their property. In addition, “some of the issues that contribute to competency are one’s capacity to receive, comprehend, and relate relevant information, one’s ability to integrate the information received and relate it to one’s own situation, and one’s capacity to evaluate benefits and risks.” 

In order to declare somebody to be incompetent in the American court system, evidence must be provided to determine the patient’s ability to carry out the activity in question. In addition, the older person must have sufficient understanding so that he or she can accurately assess consequences that include risk, benefits, obligation, and legal jeopardy. To determine whether or not someone is incompetent, “our courts usually focus on the individual’s functional ability to manage personal care and finances on a daily basis, as opposed to their clinical condition–whether or not they have Alzheimer’s or multi-infarct dementia, or whatever the diagnosis might be,” said Dr. Cooney.

Physicians advise the court of an individual’s capacity rather than competence and, according to the speaker, there is uncertainty about when they should advise the court about the patient. “When do we say that we think this person doesn’t have the capacity because of our concerns, not because of objective things that have happened, but because of our concerns about potential safety of the patient when no unsafe actions have yet been observed?” questioned Dr.