Competency Evaluations Start With Five Senses

Courts often turn to psychiatrists, particularly forensic psychiatrists, to ascertain whether an elderly person is competent. What judges often don’t understand, however, is that “not all competencies are created equal,” according to Carla Rodgers, M.D. Thus, defining where a person is on the continuum from “outspoken to outrageous” becomes a complex undertaking.

Speaking at the annual meeting of the American College of Forensic Psychiatry last month in Rancho Mirage, Calif., Rodgers urged psychiatrists who conduct competency evaluations to rely on their senses of sight, smell, touch, and hearing to fill in a substantial number of the competency evaluation blanks.

Vital clues can first be gleaned from closely observing an elderly evaluee, she pointed out—for example, by determining whether that person looks at the psychiatrist upon being introduced and whether the individual’s eyes track with the psychiatrist’s movements. Rodgers also advised assessing the evaluee’s “body habitus,” that is, whether there is any body wasting evident, signs that the person has been leaning against a chair’s arm for unacceptably long periods of time, and whether the person’s dental hygiene is adequate or is a sign of deterioration. “Teeth don’t get rotten overnight,” said Rodgers, a consultation-liaison psychiatrist in Philadelphia and clinical assistant professor of psychiatry at Robert Wood Johnson Medical School.

She also advised psychiatrists to pay attention to an evaluee’s facial expression, grooming such as nail care, and clothing. Clothing that is disheveled or rife with food stains could be signs of a loss of mental competence.

And don’t forget your nose, she stressed. A psychiatrist can gain important competency information by using his or her sense of smell. Pay attention to what the evaluee and the room smell like, Rodgers said, and if foul smells are pervasive, how the individual responds to those odors. In addition, take note of whether the person smells of smoke, alcohol, or even marijuana, the last of which may be a clue as the baby-boom generation enters “seniorhood,” she suggested.

Touch should come into play in an assessment of skin turgor, Rodgers said.

As for hearing, she urged psychiatrist evaluators to listen for wheezing and hoarseness and, though it may seem basic, whether the person can hear what the psychiatrist is saying, which includes “checking to make sure hearing aids are actually turned on.”

A panoply of signs and symptoms may appear to signal the loss of mental competency in elderly individuals, but in fact are evidence of other problems, some of which may be amenable to treatment, Rodgers said.

Among the conditions critical to evaluate, she noted, are dementia of either the Alzheimer’s or vascular type; alcohol-related dementia, “which is often overlooked”; depression, which can appear as “pseudo-dementia”; confusion that may be secondary to medications, a common finding in elderly nursing-home residents; and physical incapacitation manifest by inability to see, hear, or speak, immobility, or excretory issues, which Rodgers described as the “three Ps—pee, poop, and puke.” These can be “red flags” for incompetence, but should not be considered conclusive proof, she noted.

She emphasized that any comprehensive geriatric competency evaluation depends on three things—“time, time, and time.” That the evaluee is elderly and may show signs of dementia does not mean the evaluation should be a “rush job,” she said.

Rodgers also urged psychiatrist evaluators to obtain as much collateral data as possible. These should come from the evaluee’s medical charts and laboratory reports, hospital and nursing-home staff or other caregivers, family members, the attending physician, and other consultants.

Throughout a competency evaluation the psychiatrist should keep in mind the specific type of competency at issue.

If, for example, competency to make a will is being assessed, key issues evaluators need to assess center on whether the elderly person knows who his or her natural heirs are and the nature and extent of the estate involved.

Evaluating a person’s competence to make medical decisions, in contrast, requires that the individual know what is wrong with him or her and who is doing the treating, as well as understand the proposed treatment in general terms and the risks and benefits of that treatment compared with receiving no treatment, Rodgers explained.

And do not overlook an exploration of the family’s motives in requesting a competency evaluation, she cautioned. Do family members have reason for wanting their oddly behaving relative to be declared incompetent? ▪