During the month of May, many families and residential communities host celebrations for Mother’s Day and again in June, for Father’s Day. At these special events, it’s often a time when Attorneys for Personal Care or other appointed guardians might visit and attempt to “consult” with their family member, friend or client. Perhaps family members are seeking their mother’s input on her preferences for different types of living accommodations. Or a Guardian of Property may be seeking input on a plan for financial expenditures. Whatever the purpose, there are some key things to understand to consult effectively with a person with diminished capacity.
Consultation is anchored in effective communication. And at its core, communication depends on the sender, the receiver, and the environment. Consulting with a person with diminished capacity can be difficult for both the consultant and the person being consulted. If the person being consulted has significant cognitive impairment, it is helpful to have the basic information about the stage and type of their diagnosis. For example, a person diagnosed with moderate cognitive impairment due to mixed Alzheimer’s and vascular dementia can have quite a bit of difficulty communicating their thoughts and wishes.
Why is this important? Every person with cognitive impairment is unique, and each person responds differently to various stimuli in their environment. Canvassing for their opinions or seeking their input or direction can be challenging for families and others and could easily lead to conflict or misinterpretation. So, understanding the type of cognitive impairment can guide how you communicate.
Consider the case of a 90-year-old woman who was a primary school teacher. She was well-read, very articulate, and enjoyed teaching young children. She was also an avid bridge player. When you meet her today, she is still very social and initiates a conversation quite skillfully, but after a minute or so, she repeats the same sentences. She was diagnosed with mixed Alzheimer’s and vascular dementia at 85 years old, and today has almost no short-term memory. When she leaves her room in the retirement home, she does not remember why she left and requires someone to walk with her to the dining room so she remembers to eat at mealtimes. With little short-term memory, she cannot learn new things, such as learning to use a call bell to call for help. However, she vividly remembers her life as a young child and her parents raising her on a farm.
What makes consulting so difficult in this instance is that the person has significant cognitive impairment with little short-term memory; however, she does have times when she seems to be cognizant. Her executive function is compromised, and, as one family member described, “Mom has lost all her social filters and can be quite rude, commenting about other people.”
When her daughters sought her input on a topic, separately, a conflict ensued. The eldest daughter visited her mother and asked if she wanted to move to another retirement home with memory care facilities. She maintained that her mother was adamant about moving, especially after the daughter spoke about how nice the surroundings at the new location were. The youngest daughter visited her mother later the same day and asked the same question about moving to another retirement home. However, she insisted that her mother was adamant that she did not want to move from the current home, especially when she mentioned that her mom would be leaving her favourite caregiver behind. This set the stage for serious conflict between the daughters.
In the case described above, the mother gave conflicting answers to her daughters on the same day. Depending on the day’s activities, the time of day, mom’s awareness and ability to process information, stimuli from the surrounding environment, and numerous other factors, such as the daughter’s mentioning a positive or negative experience, the person with significant cognitive impairment could easily give two very different and conflictual answers in the space of a few hours.
About a month later, the daughters were both visiting their mother in the afternoon. They had tea once a month, as part of their longstanding habit with their mother. The environment was quiet, and they were reminiscing with their mother about their childhood. On that particular day and time, she remembered their names and was able to converse with them about staying or moving from her current home.
In summary, consulting with a person who has significant diminished capacity can be very difficult for both the consultant and the individual. As one capacity assessor recently described this type of situation with a highly intelligent person, you can still see that they have “islands of good cognition” for brief periods, surrounded by poor cognitive impairment and a lack of insight.
A second part of this article will explore specific tips and recommendations for consulting effectively and tapping into those islands of good cognition.
