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Facts of the Case: Ms. P was a 91-year-old woman who was diagnosed with metastatic cancer and placed on hospice care. She had an estate consisting of a house worth about $3 million, and two checking accounts, with a combined worth of about $200,000. She had five living children. She had signed a will several years ago that gave her house to her daughter, Stacey, who lived nearby, and dividing the rest of her property equally to the remainder of her children after death.

Ms. P lived alone in her house, with Stacey visiting daily. Then, 5 months after diagnosis, Ms. P's son, John, moved into her house to help with care. John noticed that Stacey had fired Ms. P's lawyer, put her house in a trust, named herself as a trustee, and then started to spend the money in the trust on personal expenses. She had changed all bank statements to "electronic only" and was not showing Ms. P records of her transactions.

At this time, Ms. P wished to change her will to distribute all of her property, including the value of her house, equally among all five of her living children after her death. Her lawyer was concerned about the question of testamentary capacity, ie. Does Ms. P have the mental capacity to make changes to a will at this time in her life? He was concerned that any changes to her will may be contested in the courts in the future. He contacted me to perform a formal, prospective, geropsychiatric evaluation of Ms. P's cognitive functions and testamentary capacity concurrent to her signing and executing her new will.

Assessment: I interviewed both Ms. P and John in my office. John, when interviewed alone, stated that Ms. P informed him that while Stacey was taking care of her, she often mistreated her, including withholding pain medications and yelling at her when she made mistakes in tasks, such as not cleaning up after herself. According to Mike, Ms. P used to have frequent crying spells while she was under Jane's care but is no longer having them.

I then saw Ms. P by herself, with John out of the room. I explained to Ms. P that this interview was a one-time consultation for evaluation of her testamentary capacity and did not constitute the initiation of a doctor-patient relationship. I also explained to her that the usual expectations of confidentiality that accompany psychiatric evaluations would not be present, as this report will be shared with her attorney and possibly others involved in her legal affairs, and she verbalized understanding.

At the onset of the interview, I asked Ms. P an open-ended question of what she would like her will to state, and she said, "I have five children. I have a house and things that should be divided up equally to be fair to all the kids." I asked her if she knew what it meant to make a will, and she said, "When you take the things you own, and you divide them up for when you when die." I asked her if anybody encouraged her to change her will recently, and she said, "Nobody told me to change the will. I figured it out, all by myself. I have five children, and I wanted to figure it out so they will not have to discuss it [after my death]. I want it to be my will, the way it is."

I asked Ms. P if she knew about what is in her trust currently, and she said that she owns "one big, two-story house," which she estimates to be worth "maybe two and a half million dollars." She stated that she used to own a large sized lot in a different county for many years which was sold earlier this year. She stated that she believes that the money from this lot was used to pay off her house, and the rest of it is in a bank account. She was not sure how much money she has in her bank account currently, but she estimated it to be "about one hundred and fifty thousand dollars." I asked her if she knew the names of her children to whom she would like to bequeath her assets, and she was able to name all five of them.

Ms. P stated that she was aware that she had made a will a few years ago that gave her house to John and divided the rest of her estate to be divided equally among the remainder of her five children. She says that she made this arrangement "because Stacey was the only one that lived nearby." She states that, now, "I have changed my mind, because she already has a house of her own, and the other children have use for the money too."

Psychiatric Review of Systems: Ms. P reported that her mood was "okay" and denied feeling sad or depressed. She denied any history of depressive episodes. She reported sleeping "fine" and eating well. She reported occasional passive thoughts that life was not worth living, but denied any active suicidal ideation, plans, or intent. She denied auditory or visual hallucinations. She denied paranoid ideation or ideas of reference.

Functional Status: Ms. P admitted that she has been having some memory problems, such as sometimes forgetting appointments and misplacing items. She continued to drive - she had driven earlier today, prior to the evaluation - and she denied any accidents or close calls. Her children help with medication management. She enjoyed cooking, and she occasionally went shopping accompanied by one of her children. She spent her time doing embroidery and going out to dinner and places with friends, "sometimes busier than I want to be." A home health aide helped her shower three times a week. She was independent in toileting and ambulating. Her gait was unsteady, and she ambulated with a help of a walker. She was independent in transfers.

Past Psychiatric History: Ms. P denied having seen a psychiatrist in the past or having been given a psychiatric diagnosis. She denied any psychiatric hospitalizations or previous suicide attempts. She denied being aware of having been on any psychiatric medications. She denied ever smoking cigarettes, drinking alcohol, or using illicit drugs. She denied a history of psychiatric illness in her family.

Past Medical History: Ms. P's past medical history was remarkable for hypertension and metastatic terminal cancer. She had a cardiac pacemaker placed several years ago. She denied significant pain currently. She reported feeling fatigued often but stated that the fatigue does not interfere with her activities. She denied medication allergies. Her medications were amlodipine 5 mg daily (for hypertension); metoprolol 25 mg twice a day (for blood pressure), digoxin 125 mg daily (for heart), tramadol 50 mg as needed for pain (currently using once daily), senna 8.6 mg daily for constipation, and morphine 0.03 mg/kg at night (for pain). She was written for as-need hyoscyan 0.125 mg for diarrhea and lorazepam 0.5 mg for crying spells, but she had not been using these two medications lately.

Psychosocial History: Ms. P was born in England but spent most of her life in Florida. She reported a "very nice" childhood growing up. She completed fifteen years of education. She worked as a secretary for 34 years before retiring at age 63. She married at age 21 and had six children, one of whom had passed away. Her husband passed away about 20 years ago.

Mental Status Examination: Ms. P was a very pleasant, frail, elderly woman with good grooming who was cooperative with the examination and made good eye contact. Her gait was slow and unsteady, but she was able to ambulate with the help of a walker. She appeared comfortable in her interactions with her son. Her speech was of normal rate, tone, and volume. Her mood was "okay," and her affect was pleasant and reactive. Her thought process was logical and linear, with no evidence of a psychotic thought process or gross disorganization. Her thought content was negative for any delusional content, ideas of reference, auditory or visual hallucinations, or active suicidal ideation. She had fair insight into her situation, and her judgment was also assessed to be fair. She was awake and alert, with a clear sensorium, no evidence of sedation or clouding of thought processes.

Cognitive Testing: To test Ms. P's cognitive functioning, a Mini-Mental Status Exam (MMSE), Montreal Cognitive Assessment (MOCA), and select additional tests were performed. Ms. P scored 19 out of 30 on the MMSE with "world" backwards and 17 with serial sevens. She was oriented to the month, year, and season, but not the date or day. She was oriented to the state and country, but not the town, building, or floor. She was able to register 3 objects on 1 trial but had 0/3 delayed recall [indicating memory impairment]. She scored 3/5 on spelling "world" backwards and 1/5 on subtracting 7 from 100 serially [indicating some difficulty with working memory and attention]. She was able to name a pencil and a watch [language test]. She was able to repeat a sentence, follow a three-step command, read and obey a one-step command, and write a sentence [all language tests]. She was not able to copy intersecting pentagons accurately [a test of visuospatial functioning].

Ms. P scored 14 out of 30 on the MOCA. She was not able to switch sets on an abbreviated version of the trails B task [indicating some executive dysfunction]. She made minor errors in copying a cube [indicating visuospatial dysfunction]. On the clock-drawing task, she was able to draw a small circle and put the numbers in the correct location, but she drew the minute hand incorrectly in depicting "10 past 11" [Indicating some executive dysfunction]. She was able to identify 3 animals [language]. She made one error of transposition on repeating 5 digits forwards, but she was able to repeat 3 digits in the backward order [attention, working memory]. She had 3 errors of commission on the auditory A's task [executive dysfunction]. She scored 1/5 on the serial sevens task [working memory, attention]. She was able to repeat 2 sentences accurately [language]. She was able to name 3 words starting with the letter F in 1 minute [indicating some executive functioning problems]. She was able to name abstract similarities between items [executive functioning]. She had 0/5 delayed recall, the improved to 3/5 with category cues and 4/5 with multiple choice cues [indicating some memory impairment, particularly in recall].

On additional testing, Ms. P was able to name 10/12 months of the year backwards [attention]. She was able to copy multiple loops, although with some errors, and she had some difficulty copying alternating squares with triangles but was able to complete the task with fair accuracy [indicating some executive dysfunction].

Conclusion: Based on my evaluation, it was my opinion that Ms. P did have testamentary capacity at the time of the evaluation. She understood the nature of the testamentary act, had an understanding of what was currently in her estate, had a clear plan for how she wants her estate disposed after her death with clear and rational reasons behind it, had knowledge of the individuals that will be affected by her decision, and was not suffering from an insane or psychotic delusion. When interviewed alone, she states that she is making this change in her will of her own accord, and I did not have reason to suspect foul play or undue influence in the making of this will.

Ms. P did have mild-to-moderate cognitive deficits, particularly in the domains of memory and executive functioning. However, her underlying personality, social relatedness, and understanding of her lifelong values and relationships were still intact, and she could clearly communicate and express her wishes about the disposition of her assets. The threshold to lose testamentary capacity is fairly high, and individuals with mild or moderate cognitive impairments often retain this capacity. Therefore, despite her cognitive impairments, it was my opinion that Ms. P retained her testamentary capacity.

I gave Mr. P's lawyer a report of my evaluation and advised him to execute her new will as soon as possible after my evaluation was completed, ideally within a few days.

*Note: This case is fictional and written for educational purposes. Some ideas for this case report were inspired from real cases, but names, dates, location, ages, and clinical details have been altered to protect confidentiality.

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Dr. Aazaz Haq, MD, is the founder and CEO of Bay Forensic Geropsychiatry, a consulting firm and educational resource center for Geriatric Psychiatry. He has subspecialty training in geriatric psychiatry and is certified by the American Board of Psychiatry and Neurology in both geriatric psychiatry and adult psychiatry. A practicing geriatric psychiatrist, Dr. Haq has expertise in all aspects of mental health issues pertaining to the elderly, particularly matters relating to dementia, cognitive impairment, impaired capacity, and vulnerability to undue influence.

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