1. CASE STUDY #1 AUTONOMY, CAPACITY, & DUTY TO REPORT Faustina Dannenfelser Joanne Gurin, MD Emily Kile, Esq. Roy Yaari, MD

2. CASE #1 AB, 82 yo female with gradual onset of memory loss for 8 years Mini-Mental Status Exam (MMSE) 21/30 (normal at least 24) Montreal Cognitive Assessment (MoCA) 13/30 (normal at least 26)

3. CASE #1 (cont.) Dependent on her husband for all Instrumental Activities of Daily Living (IADLs) Refuses to bathe over several months and wears soiled clothing Is physically and verbally aggressive and refusing to take any medications Drinks at least 4 glasses of wine/day

4. CASE #1 (cont.) Presents to office two daughters –one daughter has co-Medical Power Of Attorney (MPOA)/Financial POA for both parents with her brother who lives out of town Daughters report that patients husband may also be cognitively impaired along with excessive alcohol use The couple live independently and refuse help in the home except for their daughters

5. CASE #1 (cont.) Full workup has demonstrated conclusive diagnosis of mild-moderate Alzheimer dementia with behavioral impairments of agitation, delusions, and refusal to take medications Treatment options reviewed –Initiate quetiapine (dissolve in liquid) –Restart donepezil and memantine when she accepts medications Recommended that husband come in for evaluation

6. CASE #1 (cont.) BB is 88 yo male with decline in cognitive function in past 2 years –Forgets to pay bills and has been prey to solicitors –Poor short-term memory –MMSE 26/30; MoCA 22/30 Significant alcohol consumption throughout the day Drives within a 2-mile radius of home

7. CASE #1 (cont.) Full workup has demonstrated conclusive diagnosis of mild Alzheimer dementia Initiate donepezil Recommended that caregiver be initiated in the home to assist with meal preparation, medication administration, grooming and pleasant events

8. CASE #1 (cont.) Daughters work to obtain in home caregiver but BB fires her within 3 days BB reports that he is giving his wife the quetiapine each day Daughters report that neither parent is getting his/her medications routinely and the situation continues to get worse Daughter would like to pursue guardianship

9. CASE 1 – QUESTION #1 BB is incompetent. 1.TRUE 2.FALSE

10. CASE 1 – QUESTION #2 BB has full decision-making capacity. 1.TRUE 2.FALSE

11. CASE 1 – QUESTION #3 By Arizona statute, who has decision-making capacity if BB loses his? 1.Daughter 2.Son 3.A consensus of all 4 adult children 4.Physician

12. CASE 1 – QUESTION #4 Are AB and BB vulnerable adults and do they have the right to live independently? 1.Yes, they are vulnerable and should be allowed to live independently 2.No, they are NOT vulnerable and should be allowed to live independently 3.Yes, they ARE vulnerable and should NOT be allowed to live independently