Academic journal article Generations

Competency Assessment and Research in an Aging Society

Academic journal article Generations

Competency Assessment and Research in an Aging Society

Article excerpt

Evaluation of decisional abilities and functional capacities of elders has become increasingly important.

Unprecedented numbers of people in industrialized societies are now living into the eighth, ninth, and even tenth decades-into the far reaches of human old age. Unfortunately, the aging of our society is also to a significant degree the dementing of our society (Marson and Zebley, 2001). For example, the incidence and prevalence of Alzheimer's-type dementia increases steadily from age 60 on. Approximately 6 to 8 percent of all elders above age 65 have Alzheimer's disease, estimated currently to be 4 million people in the United States (Small et al.,1997). Beginning at age 60, the prevalence of Alzheimer's disease doubles every five years, so that nearly 30 percent ofthe population aged 85 and older has this disease (Small et al., 1997). When one considers that the fastest growing segment of our population are those individuals age 8o and older, the public health crisis represented by dementia becomes obvious (Larson, 2000).

As our society ages, clinical assessment of decisional abilities and higher-order functional capacities in older adults has become increasingly important (Marson et al., 2000a). In areas like medical and research consent capacity, medication compliance, financial capacity, and driving, society has a strong interest in accurately distinguishing intact from impaired functioning. Although we may respect and love our elderly nextdoor neighbor if he begins to drive erratically on our street, backing up over our gardenias or the sidewalk, we probably would like to have the Division of Motor Vehicles act as soon as possible to evaluate his capacity to operate a motor vehicle safely. Competency judgments represent society's formal attempt to make and enforce such basic discriminations regarding the quality of individuals' decisional and functional abilities. These competency judgments take the form of capacity assessments by clinicians, evaluations by authorized government agency personnel, and legal competency proceedings and findings by judges (Marson, Dymek, and Karlawish, 2001).

Over the past twenty-five years, competency has emerged as a distinct field of legal, clinical, and behavioral research (Marson and Ingram, 1996). The origins of the field lie in a series of important articles published in the late 1970s and early 1980s on the capacity of psychiatric patients to consent to treatment (Appelbaum and Roth, 1981; Appelbaum and Bateman, 1980; Appelbaum, 1982; Meisel, Roth and Lidz, 1977; Roth et al., 1982; Roth, Meisel, and Lidz, 1977). In the later 1980s and the 199os, the field benefitted from additional scholarly rigor through seminal theoretical and empirical contributions of Paul Appelbaum and Thomas Grisso (Appelbaum and Grisso, 1988; Appelbaum and Grisso, 1995; Grisso, 1986; Grisso and Appelbaum, 1991; Grisso and Appelbaum, i995a; Grisso and Appelbaum, 19956; Grisso et al., 1995). In particular, Grisso's (1986) book Evaluating Competencies represented a crucial theoretical contribution, as it offered for the first time an organizing conceptual framework and analytical guide for a range of different civil and criminal competencies.

With this conceptual foundation in place, competency research has expanded significantly in the past decade. As discussed in more detail below, this expansion has taken a number of different forms. First, there has been increasing attention paid to competency loss in nonpsychiatric patient populations, in particular, older adults with cognitive impairment (e.g., Dymek et al., 2001, and Grisso, 1995). Second, the field is moving beyond its initial focus on treatment consent capacity, and has begun to investigate other important competencies such as research consent capacity (Kim et al., 2001), financial capacity (e.g., Edelstein et al., 1993; and Marson, 2001), and driving (Drachman, Swearer, and Group, 1993; Hunt et al., 1997). Third, the field is now engaged actively with issues of clinical assessment, as reflected by the development of standardized instruments (e. …

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