Psychiatrists fed up with dealing with managed care companies might consider switching to a subspecialty where there is increasing demand for their expertise—deciding whether older people are mentally competent to handle their own affairs.

The reason is the graying of America. There have never been so many seniors—13 percent of the current population compared with only 4 percent in 1900. And as America ages, the incidence of dementia is also increasing. And as dementia increases, more and more people are "losing it," and experts are needed to decide whether they have "lost it" or not.

And the need for such talent will undoubtedly swell even more during the next few years since the over-age-65 group is the fasting growing segment in the American population.

These were the major take-home messages from a session on "measures of civil competency" that was part of the annual meeting of the American Academy of Psychiatry and the Law, held in Vancouver, British Columbia, last month.

But the demand for geriatric forensic talent is not due only to America’s graying and balding, the session revealed. It is also due to the enormous transfer of wealth that is taking place between the World War II generation and the Baby Boom generation. Once again, geriatric forensic authorities are being pressed into service to make sure that the transferees have the mental wherewithal to make rational decisions about the transfer of money.

And the demand for geriatric forensic expertise today is due to still another major factor the speakers addressed—the traditional American family undergoing a dramatic transformation. Vast numbers of people are divorcing, remarrying, and mixing and matching offspring from first, second, even third marriages. The upshot? When Dad dies, his former wives and children from various unions may well challenge his will. And that is when geriatric forensic experts will once again be sought out, this time to determine whether Dad really "had it together" when he neglected them in his will.

But even though the demand for geriatric forensic talent today has never been greater, deciding mental competency has never been harder, the session also underscored. One reason is how the law views mental competency, explained Daniel Marson, Ph.D., a lawyer, psychologist, and geriatric forensic authority with the University of Alabama in Birmingham.

Some years ago, he explained, it used to be pretty simple: If a person was diagnosed with dementia or schizophrenia, he was automatically declared mentally incompetent under the law. But no more. Today competency is no longer an all-or-nothing proposition. For instance, a person with schizophrenia might be found mentally competent while taking medications, yet mentally incompetent when not. Or an Alzheimer’s patient might be found to have a window of mental competency up to a point, but then no longer.

Another reason why it’s hard deciding mental competency today, the session revealed, is that the experts have come to realize that there are different types of mental competencies. They include the ability to drive a car; live independently; tip in a restaurant, balance a bank statement, and handle other financial matters; and capacity to make medical decisions and draw up a will. One of the earliest indications that a person has Alzheimer’s is trouble handling finances, Marson pointed out.

And determining whether a deceased person was mentally competent when he wrote a will is especially challenging, reported Sandra Baltz, M.D., a psychiatrist and geriatric forensic authority with Louisiana State University in New Orleans. The law is generally reluctant to overturn wills, she explained. However, it will do so under certain conditions. For instance, if a deceased person who has written a will had schizophrenia, the law will probably find his testament valid if written during his lucid periods, but not if it was related to his delusions. But how can it be determined whether he wrote the will during a lucid or delusional period? This is where the geriatric forensic expert must play Sherlock Holmes and interview people who had contact with the person before he died—say, neighbors, the boy who delivered his groceries, or the person at the bank—and also look for other evidence, such as a diary, which might tip the scales one way or another.

Thus, with all these complexities, it’s little wonder that geriatric forensic authorities are not always on the mark when they decide that someone is mentally incompetent. Marson and his colleagues set up a study of 29 persons who had been diagnosed with mild Alzheimer’s and 16 age-matched control subjects. They had five geriatric forensic experts, blinded to the subjects’ diagnoses, decide which subjects were mentally fit and which were not. The experts agreed on the controls, but disagreed considerably over the individuals who had been diagnosed with mild Alzheimer’s.

Marguerite Poreda, M.D., a psychiatrist with the James A. Haley Veterans Administration Medical Center in Tampa, Fla., agreed with Marson that determining which seniors are mentally competent is no easy task. Seldom are the severely demented a challenge, but sometimes the mildly demented are, she said.

So what can geriatric forensic experts do to make sure that they accurately determine whether older folks are mentally competent? Poreda offers some advice. Experts interviewing older people should take time with them since vision and hearing problems abound in seniors. Experts should do their best to see that the interviewees understand the information presented to them. Experts should keep in mind that eccentricity does not necessarily mean mental incompetency, and they should interview family members to determine whether the information given is accurate. And they should conduct a physical exam to make an informed decision about mental competency.

Still another tip comes from Marson: Evaluate the various types of mental competencies—say, the ability to drive a car or balance a bank account—separately. Incapacity in one domain does not inevitably spell a lack of proficiency in another.

Passing judgment about a person’s mental competency, Marson concluded, is not just of legal but of ethical import because any time a person is declared mentally incompetent, it will reduce his autonomy, his freedom.