- There are two questions to start with when you're noticing an older adult making poor decisions:
1) Does the behavior actually pose a danger to the person or others, and if so, what exactly is that danger?
2) Does the person understand the poor choice that he or she is making and its likely consequences?
- We recommend partnering with the right physician or other health professional to answer these questions
- Driving, fire hazards, and an inability to manage medications or finances can endanger both the individual and the public, and need to be addressed urgently
One of the most challenging occurrences is when you begin to notice an older adult — a parent, spouse, friend — making decisions that feel unsafe or harmful.
These incidents can run the gamut from refusing to take medications for a chronic medical condition (such as insulin for diabetes) to making poor decisions with money that could lead to huge financial problems (e.g., falling prey to marketing scams, suddenly making high-risk speculative investments). While these incidents come in many forms, they all lead to the same question: Is my loved one still able to make safe decisions on their own?
It's not easy to determine, but we'll outline how you can take action and ensure the safety and security of your loved one.
Start by Asking the Right Questions
Most likely, you're questioning your loved one's decision-making abilities because you've noticed a pattern of bad or worsening decisions and you've been met with resistance when you've brought it up. Before you take any further steps, there are two questions to ask yourself:
- Does the behavior actually pose a danger to the person or others, and if so, what exactly is that danger?
- Does the person understand the poor choice that he or she is making and its likely consequences?
In many cases, the answer to these questions is complex.
Does This Behavior Actually Pose a Danger?
When we love someone, our concern for their wellbeing understandably impacts the way we think through any given situation. Before you try to get your parents committed for missing a doctor's appointment, step one is to pause and ask yourself: Is this truly a dangerous situation?
That line can be blurry. Just because someone lives in a way that feels uncomfortable to you doesn't necessarily make them a personal or public health threat. People have a right to be messy or clean, on time or late, and generally just ornery — even though it may upset you. The question is if their behavior a) potentially harms themselves or others and/or b) violates the law.
Here's an exercise to try: Imagine how the same behavior would be perceived in a 35-year-old. If a younger adult missed a few doses of medication, ate high-fat food despite being overweight, or had poor personal hygiene, how would you react?
It's completely understandable to be frustrated with these behaviors. But who among us has correctly taken every single dose of their medication or not cheated on a diet, whether self-imposed or ordered by a physician? And how would you feel as a younger person if someone else's wishes were foisted upon you involuntarily? You'd probably regard it as a profound violation of your personal rights unless the behaviors seriously jeopardized you or others — and even then, you'd likely resist.
What Constitutes "Real Danger?"
Every situation is different, but a few common and concerning behaviors that can endanger both the individual and/or the public are always on the minds of geriatricians. They include:
- Driving: While taking away car keys is difficult and can make someone feel deprived of their independence, driving is an area where geriatricians tend to be more aggressive in limiting access. If you're concerned about a loved one's driving, err heavily on the side of caution given the risk not only to the older adult, but to other drivers and pedestrians.
- Fire hazards: Any activity that could cause a fire — forgetting to turn off the stove, smoking in the apartment, etc. — endangers both the individual and others. In such circumstances, it's important to intervene immediately.
- Inability to self-manage medications: Missing a dose or two of a much-needed medication isn't a reason to sound the alarm, but once you notice anything beyond that, it's important to take action. This can potentially be life threatening — e.g., someone forgetting they've already taken their morning medication and taking it again.
- Inability to manage one's finances: While not as immediately life threatening as the situations above, poor financial decision-making can be disastrous, sometimes leading to poverty and draining needed savings.
Does This Person Have the Capacity to Make Decisions Around Their Care?
Often, disagreements around decision-making involve not getting medical care a loved one thinks is needed or living in an environment that has the potential to cause harm. The question in these instances is whether or not the older adult has the ability to make the decision for themselves, irrespective of if you think it's a good one. This is what physicians refer to as decision-making capacity.
In this context, decision-making capacity should always be framed around the specific decision that is in question. Can my father drive safely? Can my mother handle her finances independently? Can my husband safely self-manage his medications?
This shouldn't be confused with the legal term "competence," which is often used to describe someone's thinking and decision-making ability across all aspects of life. Capacity typically just refers to one specific decision.
Answering these questions may seem subjective, but you don’t need to strictly rely on your own interpretations. Partnering with the right physician or other health professional can bring in a more objective perspective.
Trained medical professionals are ready to advocate for your loved one based on what is best for them — not what any of the involved parties want but what the patient needs. When skilled professionals conduct an examination, most come to the same conclusion about a given patient’s capacity. That said, the evaluation of decision-making capacity is far more nuanced than running a lab test or taking a questionnaire.
Formal assessments of decision-making capacity are usually performed by psychiatrists, but many geriatricians and other generalists are comfortable making these determinations, especially in circumstances that require immediate attention. (Note that in the event of guardianship, certain states require an assessment by a psychiatrist for the purpose of formal proceedings.)
Assessing Decision-Making Capacity
Assessing decision-making capacity begins with determining if the person understands that the poor decision they're making could be a problem. With someone who isn't taking needed medication regularly, an assessment question might be something like: "Have you ever heard of a person who got sick because they were unable to take their medicine?"
The second step is assessing whether the person thinks that they might be having that problem. In the above case, an example question would be: "Do you think not taking your insulin could result in hospitalization or worse?"
If both are responded to reasonably, the last step is determining if the person can formulate a plan that could remedy the problem. For example, "I guess I could have my daughter come and pre-arrange my medications for me," or "I would be open to using a service that would deliver my medications in pre-arranged packs to make it easier."
What Happens When Poor Decisions Continue?
Sometimes, a person is determined to lack capacity and chooses to refuse support. If this is the case, and continued interventions have been unsuccessful, the most extreme outcome would be a guardianship proceeding. This is often a divisive and contentious process that essentially involves the rescinding of rights and freedoms.
As such, it's always recommended to begin with less dramatic interventions — like getting an Uber account for someone who should stop driving and won't. The goal is to keep your loved one safe while also maintaining their rights and dignity.
Being Proactive vs. Reactive
As we age, finding the "least restrictive alternative" is important: the balance between safety and independence that we all strive for. How do you make sure that the person you love is safe without making them feel like you're trying to undermine their independence?
The answer is with proactive communication, planning, and empathy. We know there may come a time when our loved one is unable to function independently, but to avoid discomfort, we put the conversation off for as long as possible. Addressing things preemptively can help: Rather than raise the issue amidst a crisis, talk about it beforehand and make a plan together.
If you find that your loved one is resisting care, read our guide on how to introduce care into the home.