Concepts in Capacity (Part 1): What Is a Fiduciary?

As a geropsychologist and neuropsychologist, a significant part of my work involves assessing an individual's capacity to make decisions – particularly as they age. This isn't just about whether someone remembers what they had for breakfast; it's a complex evaluation of their cognitive abilities, understanding of consequences, and ability to act on their own behalf. And often, when we talk about capacity, especially in financial or legal matters, a crucial term comes up: fiduciary.

Today, in Part 1 of our "Concepts in Capacity" series, we're going to demystify what a fiduciary is, why this role is so vital, and why understanding it is paramount for older adults and their families.

What Exactly Is a Fiduciary?

At its core, a fiduciary is a person or entity that acts on behalf of another person (the "principal") in a position of trust and confidence. The fiduciary is legally and ethically bound to act solely in the best interest of the principal. This is not a casual relationship; it's one that carries significant legal duties and responsibilities.

Think of it this way: if someone is acting as your fiduciary, their own personal interests, preferences, or financial gain must always take a back seat to yours. Their duty is to protect your assets, make sound decisions for your well-being, and manage affairs exactly as you would, or as is demonstrably in your best interest if your capacity is diminished.

Common Examples of Fiduciary Relationships

You might already be more familiar with fiduciary roles than you realize. Here are some common examples relevant to older adults:

• Agent under a Power of Attorney:

  This is perhaps the most common fiduciary role for many families. If you've appointed someone with a Durable Power of Attorney for finances or healthcare, that person is your fiduciary. They are legally obligated to manage your money or make healthcare decisions according to your wishes and in your best interest.

• Trustee:

  If you've set up a trust, the person or institution named as the trustee is a fiduciary. They manage the assets within the trust for the benefit of the beneficiaries, following the terms of the trust document.

• Guardian or Conservator:

  When a court determines an individual lacks the capacity to make their own decisions, it may appoint a guardian (for personal decisions like healthcare and living arrangements) or a conservator (for financial decisions). These appointed individuals are fiduciaries with a very high legal duty to the protected person.

• Executor of a Will:

  The executor is responsible for carrying out the instructions in a deceased person's will, managing their estate, paying debts, and distributing assets. They act as a fiduciary to the estate and its beneficiaries.

• Financial Advisor (specifically a "fiduciary advisor"):

  While not all financial advisors are fiduciaries, those who are registered investment advisors (RIAs) or hold specific certifications (like Certified Financial Planner - CFP, under certain conditions) are legally required to act as fiduciaries, putting their client's interests first. This is a critical distinction to ask about when choosing a financial professional.

Why Is Understanding "Fiduciary" So Important for Older Adults and Their Families?

1. Protection Against Exploitation: Unfortunately, older adults are vulnerable to financial exploitation. A clear understanding of fiduciary duties can help families identify when someone in a position of trust is not acting in the principal's best interest. This can be a red flag for potential abuse.

2. Ensuring Wishes Are Honored: When you appoint someone as your agent in a Power of Attorney, you are entrusting them with significant power. Knowing they have a fiduciary duty means they are legally bound to follow your instructions and act as you would have wanted, particularly regarding healthcare and end-of-life decisions.

3. Peace of Mind: For older adults, knowing that the people managing their affairs or making decisions on their behalf are legally obligated to act in their best interest provides immense peace of mind.

4. Guiding Difficult Conversations: For adult children, understanding the fiduciary role can help guide discussions about managing a parent's affairs. It frames the conversation around responsibility and trust, rather than control or personal gain.

5. Legal Recourse: If a fiduciary breaches their duty (e.g., misuses funds, makes decisions against the principal's clear wishes without good reason, or benefits themselves at the principal's expense), there are legal avenues for recourse. This legal accountability is what gives the fiduciary relationship its weight.

The Interplay with Capacity

This brings us back to capacity. For a fiduciary relationship to be established properly (e.g., through a Power of Attorney), the principal must have the capacity to understand the document they are signing and the implications of granting such authority. If capacity is questioned, a court may need to step in to appoint a guardian or conservator, who then assumes the fiduciary role.

In the upcoming parts of this series, we will delve deeper into different facets of capacity – what it means clinically, how it's assessed, and the nuanced areas of decision-making that often arise as we age. But for today, remember this: the concept of a fiduciary is a cornerstone of trust and protection, especially for our aging loved ones. Understanding it is a vital first step in ensuring their well-being and honoring their legacy.

This blog series will cover several concepts important to understanding the issue of capacity. Stay tuned for Part 2!

Does Your Loved One Have the Capacity to Appoint a Fiduciary? Start with a Capacity Assessment in Los Angeles, CA

Before someone can legally designate a fiduciary—whether for financial decisions, healthcare, or estate planning—they must have the capacity to fully understand what that means. A capacity assessment in Los Angeles, CA provides the clinical insight needed to determine whether an individual can make informed, intentional choices about their future.

As a trusted neuropsychologist in Los Angeles, Dr. Stacy Reger offers compassionate, comprehensive evaluations that help families navigate complex legal and cognitive questions with confidence. Her assessments are designed to honor the individual while ensuring clarity for all involved. Take the next step:

• Call (424) 262-1925 to schedule a private consultation

• Meet with a licensed neuropsychologist for a detailed capacity evaluation

• Make informed decisions grounded in expert assessment and genuine care

OTHER SERVICES OFFERED BY DR. REGER IN LOS ANGELES, CA

In her work as a neuropsychologist and geropsychologist, Dr. Stacy Reger offers a range of services designed to support sound decision-making, safeguard autonomy, and guide families through complex transitions. Her neuropsychological assessments help clarify diagnoses such as ADHD, dementia, and traumatic brain injury—conditions that can directly impact a person’s ability to manage finances, health care, or legal affairs.

In addition to capacity evaluations, Dr. Reger provides med-legal assessments, workers’ compensation evaluations, and pre-surgical screenings to support thoughtful, well-informed planning. She also offers individual therapy for older adults, focusing on the emotional and cognitive shifts that come with aging. Whether you're seeking guidance for a specific concern or planning ahead for a loved one’s care, Dr. Reger is available for consultations, presentations, and community education.

Visit Dr. Reger’s blog to learn more about capacity, fiduciary roles, and the tools that help families make decisions with confidence and care.

Navigating Family Disagreements When a Loved One’s Capacity Is in Question

Family disagreements are an inevitable part of life, even in the most loving and cohesive units. However, these disputes take on an entirely different, often heart-wrenching, dimension when they revolve around a loved one whose cognitive or decision-making capacity is in question. As a neuropsychologist who offers capacity assessments, I’ve witnessed firsthand the strain these situations place on families.

When a parent, grandparent, or sibling begins to show signs of diminished capacity – whether due to dementia, a stroke, a progressive illness, or even a sudden injury – their ability to express their wishes, understand complex information, or manage their own affairs becomes uncertain. This ambiguity opens the door to well-intentioned, yet often conflicting, interpretations among family members about what’s best for their loved one.

The Common Flashpoints

Here are some of the most frequent areas of disagreement I encounter:

• Medical Decisions:

This is often the most critical and emotionally charged area. One sibling might advocate for aggressive medical intervention, believing it’s what their parent would have wanted, while another might argue for a more palliative approach, focusing on comfort and quality of life. The challenge is compounded when the loved one can no longer clearly articulate their own preferences or advance directives are unclear or non-existent.

• Financial Management:

Concerns about a loved one’s ability to manage their finances can lead to accusations of undue influence, exploitation, or simply poor judgment. Siblings might disagree on who should have power of attorney, how assets should be protected, or whether certain expenditures are appropriate.

• Living Arrangements:

Deciding whether a loved one can safely remain at home, needs assisted living, or requires a higher level of care is a huge decision. One child might prioritize independence, while another prioritizes safety, leading to heated debates about the best environment.

• Driving Privileges:

Taking away car keys can be a deeply painful and contentious issue, often viewed by the loved one as a loss of independence. Family members may be divided on when this step is necessary, fearing both the safety of their loved one and others on the road, versus the loved one’s desire for autonomy.

• Caregiving Responsibilities:

Even with a plan in place, the day-to-day burden of caregiving can lead to resentment and conflict if it feels unequally distributed amongst siblings or other family members.

Why Disagreements Escalate

Several factors contribute to the intensity of these family conflicts:

• Grief and Anticipatory Loss:

Families are often already grieving the gradual loss of their loved one’s former self. This emotional distress can heighten sensitivities and make rational discussion more difficult.

• Pre-existing Family Dynamics:

Long-standing sibling rivalries, unresolved past conflicts, or differing communication styles often resurface and are amplified under the stress of these circumstances.

• Guilt and Fear:

Family members may feel immense guilt about making “the wrong”decision or fear the consequences if they don’t act. This can lead to rigid stances and an inability to compromise.

• Differing Values and Beliefs:

Each family member brings their own unique values, beliefs, and experiences to the situation, which can lead to genuinely different perspectives on what constitutes “best care”.

• Lack of Clear Communication and Planning:

The absence of open conversations about future care preferences before capacity diminishes is a major contributor to later disagreements.

Strategies for Navigating Conflict: A Psychologist’s Perspective

While there’s no magic bullet, here are some strategies I recommend to families grappling with

these difficult situations:

1. Prioritize the Loved One’s Best Interest (and Presumed Wishes):

This should be the guiding principle. While it’s natural to have personal feelings, try to shift the focus to what the loved one would have wanted, or what truly serves their well-being, even if it’s uncomfortable. If they had expressed wishes when they had capacity, those should be paramount.

2. Seek Professional Assessments:

When capacity is genuinely in question, obtaining a comprehensive cognitive and psychological assessment from a neutral professional (like a geropsychologist) is crucial. This provides objective data to guide decisions and can help defuse arguments based on subjective interpretations.

3. Facilitate Open and Structured Communication:

• Scheduled Family Meetings: Regular meetings, perhaps with a neutral facilitator (a therapist, social worker, or trusted family friend), can provide a structured environment for discussion.

• “I” Statements: Encourage family members to express their concerns using “I” statements (I’m worried about Mom’s safety when she drives) rather than accusatory & You statements (You’re letting Mom endanger herself).

• Active Listening: Encourage true listening, not just waiting for your turn to speak. Try to understand the underlying concerns and fears of other family members.

4. Explore Legal Avenues (When Necessary):

If consensus cannot be reached and the loved one’s safety or finances are at risk, seeking legal counsel regarding guardianship or conservatorship may become necessary. While this can be a difficult step, it provides a legal framework for decision-making.

5. Educate Yourselves:

Learn about the loved one’s specific condition. Understanding the progression of dementia, for example, can help manage expectations and inform decisions.

6. Focus on Shared Goals, Not Just Differences:

While disagreements will exist, try to identify common ground. Everyone wants their loved one to be safe, comfortable, and cared for. Starting from these shared desires can help bridge divides.

7. Seek External Support for Yourselves:

This is immensely stressful. Individual therapy or family therapy can provide a safe space to process emotions, develop coping strategies, and learn more effective communication skills. Support groups for caregivers can also be invaluable.

8. Practice Self-Compassion:

These situations are incredibly tough. Acknowledge your own feelings of frustration, sadness, and even anger. You’re doing your best in challenging circumstances.

Navigating family disagreements when a loved one’s capacity is in question is one of the hardest journeys a family can undertake. It demands patience, empathy, and a willingness to prioritize the well-being of the loved one above personal agendas. While the path may be fraught with tears and tension, remember that by seeking professional guidance, fostering open communication, and anchoring decisions in compassion, families can navigate these stormy waters with greater clarity and ultimately, with the loved one’s best interest at heart.

Is It Time for a Capacity Assessment in Los Angeles, CA?

When questions about a loved one’s decision-making ability spark conflict, it can be hard to know how to move forward—especially when emotions run high and family members disagree. A comprehensive capacity assessment in Los Angeles, CA offers objective insight into your loved one’s cognitive strengths and limitations, helping you make informed, compassionate decisions.

Dr. Stacy Reger provides expert neuropsychological evaluations tailored to clarify capacity concerns in complex family situations. Whether you’re navigating a potential diagnosis, seeking clarity for legal or medical planning, or simply want to do what’s best for someone you love, we’re here to support you with care and professionalism. Take the first step today:

1. Contact (424) 262-1925 to schedule your appointment

2. Meet with an experienced neuropsychologist for an assessment

3. Gain clarity and confidence as you navigate critical decisions with your family.

OTHER SERVICES OFFERED BY DR. REGER IN LOS ANGELES, CA

In addition to supporting families through capacity-related challenges, Dr. Reger offers a wide range of psychological services designed to provide clarity and guidance during difficult times. Her neuropsychological assessments address concerns such as ADHD, dementia, and traumatic brain injury—helping individuals and families better understand changes in cognitive functioning. She also conducts capacity evaluations, med-legal assessments, workers’ compensation evaluations, and pre-surgical screenings to support informed decision-making. For older adults, Dr. Reger offers psychotherapy that honors the unique emotional and cognitive changes that come with aging. She is also available for consultations and presentations. Visit Dr. Reger’s blog for thoughtful guidance and expert insights.

Inconsistent Neuropsychological Test Results: Which Should I Go With?

As a clinical neuropsychologist with expertise in neuropsychological testing, I often encounter patients, families, or referring physicians who feel confused or concerned when faced with neuropsychological evaluations that seem to contradict each other. Perhaps one assessment indicated significant memory problems, while a later one showed improvement, or maybe different evaluations highlighted different areas of cognitive weakness. The natural question that arises is, "Which results are right? Which ones should we go with?"

It’s a valid question, but the answer isn't usually about picking a "winner." Neuropsychological assessment isn't like a single blood test yielding a definitive number. It's a complex process involving a battery of standardized tests to assess various cognitive functions, like memory, attention, processing speed, language, executive skills. These areas of cognition are measured within a specific context and at a particular moment in time, and I like to remind patients and providers that one data point is only one data point. Understanding why results might differ is the first step to making sense of inconsistent neuropsych test results.

Why Do Neuropsychological Evaluation Results Vary?

Several factors can contribute to inconsistencies between evaluations:

1. Real Change Over Time: Brain function isn't static. Cognitive abilities can genuinely change for a few reasons.

• Recovery: Healing after a brain injury (like concussion or stroke).

• Decline: Progression of a neurodegenerative condition (like Alzheimer's or disease or Lewy Body dementia).

• Treatment Effects: Positive or negative impacts of medications, therapy, or surgery.

• Aging: Normal cognitive changes associated with aging.

2. Differences in Testing Context: 

• Patient Factors: How were you feeling on those specific test days? Fatigue, pain, stress, anxiety, motivation, or even the time of day can influence performance. Medications taken on one day but not another can also play a role.

• Environmental Factors: Differences in the testing room (quiet vs. noisy) or the examiner's style and rapport can have subtle effects.

3. Differences in Tests Used:

   Neuropsychologists have a vast toolkit. While different tests might aim to measure "memory," they tap into distinct aspects (e.g., immediate recall vs. delayed recall, verbal vs. visual memory). One evaluator might use tests more sensitive to subtle difficulties than another.

4. Validity Concerns:

   We use specific measures to help determine if the results accurately reflect a person's actual abilities. Sometimes, factors like poor effort, misunderstanding instructions, a language barrier, or symptom exaggeration can lead to artificially low scores. The validity findings might differ between evaluations, impacting the interpretation.

5. Practice Effects:

   Repeating the same or similar tests within a relatively short timeframe can sometimes lead to improved scores simply due to familiarity, not necessarily true cognitive improvement.

So, Which Results Do We Trust?

Instead of asking "which report is right?", the more productive approach is: "What do these different sets of results, taken together, tell us about this individual's cognitive functioning over time and across contexts?"

When interpreting neuropsychological evaluation data, a neuropsychologist’s job is to integrate all available information. So, I would:

• Review Both Reports: We carefully examine the findings, methodologies, and interpretations of each evaluation.

• Consider the Context: We look at the reason for each referral, the patient's state during testing (if documented), and any relevant medical or life events occurring between evaluations.

• Analyze Test Data: We compare the specific tests used, the patterns of scores (which areas are consistently strong or weak?), and critically, the validity testing results from each assessment.

• Look Beyond Scores: We integrate test findings with clinical history, observations during the evaluations, and reported real-world functioning. Does the pattern of results make sense given everything else we know? Are there factors that would explain the differences across tests and time?
  
  
  

The goal is to develop a cohesive understanding. Do the differences reflect genuine recovery or decline? Do they point towards variability related to effort or psychological factors? Or perhaps methodological differences between the evaluations?

Inconsistency isn't necessarily a roadblock; it's often a crucial piece of the puzzle, offering insights into the dynamic nature of brain function and behavior. By carefully integrating all data points, we can arrive at the most accurate and clinically meaningful understanding to guide diagnosis and treatment recommendations. If you're facing conflicting results, discuss your concerns openly with your neuropsychologist or doctor to understand the whole picture.

Talk with a Neuropsychologist in South Bay Who Can Help You Make Sense of the Full Picture

Conflicting test results can feel overwhelming—but you don’t have to sort through them alone. Working with a skilled neuropsychologist can help you understand the context behind inconsistent findings and how they may reflect real changes, methodological differences, or testing variability.

If you’re looking for clarity and next steps, Dr. Stacy Reger offers in-depth neuropsychological consultations to help individuals and families navigate confusing evaluations with confidence. Whether you need a second opinion or help integrating multiple assessments, we're here to support you. Here’s how to get started:

1. Contact (424) 262-1925 to schedule your appointment

2. Meet with an experienced neuropsychologist for an assessment

3. Gain clarity and move forward with a more integrated understanding of your cognitive profile.

OTHER SERVICES OFFERED BY DR. REGER IN LOS ANGELES, CA

Beyond individual therapy, Dr. Reger is happy to offer various other services to serve her clients. She provides neuropsychological assessments for ADHD, dementia, traumatic brain injury, and more. She also offers therapy for older adults, med-legal and capacity assessments, workers’ compensation assessments, and pre-surgical evaluations. In addition to evaluations, she provides mental health consultations and presentations. Visit Dr. Reger’s blog for more helpful insights today!

Facing a Psych QME in California? What to Expect and How to Prepare

If you've filed a California workers' compensation claim involving a psychological injury, whether from workplace stress, harassment, trauma, or as a consequence of a physical injury, you might be scheduled for a Psychiatric Qualified Medical Evaluation (QME). This can feel daunting, but understanding the process and preparing adequately can make a significant difference.

What is a Psychiatric QME?

A QME is a physician (in this case, a psychologist or psychiatrist) certified by the California Division of Workers' Compensation (DWC) to conduct independent medical evaluations when there are disputes or questions about an injured worker's claim. A Psychiatric QME specifically evaluates mental health conditions related to a work injury.

These evaluations are crucial because psychological injuries often lack the objective physical evidence (like an X-ray) seen in other injuries. The QME's role is not to provide treatment, but to offer an unbiased, expert opinion on issues like:

• Whether a psychiatric condition is work-related (and to what extent).

• The nature and severity of the condition.

• The impact on your ability to work.

• Appropriate medical treatment.

• The level of permanent impairment, if any.

The QME is selected from a state-generated panel (list) of doctors. All these doctors have passed a state exam to be certified as a QME.

What to Expect During the Evaluation

Psychiatric QME appointments are typically lengthy, often lasting between 4 to 6 hours. Be prepared for:

1. Comprehensive Interview: The doctor will conduct an in-depth interview covering your: 

• History of the injury and related symptoms.

• Medical and mental health history (including past treatments).

• Work history and job duties.

• Social, educational, and personal history.

• Current daily functioning.
  
  

2. Review of Records: The QME will have reviewed your medical records related to the claim beforehand.
   
   

3. Psychological Testing: You will likely complete standardized psychological tests (often questionnaires on paper or computer) with a psychological evaluator. These tests provide objective data to supplement the interview, assessing emotional functioning, symptom severity, and cognitive aspects. They are designed to ensure reliability beyond just self-reporting or the doctor's observations.
   
   

How to Prepare for Your Psych QME

Preparation can help you navigate the evaluation:

• Rest and Nourish: Get a good night's sleep before the appointment. Eat a meal beforehand, as the evaluation is long. Avoid alcohol or non-prescribed drugs. If you take prescribed medications, take them as usual.

• Be Punctual: Arrive on time or slightly early to handle parking and check-in without stress. Most of the time, your attorney will tell you to arrive 30 minutes before the appointment time, to avoid any issues with starting on time.

• Be Honest and Consistent: This is crucial. Answer questions truthfully and provide consistent information. QMEs are experienced psychological evaluators, and psychological tests often have measures to detect inconsistent or exaggerated responses. The best way to represent your situation accurately is through honesty.

• Give Your Best Effort: Cooperate fully and give your genuine best effort on any tests administered. Trying to “fake bad” or give low effort in order to convey the seriousness of your concerns will cause problems with your tests, as many psych tests are designed to detect this. 

• Bring Essentials: Have your ID, any corrective lenses or hearing aids, and a list of your current medications (names and dosages). If you use any orthopedic devices for writing or reading, bring those as well. Bringing water and a snack is also a good idea due to the appointment length. You might bring brief personal notes about your symptom timeline, but the QME will receive extensive medical records separately, and can’t actually accept any additional documents from you.

• Understand the Goal: Remember the QME is an evaluator, not your treating doctor. Their focus is on providing an objective report for the workers' compensation system.

After the Evaluation

The QME has 30 days from the evaluation date to write and submit a detailed medical-legal report. This report is sent to the insurance claims administrator, your attorney (if you have one), and you (or your attorney). The findings significantly influence decisions regarding your benefits, treatment authorizations, and the overall resolution of your claim.

Facing a psychiatric QME can be stressful, but being prepared and honest allows the evaluator to get the clearest possible picture of your situation, contributing to a fair assessment of your claim.

REACH OUT TO A NEUROPSYCHOLOGIST IN SOUTH BAY TODAY

You don’t have to overcome mental health barriers alone. You can learn helpful strategies and improve your overall well-being with individual psychotherapy in California. Contact Dr. Stacy Reger to schedule a consultation and find out which therapeutic path would be ideal for your mental health journey. You can start the process by following these simple steps:

• Contact (424) 262-1925 to schedule your appointment

• Meet with an experienced neuropsychologist for an assessment

• Start getting the mental health support you deserve!

OTHER SERVICES OFFERED BY DR. REGER IN LOS ANGELES, CA

Beyond individual therapy, Dr. Reger is happy to offer various other services to serve her clients. She provides neuropsychological assessments for ADHD, dementia, traumatic brain injury, and more. She also offers therapy for older adults, med-legal and capacity assessments, workers’ compensation assessments, and pre-surgical evaluations. In addition to evaluations, she provides mental health consultations and presentations. Visit Dr. Reger’s blog for more helpful insights today!