What is Fluctuating Capacity?
Fluctuating capacity refers to a person's ability to make a specific decision varying over time due to an underlying health condition. This is a distinct and complex issue in elder care, requiring that any assessment of a person's capacity be both decision-specific and time-specific, as dictated by legislation like the Mental Capacity Act. It is not a blanket inability but a temporary or cyclical impairment of cognitive function. Conditions such as dementia, delirium from infection, and certain mental health disorders can all cause a person's capacity to fluctuate, making it a critical topic for caregivers, family members, and medical professionals to understand.
Example: Dementia and "Sundowning"
A prominent and often cited example of fluctuating capacity is seen in individuals with certain types of dementia, particularly when they experience "sundowning".
The Sundowning Phenomenon
- Morning clarity: In the morning, the person may be lucid, oriented, and fully capable of engaging in a conversation about their daily schedule or even making minor financial decisions.
- Evening confusion: As the afternoon wears on, and especially in the evening, their cognitive function declines. They may become disoriented, anxious, or confused. During this period, they may struggle to remember recent events or understand the implications of a decision, indicating a temporary lack of capacity.
This daily pattern perfectly illustrates fluctuating capacity, where the person's ability to comprehend, retain, weigh, and communicate a decision changes predictably over the course of a day. For a family member or care provider, this means that a decision made during the morning's period of clarity is valid, but the same decision-making process may be impossible later in the day.
Other Examples of Fluctuating Capacity
Delirium Caused by Infection
An example of a more temporary, non-cyclical fluctuation is delirium. A urinary tract infection (UTI) in an elderly person can lead to sudden, severe confusion and cognitive impairment, causing a temporary loss of capacity. Once the infection is treated, the delirium often subsides, and the person's mental capacity can return to its previous baseline. This highlights the importance of medical evaluation, as a reversible condition may be the root cause of the capacity change.
Mental Health Conditions
Certain mental health conditions, like bipolar disorder, can also cause fluctuating capacity. A person experiencing a manic episode might make impulsive and financially reckless decisions, showing a lack of capacity for judgment in that specific area. When their mood stabilizes, their decision-making capacity can return. This type of fluctuation can occur over weeks or months, rather than hours.
Assessing Capacity During Fluctuations
When an individual's capacity is known to fluctuate, assessment and care planning require a flexible, person-centered approach. Here are the steps involved:
- Time the assessment: Whenever possible, assessments should be timed for when the individual is most likely to have capacity. For a person with sundowning, this means a morning assessment is more appropriate than an evening one.
- Involve the care team: Family members, caregivers, and medical professionals who observe the individual's patterns can provide crucial insight into the nature and timing of the fluctuations.
- Take practical steps to support: Before concluding a lack of capacity, all practical steps must be taken to help the person decide. This could involve providing information in a simpler format, or waiting for a more lucid period.
- Adopt a longitudinal view: Legal professionals, particularly in matters of litigation, may adopt a longitudinal approach, considering the individual's decision-making ability over an extended period rather than just a single point in time.
Comparison of Fluctuating Capacity Examples
| Feature | Dementia (Sundowning) | Delirium (UTI) | Mental Illness (Bipolar) |
|---|---|---|---|
| Pattern | Predictable daily cycle | Acute, often temporary, resolves with treatment | Episodic over weeks or months |
| Onset | Gradual, progressive | Sudden onset | Related to mood cycles or medication |
| Assessment | Best conducted during periods of higher cognition (e.g., mornings) | Requires treating underlying medical issue first; assessment follows recovery | Assessment during periods of stable mood |
| Key Triggers | End-of-day fatigue, changes in light | Infection, illness | Medication changes, stress, mood shifts |
Managing Decisions for Individuals with Fluctuating Capacity
When an individual has fluctuating capacity, proactive legal and care planning is essential to protect their autonomy and well-being. Legal tools are crucial for ensuring that wishes are respected during periods when capacity is diminished.
- Advance Directives: Creating advance directives, such as a living will or a healthcare power of attorney, while the person still has capacity allows them to make their wishes known for future medical decisions.
- Power of Attorney: A durable power of attorney for finances can be established to authorize a trusted person to manage financial affairs during periods of incapacity.
- Best Interests Decisions: For decisions that must be made when the person lacks capacity and no advance plan exists, the decision must be made in their "best interests," considering their values and preferences when they were well.
Conclusion: Supporting Autonomy and Dignity
Managing a person with fluctuating capacity is a delicate balance between respecting their autonomy and ensuring their safety and well-being. By understanding the causes, recognizing the patterns, and employing appropriate legal and care strategies, we can uphold their dignity and support them in the most respectful way possible. Comprehensive care planning should always involve collaborating with the individual, their loved ones, and a multi-disciplinary team of professionals, ensuring that decisions are made with the least restriction possible and in their best interests.
For more information on legal aspects of capacity, consult the Mental Capacity Act Code of Practice.
