CPAs in an Aging Society: When Alzheimer's Disease Affects a Client

PRACTICE MANAGEMENT IMPLICATIONS

While it’s often unpleasant, you need to have a discussion with the client when you first detect problems. Even long-term clients may resent your broaching the topic and challenge your qualifications. But you are not making a diagnosis; you are merely discussing the problems you are experiencing in working with the client. You could very well lose the engagement. You may get fired or need to resign because you believe the situation has become untenable. The problems cannot be ignored, and changes to your practice management may be required.

Engagement letters and legal documents. Anticipating the cognitive problems your clients may have is the best preparation. According to the AICPA publication CPA ElderCare/PrimePlus Services: A Practitioner’s Resource Guide, it is recommended that the engagement letter include the name of a contact person designated to make decisions on behalf of the client should the client lack capacity. The contact person should hold the appropriate

durable power of attorney that permits him or her to take action in case of mental incapacity. Periodically, the engagement letter should be updated or, at the very least, the contact person named in the original letter should be reconfirmed. If the contact person has since died or is unwilling or unable to perform, a new contact person must be named.

If you find that there is no contact person or that the contact person is no longer willing or able to perform the duties, you may still be able to ensure the appropriate documents are in place. According to Pam Smith, education coordinator at the Rush University Alzheimer’s Disease Center in Chicago, individuals in the early stages of Alzheimer’s have lucid moments. During these moments of lucidity, the client can name the contact person and sign the documents. It is important for the CPA to obtain the appropriate written permission to discuss concerns with the contact person. Rule 301 of the AICPA Code of Professional Conduct imposes a duty on members to protect the confidentiality of client information. If the client does not grant permission, it maybe difficult for the CPA to discuss the client’s situation.

If the client does not have an attorney, consider recommending him or her to seek the counsel of an elder law attorney.

Enhancing your client’s capabilities. It is the CPA’s very familiarity with the client over a long period of time that provides a baseline for recognizing changes in the client’s behavior. The CPA may have to decide if a client’s changing behavior and diminishing mental capacity are interfering with the CPA/client relationship. The CPA has to rely on his or her best professional judgment as to which actions to take.

When problems first become apparent, the CPA may consider:

• Some problems may be only temporary. The recent death of a spouse, changes in medications, illnesses and infections may cause temporary problems. If the problems appear to be temporary, suggest rescheduling the meeting or cutting the meeting short. Recommend the client delay making decisions.
• If an older client is exhibiting ongoing problems, consider changing how you communicate to accommodate your client’s limitations. If it appears the client is struggling, it may be best to shorten the meeting and suggest you finish at a later date (see sidebar, “Communication Skills”).

You may also consider making changes to your practice procedures to accommodate a client’s diminished capabilities:

• Make meetings shorter but more frequent.
• Schedule meetings during the time of day the client tends to be more comfortable and aware.
• Focus on just one or two topics per meeting.
• Invite the client to bring a spouse or a trusted family member to the meeting.
• Follow up each meeting with detailed notes to send the client. For clients with more severe memory problems send a copy of meeting notes (with the client’s permission) to a family member.
• In the notes, be clear regarding who is responsible to take what action and any agreed-upon deadlines.
• It may be useful to assign an assistant to make “reminder calls” to the client the day before a meeting.
• Smith of the Rush Alzheimer’s Disease Center recommends meeting the client in his or her home. For individuals experiencing memory loss, familiar surroundings are best. In addition, the client does not have to deal with the stress of getting ready for the meeting and driving to the office and arriving there—on time. All of that takes energy that may make it difficult for the client to focus.

When Alzheimer’s interferes with the CPA/client relationship. Despite all the planning and effort, the client’s incapacity may reach a level that severely interferes with the CPA/client relationship. If a contact person is named in the engagement letter and is still able and willing to perform, it is recommended that the CPA call the person in.

In some circumstances when no contact person or family member is available, the CPA may consider contacting a state or local government agency that provides services to seniors. Many states impose a duty to report individuals who may be prone to “self neglect.” In Illinois, for example, a CPA is immune from criminal, civil or professional disciplinary action if he or she files a report with the Illinois Department on Aging if the CPA believes that doing so is in the best interest of the elderly person. State laws supersede the AICPA Code of Professional Conduct. State law may also impose an affirmative duty on the CPA to report suspected physical abuse, neglect or financial exploitation of an elderly client. You should try to become familiar with the law in your state.

CONCLUSION

The aging of our society is a personal and professional challenge for CPAs. Many CPAs will experience it within their own families. Professionally, CPAs face challenges providing services to clients with mild to moderate Alzheimer’s. But while the challenges are great, so is the opportunity for professional satisfaction by learning to work successfully with vulnerable clients and their families.