Evaluating Testamentary Capacity from Handwriting: Research & Applications Heidi H. Harralson, MA, D-BFDE Association of Forensic Document Examiners October 17, 2010, Phoenix, Arizona

Impaired Cognition Alzheimer’s Alzheimer’s Parkinson’s Parkinson’s Dementia Dementia Delirium Delirium Drugs/medications Drugs/medications Stroke Stroke

Disturbed Movement Hand movements and the generation of writing movements are complex processes involving the integration of different instances, from planning to the activation and execution of simple motor programs. Disturbances in any of these instances therefore result in disturbed movement sequences Hand movements and the generation of writing movements are complex processes involving the integration of different instances, from planning to the activation and execution of simple motor programs. Disturbances in any of these instances therefore result in disturbed movement sequences Schroter, A., Mergl, R., Burger, K., Hampel, H., Moller, H.-J., & Hegerl, U. (2003). Kinematic analysis of handwriting movements in patients with Alzheimer’s disease, mild cognitive impairment, depression and healthy controls. Dementia and Geriatric Disorders, 15,

Dysgraphia & Delirium Inability to write Inability to write Tremor Tremor Clumsiness Clumsiness Micrographia Micrographia Reiterated drawing [perseveration] Reiterated drawing [perseveration] Spatial disorders Spatial disorders Macleod, A. D., & Whitehead, L. E. (1997). Dysgraphia and terminal delirium. Palliative Medicine, 11,

Most consistent defect was reduplication of letters Most consistent defect was reduplication of letters Tendency to perseverate is a common feature of delirium Tendency to perseverate is a common feature of delirium Of the language impairments in delirium, dysgraphia is the most significantly impaired (subjects could not write their names or addresses) Of the language impairments in delirium, dysgraphia is the most significantly impaired (subjects could not write their names or addresses) Macleod, A. D., & Whitehead, L. E. (1997). Dysgraphia and terminal delirium. Palliative Medicine, 11,

Although dysgraphia is undoubtedly a sensitive sign of higher central nervous system dysfunction, it is not specific to delirium, and dysgraphic errors occur in other organic mental disorders. Although dysgraphia is undoubtedly a sensitive sign of higher central nervous system dysfunction, it is not specific to delirium, and dysgraphic errors occur in other organic mental disorders. Macleod, A. D., & Whitehead, L. E. (1997). Dysgraphia and terminal delirium. Palliative Medicine, 11,

Alzheimer’s & Dementia Kinematic Analysis Patients v. healthy controls: Patients v. healthy controls: strokes significantly less consistent lengths (variability) strokes significantly less consistent lengths (variability) Strokes consistently less consistent duration (variability) Strokes consistently less consistent duration (variability) Less peak velocity Less peak velocity Perseveration (multiple sets of responses; excessive repetitions in llll’s) Perseveration (multiple sets of responses; excessive repetitions in llll’s) Slavin, M. J., Phillips, J. G., Bradshaw, J. L., Hall, K. A., & Presnell, I. (1999). Consistency of handwriting movements in dementia of the Alzheimer’s type: A comparison of Huntington’s and Parkinson’s disease, Journal of the International Neuropsychological Society, 11,

Perseveration

Errors

Alzheimer’s & Mild Cognitive Impairment Significant correlations were found…between cognitive function and kinematic handwriting parameters, reflecting poorer motor coordination in cognitively impaired patients. Significant correlations were found…between cognitive function and kinematic handwriting parameters, reflecting poorer motor coordination in cognitively impaired patients. Loss of fine motor performance Loss of fine motor performance Performed worse on tasks Performed worse on tasks Schroter, A., Mergl, R., Burger, K., Hampel, H., Moller, H.-J., & Hegerl, U. (2003). Kinematic analysis of handwriting movements in patients with Alzheimer’s disease, mild cognitive impairment, depression and healthy controls. Dementia and Geriatric Disorders, 15,

Mild Cognitive Impairment and Mild Alzheimer’s Disease Cognitively-impaired patients Cognitively-impaired patients Higher temporal measures Higher temporal measures Pressure was lower Pressure was lower Loss of fine motor performance Loss of fine motor performance Less regular movements Less regular movements Longer “in-air” time Longer “in-air” time Werner, P., Rosenblum, S., Bar-On, G., Heinik, J., & Korczyn, A. (2006). Handwriting process variables discriminating mild Alzheimer’s disease and mild cognitive impairment. Journal of Gerontology, 61B(4),

Testamentary Capacity 25 patients referred for mental deterioration to a neuropsychological clinic 25 patients referred for mental deterioration to a neuropsychological clinic Administered Administered Milan Overall Dementia Assessment (MODA) scale Milan Overall Dementia Assessment (MODA) scale Mini Mental State Examination (MMSE) Mini Mental State Examination (MMSE) Fontana, P., Dagnino, F., Cocito, L., & Balestrino, M. (2008). Handwriting as a gauge of cognitive status: A novel forensic tool for posthumous evaluation of testamentary capacity. Neurological Sciences, 29,

Testamentary Capacity Three writing samples collected from each subject Three writing samples collected from each subject Analyzed using semi-quantitative scale Analyzed using semi-quantitative scale Verbal/lexical skills Verbal/lexical skills Spatial orientation Spatial orientation Fontana, P., Dagnino, F., Cocito, L., & Balestrino, M. (2008). Handwriting as a gauge of cognitive status: A novel forensic tool for posthumous evaluation of testamentary capacity. Neurological Sciences, 29,

Verbal/Lexical Skills Evaluation - No mistakes - Some mistakes (e.g., missing or wrong letters, words written in a wrong way), however text can be easily understood - Some mistakes (as above), however text can be understood with some effort - Some mistakes (as above), text can be understood only with considerable effort - Text not understandable Scale

Spatial Orientation Evaluation - Normally oriented rows. In each row, beginning and end correspond to the page margins - Rows slightly distorted or with beginning and end bearing little correspondence to the page margins - Rows clearly distorted or with beginning and end not corresponding to the page margins - Words or letters inserted where they do not belong in the text - Chaotic orientation of the rows Scale54321

Score Data showed that no patient who had a writing score < 5 had a MODA score higher than 60 or a MMSE higher than 20 Data showed that no patient who had a writing score < 5 had a MODA score higher than 60 or a MMSE higher than 20 The latter is believed to represent a cutoff point distinguishing mild dementia from a more severe form The latter is believed to represent a cutoff point distinguishing mild dementia from a more severe form A writing score < 5 is a strong indicator of severe mental impairment A writing score < 5 is a strong indicator of severe mental impairment

Case Study

Verbal/lexical = 3Spatial = 2Writing Index = 5 Perseveration, errors, in-air time?

Verbal/lexical = 2Spatial = 2Writing Index = 4 Irregularity, illegibility, errors

Verbal/lexical = 1Spatial = 2Writing Index = 3

Results The questioned handwriting displays erratic and distorted handwriting features including tremor, irregular alignment, errors, cross-outs, spelling errors, irregular handwriting forms, letter form errors, decreased legibility. The questioned handwriting displays erratic and distorted handwriting features including tremor, irregular alignment, errors, cross-outs, spelling errors, irregular handwriting forms, letter form errors, decreased legibility. Tremulous writing does not automatically equal cognitive impairment Tremulous writing does not automatically equal cognitive impairment

Opinion The deterioration of the questioned handwriting is consistent with the deterioration that results from health and/or medication related causes. The deterioration of the questioned handwriting is consistent with the deterioration that results from health and/or medication related causes. The deterioration of the handwriting could be caused by impaired cognitive status at the time the handwriting was executed on the questioned documents. The deterioration of the handwriting could be caused by impaired cognitive status at the time the handwriting was executed on the questioned documents.

Limitations Awkward writing position Awkward writing position Guided hand Guided hand Other medical conditions can impair handwriting without necessarily impairing cognition Other medical conditions can impair handwriting without necessarily impairing cognition focal brain lesions caused by stroke or tumor…these can selectively affect speech or visuospatial abilities 1 focal brain lesions caused by stroke or tumor…these can selectively affect speech or visuospatial abilities 1 Essential tremor (extreme cases) Essential tremor (extreme cases) 1 Fontana, P., Dagnino, F., Cocito, L., & Balestrino, M. (2008). Handwriting as a gauge of cognitive status: A novel forensic tool for posthumous evaluation of testamentary capacity. Neurological Sciences, 29,

Context Issues Alleged elder abuse Alleged elder abuse Medical/surgery complications Medical/surgery complications postoperative delirium postoperative delirium Medications Medications Morphine, Percocet, Xanax Morphine, Percocet, Xanax

Conclusion Evaluating testamentary capacity may be possible from handwriting as long as limitations are evaluated and incorporated into the opinion Evaluating testamentary capacity may be possible from handwriting as long as limitations are evaluated and incorporated into the opinion

Contact Heidi H. Harralson, MA, D-BFDE Spectrum Forensic International, LLC