1
|
Gauch M, Corsten S, Köb AL, Tüscher O, Heinrich I, Geschke K. Cope PPA-Adaptation of the Biographic-Narrative Approach for Persons with Primary Progressive Aphasia: Protocol for Clinical Trial Design. Brain Sci 2024; 14:692. [PMID: 39061432 PMCID: PMC11274457 DOI: 10.3390/brainsci14070692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/06/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
Persons with primary progressive aphasia (PPA) often experience limitations in their quality of life (QoL). Some studies have shown positive effects of speech and language therapy on QoL in persons with PPA. However, there is still a lack of evidence for disorder-specific approaches for this important therapeutic goal. The biographic-narrative approach (narraktiv) has been shown to significantly improve QoL in persons with post-stroke aphasia. In the planned study, the biographic-narrative approach will be adapted for persons with PPA (Cope PPA), and its efficacy will be investigated. First, a focus group interview with five persons with PPA will be conducted to identify the wishes and needs of participants. Based on the results, the narraktiv manual according to Corsten et al. (2015) will be revised. Second, an efficacy study will be conducted according to the new Cope PPA manual with 24 persons with PPA in a waiting group control design. The primary outcome, QoL, will be assessed using questionnaires (Stroke and Aphasia Quality of Life Scale-39) and semistructured interviews. Depressive symptoms, life satisfaction and cognitive/communicative functioning will also be assessed. If Cope PPA proves efficacy, this study may help to improve the treatment of persons with PPA.
Collapse
Affiliation(s)
- Mirjam Gauch
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (A.-L.K.); (O.T.); (I.H.); (K.G.)
| | - Sabine Corsten
- Faculty of Healthcare and Nursing, Catholic University of Applied Sciences Mainz, 55122 Mainz, Germany;
| | - Anna-Lena Köb
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (A.-L.K.); (O.T.); (I.H.); (K.G.)
| | - Oliver Tüscher
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (A.-L.K.); (O.T.); (I.H.); (K.G.)
| | - Isabel Heinrich
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (A.-L.K.); (O.T.); (I.H.); (K.G.)
| | - Katharina Geschke
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany; (A.-L.K.); (O.T.); (I.H.); (K.G.)
| |
Collapse
|
2
|
Morena D, Lippi M, Di Fazio N, Delogu G, Rinaldi R, Frati P, Fineschi V. Capacity to Consent in Healthcare: A Systematic Review and Meta-Analysis Comparing Patients with Bipolar Disorders and Schizophrenia Spectrum Disorders. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:764. [PMID: 38792947 PMCID: PMC11123007 DOI: 10.3390/medicina60050764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/27/2024] [Accepted: 04/30/2024] [Indexed: 05/26/2024]
Abstract
Background: Mental capacity is a fundamental aspect that enables patients to fully participate in various healthcare procedures. To assist healthcare professionals (HCPs) in assessing patients' capacity, especially in the mental health field, several standardized tools have been developed. These tools include the MacArthur Competence Assessment Tool for Treatment (MacCAT-T), the MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), and the Competence Assessment Tool for Psychiatric Advance Directives (CAT-PAD). The core dimensions explored by these tools include Understanding, Appreciation, Reasoning, and Expression of a choice. Objective: This meta-analysis aimed to investigate potential differences in decision-making capacity within the healthcare context among groups of patients with bipolar disorders (BD) and schizophrenia spectrum disorders (SSD). Methods: A systematic search was conducted on Medline/Pubmed, and Scopus. Additionally, Google Scholar was manually inspected, and a manual search of emerging reviews and reference lists of the retrieved papers was performed. Eligible studies were specifically cross-sectional, utilizing standardized assessment tools, and involving patients diagnosed with BD and SSD. Data from the studies were independently extracted and pooled using random-effect models. Hedges' g was used as a measure for outcomes. Results: Six studies were identified, with three studies using the MacCAT-CR, two studies the MacCAT-T, and one the CAT-PAD. The participants included 189 individuals with BD and 324 individuals with SSD. The meta-analysis revealed that patients with BD performed slightly better compared to patients with SSD, with the difference being statistically significant in the domain of Appreciation (ES = 0.23, 95% CI: 0.01 to 0.04, p = 0.037). There was no statistically significant difference between the two groups for Understanding (ES = 0.09, 95% CI:-0.10 to 0.27, p = 0.352), Reasoning (ES = 0.18, 95% CI: -0.12 to 0.47, p = 0.074), and Expression of a choice (ES = 0.23, 95% CI: -0.01 to 0.48, p = 0.60). In the sensitivity analysis, furthermore, when considering only studies involving patients in symptomatic remission, the difference for Appreciation also resulted in non-significant (ES = 0.21, 95% CI: -0.04 to 0.46, p = 0.102). Conclusions: These findings indicate that there are no significant differences between patients with BD and SSD during remission phases, while differences are minimal during acute phases. The usefulness of standardized assessment of capacity at any stage of the illness should be considered, both for diagnostic-therapeutic phases and for research and advance directives. Further studies are necessary to understand the reasons for the overlap in capacity between the two diagnostic categories compared in this study.
Collapse
Affiliation(s)
| | | | | | | | | | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00185 Rome, Italy; (D.M.); (M.L.); (N.D.F.); (G.D.); (R.R.); (V.F.)
| | | |
Collapse
|
3
|
Wexler A, Sullivan LS. Translational Neuroethics: A Vision for a More Integrated, Inclusive, and Impactful Field. AJOB Neurosci 2023; 14:388-399. [PMID: 34851808 PMCID: PMC9187971 DOI: 10.1080/21507740.2021.2001078] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
As early-career neuroethicists, we come to the field of neuroethics at a unique moment: we are well-situated to consider nearly two decades of neuroethics scholarship and identify challenges that have persisted across time. But we are also looking squarely ahead, embarking on the next generation of exciting and productive neuroethics scholarship. In this article, we both reflect backwards and turn our gaze forward. First, we highlight criticisms of neuroethics, both from scholars within the field and outside it, that have focused on speculation and lack of skepticism; the dearth of consideration of broader social issues such as justice and equality, both with regard to who speaks for neuroethics as a field and who benefits from its recommendations and findings; and the insufficient focus on the practical impact of our ethical work. Second, we embrace the concept of "translational neuroethics" to outline a vision for neuroethics that is integrated, inclusive, and impactful. Integration can help us identify more pertinent, real-world issues, and move away from speculation; inclusivity can help ensure that the questions we attend to are not merely relevant to a single subgroup but aim toward just distribution of benefits; and impact can help us think beyond guidelines and recommendations to focus on implementation. Our goal is for this call to action to help shape neuroethics into a discipline that develops rigorous research agendas through relationships with interdisciplinary partners, that is broadly inclusive and attends to issues beyond novel neurotechnologies, and that is devoted to the translation of scholarship into practice.
Collapse
|
4
|
Jawa NA, Boyd JG, Maslove DM, Scott SH, Silver SA. Informed consent practices in clinical research: present and future. Postgrad Med J 2023; 99:1033-1042. [PMID: 37265442 DOI: 10.1093/postmj/qgad039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/06/2023] [Indexed: 06/03/2023]
Abstract
Clinical research must balance the need for ambitious recruitment with protecting participants' autonomy; a requirement of which is informed consent. Despite efforts to improve the informed consent process, participants are seldom provided sufficient information regarding research, hindering their ability to make informed decisions. These issues are particularly pervasive among patients experiencing acute illness or neurological impairment, both of which may impede their capacity to provide consent. There is a critical need to understand the components, requirements, and methods of obtaining true informed consent to achieve the vast numbers required for meaningful research. This paper provides a comprehensive review of the tenets underlying informed consent in research, including the assessment of capacity to consent, considerations for patients unable to consent, when to seek consent from substitute decision-makers, and consent under special circumstances. Various methods for obtaining informed consent are addressed, along with strategies for balancing recruitment and consent.
Collapse
Affiliation(s)
- Natasha A Jawa
- Centre for Neuroscience Studies, Faculty of Health Sciences, Queen's University, Kingston, Ontario K7L 3N6, Canada
- School of Medicine, Faculty of Health Sciences, Queen's University, Kingston, Ontario K7L 3L4, Canada
| | - J Gordon Boyd
- Centre for Neuroscience Studies, Faculty of Health Sciences, Queen's University, Kingston, Ontario K7L 3N6, Canada
- Division of Neurology, Department of Medicine, Queen's University, Kingston, Ontario K7L 2V7, Canada
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario K7L 2V7, Canada
- Department of Critical Care Medicine, Kingston Health Sciences Centre, Kingston, Ontario K7L 2V7, Canada
| | - David M Maslove
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario K7L 2V7, Canada
- Department of Critical Care Medicine, Kingston Health Sciences Centre, Kingston, Ontario K7L 2V7, Canada
| | - Stephen H Scott
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario K7L 3N6, Canada
| | - Samuel A Silver
- Division of Nephrology, Department of Medicine, Queen's University, Kingston, Ontario K7L 2V7, Canada
| |
Collapse
|
5
|
Fenton L, Han SD, DiGuiseppi CG, Fowler NR, Hill L, Johnson RL, Peterson RA, Knoepke CE, Matlock DD, Moran R, Karlawish J, Betz ME. Mild Cognitive Impairment is Associated with Poorer Everyday Decision Making. J Alzheimers Dis 2023; 94:1607-1615. [PMID: 37458034 DOI: 10.3233/jad-230222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Older adults are faced with many unique and highly consequential decisions such as those related to finances, healthcare, and everyday functioning (e.g., driving cessation). Given the significant impact of these decisions on independence, wellbeing, and safety, an understanding of how cognitive impairment may impact decision making in older age is important. OBJECTIVE To examine the impact of mild cognitive impairment (MCI) on responses to a modified version of the Short Portable Assessment of Capacity for Everyday Decision making (SPACED). METHODS Participants were community-dwelling, actively driving older adults (N = 301; M age = 77.1 years, SD = 5.1; 69.4% with a college degree or higher; 51.2% female; 95.3% White) enrolled in the Advancing Understanding of Transportation Options (AUTO) study. A generalized linear model adjusted for age, education, sex, randomization group, cognitive assessment method, and study site was used to examine the relationship between MCI status and decision making. RESULTS MCI status was associated with poorer decision making; participants with MCI missed an average of 2.17 times more points on the SPACED than those without MCI (adjusted mean ratio: 2.17, 95% CI: 1.02, 4.61, p = 0.044). CONCLUSION This finding supports the idea that older adults with MCI exhibit poorer decision-making abilities than cognitively normal older adults. It also suggests that older adults with MCI may exhibit poorer decision making across a wide range of decision contexts.
Collapse
Affiliation(s)
- Laura Fenton
- Department of Psychology, USC Dornsife College of Letters, Arts, and Sciences, Los Angeles, CA, USA
| | - S Duke Han
- Department of Psychology, USC Dornsife College of Letters, Arts, and Sciences, Los Angeles, CA, USA
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA
- Department of Family Medicine, Keck School of Medicine of USC, Alhambra, CA, USA
- Department of Medicine, Keck School of Medicine of USC, Los Angeles, CA, USA
- Department of Neurology, Keck School of Medicine of USC, Los Angeles, CA, USA
- USC School of Gerontology, Los Angeles, CA, USA
| | - Carolyn G DiGuiseppi
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nicole R Fowler
- Center for Aging Research, Indiana University School of Medicine, Regenstrief Institute, Indianapolis, IN, USA
| | - Linda Hill
- School of Public Health, University of California San Diego, San Diego, CA, USA
| | - Rachel L Johnson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ryan A Peterson
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Christopher E Knoepke
- Adult & Child Consortium for Outcomes Research & Delivery Science, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Division of Cardiology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel D Matlock
- Adult & Child Consortium for Outcomes Research & Delivery Science, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, CO, USA
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan Moran
- School of Public Health, University of California San Diego, San Diego, CA, USA
| | - Jason Karlawish
- Penn Memory Center, Departments of Medicine, Medical Ethics and Health Policy, and Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Marian E Betz
- Department of Emergency Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, CO, USA
| |
Collapse
|
6
|
Decisional capacity to consent to treatment and research in patients affected by Mild Cognitive Impairment. A systematic review and meta-analysis. Int Psychogeriatr 2022; 34:529-542. [PMID: 33583459 DOI: 10.1017/s1041610220004056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To perform a meta-analysis of clinical studies on the differences in treatment or research decision-making capacity among patients with Mild Cognitive Impairment (MCI), Alzheimer's disease (AD), and healthy comparisons (HCs). DESIGN A systematic search was conducted on Medline/Pubmed, CINAHL, PsycINFO, Web of Science, and Scopus. Standardized mean differences and random-effects model were used in all cases. SETTING The United States, France, Japan, and China. PARTICIPANTS Four hundred and ten patients with MCI, 149 with AD, and 368 HCs were included. MEASUREMENTS The studies we included in the analysis assessed decisional capacity to consent by the MacArthur Competence Assessment Tool for Treatment (MAcCAT-T), MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), Capacity to Consent to Treatment Instrument (CCTI), and University of California Brief Assessment of Capacity to Consent (UBACC). RESULTS We identified 109 potentially eligible studies from 1672 records, and 7 papers were included in the meta-analysis. The meta-analysis showed that there was significant impairment in a decision-making capacity in MCI patients compared to the HCs group in terms of Understanding (SMD = -1.04, 95% CI: -1.31 to -0.77, P < 0.001; I2 = 52%, P = 0.07), Appreciation (SMD = -0.51, 95% CI: -0.66 to -0.36, P < 0.001; I2 = 0%, P = 0.97), and Reasoning (SMD = -0.62, 95% CI: -0.77, -0.47, P < 0.001; I2=0%, P =0.46). MCI patients scored significantly higher in Understanding (SMD = 1.50, 95% CI: 0.91, 2.09, P = 0.01, I2 = 78%, P = 0.00001) compared to patients affected by AD. CONCLUSIONS Patients affected by MCI are at higher risk of impaired capacity to consent to treatment and research compared to HCs, despite being at lower risk compared to patients affected by AD. Clinicians and researchers need to carefully evaluate decisional capacity in MCI patients providing informed consent.
Collapse
|
7
|
Siddiqui TG, Bjelkarøy MT, Cheng S, Kristoffersen ES, Grambaite R, Lundqvist C. The effect of cognitive function and central nervous system depressant use on mortality-A prospective observational study of previously hospitalised older patients. PLoS One 2022; 17:e0263024. [PMID: 35239678 PMCID: PMC8893618 DOI: 10.1371/journal.pone.0263024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 01/10/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Older patients are often users of prolonged Central Nervous System Depressants (CNSD) (Z-hypnotics, benzodiazepines and opioids), which may be associated with reduced cognition. The long-term effects of CNSD use and reduced cognitive function in older patients are unclear. The aim of this study was to examine whether cognitive function and CNSD use at baseline hospitalisation were associated with all-cause mortality two years after discharge. METHODS We conducted a prospective observational study, including baseline data (2017-2018) from previously hospitalised older patients (65-90 years), assessing all-cause mortality two years after discharge. We used logistic regression to assess the primary outcome, all-cause mortality two years after baseline hospitalisation. The primary predictors were cognitive function measured by The Mini Mental State Examination (MMSE) and prolonged CNSD use (continuous use ≥ 4 weeks). Adjustment variables: age, gender, education, the Hospital Anxiety and Depression Scale (HADS) and the Cumulative Illness Rating Scale for Geriatrics (CIRS-G), using receiver operating characteristics (ROC) to compare the predictive power of the models. In a sub-analysis we used, the Neurobehavioural Cognitive State Examination (Cognistat) and the Clock Drawing Test. RESULTS Two years after discharge, out of 246 baseline patients, 43 were deceased at follow-up, among these 27 (63%) were CNSD users, and 16 (36%) were non-users at baseline, (p = 0.002). In the multivariable models cognitive function (MMSE score) was a predictor of mortality (OR 0.81 (95% CI 0.69; 0.96), p = 0.014). CNSD use was associated with mortality (OR 2.71 (95% CI 1.06; 6.95), p = 0.038), with ROC AUC: 0.74-0.77 for these models. Results using Cognistat supported the findings. The Clock Drawing Test was not significant predictor of mortality. CONCLUSION Two years after discharge from the hospital, older patients with reduced cognitive function and CNSD use during hospital stay had higher mortality. This underlines that inappropriate (prolonged and concurrent) use of CNSDs should be avoided by older patients, particularly in patients with reduced cognitive function. TRIAL REGISTRATION NCT03162081, 22 May 2017.
Collapse
Affiliation(s)
- Tahreem Ghazal Siddiqui
- Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Maria Torheim Bjelkarøy
- Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Socheat Cheng
- Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Espen Saxhaug Kristoffersen
- Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Ramune Grambaite
- Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Christofer Lundqvist
- Health Services Research Unit (HØKH), Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| |
Collapse
|
8
|
Faaitiiti KL, Jupiter DC. Diabetes-Specific Dementia: A Structured Literature Review of Cognitive Assessment Methods. J Foot Ankle Surg 2022; 61:401-409. [PMID: 34893425 PMCID: PMC8936078 DOI: 10.1053/j.jfas.2021.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 11/08/2021] [Indexed: 02/03/2023]
Abstract
Diabetes mellitus is a known risk factor for the development of multiple subtypes of dementia and mild cognitive impairment. Recent research identifies a cause-specific diabetes-related dementia with a unique set of characteristics. Currently, there is no standard cognitive assessment battery recommended to specifically assess dementia that is a direct consequence of chronic diabetes, and some evaluations have been used for decades with minimal revisions, regardless of appropriateness. We performed a systematic review of the dementia/cognition evaluation methods most commonly used in the literature for assessing diabetic patients and identified which cognitive domains are typically assessed in this setting, and whether cognitive changes were more reflective of a vascular pathology, Alzheimer's pathology, or something else entirely. Search results yielded 1089 articles. After screening for appropriateness, a total of 11 full-text articles were assessed. In general, subjects in the reviewed studies were assessed using a variety of testing methods, examining different combinations of cognitive domains. A standard, clear definition of which cognitive domains are the most important to assess in diabetic patients is needed in order to determine what combination of assessment tools are most pertinent. Given the growing subset of the US population, careful reconsideration of cognitive assessment methods is needed to create self-care plans that take into account a specific collection of cognitive challenges for those with diabetes.
Collapse
Affiliation(s)
- Kelli L Faaitiiti
- Medical Student, School of Medicine, The University of Texas Medical Branch, Galveston, TX
| | - Daniel C Jupiter
- Associate Professor, Department of Preventive Medicine and Population Health, The University of Texas Medical Branch, Galveston, TX; Associate Professor, Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, TX.
| |
Collapse
|
9
|
Santos RL, Simões Neto JP, Belfort T, Lacerda IB, Dourado MCN. Patterns of impairment in decision-making capacity in Alzheimer's disease and its relationship with cognitive and clinical variables. BRAZILIAN JOURNAL OF PSYCHIATRY 2022; 44:271-278. [PMID: 35239836 PMCID: PMC9169465 DOI: 10.1590/1516-4446-2021-2180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/16/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To investigate the patterns of impairment in decision-making abilities and their relationship with cognitive and clinical symptoms in people with Alzheimer's disease. We hypothesized that decision-making abilities would not be impaired at the same level and would be related to impairment of global cognition and other clinical symptoms of the disease. METHODS Using a cross-sectional design, we included a consecutive sample of 102 people with Alzheimer's disease and their respective caregivers. We investigated the relationship between decision-making capacity and quality of life (QoL), disease awareness, mood, functionality, neuropsychiatric symptoms, and cognition. RESULTS Different levels of impairment were observed in the participants' decision-making abilities. Understanding, appreciation, and reasoning were correlated, but expressing a choice was only correlated with appreciation. Deficits in understanding were related to impaired disease awareness, lower self-reported QoL, and lower comprehension of spoken language. Better appreciation was related to better orientation and lower age. Better reasoning was related to better orientation and better self-reported QoL. Deficits in expressing a choice were related to lower self-reported QoL. CONCLUSION The pattern of impairment in decision-making abilities was not linear. Each decision-making ability was related to different cognitive and clinical deficits. Therefore, cognitive functioning is an insufficient criterion for judging an individual's decision-making ability.
Collapse
Affiliation(s)
- Raquel Luiza Santos
- Centro para Doenças de Alzheimer e Outros Transtornos Mentais na Velhice, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.,Departamento de Psicologia, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.,Departamento de Psicologia, Universidade do Grande Rio, Duque de Caxias, RJ, Brazil
| | - José Pedro Simões Neto
- Departamento de Sociologia e Ciência Política, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Tatiana Belfort
- Centro para Doenças de Alzheimer e Outros Transtornos Mentais na Velhice, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Isabel Barbeito Lacerda
- Centro para Doenças de Alzheimer e Outros Transtornos Mentais na Velhice, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Marcia Cristina Nascimento Dourado
- Centro para Doenças de Alzheimer e Outros Transtornos Mentais na Velhice, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| |
Collapse
|
10
|
Fowler ME, Marotta DA, Kennedy RE, Gerstenecker A, Gammon M, Triebel K. Reliability of self-report versus the capacity to consent to treatment instrument to make medical decisions in brain metastasis and other metastatic cancers. Brain Behav 2021; 11:e2303. [PMID: 34599852 PMCID: PMC8613414 DOI: 10.1002/brb3.2303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/25/2021] [Accepted: 07/12/2021] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To evaluate the ability of persons with metastatic cancer to self-assess their medical decision-making capacity (MDC). To investigate this, we compared an objective measure of MDC with self-ratings and evaluated predictors of agreement. METHODS Data were obtained from a cross-sectional study of metastatic cancer patients at a large academic medical center. Across all standards of MDC, sensitivity, specificity, and reliability using Gwet's AC1 statistic were calculated using the objective measure as the gold standard. Logistic regression was used to evaluate predictors of agreement between the measures across all MDC standards. RESULTS In those with brain metastases, high sensitivity (greater than 0.7), but low specificity was observed for all standards. Poor reliability was observed across all standards. Higher age resulted in higher odds of disagreement for Standard 3 (appreciation) (OR: 1.07, 95% CI: 1.00, 1.15) and Standard 4 (reasoning) (OR: 1.05, 95% CI: 1.00, 1.10). For Standard 3, chemotherapy use and brain metastases compared to other metastases resulted in higher odds of disagreement (Chemotherapy: OR: 5.62, 95% CI: 1.37, 23.09, Brain Metastases: OR: 5.93, 95% CI: 1.28, 27.55). For Standard 5 (understanding), no predictors were associated with disagreement. CONCLUSIONS For less cognitively complex standards (e.g., appreciation), self-report may be more valid and reliable than more cognitively complex standards (e.g., reasoning or understanding). However, overall, MDC self-report in the current sample is suboptimal. Thus, the need for detailed assessment of MDC, especially when patients are older or used chemotherapy, is indicated. Other studies should be conducted to assess MDC agreement longitudinally.
Collapse
Affiliation(s)
- Mackenzie E Fowler
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Dario A Marotta
- Division of Neuropsychology, Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Alabama College of Osteopathic Medicine, Dothan, Alabama, USA
| | - Richard E Kennedy
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Adam Gerstenecker
- Division of Neuropsychology, Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Meredith Gammon
- Division of Neuropsychology, Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kristen Triebel
- Division of Neuropsychology, Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| |
Collapse
|
11
|
Wiebe E, Kelly M, McMorrow T, Tremblay-Huet S, Hennawy M. Assessment of capacity to give informed consent for medical assistance in dying: a qualitative study of clinicians' experience. CMAJ Open 2021; 9:E358-E363. [PMID: 33849985 PMCID: PMC8084565 DOI: 10.9778/cmajo.20200136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Under the Canadian Criminal Code, medical assistance in dying (MAiD) requires that patients give informed consent and that their ability to consent is assessed by 2 clinicians. In this study, we intended to understand how Canadian clinicians assessed capacity in people requesting MAiD. METHODS This qualitative study used interviews conducted between August 2019 and February 2020, by phone, video and email, to explore how clinicians assessed capacity in people requesting MAiD, what challenges they had encountered and what tools they used. The participants were recruited from provider mailing listserves of the Canadian Association of MAiD Assessors and Providers and Aide médicale à mourir. Interviews were audio-recorded and transcribed verbatim. The research team met to review transcripts and explore themes as they emerged in an iterative manner. We used abductive reasoning for thematic analysis and coding, and continued to discuss until we reached consensus. RESULTS The 20 participants worked in 5 of 10 provinces across Canada, represented different specialties and had experience assessing a total of 2410 patients requesting MAiD. The main theme was that, for most assessments, the participants used the conversation about how the patient had come to choose MAiD to get the information they needed. When the participants used formal capacity assessment tools, this was mostly for meticulous documentation, and they rarely asked for psychiatric consults. The participants described how they approached assessing cases of nonverbal patients and other challenging cases, using techniques such as ensuring a quiet environment and adequate hearing aids, and using questions requiring only "yes" or "no" as an answer. INTERPRETATION The participants were comfortable doing MAiD assessments and used their clinical judgment and experience to assess capacity in ways similar to other clinical practices. The findings of this study suggest that experienced MAiD assessors do not routinely require formal capacity assessments or tools to assess capacity in patients requesting MAiD.
Collapse
MESH Headings
- Attitude of Health Personnel
- Canada
- Clinical Decision-Making/ethics
- Clinical Decision-Making/methods
- Codes of Ethics
- Euthanasia, Active, Voluntary/ethics
- Euthanasia, Active, Voluntary/legislation & jurisprudence
- Euthanasia, Active, Voluntary/psychology
- Guidelines as Topic
- Humans
- Informed Consent/standards
- Mental Competency
- Nurses
- Physicians
- Practice Patterns, Physicians'/ethics
- Practice Patterns, Physicians'/standards
- Professional Practice/statistics & numerical data
- Qualitative Research
- Right to Die/ethics
- Right to Die/legislation & jurisprudence
- Social Control, Formal/methods
- Suicide, Assisted/ethics
- Suicide, Assisted/legislation & jurisprudence
- Suicide, Assisted/psychology
Collapse
Affiliation(s)
- Ellen Wiebe
- Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; University of London (Kelly), London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; Ontario Tech University (McMorrow), Faculty of Social Science and Humanities, Legal Studies, Oshawa, Ont.; Université de Sherbrooke (Tremblay-Huet), Faculty of Law, Sherbrook, Que.; University of British Columbia (Hennawy), Kelowna, BC
| | - Michaela Kelly
- Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; University of London (Kelly), London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; Ontario Tech University (McMorrow), Faculty of Social Science and Humanities, Legal Studies, Oshawa, Ont.; Université de Sherbrooke (Tremblay-Huet), Faculty of Law, Sherbrook, Que.; University of British Columbia (Hennawy), Kelowna, BC
| | - Thomas McMorrow
- Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; University of London (Kelly), London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; Ontario Tech University (McMorrow), Faculty of Social Science and Humanities, Legal Studies, Oshawa, Ont.; Université de Sherbrooke (Tremblay-Huet), Faculty of Law, Sherbrook, Que.; University of British Columbia (Hennawy), Kelowna, BC
| | - Sabrina Tremblay-Huet
- Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; University of London (Kelly), London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; Ontario Tech University (McMorrow), Faculty of Social Science and Humanities, Legal Studies, Oshawa, Ont.; Université de Sherbrooke (Tremblay-Huet), Faculty of Law, Sherbrook, Que.; University of British Columbia (Hennawy), Kelowna, BC
| | - Mirna Hennawy
- Department of Family Practice (Wiebe), University of British Columbia, Vancouver, BC; University of London (Kelly), London School of Hygiene and Tropical Medicine, Department of Epidemiology and Population Health, London, UK; Ontario Tech University (McMorrow), Faculty of Social Science and Humanities, Legal Studies, Oshawa, Ont.; Université de Sherbrooke (Tremblay-Huet), Faculty of Law, Sherbrook, Que.; University of British Columbia (Hennawy), Kelowna, BC
| |
Collapse
|
12
|
Raffard S, Lebrun C, Laraki Y, Capdevielle D. Validation of the French Version of the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) in a French Sample of Individuals with Schizophrenia: Validation de la version française de l'instrument d'évaluation des compétences MacArthur-traitement (MacCAT-T) dans un échantillon français de personnes souffrant de schizophrénie. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:395-405. [PMID: 33064578 PMCID: PMC8172341 DOI: 10.1177/0706743720966443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Assessing an individual's capacity to consent to treatment is a complex and challenging task for psychiatrists and health-care professionals. Diminished capacity to consent to pharmacological treatment is a common concern in individuals with schizophrenia. The MacArthur Competence Assessment Tool for Treatment (MacCAT-T) is the most common tool used in individuals with schizophrenia to evaluate the decision-making abilities for judgments about competence to consent to treatment. This instrument assesses patients' competence to make treatment decisions by examining their capacities in 4 areas: understanding information relevant to their condition and the recommended treatment, reasoning about the potential risks and benefits of their choices, appreciating the nature of their situation and the consequences of their choices, and expressing a choice. Despite its importance, there is no French version of this scale. Furthermore, its factor structure has never been explored, although validated measures are strongly needed to further detect deficits in patients' decision-making abilities. The goal of this study was thus to empirically validate a French version of the MacCAT-T in a French sample of individuals with schizophrenia. METHOD In this cross-sectional study, we included 125 inpatients with a diagnosis of schizophrenia from the University Department of Adult Psychiatry in Montpellier. The MacCAT-T was administered to patients by a trained psychologist. Patients were also assessed for severity of symptoms, insight into illness, and depressive and anxiety symptoms. Inter-rater reliability and psychometric properties including internal consistency, construct validity, and discriminant and divergent validity were also investigated. RESULTS The MacCAT-T's internal consistency was high (Cronbach α of 0.91). A high degree of inter-rater reliability was found for all the areas of the MacCAT-T (intraclass correlation coefficient range, 0.92 to 0.98). Exploratory factor analysis revealed a 2-factor model. The factor analysis explained 50.03% of the total score variation. Component 1 included all subparts of "understanding." Component 2 included all subparts of "appreciation" and "reasoning" and was therefore labeled "reflexivity." After Bonferroni corrections, decision-making capacity was positively associated with insight and the severity of psychotic symptoms but not with sociodemographic variables except for education. CONCLUSIONS The MacCAT-T demonstrated a high degree of inter-rater reliability and strong psychometric properties. The French version of the MacCAT-T is a valid instrument to assess the decision-making capacity to consent to treatment in a French sample of individuals with schizophrenia.
Collapse
Affiliation(s)
- Stéphane Raffard
- University Department of Adult Psychiatry, 26905CHU Montpellier, University Montpellier 1, Hôpital la Colombière, France.,27038Université Paul Valéry Montpellier 3, EPSYLON EA, France
| | - Cindy Lebrun
- 27038Université Paul Valéry Montpellier 3, EPSYLON EA, France
| | - Yasmine Laraki
- University Department of Adult Psychiatry, 26905CHU Montpellier, University Montpellier 1, Hôpital la Colombière, France.,27038Université Paul Valéry Montpellier 3, EPSYLON EA, France
| | - Delphine Capdevielle
- University Department of Adult Psychiatry, 26905CHU Montpellier, University Montpellier 1, Hôpital la Colombière, France.,Inserm, Neuropsychiatry: Epidemiological and Clinical Research, University of Montpellier, France
| |
Collapse
|
13
|
Hamilton RKB, Phelan CH, Chin NA, Wyman MF, Lambrou N, Cobb N, Kind AJH, Blazel H, Asthana S, Gleason CE. The U-ARE Protocol: A Pragmatic Approach to Decisional Capacity Assessment for Clinical Research. J Alzheimers Dis 2020; 73:431-442. [PMID: 31868663 PMCID: PMC7388558 DOI: 10.3233/jad-190457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
With increased longevity and growth in the number of older adults comes rising rates of individuals with cognitive impairment and dementia. The expansion of this population has important implications for research on aging and dementia syndromes, namely increased enrollment of older individuals in clinical research. Ethical prerogatives, as well as historical underrepresentation of persons with dementia in research studies due to the perceived burden of traditional decisional capacity evaluations, necessitates the development of pragmatic approaches to ascertain decisional abilities in research settings. We outline a protocol used in the Wisconsin Alzheimer's Disease Research Center (ADRC) that adopts a stepped approach to the evaluation of decisional capacity meant to maximize study visit efficiency while preserving participant safety and autonomy. The protocol specifies the structure of the consent process and incorporates a brief semi-structured interview based on Appelbaum & Grisso's theoretical model for evaluating a patient's decisional capacity to provide informed consent to participate in research. This protocol is easily implemented in a research study visit and is designed to minimize participant burden and ensure reliable assessment of decisional capacity in older adults across a wide range of research protocols. The protocol emphasizes capacity optimization, using memory aids and other compensatory strategies to preserve participant autonomy while protecting welfare.
Collapse
Affiliation(s)
- Rachel K. B. Hamilton
- Department of Psychology, University of Wisconsin – Madison, Madison, WI, USA
- Geriatric Research, Education, & Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Cynthia H. Phelan
- Aurora Center for Nursing Research and Practice, Advocate Aurora Health Care, Milwaukee, WI, USA
| | - Nathaniel A. Chin
- Department of Medicine – Division of Geriatrics, School of Medicine and Public Health, University of Wisconsin – Madison, Madison, WI, USA
- Wisconsin Alzheimer’s Disease Research Center, Madison, WI, USA
| | - Mary F. Wyman
- Geriatric Research, Education, & Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
- Department of Medicine – Division of Geriatrics, School of Medicine and Public Health, University of Wisconsin – Madison, Madison, WI, USA
| | - Nickolas Lambrou
- Geriatric Research, Education, & Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Nichelle Cobb
- Health Sciences IRBs Director, University of Wisconsin – Madison, Madison, WI, USA
| | - Amy J. H. Kind
- Geriatric Research, Education, & Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
- Department of Medicine – Division of Geriatrics, School of Medicine and Public Health, University of Wisconsin – Madison, Madison, WI, USA
- Wisconsin Alzheimer’s Disease Research Center, Madison, WI, USA
| | - Hanna Blazel
- Department of Medicine – Division of Geriatrics, School of Medicine and Public Health, University of Wisconsin – Madison, Madison, WI, USA
- Wisconsin Alzheimer’s Disease Research Center, Madison, WI, USA
| | - Sanjay Asthana
- Geriatric Research, Education, & Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
- Department of Medicine – Division of Geriatrics, School of Medicine and Public Health, University of Wisconsin – Madison, Madison, WI, USA
- Wisconsin Alzheimer’s Disease Research Center, Madison, WI, USA
| | - Carey E. Gleason
- Geriatric Research, Education, & Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
- Department of Medicine – Division of Geriatrics, School of Medicine and Public Health, University of Wisconsin – Madison, Madison, WI, USA
- Wisconsin Alzheimer’s Disease Research Center, Madison, WI, USA
| |
Collapse
|
14
|
Liu H, Fang B, Chan J, Chen G. The relationship between comorbidities in dementia patients and burden on adult-child primary caregivers: Does having a secondary caregiver matter? Int J Ment Health Nurs 2019; 28:1306-1317. [PMID: 31411380 DOI: 10.1111/inm.12640] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 07/08/2019] [Accepted: 07/16/2019] [Indexed: 02/05/2023]
Abstract
Primary family caregivers of patients with dementia often experience high caregiver burden and significant decline in a range of health outcomes. The current study examined the relationship between medical comorbidities of inpatients with dementia and caregiver burden in adult-child primary caregivers, and the buffering effect of having a secondary caregiver on the relationship between patients' comorbidities and caregiver burden. The study is a secondary analysis of data from a cross-sectional observational study design. The sample comprised 477 dyads of inpatients with dementia and adult-child primary caregivers attending the neurological department of two grade A hospitals. All the inpatients were assessed with the Charlson Comorbidity Index (CCI) and the Mini-Mental State Examination (MMSE). All the adult-child primary caregivers were assessed with the Zarit Burden Interview (ZBI) and completed the questionnaires on socio-demographic data, caring hours, presence of secondary caregiver, and the level of impairment of the patient. Higher burden was associated with higher scores on the CCI and having a spouse of the patient as the secondary caregiver. A significant interaction occurred between the CCI and caregiver burden when having a spouse as the secondary caregiver, indicating the negative effect of the CCI on caregiver burden was greater when the spouse of the patient served as the secondary caregiver. In summary, the negative impact of patients' comorbidities on caregiver burden in adult-child primary caregivers was heightened when the secondary caregiver role was undertaken by the spouse of the patient with dementia. These results may inform programmes targeted to improve care arrangements for people with dementia and their caregivers.
Collapse
Affiliation(s)
- Huiying Liu
- Department of Sociology, Central South University, Changsha, Hunan province, China
| | - Boye Fang
- Department of Applied Social Science, The Hong Kong Polytechnic University, Hong Kong, China
| | - Jieling Chan
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China
| | - Gengzhen Chen
- Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| |
Collapse
|
15
|
Dutzi I, Schwenk M, Kirchner M, Bauer JM, Hauer K. "What would you like to achieve?" Goal-Setting in Patients with Dementia in Geriatric Rehabilitation. BMC Geriatr 2019; 19:280. [PMID: 31640595 PMCID: PMC6805571 DOI: 10.1186/s12877-019-1296-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 09/26/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Setting meaningful, individualized rehabilitation goals is an essential part of the rehabilitation process. Even though patients with dementia are a drastically increasing patient group in geriatric rehabilitation, empirical data about meaningful rehabilitation goals and collaborative goal-setting in this target group is missing. Cognitive impairment and lack of insight in current deficits have been discussed as barriers for participation in goal-setting, but require empirical examination. This study investigated the feasibility of a semi-structured versus a structured goal-setting approach and the types of goals, rehabilitation patients with mild to moderate dementia perceive as personally relevant. Insights in acute functional and motor deficits, differentiated by cognitive status were explored. METHODS Cohort study in a geriatric rehabilitation center. Semi-structured and ICF-based, structured interviews were applied to explore patients` rehabilitation goals. Patients` insight in deficits was operationalized as the relationship of self-ratings and objective measures of linked clinical assessments for the same functional construct. RESULTS Patients (n = 101, MMSE 22 ± 2.6, age 83.9 ± 5.9 years) stated the improvement of mobility-related functions and self-care activities (> 70%) but also psychological well-being such as handling stress or mood (> 38%) as most important rehabilitation goals. The structured interview facilitated goal-setting and provided a broader view of rehabilitation needs. Correlations between self-ratings and clinical assessments were medium to high (rho = 0.29 to 0.83) with highest associations for key motor features. Trend tests identified a significant trend between values of the clinical assessment and categories of self-ratings (p ≤ 0.01) with lower cognitive status derogating this relationship. CONCLUSIONS Collaborative goal-setting was feasible, especially when supported by a structured approach and yielded a large spectrum of functional but also psychological rehabilitation needs from the patients` perspective. Patients showed sustained insight in their actual functional impairments, limited in a subgroup of patients with more advanced cognitive impairment.
Collapse
Affiliation(s)
- Ilona Dutzi
- Department of Geriatric Research, AGAPLESION Bethanien Hospital, Geriatric Center at the University of Heidelberg, Rohrbacher Str. 149, 69126 Heidelberg, Germany
| | - Michael Schwenk
- Network Aging Research, University of Heidelberg, Bergheimer St. 20, 69115 Heidelberg, Germany
| | - Marietta Kirchner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Jürgen M. Bauer
- Department of Geriatric Research, AGAPLESION Bethanien Hospital, Geriatric Center at the University of Heidelberg, Rohrbacher Str. 149, 69126 Heidelberg, Germany
- Network Aging Research, University of Heidelberg, Bergheimer St. 20, 69115 Heidelberg, Germany
| | - Klaus Hauer
- Department of Geriatric Research, AGAPLESION Bethanien Hospital, Geriatric Center at the University of Heidelberg, Rohrbacher Str. 149, 69126 Heidelberg, Germany
| |
Collapse
|
16
|
Provencher-Renaud G, Larivée S, Sénéchal C. L’accès à l’aide médicale à mourir pour les personnes souffrant de troubles mentaux. ANNALES MEDICO-PSYCHOLOGIQUES 2019. [DOI: 10.1016/j.amp.2018.08.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
17
|
Die Entwicklung des Konzepts der Einwilligung nach Aufklärung in der psychiatrischen Forschung. Ethik Med 2019. [DOI: 10.1007/s00481-019-00532-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
18
|
Dautel A, Eckert T, Gross M, Hauer K, Schäufele M, Lacroix A, Hendlmeier I, Abel B, Pomiersky R, Gugenhan J, Büchele G, Reber KC, Becker C, Pfeiffer K. Multifactorial intervention for hip and pelvic fracture patients with mild to moderate cognitive impairment: study protocol of a dual-centre randomised controlled trial (OF-CARE). BMC Geriatr 2019; 19:125. [PMID: 31039754 PMCID: PMC6492424 DOI: 10.1186/s12877-019-1133-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 04/09/2019] [Indexed: 01/13/2023] Open
Abstract
Background A hip or pelvic fracture is a major fall-related injury which often causes a decline in mobility performance and physical activity. Over 40% of patients with hip fracture have cognitive impairment or dementia and poorer rehabilitation outcomes than those without cognitive impairment. In this subgroup, there is a lack of evidence on the best practices supporting recovery. The main aim of this study is to investigate the effects of a transitional care intervention after inpatient rehabilitation on physical activity and functional performance in this group of cognitively impaired patients. Methods/design This dual-centre, randomised controlled trial compares a multifactorial intervention with usual care as control condition. Two hundred and forty community-dwellers (≥ 65 years) with a hip or pelvic fracture and mild to moderate cognitive impairment (MMSE 17–26) are recruited at the end of inpatient rehabilitation. The four-month intervention consists of (a) an individually tailored, progressive home exercise program and physical activity promotion delivered by professional instructors and lay instructors (two home visits per week) and (b) a long-term care counselling approach addressing unmet care needs, pleasurable activities, and caregiver issues if needed. Primary outcome parameters are physical activity, measured as daily walking duration with an accelerometer-based activity monitor (activPAL™) over 72 h, and functional performance, assessed with Short Physical Performance Battery sum scores. Secondary outcome parameters are fear of falling, fall related self-efficacy, falls, quality of life, depression and activity of daily living. Data are collected at the end of rehabilitation, before the intervention at the patient’s home (baseline), after four months (post-intervention), and seven months (follow-up). In addition to completer and intent-to-treat analyses of outcomes, economic data and incremental cost-effectiveness are analysed. Discussion Existing service models of volunteer services and legal counselling provided by care counsellors were considered when developing the intervention protocol. Therefore, it should be feasible to translate and deliver the intervention into real-world practice if it has been demonstrated to be effective. Trial registration German Clinical Trials Register, DRKS00008863 (Accessed 17 Apr 2019), ISRCTN registry, ISRCTN69957256 (Accessed 17 Apr 2019).
Collapse
Affiliation(s)
- Anja Dautel
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert-Bosch-Hospital, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | | | - Michaela Gross
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert-Bosch-Hospital, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Klaus Hauer
- Agaplesion Bethanien Hospital, Heidelberg, Germany
| | - Martina Schäufele
- Hochschule Mannheim, University of Applied Science, Mannheim, Germany
| | | | - Ingrid Hendlmeier
- Hochschule Mannheim, University of Applied Science, Mannheim, Germany
| | - Bastian Abel
- Agaplesion Bethanien Hospital, Heidelberg, Germany
| | - Rebekka Pomiersky
- Agaplesion Bethanien Hospital, Heidelberg, Germany.,Hochschule Mannheim, University of Applied Science, Mannheim, Germany
| | - Julia Gugenhan
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert-Bosch-Hospital, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Gisela Büchele
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Katrin C Reber
- Department of Health Economics and Health Services Research, University Medical Centre Hamburg, Hamburg, Germany
| | - Clemens Becker
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert-Bosch-Hospital, Auerbachstrasse 110, 70376, Stuttgart, Germany
| | - Klaus Pfeiffer
- Department of Clinical Gerontology and Geriatric Rehabilitation, Robert-Bosch-Hospital, Auerbachstrasse 110, 70376, Stuttgart, Germany.
| |
Collapse
|
19
|
Schreiber N, Powell T, O'Dowd MA. Who Should Decide? Residence Capacity Evaluation of a Cognitively-Impaired Older Adult Requesting an “Unsafe” Discharge to Home. PSYCHOSOMATICS 2018; 59:612-617. [DOI: 10.1016/j.psym.2018.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 03/07/2018] [Accepted: 03/19/2018] [Indexed: 11/30/2022]
|
20
|
van Duinkerken E, Farme J, Landeira-Fernandez J, Dourado MC, Laks J, Mograbi DC. Medical and Research Consent Decision-Making Capacity in Patients with Alzheimer’s Disease: A Systematic Review. J Alzheimers Dis 2018; 65:917-930. [DOI: 10.3233/jad-180311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Eelco van Duinkerken
- Center for Epilepsy, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil
- Department of Medical Psychology, Amsterdam University Medical Centers, Free University, Amsterdam, the Netherlands
- Amsterdam Diabetes Center / Department of Internal Medicine, Amsterdam University Medical Centers, Free University, Amsterdam, the Netherlands
| | - Juliana Farme
- Department of Psychology, Pontifícia Universidade Católica Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jesus Landeira-Fernandez
- Department of Psychology, Pontifícia Universidade Católica Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcia C. Dourado
- Alzheimer’s Disease Center / Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jerson Laks
- Alzheimer’s Disease Center / Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Post Graduation Program in Translational Biomedicine- Universidade do Grande Rio, Duque de Caxias, Rio de Janeiro, Brazil
| | - Daniel C. Mograbi
- Department of Psychology, Pontifícia Universidade Católica Rio de Janeiro, Rio de Janeiro, Brazil
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| |
Collapse
|
21
|
Edwards BJ, Zhang X, Sun M, Holmes HM, Ketonen L, Guha N, Khalil P, Song J, Kesler S, Shah JB, Tripathy D, Valero V, Champlin RE. Neurocognitive deficits in older patients with cancer. J Geriatr Oncol 2018. [DOI: 10.1016/j.jgo.2018.02.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
22
|
Scholten M, Gather J. Adverse consequences of article 12 of the UN Convention on the Rights of Persons with Disabilities for persons with mental disabilities and an alternative way forward. JOURNAL OF MEDICAL ETHICS 2018; 44:226-233. [PMID: 29070707 PMCID: PMC5869457 DOI: 10.1136/medethics-2017-104414] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/21/2017] [Accepted: 09/24/2017] [Indexed: 06/01/2023]
Abstract
It is widely accepted among medical ethicists that competence is a necessary condition for informed consent. In this view, if a patient is incompetent to make a particular treatment decision, the decision must be based on an advance directive or made by a substitute decision-maker on behalf of the patient. We call this the competence model. According to a recent report of the United Nations (UN) High Commissioner for Human Rights, article 12 of the UN Convention on the Rights of Persons with Disabilities (CRPD) presents a wholesale rejection of the competence model. The High Commissioner here adopts the interpretation of article 12 proposed by the Committee on the Rights of Persons with Disabilities. On this interpretation, CRPD article 12 renders it impermissible to deny persons with mental disabilities the right to make treatment decisions on the basis of impaired decision-making capacity and demands the replacement of all regimes of substitute decision-making by supported decision-making. In this paper, we explicate six adverse consequences of CRPD article 12 for persons with mental disabilities and propose an alternative way forward. The proposed model combines the strengths of the competence model and supported decision-making.
Collapse
Affiliation(s)
- Matthé Scholten
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Jakov Gather
- Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany
| |
Collapse
|
23
|
Abstract
Children of minor parents are under-represented in clinical trials. This is largely because of the ethical, legal, and regulatory complexities in the enrolment, consent, and appropriate access of children of minor parents to clinical research. Using a case-based approach, we examine appropriate access of children of minor parents in an international vaccine trial. We first consider the scientific justification for inclusion of children of minor parents in a vaccine trial. Laws and regulations governing consent generally do not address the issue of minor parents. In their absence, local community and cultural contexts may influence consent processes. Rights of the minor parent include dignity in their role as a parent and respect for their decision-making capacity in that role. Rights of the child include the right to have decisions made in their best interest and the right to the highest attainable standard of health. Children of minor parents may have vulnerabilities related to the age of their parent, such as increased rates of poverty, that have implications for consent. Neuroscience research suggests that, by age 12-14 years, minors have adult-level capacity to make research decisions in situations with low emotion and low distraction. We conclude with a set of recommendations based on these findings to facilitate appropriate access and equity related to the participation of children of minor parents in clinical research.
Collapse
|
24
|
Smith GE, Chandler M, Fields JA, Aakre J, Locke DE. A Survey of Patient and Partner Outcome and Treatment Preferences in Mild Cognitive Impairment. J Alzheimers Dis 2018; 63:1459-1468. [PMID: 29843239 PMCID: PMC6027859 DOI: 10.3233/jad-171161] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND The patient-centered movement in health care is increasing efforts to design studies and interventions that address the outcomes that matter most to patients and their families. Research has not adequately addressed Alzheimer's disease patient and caregiver preferences. OBJECTIVE To survey the outcome and treatment preferences of patients and caregivers who had completed a multicomponent behavioral intervention for mild cognitive impairment (MCI). METHODS Extending prior work, we conducted an online survey regarding outcome and intervention preferences. Participants were patients with MCI and partners who completed the HABIT Healthy Action to Benefit Independence & Thinking ® program. RESULTS Both patient and partner respondents ranked patient quality of life as the highest priority, followed by patient self-efficacy, functional status, patient mood, and patient memory performance. Distressing behaviors and caregiver outcomes (burden, mood, and self-efficacy) had low rankings. Regarding the importance of HABIT ® program components, memory compensation training was ranked highest and wellness education lowest by all groups. CONCLUSION Additional research should compare patient preference for patient reported outcomes, traditional neuropsychological and clinician outcomes, and modern biomarker outcomes.
Collapse
Affiliation(s)
- Glenn E. Smith
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Melanie Chandler
- Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL, USA
| | - Julie A. Fields
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Jeremiah Aakre
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Dona E.C. Locke
- Department of Psychiatry and Psychology, Mayo Clinic, Scottsdale, AZ, USA
| |
Collapse
|
25
|
Bourgeois JA, Cohen MA, Erickson JM, Brendel RW. Decisional and Dispositional Capacity Determinations: Neuropsychiatric Illness and an Integrated Clinical Paradigm. PSYCHOSOMATICS 2017; 58:565-573. [DOI: 10.1016/j.psym.2017.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/07/2017] [Accepted: 07/09/2017] [Indexed: 10/19/2022]
|
26
|
Assessing capacity to consent to treatment with cholinesterase inhibitors in dementia using a specific and standardized version of the MacArthur Competence Assessment Tool (MacCAT-T). Int Psychogeriatr 2017; 29:333-343. [PMID: 27825402 DOI: 10.1017/s104161021600154x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The use of assessment tools has been shown to improve the inter-rater reliability of capacity assessments. However, instrument-based capacity assessments of people with dementia face challenges. In dementia research, measuring capacity with instruments like the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) mostly employ hypothetical treatment vignettes that can overwhelm the abstraction capabilities of people with dementia and are thus not always suitable for this target group. The primary aim of this study was to provide a standardized real informed consent paradigm that enables the dementia-specific properties of capacity to consent to treatment in people with dementia to be identified in a real informed consent process that is both externally valid and ethically justifiable. METHODS The sample consisted of 53 people with mild to moderate dementia and a group of 133 people without cognitive impairment. Rather than using a hypothetical treatment vignette, we used a standardized version of the MacCAT-T to assess capacity to consent to treatment with cholinesterase inhibitors in people with dementia. Inter-rater reliability, item statistics, and psychometric properties were also investigated. RESULTS Intraclass correlations (ICCs) (0.951-0.990) indicated high inter-rater reliability of the standardized real informed consent paradigm. In the dementia group, performance on different items of the MacCAT-T varied. Most people with dementia were able to express a treatment choice, and were aware of the need to take a tablet. Further information on the course of the disorder and the benefits and risks of the treatment were less understood, as was comparative reasoning regarding treatment alternatives. CONCLUSION The standardized real informed consent paradigm enabled us to detect dementia-specific characteristics of patients' capacity to consent to treatment with cholinesterase inhibitors. In order to determine suitable enhanced consent procedures for this treatment, we recommend the consideration of MacCAT-T results on an item level. People with dementia seem to understand only basic information. Our data indicate that one useful strategy to enhance capacity to consent is to reduce attention and memory demands as far as possible.
Collapse
|
27
|
Santos RL, Sousa MFBD, Simões Neto JP, Bertrand E, Mograbi DC, Landeira-Fernandez J, Laks J, Dourado MCN. MacArthur Competence Assessment Tool for Treatment in Alzheimer disease: cross-cultural adaptation. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:36-43. [DOI: 10.1590/0004-282x20160181] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 09/13/2016] [Indexed: 11/22/2022]
Abstract
ABSTRACT Objective: We adapted the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) to Brazilian Portuguese, pilot testing it on mild and moderate patients with Alzheimer's disease (AD). Methods: The cross-cultural process required six steps. Sixty-six patients with AD were assessed for competence to consent to treatment, global cognition, working memory, awareness of disease, functionality, depressive symptoms and dementia severity. Results: The items had semantic, idiomatic, conceptual and experiential equivalence. We found no difference between mild and moderate patients with AD on the MacCAT-T domains. The linear regressions showed that reasoning (p = 0.000) and functional status (p = 0.003) were related to understanding. Understanding (p = 0.000) was related to appreciation and reasoning. Awareness of disease (p = 0.001) was related to expressing a choice. Conclusions: The MacCAT-T adaptation was well-understood and the constructs of the original version were maintained. The results of the pilot study demonstrated an available Brazilian tool focused on decision-making capacity in AD.
Collapse
Affiliation(s)
| | | | | | | | - Daniel C. Mograbi
- Pontifícia Universidade Católica do Rio de Janeiro, Brasil; King's College London, UK
| | | | - Jerson Laks
- Universidade Federal do Rio de Janeiro, Brasil
| | | |
Collapse
|
28
|
Canadian perspectives on the clinical actionability of neuroimaging in disorders of consciousness. Can J Neurol Sci 2016; 42:96-105. [PMID: 25804248 DOI: 10.1017/cjn.2015.8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Acquired brain injury is a critical public health and socioeconomic problem in Canada, leaving many patients in vegetative, minimally conscious, or locked-in states, unresponsive and unable to communicate. Recent advances in neuroimaging research have demonstrated residual consciousness in a few exemplary patients with acquired brain injury, suggesting potential misdiagnosis and changes in prognosis. Such progress, in parallel with research using multimodal brain imaging technologies in recent years, has promising implications for clinical translation, notwithstanding the many challenges that impact health care and policy development. This study explored the perspectives of Canadian professionals with expertise either in neuroimaging research, disorders of consciousness, or both, on the potential clinical applications and implications of imaging technology. METHODS Twenty-two professionals from designated communities of neuroimaging researchers, ethicists, lawyers, and practitioners participated in semistructured interviews. Data were analyzed for emergent themes. RESULTS The five most dominant themes were: (1) validation and calibration of the methods; (2) informed consent; (3) burdens on the health care system; (4) implications for the Canadian health care system; and (5) possibilities for improved prognosis. CONCLUSIONS Movement of neuroimaging from research into clinical care for acquired brain injury will require careful consideration of legal and ethical issues alongside research reliability, responsible distribution of health care resources, and the interaction of technological capabilities with patient outcome.
Collapse
|
29
|
Palermo MT, Bogaerts S. Sex Selling and Autism Spectrum Disorder: Impaired Capacity, Free Enterprise, or Sexual Victimization? JOURNAL OF FORENSIC PSYCHOLOGY PRACTICE 2015. [DOI: 10.1080/15228932.2015.1053557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
30
|
Buller T. Advance consent, critical interests and dementia research. JOURNAL OF MEDICAL ETHICS 2015; 41:701-707. [PMID: 25118248 DOI: 10.1136/medethics-2014-102024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 07/29/2014] [Indexed: 06/03/2023]
Abstract
Although advance directives have become a familiar instrument within the context of treatment, there has been minimal support for their expansion into the context of research. In this paper I argue that the principle of precedent autonomy that grants a competent person the right to refuse life-sustaining treatment when later incompetent, also grants a competent person the right to consent to research that is greater than minimal risk. An examination of the principle of precedent autonomy reveals that a future-binding research decision is within the scope of a competent person's critical interests, if the decision is consistent with what the person believes gives her life intrinsic value.
Collapse
|
31
|
Informierte Einwilligung in der Demenzforschung. Eine qualitative Studie zum Informationsverständnis von Probanden. Ethik Med 2015. [DOI: 10.1007/s00481-015-0359-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
32
|
Prick AE, de Lange J, van 't Leven N, Pot AM. Process evaluation of a multicomponent dyadic intervention study with exercise and support for people with dementia and their family caregivers. Trials 2014; 15:401. [PMID: 25336121 PMCID: PMC4219091 DOI: 10.1186/1745-6215-15-401] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 10/03/2014] [Indexed: 11/13/2022] Open
Abstract
Background A randomized controlled trial of a multicomponent dyadic intervention (a translated and adapted version of an intervention that has been shown to be effective for people with dementia in the USA) was performed. The exercise and support intervention was intended to reduce depressive symptoms of people with dementia and their caregivers. The purpose of this process evaluation is to create in-depth insight into the delivery of the intervention and the effect analysis, to prevent drawing inappropriate conclusions on the efficacy or effectiveness of the intervention, and to formulate recommendations for future studies on complex geriatric interventions. Methods Qualitative and quantitative data were collected. The process evaluation was performed according to the model presented by Reelick and colleagues, which encompasses the following three process components: (1) success rate of recruitment and quality of the study population; (2) the quality of execution of the complex intervention; and (3) the process of acquisition of the data. Results The study design met high research standards and the intervention was carefully delivered. Evaluation of the study population quality revealed a profound recruitment process resulting in a reasonable sample size. Attrition rate during follow-up was acceptable. With regard to the evaluation of the intervention quality, most interviewed participants experienced benefits of the intervention. Attendance at the home visits was high and attrition to homework was moderate. Evaluation of the data acquisition showed the positive value of the use of a mixed design; qualitative analysis of the intervention revealed outcomes not measured in the quantitative analysis. Conclusions The process evaluation revealed a carefully and soundly performed study. The mixed design contributed to valuable insights. However, there were some restrictions worth considering. The intervention components may have a different feasibility by moderate attrition to homework and some negative experiences of participants, which may be an indication of too intensive an intervention for this frail population in this specific country. As a result, the results of the statistical effect analysis should be interpreted with caution. Trial registration The study has been registered at the Netherlands National Trial Register: NTR1802, registration date 6 May 2009.
Collapse
Affiliation(s)
- Anna-Eva Prick
- Department of Clinical psychology and the EMGO institute for Health and Care Research, Faculty of Psychology and Education, VU University, Van der Boechorststraat 1, 1081, BT, Amsterdam, The Netherlands.
| | | | | | | |
Collapse
|
33
|
Synnot A, Ryan R, Prictor M, Fetherstonhaugh D, Parker B. Audio-visual presentation of information for informed consent for participation in clinical trials. Cochrane Database Syst Rev 2014; 2014:CD003717. [PMID: 24809816 PMCID: PMC6599866 DOI: 10.1002/14651858.cd003717.pub3] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Informed consent is a critical component of clinical research. Different methods of presenting information to potential participants of clinical trials may improve the informed consent process. Audio-visual interventions (presented, for example, on the Internet or on DVD) are one such method. We updated a 2008 review of the effects of these interventions for informed consent for trial participation. OBJECTIVES To assess the effects of audio-visual information interventions regarding informed consent compared with standard information or placebo audio-visual interventions regarding informed consent for potential clinical trial participants, in terms of their understanding, satisfaction, willingness to participate, and anxiety or other psychological distress. SEARCH METHODS We searched: the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library, issue 6, 2012; MEDLINE (OvidSP) (1946 to 13 June 2012); EMBASE (OvidSP) (1947 to 12 June 2012); PsycINFO (OvidSP) (1806 to June week 1 2012); CINAHL (EbscoHOST) (1981 to 27 June 2012); Current Contents (OvidSP) (1993 Week 27 to 2012 Week 26); and ERIC (Proquest) (searched 27 June 2012). We also searched reference lists of included studies and relevant review articles, and contacted study authors and experts. There were no language restrictions. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials comparing audio-visual information alone, or in conjunction with standard forms of information provision (such as written or verbal information), with standard forms of information provision or placebo audio-visual information, in the informed consent process for clinical trials. Trials involved individuals or their guardians asked to consider participating in a real or hypothetical clinical study. (In the earlier version of this review we only included studies evaluating informed consent interventions for real studies). DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for inclusion and extracted data. We synthesised the findings using meta-analysis, where possible, and narrative synthesis of results. We assessed the risk of bias of individual studies and considered the impact of the quality of the overall evidence on the strength of the results. MAIN RESULTS We included 16 studies involving data from 1884 participants. Nine studies included participants considering real clinical trials, and eight included participants considering hypothetical clinical trials, with one including both. All studies were conducted in high-income countries.There is still much uncertainty about the effect of audio-visual informed consent interventions on a range of patient outcomes. However, when considered across comparisons, we found low to very low quality evidence that such interventions may slightly improve knowledge or understanding of the parent trial, but may make little or no difference to rate of participation or willingness to participate. Audio-visual presentation of informed consent may improve participant satisfaction with the consent information provided. However its effect on satisfaction with other aspects of the process is not clear. There is insufficient evidence to draw conclusions about anxiety arising from audio-visual informed consent. We found conflicting, very low quality evidence about whether audio-visual interventions took more or less time to administer. No study measured researcher satisfaction with the informed consent process, nor ease of use.The evidence from real clinical trials was rated as low quality for most outcomes, and for hypothetical studies, very low. We note, however, that this was in large part due to poor study reporting, the hypothetical nature of some studies and low participant numbers, rather than inconsistent results between studies or confirmed poor trial quality. We do not believe that any studies were funded by organisations with a vested interest in the results. AUTHORS' CONCLUSIONS The value of audio-visual interventions as a tool for helping to enhance the informed consent process for people considering participating in clinical trials remains largely unclear, although trends are emerging with regard to improvements in knowledge and satisfaction. Many relevant outcomes have not been evaluated in randomised trials. Triallists should continue to explore innovative methods of providing information to potential trial participants during the informed consent process, mindful of the range of outcomes that the intervention should be designed to achieve, and balancing the resource implications of intervention development and delivery against the purported benefits of any intervention.More trials, adhering to CONSORT standards, and conducted in settings and populations underserved in this review, i.e. low- and middle-income countries and people with low literacy, would strengthen the results of this review and broaden its applicability. Assessing process measures, such as time taken to administer the intervention and researcher satisfaction, would inform the implementation of audio-visual consent materials.
Collapse
Affiliation(s)
| | | | - Megan Prictor
- School of Public Health and Human Biosciences, La Trobe UniversityCochrane Consumers and Communication Review GroupBundooraAustralia3086
| | - Deirdre Fetherstonhaugh
- La Trobe UniversityAustralian Centre for Evidence Based Aged Care (ACEBAC)BundooraAustralia3086
| | - Barbara Parker
- La Trobe UniversityAustralian Institute for Primary Care & Ageing, Faculty of Health SciencesBundooraAustralia3086
| |
Collapse
|
34
|
Johnson M, Lin F. Communication Difficulty and Relevant Interventions in Mild Cognitive Impairment: Implications for Neuroplasticity. TOPICS IN GERIATRIC REHABILITATION 2014; 30:18-34. [PMID: 25356002 PMCID: PMC4209953 DOI: 10.1097/tgr.0000000000000001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Mild Cognitive Impairment (MCI) represents a critical point for controlling cognitive decline. Patterns of communication difficulty have been observed in patients with MCI and warrant examination and management. The present systematic review examined (1) characteristics of communication difficulty in MCI by focusing on two domains: expressive and receptive communication, and (2) cognitive interventions that addressed communication difficulties in individuals with MCI. Of the 28 observational studies we reviewed, expressive and receptive communications were generally impaired in individuals with MCI, compared to their healthy counterparts. However, only one of seven interventions effectively improved communication related outcomes. We finished the paper with a discussion about how neuroplasticity influences communication abilities in individuals with MCI to inform the future development of interventions for communication difficulty.
Collapse
Affiliation(s)
| | - Feng Lin
- School of Nursing, University of Rochester Medical Center
- AD-CARE Program, Department of Psychiatry, School of Medicine and Dentistry, University of Rochester Medical Center
| |
Collapse
|
35
|
Gather J, Vollmann J. Physician-assisted suicide of patients with dementia. A medical ethical analysis with a special focus on patient autonomy. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2013; 36:444-453. [PMID: 23850340 DOI: 10.1016/j.ijlp.2013.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
For many years there has been a controversial international debate on physician-assisted suicide (PAS). While proponents of PAS regularly refer to the unbearable suffering and the right of self-determination of incurably ill patients, critics often warn about the diverse risks of abuse. In our article, we aim to present ethical arguments for and against PAS for patients in an early stage of dementia. Our focus shall be on ethical questions of autonomy, conceptual and empirical findings on competence and the assessment of mental capacity to make health care decisions. While the capacity to make health care decisions represents an ethically significant precondition for PAS, it becomes more and more impaired in the course of the dementia process. We present conditions that should be met in order to ethically justify PAS for patients with dementia. From both a psychiatric and an ethical perspective, a thorough differential diagnosis and an adequate medical and psychosocial support for patients with dementia considering PAS and their relatives should be guaranteed. If, after due deliberation, the patient still wishes assistance with suicide, a transparent and documented assessment of competence should be conducted by a professional psychiatrist.
Collapse
Affiliation(s)
- Jakov Gather
- Department of Psychiatry, LWL University Hospital, Ruhr-University Bochum, Germany.
| | | |
Collapse
|
36
|
Lui VWC, Lam LCW, Chau RCM, Fung AWT, Wong BML, Leung GTY, Leung KF, Chiu HFK, Karlawish JHT, Appelbaum PS. Structured assessment of mental capacity to make financial decisions in Chinese older persons with mild cognitive impairment and mild Alzheimer disease. J Geriatr Psychiatry Neurol 2013; 26:69-77. [PMID: 23504307 DOI: 10.1177/0891988713481268] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Previous studies suggested that patients with mild cognitive impairment (MCI) or dementia can have impaired and declining financial skills and abilities. The purpose of this study is to test a clinically applicable method, based on the contemporary legal standard, to examine directly the mental capacity to make financial decisions and its component decision-making abilities among patients with MCI and early dementia. A total of 90 patients with mild Alzheimer disease (AD), 92 participants with MCI, and 93 cognitively normal control participants were recruited for this study. Their mental capacity to make everyday financial decisions was assessed by clinician ratings and the Chinese version of the Assessment of Capacity for Everyday Decision-Making (ACED). Based on the clinician ratings, only 53.5% were found to be mentally competent in the AD group, compared with 94.6% in the MCI group. However, participants with MCI had mild but significant impairment in understanding, appreciating, and reasoning abilities as measured by the ACED. The ACED provided a reliable and clinically applicable structured framework for assessment of mental capacity to make financial decisions.
Collapse
Affiliation(s)
- Victor W C Lui
- Department of Psychiatry, Tai Po Hospital, Hong Kong, Republic of China.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Lamont S, Jeon YH, Chiarella M. Assessing patient capacity to consent to treatment: an integrative review of instruments and tools. J Clin Nurs 2013; 22:2387-403. [DOI: 10.1111/jocn.12215] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2012] [Indexed: 12/12/2022]
Affiliation(s)
- Scott Lamont
- Mental Health Liaison Nursing; Prince of Wales Hospital; Sydney NSW Australia
| | - Yun-Hee Jeon
- Sydney Nursing School; University of Sydney; Sydney NSW Australia
| | - Mary Chiarella
- Sydney Nursing School; University of Sydney; Sydney NSW Australia
| |
Collapse
|
38
|
Abstract
OBJECTIVE Critically ill patients frequently display impaired decision-making capacity due to their underlying illness and the use of sedating medications. Healthcare providers often rely on surrogates to make decisions for medical care and participation in clinical research. However, the accuracy of surrogate decisions for a variety of critical care research studies is poorly understood. DESIGN Cross-sectional observational study. SETTING Academic medical center. PATIENTS Medical intensive care unit patients and their designated surrogates. INTERVENTION Patients were asked whether they would consent to participate in hypothetical research studies of increasing complexity, and surrogates independently indicated whether they would consent to enroll the patient in the same scenarios. RESULTS Overall, 69 medical intensive care unit patients were enrolled into the study. The majority of surrogates were either the spouse (58%) or parent (22%) of the patient. The percentage of patients that would agree to participate in a research study and the percentage of surrogates that would agree to have the patient enrolled into a research study both declined as the risk of the study increased (p < .001 for both analyses). In addition, the overall discrepancy, the false-negative rates, and the false-positive rates between patient and surrogates were greater as the risk of the study increased (p < .001, p < .001, and p = .049, respectively). κ values for all seven scenarios demonstrated less-than-moderate agreement (range 0.03-0.41). CONCLUSIONS There are significant discrepancies in the willingness to participate in various types of clinical research proposals between critically ill patients and their surrogate decision makers. The results of this study raise concerns about the use of surrogate consent for inclusion of critically ill patients into research protocols.
Collapse
|
39
|
Galpern WR, Corrigan-Curay J, Lang AE, Kahn J, Tagle D, Barker RA, Freeman TB, Goetz CG, Kieburtz K, Kim SYH, Piantadosi S, Comstock Rick A, Federoff HJ. Sham neurosurgical procedures in clinical trials for neurodegenerative diseases: scientific and ethical considerations. Lancet Neurol 2012; 11:643-50. [PMID: 22710757 DOI: 10.1016/s1474-4422(12)70064-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There have been several recent scientific advances in gene-based and cell-based therapies that might translate into novel therapeutic approaches for neurodegenerative disorders. Such therapies might need to be directly delivered into the CNS, and complex scientific and ethical assessment will be needed to determine whether a sham neurosurgical arm should be included in clinical trials assessing these agents. We have developed a framework of points for investigators to consider when designing trials that involve direct delivery of a therapeutic agent to the CNS. The inclusion of a sham neurosurgical arm will be guided in part by the objectives of the clinical study (preliminary safety, optimisation, and feasibility vs preliminary efficacy vs confirmatory efficacy) and the need to minimise bias and confounds. Throughout the clinical development process, the perspectives of researchers, ethicists, and patients must be considered, and risks should be minimised whenever possible in a manner that is consistent with good trial design.
Collapse
Affiliation(s)
- Wendy R Galpern
- Office of Clinical Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 6001 Executive Blvd, #2225, Bethesda, MD 20892, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Capacity to make decisions on medication management in Chinese older persons with mild cognitive impairment and mild Alzheimer's disease. Int Psychogeriatr 2012; 24:1103-11. [PMID: 22336031 DOI: 10.1017/s1041610212000129] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This study aimed to assess if decisional capacity and the four decision-making abilities related to decisions concerning medication management were impaired among community-dwelling Chinese older persons in Hong Kong with amnestic mild cognitive impairment (MCI) and mild Alzheimer's disease (AD), as compared with cognitively normal older adults. METHODS Two hundred and ninety-one Chinese community-dwelling older adults were recruited. The four decision-making abilities and decisional capacity were assessed by using the Chinese version of the Assessment of Capacity for Everyday Decision-Making (ACED) and independent clinician ratings based on the definition in the UK Mental Capacity Act 2005, respectively. RESULTS Ninety-nine participants (34%) were diagnosed with MCI and ninety-five (33%) with mild AD. Although almost all (96%) of the participants in the MCI group were found to be mentally competent to make decisions on medication management in clinician ratings, their decision-making abilities as measured by the ACED were significantly lower than those of the cognitively normal controls. CONCLUSIONS Results from this study suggest that abilities related to decisions on medication management are impaired before the clinical diagnosis of dementia is made. Use of specific and structured assessment of the relevant decisional abilities may enhance clinical judgment.
Collapse
|
41
|
Hickman NJ, Prochaska JJ, Dunn LB. Screening for understanding of research in the inpatient psychiatry setting. J Empir Res Hum Res Ethics 2011; 6:65-72. [PMID: 21931239 PMCID: PMC3357117 DOI: 10.1525/jer.2011.6.3.65] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
People with mental illness constitute a substantial proportion of smokers and an important population for smoking cessation research. Obtaining informed consent in this population is a critical ethical endeavor. We examined performance on a three-item instrument (3Q) designed to screen for understanding of several key elements of research: study purpose, risks, and benefits. Patients were clinically diagnosed with primary unipolar depression (n = 40), a primary psychotic disorder (n = 32), both mood and psychotic disorders (n = 17), and primary bipolar disorder (n = 14). Among an ethnically diverse sample of 124 psychiatric inpatients approached for a smoking cessation trial, 107 (86%) performed adequately on the 3Q (i.e., obtained a score of at least 3 out of a possible 6). Patients were better able to identify the study risks and benefits than to describe the study purpose. The 3Q appears to be a useful tool for researchers working with vulnerable psychiatric patients.
Collapse
Affiliation(s)
- Norval J Hickman
- Treatment Research Center in the Department of Psychiatry, University of California-San Francisco, 401 Parnassus Avenue, San Francisco, CA 94143, USA.
| | | | | |
Collapse
|
42
|
Subjects agree to participate in environmental health studies without fully comprehending the associated risk. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2011; 8:830-41. [PMID: 21556181 PMCID: PMC3083672 DOI: 10.3390/ijerph8030830] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 03/02/2011] [Accepted: 03/08/2011] [Indexed: 11/28/2022]
Abstract
Recent advances in environmental health research have greatly improved our ability to measure and quantify how individuals are exposed. These advances, however, bring bioethical uncertainties and potential risks that individuals should be aware of before consenting to participate. This study assessed how well participants from two environmental health studies comprehended consent form material. After signing the consent form, participants were asked to complete a comprehension assessment tool. The tool measured whether participants could recognize or recall six elements of the consent form they had just reviewed. Additional data were collected to look for differences in comprehension by gender, age, race, and the time spent reading the original consent form. Seventy-three participants completed a comprehension assessment tool. Scores ranged from 1.91 to 6.00 (mean = 4.66); only three people had perfect comprehension scores. Among the least comprehended material were questions on study-related risks. Overall, 53% of participants were not aware of two or more study-related risks. As environmental public health studies pose uncertainties and potential risks, researchers need to do more to assess participants’ understanding before assuming that individuals have given their ‘informed’ consent.
Collapse
|