Assessment of capacity in an aging society

How do geriatricians evaluate decision-making ability for older adults with cognitive impairment? Results from an European survey

CONTEXT

The assessment of decision-making ability of older adults with cognitive impairment is a complex challenge that geriatricians often face in relation to risk-taking situations (driving, aging in place, financial decisions, etc.). However, there are no clear and consensual practice guidelines. An overview of current practices and needs seemed necessary.

METHODS

We co-created and conducted an online survey to describe practice and knowledge, among European geriatricians. The survey was structured in 3 parts: a description of the professional's practice regarding cognitive impairment, a specific questionnaire about everyday risky decision-making evaluation and an investigation of the clinician's knowledge about relevant ethical and legal recommendations. Each part consisted of both multiple choice and open questions, analyzed through descriptive statistics and qualitative analysis methods.

RESULTS

Based on the responses of 123 geriatricians across Europe, our survey showed that clinical interview is the cornerstone of geriatric assessment of decision-making ability of patients with mild to moderate dementia. When faced with risk-taking dilemma situations, geriatricians tend to favor a context of safety above autonomy, but they can support risky decision-making if it is consistent with the patient's previous lifestyle, depending on the degree of risk to self and others, on the decision-making ability assessed, and if there is some form of shared decision-making.

CONCLUSION

Assessing decision-making ability is challenging for geriatricians, who in our study relied more on their clinical interview and global cognitive tests than more in-depth evaluations. Supporting independent decision-making, when associated with risk-taking, requires better detection and anticipation shared with the patient environment.

Waiting for guardianship in a public hospital geriatric inpatient unit: a mixed methods observational case series

BACKGROUND

Patients in acute hospital settings waiting for guardianship and financial management (FM) hearings experience extended length of stay (LOS), with known consequences for frail elderly. This, together with universal agreement that substitute decision-making is a last resort measure, an imperative exists to examine guardianship and FM applications made from within hospital for geriatric inpatients.

AIMS

This study aims to examine processes around Guardianship applications in a public hospital Geriatric inpatient setting including times to, reasons for and outcomes of referral; and to explore the content of the medical records in relation to criteria for application.

METHOD

This was a mixed methods observational case series using descriptive data supplemented by qualitative case-note analysis of inpatients referred for guardianship (with/without FM) from 2018 to 2020 in a New South Wales Geriatric Medicine inpatient unit. Medical records were examined for evidence of operationalised criteria for guardianship, aligned with disability, capacity and need/risk common to most Australian jurisdictions.

RESULTS

Of 45 patients with guardianship applications, 98% were granted guardians and 33 of 37 (89%) FM applications. Multiple risks underpinned applications, most commonly frequent falls (49%) and medication mismanagement (49%). Although only 29% were in receipt of services preadmission, 98% were discharged to residential care. Average hospital LOS was 70 days (interquartile range, 35), contributed to by delays between admission and decision to apply for guardianship/FM (median, 28 inpatient days) and uncertainties around or lack of documented capacity assessments.

CONCLUSION

This study identifies potential points along pathways towards guardianship in hospital settings, which might be targeted to streamline if not divert some of these applications. Points of intervention include at initiation of applications, with consideration of alternatives to substitute decision-making by addressing patient needs and using supported decision-making, while improving clinician understanding of capacity assessment and guardianship.

The relationship between cadmium and cognition in the elderly: a systematic review

Context: The relationship between cadmium (Cd) and the cognition of the elderly is indistinct.Objective: To summarise the studies on the relationship between the cognition of the elderly and Cd.Methods: Literatures were searched in PubMed, Web of Science, China National Knowledge Infrastructure (CNKI), and Wan fang database on April 25, 2022. The entries in the STROBE statement were used to evaluate the literature quality; all the quantitative studies that met the requirements were systematically summarised.Results: Blood Cd was negatively correlated with the cognitive ability of the elderly, corresponding to different cognitive ability assessment methods, the regression coefficients were: -0.11 (-0.20, -0.03), -0.46 (-0.71, -0.21), -0.54 (-0.90, -0.17), -0.19 (-0.37, -0.01), and -2.29 (-3.41, -1.16). The regression coefficients between urinary Cd level and cognition score were -1.42 (-2.38, -0.46), and 0.76 (-1.28, -0.23). When dietary Cd increased by 1 μg/kg, the composite z-score decreased by 3.64 (p = 0.001). There was no significant correlation between drinking water Cd, fingernail Cd and cognition (p > 0.05).Conclusion: We concluded that blood Cd (including whole blood and plasma), urine Cd and dietary Cd were negatively correlated with the cognition of the elderly, but the relationship between Cd in drinking water and fingernails and cognition was not statistically significant.

Healthcare decision-making capacity in old age: A qualitative study

Objectives

Research about decision-making capacity has been growing in the last decades. That relates to more concerns regarding patients' autonomy, and an increase in diseases that can negatively impact capacity. This research aims to: explore perceptions, legal aspects, and assessment procedures related to healthcare decision-making capacity in older adults with cognitive impairment; and study the first version of a new assessment instrument of this capacity.

Method

Nine focus groups were conducted, including healthcare, law and justice, nursing home professionals, institutionalized older adults, and dwelling older adults. Focus group discussions followed semi-structured interview scripts, specifically developed for each group. After group discussions, the assessment instrument was presented, and participants were asked to evaluate each item relevance and comprehensibility. Qualitative coding of the transcriptions was performed with resource to MAXQDA, using direct content analysis.

Results

Six primary themes emerged from the qualitative analysis: Decision-making capacity features; Abilities implied in decision-making; Factors influencing decision-making; Obstacles to decision-making; Legal aspects; and Assessment procedures.

Discussion

Results corroborate previous theoretical formulations of capacity. Generally, research results have implications for clinical and assessment practices, as well as preventive strategies that can improve older adult's decision-making capacity. Assessment procedures of capacity should include a thorough protocol for the assessment of cognition, functionality, depressive symptoms, and decision-making abilities. In this respect, the need for an assessment tool that can provide valid information during evaluation processes is highlighted. Concerning the strategies to promote decision-making capacity, these rely on improving older adult's health literacy and healthcare providers communication skills, as well as conduct actions to reduce stigma toward people with dementia.

Home-delivered meals for people with dementia: Which model delays nursing home placement? - Protocol for a feasibility pilot

BACKGROUND

Home-delivered meals promote food security, socialization, and independence among homebound older adults. However, it is unclear which of the two predominant modes of meal delivery, daily-delivered vs. drop-shipped, frozen meals, promotes community living for homebound older adults with dementia. Our objective is to present the protocol for a pilot multisite, two-arm, pragmatic feasibility trial comparing the effect of two modes of meal delivery on nursing home placement among people with dementia. We include justifications for individual randomization with different consent processes and waivers for specific elements of the trial.

METHODS

236 individuals with dementia on waiting lists at three Meals on Wheels programs' in Florida and Texas will be randomized to receive either: 1) meals delivered multiple times per week by a Meals on Wheels volunteer or paid driver who may socialize with and provide an informal wellness check or 2) frozen meals that are mailed to participants' homes every two weeks. We will evaluate and refine processes for recruitment and randomization; assess adherence to the intervention; identify common themes in participant experience; and test processes for linking participant data with Medicare records and nursing home assessment data. We will conduct exploratory analyses examining time to nursing home placement, the primary outcome for the larger trial.

CONCLUSION

This pilot will inform the follow-on large-scale, definitive pragmatic trial. In addition, the justifications for individual randomization with differing consent procedures for elements of a pragmatic trial provide a model for future trialists looking to develop ethical and feasible pragmatic studies enrolling people with dementia.

The Relationship Between Decision-making Capacity and the Domains of Awareness in Alzheimer Disease

People with Alzheimer dementia (PwAD) who are aware of their overall cognitive function and diagnosis are more likely to be judged competent in decision-making capacity. Therefore, we aimed to investigate the relationship between decision-making capacity and the different domains of awareness and the relationship between decision-making capacity and the cognitive and clinical impairment of the PwAD. Using a cross-sectional design, we included 121 PwAD and their caregivers. Awareness was assessed across domains, including cognitive functioning and health condition, functional activity impairments, emotional state, social functioning, and interpersonal relationships. The MacArthur Competence Assessment Tool for Treatment was adopted to gather information about decision-making abilities. We found that decision-making capacity is related to the cognitive and functional domains of awareness and relatively independent of the emotional functioning and the relationship domains. Our finding highlighted that PwAD who are unaware of the disease or the cognitive and functional impairments might be unlikely to appreciate the personal benefits of a proposed health treatment or to understand and judge the personal consequences of a decision accurately.

Piloting the global capacity education e-tool: can capacity be taught to health care professionals across different international jurisdictions?

Determining decision-making capacity is part of everyday business for health care professionals working with older adults. We used a modified Delphi approach to develop an inclusive curriculum for a capacity education e-tool with global application and clinical relevance to a range of disciplines. The tool comprised: (i) 25 questions forming a "pre-test" for the adaptive and personalized e-Learning platform; (ii) a learning module based on the participant's response to the "pre-test"; (iii) a "post-test" (the same baseline 25 questions) to test knowledge translation. The tool was tested on 31 health care professionals across Israel (8), Canada (15), and Australia (8) from the following disciplines: General Practitioners (GP) (19), Internal Medicine (1), Palliative Care GP (2); Palliative Care Physician (2), Geriatrician (2); and one of each: Psychologist, Occupational Therapist, Psychiatrist, Aged Care Researcher, and Aged Care Pharmacist. The mean baseline pre-test score was 19.1/25 (S.D. =1.61; range 15-22) and post-test score 21.7/25 (S.D.= 1.42; range 18-24); with a highly significant improvement in test scores (paired t-test P < 0.0001; t=10.81 on 30 df). This is the first such pilot study to demonstrate that generic capacity principles can be taught to health care professionals from different disciplines regardless of jurisdiction.

“As Long As I’m Me”: From Personhood to Personal Identity in Dementia and Decision-making

As older people begin to develop dementia, we confront ethical questions about when and how to intervene in their increasingly compromised decision-making. The prevailing approach in bioethics to tackling this challenge has been to develop theories of “decision-making capacity” based on the same characteristics that entitle the decisions of moral persons to respect in general. This article argues that this way of thinking about the problem has missed the point. Because the disposition of property is an identity-dependent right, what matters in dementia and decision-making is an individual’s personal identity with their prior self, not their moral personhood. Therefore, in considering when and how we ought to intervene in the decision-making of those with dementia, we must look to the philosophy of personal identity rather than personhood.

Capacity assessment training in geropsychology: Creating and evaluating an outpatient capacity clinic to fill a training gap

Assessment of decision-making capacity of older adults is a growing area of practice but training opportunities are lacking. We present a needs assessment, program characteristics, pilot clinic process (n= 52 referrals) and outcome training (n= 4 interns) data for a capacity training clinic. Process data reveal that the training clinic provided consistent referrals (1 per week) across multiple capacity domains (independent living, treatment consent, and financial capacities), with 27% of referrals providing opportunities for training in protective services. Outcome data found three of the four interns reported proficient skills in capacity assessment, as well as improved skills in six areas related to capacity assessment: knowledge of limitations of assessment methods, person-environment interaction, identifying and applying ethical and legal standards, utilizing cognitive assessments, communicating results and recommendations, and assessing risk. The discussion shares lessons learned for the development of future training rotations and clinics in the capacity assessment.

End-of-Life Decision-Making Capacity in Older People With Serious Mental Illness

Background: The study's main aim was to assess the end-of-life decision-making capacity and health-related values of older people with serious mental illness. Methods: A cross-sectional, observational study, was done at Weskoppies Psychiatric Hospital, Gauteng Province, South Africa that included 100 adults older than 60 years of age and diagnosed with serious mental illness. The Mini-Cog and a semi-structured clinical assessment of end-of-life decision-making capacity was done before a standardized interview, Assessment of Capacity to Consent to Treatment, was administered. This standardized instrument uses a hypothetical vignette to assess decision-making capacity and explores healthcare-related values. Results: The Assessment of Capacity to Consent to Treatment scores correlated (p < 0.001) with the outcomes of the semi-structured decision-making capacity evaluation. Significant correlations with impaired decision-making capacity included: lower scores on the Mini-Cog (p < 0.001); a duration of serious mental illness of 30-39 years (p = 0025); having a diagnosis of schizophrenia spectrum disorders (p = 0.0007); and being admitted involuntarily (p < 0.0001). A main finding was that 65% of participants had decision-making capacity for end-of-life decisions, were able to express their values and engage in advance care discussions. Discussion and Conclusion: Healthcare providers have a duty to initiate advance care discussions, optimize decision-making capacity, and protect autonomous decision-making. Many older patients with serious mental illness can engage in end-of-life discussions and can make autonomous decisions about preferred end-of-life care. Chronological age or diagnostic categories should never be used as reasons for discrimination, and older people with serious mental illness should receive end-of-life care in keeping with their preferences and values.

Understanding the Perspectives of Seniors on Dementia and Decision-Making

BACKGROUND

The legal doctrine of capacity, which governs legally-authorized intervention in the decision-making of persons with dementia, has been subject to recent scholarly criticism and reform efforts. Such efforts require a coherent normative theory of when and how intervention in the decision-making of those with dementia is appropriate. This mixed-methods study sought to understand the perspectives of seniors on this normative question.

METHODS

A survey, including closed- and open-ended questions and conversational interviews, was conducted.

RESULTS

Quantitative results of 236 seniors were heterogeneous but showed important patterns. Qualitative results from survey data and interviews of 25 seniors presented 6 key themes: (1) a difficulty of giving concrete answers; (2) reliance on professional opinions; (3) concern for personal identity; (4) fear of abuse; (5) trust of family; and (6) fear of dementia.

CONCLUSIONS

The study suggests support among seniors for: (1) a model of "supported decision-making" rather than "surrogate decision-making;" (2) a presumption that in order to preclude a person with dementia from making more "personal" decisions a more heightened showing of incapacity is required; and (3) a shift to a model of capacity as based more on features such as long term memory and relationships rather than cognitive functions or values. In reforming our understandings of capacity, ethicists and practitioners will have to navigate tensions found in the qualitative data, including: (1) between participants' fear of abuse and their expressions of trust in family members to decide when intervention is appropriate; and (2) between expressions of confidence in medical professionals' ability to tell participants when they are no longer able to make decisions and participants' own understanding of the question in terms of the philosophical construct of personal identity.

Neuropsychology and the dementia spectrum: Differential diagnosis, clinical management, and forensic utility

BACKGROUND

The utility of neuropsychology in the treatment and evaluation of neuropsychological disorders and neurodegenerative diseases is supported by scientific study. As a discipline, neuropsychology's value and efficacy when applied to the dementia spectrum are rooted in its inherent adaptability as a practical, cost-effective, and scientifically based resource for differential diagnosis, treatment planning, and forensic decision making.

OBJECTIVES

This article provides a framework for conceptualizing dementia as a spectrum of disorders and outlines a rationale for preferential reliance upon neuropsychological tenets. The function of neuropsychology in differential diagnosis, clinical management, integrative care, and forensic applications is delineated for use as a contemporary interdisciplinary reference.

METHODOLOGY

An overview of the literature on dementia as a spectrum of disorders has been integrated with the science and practice of neuropsychology.

CONCLUSIONS

The utility of neuropsychology emanates from its focus on brain functioning and the discipline's appreciation for the relationship between brain functioning and cognition, mental state, and behavior. Early and routine referral for neuropsychological assessment allows for the objective determination of normal versus abnormal neurocognitive functioning, provides a baseline for serial reassessment, and leads to the more rapid deployment of effective treatments. Beyond the hospital and clinic, neuropsychological expertise is increasingly sought after as integral to the legal system when decisions regarding eligibility for long term care and questions about capacity require objective and reliable measurement.

End-of-life decision-making capacity in an elderly patient with schizophrenia and terminal cancer

Medical practitioners are confronted daily with decisions about patients’ capacity to consent to interventions. To address some of the pertinent issues with these assessments, the end-of-life decision-making capacity of a 72-year-old female with treatment-resistant schizophrenia and terminal cancer is discussed, as are the role of the treating clinician and the importance of health-related values. There is a recommendation that the focus of these assessments can rather be on practical outcomes, especially when capacity issues arise. This implies that the decision-making capacity of the patient is only practically important when the treatment team is willing to proceed against the patient’s wishes. This shifts the focus from a potentially difficult assessment to the simpler question of whether the patient’s capacity will change the treatment approach. Clinicians should attend to any possible underlying issues, instead of focusing strictly on capacity. Compared to the general populations people with serious mental illness (SMI) have higher rates of physical illness and die at a younger age, but they do not commonly access palliative care services. Conversations about end-of-life care can occur without fear that a person’s psychiatric symptoms or related vulnerabilities will undermine the process. More research about palliative care and advance care planning for people with SMI is needed. This is even more urgent in light of the coronavirus disease-2019 (COVID-19) pandemic, and South African health services should consider recommendations that advanced care planning should be routinely implemented. These recommendations should not only focus on the general population and should include patients with SMI.

Bioethical implications of end-of-life decision-making in patients with dementia: a tale of two societies

End-of-life decision-making in patients with dementia is a complex topic. Belgium and the Netherlands have been at the forefront of legislative advancement and progressive societal changes concerning the perspectives toward physician-assisted death (PAD). Careful consideration of clinical and social aspects is essential during the end-of-life decision-making process in patients with dementia. Geriatric assent provides the physician, the patient and his family the opportunity to end life with dignity. Unbearable suffering, decisional competence, and awareness of memory deficits are among the clinical considerations that physicians should incorporate during the end-of-life decision-making process. However, as other societies introduce legislature granting the right of PAD, new social determinants should be considered; Mexico City is an example. Current perspectives regarding advance euthanasia directives (AED) and PAD in patients with dementia are evolving. A new perspective that hinges on the role of the family and geriatric assent should help culturally heterogeneous societies in the transition of their public health care policies regarding end-of-life choices.

Mapping dementia and cognitive decline in testamentary capacity

Cognitive assessment is central to the evaluation of testamentary capacity. Such assessment is currently performed in a subjective, unreliable and non-standardized manner. Dementia, a cognitive illness, poses one of the largest threats to testamentary capacity in modern society. A better understanding of the ways in which dementia related cognitive impairment can affect a testator's ability to meet the relevant legal criteria to make a will is needed. A review of the literature over the past ten years focusing on what cognitive abilities are required to satisfy the legal criteria for testamentary capacity has highlighted an alarming scarcity of work in this area. There is little discussion spanning beyond general acknowledgement of the importance of memory and executive function. The specifics of how cognitive impairment impacts the four limbs of Banks v Goodfellow are rarely addressed. Several additional areas of cognitive function of importance to assessing testamentary capacity are the subject of this article.

Clinical Considerations in Physician-Assisted Death for Probable Alzheimer's Disease: Decision-Making Capacity, Anosognosia, and Suffering

Background

Requests for physician-assisted death (PAD) in patients with cognitive impairment are complex and require careful consideration. Of particular difficulty is determination of whether the request is voluntary and well considered.

Results

Euthanasia and physician-assisted suicide (PAS) are both legal in The Netherlands, Luxemburg, Colombia, and Canada. Euthanasia is legal in Belgium, while PAS is legal in Switzerland and Oregon, Washington, Montana, Vermont, and California (USA). Upon a PAD request, evaluation of the capacity to consent medical treatment is relevant for the decision-making process, while evaluation of testamentary capacity is appropriate before an advance euthanasia directive is written. Anosognosia assessment throughout the Alzheimer's disease continuum provides essential and relevant information regarding the voluntary and well-considered nature of the PAD request; meanwhile, early assessment of hypernosognosia or subjective cognitive decline assists in formulation of a clinical prognosis. Furthermore, the assessment of physical and psychological suffering should incorporate verbal and nonverbal cues as well as consideration of the psychosocial factors that might affect due care criteria.

Conclusion

The clinical approach to a PAD request should consider the legal framework and the decision-making capacity, assess memory deficit awareness and the perception of suffering, and evaluate mental competency when considered pertinent.

Advance Care Planning for Persons with Intellectual Disabilities

Abstract. As people live longer, they become more likely to die from prolonged, incurable, chronic illnesses occurring more frequently in old age. This study explores the usefulness, quality, and reliability of documented advance care planning interviews to determine the decision-making capacity of persons with intellectual disabilities (IDs). A volunteer sample of 60 persons rated the capacity to consent to treatment of four persons deciding on two end-of-life decisions. Sensitivity, specificity, and percent agreement were calculated. Interrater reliability was assessed using Fleiss’ κ and Krippendorff’s α. A Yates’ corrected χ2 was used to analyze differences in ratings between groups of raters. The sensitivity value was 62%; the specificity value was 95%. The percent agreement for all participants was 70%, Fleiss’ κ was 0.396, and Krippendorff’s α was 0.395. Of the participants, 72 found documented advance care planning discussions useful for diagnosing the decision-making capacity of people with IDs. The documented interviews helped to identify those persons with IDs who had the decision-making capacity. Documented interviews on end-of-life decisions could make a valuable contribution to fostering their self-determination in end-of-life issues.

Systematic Review of Measurement Property Evidence for 8 Financial Management Instruments in Populations With Acquired Cognitive Impairment

OBJECTIVES

To critically appraise the measurement property evidence (ie, psychometric) for 8 observation-based financial management assessment instruments.

DATA SOURCES

Seven databases were searched in May 2015.

STUDY SELECTION

Two reviewers used an independent decision-agreement process to select studies of measurement property evidence relevant to populations with adulthood acquired cognitive impairment, appraise the quality of the evidence, and extract data. Twenty-one articles were selected.

DATA EXTRACTION

This review used the COnsensus-based Standards for the selection of health Measurement Instruments review guidelines and 4-point tool to appraise evidence. After appraising the methodologic quality, the adequacy of results and volume of evidence per instrument were synthesized. Measurement property evidence with high risk of bias was excluded from the synthesis.

DATA SYNTHESIS

The volume of measurement property evidence per instrument is low; most instruments had 1 to 3 included studies. Many included studies had poor methodologic quality per measurement property evidence area examined. Six of the 8 instruments reviewed had supporting construct validity/hypothesis-testing evidence of fair methodologic quality. There is a dearth of acceptable quality content validity, reliability, and responsiveness evidence for all 8 instruments.

CONCLUSIONS

Rehabilitation practitioners assess financial management functions in adults with acquired cognitive impairments. However, there is limited published evidence to support using any of the reviewed instruments. Practitioners should exercise caution when interpreting the results of these instruments. This review highlights the importance of appraising the quality of measurement property evidence before examining the adequacy of the results and synthesizing the evidence.

Qualitative analysis of the capacity to consent to treatment in patients with a chronic neurodegenerative disease: Alzheimer's disease / Analisi qualitativa sulla capacità a prestare consenso al trattamento in pazienti con malattie cronico degenerative neuropsicoorganiche: Demenza di Alzheimer

OBJECTIVE

Informed consent is an essential element in doctor-patient relationship. In particular, obtaining valid informed consent from patients with neurocognitive diseases is a critical issue at present. For this reason, we decided to conduct research on elderly patients with Alzheimer's disease ( Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) to assess their capacity to make treatment decisions.

METHODS

The experimental group comprised 70 Alzheimer patients who were admitted to the Neurodegenerative Disease Unit of the University of Bari. The control group consisted of 83 elderly patients without neurocognitive disorders who were hospitalized in the Geriatric Unit at the same university. After providing written consent to participate in the research, each subject underwent the following assessments: (a) assessment of comprehension sheet, (b) Neuropsychiatric Inventory (NPI) and Global Functioning Evaluation (GFE), (c) neurological evaluation, (d) neuropsychological assessment with a full battery of tests, (d) The MacArthur Treatment Competence Study (MacArthur Competence Assessment Tool for Treatment (MacCAT-T); understanding, appreciating, reasoning and expressing a choice) and (e) a semi-structured interview administered by the patient's caregiver.

RESULTS/CONCLUSION

The present survey was designed to analyze possible qualitative and quantitative correlations between cognitive functioning and capacity to consent in relation to different degrees of severity of the neurodegenerative disorder. A large portion of the patients in our experimental sample did not appear to have the capacity to provide a valid consent. The authors present initial results of this study and discuss their possible implications.

Testamentary Capacity Assessment: Legal, Medical, and Neuropsychological Issues

INTRODUCTION

The increase in the aging population and the number of patients with dementia led to the research in older adults' capacity assessment over the last 3 decades. Many cases of contested wills occur due to lack of testamentary capacity (TC), especially in cases of dementia.

AIM

Purpose of the present study was to overview the legal, medical, and neuropsychological aspects of TC as well as the instruments used for TC assessment.

FINDINGS

The testator/testatrix with intact TC has realistic perception of his or her property value, lack of psychopathology affecting contact with reality, and intact intention of how and to whom he or she will dispose his or her assets. It is frequent for the health practitioners to serve as "gold standards assessors" by examining an individual's ability to make a valid will and giving evidence to the court to support or not a will contest. The TC assessment is a complex process of clinical and legal practice requiring usually a variety of methods, that is, interviews, evaluation of clinical records, and administration of neuropsychological instruments.

CONCLUSION

The evaluation of TC is a multidimensional process that integrates both the legal and medical field, requiring a collaborative approach to its definition and assessment.

Financial capacity in dementia: a systematic review

OBJECTIVES

Financial capacity (FC) refers to a set of cognitively mediated abilities related to one's competency to manage propriety and income. Identifying intact from impaired FC in older persons with dementia is a growing concern in geriatric practice, but the best methods to assess this function still need to be determined. This study aims to review data on FC in dementia and on instruments used to assess this domain of capacity.

METHODS

Database search was performed in Medline, ISI Web of Knowledge, LILACS and PsycINFO. Studies that objectively assessed FC in dementia of any etiology were included.

RESULTS

Of a total of 125 articles, 10 were included. Mild Alzheimer's Disease (AD) was associated with impaired complex FC abilities, namely checkbook management, bank statement management and financial judgment, but simple FC skills were preserved. Moderate AD was associated with impairment in all domains of FC. The Financial Capacity Instrument (FCI) was applied in most of the selected studies and correlated with neuropsychological and neuroimaging variables.

CONCLUSIONS

Early dementia is associated with partially preserved FC. More validation studies using objective and evidence-based FC assessment tools, such as the FCI, are still needed.

Dementia and legal determination of capacity

OBJECTIVE

To assess the legal capacity and guardianship proceedings in patients diagnosed with dementia.

METHODS

Ninety-seven patients diagnosed with dementia and seen at a tertiary hospital were evaluated.

RESULTS

Of these 97 patients, 60 (62%) were female. The mean age of the patients was 77.9 years; average schooling was 5.5 years. The main diagnosis was Alzheimer's disease (73%): 16 patients were at a mild stage, eight at a moderate stage and 73 at an advanced stage of dementia. Only 28 patients had been legally declared incapable.

CONCLUSION

The large numbers of patients at an advanced stage of dementia, and the relatively few patients legally declared incapable show that legal issues in dementia are problematic.

Phishing suspiciousness in older and younger adults: The role of executive functioning

Phishing is the spoofing of Internet websites or emails aimed at tricking users into entering sensitive information, with such goals as financial or identity theft. The current study sought to determine whether age is associated with increased susceptibility to phishing and whether tests of executive functioning can predict phishing susceptibility. A total of 193 cognitively intact participants, 91 younger adults and 102 older adults, were primarily recruited through a Psychology department undergraduate subject pool and a gerontology research registry, respectively. The Executive Functions Module from the Neuropsychological Assessment Battery and the Iowa Gambling Task were the primary cognitive predictors of reported phishing suspiciousness. Other predictors included age group (older vs. younger), sex, education, race, ethnicity, prior knowledge of phishing, prior susceptibility to phishing, and whether or not browsing behaviors were reportedly different in the laboratory setting versus at home. A logistic regression, which accounted for a 22.7% reduction in error variance compared to the null model and predicted phishing suspiciousness with 73.1% (95% CI [66.0, 80.3]) accuracy, revealed three statistically significant predictors: the main effect of education (b = 0.58, SE = 0.27) and the interactions of age group with prior awareness of phishing (b = 2.31, SE = 1.12) and performance on the Neuropsychological Assessment Battery Mazes test (b = 0.16, SE = 0.07). Whether or not older adults reported being suspicious of the phishing attacks used in this study was partially explained by educational history and prior phishing knowledge. This suggests that simple educational interventions may be effective in reducing phishing vulnerability. Although one test of executive functioning was found useful for identifying those at risk of phishing susceptibility, four tests were not found to be useful; these results speak to the need for more ecologically valid tools in clinical neuropsychology.

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)

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.

Dementia, Decision Making, and Capacity

After participating in this activity, learners should be better able to:• Assess the neuropsychological literature on decision making and the medical and legal assessment of capacity in patients with dementia• Identify the limitations of integrating findings from decision-making research into capacity assessments for patients with dementia ABSTRACT: Medical and legal professionals face the challenge of assessing capacity and competency to make medical, legal, and financial decisions in dementia patients with impaired decision making. While such assessments have classically focused on the capacity for complex reasoning and executive functions, research in decision making has revealed that motivational and metacognitive processes are also important. We first briefly review the neuropsychological literature on decision making and on the medical and legal assessment of capacity. Next, we discuss the limitations of integrating findings from decision-making research into capacity assessments, including the group-to-individual inference problem, the unclear role of neuroimaging in capacity assessments, and the lack of capacity measures that integrate important facets of decision making. Finally, we present several case examples where we attempt to demonstrate the potential benefits and important limitations of using decision-making research to aid in capacity determinations.

Informed Consent to Research with Cognitively Impaired Adults: Transdisciplinary Challenges and Opportunities

Due to issues related to informed research consent, older adults with cognitive impairments are often excluded from high-quality studies that are not directly related to cognitive impairment, which has led to a dearth of evidence for this population. The challenges to including cognitively impaired older adults in research and the implications of their exclusion are a transdisciplinary issue. The ethical challenges and logistical barriers to conducting research with cognitively impaired older adults are addressed from the perspectives of three different fields-social work, emergency medicine, and orthopaedic surgery. Issues related to funding, study design, intervention components, and outcomes are discussed through the unique experiences of three different providers. A fourth perspective-medical research ethics-provides alternatives to exclusion when conducting research with cognitively impaired older adults such as timing, corrective feedback and plain language, and capacity assessment and proxy appointments. Given the increasing aging population and the lack of evidence on cognitively impaired older adults, it is critical that researchers, funders, and institutional review boards not be dissuaded from including this population in research studies.

Swimming against the Tide: A Case Study on the Removal of Conservatorship and Guardianship

OBJECTIVE

This article evaluates the role healthcare providers play in balancing safety versus autonomy among elders when performing capacity evaluations.

METHODS

Presentation of a case study consisting of an 85-year-old, Caucasian, widowed, male, post-stroke veteran, residing in long-term care. He was assigned a permanent court-appointed joint guardian and conservator, but wanted to remove both of these as he felt he had the ability to manage his own affairs. This case study specifically addresses the issue of financial capacity.

RESULTS

After completion of the evaluation, a case was made for the least restrictive means balancing patient autonomy and protection, opting for a limited conservatorship. The court, using the evaluation as evidence, completely removed the guardianship and conservatorship.

CONCLUSIONS

This article outlines how providers can navigate multiple roles, team dynamics, and advocate for enhancing the capacity of an older adult.

Consent, Refusal, and Waivers in Patient-Centered Dysphagia Care: Using Law, Ethics, and Evidence to Guide Clinical Practice

PURPOSE

When patients refuse medical or rehabilitation procedures, waivers of liability have been used to bar future lawsuits. The purpose of this tutorial is to review the myriad issues surrounding consent, refusal, and waivers. The larger goal is to invigorate clinical practice by providing clinicians with knowledge of ethics and law. This tutorial is for educational purposes only and does not constitute legal advice.

METHOD

The authors use a hypothetical case of a "noncompliant" individual under the care of an interdisciplinary neurorehabilitation team to illuminate the ethical and legal features of the patient-practitioner relationship; the elements of clinical decision-making capacity; the duty of disclosure and the right of informed consent or informed refusal; and the relationship among noncompliance, defensive practices, and iatrogenic harm. We explore the legal question of whether waivers of liability in the medical context are enforceable or unenforceable as a matter of public policy.

CONCLUSIONS

Speech-language pathologists, among other health care providers, have fiduciary and other ethical and legal obligations to patients. Because waivers try to shift liability for substandard care from health care providers to patients, courts usually find waivers of liability in the medical context unenforceable as a matter of public policy.

Diagnostic Differences and Demographic Predictors of Respondents Adjudicated Civilly Incompetent Versus Competent

The purpose of this study was to determine if diagnostic and demographic variables predict civil competency adjudications, a topic that has received scant research attention. Respondents (i.e., individuals alleged to be incompetent) were evaluated by a licensed psychologist to assist the court in civil competency and possible guardianship determination. Prior research using some of the same participants demonstrated select differences on activities of daily living between these groups (Quickel & Demakis, ), but the current set of analyses was not conducted. The current study included 107 competency evaluations in Mecklenburg County North Carolina and, at conclusion of the case, the public record of the adjudication was obtained. Based on prior legal theorizing in related criminal areas--focused on discrimination of individuals with mental illness--we predicted that cases involving respondents with psychiatric diagnoses would be likely to be overrepresented in those referred for evaluation as well as those subsequently adjudicated incompetent. A series of analyses indicated no statistical differences between competency groups (psychiatric/substance abuse, neurological, both psychiatric and neurological, and intellectually disabled). In a series of exploratory logistic regression analyses, we found that respondents who were single versus in a relationship and those not living at home versus living at home were significantly more likely to be adjudicated incompetent, even after controlling for difference in activities of daily living. There were no differences in incompetency adjudication by age, education, gender, race, or relationship status. Results are discussed in terms of implications for individuals with mental illness in incompetency hearings, as well as specific issues for psychologists evaluating a broad range of respondents.

Conceptual issues in 'cognitive impairment'

PURPOSE OF REVIEW

This review aims to set out the recent writings relevant to acquired cognitive impairment in an attempt to reveal some of the underlying conceptual issues.

RECENT FINDINGS

The huge strides being taken to diagnose Alzheimer's and other dementias early, including pre-symptomatically, raise important ethical issues. But there are broader conceptual issues too, around the notion of normal ageing. New techniques, such as deep brain stimulation, raise further ethical concerns, but may be relevant to deeper philosophical issues. Meanwhile, capacity continues to be of interest to researchers in the field of cognitive impairment, but the 'United Nations Convention on the Rights of Persons with Disabilities' is raising questions about our understanding of the nature of capacity. These new ideas reflect shifts in our understanding of personhood. How we think about the person is relevant to how we think about dilemmas over artificial nutrition and is also pertinent to debates about rational suicide in response to a diagnosis of dementia. A person-centred view allows us to think more broadly about cognitive impairment.

SUMMARY

Cognitive impairment challenges us to think broadly, to see such impairment as something to be dealt with in the context of our multifaceted life-worlds.

Predictors of financial capacity performance in older adults using the Financial Competence Assessment Inventory

BACKGROUND

Declines in financial capacity in later life may arise from both neurocognitive and/or psychiatric disorders. The influence of socio-demographic, cognitive, health, and psychiatric variables on financial capacity performance was explored.

METHODS

Seventy-six healthy community-dwelling adults and 25 older patients referred for assessment of financial capacity were assessed on pertinent cognitive, psychiatric, and financial capacity measures, including Addenbrooke's Cognitive Examination - Revised (ACE-R), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Geriatric Depression Scale (GDS), Geriatric Anxiety Inventory (GAI), selected Neuropsychiatric Inventory (NPI) items, Financial Competence Assessment Inventory (FCAI), and Social Vulnerability Scale (SVS).

RESULTS

The internal consistency of the debt management subscale of the FCAI was relatively poor in our sample. Financial capacity performance differed between controls and patients. In our sample, performance on the FCAI was predicted by Mini-Mental State Examination, IQCODE, and GAI, but not by ACE-R, GDS, NPI items, or SVS (adjusted R(2) = 0.7059).

CONCLUSIONS

Anxiety but not depression predicted financial capacity performance, possibly reflecting relatively low variance of depressive symptoms in this sample. Current cognitive decline as measured by the informant-rated IQCODE was more highly correlated to financial capacity than either educational attainment or ACE-R scores. Lack of significance of ACE-R data may reflect the instrument's decreased sensitivity to domains relevant to financial capacity, compared with more detailed neuropsychological assessment tools. The FCAI displayed fairly robust psychometric properties apart from the debt management subscale.

Reference intervals for serum cystatin C and factors influencing cystatin C levels other than renal function in the elderly

Objective

The present study aimed to establish reference intervals for serum cystatin C (Scys-C) stratified by stages of chronic kidney disease, explore factors influencing Scys-C and compare the performance of Scys-C with serum creatinine (Scr) in the young and elderly.

Methods

A total of 800 participants, 516 young (<60 years) and 284 old (≥60 years) subjects were included in this study. Scys-C and Scr were assayed by the partical-enhanced immunoturbidimetry method and enzymatic method respectively. 95% reference interval was adopted to evaluate reference intervals. Influencing factors were characterized by multivariate linear regression analysis. Relationship between reference glomerular filtration rate (rGFR) and Scys-C or Scr was determined by correlation coefficient.

Results

Reference intervals for Scys-C were calculated to be 0.71–1.38 mg/L, 0.83–1.67 mg/L, 1.02–2.61 mg/L, 1.32–4.48 mg/L, 1.95–6.11 mg/L in the aged in CKD G1, G2, G3a, G3b and G4-5 stages, respectively. Body mass index(BMI), nephritis, kidney neoplasm and hypertension were demonstrated as factors affecting Scys-C in the elderly while gender, nephritis and kidney neoplasm were clarified as influencing factors in the young group. Scr levels were affected by more factors, such as body surface area and hematological disease. Correlation coefficient between rGFR and Scys-C or Scr showed that serum Scys-C was superior to Scr, especially in the subjects with mildly decreased renal function (−0.593 vs. −0.520).

Conclusions

Factors other than renal function influenced Scys-C when applying to evaluate glomerular filtration rate (GFR), such as BMI, nephritis, kidney neoplasm and hypertension, and Scys-C had higher correlation with GFR than Scr in the elderly.