Computerized history and self-assessment questionnaire for diagnostic screening among patients with dementia

Neuropsychological performance within-person variability is associated with reduced treatment consent capacity

OBJECTIVE

The capacity of older adults to make healthcare decisions is often impaired in dementia and has been linked to performance on specific neuropsychological tasks. Within-person across-test neuropsychological performance variability has been shown to predict future dementia. This study examined the relationship of within-person across-test neuropsychological performance variability to a current construct of treatment decision (consent) capacity.

METHODS

Participants completed a neuropsychological test battery and a standardized capacity assessment. Standard scores were used to compute mean neuropsychological performance and within-person across-test variability. Assessments were performed in the participant's preferred location (e.g., outpatient clinic office, senior center, or home). Participants were recruited from the community with fliers and advertisements and consisted of men (N = 79) and women (N = 80) with (N = 83) or without (N = 76) significant cognitive impairment. Participants completed the MacArthur Competence Assessment Tool-Treatment and 11 neuropsychological tests commonly used in the cognitive assessment of older individuals.

RESULTS

Neuropsychological performance and within-person variability were independently associated with continuous and dichotomous measures of capacity, and within-person neuropsychological variability was significantly associated with within-person decisional ability variability. Prevalence of incapacity was greater than expected in participants with and without significant cognitive impairment when decisional abilities were considered separately.

CONCLUSION

These findings are consistent with an emerging construct of consent capacity in which discrete decisional abilities are differentially associated with cognitive processes and indicate that the sensitivity and accuracy of consent capacity assessments can be improved by evaluating decisional abilities separately.

Three methods of assessing values for advance care planning: comparing persons with and without dementia

Advance care planning ideally includes communication about values between patients, family members, and care providers. This study examined the utility of health care values assessment tools for older adults with and without dementia. Adults aged 60 and older, with and without dementia, completed three values assessment tools-open-ended, forced-choice, and rating scale questions-and named a preferred surrogate decision maker. Responses to forced-choice items were examined at 9-month retest. Adults with and without dementia appeared equally able to respond meaningfully to questions about values regarding quality of life and health care decisions. People with dementia were generally as able as controls to respond consistently after 9 months. Although values assessment methods show promise, further item and scale development work is needed. Older adults with dementia should be included in clarifying values for advance care planning to the extent that they desire and are able.

Cognitive performance predicts treatment decisional abilities in mild to moderate dementia

OBJECTIVE

To examine the contribution of neuropsychological test performance to treatment decision-making capacity in community volunteers with mild to moderate dementia.

METHODS

The authors recruited volunteers (44 men, 44 women) with mild to moderate dementia from the community. Subjects completed a battery of 11 neuropsychological tests that assessed auditory and visual attention, logical memory, language, and executive function. To measure decision making capacity, the authors administered the Capacity to Consent to Treatment Interview, the Hopemont Capacity Assessment Interview, and the MacCarthur Competence Assessment Tool--Treatment. Each of these instruments individually scores four decisional abilities serving capacity: understanding, appreciation, reasoning, and expression of choice. The authors used principal components analysis to generate component scores for each ability across instruments, and to extract principal components for neuropsychological performance.

RESULTS

Multiple linear regression analyses demonstrated that neuropsychological performance significantly predicted all four abilities. Specifically, it predicted 77.8% of the common variance for understanding, 39.4% for reasoning, 24.6% for appreciation, and 10.2% for expression of choice. Except for reasoning and appreciation, neuropsychological predictor (beta) profiles were unique for each ability.

CONCLUSIONS

Neuropsychological performance substantially and differentially predicted capacity for treatment decisions in individuals with mild to moderate dementia. Relationships between elemental cognitive function and decisional capacity may differ in individuals whose decisional capacity is impaired by other disorders, such as mental illness.

Neuropsychological predictors of decision-making capacity over 9 months in mild-to-moderate dementia

BACKGROUND

Older adults with dementia may have diminished capacity to make medical treatment decisions.

OBJECTIVE

To examine rates and neuropsychological predictors of treatment decision making, or consent capacity, among older adults with dementia over 9 months.

DESIGN

Consent capacity was assessed initially and 9 months later in subjects with and without dementia using a longitudinal repeated measures design.

PARTICIPANTS

Fifty-three older adults with dementia and 53 similarly aged adults without dementia.

MEASUREMENTS

A standardized measure MacArthur Competence Assessment Tool-Treatment of 4 legal standards for capacity (Understanding, Appreciation, Reasoning, and Expressing a Choice) and a neuropsychological battery.

RESULTS

In the dementia group, 9.4% had impaired capacity initially, and 26.4% had impaired capacity at 9 months. Mean scores in the dementia group were impaired relative to controls initially and at 9 months for Understanding (initial t=2.49, P=.01; 9-month t=3.22, P<.01) and Reasoning (initial t=2.18, P=.03; 9-month t=4.77, P<.01). Declining capacity over 9 months was attributable to a further reduction in Reasoning (group x time F=9.44, P=.003). Discriminant function analysis revealed that initial scores on naming, delayed Logical Memory, and Trails B were associated with impaired capacity at 9 months.

CONCLUSIONS

Some patients with mild-to-moderate dementia develop a clinically relevant impairment of consent capacity within a year. Consent capacity in adults with mild-to-moderate dementia should be reassessed periodically to ensure that it is adequate for each specific informed consent situation. Interventions that maximize Understanding and Reasoning by supporting naming, memory, and flexibility may help to optimize capacity in this patient group.

Capacity to consent to treatment: empirical comparison of three instruments in older adults with and without dementia

PURPOSE

The purpose of this study was to compare adults with and without dementia on capacities to consent to treatment as assessed by three instruments.

DESIGN AND METHODS

Eighty-eight older adults with mild to moderate dementia were compared with 88 matched controls on four indices of legal competency to consent to medical treatment as assessed with three capacity instruments.

RESULTS

Mean performance of adults with dementia on a legal standard of understanding treatment information was impaired relative to controls on all instruments, and it was also impaired for an appreciation standard on one instrument and a reasoning standard on two instruments. However, in categorical ratings, most adults with dementia were within the normal range on all decisional capacities. Legal standards were operationalized differently across the three instruments for the capacities of appreciation and reasoning.

IMPLICATIONS

Most adults with mild dementia can participate in medical decision making as defined by legal standards, although memory impairments may limit demonstration of understanding of diagnostic and treatment information. In dementia, assessments of reasoning about treatment options should focus on whether a person can describe salient reasons for a specific choice, whereas assessments of appreciation of the meaning of diagnostic and treatment information should focus on whether a person can describe the implications of various choices for future states. More research is needed to establish the reliability and validity of assessment tools and of capacity constructs.

Use of surrogate respondents in studies of stroke and dementia

A study was performed to determine the misclassification of information on exposure when surrogate informants are interviewed. Information from nondementia patients admitted to a geriatric ward was compared with that obtained from the patients' family members or friends (informants). Thirty-seven patients were recruited (17 with current or previous stroke, and 20 no history of stroke). Information on past medical and family history, cigarette smoking and alcohol consumption was collected using a questionnaire that was administered independently to patients and informants. For nonstroke patients, agreement on smoking and alcohol consumption at different ages was generally good. Informants reported slightly lower smoking and alcohol intake than patients: 1.3 fewer total pack-years (95% CI, -3.8, +6.5) and 2.7 fewer units/week (95% CI, -1.5, +6.9), respectively. For stroke patients, informants tended to report a greater smoking consumption at all ages, and a slightly higher alcohol consumption. Informants reported an excess of 7.4 total pack-years (95% CI, -1.2, + 16.0) and 2.19 units/week (95% CI, -1.0, +5.3). Agreement for medical history was good, except for hypertension. There was poor agreement for family medical history. The impact of misclassification is discussed.

Caregiver's anticipatory grief in dementia: a pilot study

Twenty-seven wives who care for their spouses suffering from dementia completed the Anticipatory Grief Scale (AGS) and the Hopkins Symptom Checklist--SCL-90-R. The alpha coefficient for the AGS was 0.84, indicating good internal consistency. The AGS was also positively and significantly correlated (p less than 0.001) with the depression, anxiety, and hostility dimensions of the SCL-90-R, demonstrating good validity. The study explores bereavement issues of spouses of patients with dementia and provides preliminary findings on a new instrument to measure anticipatory grief.

Brief screening tests versus clinical staging in senile dementia of the Alzheimer type

Several brief screening tests of cognitive function were compared with a reliable and valid global rating of the presence and severity of senile dementia of the Alzheimer type, the Washington University Clinical Dementia Rating (CDR). The six-item Short Blessed Test, the Short Portable Mental Status Questionnaire, the 26-item Blessed Information-Memory-Concentration Test, the Blessed Dementia Scale, and the Blessed Dementia Scale-Cognitive were able to discern both the presence of dementia and its severity. The six-item Short Blessed Test is preferred as a screening test because of its brevity, administration to the subject only, inclusion of a learning task, reliability, and neuropathologic validity. Evidence is presented for the convergent validity of the Initial Subject Protocol, used to derive the Clinical Dementia Rating.

History-taking in the elderly with and without cognitive impairment. How useful is it?

To assess the usefulness of interviewing older adults with cognitive impairment, we analyzed data from the NIMH Epidemiologic Catchment Area Study. People aged 65 and older with cognitive impairment were twice as likely as age-matched unimpaired elders to report sufficient symptoms of psychiatric disorders to qualify for a current diagnosis (16% vs 7%), and were also more likely to qualify for a lifetime diagnosis (25% vs 15%). We considered whether this excess could be due to random responses by the impaired, but found the rank order of their symptoms very similar to that of the unimpaired. Although dementia is thought to affect recent more than remote memory, the impaired were no less likely than the unimpaired to report disorders of recent onset. We also compared the cognitively impaired and unimpaired with respect to their reliability as assessed by reinterview one year later and found no significant difference. We conclude that there is no reason to believe that the excess of disorders in the mildly impaired is an artifact caused by their poorer performance as respondents. Interviewing the elderly person with cognitive impairment is a useful way of discovering concurrent disorders that may be treatable.