Genetics, ethics, and Alzheimer disease

Ethical issues in susceptibility genetic testing for late-onset neurodegenerative diseases

Genome-wide association studies have revolutionized our understanding of the genetic architecture of complex traits and diseases over the last decade. This knowledge is enabling clinicians, researchers, and direct-to-consumer genetics companies to conduct disease susceptibility testing based on powerful methods such as polygenic risk scoring. However, these technologies raise a set of complex ethical, legal, social, and policy considerations. Here we review and discuss a series of ethical dilemmas associated with susceptibility genetic testing for the two most common late-onset neurodegenerative diseases, Alzheimer's and Parkinson's disease, including testing in asymptomatic individuals. Among others, these include informed consent, disclosure of results and unexpected findings, mandatory screening, privacy and confidentiality, and stigma and genetic discrimination. Importantly, appropriate counseling is a deciding factor for the ethical soundness of genetic testing, which poses a challenge for the regulation of these tests and the training of healthcare professionals. As genetic knowledge about these diseases continues growing and genetic testing becomes more widespread, it is increasingly important to raise awareness among researchers, medical practitioners, genetic counselors, and decision makers about the ethical, legal, and social issues associated with genetic testing for polygenic diseases.

Development and evaluation of a statewide autopsy education workshop

The role of autopsy is critical in confirming diagnoses and advancing research in Alzheimer's disease. In collaboration with the Alzheimer's Association chapters in Michigan, the staff of the Education Core of the Michigan Alzheimer's Disease Research Center developed, implemented, and evaluated an educational intervention based on a train-the-trainer model to disseminate information about autopsy to chapter staff and volunteers. Participants at a one-day Autopsy Education Workshop (AEW) developed skills to make presentations about autopsy in their local communities and assist family caregivers with decision-making. Participants reported significant gains in knowledge about autopsy and an increased level of confidence in discussing autopsy withfamily members. The AEW curriculum and evaluation design will be described.

Perspectives on medical research involving men in schizophrenia and HIV-related protocols

Ethical issues in research on serious physical and mental illnesses have received great attention, and yet little is known about how the perspectives of clinical research participants with different diagnoses may compare. We conducted a preliminary study to examine the attitudes of men enrolled in schizophrenia-related protocols and in HIV-related protocols regarding the importance of medical research, key aspects of research participation, and the acceptability of research involvement by various groups. A total of 33 men enrolled in schizophrenia protocols and 15 men enrolled in HIV-related protocols volunteered for our study. Respondents affirmed the importance of medical research and endorsed many positive things about participation. Autonomy and altruism were identified as motivators for research involvement. Participation by diverse groups was seen as acceptable. Respondents expressed comfort and little stress with the interview process. Men in different diagnostic groups largely saw the issues the same. Our findings thus suggest that people with schizophrenia and HIV/AIDS who are enrolled in protocols may share a number of core attitudes or beliefs related to ethical aspects of research participation. Further study is needed to explore how research involvement may influence perspectives and whether differences in views exist across people with diverse physical and mental illnesses.

Translating basic aging research into geriatric health care

Aging processes are amenable to molecular genetic analyses. Two aspects of such research have been selected for discussion in this paper because of current great interest and their relevance to human aging. Studies on telomeres have revealed new insights on the control of cellular replicative senescence and provided a means to extend the cell's life span during in vitro cultivation. Emerging studies on genetic biomarkers have identified genes that appear to be associated with longevity or with risk factors for aging-related diseases, and raised considerations of ways to reduce disease expression. An interchange between basic scientists and clinicians would encourage new thoughts on the feasibility of translating these fundamental studies into interventions that promote healthier longevity.

Autopsy recruitment program for African Americans

A specialized brain autopsy recruitment program was implemented within the context of advance medical directives and end-of-life treatment decisions. The program was implemented within the framework of a larger study. The purpose of the program was to (1) improve the rate of consent for brain autopsy among African Americans diagnosed with stroke and dementia, and (2) obtain more empirical information on the underlying reasons for the low response rate (4%) in this minority group. A convenience sample of 133 patient and family caregiver pairs was selected for participation. Face-to-face, open-ended interviews were conducted to ascertain reasons for autopsy preferences and to identify respondents interested in the postmortem procedure. Preferences for brain autopsy were ascertained and individuals interested in the procedure were subsequently followed through death or over the 2 1/2 year course of the study. Brain necropsies were conducted on patients requesting the examination. Thirty-six (36) patient and family pairs consented to the procedure, 16 were indecisive and 81 refused. Factors influencing decisions included existing attitudes toward autopsy, family agreement regarding the procedure, and assurance that funeral arrangements would not be delayed. Ninety deaths and two autopsies were conducted before implementation of the specialized recruitment program, yielding a 2.22% completion rate, and 34 deaths with 10 postmortems conducted within the time frame of the recruitment study, yielding a 29% autopsy completion rate. Fisher exact test (p < 0.0001) revealed a significant difference in the proportion of autopsies completed before and after implementation of the specialized recruitment program. Findings strongly suggest that culturally sensitive recruitment programs may increase the rate of autopsy request made by African American caregivers for relatives diagnosed with dementia and stroke. To obtain a higher rate of consent than that obtained in the general population, the program must contain ethnically sensitive recruitment strategies.

The psychological impact of genetic testing for Alzheimer disease

Information regarding one's genetic risk for a particular disease might effectively inform medical, financial, and reproductive decisions and perhaps promote established risk reduction behaviors. However, genetic testing may also lead to significant levels of anxiety, depression, or other forms of distress, especially when psychological coping strategies and social reserves are not adequate to manage positive or inconclusive results. This paper focuses on the psychological impact of predisposition genetic for Alzheimer disease (AD). We present stress and coping models that capture the essence of this impact and discuss the potential role of counseling and follow-up interventions. The discussion draws primarily from the experiences of professionals working with other diseases, and seeks to expand that experience into the AD arena. In addition, we emphasize two issues we believe need additional attention in the psychological literature regarding genetic testing and counseling: (i) the psychosocial vulnerability of individuals being tested and, (ii) the sociocultural context of the AD patient and their family members.

The impact of Alzheimer disease genetics on expert and advanced gerontological nursing practice

Alzheimer disease (AD), a progressive neurodegenerative disorder, is the most common cause of dementia in the United States, affecting as many as 4 million people. Extensive research is under way to identify environmental and genetic risk factors for this complex disease. Currently, four genes are associated with an increased risk for AD: the amyloid precursor protein gene on chromosome 21, the Presenilin I gene on chromosome 14, the Presenilin II gene on chromosome 1, and the apolipoprotein E gene on chromosome 19. Expert and advanced practice gerontological nurses are faced with new challenges as a result of these gene discoveries. Gerontological nurses should assess for relevant environmental and genetic risk factors; obtain comprehensive family health histories recorded as pedigrees; integrate genetic information into diagnosis, intervention, and evaluation strategies; initiate and coordinate referrals to genetic specialists; and provide ongoing emotional and decision-making support for patients and families experiencing AD.

Genetic testing in Alzheimer's disease. Benefits risks and public policy

1. Genetic research is providing new information about the structure and function of genes associated with diseases such as Alzheimer's disease. 2. The ability to perform genetic tests to diagnose or predict disease often exists before the ability to prevent or treat disease. 3. Genetic tests are associated with both benefits and risks, which likely will apply to the Alzheimer's disease population. 4. Safe and effective tests, laboratories of assured quality, competent providers, assured privacy of genetic information, and informed consumers are important prerequisites to the successful integration of genetic tests into health care services.

Clinical rationale of genetic testing in dementia

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The experience of dementia: a review of the literature and implications for nursing practice

This paper explores the early experience of dementia when the veil of uncertainty that surrounds the diagnosis of this condition is lifted. Consideration will also be given to the impact of dementia on carers and the service demands that are created. In the UK alone there are estimated to be 636,000 people living with dementia, with this figure rising to just under 900,000 by the year 2021. In the USA the projected number of people with Alzheimer's disease is expected to be 9,000,000 by the year 2040 Despite a wealth of social and gerontological research on the impact of dementia upon family carers, service responses and policy initiatives are fragmented because dementia is excluded from some important recent initiatives, such as the Mental Health Task Force. Current services and interventions focus predominantly on the later stages of dementia, when a meaningful perspective of the person with dementia is difficult to obtain. Nursing has a relatively long history of caring for people with dementia and their family carers. The paper will also consider the contribution of nursing and nursing research to the field and explore additional avenues for service intervention and education.

Caring for a parent with Alzheimer's disease: process of daughter caregiver stress

This study aimed to explore the process of caregiver stress associated with the care of a parent with Alzheimer's disease, the perception of the relationship with the parent, the image of the caregiver role, and the contextual aspects of coping and social support relationships. The grounded theory method was used to analyse the daughter caregiving process for 17 women. Findings included substantive theory and 13 hypotheses. This study provides an expanded awareness of the interrelationship between caregiver stress and the contextual aspects of social support, coping, and the nature of the prior filial relationship.

Ethical concerns in the research and treatment of complex disease

Research on and treatment of complex diseases raise familiar ethical issues concerning informed consent, privacy, confidentially, insurability, employability and social stigma. Consideration of the family as the unit of study, or point of medical intervention, presents some additional twists to these common ethical concerns. In addition, complex diseases present particular ethical challenges because different social and political incentives accompany placing emphasis on either the genetic or the environmental components of the diseases (e.g. in allocating research funds or ascribing responsibility for illness).

Fairhill guidelines on ethics of the care of people with Alzheimer's disease: a clinical summary. Center for Biomedical Ethics, Case Western Reserve University and the Alzheimer's Association

These guidelines summarize the content of meetings of family caregivers and individuals with dementia of the Alzheimer's type who identified and spoke on ethical issues in dementia care and who engaged in dialogue with an interdisciplinary and interprofessional group of individuals working in the field of Alzheimer's disease. This inductive method begins with attentive listening to the voices of the affected population and family members, in contrast with a theoretical and deductive approach to ethics.