Medicolegal, employment, and insurance issues in APOE genotyping and Alzheimer's disease

Is the APOE ∊4 Allele a Risk to Person-Environment Fit?

This study uses Lawton’s model of “the good life” to examine whether the Apolipoprote in E-∊4 genotype functions as a risk factor not only for specific diseases but also for a misfit between elders’ personal needs and their physical and social environments. A biracial cohort of communitydwelling elders from five North Carolina Piedmont counties was assessed annually for 10 years. Six-year survivors (N = 2,076) were genotyped for this retrospective-prospective cohort study. Compared to those in whom this allele was absent, participants with the 4 allele were not different in social or residential resources, social behavioral competence, or perceived quality of resources. Exposed elders had an excess 10-year adjusted risk of institutionalization of 1.72 (95% CI = 1.29, 2.29), totally mediated by cognitive problems. The threat of the APOE 4 genotype to person-environment fit is mediated by cognitive problems, a finding that has focused but important implications for residential decision making in late life.

Evaluation of genetic tests: APOE genotyping for the diagnosis of Alzheimer disease

Many studies have now confirmed the association between inheritance of the epsilon 4 allele of the apolipoprotein E (APOE) gene and Alzheimer disease (AD). However, although the medical community holds the near-unanimous opinion that APOE genotyping should not be used for prediction in asymptomatic individuals, controversy remains about whether it should be used for diagnosis in patients who show signs of dementia. We assessed critically the recent clinical studies, on the basis of four criteria recommended to ensure safety and effectiveness of genetic tests. We also developed a formal framework for evaluating the usefulness of APOE genotyping using decision-theoretic principles. We conclude that neither the presence nor absence of an epsilon 4 allele provides diagnostic certainty, and the proper interpretation of either result in heterogeneous populations requires further investigation. The appropriate role of APOE genotyping among elements of a traditional assessment for AD has not been determined. Whether APOE genotyping provides sufficient information to change patient management decisions has not been determined. APOE genotyping presents foreseeable, significant psychosocial consequences for family members that must be weighed against any psychosocial benefits. Therefore, the diagnostic use of APOE genotyping outside research settings is premature until such testing is shown to be of practical value.

The law, adolescents, and the APOE epsilon 4 genotype: a view from Canada

The presence of an apolipoprotein E (APOE) epsilon 4 allele may be a risk factor for the severity of the consequences of head trauma, both short-term and long-term. If this proves to be true, genetic testing for APOE status might be encouraged, or required, to minimize the costs of participation in high-contact sports, such as ice hockey, soccer, rugby, and boxing, where head injury is likely to occur. Under some circumstances, testing minors for this purpose might be justifiable. This would raise complex ethical and legal questions about respective powers and rights of adolescents and parents. The wishes of the "nearly competent" adolescent not to be tested should override parental desires for testing, although such a conclusion has only limited warrant in Canadian law. If a mature adolescent wishes testing, but the parents do not, testing may be permissible--although Canadian law is again unclear. The physician should not be able to inform the parents of the test results without the adolescent's consent, nor should the adolescent be forced to disclose those results.