Supporting older patients in making healthcare decisions: The effectiveness of decision aids; A systematic review and meta-analysis

OBJECTIVE

To systematically review randomized controlled trials and clinical controlled trials evaluating the effectiveness of Decision Aids (DAs) compared to usual care or alternative interventions for older patients facing treatment, screening, or care decisions.

METHODS

A systematic search of several databases was conducted. Eligible studies included patients ≥ 65 years or reported a mean of ≥ 70 years. Primary outcomes were attributes of the choice made and decision making process, user experience and ways in which DAs were tailored to older patients. Meta-analysis was conducted, if possible, or outcomes were synthesized descriptively.

RESULTS

Overall, 15 studies were included. Using DAs were effective in increasing knowledge (SMD 0.90; 95% CI [0.48, 1.32]), decreasing decisional conflict (SMD -0.15; 95% CI [-0.29, -0.01]), improving patient-provider communication (RR 1.67; 95% CI [1.21, 2.29]), and preparing patients to make an individualized decision (MD 35.7%; 95% CI [26.8, 44.6]). Nine studies provided details on how the DA was tailored to older patients.

CONCLUSION

This review shows a number of favourable results for the effectiveness of DAs in decision making with older patients.

PRACTICE IMPLICATIONS

Current DAs can be used to support shared decision making with older patients when faced with treatment, screening or care decisions.

Age Influences Loss Aversion Through Effects on Posterior Cingulate Cortical Thickness

Decision-making strategies shift during normal aging and can profoundly affect wellbeing. Although overweighing losses compared to gains, termed "loss aversion," plays an important role in choice selection, the age trajectory of this effect and how it may be influenced by associated changes in brain structure remain unclear. We therefore investigated the relationship between age and loss aversion, and tested for its mediation by cortical thinning in brain regions that are susceptible to age-related declines and are implicated in loss aversion - the insular, orbitofrontal, and anterior and posterior cingulate cortices. Healthy participants (n = 106, 17-54 years) performed the Loss Aversion Task. A subgroup (n = 78) provided structural magnetic resonance imaging scans. Loss aversion followed a curvilinear trajectory, declining in young adulthood and increasing in middle-age, and thinning of the posterior cingulate cortex mediated this trajectory. The findings suggest that beyond a threshold in middle adulthood, atrophy of the posterior cingulate cortex influences loss aversion.

Is Reliance on the Affect Heuristic associated with Age?

OBJECTIVES

With age, decision makers rely more on heuristic and affect-based processing. However, age differences have not been quantified with respect to the affect heuristic which derives judgments based on positive and negative feelings towards stimuli and concepts. The present study examined whether reliance on the affect heuristic is associated with age, whether these patterns vary by task type, and which covariates account for age effects.

METHOD

In a pre-registered study, an adult lifespan sample (N = 195, 21 - 90 years, Mage = 52.95, 50% female, 71% non-Hispanic White) completed a battery of cognitive, personality, and socioemotional covariates as well as three established affect heuristic tasks: (1) a risk-benefit task, (2) a dread-inference task, and (3) an affect-impact task. Reliance on affect was indexed through (1) a negative relationship between perceived food risks and benefits, (2) a positive relationship between feelings of dread and statistical inferences about mortality risks, and (3) a positive relationship between affective responses and impact judgments when evaluating catastrophes.

RESULTS

For all three tasks, usage of the affect heuristic was documented at the group and the individual level. Contrary to hypotheses, age was not associated with affect heuristic use for any of the tasks. Affect heuristic indices did not correlate across tasks and showed no consistent associations with the covariates.

DISCUSSION

Results suggest that the use of affect-based heuristics is context- or stimulus-dependent rather than a stable, age-associated trait. Further research is needed to validate the present results across additional domains, tasks, and stimulus types.

Patient Experiences in Selecting a Medicare Part D Prescription Drug Plan

INTRODUCTION

Medicare beneficiaries often report that the process of choosing a prescription drug plan is frustrating and confusing and many do not enroll in the plan that covers their drugs at the lowest cost.

METHODS

We conducted 4 focus groups to understand beneficiaries' experiences in selecting a drug plan to identify what resources and factors were most important to them. Participants were patients served by a multispecialty delivery system and were primarily affluent and Caucasian.

RESULTS

While low cost was essential to many, other characteristics like having the same plan as a partner, company reputation, convenience, and anticipation of possible future health problems were sometimes more important. Although some used resources including insurance brokers, counselors, and websites beyond Medicare.gov, many expressed a desire for greater assistance with and greater simplicity in the choice process.

CONCLUSION

Although older adults would likely benefit from greater assistance in choosing Medicare Part D prescription drug plans, more research is necessary to understand how to help with decision-making in this context.

Decision aids to help older people make health decisions: a systematic review and meta-analysis

BACKGROUND

Decision aids have been overall successful in improving the quality of health decision making. However, it is unclear whether the impact of the results of using decision aids also apply to older people (aged 65+). We sought to systematically review randomized controlled trials (RCTs) and clinical controlled trials (CCTs) evaluating the efficacy of decision aids as compared to usual care or alternative intervention(s) for older adults facing treatment, screening or care decisions.

METHODS

A systematic search of (1) a Cochrane review of decision aids and (2) MEDLINE, Embase, PsycINFO, Cochrane library central registry of studies and Cinahl. We included published RCTs/CCTs of interventions designed to improve shared decision making (SDM) by older adults (aged 65+) and RCTs/CCTs that analysed the effect of the intervention in a subgroup with a mean age of 65+. Based on the International Patient Decision aid Standards (IPDAS), the primary outcomes were attributes of the decision and the decision process. Other behavioral, health, and health system effects were considered as secondary outcomes. If data could be pooled, a meta-analysis was conducted. Data for which meta-analysis was not possible were synthesized qualitatively.

RESULTS

The search strategy yielded 11,034 references. After abstract and full text screening, 22 papers were included. Decision aids performed better than control resp. usual care interventions by increasing knowledge and accurate risk perception in older people (decision attributes). With regard to decision process attributes, decision aids resulted in lower decisional conflict and more patient participation.

CONCLUSIONS

This review shows promising results on the effectiveness of decision aids for older adults. Decision aids improve older adults' knowledge, increase their risk perception, decrease decisional conflict and seem to enhance participation in SDM. It must however be noted that the body of literature on the effectiveness of decision aids for older adults is still in its infancy. Only one decision aid was specifically developed for older adults, and the mean age in most studies was between 65 and 70, indicating that the oldest-old were not included. Future research should expand on the design, application and evaluation of decision aids for older, more vulnerable adults.

Age Differences in Trade-off Decisions: Different Strategies but Similar Outcomes

L'objectif principal de cette étude était d'examiner les différences conditionnées par l'âge dans le traitement des stratégies de décisions émotionnellement difficiles. En outre, l'étude a testé les contributions pertinentes des mécanismes cognitifs et émotionnels à des différences dans le traitement de ces stratégies conditionnées par l'âge. Quarante jeunes adultes et quarante adultes plus âgés, en tout, ont été assignés au hasard soit à un niveau élevé ou à un niveau bas de difficulté émotionnelle qu'implique la décision d'acheter une automobile. MouselabWEB logiciel a été utilisé pour tracer les stratégies de traitement des partici- pants. Les résultats ont montré que les personnes âgées étaient plus susceptibles d'utiliser des stratégies de traitement basées sur les attributs, tandis que les jeunes adultes étaient plus susceptibles d'utiliser des stratégies de traitement basées sur des solutions de rechange à l'état très émotive. D'autre part, les jeunes adultes et les adultes plus âgés ont préféré utiliser des stratégies de traitement fondées sur des alternatives dans des conditions d'émotion faible. De plus, les résultats suggèrent que la mesure cognitive (c'est à dire, programmation de chiffres-symboles) n'était pas corrélée avec les effets de l'âge sur les stratégies de traitement.

Risky choice in younger versus older adults: Affective context matters

Earlier frameworks have indicated that older adults tend to experience decline in their deliberative decisional capacity, while their affective abilities tend to remain intact (Peters, Hess, Västfjäll, & Auman, 2007). The present study applied this framework to the study of risky decision-making across the lifespan. Two versions of the Columbia Card Task (CCT) were used to trigger either affective decision-making (i.e., the “warm” CCT) or deliberative decision-making (i.e., the “cold” CCT) in a sample of 158 individuals across the lifespan. Overall there were no age differences in risk seeking. However, there was a significant interaction between age and condition, such that older adults were relatively more risk seeking in the cold condition only. In terms of everyday decision-making, context matters and risk propensity may shift within older adults depending upon the context.

Age differences in risky choice: a meta-analysis

Does risk taking change as a function of age? We conducted a systematic literature search and found 29 comparisons between younger and older adults on behavioral tasks thought to measure risk taking (N= 4,093). The reports relied on various tasks differing in several respects, such as the amount of learning required or the choice framing (gains vs. losses). The results suggest that age-related differences vary considerably as a function of task characteristics, in particular the learning requirements of the task. In decisions from experience, age-related differences in risk taking were a function of decreased learning performance: older adults were more risk seeking compared to younger adults when learning led to risk-avoidant behavior, but were more risk averse when learning led to risk-seeking behavior. In decisions from description, younger adults and older adults showed similar risk-taking behavior for the majority of the tasks, and there were no clear age-related differences as a function of gain/loss framing. We discuss limitations and strengths of past research and provide suggestions for future work on age-related differences in risk taking.

If only I had taken my usual route…: age-related differences in counter-factual thinking

Previous research suggests that young adults can shift between rational and experiential modes of thinking when forming social judgments. The present study examines whether older adults demonstrate this flexibility in thinking. Young and older adults completed an If-only task adapted from Epstein, Lipson, and Huh's (1992 , Journal of Personality and Social Psychology, 62, 328) examination of individuals' ability to adopt rational or experiential modes of thought while making a judgment about characters who experience a negative event that could have been avoided. Consistent with our expectations for their judgments of the characters, young adults shifted between experiential and rational modes of thought when instructed to do so. Conversely, regardless of the mode of thought being used or the order with which they adopted the different modes of thought (i.e., shifting from experiential to rational in Study 1 and from rational to experiential in Study 2), older adults consistently offered judgments and justifications that reflected a preference for experiential-based thought.

Effect of aging on the perceptions of physical and mental health in an Australian population

The aim of this study was to examine the impact of age on the perceptions of mental and physical health in an Australian population. A cross-sectional study of the Queensland population was conducted via telephone interviews (n = 1165). The Short Form-12 Health Survey was used to measure the population's perceived physical and mental health and additional demographic information was collected. Groups with participants who were aged 18-24, 25-34, 35-44, 45-54, 55-64, and > 65 years were compared. The results suggested that the participants' perceptions of mental health gradually increased with age, as the 55-64 and > 65 years old age groups scored significantly higher than did the younger age groups. Conversely, the older participants scored significantly lower than the younger participants on the physical health scale. Further research is warranted to consider the factors that might influence the perceptions of mental health across the life span.

Emotional and informational patient cues: the impact of nurses' responses on recall

OBJECTIVE

To investigate older cancer patients' informational and emotional cues, how nurses respond to these cues and the effect of cues and responses on patients' information recall.

METHODS

105 cancer patients (aged >or=65 years) completed a recall questionnaire after an educational session preceding chemotherapy treatment. Recall was checked against the actual communication in videorecordings of the consultations. Patients' emotional and informational cues and subsequent responses by the nurse were rated using an adaptation of the Medical Interview Aural Rating Scale (MIARS).

RESULTS

Patients gave more informational than emotional cues. The most frequent response to emotional cues was distancing followed by acknowledgement. Nurses gave appropriate information in response to the majority of informational cues. Patients' expression of emotional or informational cues did not influence recall; neither did nurses' responses to informational cues. Responses to emotional cues did affect recall. The more nurses responded by giving 'minimal' encouragements (e.g. 'Hmmm'), the more patients recalled, while distancing responses (e.g. switching focus) were associated with lower recall scores.

CONCLUSION

Responding to patients' emotions is likely to impact information recall.

PRACTICE IMPLICATIONS

These results highlight the importance of addressing patients' expressions of emotions in the context of patient education, as it enhances information recall.

Aging and cognition

As we grow older, we gain knowledge and experience greater emotional balance, but we also experience memory loss and difficulties in learning new associations. Which cognitive abilities decline, remain stable or improve with age depends on the health of the brain and body as well as on what skills are practiced or challenged in everyday life. Recent research provides a growing understanding of the relationship between physical and cognitive changes across the life span and reveals ways to increase mental sharpness and avoid cognitive decline. Copyright © 2010 John Wiley & Sons, Ltd. For further resources related to this article, please visit the WIREs website.

How much choice is too much? The case of the Medicare prescription drug benefit

OBJECTIVE

To study the impact of the number of choices and age on measures of performance in choosing a Medicare prescription drug plan.

DATA SOURCE/STUDY SETTING

One hundred ninty-two healthy individuals age 18 and older, half age 65 or older, in Claremont, California.

STUDY DESIGN

Participants were randomly assigned to 3, 10, or 20 hypothetical drug plans and asked four factual questions. Statistical models controlled for experimental group, age, gender, race, education, income, marital status, and health status.

PRIMARY FINDINGS

Older age and greater number of plans were significantly associated with fewer correct answers. Although older adults were less likely to identify the plan that minimized total annual cost, they were more likely to state that they were "very confident" they chose the correct plan.

CONCLUSIONS

The results raise concerns about the difficulties that older adults may have in navigating the wide range of drug plan choices available.