Competency issues in dementia: medical decision making, driving, and independent living

Evaluating functional abilities within the context of memory assessment: A practice survey of neuropsychologists

Objective: Functioning in daily life is an important consideration when differentiating between individuals with normal cognition, mild neurocognitive disorder, and major neurocognitive disorder. Despite this, there is no gold standard measurement approach for assessing functional abilities and few guidelines on how to do so. The objective of this study was to examine neuropsychologists' practices regarding the assessment of functional abilities across the spectrum of memory ability. Method: A total of 278 psychologists who routinely conduct neuropsychological assessments completed an online survey (estimated 15% response rate) querying their practices and perspectives with respect to the assessment of functional abilities. Results: Respondents identified that changes to several components of daily functioning, including activities of daily living, were important when evaluating functional abilities. Respondents reported utilizing a variety of instruments to assess functioning, with an overwhelming majority indicating the use of semi-structured interviews. Although most respondents are satisfied with existing tools, a quarter of respondents felt strongly that there was a need for more instruments of everyday functioning. Respondents further indicated that their recommendations to patients, particularly regarding compensatory strategies and follow-up with other professionals, were informed by results of their functional assessment. Conclusions: Overall, our survey results indicate that neuropsychologists perceive multiple factors of daily life to be important considerations when evaluating functioning, use a variety of techniques to assess functioning, and perceive a need for more measures of functional abilities.

Advance Care Planning for Seniors Diagnosed with Dementia: A Scoping Review of the Canadian Literature

Advance care planning (ACP) is commonly recommended for persons living with dementia. Increasing age and uncertain disease trajectory add complexity to this process. A scoping review of the Canadian literature was completed to assess the feasibility and acceptability of ACP for seniors (≥ 65 years of age) diagnosed with dementia and to provide practice, policy, and research recommendations towards ACP as a critical aspect of care. Twenty-nine articles were grouped into five themes: (1) feasibility of patient engagement in ACP; (2) opinions regarding medical assistance in dying (MAiD) for incompetent patients; (3) knowledge translation to support persons living with dementia, professionals, and caregivers; (4) barriers to and facilitators of the delivery of holistic dementia care; and (5) Indigenous health considerations. Additional research should consider socio-demographic and social/cultural factors associated with older persons living with dementia's engagement in ACP. Future policies warrant a multidisciplinary approach when reviewing legalities. Finally, ACP knowledge translation should become a routine aspect of dementia care.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

The development of the Promoting Independence in Dementia (PRIDE) intervention to enhance independence in dementia

OBJECTIVE

Support after a diagnosis of dementia may facilitate better adjustment and ongoing management of symptoms. The aim of the Promoting Independence in Dementia (PRIDE) study was to develop a postdiagnostic social intervention to help people live as well and as independently as possible. The intervention facilitates engagement in evidence-based stimulating cognitive, physical and social activities.

METHODS

Theories to promote adjustment to a dementia diagnosis, including theories of social learning and self-efficacy, were reviewed alongside self-management and the selective optimization model, to form the basis of the intervention. Analyses of two longitudinal databases of older adults, and qualitative analyses of interviews of older people, people with dementia, and their carers about their experiences of dementia, informed the content and focus of the intervention. Consensus expert review involving stakeholders was conducted to synthesize key components. Participants were sourced from the British NHS, voluntary services, and patient and public involvement groups. A tailored manual-based intervention was developed with the aim for this to be delivered by an intervention provider.

RESULTS

Evidence-based stimulating cognitive, physical, and social activities that have been shown to benefit people were key components of the proposed PRIDE intervention. Thirty-two participants including people with dementia (n=4), carers (n=11), dementia advisers (n=14), and older people (n=3) provided feedback on the drafts of the intervention and manual. Seven topics for activities were included (eg, "making decisions" and "getting your message across"). The manual outlines delivery of the intervention over three sessions where personalized profiles and plans for up to three activities are developed, implemented, and reviewed.

CONCLUSION

A manualized intervention was constructed based on robust methodology and found to be acceptable to participants. Consultations with stakeholders played a key role in shaping the manualized PRIDE intervention and its delivery. Unlike most social interventions for dementia, the target audience for our intervention is the people with dementia themselves.

Caregivers' Experience of Decision-Making regarding Diagnostic Assessment following Cognitive Screening of Older Adults

Targeted screening for dementia among older adults in primary healthcare has potential benefits such as better clinical outcomes and the opportunity to access services. Cognitive screening can be followed up by further diagnostic assessment to determine a diagnosis of dementia. Unfortunately, the rates of accepting further diagnostic assessment following cognitive screening are low. The objective of this study was to explore the caregivers' decision-making process regarding uptake of diagnostic assessment following positive screening results. A qualitative design was employed, and interpretative phenomenological analysis was used to analyze the data. Three major themes in caregiver decision-making were identified: gathering information, protecting the patient, and balancing obligation and convenience in caregiving. These findings suggest that the decision-making process involved effort to process information through observations of the patient and that caregivers emphasized quality of life.

Development of a Short-Form of the Medication Management Test: Evaluation of Dimensionality, Reliability, Information and Measurement Equivalence Using Latent Variable Models

BACKGROUND AND PURPOSE

The Medication Management Test (MMT) measures higher cognitive functioning. The aim of the analyses presented was to reduce assessment burden by developing a short-form version, and describe its psychometric properties.

METHODS

Factor analyses, item response theory (IRT), and differential item functioning (DIF) were performed to examine the dimensionality, reliability information, and measurement equivalence.

RESULTS

The ratio of the first two extracted eigenvalues from the exploratory principal component analysis was 7.62, indicating essential unidimensionality. Although one item "needs prompting for pill regime" evidenced DIF above the threshold for education and race/ethnicity, the magnitude was relatively small and the impact minimal. IRT-based reliability estimates were high (>0.80) across all subgroups.

CONCLUSIONS

Because medication management is an important task associated with independent living, it is critical to assess whether medications can be self-administered safely.

Perception of domestic risks among carers for dependent older persons

BACKGROUND

Despite growing interest for home care, little evidence exists on the perception of domestic risk among carers for dependent older persons. This study aims to characterize the risks to which carers of aging dependent individuals are exposed, and to determine whether these risk dimensions are predictive for effective support, for burden, and for psychological distress.

METHODS

Seventy care partners were questioned about the risk situations identified at the homes of the old people they care for, about the burden they felt in their role, and about their feelings of psychological distress. Securing was evaluated by means of sensibility measures, and overprotection was evaluated by means of specificity measures.

RESULTS

Risk rates were high for loneliness of the old people, wandering, burns, and unsatisfactory health monitoring. There was very little overlap between identification of the risks and implementation of solutions by the caregiver, except for the risks that involved heat. The distinction between accurate securing and overprotection is especially important, because the burden of care partners was linked to uncontrolled domestic risks.

CONCLUSION

Typologies of reactions to risk, characterized by a signal detection approach, could contribute to a better understanding of the situations experienced by care partners, especially situations of neglect and of overprotection.

Alzheimer's disease and the law: positive and negative consequences of structural stigma and labeling in the legal system

OBJECTIVE

To explore the meaning and consequences of labeling on structural stigma in the context of Alzheimer's disease (AD) in the legal system.

METHOD

This qualitative study was made up of three focus groups including social workers and lawyers (n = 26). Participants were asked to report their experience in circumstances in which persons with AD and their family members engage with the legal system. Thematic analysis using the constant comparative method was used.

RESULTS

The discussions in the focus groups raised two overall themes. (1) The significance of the medical diagnostic labeling of AD in the legal system and (2) the consequences of labeling of AD within the legal system. This last theme included four sub-themes: (a) negative consequences of labeling; (b) reasons associated with negative consequences of labeling; (c) positive consequences of labeling; and (d) reasons associated with positive consequences of labeling.

CONCLUSION

Findings of the study provide a first foundation for future research on the meaning and consequences of labeling in legal cases involving persons with AD. They suggest that increasing judges' knowledge about AD and reforming the existing 'status-based' legal capacity legislation might benefit by limiting the legal weight given today to the medical diagnosis.

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.

The Legal System and Alzheimer's Disease: Social Workers and Lawyers' Perceptions and Experiences

The expected increase in the number of people living with Alzheimer's disease (AD) worldwide will be accompanied by an increase in the number of cases involving persons with AD brought up to the courts. This study examined the perceptions and experiences of social workers and lawyers regarding these cases. Three focus groups including social workers and lawyers (n = 26) were conducted. Two main themes were raised by the participants: (a) the role of social workers and lawyers in court cases regarding AD, and (b) the need for improving legal encounters involving persons with AD. Similarities and differences were found in both professionals' interpretations of these shared themes. Results of this study emphasize the need for increasing the knowledge and interprofessional training provided to social workers and lawyers involved in legal cases dealing with issues involving persons with Alzheimer's disease.

Ability of older people with dementia or cognitive impairment to manage medicine regimens: a narrative review

Impaired cognition has a significant impact on a person’s ability to manage their medicines. The aim of this paper is to provide a narrative review of contemporary literature on medicines management by people with dementia or cognitive impairment living in the community, methods for assessing their capacity to safely manage medicines, and strategies for supporting independent medicines management. Studies and reviews addressing medicines management by people with dementia or cognitive impairment published between 2003 and 2013 were identified via searches of Medline and other databases. The literature indicates that as cognitive impairment progresses, the ability to plan, organise, and execute medicine management tasks is impaired, leading to increased risk of unintentional non-adherence, medication errors, preventable medication-related hospital admissions and dependence on family carers or community nursing services to assist with medicines management. Impaired functional capacity may not be detected by health professionals in routine clinical encounters. Assessment of patients’ (or carers’) ability to safely manage medicines is not undertaken routinely, and when it is there is variability in the methods used. Self-report and informant report may be helpful, but can be unreliable or prone to bias. Measures of cognitive function are useful, but may lack sensitivity and specificity. Direct observation, using a structured, standardised performance-based tool, may help to determine whether a person is able to manage their medicines and identify barriers to adherence such as inability to open medicine packaging. A range of strategies have been used to support independent medicines management in people with cognitive impairment, but there is little high-quality research underpinning these strategies. Further studies are needed to develop and evaluate approaches to facilitate safe medicines management by older people with cognitive impairment and their carers.

Comparing the driving behaviours of individuals with frontotemporal lobar degeneration and those with Alzheimer's disease

BACKGROUND

Assessing driving aptitude in dementia patients is critically important for both patient and public safety. However, there have been only a few reports on the driving behaviours and accident risk of patients with dementia, especially frontotemporal lobar degeneration (FTLD). Therefore, we compared the characteristics of driving behaviours in patients with FTLD and those with Alzheimer's disease (AD).

METHODS

The subjects were 28 FTLD and 67 AD patients who visited the Department of Psychiatry, Kochi Medical School Hospital. We conducted semi-structured interviews with their families and caregivers about traffic accident history and changes in patient driving behaviours after dementia onset and then compared the findings between the two groups.

RESULTS

Overall changes in driving behaviours were reported in 89% (25/28) and 76% (51/67) of the FTLD and AD patients, respectively (P = 0.17). In the FTLD group, difficulty in judging inter-vehicle distances, ignoring road signs and traffic signals, and distraction were reported in 50% (14/28), 61% (17/28), and 50% (14/28) of patients, respectively, and 75% (21/28) patients had caused a traffic accident after dementia onset. The risk of causing an accident was higher in the FTLD group than in the AD group (odds ratio = 10.4, 95% confidence interval = 3.7-29.1). In addition, the mean duration between dementia onset and a traffic accident was 1.35 years in the FTLD group compared with 3.0 years in the AD group (P < 0.01).

CONCLUSIONS

Patients with FTLD were more likely to show dangerous driving behaviours than those with AD, and the risk of causing a traffic accident may be higher in patients with FTLD from an early disease stage.

Everyday decision-making in dementia: findings from a longitudinal interview study of people with dementia and family carers

BACKGROUND

Exercising choice and control over decisions is central to quality of life. The Mental Capacity Act 2005 (England and Wales) provides a legal framework to safeguard the rights of people with dementia to make their own decisions for as long as possible. The impact of this on long-term planning has been investigated; everyday decision-making in people's own homes remains unexplored.

METHODS

Using a phenomenological approach, we interviewed 12 dyads (one person with dementia + one carer) four times over one year to ascertain experience of decision-making, how decisions were negotiated, and how dynamics changed. Qualitative interviews were conducted in people's own homes, and thematic analysis was applied to transcripts.

RESULTS

Respecting autonomy, decision-specificity and best interests underlay most everyday decisions in this sample. Over time, dyads transitioned from supported decision-making, where person with dementia and carer made decisions together, to substituted decision-making, where carers took over much decision-making. Points along this continuum represented carers' active involvement in retaining their relative's engagement through providing cues, reducing options, using retrospective information, and using the best interests principle. Long-term spouse carers seemed most equipped to make substitute decisions for their spouses; adult children and friend carers struggled with this.

CONCLUSIONS

Carers may gradually take on decision-making for people with dementia. This can bring with it added stresses, such as determining their relative's decision-making capacity and weighing up what is in their best interests. Practitioners and support services should provide timely advice to carers and people with dementia around everyday decision-making, and be mindful how abilities may change.

Measures of everyday competence in older adults with cognitive impairment: a systematic review

BACKGROUND

The issue of safety of the cognitively impaired elderly people living alone has been continuously raised. Traditional psychometric measures of cognitive abilities may not adequately reflect older adults' functioning in a real everyday context.

OBJECTIVES

To conduct a systematic review on instruments available for evaluating the everyday problem-solving or everyday competence of the elderly with cognitive impairment and to critically review the measurement properties of the identified instruments.

METHODS

We searched the databases such as Cinahl, Medline, PsycINFO, AARP Ageline, ProQuest and the Cochrane Library for the time period between January 1995 and December 2010. Reference lists of the included papers were also manually searched.

RESULTS

Five instruments were included. All the instruments focused their framework on Instrumental Activities of Daily Living (IADL) domains which meet well with suggestions from other studies on the importance of IADL in determining an elderly individual's capability to live independently in the community. No available instruments for the moderate to severe impairment group were identified under this review.

CONCLUSIONS

Few existing instruments to assess the ability of everyday problem-solving of the elderly with cognitive impairment can be identified in the literature. Further research validating them against functional, real-world outcomes is needed.

Dependence as a unifying construct in defining Alzheimer's disease severity

This article reviews measures of Alzheimer's disease (AD) progression in relation to patient dependence and offers a unifying conceptual framework for dependence in AD. Clinicians typically characterize AD by symptomatic impairments in three domains: cognition, function, and behavior. From a patient's perspective, changes in these domains, individually and in concert, ultimately lead to increased dependence and loss of autonomy. Examples of dependence in AD range from a need for reminders (early AD) to requiring safety supervision and assistance with basic functions (late AD). Published literature has focused on the clinical domains as somewhat separate constructs and has given limited attention to the concept of patient dependence as a descriptor of AD progression. This article presents the concept of dependence on others for care needs as a potential method for translating the effect of changes in cognition, function, and behavior into a more holistic, transparent description of AD progression.

Impact of a self-administration of medications programme on elderly inpatients' competence to manage medications: a pilot study

WHAT IS KNOWN AND OBJECTIVES

Changes to medication regimens and failure to involve patients in management of their medications whilst in hospital may result in medication errors or non-adherence at home after discharge. Self-administration of medications programmes (SAMP) have been used to address this issue. The objective of this study was to assess the impact of a SAMP on elderly hospital inpatients' competence to manage medications and their medication adherence behaviours.

METHODS

The SAMP comprised three stages: education, progressing to supervised self-administration and finally to independent self-administration. Decisions to progress patients to the next level, and whether they passed or failed the SAMP, were made by the ward pharmacist and nursing staff. The Drug Regimen Unassisted Grading Scale (DRUGS) was used to assess patients' competence to manage medications at various time points. Tablet count and the Tool for Adherence Behaviour Screening (TABS) were used as adherence measures.

RESULTS AND DISCUSSION

Participants (n = 24) with a mean age of 77.4 years, were mainly female and generally had a high level of functioning. They were prescribed a mean of 9.0 medications at the time of commencing the SAMP. Twenty-two of the 24 participants successfully completed the SAMP. DRUGS scores at discharge improved significantly (P<0.001) compared with that before commencement of medication self-administration. Participants reported a significant decrease (P = 0.02) in non-adherent behaviour and a trend towards improved adherent behaviour (P=0.08) after participation in the SAMP.

WHAT IS NEW AND CONCLUSION

An inpatient SAMP improved elderly patients' ability to competently manage and adhere to their prescribed medications regimen. This finding needs to be confirmed in a larger controlled trial.

Living alone with dementia: an interpretive phenomenological study with older women

AIM

This paper is a report of a study of the meaning of living alone from the perspective of older people with dementia.

BACKGROUND

Risks and problems experienced by older women living alone have been investigated mostly through quantitative research. Balancing their safety and autonomy is a serious international community care dilemma. Older people's perspectives have been muted in qualitative research on living alone with dementia.

METHOD

Using an interpretive phenomenological approach and van Manen's method, 14 interviews were conducted in Ontario, Canada from January 2004 to April 2005 with eight older women diagnosed with Alzheimer disease or a related dementia.

FINDINGS

The theme holding back time expressed the temporal meaning of living alone. Pharmacological treatments represented stored time, offering the opportunity to hold back future dreaded time. Past experience with others with dementia was a context for holding on to now and facing some risks of living alone with memory loss. The women acknowledged the limited time remaining for, and identified endpoints to, living alone.

CONCLUSION

Insight into the impact of past experience with others with dementia could inform nursing assessment and advocacy for health/social services that are sensitive to the potential emotional impact of mixing people with varied levels of dementia in the same programme.

Cognitive impairment and driving: A review of the literature

Although some drivers with mild dementia may continue to drive after the condition has been diagnosed, the ability to drive a motor vehicle safely is eventually lost as the disease progresses. Clinicians involved in dementia care are often asked to make an assessment on whether a patient is fit to drive, even though they often lack basic knowledge and formal training in this area. The purpose of this review was to identify the factors that may differentiate safe from unsafe drivers with cognitive impairment and to discuss management strategies. Isolated information about staging measures or particular cognitive tests was found to be insufficient for decision making. Driving fitness counseling for patients with cognitive impairment requires a solid knowledge base, comprehensive assessment and thoughtful communication.

Standardised assessment of patients' capacity to manage medications: a systematic review of published instruments

BACKGROUND

Older people are commonly prescribed complex multi-drug regimens while also experiencing declines in the cognitive and physical abilities required for medication management, leading to increased risk of medication errors and need for assisted living. The purpose of this study was to review published instruments designed to assess patients' capacity to self-administer medications.

METHODS

Searches of Medline, EMBASE, CINAHL, PsycINFO, International Pharmaceutical Abstracts, Health and Psychosocial Instruments, Google, and reference lists of identified publications were conducted to identify English-language articles describing development and validation of instruments designed to assess patients' capacity to self-administer medications. Methodological quality of validation studies was rated independently against published criteria by two reviewers and reliability and validity data were reviewed.

RESULTS

Thirty-two instruments were identified, of which 14 met pre-defined inclusion criteria. Instruments fell into two categories: those that used patients' own medications as the basis for assessment and those that used a simulated medication regimen. The quality of validation studies was generally low to moderate and few instruments were subjected to reliability testing. Most instruments had some evidence of construct validity, through associations with tests of cognitive function, health literacy, activities of daily living or measures of medication management or adherence. Only one instrument had sensitivity and specificity data with respect to prediction of medication-related outcomes such as adherence to therapy. Only three instruments had validity data from more than one independent research group.

CONCLUSION

A number of performance-based instruments exist to assess patients' capacity to manage their own medications. These may be useful for identifying physical and cognitive barriers to successful medication management, but further studies are needed to determine whether they are able to accurately and reliably predict medication outcomes.

Evaluation of the driving ability in disabled persons: A practitioners' view

PURPOSE AND METHODS

The purpose of this paper is to present, on the basis of four genuine cases from the Rehabilitation Research Unit of Oulu University, the theoretical frame in which evaluations of driving ability of disabled persons can be made.

RESULTS

First, it is not the operations with the control devices but the correct mental actions which the driver carries out with the help of the control devices which are crucial for safe driving. Second, driving ability is only partly a biomedical object of research and one ought to avoid an excessive medicalisation of an evaluation of driving ability. Third, the driver meets traffic situations not by his or her separate biological or psychological functions, such as vision, attention, memory, thinking, motives, but as an integrated whole, as a personality.

CONCLUSIONS

By its complexity an evaluation of driving ability can be compared to an evaluation of working capacity where often a multidisciplinary team is needed. When evaluating driving ability we have to take a step from low-level motor operations towards high-level mental actions, from the measurement of acuity of eyesight towards the testing of the flexibility of perception, from the diagnosis-based evaluation to the patient-based evaluation, from using the common pencil-paper tests towards the traffic-related task-specific tests and from the testing of separate single general non-driving-related factors towards an evaluation of the theoretically based driving performance as whole.

Family physicians' perceptions and predictors regarding the competence of a person with Alzheimer's disease

OBJECTIVE

The aim of the present study was to assess family physicians' perceptions about the competence of a person with AD.

METHODS

Telephone interviews were conducted with a representative sample of 395 family physicians using an experimental vignette methodology, varying in the severity of the disease. Participants were requested to rate the competence of the person described in the vignette in the areas of driving, health-decision making, financial decisions, and the performance of instrumental activities of daily living.

RESULTS

Results of the study showed that family physicians perceived the person described in the vignette to be highly incompetent in items involving safety issues. Only a small variety of factors were associated with these perceptions. The main factors were the severity of the disease as reflected in the vignette, participants' perceptions regarding the dangerousness and responsibility of the person with AD, and the percentage of patients aged 65 + with cognitive deterioration in the physician's practice.

CONCLUSION

The assessment of competence in persons with AD is a subtle and complex process. Future research is urgently needed to further explore the factors affecting the process, such as stigmatic views.

Driving abilities in frontotemporal dementia patients

OBJECTIVE

To evaluate driving competency and the relationship between neuropsychiatric symptoms and driving behavior in frontotemporal dementia (FTD) patients.

METHODS

Fifteen patients with a diagnosis of FTD and 15 healthy controls were administered a driving simulation task. Measures of driving performance and neuropsychiatric symptoms were assessed.

RESULTS

The FTD patients received more speeding tickets, ran more stop signs and were involved in more off-road crashes and collisions than the controls. The patients' overall average speed was significantly higher. Driving performance was correlated with agitated behavior.

CONCLUSIONS

Behavioral changes characteristic of FTD patients have an impact on their driving skills leading to inappropriate driving behavior.

Voting rights for older Americans with dementia: Implications for health care providers

As the population of the United States ages, the prevalence of dementias such as Alzheimer's disease (AD) will increase. With this demographic shift, some older registered voters will lack the cognitive ability to weigh the variables involved in voting and making an informed decision at the ballot. Ramifications of this situation have only recently been considered. Medical and legal procedures to delineate the capacity to vote are lacking in our national policy and are in need of an overhaul. Caution must be taken to avoid indiscriminant disenfranchisement of people with dementia. Health care providers play a pivotal role in supporting older adults with dementia who exercise their voting rights. The purpose of this article is to discuss issues related to voting and older adults with dementia. Implications for gerontological health care providers are presented.

A dependency model for patients with Alzheimer's disease: its validation and relationship to the costs of care--the LASER-AD Study

BACKGROUND

Loss of independence becomes more marked as Alzheimer's disease (AD) progresses and contributes significantly to its societal and economic burden. Existing measures of functional disability focus either on basic or on instrumental activities of daily living (ADL). It would be more appropriate to combine these but, using existing assessment tools, this would involve considerable quantitative analysis. Recently, a qualitative and pragmatic system of classifying AD patients according to levels of dependency has been developed in a Belgian cohort.

OBJECTIVES

To validate independently, in a UK community setting, a functional classification model of AD patients and to explore the relationship between dependency and costs of care using this model.

RESEARCH DESIGN AND METHODS

Longitudinal epidemiological study of 224 AD patients. Data were collected at baseline and at 6 months on ADL, global state, cognition, behavioural dimensions, depression, quality of life and resource utilisation using validated instruments. An automatic classification algorithm was performed to allow identification of dependency clusters. The scheme was tested for validity against other simultaneously collected data including health and social care costs. The relationship between dependency and costs of care was explored using ANOVA models.

RESULTS

Analysis of the ADL assessment instruments produced three ADL sub-scores by which patients could be classified into one of three disability clusters: ('non-dependent', 'non-dependent with instrumental functional disability', and 'dependent'). Good external validity of the classification scheme was demonstrated by correlation with simultaneously collected data. After a backward selection process on ANOVA model (at a 5% level), institutionalisation and the most dependent status were the most significant cost drivers.

CONCLUSIONS

Qualitative classification of AD patients using dependency levels is a simple and validated approach. Applying this approach showed that institutionalisation and the most 'dependent' status were independently and significantly associated with high care cost.

Barriers to treatment: the unique challenges for physicians providing dementia care

Evaluating and treating dementia is intellectually demanding and enormously satisfying. However, physicians providing dementia care also confront unique challenges that cause discomfort and overwhelming frustration unless they are recognized and overcome. Physicians must care for individuals who do not adopt the "sick role." They must establish and maintain rapport with patients while also approaching collateral sources to obtain a complete history. They must develop a complex alliance with the patient, caregivers, community agencies, and other health professionals to provide effective treatment. Physicians must relate "bad news" to several people at once who are unequally prepared for it, while dealing with their own diagnostic uncertainty. Furthermore, physicians must honor patient autonomy and balance it with the needs of caregivers. Since the demands of providing dementia care are not typical of most medical practice, the special attributes needed are often not taught to students or adequately reimbursed by health insurance. The quality of dementia care will improve when strategies that address these aspects of care for patients with dementia are widely adopted.