Medical decision-making capacity in cognitively impaired Parkinson's disease patients without dementia

Access to device-aided therapies in advanced Parkinson's disease: navigating clinician biases, patient preference, and prognostic uncertainty

Device-aided therapies (DAT), which include deep brain stimulation and pump-based continuous dopaminergic stimulation with either levodopa or apomorphine, are among the major advances in the clinical management of Parkinson's disease (PD). Although DAT are being increasingly offered earlier in the disease course, their classical indication remains advanced PD. Theoretically, every patient should be offered transition to DAT when faced with refractory motor and nonmotor fluctuations and functional decline. Worldwide clinical reality is far from these ideal, and, therefore, question the "real-world" equal opportunity of access to DAT for PD patients with advanced PD-even within a single health care system. Differences in access to care, referral pattern (timing and frequency), as well as physician biases (unconscious/implicit or conscious/explicit bias), and patients' preferences or health-seeking behaviour are to be considered. Compared to DBS, little information is available concerning infusion therapies, as well as neurologists' and patients' attitudes towards them. This viewpoint aims to be thought-provoking and to assist clinicians in moving through the process of DAT selection, by including in their decision algorithm their own biases, patient perspective, ethical concerns as well as the current unknowns surrounding PD prognosis and DAT-related long-term side effects for a given patient.

Patients with multiple sclerosis choose a collaborative role in making treatment decision: results from the Italian multicenter SWITCH study

BACKGROUND

Clinicians are increasingly recognizing the importance of shared decision-making in complex treatment choices, highlighting the importance of the patient's rationale and motivation for switching therapies. This study aimed to evaluate the association between different modalities of changing multiple sclerosis (MS) treatments, cognitive profile and attitude and preferences of patients concerning treatment choice.

METHODS

This multicenter cross-sectional study was conducted at 28 Italian MS centers in the period between June 2016 and June 2017. We screened all MS patients treated with any DMT, with a treatment compliance of at least 80% of therapy administered during the 3 last months who needed to modify MS therapy because of efficacy, safety or other reasons during a follow-up visit. At the time of switching the symbol digit modalities test (SDMT) and the Control Preference Scale (CPS) were evaluated. According to the CPS, patients were classified as "active" (i.e. who prefer making the medical decision themselves), "collaborative" (i.e. who prefer decisions be made jointly with the physician), or "passive" (i.e. who prefer the physician make the decision).

RESULTS

Out of 13,657 patients recorded in the log, 409 (3%) changed therapy. Of these, 336 (2.5%) patients, 69.6% were female and with mean age 40.6 ± 10.5 years, were enrolled. According to the CPS score evaluation, a significant high percentage of patients (51.1%) were considered collaborative, 74 patients (22.5%) were passive, and 60 (18.2%) patients were active. Stratifying according to CPS results, we found a higher SDMT score among collaborative patients compared to active and passive ones (45.8 ± 12.3 versus 41.0 ± 13.2 versus 41.7 ± 12.8, p < 0.05).

CONCLUSION

In this study, the CPS evaluation showed that more than 50% of patients who needed to change therapy chose a "collaborative" role in making treatment decision. Cognitive profile with SDMT seems to correlate with patients' preference on treatment decision, showing better scores in collaborative patients.

Decisional capacity to consent to treatment and research in patients affected by Mild Cognitive Impairment. A systematic review and meta-analysis

OBJECTIVES

To perform a meta-analysis of clinical studies on the differences in treatment or research decision-making capacity among patients with Mild Cognitive Impairment (MCI), Alzheimer's disease (AD), and healthy comparisons (HCs).

DESIGN

A systematic search was conducted on Medline/Pubmed, CINAHL, PsycINFO, Web of Science, and Scopus. Standardized mean differences and random-effects model were used in all cases.

SETTING

The United States, France, Japan, and China.

PARTICIPANTS

Four hundred and ten patients with MCI, 149 with AD, and 368 HCs were included.

MEASUREMENTS

The studies we included in the analysis assessed decisional capacity to consent by the MacArthur Competence Assessment Tool for Treatment (MAcCAT-T), MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR), Capacity to Consent to Treatment Instrument (CCTI), and University of California Brief Assessment of Capacity to Consent (UBACC).

RESULTS

We identified 109 potentially eligible studies from 1672 records, and 7 papers were included in the meta-analysis. The meta-analysis showed that there was significant impairment in a decision-making capacity in MCI patients compared to the HCs group in terms of Understanding (SMD = -1.04, 95% CI: -1.31 to -0.77, P < 0.001; I² = 52%, P = 0.07), Appreciation (SMD = -0.51, 95% CI: -0.66 to -0.36, P < 0.001; I² = 0%, P = 0.97), and Reasoning (SMD = -0.62, 95% CI: -0.77, -0.47, P < 0.001; I²=0%, P =0.46). MCI patients scored significantly higher in Understanding (SMD = 1.50, 95% CI: 0.91, 2.09, P = 0.01, I² = 78%, P = 0.00001) compared to patients affected by AD.

CONCLUSIONS

Patients affected by MCI are at higher risk of impaired capacity to consent to treatment and research compared to HCs, despite being at lower risk compared to patients affected by AD. Clinicians and researchers need to carefully evaluate decisional capacity in MCI patients providing informed consent.

The epidemiology of cognitive function in Parkinson's disease

Epidemiology is the study of the distribution of disease in human populations, which is important in evaluating burden of illness, identifying modifiable risk factors, and planning for current and projected needs of the health care system. Parkinson's disease (PD) is the second most common serious neurodegenerative illness and is expected to further increase in prevalence. Cognitive changes are increasingly viewed as an integral non-motor feature in PD, emerging even in the prodromal phase of the disease. The prevalence of PD-MCI ranges from 20% to 40% depending on the population studied. The incidence of PD-dementia increases with duration of disease, with estimates growing from 3% to 30% of individuals followed for 5 years or less to over 80% after 20 years. There are several challenges in estimating the frequency of cognitive change, including only recently standardized diagnostic criteria, variation depending on exact neuropsychological evaluations performed, and differences in population sampling. Clinical features associated with cognitive decline include older age, increased disease duration and severity, early gait dysfunction, dysautonomia, hallucinations and other neuropsychiatric features, the presence of REM behavior disorder, and posterior predominant dysfunction on neuropsychological testing. There is increasing evidence that genetic risk factors, in particular GBA and MAPT mutations, contribute to cognitive change. Possible protective factors include higher cognitive reserve and regular exercise. Important sequelae of cognitive decline in PD include higher caregiver burden, decreased functional status, and increased risk of institutionalization and mortality. Many remaining uncertainties regarding the epidemiology of cognitive change in PD require future research, with improved biomarkers and more sensitive and convenient outcome measures.

Medicolegal Implications of Mild Neurocognitive Disorder

INTRODUCTION

The syndromes of mild cognitive impairment (MCI) or mild neurocognitive disorder (MiND), often prodromal to dementia (Major Neurocognitive Disorder), are characterized by acquired clinically significant changes in one or more cognitive domains despite preserved independence. Mild impairment has significant medicolegal consequences for an affected person and their care system. We review the more common etiologies of MiND and provide a systematic review of its medicolegal implications.

METHODS

We conducted a systematic review of the peer-reviewed English literature on medicolegal aspects of MCI or MiND using comprehensive search terms and expanding our review to include sources cited by these reports.

RESULTS

Impairment of memory, executive function, social cognition, judgment, insight or abstraction can alter an individual's abilities in a variety of areas that include decision making, informed consent, designation of a surrogate decision-maker such as a health care proxy, understanding and management of financial affairs, execution of a will, or safe driving.

CONCLUSION

Even mild cognitive impairment can have significant behavioral consequences. Clinicians can assist care partners and persons with MCI or MiND by alerting them to the medicolegal concerns that often accompany cognitive decline. Early recognition and discussion can help a care system manage medicolegal risk more effectively and promote thoughtful advance planning.

Reliability of self-report versus the capacity to consent to treatment instrument to make medical decisions in brain metastasis and other metastatic cancers

OBJECTIVE

To evaluate the ability of persons with metastatic cancer to self-assess their medical decision-making capacity (MDC). To investigate this, we compared an objective measure of MDC with self-ratings and evaluated predictors of agreement.

METHODS

Data were obtained from a cross-sectional study of metastatic cancer patients at a large academic medical center. Across all standards of MDC, sensitivity, specificity, and reliability using Gwet's AC1 statistic were calculated using the objective measure as the gold standard. Logistic regression was used to evaluate predictors of agreement between the measures across all MDC standards.

RESULTS

In those with brain metastases, high sensitivity (greater than 0.7), but low specificity was observed for all standards. Poor reliability was observed across all standards. Higher age resulted in higher odds of disagreement for Standard 3 (appreciation) (OR: 1.07, 95% CI: 1.00, 1.15) and Standard 4 (reasoning) (OR: 1.05, 95% CI: 1.00, 1.10). For Standard 3, chemotherapy use and brain metastases compared to other metastases resulted in higher odds of disagreement (Chemotherapy: OR: 5.62, 95% CI: 1.37, 23.09, Brain Metastases: OR: 5.93, 95% CI: 1.28, 27.55). For Standard 5 (understanding), no predictors were associated with disagreement.

CONCLUSIONS

For less cognitively complex standards (e.g., appreciation), self-report may be more valid and reliable than more cognitively complex standards (e.g., reasoning or understanding). However, overall, MDC self-report in the current sample is suboptimal. Thus, the need for detailed assessment of MDC, especially when patients are older or used chemotherapy, is indicated. Other studies should be conducted to assess MDC agreement longitudinally.

Research Involving Participants With Impaired Consent Capacity: An Examination of Methods to Determine Capacity to Consent

OBJECTIVE

To examine methods of assessing consent capacity in research protocols involving participants with impaired consent capacity, and examine instruments used to evaluate research consent capacity.

METHODS

A retrospective review of 330 active research protocols involving participants lacking capacity to consent over a 10-year period (January 1, 2009, through March 1, 2019) was conducted to collect protocol characteristics (medical specialty, level of risk and type of study, consent and assent procedures, and type of vulnerable or protected population). Methods to assess consent capacity are described, and instruments to assess consent capacity are summarized.

RESULTS

The specialties most frequently involving participants with impaired consent capacity in research were Neurology (27.3%), Critical Care (16.7%), and Surgery (10%). Type of studies are observational (43.9%), clinical trials (33%), chart review (11.5%), biobank (6.1%), and biomarker (5.5%). Minimal risk (53.3%) outnumbered greater than minimal risk (46.7%) studies. Most obtained written informed consent (77%) and assent (40.9%). The most common method to assess consent capacity was direct assessment by investigators (32.7%). Only 86 (26%) studies used instruments to assess consent capacity. Of the 13 instruments used, the most common was the Evaluation of Decision-Making Capacity for Consent to Act as a Research Subject, and is the only instrument that assesses all four components of decisional capacity: understanding, appreciation, reasoning, and choice.

CONCLUSION

Generally, there was lack of uniformity in determining capacity to consent to research participation. Very few studies used instruments to assess consent capacity. Institutional review boards can provide greater guidance for research consent capacity determination.

Assessment of the Financial Capacity in Elderly: Approach and Challenges in Indian Scenario

The elderly population, with those individuals above the age of 60 years, is increasing exponentially, attributable to higher life expectancy as a result of improved health care, socioeconomic level, and quality of life. As they grow older (>80 years), it becomes difficult to manage their basic needs and daily living. A report on Decade of Healthy Ageing estimates that 14% of people aged 60 years and above cannot meet their basic daily needs which include the ability to manage finances. Some elderly people depend on others to manage finances because of their inability to make decisions resulting in conflicts and communication problems between siblings and other members of the family and lodging of civil lawsuits in India's joint family unit. So, decision-making is an important area to assess in the elderly people, given its clinical, legal, and ethical aspects. Courts of law can refer to older persons for assessing their capacity to manage finances, though there are no structured clinical procedures to assess it in India. This article evaluates existing methods around the world, discusses the challenges associated with the assessment, and provides clinicians with guidance on assessing financial capacity from an Indian perspective.

Quadruple Decision Making for Parkinson's Disease Patients: Combining Expert Opinion, Patient Preferences, Scientific Evidence, and Big Data Approaches to Reach Precision Medicine

Clinical decision making for Parkinson’s disease patients is supported by a combination of three distinct information resources: best available scientific evidence, professional expertise, and the personal needs and preferences of patients. All three sources have clear value but also share several important limitations, mainly regarding subjectivity, generalizability and variability. For example, current scientific evidence, especially from controlled clinical trials, is often based on selected study populations, making it difficult to translate the outcome to the care for individual patients in everyday clinical practice. Big data, including data from real-life unselected Parkinson populations, can help to bridge this information gap. Fine-grained patient profiles created from big data have the potential to aid in identifying therapeutic approaches that will be most effective given each patient’s individual characteristics, which is particularly important for a disorder characterized by such tremendous interindividual variability as Parkinson’s disease. In this viewpoint, we argue that big data approaches should be acknowledged and harnessed, not to replace existing information resources, but rather as a fourth and complimentary source of information in clinical decision making, helping to represent the full complexity of individual patients. We introduce the ‘quadruple decision making’ model and illustrate its mode of action by showing how this can be used to pursue precision medicine for persons living with Parkinson’s disease.

The capacity to consent to treatment in amyotrophic lateral sclerosis: a preliminary report

BACKGROUND

Facing the relentless worsening of their condition, ALS patients are required to make decisions on treatments and end-of-life care. A cognitive impairment showed to be a negative prognostic factor in ALS patients, perhaps affecting the ability to make informed decisions. Notwithstanding its crucial role, the capacity to consent to treatment (CCT) has never been evaluated in these patients.

OBJECTIVES

To assess the CCT in an ALS cohort in comparison to a control group, and to study the effects of demographic and clinical variables on this high-level cognitive function.

METHODS

102 ALS patients and 106 healthy controls (HC) were enrolled. CCT was assessed using the MacArthur Competence Assessment Tool for Treatment (MAC-CAT-T) and the performance was classified into the three CCT outcomes (full credit, partial credit, no credit). Cognitive and psychological variables were assessed by MMSE, phonemic fluencies, Frontal System Behavioural Scale (FrSBe), and ALS Depression Inventory (ADI). Clinical and demographic variables were analyzed as possible predictors of the MAC-CAT-T outcomes. After a 1-year follow-up, CCT and neuropsychological assessments were repeated.

RESULTS

Most ALS patients (i.e., from 75 to 83% according to the different sub-items) retain full CCT. However, a subpopulation of the ALS patients showed a reduced CCT with respect to the HC. Age, education, phonemic fluency, and depression appeared related to the CCT outcomes. After 1 year, only the reasoning items worsened.

CONCLUSIONS

This is a preliminary report suggesting that the large majority of ALS patients can retain full ability to choose between treatment options. However, demographic and neuropsychological variables may affect CCT, pointing to the need for special attention to the consent disclosure in this disease.

Determining medical decision-making capacity in brain tumor patients: why and how?

Background

Brain tumor patients are at high risk of impaired medical decision-making capacity (MDC), which can be ethically challenging because it limits their ability to give informed consent to medical treatments or participation in research. The European Association of Neuro-Oncology Palliative Care Multidisciplinary Task Force performed a systematic review to identify relevant evidence with respect to MDC that could be used to give recommendations on how to cope with reduced MDC in brain tumor patients.

Methods

A literature search in several electronic databases was conducted up to September 2019, including studies with brain tumor and other neurological patients. Information related to the following topics was extracted: tools to measure MDC, consent to treatment or research, predictive patient- and treatment-related factors, surrogate decision making, and interventions to improve MDC.

Results

A total of 138 articles were deemed eligible. Several structured capacity-assessment instruments are available to aid clinical decision making. These instruments revealed a high incidence of impaired MDC both in brain tumors and other neurological diseases for treatment- and research-related decisions. Incapacity appeared to be mostly determined by the level of cognitive impairment. Surrogate decision making should be considered in case a patient lacks capacity, ensuring that the patient's "best interests" and wishes are guaranteed. Several methods are available that may help to enhance patients' consent capacity.

Conclusions

Clinical recommendations on how to detect and manage reduced MDC in brain tumor patients were formulated, reflecting among others the timing of MDC assessments, methods to enhance patients' consent capacity, and alternative procedures, including surrogate consent.

Neurocognitive Models of Medical Decision-Making Capacity in Traumatic Brain Injury Across Injury Severity

OBJECTIVE

To identify neurocognitive predictors of medical decision-making capacity (MDC) in participants with mild and moderate/severe traumatic brain injury (TBI).

SETTING

Academic medical center.

PARTICIPANTS

Sixty adult controls and 104 adults with TBI (49 mild, 55 moderate/severe) evaluated within 6 weeks of injury.

DESIGN

Prospective cross-sectional study.

MAIN MEASURES

Participants completed the Capacity to Consent to Treatment Instrument to assess MDC and a neuropsychological test battery. We used factor analysis to reduce the battery test measures into 4 cognitive composite scores (verbal memory, verbal fluency, academic skills, and processing speed/executive function). We identified cognitive predictors of the 3 most clinically relevant Capacity to Consent to Treatment Instrument consent standards (appreciation, reasoning, and understanding).

RESULTS

In controls, academic skills (word reading, arithmetic) and verbal memory predicted understanding; verbal fluency predicted reasoning; and no predictors emerged for appreciation. In the mild TBI group, verbal memory predicted understanding and reasoning, whereas academic skills predicted appreciation. In the moderate/severe TBI group, verbal memory and academic skills predicted understanding; academic skills predicted reasoning; and academic skills and verbal fluency predicted appreciation.

CONCLUSIONS

Verbal memory was a predictor of MDC in controls and persons with mild and moderate/severe TBI. In clinical practice, impaired verbal memory could serve as a "red flag" for diminished consent capacity in persons with recent TBI.

The effects of normal aging on multiple aspects of financial decision-making

OBJECTIVES

Financial decision-making (FDM) is crucial for independent living. Due to cognitive decline that accompanies normal aging, older adults might have difficulties in some aspects of FDM. However, an improved knowledge, personal experience and affective decision-making, which are also related to normal aging, may lead to a stable or even improved age-related performance in some other aspects of FDM. Therefore, the present explorative study examines the effects of normal aging on multiple aspects of FDM.

METHODS

One-hundred and eighty participants (range 18-87 years) were assessed with eight FDM tests and several standard neuropsychological tests. Age effects were evaluated using hierarchical multiple regression analyses. The validity of the prediction models was examined by internal validation (i.e. bootstrap resampling procedure) as well as external validation on another, independent, sample of participants (n = 124). Multiple regression and correlation analyses were applied to investigate the mediation effect of standard measures of cognition on the observed effects of age on FDM.

RESULTS

On a relatively basic level of FDM (e.g., paying bills or using FDM styles) no significant effects of aging were found. However more complex FDM, such as making decisions in accordance with specific rules, becomes more difficult with advancing age. Furthermore, an older age was found to be related to a decreased sensitivity for impulsive buying. These results were confirmed by the internal and external validation analyses. Mediation effects of numeracy and planning were found to explain parts of the association between one aspect of FDM (i.e. Competence in decision rules) and age; however, these cognitive domains were not able to completely explain the relation between age and FDM.

CONCLUSION

Normal aging has a negative influence on a complex aspect of FDM, however, other aspects appear to be unaffected by normal aging or improve.

Medical decision-making capacity and its cognitive predictors in progressive MS: Preliminary evidence

BACKGROUND

Medical decision-making capacity (MDC) refers to the ability to make informed decisions about treatment and declines in cognition are associated with declines in MDC across multiple disease entities. However, although it is well known that cognitive impairment is prevalent in multiple sclerosis (MS), little is known about MDC in the disease.

METHODS

Data from 22 persons with progressive MS and 18 healthy controls were analyzed. All diagnoses were made by a board-certified neurologist with experience in MS. All study participants were administered a vignette-based measure of MDC and also a neuropsychological battery.

RESULTS

Performance on three MDC consent standards (i.e., Appreciation, Reasoning, Understanding) was significantly lower for people with progressive MS as compared to healthy controls. In the progressive MS group, verbal fluency was the primary cognitive predictor for both Reasoning and Understanding consent standards. Verbal learning and memory was the primary cognitive predictor for Appreciation. MS severity was not significantly correlated with any MDC variable.

CONCLUSION

MDC is a complex and cognitively mediated functional ability that is impaired in many people with progressive MS. Verbal measures of fluency and memory are strongly associated with MDC performances in the current sample of people with MS and could potentially be utilized to quickly screen for MDC impairment in MS.

Are non-demented patients with Parkinson's disease able to decide about their own treatment?

INTRODUCTION

Patients with Parkinson's disease (PD) are often confronted with difficult medical decisions, which might be hampered by cognitive impairment or chronic stress. Little is known, however, about the capacity to make medical decisions and the influence of cognition and stress on this ability. This study determined whether non-demented Parkinson's disease patients are able to make medical decisions and whether this capacity is influenced by cognition and stress.

METHODS

Forty-six Parkinson's disease patients and 94 healthy controls were assessed with the MacArthur Competence Assessment Tool for Treatment during which participants were presented with deep brain stimulation as a treatment option for a fictional Parkinson's disease patient. Furthermore, all participants were examined with a stress questionnaire and a neuropsychological test battery.

RESULTS

Parkinson's disease patients performed better on the total scale and 'Understanding' subscale of the MacArthur Competence Assessment Tool for Treatment than healthy controls. Lower performance on the Concept Shifting Test in the Parkinson's disease group and lower performance on Letter Digit Substitution Test in the healthy control group predicted lower medical decision-making capacity. No association was found between stress and medical decision-making.

CONCLUSION

Non-demented Parkinson's disease patients show no impairments in medical decision-making compared to healthy controls. In fact, Parkinson's disease patients have a better understanding of their disease and the benefits and risks of treatment options than healthy controls. Psychomotor speed and attention were negatively associated with medical decision-making in both groups. This implies that when these cognitive functions decline, the capacity to make medical decisions also declines.

Assessment of Healthcare Decision-making Capacity

It is often necessary for neuropsychologists, clinical psychologists, and other healthcare professionals to assess an individual's capacity to consent to treatment related to healthcare. This task can be challenging and requires a delicate balance of both respect for individuals' autonomy, as well as the protection of individuals with diminished capacity to make an autonomous decision. The purpose of the present review is to provide an overview of the conceptual model of decisional capacity as well as a brief summary of some of the currently available instruments designed to help evaluate medical decision making. In addition, current empirical literature on the relationship between neuropsychological abilities and decision-making capacity is discussed and a brief set of recommendations is provided to further aid clinicians or consultants when they are required to complete the ethically important but difficult task of making determinations about healthcare decision-making capacity.

Research consent capacity varies with executive function and memory in Parkinson's disease

BACKGROUND

We examined the association between cognitive domains and research consent capacity in PD. Our hypothesis was that research consent capacity is best predicted by executive function.

METHODS

A cohort of 90 PD patients and 30 healthy older adults were administered the MacArthur Competence Assessment Tool for Clinical Research, Dementia Rating Scale-2, and the MoCA. Experts classified patients as either "capable" or "not capable" of providing informed consent to participate in two clinical trials.

RESULTS

MacArthur Competence Assessment Tool for Clinical Research Reasoning scores for both clinical trial types were most associated with executive functions and delayed recall. As scores on these domains improved, the odds of an expert rating of "capable of consent" increased.

CONCLUSIONS

These results extend our previous findings by demonstrating that memory and executive abilities appear closely associated with capacity when evaluated using either a structured interview or expert judgment of that interview.

Enhancing Medical Decision-Making Evaluations: Introduction of Normative Data for the Capacity to Consent to Treatment Instrument

A number of measures have been developed to assess medical decision-making capacity (MDC) in adults. However, their clinical utility is limited by a lack of available normative data. In the current study, we introduce age-independent and age-adjusted normative data for a measure of MDC: the Capacity to Consent to Treatment Instrument. The sample consisted of 308 cognitively normal, community-dwelling adults ranging in age from 19 to 86 years. For age-adjusted norms, individual raw scores were first converted to age-corrected scaled scores based on position within a cumulative frequency distribution and then grouped according to empirically supported age ranges. For age-independent norms, the same method was utilized but without age-corrections being applied or participants being grouped into age ranges. This study has the potential to enhance MDC evaluations by allowing clinicians to compare a patient's performance on the Capacity to Consent to Treatment Instrument with that of adults regardless of age as well as to same age peers. Tables containing normative corrections are supplementary material available online at http://asm.sagepub.com/supplemental.

Systematic review on the prevalence of lack of capacity in medical and psychiatric settings

Recent court cases in England and Wales have refocused attention on patients' decision-making capacity to consent. Little is known about the prevalence of incapacity across specialities but decision-making capacity is likely to be overestimated by clinicians. The aim of this systematic review is to estimate the prevalence of incapacity to consent to treatment or admission in different medical and psychiatric settings, and compare the two. We conducted an electronic search following PRISMA principles and included 35 studies in psychiatric and 23 studies in medical settings. The 58 included studies revealed 70 data sets across all settings. For psychiatric settings the weighted average proportion of patients with incapacity was 45% (95% confidence interval (CI) 39-51%). For medical settings, the weighted average proportion of patients with incapacity was 34% (95% CI 25-44%). The two groups are not significantly different from each other in terms of the proportion of incapacity (p=0.92). A considerable number of medical and psychiatric patients lack capacity to make treatment and assessment decisions. Clinicians should be more alert to the possibility that their patients may lack decision-making capacity. Assessment of capacity should be frequent using the appropriate legal frameworks to act in the best interest of patients.

Cognitive Predictors of Reasoning through Treatment Decisions in Patients with Newly Diagnosed Brain Metastases

To examine the association between reasoning through medical treatment decisions and cognition in a sample of patients with brain metastasis. The association between reasoning and cognition was examined using data from 41 patients with diagnosed brain metastasis. All diagnoses were made by a board-certified radiation oncologist and were verified histologically. In total, 41 demographically matched, cognitively healthy controls were also included to aid in classifying patients with brain metastasis according to reasoning status (i.e., intact or impaired). Results indicate that measures of episodic memory and processing speed were associated with reasoning. Using these two predictors, actuarial equations were constructed that can be used to help screen for impaired reasoning ability in patients' with brain metastasis. The equations presented in this study have clinical significance as they can be used to help identify patients at risk for possessing a diminished ability to reason through medical treatment decisions and, thus, are in need of a more comprehensive evaluation of their medical decision-making capacity.

Cognitive fluctuations as a challenge for the assessment of decision-making capacity in patients with dementia

Decision-making capacity (DMC) is an indispensable prerequisite for medical treatment choices, including consent to treatment, treatment discontinuation, and refusal of treatment. In patients with dementia, DMC is often affected. A particular challenge in assessing DMC are cognitive fluctuations that may lead to a fluctuation in DMC as well. Cognitive fluctuations are a diagnostic core feature of dementia with Lewy bodies and occur in Parkinson's and Alzheimer's diseases. In this article, these challenges are discussed and suggestions for assessing the DMC of patients with dementia with cognitive fluctuations are presented.

First-in-human cell transplant trials in Parkinson's disease: The need for an improved informed consent process

First-in-human clinical trials of innovative medical procedures, such as cell transplantation for Parkinson's disease, present a variety of ethical challenges. In an era of rapidly developing stem cell technologies likely to be translated into clinical trials over the next few years, it is critical that ethical concerns be fully considered. One important undertaking is ensuring that research participants give free and truly informed consent. This will necessitate adequate disclosure of risks and benefits at a time when these are incompletely defined; ensuring understanding of a complex research protocol when there is significant possibility of therapeutic misconception; and careful determination of capacity for informed consent in patients with a neurodegenerative disorder that is known to affect cognition. Here we call attention to the ethical issues that researchers conducting these types of trials will face when trying to obtain a genuinely informed consent, and we suggest possible solutions.

Cognitive predictors of understanding treatment decisions in patients with newly diagnosed brain metastasis

BACKGROUND

Medical decision-making capacity is a higher-order functional skill that refers to a patient's ability to make informed, sound decisions related to care and treatment. In a medical context, understanding is the most cognitively demanding consent standard and refers to a patient's ability to comprehend information to the extent that informed decisions can be made.

METHODS

The association between reasoning and cognition was examined using data from 41 patients with diagnosed brain metastasis. All diagnoses were made by a board-certified radiation oncologist and were verified histologically. In total, 41 demographically matched, cognitively healthy controls were also included to aid in classifying patients with brain metastasis according to reasoning status (ie, intact or impaired).

RESULTS

Results indicate that measures of simple attention, verbal fluency, verbal memory, processing speed, and executive functioning were all associated with understanding, and that verbal memory and phonemic fluency were the primary cognitive predictors. Using these two primary predictors, equations can be constructed to predict the ability to understand treatment decisions in patients with brain metastasis.

CONCLUSIONS

Although preliminary, these data demonstrate how cognitive measures can estimate understanding as it relates to medical decision-making capacities in these patients. Clinically, these findings suggest that poor verbal memory and expressive language function could serve as "red flags" for reduced consent capacity in this patient population, thus signaling that a more comprehensive medical decision-making capacity evaluation is warranted.

Cognitive impairment and dementia in Parkinson's disease: practical issues and management

Cognitive impairment and dementia pose particular challenges in the management of patients with Parkinson's disease (PD). Decision-making capacity can render patients vulnerable in a way that requires careful ethical considerations by clinicians with respect to medical decision making, research participation, and public safety. Clinicians should discuss how future decisions will be made as early in the disease course as possible. Because of cognitive, visual, and motor impairments, PD may be associated with unsafe driving, leading to early driving cessation in many. DBS of the STN and, to a lesser degree, globus pallidus interna (GPi) has consistently been associated with decreased verbal fluency, but significant global cognitive decline is usually not observed in patients who undergo rigorous selection. There are some observations suggesting lesser cognitive decline in GPi DBS than STN DBS, but further research is required. Management of PD dementia (PDD) patients involves both pharmacological and nonpharmacological measures. Patients with PDD should be offered treatment with a cholinesterase inhibitor taking into account expected benefits and potential risks. Treatment with neuroleptics may be necessary to treat psychosis; classical neuroleptics, as well as risperidone and olanzapine, should be avoided. Quetiapine might be considered first-line treatment because it does not need special monitoring, although the strongest evidence for efficacy exists for clozapine. Evidence from randomized, controlled studies in the PDD population is lacking; selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors may be used to treat depressive features. Clonazepam or melatonin may be useful in the treatment of rapid eye movement behavior disorder.

People with Parkinson's disease and normal MMSE score have a broad range of cognitive performance

Cognitive impairment, including dementia, is common in Parkinson's disease (PD). The Mini-Mental State Examination (MMSE) has been recommended as a screening tool for Parkinson's disease dementia (PDD), with values below 26 indicative of possible dementia. Using a detailed neuropsychological battery, we examined the range of cognitive impairment in PD patients with an MMSE score of 26 or higher. In this multicenter, cross-sectional, observational study, we performed neuropsychological testing in a sample of 788 PD patients with MMSE scores of 26 or higher. Evaluation included tests of global cognition, executive function, language, memory, and visuospatial skills. A consensus panel reviewed results for 342 subjects and assigned a diagnosis of no cognitive impairment, mild cognitive impairment, or dementia. Sixty-seven percent of the 788 subjects performed 1.5 standard deviations below the normative mean on at least one test. On eight of the 15 tests, more than 20% of subjects scored 1.5 standard deviations or more below the normative mean. Greatest impairments were found on Hopkins Verbal Learning and Digit Symbol Coding tests. The sensitivity of the MMSE to detect dementia was 45% in a subset of participants who underwent clinical diagnostic procedures. A remarkably wide range of cognitive impairment can be found in PD patients with a relatively high score on the MMSE, including a level of cognitive impairment consistent with dementia. Given these findings, clinicians must be aware of the limitations of the MMSE in detecting cognitive impairment, including dementia, in PD.

Assessing decision-making capacity at end of life

OBJECTIVE

Patients with terminal illness often face important medical decisions that may carry ethical and legal implications, yet they may be at increased risk for impaired decisional capacity. This study examined the prevalence of impairment on the four domains of decisional capacity relevant to existing legal standards.

METHOD

Twenty-four adults diagnosed with a terminal illness completed the MacArthur Competence Assessment Tool for Treatment, a semi-structured measure of decision-making capacity and measures of cognitive functioning and psychological distress.

RESULTS

Approximately one third of the sample demonstrated serious impairment on at least one domain of decisional capacity. The greatest proportion of impairment was found on subscales that rely heavily on verbal abilities. Decisional capacity was significantly associated with cognitive functioning and education, but not with symptoms of anxiety or depression.

CONCLUSIONS

This study is the first to examine decisional capacity in patients with terminal illness relative to legal standards of competence. Although not universal, decisional impairment was common. Clinicians working with terminally ill patients should frequently assess capacity as these individuals are called on to make important medical decisions. Comprehensive assessment will aid clinicians in their responsibility to balance respect for patient autonomy with their responsibility to protect patients from harm resulting from impaired decisional capacity.

Assessment of functional change and cognitive correlates in the progression from healthy cognitive aging to dementia

OBJECTIVE

There is currently limited understanding of the course of change in everyday functioning that occurs with normal aging and dementia. To better characterize the nature of this change, we evaluated the types of errors made by participants as they performed everyday tasks in a naturalistic environment.

METHOD

Participants included cognitively healthy younger adults (YA; n = 55) and older adults (OA; n = 88), and individuals with mild cognitive impairment (MCI: n = 55) and dementia (n = 18). Participants performed 8 scripted everyday activities (e.g., filling a medication dispenser) while under direct observation in a campus apartment. Task performances were coded for the following errors: inefficient actions, omissions, substitutions, and irrelevant actions.

RESULTS

Performance accuracy decreased with age and level of cognitive impairment. Relative to the YAs, the OA group exhibited more inefficient actions which were linked to performance on neuropsychological measures of executive functioning. Relative to the OAs, the MCI group committed significantly more omission errors which were strongly linked to performance on memory measures. All error types were significantly more prominent in individuals with dementia. Omission errors uniquely predicted everyday functional status as measured by both informant-report and a performance-based measure.

CONCLUSIONS

These findings suggest that in the progression from healthy aging to MCI, everyday task difficulties may evolve from task inefficiencies to task omission errors, leading to inaccuracies in task completion that are recognized by knowledgeable informants. Continued decline in cognitive functioning then leads to more substantial everyday errors, which compromise ability to live independently.

Cognition in movement disorders: where can we hope to be in ten years?

Cognitive impairment and dementia associated with movement disorders represent a major management challenge and area of unmet need. This article has focused upon Parkinson's disease as an exemplar condition, but many of the roadblocks and efforts to overcome these are applicable, in a general sense, to other disorders. Short of a "penicillin moment"-a chance discovery or piece of unintended good fortune-progress is likely to be incremental. Cognitive therapies may end up being multiple and possibly multimodal, parallel with the cancer therapy field. Ultimately, benefit for one condition may extend to others as commonality in protein aggregation, synergistic pathological effects between proteins, and pathological spread emerges. © 2014 International Parkinson and Movement Disorder Society.

Impaired financial abilities in Parkinson's disease patients with mild cognitive impairment and dementia

PURPOSE

Financial capacity (FC) is an instrumental activity of daily living (IADL) critical to independent functioning and sensitive to cognitive impairment in dementia. Little is known about FC in cognitively impaired patients with Parkinson's disease (PD). The present study investigated FC in PD patients with prodromal and clinical dementia.

METHODS

Participants were 20 older controls and 35 PD patients who met consensus criteria for either mild cognitive impairment (PD-MCI, n = 18) or PD dementia (PDD, n = 17). FC was assessed using a standardized performance based measure consisting of 9 domain and two global scores (Financial Capacity Instrument; FCI) (1). FCI domain and global performance scores were compared across groups. Capacity impairment ratings (no impairment, mild/moderate impairment, severe impairment) were calculated for each PD patient's domain and global scores.

RESULTS

Relative to controls, PD-MCI patients were impaired on both FCI global scores and domains of basic monetary skills, financial concepts, and investment decision-making. Relative to both controls and PD-MCI patients, PDD patients were impaired on virtually all FCI variables. With respect to impairment ratings, greater than 50% of PD-MCI patients and greater than 90% of PDD patients were classified as either mild/moderate or severely impaired on the two FCI global scores.

CONCLUSIONS

Impairment of financial capacity is already present in PD-MCI and is advanced in PDD. Complex cognitively-mediated IADLs such as financial capacity appear to be impaired early in the course of PD dementia.

Cognitive impairment and PD patients' capacity to consent to research

OBJECTIVE

To examine how cognitive impairment affects Parkinson disease (PD) patients' research consent capacity.

METHODS

A cross-sectional study of 90 patients with PD, divided using Mattis Dementia Rating Scale-2 scores into 3 groups of 30 (normal, borderline, and impaired), and 30 neurologically normal older adults completed 2 capacity interviews (an early-phase randomized and controlled drug trial and a sham-controlled surgical implantation of genetic tissue) using the MacArthur Competence Assessment Tool for Clinical Research. Expert clinicians used the interviews to classify the patients as either capable or not capable of providing their own informed consent. These judgments were compared with performance on the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE).

RESULTS

Cognitively normal PD patients typically scored well on the capacity measures. In contrast, patients with impaired cognition were not capable of providing their own informed consent: 17% (5/30) on the drug trial and 3% (1/30) on the surgery trial were judged capable. Patients with borderline impairment showed adequate performance on measures of appreciation and reasoning, but impaired performance on understanding the drug trial compared with normal controls and normal PD patients, and on understanding the surgery trial compared with normal controls. Sixty-seven percent (20/30) on the drug trial and 57% (17/30) on the surgery trial were judged capable of consent. Receiver operating characteristic analyses showed that the MMSE and MoCA could detect the likelihood of impaired capacity, with the MoCA demonstrating greater sensitivity.

CONCLUSIONS

PD patients with borderline cognitive impairment have impairments in their decisional capacity. The MoCA may be useful to identify the patients at risk of impaired capacity.

Moving from physician-centered care towards patient-centered care for Parkinson's disease patients

Today's society is changing rapidly and individuals increasingly favor an active role in designing their own lives. Contemporary patients are no exception, but the present health care system-which is organized primarily from the provider's perspective-is not yet prepared for this development. Here, we argue that an alternative way to organize health care, namely more from the patient's perspective, may help to contain costs, while improving the quality, safety and access to care. This involves a redefinition of the patient-doctor relationship, such that patients are no longer regarded as passive objects, but rather as active subjects who work as partners with health care professionals to optimize health ('participatory medicine'). The opportunities that come with such a collaborative and patient-centered care model are reviewed within the context of patients with Parkinson's disease. We also discuss societal and Parkinson-specific barriers that could impede implementation of this alternative care model to the management of Parkinson's disease and other chronic conditions.

Clinical and ethical aspects of financial capacity in dementia: a commentary

In contrast to issues like treatment and research consent capacity, financial capacity has received relatively little clinical and ethical attention in the dementia literature. Yet issues of financial capacity emerge frequently in patients with Alzheimer's disease (AD), Parkinson's disease (PD) and related dementias, and commonly present ethical and clinical challenges for clinicians treating these patients. These issues include whether a patient with possible dementia has sufficient capacity independently to manage their financial affairs, needs referral for financial capacity assessment, and/or is being financially exploited or abused by others. The accurate identification, assessment and successful handling of such financial capacity issues can have a substantial impact on the financial and psychological well-being of patients and their family members. The present commentary presents an overview of financial capacity and associated clinical and ethical issues in dementia, and describes a set of possible clinician roles regarding these issues as they arise in clinical practice. The commentary concludes with a section describing educational resources available to clinicians and bioethicists seeking additional guidance in handling financial capacity issues. The ultimate goal of the paper is to focus clinical and ethical attention on a neglected capacity that is of fundamental importance for patients, families, and health care and legal professionals.

Clinical and ethical aspects of financial capacity in dementia: a commentary

In contrast to issues such as treatment and research consent capacity, financial capacity has received relatively little clinical and ethical attention in the dementia literature. Yet issues of financial capacity emerge frequently in patients with Alzheimer disease, Parkinson disease, and related dementias, and commonly present ethical and clinical challenges for clinicians treating these patients. These issues include whether a patient with possible dementia has sufficient capacity to manage independently their financial affairs, needs referral for financial capacity assessment, and/or is being financially exploited or abused by others. The accurate identification, assessment and successful handling of such financial capacity issues can have a substantial impact on the financial and psychological well-being of patients and their family members. This commentary presents an overview of financial capacity and associated clinical and ethical issues in dementia and describes a set of possible clinician roles regarding these issues as they arise in clinical practice. The commentary concludes with a section describing educational resources available to clinicians and bioethicists seeking additional guidance in handling financial capacity issues. The ultimate goal of the article is to focus clinical and ethical attention on a neglected capacity that is of fundamental importance for patients, families, and healthcare and legal professionals.

Neurodegeneration across stages of cognitive decline in Parkinson disease

OBJECTIVE

To assess regions and patterns of brain atrophy in patients with Parkinson disease (PD) with normal cognition (PD-NC), mild cognitive impairment (PD-MCI), and dementia-level cognitive deficits (PDD).

DESIGN

Images were quantified using a region-of-interest approach and voxel-based morphometry analysis. We used a high-dimensional pattern classification approach to delineate brain regions that collectively formed the Spatial Pattern of Abnormalities for Recognition of PDD.

SETTING

The Parkinson's Disease and Movement Disorders Center at the University of Pennsylvania.

SUBJECTS

Eighty-four PD patients (61 PD-NC, 12 PD-MCI, and 11 PDD) and 23 healthy control subjects (HCs) underwent magnetic resonance imaging of the brain.

RESULTS

The PD-NC patients did not demonstrate significant brain atrophy compared with HCs. Compared with PD-NC patients, PD-MCI patients had hippocampal atrophy (β = -0.37; P = .001), and PDD patients demonstrated hippocampal (β = -0.32; P = .004) and additional medial temporal lobe atrophy (β = -0.36; P = .003). The PD-MCI patients had a different pattern of atrophy compared with PD-NC patients (P = .04) and a similar pattern to that of PDD patients (P = .81), characterized by hippocampal, prefrontal cortex gray and white matter, occipital lobe gray and white matter, and parietal lobe white matter atrophy. In nondemented PD patients, there was a correlation between memory-encoding performance and hippocampal volume.

CONCLUSIONS

Hippocampal atrophy is a biomarker of initial cognitive decline in PD, including impaired memory encoding and storage, suggesting heterogeneity in the neural substrate of memory impairment. Use of a pattern classification approach may allow identification of diffuse regions of cortical gray and white matter atrophy early in the course of cognitive decline.

Alzheimer's disease pattern of brain atrophy predicts cognitive decline in Parkinson's disease

Research suggests overlap in brain regions undergoing neurodegeneration in Parkinson's and Alzheimer's disease. To assess the clinical significance of this, we applied a validated Alzheimer's disease-spatial pattern of brain atrophy to patients with Parkinson's disease with a range of cognitive abilities to determine its association with cognitive performance and decline. At baseline, 84 subjects received structural magnetic resonance imaging brain scans and completed the Dementia Rating Scale-2, and new robust and expanded Dementia Rating Scale-2 norms were applied to cognitively classify participants. Fifty-nine non-demented subjects were assessed annually with the Dementia Rating Scale-2 for two additional years. Magnetic resonance imaging scans were quantified using both a region of interest approach and voxel-based morphometry analysis, and a method for quantifying the presence of an Alzheimer's disease spatial pattern of brain atrophy was applied to each scan. In multivariate models, higher Alzheimer's disease pattern of atrophy score was associated with worse global cognitive performance (β = -0.31, P = 0.007), including in non-demented patients (β = -0.28, P = 0.05). In linear mixed model analyses, higher baseline Alzheimer's disease pattern of atrophy score predicted long-term global cognitive decline in non-demented patients [F(1, 110) = 9.72, P = 0.002], remarkably even in those with normal cognition at baseline [F(1, 80) = 4.71, P = 0.03]. In contrast, in cross-sectional and longitudinal analyses there was no association between region of interest brain volumes and cognitive performance in patients with Parkinson's disease with normal cognition. These findings support involvement of the hippocampus and parietal-temporal cortex with cognitive impairment and long-term decline in Parkinson's disease. In addition, an Alzheimer's disease pattern of brain atrophy may be a preclinical biomarker of cognitive decline in Parkinson's disease.

Cognitive impairment in nondemented Parkinson's disease

A substantial percentage of patients with newly diagnosed Parkinson's disease without dementia are reported to be affected by cognitive impairment (CI). In practice, however, CI is underrecognized, as the signs may not be apparent in early-stage disease and many routine assessment tools lack the sensitivity to detect subtle cognitive dysfunction. Patients with PD and mild CI (MCI) may have a higher risk of developing dementia than cognitively intact PD patients; however, it is not currently known which patients with CI are at increased risk of developing dementia. This review summarizes current knowledge about CI in nondemented PD; it discusses the structural and functional changes associated with CI and addresses areas of unmet needs. We focus on questions that should be addressed in future studies to achieve consensus on its characteristics and definition, pathophysiology, epidemiology, diagnosis and assessment, and treatment and management.

MDS Task Force on mild cognitive impairment in Parkinson's disease: critical review of PD-MCI

There is controversy regarding the definition and characteristics of mild cognitive impairment in Parkinson's disease. The Movement Disorder Society commissioned a Task Force to critically evaluate the literature and determine the frequency and characteristics of Parkinson's disease-mild cognitive impairment and its association with dementia. A comprehensive PubMed literature review was conducted using systematic inclusion and exclusion criteria. A mean of 26.7% (range, 18.9%-38.2%) of nondemented patients with Parkinson's disease have mild cognitive impairment. The frequency of Parkinson's disease-mild cognitive impairment increases with age, disease duration, and disease severity. Impairments occur in a range of cognitive domains, but single domain impairment is more common than multiple domain impairment, and within single domain impairment, nonamnestic is more common than amnestic impairment. A high proportion of patients with Parkinson's disease-mild cognitive impairment progress to dementia in a relatively short period of time. The primary conclusions of the Task Force are that: (1) Parkinson's disease-mild cognitive impairment is common, (2) there is significant heterogeneity within Parkinson's disease-mild cognitive impairment in the number and types of cognitive domain impairments, (3) Parkinson's disease-mild cognitive impairment appears to place patients at risk of progressing to dementia, and (4) formal diagnostic criteria for Parkinson's disease-mild cognitive impairment are needed.

Moving towards patient-centered healthcare for patients with Parkinson's disease

INTRODUCTION

Quality of care is becoming increasingly important in the field of movement disorders. Patient-centeredness is a crucial element of quality of care, but has thus far received limited attention regarding the treatment of movement disorder syndromes. As a first step towards patient-centered care in Parkinson's disease (PD), we explored the unmet needs of PD patients and their informal caregivers.

METHODS

Eight focus group discussions involving 40 PD patients (mean age 62 years, Hoehn & Yahr stage 1-3) and 20 informal caregivers (mean age 63 years) were organized to explore the experiences in relation to patient-centered care. The key elements of patient-centeredness - as defined by the Picker Institute and the World Health Organization - were used as a framework for discussion and qualitative analysis.

RESULTS

Patients and informal caregivers desired more emotional support from healthcare professionals, and wanted more active involvement in clinical decision making, but currently lacked sufficient information to do so. Participants also missed the tools to find professionals with PD expertise. Finally, they identified a lack of multidisciplinary collaboration as a major bottleneck in the current healthcare system.

CONCLUSIONS

We identified various unmet needs among PD patients and informal caregivers. These joint experiences represent a disease-specific model of patient-centeredness for PD, which can assist healthcare professionals in implementing patient-centered care tailored to the preferences of each individual patient. The present findings will be used to construct a patient-centeredness questionnaire for PD that will clarify the quality of care from a patient's perspective.

The epidemiology of dementia associated with Parkinson's disease

Parkinson's disease (PD) is the second most common neurodegenerative illness after Alzheimer's disease (AD). Cognitive impairment and dementia are common features in PD and characterized by a wide range of cognitive deficits distinct from those seen in AD. Mild cognitive impairment occurs even early in PD and is associated with shorter time to dementia. The purpose of this review is to present recent findings on clinical aspects of dementia in PD and to elucidate underlying clinical and neurobiological risk factors.

The treatment of cognitive impairment associated with Parkinson's disease

Cognitive impairment and dementia associated with Parkinson's disease (PD) are common and often have devastating effects upon the patient and their family. Early cognitive impairment in PD is frequent, and the functional impact may be underestimated. Optimal management will rely upon better identification of the predominant symptoms and greater knowledge of their pathophysiological basis. The management of dementia in PD (PD-D) also has to consider the significant neuropsychiatric burden that frequently accompanies the cognitive decline, as well as fluctuations in attention. Atypical anti-psychotics have a limited role at present in treating PD-D, although new drugs are under development. The mainstay of drug management for people with PD-D is cholinesterase inhibitors, although recent trials have suggested that the N-methyl-D aspartate antagonist memantine may also have some benefit. Disease modification remains the ultimate goal for preventing the inexorable decline in PD-D, although effective interventions are still some way off. Limited benefit may, however, be possible through exercise programmes and so-called "medical foods", although randomised trials are required to confirm largely anecdotal observations.

Utility of the NeuroTrax computerized battery for cognitive screening in Parkinson's disease: comparison with the MMSE and the MoCA

To determine the utility of a computerized assessment in Parkinson's disease (PD), we compared the cognitive performance of 50 PD patients on the NeuroTrax computerized battery relative to the mini-mental state examination (MMSE) and the Montreal Cognitive Assessment (MoCA). The results revealed fair agreement between impairment on the NeuroTrax and the MMSE (kappa=.291, p=.031) but only slight agreement between the NeuroTrax and the MoCA (kappa=.138, p = .054) and between the MoCA and the MMSE (kappa = .168, p = .069). The NeuroTrax identified 52% of the sample as average or above, 40% as below average, and 8% as impaired. The MoCA identified 54% of the sample as impaired (28% average or above and 18% below average), while the MMSE identified 66% as average or above (20% below average and 14% impaired). Several stepwise regressions revealed that executive and verbal functions were the best predictors of cognitive functioning on the NeuroTrax, while memory recall, serial sevens, naming, and abstraction were the best predictors on the MoCA. These results suggest that although the NeuroTrax may be useful in identifying executive cognitive deficits in PD, similar to the MMSE the NeuroTrax may lack optimal sensitivity. While the MoCA is sensitive, it may be too stringent in overclassifying PD patients as impaired.

Medical decision-making capacity in patients with malignant glioma

OBJECTIVE

Patients with malignant glioma (MG) must make ongoing medical treatment decisions concerning a progressive disease that erodes cognition. We prospectively assessed medical decision-making capacity (MDC) in patients with MG using a standardized psychometric instrument.

METHODS

Participants were 22 healthy controls and 26 patients with histologically verified MG. Group performance was compared on the Capacity to Consent to Treatment Instrument (CCTI), a psychometric measure of MDC incorporating 4 standards (choice, understanding, reasoning, and appreciation), and on neuropsychological and demographic variables. Capacity outcomes (capable, marginally capable, or incapable) on the CCTI standards were identified for the MG group. Within the MG group, scores on demographic, clinical, and neuropsychological variables were correlated with scores on each CCTI standard, and significant bivariate correlates were subsequently entered into exploratory stepwise regression analyses to identify multivariate cognitive predictors of the CCTI standards.

RESULTS

Patients with MG performed significantly below controls on consent standards of understanding and reasoning, and showed a trend on appreciation. Relative to controls, more than 50% of the patients with MG demonstrated capacity compromise (marginally capable or incapable outcomes) in MDC. In the MG group, cognitive measures of verbal acquisition/recall and, to a lesser extent, semantic fluency predicted performance on the appreciation, reasoning, and understanding standards. Karnofsky score was also associated with CCTI performance.

CONCLUSIONS

Soon after diagnosis, patients with malignant glioma (MG) have impaired capacity to make treatment decisions relative to controls. Medical decision-making capacity (MDC) impairment in MG seems to be primarily related to the effects of short-term verbal memory deficits. Ongoing assessment of MDC in patients with MG is strongly recommended.

Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease

BACKGROUND

Due to the high prevalence of mild cognitive impairment (MCI) and dementia in Parkinson disease (PD), routine cognitive screening is important for the optimal management of patients with PD. The Montreal Cognitive Assessment (MoCA) is more sensitive than the commonly used Mini-Mental State Examination (MMSE) in detecting MCI and dementia in patients without PD, but its validity in PD has not been established.

METHODS

A representative sample of 132 patients with PD at 2 movement disorders centers was administered the MoCA, MMSE, and a neuropsychological battery with operationalized criteria for deficits. MCI and PD dementia (PDD) criteria were applied by an investigator blinded to the MoCA and MMSE results. The discriminant validity of the MoCA and MMSE as screening and diagnostic instruments was ascertained.

RESULTS

Approximately one third of the sample met diagnostic criteria for a cognitive disorder (12.9% PDD and 17.4% MCI). Mean (SD) MoCA and MMSE scores were 25.0 (3.8) and 28.1 (2.0). The overall discriminant validity for detection of any cognitive disorder was similar for the MoCA and the MMSE (receiver operating characteristic area under the curve [95% confidence interval]): MoCA (0.79 [0.72, 0.87]) and MMSE (0.76 [0.67, 0.85]), but as a screening instrument the MoCA (optimal cutoff point = 26/27, 64% correctly diagnosed, lack of ceiling effect) was superior to the MMSE (optimal cutoff point = 29/30, 54% correctly diagnosed, presence of ceiling effect).

CONCLUSIONS

The Montreal Cognitive Assessment, but not the Mini-Mental State Examination, has adequate psychometric properties as a screening instrument for the detection of mild cognitive impairment or dementia in Parkinson disease. However, a positive screen using either instrument requires additional assessment due to suboptimal specificity at the recommended screening cutoff point.

Clinical ethics issues in geriatric psychiatry

Psychiatrists face a number of ethical challenges when caring for older adults and their families. Of paramount importance is ensuring that older adults have the capacity to make decisions about their medical care and their overall welfare. Psychiatrists must remain alert for the possibility of incapacity, which, if suspected, should prompt a thorough evaluation of decisional capacities. There is a robust literature guiding clinicians conducting such evaluations. Geriatric care focuses on maintaining or improving quality of life, which is especially relevant in end-of-life situations. With the aging of the United States population, discussion must take place at a societal level regarding a fair and just distribution of medical resources. Psychiatrists must be vigilant that the mental health needs of older adults, including access to effective therapies, are addressed adequately in such discussions.