Older adults prefer less choice than young adults

Education, relationships, and place: life choices in the narratives of university master students

Choice is one of the most roughly defined concepts in contemporary social sciences. Previous studies have elucidated the factors that influence young people's choices in different life situations. However, it is still unclear how young people evaluate these choices and how they integrate them into their biographies. In this study, we examine the narratives of 30 first-year master's students at HSE University with regard to two categories of life choices: those that they perceive as fortunate and those that they perceive as unfortunate. Using a written online survey, the data was collected in the spring of 2022. To categorize the different decision kinds, thematic analysis was applied. Overall, we discovered that narratives about the life choices made by master students concentrated on education, relationships and place.

Adult age differences in risk perception and risk taking

Research on self-reported risk perception and risk taking suggests age-related decrements in risk preference, with older adults less likely to engage in general and domain-specific risk taking (i.e., in financial, health-related, ethical, career, and leisure contexts). Data relating to social risks, however, are inconsistent. With respect to behavioral risk-taking tasks, age-related differences vary depending on task characteristics and older adults' cognitive capacities. Specifically, older adults are less good at learning to take advantageous risks and take fewer risks when faced with gains, especially financial and mortality-based ones. We contextualize these trends by referencing relevant theoretical frameworks (see Frey et al., 2021 [1]) and by drawing on the COVID-19 pandemic to illustrate recent examples of age-related differences in real-life risk responses.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

PRACTICE IMPLICATIONS

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

Susceptibility to default effects does not differ by age

Decision makers are more likely to passively accept than to actively reject preselected default options. Age differences in such "default effects" have not been systematically examined, but prior research reports age-related variation in several known determinants of default effects suggesting that they may be more common in older as compared to younger adults. To address this question, a representative life span sample (N = 500; Mage = 49.90, SDage = 19.34; 51% female, 49% male; 67% non-Hispanic White) responded to a preregistered online study. Participants completed a default effect task comprising two conditions, one requiring opt-out and one requiring opt-in decisions (i.e., 15 vs. 0 preselected features each). Susceptibility to defaults was assessed as the discrepancy between the number of features selected within each condition. In addition, we collected data on known determinants of default effects (i.e., perceived endowment, endorsement, ease, experience making similar choices, importance of the choice, and affective responses to the choice). Finally, we screened demographic background, personality, socioemotional and health status, and cognitive ability. Susceptibility to default effects was evident both at the individual and the group level. Unlike hypothesized, older age did not predict greater susceptibility to defaults, and older adults were less likely to endorse determinants of default effect compliance. Of the covariates assessed, only identifying as non-Hispanic White, greater perceived endorsement, greater perceived ease, and lower perceived importance of making the right choice predicted decision makers' susceptibility to default effects. Thus, our findings suggest that susceptibility to decision defaults does not vary by age. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Age differences in option choice: Is the option framing effect observed among older adults?

Previous studies reported that consumers choose a higher number of options in subtractive framing (-OF), which delete the unnecessary options from the full model with all options chosen than in additive framing (+OF), which adds options to a simple base model. The purposes of this study are to examine the effect of age on option framing and the differences of product type on the option framing effect using two product scenarios (travel package and medical examination). Participants were 40 younger and 40 older adults. We measured the number of options chosen, total price, choice difficulty, and choice satisfaction. In addition, cognitive functions (coding, symbol search, digit span, arithmetic, and information) were assessed. Results revealed that older and younger adults chose more options in the -OF condition for both the scenarios. For the medical examination, older adults chose more options than did the younger adults in both -OF and +OF conditions. Developmental shift in goals and motivation related to life-span may explain the differences between the age differences.

The development and utility of a multicriteria patient decision aid for people contemplating treatment for osteoarthritis

BACKGROUND

There are a range of treatment options for osteoarthritis (OA) of the knee and hip, each with a unique profile of risks and benefits. Patient decision aids can help incorporate patient preferences in treatment decision-making. The aim of this study was to develop and test the utility of a patient decision aid for OA that was developed using a multicriteria decision analytic framework.

METHODS

People contemplating treatment for OA who had accessed the website myjointpain.org.au were invited to participate in the study by using the online patient decision aid. Two forms of the patient decision aid were created: A shorter form and a longer form, which allowed greater customization that was offered to respondents after they had completed the shorter form. Respondents also completed questions asking about their experience using the patient decision aid.

RESULTS

A total of 625 self-selected respondents completed the short-form and 180 completed the long-form. Across both forms, serious side effects, pain and function were rated as the most important treatment outcomes. Most respondents (64%) who completed the longer form reported that using the tool was a positive experience, 38% reported that using the tool had changed their mind and 48% said that using the tool would improve the quality of their decision-making.

CONCLUSIONS

Overall, the findings suggest that this patient decision aid may be of use to a substantial number of people in facilitating appropriate treatment decision-making.

PATIENT OR PUBLIC CONTRIBUTION

Service users of myjointpain.org.au were involved through their participation in the study, and their feedback will guide the development of future iterations of the tool.

Wishes and Needs of Nursing Home Residents: A Scoping Review

Falling birth rates and rising life expectancy are leading to global aging. The proportional increase in older people can be observed in almost all countries and regions worldwide. As a result, more people spend their later years in nursing homes. In homes where person-centered care is implemented, residents report greater satisfaction and quality of life. This approach is based on the wishes and needs of the residents. Therefore, the purpose of this scoping review is to explore the wishes and needs of nursing home residents. A scoping review of the literature was conducted in which 12 databases were systematically searched for relevant articles according to PRISMA-ScR guidelines. Both quantitative and qualitative study designs were considered. A total of 51 articles met the inclusion criteria. Included articles were subjected to thematic analysis and synthesis to categorize findings into themes. The analysis identified 12 themes to which the wishes and needs were assigned: (1) Activities, leisure, and daily routine; (2) Autonomy, independence, choice, and control; (3) Death, dying, and end-of-life; (4) Economics; (5) Environment, structural conditions, meals, and food; (6) Health condition; (7) Medication, care, treatment, and hygiene; (8) Peer relationship, company, and social contact; (9) Privacy; (10) Psychological and emotional aspects, security, and safety; (11) Religion, spirituality; and (12) Sexuality. Nursing home residents are not a homogeneous group. Accordingly, a wide range of needs and wishes are reported in the literature, assigned to various topics. This underscores the need for tailored and person-centered approaches to ensure long-term well-being and quality of life in the nursing home care setting.

Management of elderly patients with esophageal squamous cell cancer

This review focuses on the treatment about elderly esophageal cancer to clarify the current situation regarding our clinical question. Although there are several reviews about elderly esophageal cancer treatment, there are fundamental differences between Japan and the rest of the world. Two main differences are raised: histological differences and treatment strategies for resectable patients. We overview each status according to following clinical questions. First, there are no established evaluation criteria for frail. Second, selection criteria for surgery or non-surgery are not established. Third, few specific treatments for elderly patients (EPs) are investigated. In conclusion, there are many reports about treatment of esophageal squamous cell carcinoma for EPs, although treatment strategy is still controversial. We have to consider well-designed prospective trial to confirm specific treatment strategy according to each stage.

Effectiveness of a video-based advance care planning intervention in hospitalized elderly patients: A randomized controlled trial

AIM

This study aimed to develop a video-based advance care planning intervention, and examine the effectiveness of the intervention on knowledge, behavioral intentions and advance directive signing among older patients admitted to a geriatric unit in Taiwan.

METHODS

This randomized controlled trial was carried out in two geriatric wards of a medical center in northern Taiwan, between June 2014 and June 2015. The participants were randomly assigned to the intervention (n = 39) or control (n = 43) group. Participants in the intervention group watched a 5-min video regarding advance care planning. The control group received usual care. Structured questionnaires on advance care planning knowledge and behavioral intentions were administered to both groups before and after the intervention. Advance directive signing was carried out until 2 weeks after hospital discharge through a chart review.

RESULTS

The intervention group showed a significantly higher advance care planning knowledge score and behavioral intention score than the control group post-intervention. The rate of advance directive signing was 33.3% in the intervention group and 9.3% in the control group (P = 0.01).

CONCLUSIONS

This study showed the effectiveness of video-based interventions in increasing advance care planning knowledge, behavioral intention and advance directive signing among hospitalized older patients. Geriatric wards could use our model to promote advance care planning among older patients. Geriatr Gerontol Int 2021; 21: 478-484.

Decision experience in hyperchoice: the role of numeracy and age differences

Due to new technologies, a profusion of products is released onto store shelves and the Internet, resulting in a special choice condition termed hyperchoice. Past research on whether hyperchoice deteriorates decision experience is mixed. The present study hypothesizes the experience in the scenario of hyperchoice may be moderated by individual characteristics, including numeracy and age differences. A total of 116 older adults and 112 younger adults were recruited from Amazon Mechanical Turk. Along with the Rasch-based numeracy scale, each participant completed a consumer and a gamble choice task. In both tasks, the number of options being presented to participants was manipulated to create a hyperchoice condition (sixteen options) and a simple-choice condition (four options). Dependent variables were post-choice difficulty and satisfaction. Multiple regressions were performed with SPSS 24.0 to test the hypothesis. As a result, hyperchoice was related to greater decision difficulty in both choice tasks. Moreover, there was an interaction between numeracy and hyperchoice in the gamble task. Specifically, whereas higher numerate participants’ experienced difficulty and satisfaction were relatively stable between the two choice conditions, lower numerate participants experienced more difficulty and dissatisfaction in the hyperchoice condition than in the simple-choice condition. Additionally, compared to younger adults, older adults reported greater decision difficulty and lower decision satisfaction, regardless of choice condition. The study supported the notion that the specific effect of hyperchoice was moderated by individual factors. The study implied merchants should adopt strategies to ease decision experience and advocated for numeracy education.

User-Centered Design and Evaluation of a Web-Based Decision Aid for Older Adults Living With Mild Cognitive Impairment and Their Health Care Providers: Mixed Methods Study

Background

Mild cognitive impairment (MCI) is often considered a transitional state between normal and pathologic (eg, dementia) cognitive aging. Although its prognosis varies largely, the diagnosis carries the risk of causing uncertainty and overtreatment of older adults with MCI who may never progress to dementia. Decision aids help people become better informed and more involved in decision making by providing evidence-based information about options and possible outcomes and by assisting them in clarifying their personal values in relation to the decision to be made.

Objective

This study aimed to incorporate features that best support values clarification and adjust the level of detail of a web-based decision aid for individuals with MCI.

Methods

We conducted a rapid review to identify options to maintain or improve cognitive functions in individuals with MCI. The evidence was structured into a novel web-based decision aid designed in collaboration with digital specialists and graphic designers. Qualitative and user-centered evaluations were used to draw on users’ knowledge, clarify values, and inform potential adoption in routine clinical practice. We invited clinicians, older adults with MCI, and their caregivers to evaluate the decision aid in 6 consecutive rounds, with new participants in each round. Quantitative data were collected using the Values Clarity and Informed subscales of the Decisional Conflict Scale, the System Usability Scale, the Ottawa Acceptability questionnaire, and a 5-point satisfaction rating scale. We verified their comprehension using a teach-back method and recorded usability issues. We recorded the audio and computer screen during the session. An inductive thematic qualitative analysis approach was used to identify and describe the issues that arose. After each round, an expert panel met to prioritize and find solutions to mitigate the issues. An integrated analysis was conducted to confirm our choices.

Results

A total of 7 clinicians (social workers, nurses, family physicians, psychologists) and 12 older (≥60 years) community-dwelling individuals with MCI, half of them women, with education levels going from none to university diploma, were recruited and completed testing. The thematic analysis revealed 3 major issues. First, the user should be guided through the decision-making process by tailoring the presentation of options to users’ priorities using the values clarification exercise. Second, its content should be simple, but not simplistic, notably by using information layering, plain language, and pictograms. Third, the interface should be intuitive and user friendly, utilize pop-up windows and information tips, avoid drop-down menus, and limit the need to scroll down. The quantitative assessments corroborated the qualitative findings.

Conclusions

This project resulted in a promising web-based decision aid that can support decision making for MCI intervention, based on the personal values and preferences of the users. Further ongoing research will allow its implementation to be tested in clinical settings.

Leveraging goals to incentivize healthful behaviors across adulthood

Despite abundant evidence for the benefits of physical activity on aging trajectories, older Americans remain largely inactive. The present study was designed to examine age differences in responsiveness to financial incentives to increase walking. Grounded in socioemotional selectivity theory, we examined the effectiveness of financial incentives that varied in prosociality. Three types of incentives were presented to community-residing adults 18-92 years of age (N = 450). Participants were randomly assigned to 1 of 5 conditions: personal, loved one, charity, choice, or a no-incentive control group. Average daily step counts were measured using pedometers during a baseline week, during the incentivized period, and after the incentivized period ended. Overall, financial incentives significantly increased walking compared to a control group. Whereas personal incentives were effective regardless of age, incentives to earn for charities were starkly more effective in older adults than younger adults. Moreover, 1 week after the incentivized period ended, older participants were more likely to maintain increased step counts, whereas younger people reverted to baseline step counts. Findings suggest that financial incentives can increase walking in a wide age range and that charitable incentives may be especially effective in health interventions targeting older adults. The importance of aligning incentives with age-related goals is discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Demographic and attitudinal antecedents of consumers' use and self-investment trajectories over time in an online TV content platform

Purpose

To investigate if online TV content platforms create value for consumers (and increase use) by offering its users the possibility to self-invest in the service (by giving personal content preferences). We link demographic and attitudinal antecedents to the relation between self-investment and use.

Design/methodology/approach

Data were collected together with a Belgian media company (N = 4,136). To test the effects a latent growth model was composed in a multigroup setting with gender as the grouping variable. The model is analyzed through structural equation modeling in Mplus 8.0.

Findings

In general, strong relations between self-investment and increased use were found, although the effect of self-investment on use was stronger for female consumers. Furthermore, we established strong hedonic effects on using and investing in the service. For men, easy to use platforms lead to less self-investment.

Research limitations/implications

Our findings are restricted to free services. Furthermore, attitudinal variables are antecedents of behaviors. However, a more complex interplay between behavioral and attitudinal variables is possible. Further research could use repeatedly measured attitudinal measures and link these to behaviors over time.

Practical implications

Service developers could offer different platform interactions to different segments to create consumer value. Women seem more receptive for extra functionalities, such as the possibility to indicate preferences. Men mainly focus on the content offered.

Originality/value

This study focuses on a new form of media distribution, online TV content platforms, where we investigate two related behaviors of users over time (self-investment and use) instead of a general approximation of use. Multi-source data were used.

Judging Truth

Deceptive claims surround us, embedded in fake news, advertisements, political propaganda, and rumors. How do people know what to believe? Truth judgments reflect inferences drawn from three types of information: base rates, feelings, and consistency with information retrieved from memory. First, people exhibit a bias to accept incoming information, because most claims in our environments are true. Second, people interpret feelings, like ease of processing, as evidence of truth. And third, people can (but do not always) consider whether assertions match facts and source information stored in memory. This three-part framework predicts specific illusions (e.g., truthiness, illusory truth), offers ways to correct stubborn misconceptions, and suggests the importance of converging cues in a post-truth world, where falsehoods travel further and faster than the truth.

Should we involve patients more actively? Perspectives of the multidisciplinary team on shared decision-making for older patients with metastatic castration-resistant prostate cancer

OBJECTIVE

To evaluate perspectives of the multidisciplinary team concerning shared decision-making (SDM) in treatment decisions for older patients with metastatic castration-resistant prostate cancer (mCRPC).

MATERIALS AND METHODS

A survey among Dutch healthcare providers was conducted to assess healthcare providers' perspectives on patient involvement in decision-making and the value of a decision aid (DA) in the decision-making process. Treatment recommendations were assessed using hypothetical cases in which providers were asked to evaluate their likelihood of pursuing listed treatment options.

RESULTS

In total, 170 Dutch healthcare providers, including 82 urologists, 31 oncologists, and 57 oncology nurses completed the survey. Sixty-two percent of urologists, 65% of oncologists, and 51% of oncology nurses found that mCRPC patients take a passive role in decision-making and delegate treatment decisions to doctors due to advanced age (p = .45). Yet, 70% of urologists, 71% of oncologists, and 63% of oncology nurses agreed that mCRPC patients should be always involved in decision-making (p = .91). Fifty-two percent of urologists and 55% of oncologists stated that they are inadequately trained to apply SDM in clinical practice. Conversely, only 20% of oncology nurses believed that oncology nurses are inadequately trained. Fifty-four percent of all providers considered a DA suitable to support these patients and their healthcare providers in the decision-making process. All hypothetical cases showed variation in treatment recommendations among providers, with each of the five treatments ranging from extremely likely to extremely unlikely.

CONCLUSIONS

The wide variation of treatment recommendations observed among the multidisciplinary team suggests that mCRPC patients and their healthcare providers may benefit from implementation of informed SDM. Given the perceived passive role of older patients with mCRPC in decision-making, interventions to engage them are needed. With slightly more than half of respondents finding DAs useful to facilitate the decision-making process, development and implementation of a DA would be an interesting field of research.

Characteristics of the spouse caregiving experience: Comparison between early- and late-onset dementia

OBJECTIVES

To investigate the characteristics of the caregiving experience according to age at onset of dementia to adapt support programs.

METHOD

Fifty-seven spouse caregivers of persons with early-onset dementia (PEOD) and 93 spouse caregivers of persons with late-onset dementia (PLOD) participated. The characteristics of the caregiving experience were assessed using questionnaires. We compared the two groups according to age at onset of the disease using a multivariate test, Pillai's Trace test.

RESULTS

The analysis showed that there were similarities and differences between the two groups of spouse caregivers. All spouse caregivers were confident in their caregiving role and fairly well prepared for future needs and reported mild depressive and anxious symptoms. However, they lacked informal support, had low confidence in requesting respite care and reported effects on their health. Compared to spouse caregivers of PLOD, spouse caregivers of PEOD had more severe perceptions of the cognitive disorders of persons with dementia (PWD) and had a better sense of preparedness and knowledge of services. Spouse caregivers of PLOD were more confident in their ability to control disturbing thoughts.

CONCLUSION

The results suggest that programs should provide information on support networks to improve preparedness for spouse caregivers of PLOD as well as emphasizing positive coping strategies for caregivers of PEOD to maintain good-quality relationships with PWD, which influences the perception of the symptoms. For both groups, family relationships should be considered.

Development of the Taiwanese version of the Health Enhancement Lifestyle Profile (HELP-T)

OBJECTIVES

To develop and validate a Taiwanese version of the Health Enhancement Lifestyle Profile (HELP-T) for community-dwelling older Taiwanese adults (≥ 55 years).

METHODS

The original Health Enhancement Lifestyle Profile (HELP) is a 56-item self-report questionnaire measuring various aspects of health-related lifestyles in older adults. The standard cultural-adaptation procedure was used for questionnaire translation and modification. A field test was conducted for culturally specific item selection, rating-scale analysis, and psychometric validation of the HELP-T in a sample of 274 community-dwelling older adults via classical test theory.

RESULTS

The 59-item HELP-T is culturally adapted from the original 56-item HELP. The original 6-point rating scale was modified to a 3-point scale for easy use by Taiwanese older adults. The HELP-T had good internal consistency (Cronbach's alpha = 0.82). The test-retest reliability for the total score was high (0.92), and moderate to high (range: 0.57-0.92) for subscales. The construct validity was supported by the significant correlations between each subscale and the total score (Spearman's rho = 0.41-0.67, p < 0.0001) and by the ability of the scores to significantly discriminate between participants with different levels of self-rated health (p = 0.0001).

CONCLUSIONS

The HELP-T is a suitable clinical tool for assessing and monitoring lifestyle risk factors, establishing client-centered lifestyle intervention goals, and determining the outcomes of lifestyle interventions.

Decision-making competence in younger and older adults: which cognitive abilities contribute to the application of decision rules?

Older adults perform worse than younger adults when applying decision rules to choose between options that vary along multiple attributes. Although previous studies have shown that general fluid cognitive abilities contribute to the accurate application of decision rules, relatively little is known about which specific cognitive abilities play the most important role. We examined the independent roles of working memory, verbal fluency, semantic knowledge, and components of executive functioning. We found that age-related decline in applying decision rules was statistically mediated by age-related decline in working memory and verbal fluency. Our results have implications for theories of aging and decision-making.

Community Pharmacists' Perspectives of a Decision Aid for Managing Type 2 Diabetes in Ontario

OBJECTIVES

Decision aids are tools designed to help patients make choices about their health care. We explored pharmacists' perceptions of an evidence-based diabetes decision aid developed by the Mayo Clinic, Diabetes Medication Choice (DMC). Using DMC as a reference, we aimed to explore pharmacists' perspectives on decision aids, their place in a community pharmacy setting and the implementing of a decision aid, such as DMC, in Ontario.

METHODS

We used semistructured interviews with a convenience sample of community pharmacists from Ontario. We applied a thematic analysis to the data.

RESULTS

We conducted 16 interviews with pharmacists, of whom 9 were certified diabetes educators, and 10 were female. Three themes emerged from the data: pharmacists' knowledge and awareness of decision aids; pharmacists' perceptions of the DMC decision aids, and implementation of the DMC decision aids in Ontario pharmacies. Participants discussed their limited experience with and training in the use of decision aids. Although many participants agreed that the DMC decision aids may contribute to patient-centred care, all agreed that significant changes were needed to be made to implement this tool in practice.

CONCLUSIONS

Pharmacists felt that the use of decision aids in community pharmacies in Ontario may improve patient-centred care. Modifications, however, are needed to improve the applicability to their context and fit into their workflow. Empirical data concerning the impact of decision aids in community pharmacy is needed.

Merely a rhetorical promise? Older users' opportunities for choice and control in Swedish individualised home care services

A policy shift has taken place in Sweden towards individualised elder-care and consumer choice. The aim of the study is to investigate how older users of home care services view and experience their opportunities of exerting influence and having choice and control in their everyday living, in terms of receiving preferred services that are flexible and responsive to their actual needs and priorities. The study was conducted in three local elder-care authorities, reflecting diverse present models of organising home care services in Sweden. Data consisted of responses to a postal survey (N = 2,792) and reports from qualitative interviews (N = 28) with older users. Our findings point to similarities rather than differences between the views and experiences of the users in the three participating local municipal elder-care authorities. A majority of users were positive about their home care services. The experiences ranged from being active and enabled to choose between providers and services, to being more or less passive dependants having to rely on the decisions of family and staff. The importance of supportive relationships, and interdependence between older people and their formal as well as informal support networks, became clear. Our findings may guide policy makers in refining home care services, irrespective of preferred model. In particular, efforts to facilitate staff continuity and prevent high staff turnover need to be prioritised.

Multilevel predictors of colorectal cancer testing modality among publicly and privately insured people turning 50

Understanding multilevel predictors of colorectal cancer (CRC) screening test modality can help inform screening program design and implementation. We used North Carolina Medicare, Medicaid, and private, commercially available, health plan insurance claims data from 2003 to 2008 to ascertain CRC test modality among people who received CRC screening around their 50th birthday, when guidelines recommend that screening should commence for normal risk individuals. We ascertained receipt of colonoscopy, fecal occult blood test (FOBT) and fecal immunochemical test (FIT) from billing codes. Person-level and county-level contextual variables were included in multilevel random intercepts models to understand predictors of CRC test modality, stratified by insurance type. Of 12,570 publicly-insured persons turning 50 during the study period who received CRC testing, 57% received colonoscopy, whereas 43% received FOBT/FIT, with significant regional variation. In multivariable models, females with public insurance had lower odds of colonoscopy than males (odds ratio [OR] = 0.68; p < 0.05). Of 56,151 privately-insured persons turning 50 years old who received CRC testing, 42% received colonoscopy, whereas 58% received FOBT/FIT, with significant regional variation. In multivariable models, females with private insurance had lower odds of colonoscopy than males (OR = 0.43; p < 0.05). People living 10-15 miles away from endoscopy facilities also had lower odds of colonoscopy than those living within 5 miles (OR = 0.91; p < 0.05). Both colonoscopy and FOBT/FIT are widely used in North Carolina among insured persons newly age-eligible for screening. The high level of FOBT/FIT use among privately insured persons and women suggests that renewed emphasis on FOBT/FIT as a viable screening alternative to colonoscopy may be important.

Choice, freedom, and well-being: considerations for public policy

It is commonly assumed in affluent, Western, democratic societies that by enhancing opportunities for choice, we enhance freedom and well-being, both by enabling people to get exactly what they want and by enabling people to express their identities. In this paper, we review evidence that the relationships between choice, freedom, and well-being are complex. The value of choice in itself may depend on culture, and even in cultural contexts that value choice, too much choice can lead to paralysis, bad decisions, and dissatisfaction with even good decisions. Policy-makers are often in a position to enhance well-being by limiting choice. We suggest five questions that policy-makers should be asking themselves when they consider promulgating policies that will limit choice in the service of enhanced well-being. The relationships between choice, freedom, and well-being are not simple, and an appreciation of their complexity may help policy-makers target their interventions more effectively.

Age Differences in Information Use While Making Decisions: Resource Limitations or Processing Differences?

Recent research on the decision-making abilities of older adults has shown that they use less information than young adults. One explanation ascribes this age difference to reductions in cognitive abilities with age. The article includes three experimental studies that focused on determining the conditions in which older and young adults would display dissimilar information processing characteristics. Findings from Studies 1 and 2 demonstrated that older adults are not necessarily at greater disadvantage than young adults in decision contexts that demand more information processing resources. Findings from Study 3 indicated that older adults when faced with decisions that require greater processing are likely to use a strategy that reduces the amount of information needed, whereas younger adults rely on strategies that utilize more resources. Combined the findings indicate that older adults change their decision-making strategies based on the context and information provided. Furthermore, support is provided for processing difference.

Choosing to be happy? Age differences in "maximizing" decision strategies and experienced emotional well-being

Maximizing is a decision strategy that seeks the very best option, which is more elaborate and potentially more regret inducing than choosing an option that is "good enough." In surveys with a large national sample, we find that older adults are less likely than younger adults to self-report maximizing, which is associated with their better experienced well-being reported 2 years later. This pattern holds after controlling for demographic characteristics and negative life events. Our findings suggest that older adults could possibly be opting for decision strategies that make them happier. We discuss implications for interventions that aim to improve decision making. (PsycINFO Database Record

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Free choice in residential care for older people - A philosophical reflection

OBJECTIVE

Free choice in elderly care services is a debated issue. Using the theoretical support of philosophers of free will, this paper explores free choice in relocation to residential care. The three dominant perspectives within this field of philosophy, libertarianism, determinism and compatibilism, are applied from the perspective of the older individual to the process of moving.

METHOD

Empirical data were collected through qualitative interviews with 13 older individuals who had recently moved into residential care.

RESULTS

These individuals had made the choice to move following either a health emergency or incremental health problems. In a deterministic perspective they had no alternative to moving, which was the inevitable solution to their various personal problems. A network of people important to them assisted in the move, making the choice possible. However, post-move the interviewees' perspective had changed to a libertarian or compatibilist interpretation, whereby although the circumstances had conferred little freedom regarding the move.

CONCLUSIONS

The interviewees reported a high degree of self-determination in the process. It appeared that in order to restore self-respect and personal agency, the older individuals had transformed their restricted choice into a choice made of free will or freer will.

Exploratory decision-making as a function of lifelong experience, not cognitive decline

Older adults perform worse than younger adults in some complex decision-making scenarios, which is commonly attributed to age-related declines in striatal and frontostriatal processing. Recently, this popular account has been challenged by work that considered how older adults' performance may differ as a function of greater knowledge and experience, and by work showing that, in some cases, older adults outperform younger adults in complex decision-making tasks. In light of this controversy, we examined the performance of older and younger adults in an exploratory choice task that is amenable to model-based analyses and ostensibly not reliant on prior knowledge. Exploration is a critical aspect of decision-making poorly understood across the life span. Across 2 experiments, we addressed (a) how older and younger adults differ in exploratory choice and (b) to what extent observed differences reflect processing capacity declines. Model-based analyses suggested that the strategies used by the 2 groups were qualitatively different, resulting in relatively worse performance for older adults in 1 decision-making environment but equal performance in another. Little evidence was found that differences in processing capacity drove performance differences. Rather the results suggested that older adults' performance might result from applying a strategy that may have been shaped by their wealth of real-word decision-making experience. While this strategy is likely to be effective in the real world, it is ill suited to some decision environments. These results underscore the importance of taking into account effects of experience in aging studies, even for tasks that do not obviously tap past experiences.

New perspectives for motivating better decisions in older adults

Decision-making competence in later adulthood is affected by declines in cognitive skills, and age-related changes in affect and experience can sometimes compensate. However, recent findings suggest that age-related changes in motivation also affect the extent to which adults draw from experience, affect, and deliberative skills when making decisions. To date, relatively little attention has been given to strategies for addressing age-related changes in motivation to promote better decisions in older adults. To address this limitation, we draw from diverse literatures to suggest promising intervention strategies for motivating older recipients’ motivation to make better decisions. We start by reviewing the life-span developmental literature, which suggests that older adults’ motivation to put effort into decisions depends on the perceived personal relevance of decisions as well as their self-efficacy (i.e., confidence in applying their ability and knowledge). Next, we discuss two approaches from the health intervention design literature, the mental models approach and the patient activation approach, which aim to improve motivation for decision making by improving personal relevance or by building self-efficacy or confidence to use new information and skills. Using examples from these literatures, we discuss how to construct interventions to motivate good decisions in later adulthood.

Communication with older, seriously ill patients

This article describes effective communication strategies in caring for older, seriously ill patients and their surrogates/caregivers. Specific skills in three core functions are highlighted: (i) empathic communication (ii) information provision and (iii) enabling decision making. Empathy skills include using 'NURSE' statements and assuring a continuous relationship. Tailored information and empathic communication can be used to facilitate information processing and overcome age-related communication barriers. Eliciting patients' goals of care is critical in decision making. Surrogates need assistance when making decisions for patients and often themselves have support and information needs. Suggestions are made to ensure patients' and caregivers' needs are met.

State-based versus reward-based motivation in younger and older adults

Recent decision-making work has focused on a distinction between a habitual, model-free neural system that is motivated toward actions that lead directly to reward and a more computationally demanding goal-directed, model-based system that is motivated toward actions that improve one's future state. In this article, we examine how aging affects motivation toward reward-based versus state-based decision making. Participants performed tasks in which one type of option provided larger immediate rewards but the alternative type of option led to larger rewards on future trials, or improvements in state. We predicted that older adults would show a reduced preference for choices that led to improvements in state and a greater preference for choices that maximized immediate reward. We also predicted that fits from a hybrid reinforcement-learning model would indicate greater model-based strategy use in younger than in older adults. In line with these predictions, older adults selected the options that maximized reward more often than did younger adults in three of the four tasks, and modeling results suggested reduced model-based strategy use. In the task where older adults showed similar behavior to younger adults, our model-fitting results suggested that this was due to the utilization of a win-stay-lose-shift heuristic rather than a more complex model-based strategy. Additionally, within older adults, we found that model-based strategy use was positively correlated with memory measures from our neuropsychological test battery. We suggest that this shift from state-based to reward-based motivation may be due to age related declines in the neural structures needed for more computationally demanding model-based decision making.

'I'm happy that I can still walk'--Participation of the elderly in home care as a specific group with specific needs and wishes

BACKGROUND

Taking the needs, wishes and experiential knowledge of clients into account is considered to result in a better fit between the supply and demand of modern health care, contributing to the improvement of individual care, organizations, institutions and policy. However, the current generation of the elderly have had little experience of consumer-oriented public services. They are said to be less likely to discuss their needs and wishes with individual caregivers and health-care organisations. As a result, they might not receive care matching their needs and wishes.

AIM

To examine how the elderly themselves refer to their age and their needs and wishes for individual and collective participation in home-based care to get a better understanding of their participation in their own health care.

METHODS

Content analysis of 20 semi-structured in-depth interviews with elderly recipients of care in the Netherlands.

RESULTS

The need and ability of the elderly to discuss their experiences are strongly affected by physical and mental limitations, social cultural characteristics and their experiences of life. As a result, the elderly encounter many limitations in discussing their experiences with their individual caregivers and their home-care organisation. However, this does not mean that the elderly do not have needs and wishes that they want taken into account.

CONCLUSION

The challenge is to create a more responsive environment and to find new, creative ways of facilitating the expression of the needs and wishes of the elderly, according to the specific values and norms of their generation.

More Is Not Always Better: Intuitions About Effective Public Policy Can Lead to Unintended Consequences

Public policy decisions often appear based on an assumption that providing more options, more information, and greater decision-making autonomy to consumers will produce better outcomes. We examine reasons why this "more-is-better" approach exists based on the psychological literature. Although better outcomes can result from informed consumer choice, we argue that more options, information, and autonomy can also lead to unintended negative consequences. We use mostly health-related policies and guidelines from the United States and elsewhere as exemplars. We consider various psychological mechanisms that cause these unintended consequences including cognitive overload, affect, and anticipated regret, information salience and availability, and trust in governments as authoritative information providers. We also point toward potential solutions based on psychological research that may reduce the negative unintended consequences of a "more-is-better" approach.

Decisions from experience: adaptive information search and choice in younger and older adults

In real-world decision making, choice outcomes, and their probabilities are often not known a priori but must be learned from experience. The dopamine hypothesis of cognitive aging predicts that component processes of experience-based decision making (information search and stimulus–reward association learning) decline with age. Many existing studies in this domain have used complex neuropsychological tasks that are not optimal for testing predictions about specific cognitive processes. Here we used an experimental sampling paradigm with real monetary payoffs that provided separate measures of information search and choice for gains and losses. Compared with younger adults, older adults sought less information about uncertain risky options. However, like younger adults, older participants also showed evidence of adaptive decision making. When the desirable outcome of the risky option was rare (p = 0.10 or 0.20), both age groups engaged in more information search and made fewer risky choices, compared with when the desirable outcome of the risky option was frequent (p = 0.80 or 0.90). Furthermore, loss options elicited more sampling and greater modulation of risk taking, compared with gain options. Overall, these findings support predictions of the dopamine hypothesis of cognitive aging, but they also highlight the need for additional research into the interaction of age and valence (gain vs. loss) on experience-based choice.

Choosing with confidence: Self-efficacy and preferences for choice

Previous research on the role of choice set size in decision making has focused on decision outcomes and satisfaction. In contrast, little is known about interindividual differences in preferences for larger versus smaller choice sets, let alone the causes of such differences. Drawing on self-efficacy theory, two studies examined the role of decision-making self-efficacy in preferences for choice. Using a correlational approach, Study 1 (n = 89) found that decision-making self-efficacy was positively associated with preferences for choice across a range of consumer decisions. This association was found both between- and within-subjects. Study 2 (n = 65) experimentally manipulated decision-making self-efficacy for an incentive-compatible choice among photo printers. Preferences for choice and pre-choice information seeking were significantly lower in a low-efficacy condition compared to a high-efficacy condition and a control group. Future research directions and implications for decision-making theory and public policy are discussed.

Elderly Patients’ Experiences of Meeting With the Doctor

Previous research has provided contradictory findings on how important it is for elderly patients to actively participate in the meeting with their doctors. Using descriptive and exploratory interview study with 20 elderly patients discharged from medicine and geriatric hospital care in Sweden, the authors describe how elderly patients experience their meetings with their doctor in the hospital setting. The results indicate that the meetings between elderly patients and doctors are influenced by the nature and shape of the conversation, which are influenced by power and interaction. A good relationship between an elderly patient and his or her doctor leads to reduced apprehension and increased faith in the health care system. This study was inspired by the sociocultural perspective and highlights the importance of the health care sector becoming a learning organization in which doctors are trained to prevent misunderstandings in their meetings with elderly patients.

Age, time, and decision making: from processing speed to global time horizons

Time and time perceptions are integral to decision making because any meaningful choice is embedded in a temporal context and requires the evaluation of future preferences and outcomes. The present review examines the influence of chronological age on time perceptions and horizons and discusses implications for decision making across the life span. Time influences and interacts with decision making in multiple ways. Specifically, this review examines the following topic areas: (1) processing speed and decision time, (2) internal clocks and time estimation, (3) mental representations of future time and intertemporal choice, and (4) global time horizons. For each aspect, patterns of age differences and implications for decision strategies and quality are discussed. The conclusion proposes frameworks to integrate different lines of research and identifies promising avenues for future inquiry.

Age and the purchase of prescription drug insurance by older adults

The Medicare Part D Prescription Drug Program places an unprecedented degree of choice in the hands of older adults despite concerns over their ability to make effective decisions and desire to have extensive choice in this context. While previous research has compared older adults to younger adults along these dimensions, our study, in contrast, examines how likelihood to delay decision making and preferences for choice differ by age among older age cohorts. Our analysis is based on responses of older adults to a simulation of enrollment in Medicare Part D. We examine how age, numeracy, cognitive reflection, and the interaction between age and performance on these instruments are related to the decision to enroll in a Medicare prescription drug plan and preference for choice in this context. We find that numeracy and cognitive reflection are positively associated with enrollment likelihood and that they are more important determinants of enrollment than age. We also find that greater numeracy is associated with a lower willingness to pay for choice. Hence, our findings raise concern that older adults, and, in particular, those with poorer numerical processing skills, may need extra support in enrolling in the program: they are less likely to enroll than those with stronger numerical processing skills, even though they show greater willingness to pay for choice.

Consumers of eldercare in Sweden: the semblance of choice

In Sweden and other countries, the benefits of user choice and market forces are often voiced in relation to the provision of medical care and social services. Policy makers increasingly view people as customers and consumers of care services. Among very old people-the most frequent care users-how many have the capacity necessary to find information and make decisions concerning providers of medical and social services? Using a nationally representative sample of Swedes aged 77+ (SWEOLD) in 2002 this study describes the prevalence of cognitive, physical and sensory resources associated with the capacity to make and carry out informed choices concerning medical and social care providers. Results showed that one third of a nationally representative sample of persons aged 77+ scored low on a cognitive test or they were so cognitively impaired that they could not be interviewed directly. Another 22% scored poorly on a test of the ability to find and process information. A further 32% had adequate cognition but had limitations in sensory function or mental vitality or were unable to go outside on their own. A total of 10% did not report any of the measured problems. In general, care utilisation increases with age. As health problems increase, physical and cognitive abilities decline. Results suggest that those elderly people who are most dependent on care services and who could benefit most from a "good choice", are also those who have the highest prevalence of cognitive and physical limitations associated with the capacity to act as a rational consumer of care services.

Choosing the right medicare prescription drug plan: the effect of age, strategy selection, and choice set size

OBJECTIVE

The Medicare Modernization Act of 2003 (better known as Medicare Part D) represents the most important change to Medicare since its inception in the mid-1960s. The large number of drug plans being offered has raised concern over the complex design of the program. The purposes of this article are to examine the effect of age and choice set size (3 vs. 9 drug plans) on decision processes, strategy selection, and decision quality within the Medicare Part D program.

METHOD

One hundred fifty individuals completed a MouselabWeb study, a computer-based program that allowed us to trace the information acquisition process, designed to simulate the official Medicare Web site.

RESULTS

The data reveal that participants identified the lowest cost plan only 46% of the time. As predicted, an increase in choice set size (3 vs. 9) was associated with 0.25 times the odds of correctly selecting the lowest cost plan, representing an average loss of $48.71. Older participants, likewise, tended to make poorer decisions.

CONCLUSION

The study provides some indication that decision strategy mediates the association between age and choice quality and provides further insight regarding how to better design a choice environment that will improve the performance of older consumers.

Making choices about support services: disabled adults' and older people's use of information

This paper explores how disabled adults and older people find and use information to help make choices about services. It presents findings from a qualitative longitudinal study in England. Thirty participants had support needs that fluctuated, meaning that additional services might be needed on a temporary basis; and 20 had the sudden onset of support needs resulting from an accident or rapid deterioration in health. Each disabled adult or older person was interviewed three times between 2007 and 2009, using a semi-structured topic guide. They were asked to discuss a recent choice about services, focussing, amongst other things, on their use of information. Interviews were transcribed and coded, then charted according to emergent themes. A wide range of choices and sources of information were discussed. These were dominated by health and to some extent by social care. Key findings are that information was valuable not just in weighing up different service options, but as a precondition for such choices, and that disabled adults and older people with the gradual onset of support needs and no prior knowledge about services can be disadvantaged by their lack of access to relevant information at this pre-choice stage. Timely access to information was also important, especially for people without the support of emergency or crisis management teams. Healthcare professionals were trusted sources of information but direct payment advisers appeared less so. Ensuring that practitioners are confident in their knowledge of direct payments, and have the communication skills to impart that knowledge, is essential. There may be a role also for specialist information advocates or expert lay-advisers in enabling disabled adults and older people to access and consider information about choices at relevant times.

Challenges and opportunities for developing and implementing incentives to improve health-related behaviors in older adults

There is growing interest in using patient-directed incentives to change health-related behaviors. Advocates of incentive programs have proposed an ambitious research agenda for moving patient incentive programs forward. The unique cognitive and psychological features of older adults, however, present a challenge to this agenda. In particular, age-related changes in emotional regulation, executive function, and cognitive capacities, and a preference for collaborative decision-making raise questions about the suitability of these programs, particularly the structure of current financial incentives, for older adults. Differences in decision-making in older adults need to be accounted for in the design and implementation of financial incentive programs. Financial incentive programs adjusted to characteristics of older adult populations may be more likely to improve the lives of older persons and the economic success of programs that serve them.

Modulation of decision-making in a gambling task in older adults with transcranial direct current stimulation

Cognitive performance usually declines in older adults as a result of neurodegenerative processes. One of the cognitive domains usually affected is decision-making. Based on our recent findings suggesting that non-invasive brain stimulation can improve decision-making in young participants, we studied whether bifrontal transcranial direct current stimulation (tDCS) applied over the right and left prefrontal cortex of older adult subjects can change balance of risky and safe responses as it can in younger individuals. Twenty-eight subjects (age range from 50 to 85 years) performed a gambling risk task while receiving either anodal tDCS over the right and cathodal tDCS over the left dorsolateral prefrontal cortex (DLPFC), anodal tDCS over the left with cathodal tDCS over the right DLPFC, or sham stimulation. Our main finding was a significant group effect showing that participants receiving left anodal/right cathodal stimulation chose more often high-risk prospects as compared with participants receiving sham or those receiving right anodal/left cathodal stimulation. This result is contrary to previous findings in young subjects, suggesting that modulation of cortical activity in young and elderly results in opposite behavioral effects; thus supporting fundamental changes in cognitive processing in the elderly.