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Donders J, Maher T. Clinical Utility of the Neuropsychological Assessment Battery Judgment Subtest in the Evaluation of Older Adults. Arch Clin Neuropsychol 2024:acae035. [PMID: 38712367 DOI: 10.1093/arclin/acae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/05/2024] [Accepted: 04/11/2024] [Indexed: 05/08/2024] Open
Abstract
OBJECTIVE The purpose of this retrospective archival study was to explore the clinical utility of the Judgment subtest of the Neuropsychological Assessment Battery (NAB) in older adults who were referred because of cognitive concerns. Specifically, we were interested in how NAB Judgment covaried with other measures of executive functioning. METHOD 226 adults, aged 61-89 years (48% dementia, 35% mild cognitive impairment, 18% cognitively intact) completed NAB Judgment. They also completed Trail Making Test (TMT) A and B. In addition, Behavior Rating Inventory of Executive Function (BRIEF-A) informant and self-reports were obtained to measure executive functioning in daily life. RESULTS Scores on NAB Judgment did not correlate significantly with BRIEF-A informant ratings. However, there was a statistically significant correlation between BRIEF-A informant ratings and TMT B. Better performance on TMT B was associated with fewer informant concerns. Furthermore, subgroups with versus without informant BRIEF-A Metacognition indices in the range of impairment demonstrated a statistically significant difference on TMT B but not on Judgment. CONCLUSIONS Executive functioning in older adults should not be assessed using NAB Judgment alone. Such an evaluation should be supplemented with other in-person tests as well as informant ratings of daily functioning.
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Affiliation(s)
- Jacobus Donders
- Department of Psychology, Mary Free Bed Rehabilitation Hospital, Grand Rapids, MI, USA
| | - Tracy Maher
- Department of Psychology, Mary Free Bed Rehabilitation Hospital, Grand Rapids, MI, USA
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Santos RL, Simões Neto JP, Belfort T, Lacerda IB, Dourado MCN. Patterns of impairment in decision-making capacity in Alzheimer's disease and its relationship with cognitive and clinical variables. BRAZILIAN JOURNAL OF PSYCHIATRY 2022; 44:271-278. [PMID: 35239836 PMCID: PMC9169465 DOI: 10.1590/1516-4446-2021-2180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/16/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To investigate the patterns of impairment in decision-making abilities and their relationship with cognitive and clinical symptoms in people with Alzheimer's disease. We hypothesized that decision-making abilities would not be impaired at the same level and would be related to impairment of global cognition and other clinical symptoms of the disease. METHODS Using a cross-sectional design, we included a consecutive sample of 102 people with Alzheimer's disease and their respective caregivers. We investigated the relationship between decision-making capacity and quality of life (QoL), disease awareness, mood, functionality, neuropsychiatric symptoms, and cognition. RESULTS Different levels of impairment were observed in the participants' decision-making abilities. Understanding, appreciation, and reasoning were correlated, but expressing a choice was only correlated with appreciation. Deficits in understanding were related to impaired disease awareness, lower self-reported QoL, and lower comprehension of spoken language. Better appreciation was related to better orientation and lower age. Better reasoning was related to better orientation and better self-reported QoL. Deficits in expressing a choice were related to lower self-reported QoL. CONCLUSION The pattern of impairment in decision-making abilities was not linear. Each decision-making ability was related to different cognitive and clinical deficits. Therefore, cognitive functioning is an insufficient criterion for judging an individual's decision-making ability.
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Affiliation(s)
- Raquel Luiza Santos
- Centro para Doenças de Alzheimer e Outros Transtornos Mentais na Velhice, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.,Departamento de Psicologia, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, RJ, Brazil.,Departamento de Psicologia, Universidade do Grande Rio, Duque de Caxias, RJ, Brazil
| | - José Pedro Simões Neto
- Departamento de Sociologia e Ciência Política, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Tatiana Belfort
- Centro para Doenças de Alzheimer e Outros Transtornos Mentais na Velhice, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Isabel Barbeito Lacerda
- Centro para Doenças de Alzheimer e Outros Transtornos Mentais na Velhice, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Marcia Cristina Nascimento Dourado
- Centro para Doenças de Alzheimer e Outros Transtornos Mentais na Velhice, Instituto de Psiquiatria, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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Heng WAM, Lin YP, Chua WL, Chan EY. The early stages of caregiving: A qualitative study into the caregiving experiences of Asian family caregivers of persons with newly-diagnosed dementia. Geriatr Nurs 2021; 42:1517-1524. [PMID: 34735998 DOI: 10.1016/j.gerinurse.2021.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/12/2021] [Accepted: 10/14/2021] [Indexed: 11/30/2022]
Abstract
In Asian societies, the responsibility of caring for persons with dementia often falls upon an immediate family member. However, little attention has been paid to the early stages of caregiving, as well as their transition into a more experienced caregiver. Thus, a qualitative descriptive study involving a purposive sample of 11 main family caregivers of a person with newly diagnosed dementia was recruited from a tertiary hospital in Singapore. Three themes emerged from the data analysis: (1) Suspicions to seeking confirmation of dementia, (2) Grappling with dementia diagnosis, and (3) Making adjustments for the future. Areas of needs and support identified during the early caregiving journey suggest the need for caregivers to be prepared for the practical and emotional challenges. Unique to the Asian culture, our findings put forth the advocacy of engaging persons with dementia in the discussions of their long-term care and options.
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Affiliation(s)
| | | | - Wei Ling Chua
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ee-Yuee Chan
- Nursing Research Unit, Nursing Service, Tan Tock Seng Hospital, Singapore; Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Raffard S, Lebrun C, Laraki Y, Capdevielle D. Validation of the French Version of the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) in a French Sample of Individuals with Schizophrenia: Validation de la version française de l'instrument d'évaluation des compétences MacArthur-traitement (MacCAT-T) dans un échantillon français de personnes souffrant de schizophrénie. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2021; 66:395-405. [PMID: 33064578 PMCID: PMC8172341 DOI: 10.1177/0706743720966443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Assessing an individual's capacity to consent to treatment is a complex and challenging task for psychiatrists and health-care professionals. Diminished capacity to consent to pharmacological treatment is a common concern in individuals with schizophrenia. The MacArthur Competence Assessment Tool for Treatment (MacCAT-T) is the most common tool used in individuals with schizophrenia to evaluate the decision-making abilities for judgments about competence to consent to treatment. This instrument assesses patients' competence to make treatment decisions by examining their capacities in 4 areas: understanding information relevant to their condition and the recommended treatment, reasoning about the potential risks and benefits of their choices, appreciating the nature of their situation and the consequences of their choices, and expressing a choice. Despite its importance, there is no French version of this scale. Furthermore, its factor structure has never been explored, although validated measures are strongly needed to further detect deficits in patients' decision-making abilities. The goal of this study was thus to empirically validate a French version of the MacCAT-T in a French sample of individuals with schizophrenia. METHOD In this cross-sectional study, we included 125 inpatients with a diagnosis of schizophrenia from the University Department of Adult Psychiatry in Montpellier. The MacCAT-T was administered to patients by a trained psychologist. Patients were also assessed for severity of symptoms, insight into illness, and depressive and anxiety symptoms. Inter-rater reliability and psychometric properties including internal consistency, construct validity, and discriminant and divergent validity were also investigated. RESULTS The MacCAT-T's internal consistency was high (Cronbach α of 0.91). A high degree of inter-rater reliability was found for all the areas of the MacCAT-T (intraclass correlation coefficient range, 0.92 to 0.98). Exploratory factor analysis revealed a 2-factor model. The factor analysis explained 50.03% of the total score variation. Component 1 included all subparts of "understanding." Component 2 included all subparts of "appreciation" and "reasoning" and was therefore labeled "reflexivity." After Bonferroni corrections, decision-making capacity was positively associated with insight and the severity of psychotic symptoms but not with sociodemographic variables except for education. CONCLUSIONS The MacCAT-T demonstrated a high degree of inter-rater reliability and strong psychometric properties. The French version of the MacCAT-T is a valid instrument to assess the decision-making capacity to consent to treatment in a French sample of individuals with schizophrenia.
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Affiliation(s)
- Stéphane Raffard
- University Department of Adult Psychiatry, 26905CHU Montpellier, University Montpellier 1, Hôpital la Colombière, France.,27038Université Paul Valéry Montpellier 3, EPSYLON EA, France
| | - Cindy Lebrun
- 27038Université Paul Valéry Montpellier 3, EPSYLON EA, France
| | - Yasmine Laraki
- University Department of Adult Psychiatry, 26905CHU Montpellier, University Montpellier 1, Hôpital la Colombière, France.,27038Université Paul Valéry Montpellier 3, EPSYLON EA, France
| | - Delphine Capdevielle
- University Department of Adult Psychiatry, 26905CHU Montpellier, University Montpellier 1, Hôpital la Colombière, France.,Inserm, Neuropsychiatry: Epidemiological and Clinical Research, University of Montpellier, France
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Gaubert F, Chainay H. Decision-Making Competence in Patients with Alzheimer's Disease: A Review of the Literature. Neuropsychol Rev 2021; 31:267-287. [PMID: 33576942 DOI: 10.1007/s11065-020-09472-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
Decision-making competence (DMC) appears to be influenced by the congruency between the characteristics of the individual, the task and the context. Indeed, the ability to make decisions seems to be highly sensitive to cognitive changes as observed, in particular, in the healthy elderly. Few studies have investigated these relations in pathological ageing. In this review, we focus on DMC in patients with Alzheimer's disease (AD) and the links its impairment could have with deficits in episodic memory, working memory, and executive functions. Decision-making under risk and under ambiguity appears to be impaired early in the progress of AD, with the deficit being greater during the later stages of the disease. In addition, some studies suggest that the impairment of DMC is exacerbated by deficits in other cognitive functions, in particular working memory and executive functions. This degradation in the ability to make decisions seriously affects the quality of life of patients and their relatives, since they frequently face important decisions, especially concerning healthcare, finance or accommodation. Thus, the growing incapacity to decide for themselves increases patients' and caregivers' stress and burden. The challenge for future studies is to determine how best to help patients and their families in the decisional process.
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Affiliation(s)
- Fanny Gaubert
- Laboratoire d'Etude des Mécanismes Cognitifs, Université Lyon 2, 5 avenue Pierre Mendès France, 69676, Bron, France.
| | - Hanna Chainay
- Laboratoire d'Etude des Mécanismes Cognitifs, Université Lyon 2, 5 avenue Pierre Mendès France, 69676, Bron, France
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Psychiatric Illness and Medical Decision-Making Capacity: A Retrospective Study in Medical Settings. PSYCHIATRY INTERNATIONAL 2020. [DOI: 10.3390/psychiatryint1020012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Determination of medical decision-making capacity (DMC) is one of the common encounters in Consultation-Liaison Psychiatry (CLP) services. It is a common misbelief that patients with “psych history” lack capacity more often than patients without mental illness. The study aims to examine the relationship between mental illness and DMC in patients presented to acute medical settings. The study is a retrospective chart review, where data were collected from the patients admitted to the medical units and assessed for capacity by a psychiatrist. Clinical and demographic characteristics were compared between two groups (patients having capacity and lacking capacity) using t-tests or chi-square tests, as appropriate. The commonest reason for DMC evaluation requests was for the patients who wanted to leave the hospital against medical advice. Overall, 53% (52/98) of the patients evaluated for DMC were found to lack capacity. Group of patients lacking DMC had a significantly higher percentage of males (58% vs. 35%) but were significantly less employed (8% vs. 10%). No significant difference was observed in other demographic characteristics and primary psychiatric diagnoses (past and current) among the two groups. However, patients lacking capacity were found to have a significantly more occurrence of current (48% vs. 11%) and past (23% vs. 4%) history of neurocognitive disorder, and larger trend significance (31% vs. 15%) of active psychiatric symptoms. We conclude that patients with neurocognitive disorders and active psychiatric symptoms might have poor DMC but not all patients who have psychiatric diagnoses lack medical DMC. Larger studies especially in outpatient psychiatric settings are suggested to derive more conclusive results.
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Chang WZD, Bourgeois MS. Effects of Visual Aids for End-of-Life Care on Decisional Capacity of People With Dementia. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2020; 29:185-200. [PMID: 31869247 DOI: 10.1044/2019_ajslp-19-0028] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Purpose This study evaluated the decision-making capacity of persons with mild and moderate dementia on end-of-life care when using visual aids. A secondary purpose was to learn whether the judges naive to the experimental conditions would rate participants' decisional abilities as better when augmented by visual aids, thereby validating the behavioral changes due to the use of these external support. Method Twenty older adults with mild and moderate dementia demonstrated Understanding, Expressing a Choice, Reasoning, and Appreciation of 2 medical vignettes under 2 counterbalanced conditions: verbal alone or verbal with visual aids. Transcripts were analyzed and scored to measure decisional skills. Twelve judges rated participants' decisional abilities using a 7-point Likert scale. Results Participants demonstrated significantly better overall decisional capacity in Understanding, Reasoning, and Appreciation when supported by visual aids during the decision-making process. No significant differences between conditions were found in Expressing a Choice, the decisional skill Logical Sequence under Reasoning, and Acknowledgment under Appreciation. Overall, the judges' ratings validated these outcomes; the judges' ratings reflected greater agreement in the visual condition than in the verbal condition. Conclusions Findings indicated that visual aids (a) improved the decision-making capacity of individuals with dementia in comprehending medical information, employing supportive reasons, and relating this information to his or her own situation and (b) contain the potential for judges who majored or are majoring in speech-language pathology to reach a stronger consensus when determining the decision-making capacity of individuals with dementia.
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Affiliation(s)
- Wan-Zu D Chang
- Department of Speech and Hearing Science, The Ohio State University, Columbus
| | - Michelle S Bourgeois
- Department of Communication Sciences & Disorders, University of South Florida, Tampa
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Carabellese F, Felthous AR, La Tegola D, Piazzolla G, Distaso S, Logroscino G, Leo A, Ventriglio A, Catanesi R. Qualitative analysis of the capacity to consent to treatment in patients with a chronic neurodegenerative disease: Alzheimer's disease / Analisi qualitativa sulla capacità a prestare consenso al trattamento in pazienti con malattie cronico degenerative neuropsicoorganiche: Demenza di Alzheimer. Int J Soc Psychiatry 2018; 64:26-36. [PMID: 29183264 DOI: 10.1177/0020764017739642] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Informed consent is an essential element in doctor-patient relationship. In particular, obtaining valid informed consent from patients with neurocognitive diseases is a critical issue at present. For this reason, we decided to conduct research on elderly patients with Alzheimer's disease ( Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) to assess their capacity to make treatment decisions. METHODS The experimental group comprised 70 Alzheimer patients who were admitted to the Neurodegenerative Disease Unit of the University of Bari. The control group consisted of 83 elderly patients without neurocognitive disorders who were hospitalized in the Geriatric Unit at the same university. After providing written consent to participate in the research, each subject underwent the following assessments: (a) assessment of comprehension sheet, (b) Neuropsychiatric Inventory (NPI) and Global Functioning Evaluation (GFE), (c) neurological evaluation, (d) neuropsychological assessment with a full battery of tests, (d) The MacArthur Treatment Competence Study (MacArthur Competence Assessment Tool for Treatment (MacCAT-T); understanding, appreciating, reasoning and expressing a choice) and (e) a semi-structured interview administered by the patient's caregiver. RESULTS/CONCLUSION The present survey was designed to analyze possible qualitative and quantitative correlations between cognitive functioning and capacity to consent in relation to different degrees of severity of the neurodegenerative disorder. A large portion of the patients in our experimental sample did not appear to have the capacity to provide a valid consent. The authors present initial results of this study and discuss their possible implications.
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Affiliation(s)
- Felice Carabellese
- 1 Section of Criminology and Forensic Psychiatry, University of Bari, Bari, Italy
| | - Alan R Felthous
- 2 Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Donatella La Tegola
- 1 Section of Criminology and Forensic Psychiatry, University of Bari, Bari, Italy
| | | | - Salvatore Distaso
- 1 Section of Criminology and Forensic Psychiatry, University of Bari, Bari, Italy
| | - Giancarlo Logroscino
- 4 Neurodegenerative Disease Unit, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Antonio Leo
- 4 Neurodegenerative Disease Unit, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | - Antonio Ventriglio
- 5 Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Roberto Catanesi
- 1 Section of Criminology and Forensic Psychiatry, University of Bari, Bari, Italy
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Assessing capacity to consent to treatment with cholinesterase inhibitors in dementia using a specific and standardized version of the MacArthur Competence Assessment Tool (MacCAT-T). Int Psychogeriatr 2017; 29:333-343. [PMID: 27825402 DOI: 10.1017/s104161021600154x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The use of assessment tools has been shown to improve the inter-rater reliability of capacity assessments. However, instrument-based capacity assessments of people with dementia face challenges. In dementia research, measuring capacity with instruments like the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) mostly employ hypothetical treatment vignettes that can overwhelm the abstraction capabilities of people with dementia and are thus not always suitable for this target group. The primary aim of this study was to provide a standardized real informed consent paradigm that enables the dementia-specific properties of capacity to consent to treatment in people with dementia to be identified in a real informed consent process that is both externally valid and ethically justifiable. METHODS The sample consisted of 53 people with mild to moderate dementia and a group of 133 people without cognitive impairment. Rather than using a hypothetical treatment vignette, we used a standardized version of the MacCAT-T to assess capacity to consent to treatment with cholinesterase inhibitors in people with dementia. Inter-rater reliability, item statistics, and psychometric properties were also investigated. RESULTS Intraclass correlations (ICCs) (0.951-0.990) indicated high inter-rater reliability of the standardized real informed consent paradigm. In the dementia group, performance on different items of the MacCAT-T varied. Most people with dementia were able to express a treatment choice, and were aware of the need to take a tablet. Further information on the course of the disorder and the benefits and risks of the treatment were less understood, as was comparative reasoning regarding treatment alternatives. CONCLUSION The standardized real informed consent paradigm enabled us to detect dementia-specific characteristics of patients' capacity to consent to treatment with cholinesterase inhibitors. In order to determine suitable enhanced consent procedures for this treatment, we recommend the consideration of MacCAT-T results on an item level. People with dementia seem to understand only basic information. Our data indicate that one useful strategy to enhance capacity to consent is to reduce attention and memory demands as far as possible.
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Mukherjee A, Livinski AA, Millum J, Chamut S, Boroumand S, Iafolla TJ, Adesanya MR, Dye BA. Informed consent in dental care and research for the older adult population: A systematic review. J Am Dent Assoc 2017; 148:211-220. [PMID: 28065430 DOI: 10.1016/j.adaj.2016.11.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/19/2016] [Accepted: 11/28/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ethics in health care and research is based on the fundamental principle of informed consent. However, informed consent in geriatric dentistry is not well documented. Poor health, cognitive decline, and the passive nature of many geriatric patients complicate this issue. METHODS The authors completed this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The authors searched the PubMed (MEDLINE), Web of Science, PsycINFO, and Cochrane Library databases. The authors included studies if they involved participants 65 years or older and discussed topics related to informed consent beyond obtaining consent for health care. The authors explored informed consent issues in dentistry and other biomedical care and research. RESULTS The authors included 80 full-text articles on the basis of the inclusion criteria. Of these studies, 33 were conducted in the United States, 29 addressed consent issues in patients with cognitive impairment, 29 were conducted in patients with medical conditions, and only 3 involved consent related to dental care or research. CONCLUSIONS Informed consent is a neglected topic in geriatric dental care and research. Substantial knowledge gaps exist between the understanding and implementation of consent procedures. Additional research in this area could help address contemporary consent issues typically encountered by dental practitioners and to increase active participation from the geriatric population in dental care and research. PRACTICAL IMPLICATIONS This review is the first attempt, to the authors' knowledge, to identify informed consent issues comprehensively in geriatric dentistry. There is limited information in the informed consent literature covering key concepts applicable to geriatric dentistry. Addressing these gaps could assist dental health care professionals in managing complex ethical issues associated with geriatric dental patients.
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Smebye KL, Kirkevold M, Engedal K. Ethical dilemmas concerning autonomy when persons with dementia wish to live at home: a qualitative, hermeneutic study. BMC Health Serv Res 2016; 16:21. [PMID: 26787190 PMCID: PMC4717656 DOI: 10.1186/s12913-015-1217-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 12/08/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Caring for people with dementia living in their own homes is a challenging care issue that raises ethical dilemmas of how to balance autonomy with their safety and well-being. The theoretical framework for this study consisted of the concepts of autonomy, beneficence, non-maleficence, paternalism and from the ethics of care. The aim of this study was to explore ethical dilemmas concerning autonomy that were identified when persons with dementia wished to live at home. METHODS This Norwegian study had a qualitative, hermeneutic design and was based on nine cases. Each case consisted of of a triad: the person with dementia, the family carer and the professional caregiver. Inclusion criteria for the persons with dementia were: (1) 67 years or older (2) diagnosed with dementia (3) Clinical Dementia Rating score 2 i.e. dementia of moderate degree (4) able to communicate verbally and (5) expressed a wish to live at home. The family carers and professional caregivers registered in the patients' records were included in the study. An interview guide was used in interviews with family carers and professional caregivers. Field notes were written after participant observation of interactions between persons with dementia and professional caregivers during morning care or activities at a day care centre. By means of deductive analysis, autonomy-related ethical dilemmas were identified. The final interpretation was based on perspectives from the theoretical framework. RESULTS The analysis revealed three main ethical dilemmas: When the autonomy of the person with dementia conflicted with (1) the family carer's and professional caregiver's need to prevent harm (non-maleficence) (2) the beneficence of family carers and professional caregivers (3) the autonomy of the family carer. CONCLUSIONS In order to remain living in their own homes, people with dementia accepted their dependence on others in order to uphold their actual autonomy and live in accordance with their identified values. Paternalism could be justified in light of beneficence and non-maleficence and within an ethics of care.
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Affiliation(s)
| | - Marit Kirkevold
- Institute for Health and Society, Faculty of Medicine, University of Oslo, Blindern, P.B. 1130, 0318 Oslo, Norway
- Institute of Public Health, Aarhus University, Aarhus, Denmark
| | - Knut Engedal
- Norwegian Centre for Aging and Health, Vestfold Health Trust, 3130 Tønsberg, Norway
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Hein IM, Daams J, Troost P, Lindeboom R, Lindauer RJL. Accuracy of assessment instruments for patients' competence to consent to medical treatment or research. Hippokratia 2015. [DOI: 10.1002/14651858.cd011099.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Irma M Hein
- De Bascule and Academic Medical Center; Department of Child and Adolescent Psychiatry; Meibergdreef 5 Amsterdam Netherlands 1105 AZ
| | - Joost Daams
- Academic Medical Center; Amsterdam Netherlands
| | - Pieter Troost
- De Bascule and Academic Medical Center; Department of Child and Adolescent Psychiatry; Meibergdreef 5 Amsterdam Netherlands 1105 AZ
| | | | - Ramón JL Lindauer
- De Bascule and Academic Medical Center; Department of Child and Adolescent Psychiatry; Meibergdreef 5 Amsterdam Netherlands 1105 AZ
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Gambina G, Bonazzi A, Valbusa V, Condoleo MT, Bortolami O, Broggio E, Sala F, Moretto G, Moro V. Awareness of cognitive deficits and clinical competence in mild to moderate Alzheimer's disease: their relevance in clinical practice. Neurol Sci 2014; 35:385-90. [PMID: 23959532 DOI: 10.1007/s10072-013-1523-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 08/07/2013] [Indexed: 11/26/2022]
Abstract
Awareness of cognitive deficits and clinical competence were investigated in 79 mild to moderate Alzheimer's disease patients. Awareness was assessed by the anosognosia questionnaire for dementia, and clinical competence by specific neuropsychological tests such as trail making test-A, Babcock story recall test, semantic and phonemic verbal fluency. The findings show that 66 % of the patients were aware of memory deficits, while the 34 % were unaware. Deficit in awareness correlated with lower scores on the Mini Mental State Examination test that, in the score range from 24.51 to 30 and from 19.50 to 24.50, appeared to be a significant predictor of level of awareness. None of the AD patients had fully preserved clinical competence, only 7 patients (9 %) had partially preserved clinical competence and 72 patients (91 %) had completely lost clinical competence. All the patients with partially preserved clinical competence (9 %) were aware of their memory deficit. The study indicates that neuropsychological tests used for the assessment of executive functions are not suitable for investigating clinical competence. Therefore, additional and specific tools for the evaluation of clinical competence are necessary. Indeed, these might allow clinicians to identify AD patients who, despite their deficits in selected functions, retain their autonomy of choice as well as recognize those patients who should proceed to the nomination of a legal representative.
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Lui VWC, Lam LCW, Chau RCM, Fung AWT, Wong BML, Leung GTY, Leung KF, Chiu HFK, Karlawish JHT, Appelbaum PS. Structured assessment of mental capacity to make financial decisions in Chinese older persons with mild cognitive impairment and mild Alzheimer disease. J Geriatr Psychiatry Neurol 2013; 26:69-77. [PMID: 23504307 DOI: 10.1177/0891988713481268] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Previous studies suggested that patients with mild cognitive impairment (MCI) or dementia can have impaired and declining financial skills and abilities. The purpose of this study is to test a clinically applicable method, based on the contemporary legal standard, to examine directly the mental capacity to make financial decisions and its component decision-making abilities among patients with MCI and early dementia. A total of 90 patients with mild Alzheimer disease (AD), 92 participants with MCI, and 93 cognitively normal control participants were recruited for this study. Their mental capacity to make everyday financial decisions was assessed by clinician ratings and the Chinese version of the Assessment of Capacity for Everyday Decision-Making (ACED). Based on the clinician ratings, only 53.5% were found to be mentally competent in the AD group, compared with 94.6% in the MCI group. However, participants with MCI had mild but significant impairment in understanding, appreciating, and reasoning abilities as measured by the ACED. The ACED provided a reliable and clinically applicable structured framework for assessment of mental capacity to make financial decisions.
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Affiliation(s)
- Victor W C Lui
- Department of Psychiatry, Tai Po Hospital, Hong Kong, Republic of China.
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15
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Fetherstonhaugh D, Tarzia L, Nay R. Being central to decision making means I am still here!: the essence of decision making for people with dementia. J Aging Stud 2013; 27:143-50. [PMID: 23561279 DOI: 10.1016/j.jaging.2012.12.007] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 12/05/2012] [Accepted: 12/28/2012] [Indexed: 10/27/2022]
Abstract
The ability to make choices and decisions, and to have those decisions upheld, is central to self-determination. For people living with a diagnosis of dementia, however, it can be difficult to remain involved in decision making. While many studies show that people with mild or moderate dementia have the ability to participate in decision making, there are also indications that the attitudes of those around them, including health professionals and family carers, can sometimes be a barrier, and there is generally little understanding about the nature of decision making for this population. This small pilot study draws on van Manen's approach to phenomenology to explore the essence of decision making for people living with dementia. The findings highlight the importance of remaining central to decision making, and the key role that subtle support from carers plays in enabling this.
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Affiliation(s)
- Deirdre Fetherstonhaugh
- Australian Centre for Evidence Based Aged Care, La Trobe University, 3086 Victoria, Australia.
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Capacity to make decisions on medication management in Chinese older persons with mild cognitive impairment and mild Alzheimer's disease. Int Psychogeriatr 2012; 24:1103-11. [PMID: 22336031 DOI: 10.1017/s1041610212000129] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This study aimed to assess if decisional capacity and the four decision-making abilities related to decisions concerning medication management were impaired among community-dwelling Chinese older persons in Hong Kong with amnestic mild cognitive impairment (MCI) and mild Alzheimer's disease (AD), as compared with cognitively normal older adults. METHODS Two hundred and ninety-one Chinese community-dwelling older adults were recruited. The four decision-making abilities and decisional capacity were assessed by using the Chinese version of the Assessment of Capacity for Everyday Decision-Making (ACED) and independent clinician ratings based on the definition in the UK Mental Capacity Act 2005, respectively. RESULTS Ninety-nine participants (34%) were diagnosed with MCI and ninety-five (33%) with mild AD. Although almost all (96%) of the participants in the MCI group were found to be mentally competent to make decisions on medication management in clinician ratings, their decision-making abilities as measured by the ACED were significantly lower than those of the cognitively normal controls. CONCLUSIONS Results from this study suggest that abilities related to decisions on medication management are impaired before the clinical diagnosis of dementia is made. Use of specific and structured assessment of the relevant decisional abilities may enhance clinical judgment.
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Abstract
Impairments in patients with dementia and other disorders affecting cognition may have a negative impact on their capacity to provide consent to treatment or to participation in research. A growing literature confirms that even patients with mild cognitive impairment may experience decrements in decisional abilities, findings that are more pronounced still in the early stages of dementia. However, most patients with mild dementia probably remain competent to provide a valid consent to treatment or research, and even some patients with moderate dementia may retain capacity in particular circumstances. Clinical evaluation of decisional competence has been augmented by structured approaches, including reliable instruments that may be used in the clinical setting. To avoid needlessly depriving patients of their right to make health care decisions, evaluations should be designed to maximize patient performance. However, when substitute consent is necessary, state laws generally provide a range of options, including advance directives and familial consent.
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Affiliation(s)
- Paul S Appelbaum
- New York State Psychiatric Institute, Unit #122, 1051 Riverside Drive, New York, NY 10032, USA.
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