Aging and Decision-Making: A Conceptual Framework for Future Research - A Mini-Review

Shared decision-making in psoriasis care: Evaluation of how patients' perception of clinicians' delivery of care changes by age and sex

BACKGROUND

Shared decision-making (SDM) refers to a collaborative process in which clinicians assist patients in making medically informed, evidence-based decisions that align with their values and preferences. There is a paucity of literature on SDM in dermatology.

OBJECTIVE

We aim to assess whether male and female psoriasis patients evaluate their clinicians' engagement in SDM differently across different age groups.

METHODS

Cross-sectional study using data from the 2014-2017 and 2019 Medical Expenditure Panel Surveys (MEPS).

RESULTS

A weighted total of 7,795,608 psoriasis patients were identified. SDM Scores ranged from 1 to 4, with 4 representing the most favorable patient evaluation of their clinicians' engagement in SDM. We conducted multivariate linear regression to compare mean SDM Scores in male psoriasis patients versus female psoriasis patients across different patient age groups. Female patients ages 60-69 perceived significantly greater clinician engagement in SDM compared to age-matched male patients (female patient perception of SDM 3.65 [95%CI:3.61-3.69] vs. male patient perception of SDM 3.50 [95%CI:3.43-3.58], p<0.005). The same trend of older female patients evaluating their clinicians' engagement in SDM significantly higher than their age-matched male counterparts exists for the age group >70 (p<0.005). No significant differences between male and female patients' evaluations of their clinicians' engagement in SDM were demonstrated in subjects younger than 60. All calculations were adjusted for demographic and clinical factors.

CONCLUSIONS

Compared to older male psoriasis patients, older female psoriasis patients evaluated their clinicians to be more engaged in shared decision-making.

Assistive technology services for adults with disabilities in state-federal vocational rehabilitation programs

PURPOSE

Prior research indicates that the provision of assistive technology (AT) services positively predicts successful employment outcomes in vocational rehabilitation (VR) programs. While AT services can be promising, they are underutilized overall, and there are apparent disparities in AT service utilization. The purpose of this study was to identify sociodemographic factors which may act as barriers to receiving AT services in VR programs. Recognizing potential disparities is the first step in improving equity in access to beneficial services.

MATERIALS AND METHODS

This study is a retrospective analysis of national data collected by the Rehabilitation Service Administration's Case Service Report from fiscal years 2017-2019. The sample included 788,173 cases that reported having a disability, were aged ≥18 years old, was deemed eligible for VR services, and had a complete set of data.

RESULTS

Less than 9% of VR clients received AT services. We ran a multiple logistic regression analysis to examine the independent effects of various sociodemographic variables on the likelihood of receiving AT services through VR programs. The following client characteristics were associated with a lower likelihood of receiving AT services: men, unemployed, minority, low income, significant disability, non-enrolled in post-secondary education, mental or cognitive disability, less education, and younger age (all p < .001).

CONCLUSION

The findings emphasize the need for more research to identify underlying mechanisms and potential solutions to these apparent disparities in access to AT services for adults with disabilities. Future research and implications are provided.

'It is empowering and gives people dignity in a very difficult process': A multistage, multimethod qualitative study to understand the views of end users in the cultural adaptation of a dementia and driving decision aid

BACKGROUND

Decisions about driving for individuals living with dementia (ILWD) can be challenging. There are limited evidence-based person-centred interventions in the United Kingdom that support decisions about transitioning to not driving or guidelines for developing decision aids for ILWD. This study aimed to understand the important features of a decision aid through the cultural adaptation of Australian dementia and driving decision aid (DDDA) for ILWD residing in the United Kingdom.

METHODS

This qualitative study was theoretically underpinned by a person-centred framework and conducted over three stages: (1) Development of a draft UK-specific DDDA; (2) semistructured interviews with ILWD and an online survey with stakeholders to obtain their views on a draft UK DDDA and (3) content analysis and synthesis of qualitative data to inform the final version of the decision aid.

RESULTS

Eleven ILWD and six of their spouses participated in interviews, and 102 stakeholders responded to an online survey. The four broad features identified as important to include in a decision aid for drivers living with dementia were: a structured and interactive format; positive and supportive messaging and presentation; relevant and concise content and choice-centred. The perceived benefits of the decision aid were identified as supporting conversations, enhancing collaborative decision making and enabling agency with decisions about driving and future mobility options.

CONCLUSIONS

Decision aids that are underpinned by interactive choice-driven questions enhance a person-centred approach to decisions about driving. Positively framing decision aids through the presentation and content can facilitate engagement with the decision-making process about driving. The findings have implications for the development of decision aids designed for ILWD on other important health and social topics.

PATIENT AND PUBLIC INVOLVEMENT

Advocating for the development of a UK DDDA were ILWD. Healthcare professionals contributed to the development of a draft UK DDDA. Former and current drivers living with dementia, family members, healthcare professionals and other support networks of ILWD participated in interviews or an online survey which informed the final version of the UK DDDA.

Decision-making involvement and onset of cognitive impairment in community-dwelling older care recipients: a 2-year longitudinal study

BACKGROUND

The decision-making of older adults and people with dementia is attracting more attention among healthcare professionals. While cognitive impairment has been examined as a factor related to decision-making, it can also be assumed that involvement in decision-making leads to the maintenance of cognitive function. This study examined the association of the decision-making process with the onset of cognitive impairment.

METHODS

We analyzed data from a 2-year longitudinal panel survey of community-dwelling care recipients aged ≥65 years in Japan. The sample included 406 participants who responded to both baseline and follow-up surveys, were cognitively intact at baseline, and had no missing cognitive impairment data regarding onset at follow-up. The status of decision-making involvement was assessed using a single item and classified into four categories: 'very involved,' 'less involved,' 'unclear about desired care,' and 'having no one to share the decision.'

RESULTS

Among the participants (women, 65.0%; ≥75 years old: 68.2%), the incidence of cognitive impairment during the follow-up was 26.6%. Multivariable logistic regression showed that, compared with highly involved participants, those who lacked clarity about desired care were more likely to develop an onset of cognitive impairment (odds ratio: 5.49; 95% confidence interval: 1.63-18.54; P = 0.006).

CONCLUSION

Even among cognitively intact care recipients, those who are not able to formulate their desired care may be at risk of cognitive decline. Therefore, support for the decision-making process, not limited to the final decision, is essential to improving the prognosis of community-dwelling care recipients.

Patterns of self-care decision-making and associated factors: A cross-sectional observational study

OBJECTIVE

The aim of this study was to identify for the first time patterns of self-care decision-making (i.e. the extent to which participants viewed contextual factors influencing decisions about symptoms) and associated factors among community-dwelling adults with chronic illness.

METHODS

This was a secondary analysis of data collected during the development and psychometric evaluation of the 27-item Self-Care Decisions Inventory that is based on Naturalistic Decision-Making (n = 430, average age = 54.9 ± 16.2 years, 70.2 % female, 87.0 % Caucasian, average number of chronic conditions = 3.6 ± 2.8). Latent class mixture modeling was used to identify patterns among contextual factors that influence self-care decision-making under the domains of external, urgency, uncertainty, cognitive/affective, waiting/cue competition, and concealment. Multivariate multinomial regression was used to identify additional socio-demographic, clinical, and self-care behavior factors that were different across the patterns of self-care decision-making.

RESULTS

Three patterns of self-care decision-making were identified in a cohort of 430 adults. A 'maintainers' pattern (48.1 %) consisted of adults with limited contextual influences on self-care decision-making except for urgency. A 'highly uncertain' pattern (23.0 %) consisted of adults whose self-care decision-making was largely driven by uncertainty about the cause or meaning of the symptom. A 'distressed concealers' pattern (28.8 %) consisted of adults whose self-care decision-making was highly influenced by external factors, cognitive/affective factors and concealment. Age, education, financial security and specific symptoms were significantly different across the three patterns in multivariate models.

CONCLUSION

Adults living with chronic illness vary in the extent to which contextual factors influence decisions they make about symptoms, and would therefore benefit from different interventions.

Age-group differences in trust-related decision-making and learning

Facial impressions contribute to evaluations of trustworthiness. Older adults are especially vulnerable to trust violations, incurring risks for deception and exploitation. Using the newly developed social Iowa Gambling Task (S-IGT), we examined age-group differences in the impact of facial trustworthiness on decision-making and learning. In the congruent condition (CS-IGT), advantageous decks were paired with trustworthy faces and disadvantageous decks with untrustworthy faces. In the incongruent condition (IS-IGT), this pairing was reversed. Younger (n = 143) and older (n = 129) participants completed either the standard Iowa Gambling Task (IGT), CS-IGT, or IS-IGT. Both age groups preferred trustworthy faces in their initial choices. Older adults performed worse than younger adults across all tasks over time. Further, compared to younger adults, older adults performed worse on the IS-IGT, suggesting that incongruent facial cues interfered with older adults' performance, which aligns with reduced sensitivity to negative social reputations in aging. Multilevel modeling also indicated that age-group differences were most pronounced across all tasks in the last 40 trials. Together these findings suggest that differences between younger and older adults in experience-dependent decision-making are magnified in social contexts that involve a "wolf in sheep's clothing," which may reflect age-related difficulties in integrating incongruent information.

Cancer treatment-related decision-making among culturally and linguistically diverse older adults with cancer: A scoping review by the International Society of Geriatric Oncology Nursing and Allied Health Interest Group

INTRODUCTION

Countries with large economies are observing a growing number of culturally and linguistically diverse (CALD) older adults, many of whom will be affected by cancer. Little is known about the experiences and factors that influence cancer treatment decision-making in this population. The purposes of this scoping review are: (1) to summarize the published literature on cancer treatment-related decision-making with this population; and (2) to identify potential differences in how cancer treatment decisions are made compared to non-CALD older adults with cancer.

MATERIALS AND METHODS

We conducted a scoping review following Arksey and O'Malley and Levac methods, Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review Guidelines. We conducted a comprehensive multidatabase search, screening 1,139 titles/abstracts. Following data abstraction, we analyzed the data using tabular and narrative summary.

RESULTS

We extracted data from six studies that met the inclusion criteria: four quantitative and two qualitative; five from the United States and one from Canada. Three themes were identified: (1) barriers to decision-making, (2) the influence of family and friends on decisionmaking, and (3) differences in uptake and types of treatment received between CALD and non-CALD older adults.

DISCUSSION

This comprehensive review of treatment decision-making among CALD older adults with cancer highlights the paucity of research in this area. The findings are limited to North American populations and may not represent experiences in other regions of the world. Future research should focus on studying their treatment-related decision-making experiences to improve the quality of care for this vulnerable population.

Change in Decision-Making Analysis and Preferences in Old Age

OBJECTIVES

To test the hypotheses that decision making ability declines in old age and that a higher level of cognitive reserve is associated with a reduced rate of decline.

METHODS

As part of an ongoing cohort study, 982 older adults without dementia at study enrollment completed measures of purpose in life and cognitive activity which were used as markers of cognitive reserve. At annual intervals thereafter, they completed 6 tests of decision making.

RESULTS

In a factor analysis of baseline decision making scores, 3 measures (financial/health literacy, financial/health decision making, scam susceptibility) loaded on an "analytic" factor and 3 (temporal discounting small stakes, temporal discounting large stakes, risk aversion) loaded on a "preferences" (for temporal discounting and avoiding risk) factor. During a mean of 4.7 years of follow-up (standard deviation = 2.9), analytic factor scores decreased (mean = 0.042-unit per year, standard error [SE] = 0.006, p < .001) and preferences factor scores increased (mean = 0.021-unit per year, SE = 0.006, p < .001), with a correlation of 0.13 (p < .001) between rates of change. Evidence of an association between cognitive reserve and decision making was mixed with purpose in life related to change in analytic decision making, whereas past (but not current) cognitive activity was related to change in decision making preferences.

DISCUSSION

Decision making analysis and preferences change over time in late life. Change over time in decision making components is relatively independent and differentially related to age and cognitive reserve.

Development and preliminary usability testing of an electronic conversation guide incorporating patient values and prognostic information in preparation for older people's decision-making near the end of life

Initiating end-of-life conversations can be daunting for clinicians and overwhelming for patients and families. This leads to delays in communicating prognosis and preparing for the inevitable in old age, often generating potentially harmful overtreatment and poor-quality deaths. We aimed to develop an electronic resource, called Communicating Health Alternatives Tool (CHAT) that was compatible with hospital medical records software to facilitate preparation for shared decision-making across health settings with older adults deemed to be in the last year of life. The project used mixed methods including: literature review, user-directed specifications, web-based interface development with authentication and authorization; clinician and consumer co-design, iterative consultation for user testing; and ongoing developer integration of user feedback. An internet-based conversation guide to facilitate clinician-led advance care planning was co-developed covering screening for short-term risk of death, patient values and preferences, and treatment choices for chronic kidney disease and dementia. Printed summary of such discussion could be used to begin the process in hospital or community health services. Clinicians, patients, and caregivers agreed with its ease of use and were generally accepting of its contents and format. CHAT is available to health services for implementation in effectiveness trials to determine whether the interaction and documentation leads to formal decision-making, goal-concordant care, and subsequent reduction of unwanted treatments at the end of life.

Decisional conflict and its determinants among patients with cancer undergoing immunotherapy combined with chemotherapy or targeted therapy: a cross-sectional study

Decisional conflict might occur during shared decision-making (SDM) because immunotherapy is a rather novel treatment option for patients with cancer. To explore the prevalence and severity of physical and psychological symptoms and the effort invested in SDM in relation to decisional conflict among patients with cancer undergoing immunotherapy combined with chemotherapy or targeted therapy. This was a cross-sectional survey study. The SURE version of the Decisional Conflict Scale was used to screen cancer patients' decisional conflict status. Demographic or clinical characteristics, physical symptoms and psychological distress; efforts invested in the SDM process were also assessed as potential factors related to decisional conflict. One hundred seventeen patients surveyed, the prevalence of fatigue (79.5%), sleep disturbance (78.6%), poor appetite (67.5%), and pain (58.1%) symptoms were high and the severity was at moderate levels. The prevalence of pruritus (40.2%), rash (34.2%), dry skin (41.9%), and diarrhea (17.1%) symptoms were low and the severity was at mild levels. 65.8% of patients reported uncertainty, with mild to moderate levels. Furthermore, 97.4% of the patients made some effort in SDM, and the effort level was moderate (mean: 5.56 ± 2.02). 64.1% of patients were certain that immunotherapy was the best option. Age, uncertainty, and effort in the SDM process were major factors related to decisional conflict. We observed that older patients (age: ≥ 65) and those with higher uncertainty levels and less effort in SDM reported higher levels of decisional conflict. Future studies should explore older patients' decisional related needs of immunotherapy. Interventions should be designed to reduce the uncertainty experienced by patients with cancer and enhance their understanding of immunotherapy to enable them to take more effort in the SDM process.

Gambling and Aging: An Overview of a Risky Behavior

Gambling is a field of study that has grown since the 2000s. Much research has focused on adolescents and youth as a vulnerable population. The rate of aging gamblers is increasing; however, evidence-based knowledge of this population is still too sparse. After introducing the issue (1), this article provides a narrative review of older adults' gambling through three sections: (2) older adult gamblers (age, characteristics, and motivations), (3) gambling as a risky decision-making situation, and (4) gambling disorder related to older adults. By drawing on the existing literature from a problematization perspective, this type of review can highlight complex and original research topics and provoke thought and controversy to generate avenues for future research. This narrative review provides an overview of the existing literature on gambling among older adults and offers perspectives on how aging can affect decision-making and thus gambling for this population. Older adults are a specific population, not only in terms of the consequences of gambling disorders but also in terms of the motivations and cognitions underlying gambling behaviors. Studies on behavioral science focusing on decision-making in older adults could help in the development of public policy in terms of targeted prevention.

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).

Information Avoidance in Consumer Choice: Do Avoidance Tendencies and Motives Vary by Age?

Prior research suggests that older adults seek less information in consumer choices than younger adults do. However, it remains unclear if intentional information avoidance plays a role in such effects. To test this possibility, we examined age differences in deliberate information avoidance in consumer decisions and explored a range of potential motives. Adult lifespan samples completed two pre-registered online studies, which assessed information avoidance using a slider scale (Study 1, N =195) and a forced-choice task (Study 2, N = 500). In Study 1, age differences in information avoidance were not significant, but methodological limitations could have obscured age effects. In Study 2, age was associated with higher information avoidance. Avoidance was higher among participants who reported that the information would not impact decision preferences, would elicit more negative affect, and would be useless. Although age was associated with lower perceived impact on decision preferences and lower concerns about affective responses, age differences in information avoidance remained significant when these variables were statistically controlled. In conclusion, in the context of consumer choices, deliberate information avoidance is higher among older consumers. Thus, interventions to promote the acquisition of relevant information would benefit from being tailored to the target age group.

Pay One or Pay All? The Role of Incentive Schemes in Decision Making Across Adulthood

OBJECTIVES

This research addresses how younger and older adults' decisions and evaluations of gains and losses are affected by the way in which monetary incentives are provided. We compared 2 common incentive schemes in decision making: pay one (only a single decision is incentivized) and pay all (incentives across all decisions are accumulated).

METHOD

Younger adults (18-36 years; n = 147) and older adults (60-89 years; n = 139) participated in either a pay-one or pay-all condition and made binary choices between two-outcome monetary lotteries in gain, loss, and mixed domains. We analyzed participants' decision quality, risk taking, and psychometric test scores. Computational modeling of cumulative prospect theory served to measure sensitivity to outcomes and probabilities, loss aversion, and choice sensitivity.

RESULTS

Decision quality and risk aversion were higher in the gain than mixed or loss domain, but unaffected by age. Loss aversion was higher, and choice sensitivity was lower in older than younger adults. In the pay-one condition, the value functions were more strongly curved, and choice sensitivity was higher than in the pay-all condition.

DISCUSSION

An opportunity of accumulating incentives has similar portfolio effects on younger and older adults' decisions. In general, people appear to decide less cautiously in pay-all than pay-one scenarios. The impact of different incentive schemes should be carefully considered in aging and decision research.

‘…it's hard to prepare yourself, it's like a death’: barriers and facilitators to older people discussing and planning for driving retirement

Driving is the preferred mode of transport for many older drivers, providing mobility to maintain independence and quality of life. The loss of driving privilege has negative psychosocial consequences, including depression. Early discussions and planning for driving retirement are therefore essential. Driving retirement, however, is typically a taboo topic for older drivers and their support networks. To understand why discussions and planning about driving retirement are avoided, 43 semi-structured interviews were conducted with older drivers in New South Wales, Australia. Drawing on Löckenhoff's ageing and decision-making framework, thematic analysis of transcripts offers insights into why discussions and planning for driving retirement are avoided or facilitated. The findings reveal most older drivers had not discussed or planned for driving retirement. Barriers to discussing and planning for driving retirement included: perceptions of loss, change, death and denial. Facilitators to discussing or planning for driving retirement included: declining health and driving confidence, medical advice, age or car accident. Driving retirement in car-dependent societies is a major life event, symbolising an end-of-life stage for many older people. This paper calls for strategies to encourage early and regular discussions about driving retirement with older drivers. To support older drivers’ transition to driving retirement, an understanding of the value and meaning placed on driving in the context of the individuals' identity and lifestyle is recommended.

Executive Functions in Decision Making under Ambiguity and Risk in Healthy Adults: A Scoping Review Adopting the Hot and Cold Executive Functions Perspective

Decision making (DM) has a pivotal role in supporting individual autonomy and well-being. It is considered a complex ability exploiting many cognitive functions, among which executive functions (EFs) are crucial. Few studies analyzed the role played by EFs in DM in healthy adults under ambiguity and risk, which are common conditions for most decisions in daily life. This scoping review aims to analyze the relationships between two individual tasks widely used to assess DM under these conditions (Iowa Gambling Task and Game of Dice Task) and EFs. According to the organizing principle that conceptualizes hot and cold EFs, DM under such conditions mainly implies hot EFs, but the relationship with cold EFs is still unclear. Using such an approach, a comprehensive framework is provided, highlighting main findings and identifying possible gaps in the literature. The results suggest different roles played by cold EFs in DM under ambiguity and risk, according to the characteristics of the tasks. The findings can offer guidance to further studies and to design interventions to support DM in healthy adults.

Age and Framing Effects in the Balloon Analogue Risk Task (BART)

OBJECTIVES

Prior research has documented age differences in risky decisions and indicates that they are susceptible to gain versus loss framing. However, previous studies focused on 'decisions from description' that explicitly spell out the probabilities involved. The present study expands this literature by examining the effects of framing on age differences in the Balloon Analogue Risk Task (BART), a widely used and ecologically valid measure of experience-based risky decision-making that involves pumping a virtual balloon.

METHOD

In a pre-registered study, younger (aged 18-30, n =129) and older adults (aged 60 and over, n=125) were randomly assigned to either a gain version of the BART, where pumping the balloon added monetary gains, or a loss version, where pumping the balloon avoided monetary losses.

RESULTS

We found a significant age by frame interaction on risk-taking: in the loss frame, older adults pumped more frequently and experienced more popped balloons than younger adults, whereas in the gain frame no significant age differences were found. Total performance on the BART did not vary by age or frame. Supplementary analyses indicated that age differences in pumping rates were most pronounced at the beginning of the BART and leveled off in subsequent trials. Controlling for age differences in motivation, personality, and cognition did not account for age differences in risk-taking.

DISCUSSION

In combination, findings suggest that age differences in risk-taking on the BART are more pronounced when the task context emphasizes avoiding losses rather than achieving gains.

The Differences and Perspectives Between Elderly Individuals and Their Surrogates Regarding End-of-Life Care: A Mixed Methods Study

Background: Family members often take the place of decision-making for elderly individuals. Previous studies showed that family members could not predict elderly individuals' thoughts about end-of-life care. Objectives: The aims are to understand the differences and perspectives between elderly individuals and surrogates regarding end-of-life care. Design: A mixed methods study comprising a cross-sectional survey and field notes analysis. Setting: Two geriatric wards in a veterans hospital located in northern Taiwan. Subjects: Fifty-five pairs of elderly individuals and their surrogates. Measurements: Life support preferences questionnaire and field notes. Results: The quantitative data showed that the elderly individuals and their surrogates had proper consistency in cardiopulmonary resuscitation and surgery. However, their consistency was poor in antibiotics and nasogastric tube feeding. Four themes were identified in qualitative data: recognizing old age, struggling with hope and peace, worries and concerns, and control of life. Recognizing old age for both elderly individuals and their surrogates was critical. Elderly individuals and their surrogates may seek a ray of hope among aggressive treatments and struggle with hope and peace. A lot of worries and concerns were mentioned, including contextual concerns. Elderly individuals need to depend on their ability to control their life. Conclusions: The study highlights elderly individuals' and their surrogates' considerations for antibiotics and nasogastric tube feeding. Furthermore, elderly individuals expressed that it is different for making decisions for themselves or others; thus, future studies can further explore whether elderly individuals allow their surrogates leeway from their wishes.

People with jumping to conclusions bias tend to make context-independent decisions rather than context-dependent decisions

Beads task (BT) uses a probabilistic reasoning paradigm and reveals jumping to conclusions (JTC) bias, the tendency to make premature judgments based on insufficient information (i.e., making fewer draws to decision-DTD). In this study, healthy participants (N = 207) were tested on the 80:20 and 60:40 color ratio versions of BT. We investigated associations of JTC bias with a set of cognitive bias problems and Cognitive Bias Task (CBT), a non-veridical (agent-centered) decision-making task that determines context-dependent and context-independent decision-making bias.Results showed that the converted CBT scores were negatively, and cognitive bias scores were positively correlated with JTC bias (DTD ≤ 2) on both versions of the BT. The CBT demonstrated to have satisfactory convergent and predictive validity for JTC bias. The findings suggest that people with JTC bias fail to solve cognitive bias problems and are more likely to make context-independent response selections than context-dependent response selections.

Informant report of practical judgment ability in a clinical sample of older adults with subjective cognitive decline, mild cognitive impairment, and dementia

Despite the importance of capturing problems with judgment and decision-making during neuropsychological evaluations of older adults, there are a limited number of validated measures and no informant rating scales. We developed an informant measure that captures compromised judgment related to safety, medical, financial, and social-ethical issues After item refinement and piloting in a memory disorders clinic, we utilized the Test of Practical Judgment-Informant (TOP-J-Informant) at two clinics in the Midwestern U.S., including 189 patient/informant dyads (mean age = 79.0, median years of education = 13, % female = 67.7) with various preclinical and clinical dementia conditions. We found psychometric support, including evidence for convergent, divergent, and criterion-related validity, and internal consistency. Importantly, we were able to discriminate between diagnostic groups in the expected direction. The TOP-J-Informant is brief (<5 minutes), easy to administer, and can reveal areas of concern related to poor judgment when administered in the context of a neuropsychological evaluation or clinic visit.

Characterizing the Heterogeneity of Aging: A Vision for a Staging System for Aging

Introduction: Older adulthood encompasses several decades of change and heterogeneity. Primary care providers need a geriatric comprehensive vision for defining older adult subpopulations.

Methods: Using PubMed and Google searches, we reviewed the literature on epidemiology of age-related physiological changes, age-related diseases and geriatric syndromes, functional state, and emotional and social changes. We divided old age into strata based on chronological age and strata based on functional state, disease burden, and geriatric syndromes.

Results: We describe 4 chronological-age strata beginning at age 60, and 4 functional-age strata based on frailty according to a modified clinical frailty scale. We provide clinical considerations and anticipatory guidance topics for each of the age strata and functional strata.

Conclusion: Chronological age, functional status, chronic disease burden and geriatric syndromes, and life expectancy are all important domains that impact clinical care and appropriate anticipatory guidance for individual older adults. Better knowledge for differentiating subpopulations of older adults may improve clinical care, reduce medical overuse, improve personalized anticipatory guidance, and focus on the impact of functional state on the quality of life.

Alterations in Neural Responses and Pain Perception in Older Adults During Distraction

OBJECTIVE

Although it is acknowledged that pain may be modulated by cognitive factors, little is known about the effect of aging on these control processes. The present study investigated electroencephalographical correlates of pain processing and its cognitive modulation in healthy older individuals.

METHODS

For this purpose, the impact of distraction on pain was evaluated in 21 young (9 men; 20.71 [2.30]) and 20 older (10 men; 66.80 [4.14]) adults. Participants received individually adjusted electrical pain stimuli in a high-distraction condition (one-back task) and in a low-distraction condition (simple letter response task). Pain-related evoked potentials and pain ratings were analyzed.

RESULTS

Both groups rated pain as less intense (F(1,39) = 13.954, p < .001) and less unpleasant (F(1,39) = 10.111, p = .003) when it was experienced during the high- rather than the low-distraction condition. However, in comparison to younger participants, older adults gave higher unpleasantness ratings to painful stimulation (F(1,39) = 4.233, p = .046), accompanied by attenuated neural responses (N1-P1 and P3 amplitudes), regardless of the distraction condition (F(1,38) = 6.028 [p = .019] and F(1,38) = 6.669 [p = .014], respectively).

CONCLUSIONS

Older participants felt pain relief through distraction, like younger participants. However, we also found that aging may enhance affective aspects of pain perception. Finally, our results show that aging is characterized by reduced neural processing of painful stimuli. This phenomenon could be related to the increased vulnerability of older participants to develop chronic pain.

Age Influences Loss Aversion Through Effects on Posterior Cingulate Cortical Thickness

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

Gambling and ageing: less illusion but more risk

Seniors are a population of concern due to exposure to both increasing gambling venues and powerful age-specific risk factors. There has been only limited research on this population so far, but studies conducted among younger adults suggest that the illusion of control is a key factor, leading players to develop strategies that increase their risk-taking in gambling. Time perspective (TP) is a good indicator of risky behaviours in a number of different areas, including health and the environment. In the present study, we sought to identify the age-specific cognitive mechanisms underlying gambling behaviour in normal ageing. We asked 115 emerging adults (mean age = 20.86 years), 86 young adults (mean age = 30.59), 82 middle-aged adults (mean age = 44.57) and 108 seniors (mean age = 65.19) to play an online game. We rated their illusion of control, risk-taking and TP. Analysis revealed that seniors took more risks and had less illusion of control than younger adults. The fatalistic-present TP positively influenced the illusion of control, such that perceiving the present as being determined by uncontrollable forces increased the perceived level of control. Finally, we found an influence of age on TP. These results suggest that seniors constitute a specific population in terms of gambling-related cognitions and behaviours. Including TP in risky behaviour assessments would allow the development of tailor-made preventive measures.

Major Depressive Disorder in Older Patients as an Inflammatory Disorder: Implications for the Pharmacological Management of Geriatric Depression

Depression is a common and highly disabling condition in older adults. It is a heterogenous disorder and there is emerging evidence of a link between inflammation and depression in older patients, with a possible inflammatory subtype of depression. Persistent low-level inflammation, from several sources including psychological distress and chronic disease, can disrupt monoaminergic and glutaminergic systems to create dysfunctional brain networks. Despite the evidence for the role of inflammation in depression, there is insufficient evidence to recommend use of any putative anti-inflammatory agent in the treatment of depression in older adults at this stage. Further characterisation of markers of inflammation and stratification of participants with elevated rates of inflammatory markers in treatment trials is needed.

The role of cognition and reinforcement sensitivity in older adult decision-making under explicit risk conditions

Introduction: Previous research has suggested that individual differences in executive functions, memory and reinforcement sensitivity are associated with performance on behavioral decision-making tasks. Decision-making performance may also decline with age, however there is a lack of research on the interplay of cognitive and affective processes, and their impact on older adult decision-making. This study examined associations between executive functions, memory and reinforcement sensitivity on the Game of Dice Task (a measure of decision-making under explicit risk) among older adults.Method: One thousand and two older adults without cognitive impairment (aged 72-78 years) participated as part of an Australian longitudinal cohort study (the Personality and Total Health Through Life study). Decision-making sub-types were identified through cluster analysis and multinomial logistic regression was used to assess associations with measures of cognition and reinforcement sensitivity.Results: Cluster analysis identified three decision-making sub-types, which we label "advantageous," "disadvantageous" and "switching." Multivariate analyses found that relative to the mid-performing "switching" sub-type, advantageous decision-makers were more likely to be younger, male and have higher scores on a test of verbal learning. Disadvantageous decision-makers were more likely to have poorer scores on some components of executive function (set shifting, but not working memory or inhibitory control), although this effect was partly attenuated by a measure of reinforcement sensitivity (reward responsiveness).Conclusion: These results indicate that specific components of learning and executive functions are influential in decision-making under explicit risk among a sample of older adults.

Contextual Processing and the Impacts of Aging and Neurodegeneration: A Scoping Review

Contextual processing (or context processing; CP) is an integral component of cognition. CP allows people to manage their thoughts and actions by adjusting to surroundings. CP involves the formation of an internal representation of context in relation to the environment, maintenance of this information over a period of time, and the updating of mental representations to reflect changes in the environment. Each of these functions can be affected by aging and associated conditions. Here, we introduced contextual processing research and summarized the literature studying the impact of normal aging and neurodegeneration-related cognitive decline on CP. Through searching the PubMed, PsycINFO, and Google Scholar databases, 23 studies were retrieved that focused on the impact of aging, mild cogniitve impairment (MCI), Alzheimer's disease (AD), and Parkinson's disease (PD) on CP. Results indicated that CP is particularly vulnerable to aging and neurodegeneration. Older adults had a delayed onset and reduced amplitude of electrophysiological response to information detection, comparison, and execution. MCI patients demonstrated clear signs of impaired CP compared to normal aging. The only study on AD suggested a decreased proactive control in AD participants in maintaining contextual information, but seemingly intact reactive control. Studies on PD restricted to non-demented older participants, who showed limited ability to use contextual information in cognitive and motor processes, exhibiting impaired reactive control but more or less intact proactive control. These data suggest that the decline in CP with age is further impacted by accelerated aging and neurodegeneration, providing insights for improving intervention strategies. This review highlights the need for increased attention to research this important but understudied field.

How does decisional capacity evolve with normal cognitive aging: systematic review of the literature

PURPOSE

Aging is associated with increased needs related to complex decisions, particularly in medical and social issues. However, the complexity of decision-making involves many neurological functions and structures which are potentially altered by cognitive aging.

METHODOLOGY

A systematic review was conducted in accordance with PRISMA guidelines to examine changes in decision-making occurring in normal cognitive aging. The keywords "decision making" and "normal aging" were used to find the clinical studies and literature reviews focused on these changes.

RESULTS

A total of 97 articles were considered in the review, and ultimately 40 articles were selected, including 30 studies and 10 literature reviews. The data from these studies were of uneven quality and too disparate to allow meta-analysis according to PRISMA criteria. Nevertheless, a key result of the analysis is the decrease of processing speed with aging. In ambiguous decision-making situations, the alteration of the ventromedial system is associated with changes in motivation profiles. These changes can be compensated by experience. However, difficulties arise for older adults in the case of one-off decisions, which are very common in the medical or medico-social domains.

CONCLUSIONS

Cognitive aging is associated with a slowdown in processing speed of decision-making, especially in ambiguous situations. However, decision-making processes which are based on experience and cases in which sufficient time is available are less affected by aging. These results highlight the relativity of decision-making capacities in cognitive aging.

Individual predictors of tactical planning performance in junior military officers

This exploratory study examined the influence of personal and psycholinguistic factors on tactical planning performance in a convenience sample of Australian Army personnel. Sixty male junior officers undertaking a tactical training course completed self-report measures of decision-making style, problem-solving appraisal, personality, and tactical planning expertise. A measure of general cognitive ability was sourced from participants' military records. During the course, officers completed several tactical planning exercises that were assessed by course instructors, and an overall measure of tactical planning performance was derived. Psycholinguistic data was derived from participants' thought processes elicited during an analogous planning exercise using a written think-aloud protocol. Automatic linear modeling analyses identified the combination of greater expertise and intuitive decision-making style, less spontaneous decision-making style and problem-solving confidence, younger age, and greater use of words relating to risk and past-focused concepts in their thought records, as significant predictors of better tactical planning, accounting for 55% of the variance in performance. Additionally, general cognitive ability, conscientiousness, and rational decision-making style shared moderate positive bivariate correlations with planning performance. This research has identified individual factors that contribute to tactical mission planning, along with future research avenues, which may inform the training of military commanders at the tactical level.

Neural mechanisms of decision-making in aging

The present review synthesizes findings on decision neuroscience and aging by focusing on decision processes that have been extensively studied in neuroeconomics and critically assessing the driving mechanisms of age-related change. The paper first highlights age-related changes to key brain structures that have been implicated in decision-making, then, reviews specific decision components and discusses investigations of age-related changes to their neural mechanisms. The review also weighs evidence for organic brain aging versus age-related changes to social and psychological factors in mediating age effects. Reviewed findings are discussed in the context of theories and frameworks that have been used to explain trajectories of change in decision-making across adulthood. This article is categorized under: Psychology > Development and Aging Psychology > Reasoning and Decision-Making Neuroscience > Cognition.

Older Adults Show Diminished Sensitivity to Potential Losses in Social Bargaining

Objectives

Leaders in many organizations are older adults who routinely make decisions in social bargaining situations. However, we know little about the age-related differences in strategic decision making.

Methods

In the current study (n = 182), using a modified Prisoner’s Dilemma game (PDG), we examined two important intrinsic motivations for non-cooperation: fear of betrayal and greedy desire to exploit other people among young and older Chinese Singaporeans.

Results

Results showed that compared with young adults, older adults demonstrated an intact greed motive but a diminished fear motive in the PDG.

Discussion

Our findings suggest a diminished sensitivity to social threat or potential losses due to betrayal in older adults’ social decision making. Older adults may have a declined ability to assess social threats even though they retain the motivation to gain an exploitive advantage.

Preferences for surrogate designation and decision-making process in older versus younger adults with cancer: A comparative cross-sectional study

OBJECTIVE

To compare the preferences of older (≥70 years old) versus younger (<70 years old) cancer patients regarding surrogate designation and decision making.

METHODS

A cross-sectional survey. Patient characteristics and information about surrogacy and involvement in decision making were collected. Associations between patient characteristics and preferences were examined.

RESULTS

The study included 130 patients aged ≥70 years (mean age 80 years) and 102 patients aged <70 years (mean age 55) and. Factors independently associated with surrogate knowledge (66%): younger age, more children living nearby, high income; factors associated with having already designated a surrogate (62%): younger age, decreased number of daily medications; factors associated with designating a surrogate after questionnaire administration (40%): low education, metastasis. Patients requiring an informed consent for any intervention was associated with older age (adjusted OR [aOR]_{per year} = 1.04[95% confidence interval 1.00-1.08]), not living alone (aOR = 2.52[1.00-6.36]), and having children (aOR = 4.49[1.13-17.81]).

CONCLUSION

All cancer patients, wanted to be fully informed and 72% wanted to be involved in medical decisions. Preferences for decision control vary between age groups, depending on family members' presence and living alone.

PRACTICE IMPLICATIONS

Sharing complete and clear information should be an important key in the process of cancer patients' care, regardless of patient age.