Age, Loss Minimization, and the Role of Probability for Decision-Making

Older adults select different but not simpler strategies than younger adults in risky choice

Younger and older adults often differ in their risky choices. Theoretical frameworks on human aging point to various cognitive and motivational factors that might underlie these differences. Using a novel computational model based on the framework of resource rationality, we find that the two age groups rely on different strategies. Importantly, older adults did not use simpler strategies than younger adults, they did not select among fewer strategies, they did not make more errors, and they did not put more weight on cognitive costs. Instead, older adults selected strategies that had different risk propensities than those selected by younger adults. Our modeling approach suggests that age differences in risky choice are not necessarily a consequence of cognitive decline; instead, they may reflect motivational differences between age groups.

Adult age differences in value-based decision making

A better understanding of age-related differences in judgment and decision making is important from both theoretical and applied perspectives. In this review, we focus on value-based decisions across adulthood and specifically on how loss aversion (a relatively stronger weight of losses than gains on decisions) and the relative motivational impact of gains and losses may change with aging. In doing so, we will also cover recent findings about the effects of gain or loss incentives on performance in cognitive tasks that involve attention, learning, and remembering. We point out open questions and critical moderating variables for future theorizing and research.

Evaluating Patient Preferences in Benign Prostatic Hyperplasia Treatment Using Conjoint Analysis

OBJECTIVE

To quantify BPH patient preferences to promote guidelines-compliant, patient-centered care. Discordance between patient and urologist priorities for the treatment of benign prostatic hyperplasia (BPH) hinders patient-centered care. Physician assumptions regarding patient preferences lead to dissatisfied patients; a poor outcome in any quality of life surgery. American Urologic Association guidelines urge urologists to consider patient preferences when recommending a BPH treatment.

METHODS

In this cross-sectional, online survey study using researchmatch.org, participants were required to decide between theoretical BPH treatments in a balanced, choice-based conjoint analysis. The treatments had varying levels of four attributes: efficacy, recovery difficulty, risk of complications (Clavien-Dindo 2+), and risk of de novo ejaculatory dysfunction. Demographic information and International Prostate Symptom Score (IPSS) were collected and analyzed using comparative statistics. Each attribute was analyzed using a conditional logit model, and attribute importance (range in utility between attribute-levels) was calculated.

RESULTS

Out of 1235 recruited participants, 812 (66%) completed the study. Median IPSS and age was 6 (IQR 3-12) and 56 (IQR 38-67), respectively. Complication risk was the most important attribute, followed by efficacy, recovery difficulty, and risk of ejaculatory dysfunction. In a subgroup analysis of age quartiles, participants age <38 and >67 held efficacy (31%) and complication risk (47%) to the highest relative importance, respectively.

CONCLUSIONS

Males valued BPH treatments that minimize complication risks, while ejaculatory dysfunction was least impactful. Variation in results between age subgroups emphasizes the need for individualized care to maximize patient satisfaction.

Losing Money and Motivation: Effects of Loss Incentives on Motivation and Metacognition in Younger and Older Adults

Incentives are usually expected to increase motivation and cognitive control and to thereby improve performance. A small but growing number of studies have begun to investigate whether the effects of incentive on cognitive performance differ for younger vs. older adults. Most have used attention and cognitive control paradigms, trial-wise implementation of incentive condition, and gain incentives (reward), with only a very few investigating the effects of loss incentives. The present study takes a complementary approach: We tested younger and older adults in a working memory paradigm with loss incentives implemented session-wide (between subjects). We also included self-report measures to ask how loss incentive affected participants’ perceptions of the mental demand of the task, as well as their perceived effort, frustration, motivation, distraction, and metacognitive judgments of how well they had performed. This allowed us to test the disparate predictions of different theoretical views: the intuitive hypothesis that incentive should increase motivation and performance, the motivational shift proposal that older adults are especially motivated to avoid losses (Freund and Ebner, 2005), a heuristic “positivity effect” perspective that older adults ignore losses (Brassen et al., 2012; Williams et al., 2017), and a more nuanced view that suggests that when negative information is unavoidable and increases perceived costs, older adults may instead disengage from the situation (Charles, 2010; Hess, 2014). The results seemed most consistent with the more nuanced view of the positivity effect. While neither group showed incentive-related performance differences, both younger and older adults reported greater perceived demand and frustration under loss incentive, especially in the most challenging conditions. Loss incentive increased the accuracy of immediate metacognitive judgments, but reduced the accuracy of later, more global judgments of competency for older adults. Self-report measures suggested that the loss incentive manipulation was distracting to young adults and demotivating for older adults. The results suggest a need for caution in generalizing from existing studies to everyday life, and that additional studies parameterizing critical aspects of task design and incentive manipulation are needed to fully understand how incentives affect cognition and motivation in younger and older adults.

Age, knowledge, preferences, and risk tolerance for invasive cardiac care

BACKGROUND/OBJECTIVES

The extent to which individual knowledge, preferences, and priorities explain lower use of invasive cardiac care among older vs. younger adults presenting with acute coronary syndrome (ACS) is unknown. We directly surveyed a group of patients to ascertain their preferences and priorities for invasive cardiovascular care.

DESIGN

We performed a prospective cohort study of adults hospitalized with ACS. We surveyed participants regarding their knowledge, preferences, goals, and concerns for cardiac care, as well as their risk tolerance for coronary artery bypass grafting (CABG).

SETTING

Single academic medical center.

PARTICIPANTS

Six hundred twenty-eight participants (373 <75 years old; 255 ≥75 years old).

MEASUREMENTS

We compared baseline characteristics, knowledge, priorities, and risk tolerance for care across age strata. We also assessed pairwise differences with 95% confidence intervals (CI) between age groups for key variables of interest.

RESULTS

Compared with younger patients, older participants had less knowledge of invasive care; were less willing to consider cardiac catheterization (difference between 75-84 and< 65 years old: -7.8%, 95% CI: -14.4%,-1.3%; for ≥85 vs. <65: -15.7%, 95% CI: -29.8%,-1.6%), percutaneous coronary intervention (difference between 75-84 and< 65 years old: -12.8%, 95% CI: -20.8%,-4.8%; for ≥85 vs. <65: -24.8%, 95% CI: -41.2%,-8.5%), and CABG (difference between 75-84 and< 65 years old: -19.0%, 95% CI: -28.2%,-9.9%; for ≥85 vs. <65: -39.1%, 95% CI: -56.0%,-22.2%); and were more risk averse for CABG surgery (p < .001), albeit with substantial inter-individual variability and individual outliers. Many patients who stated they were not initially willing to undergo an invasive cardiovascular procedure actually ended up undergoing the procedure (49% for cardiac catheterization and 22% for PCI or CABG).

CONCLUSION

Age influences treatment goals and willingness to consider invasive cardiac care, as well as risk tolerance for CABG. Individuals' willingness to undergo invasive cardiovascular procedures loosely corresponds with whether that procedure is performed after discussion with the care team.

Strive to Win or Not to Lose? Age-Related Differences in Framing Effects on Effort-Based Decision-Making

Objectives

This study sought to assess how framing effects modulate age-related differences in effort-based decision-making. Consistent with the selection, optimization, and compensation (SOC) model’s loss prevention account of aging, we predicted that older adults would be more willing to select high-effort options in loss contexts than gain contexts.

Method

Older and younger adults completed the effort expenditure for rewards task (EEfRT) in either a gain or loss context. The EEfRT is an effort-based decision-making paradigm in which participants choose between a low-effort, “easy” option and a high-effort, “hard” option for several trials. The probability and value of an outcome varies on a trial-by-trial basis.

Results

The results supported our prediction and the SOC model. Older adults chose more high-effort, difficult options in loss frames than gain frames. Older adults also chose more low-effort, easy options than younger adults in gain contexts, but did not differ from younger adults in loss contexts.

Discussion

These findings demonstrate that framing effects impact older adults’ effort-based decisions. Older adults appear willing to incur a greater “cost” in the form of effort to prevent a loss than to attain a reward.