Cognitive models that predict physician judgments of capacity to consent in mild Alzheimer's disease

Shades of grey: choice, control and capacity in alcohol-related brain damage

Liaison psychiatrists have identified that conducting capacity assessments in general hospital patients with alcohol-related brain damage (ARBD) can be challenging. This educational article uses the fictitious case of a man with ARBD, alcohol dependence and significant self-neglect, focusing on assessment of his capacity to decide about moving into a care home on discharge. We provide an overview of clinical, legal and ethical literature relevant to decision-making and capacity assessment in individuals with ARBD, with the aim of guiding clinicians approaching complex capacity assessments.

Influence of Dispositional Optimism on Ethically Salient Research Perspectives: A Pilot Study

Research participants should be drawn as fairly as possible from the potential volunteer population. Underlying personality traits are underexplored as factors influencing research decision-making. Dispositional optimism, known to affect coping, physical health, and psychological well-being, has been minimally studied with respect to research-related attitudes. We conducted an exploratory, online survey with 151 individuals (with self-reported mental illness [n = 50], physical illness [n = 51], or neither [n = 50]) recruited via MTurk. We evaluated associations between dispositional optimism (assessed with the Life Orientation Test-Revised) and general research attitudes, perceived protectiveness of five research safeguards, and willingness to participate in research using safeguards. Strongly optimistic respondents expressed more positive research attitudes and perceived four safeguards as more positively influencing willingness to participate. Optimism was positively associated with expressed willingness to participate in clinical research. Our findings add to a limited literature on the influence of individual traits on ethically salient research perspectives.

Decision-making capacity: from testing to evaluation

Decision-making capacity (DMC) is the gatekeeping element for a patient's right to self-determination with regard to medical decisions. A DMC evaluation is not only conducted on descriptive grounds but is an inherently normative task including ethical reasoning. Therefore, it is dependent to a considerable extent on the values held by the clinicians involved in the DMC evaluation. Dealing with the question of how to reasonably support clinicians in arriving at a DMC judgment, a new tool is presented that fundamentally differs from existing ones: the U-Doc. By putting greater emphasis on the judgmental process rather than on the measurement of mental abilities, the clinician as a decision-maker is brought into focus, rendering the tool more of an evaluation guide than a test instrument. In a qualitative study, the perceived benefits of and difficulties with the tool have been explored. The findings show on the one hand that the evaluation aid provides basic orientation, supports a holistic perspective on the patient, sensitizes for ethical considerations and personal biases, and helps to think through the decision, to argue, and to justify one's judgment. On the other hand, the room for interpretation due to absent operationalisations, related ambiguities, and the confrontation with one's own subjectivity may be experienced as unsettling.

Competency of aMCI patients to consent to cholinesterase treatment

BACKGROUND

In medical practice, a patient's loss of competency is a major obstacle when choosing a treatment and a starting treatment program smoothly. A large number of studies have revealed the lack of medical competency in patients with dementia. However, there have been only a few reports focusing on the capacity of patients with mild cognitive impairment (MCI) to make a medical choice.

METHODS

In this study, we evaluated the competency of 40 patients with amnestic MCI (aMCI) and 33 normal subjects to make a medical choice using the MacArthur Competence Assessment Tool-Treatment (MacCAT-T). We compared the judgement of a team conference using the recorded semi-structured interview with the clinical judgement of a chief clinician.

RESULTS

A team conference concluded that 12 aMCI patients had no competency, and the clinical judgement, without any special interview, judged that five aMCI patients had no competency. All subjects in the control groups were judged to be competent to consent to treatment by both clinicians and the team conference.

CONCLUSIONS

Without supplementary tools such as explanatory documents, not a few patients with aMCI were judged by a team conference to have no competency to consent to therapy even in a relatively simple and easy case. In contrast, clinical physicians tended to evaluate the competency of aMCI patients in a generous manner.

Goals of Care: Understanding the Outcomes that Matter Most

Advanced care planning is a critically important part of the care of seriously and critically ill patients. A responsibility of all physicians as part of primary palliative care, advanced care planning discussions are more than discussions about code status and should begin early and proceed in parallel with recovery-focused care. Strategies and best practices for advanced care planning in the elective setting and when time is short are reviewed, as are the myriad legal documents that can be used to provide a physical representation of the advanced care planning discussions.

The marriage of psychology and law: testamentary capacity

Banks v. Goodfellow [1870. LR 5 QB 549 (Eng.)] is almost 150 years old, yet still stands as authority for the principle that unsoundness of the mind will not rebut testamentary capacity where it does not affect the will itself. Readers of this journal would know that psychology has advanced greatly during this sesquicentenary, and yet the law relating to testamentary capacity has remained relatively stagnant. We review the present laws relating to decision-making for adults with impaired capacity, particularly in Queensland, and also review various models of gauging decision-making capacity in other jurisdictions. We argue that qualified experts should be enlisted to make determinations about testamentary capacity when questions of capacity arise. We also argue the case for the development of scientifically validated protocols to assess decision-making capacity in the testamentary context.

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)

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.

Measuring informed consent capacity in an Alzheimer's disease clinical trial

INTRODUCTION

Accurately and efficiently determining a participant's capacity to consent to research is critically important to protect the rights of patients with Alzheimer's disease (AD).

METHODS

Understanding of the informed consent document was assessed in 613 community-dwelling patients with mild-to-moderate AD enrolled in a randomized, placebo-controlled trial. Associations were examined between clinically determined capacity to consent and (1) patient demographics and clinical characteristics and (2) the Informed Consent Questionnaire (ICQ), an objective measurement of a participant's factual understanding and perceived understanding.

RESULTS

A total of 453 (74%) participants were determined to have capacity to consent by clinical judgment. ICQ perceived understanding, race, measures of cognitive function, and caregiver time were all significantly associated with the determination of capacity in multivariate analyses.

DISCUSSION

We found a significant association between capacity and disease severity level, caregiver time, race, and ICQ perceived understanding.

Cognitive Citizenship: Access to Hip Surgery for People with Dementia

Dementia and chronic hip disease are both more prevalent with advancing age. Given this, the number of people with both dementia and hip disease is likely to increase in an ageing population such as the UK. This article raises questions about how people with dementia and chronic hip disease are conceptualized in the context of evidence-based medicine, and whether this conceptualization may limit unfairly their access to surgical services. The published clinical research discourse at the interface of hip disease and dementia is taken as an ‘evidence-base’, and is evaluated in terms of its suitability for informing professional decisions about viability for surgery. The analysis suggests that the outcomes criteria used to determine patient viability serve to discriminate unfairly against people with dementia. If such discrimination exists, it necessarily militates against the promotion of health-related citizenship rights of the cognitively impaired, creating an evidence-based culture that encourages a problematic model of cognitive citizenship.

Capacity issues and decision-making in dementia

Capacity to make one's own decisions is fundamental to the autonomy of the individual. Capacity is a functional assessment made by a clinician to determine if a patient is capable of making a specific decision. Competency is a global assessment and legal determination made by a judge in court. Capacity evaluation for a patient with dementia is used to determine whether the patient is capable of giving informed consent, participate in research, manage their finances, live independently, make a will, and have ability to drive. Patients with dementia cannot be assumed to have impaired capacity. Even a patient with moderate or severe dementia, with obviously impaired capacity may still be able to indicate a choice and show some understanding. Four key components of decision-making in a capacity evaluation include understanding, communicating a choice, appreciation, and reasoning. Assessment of capacity requires a direct interview with the patient using open-ended questions and may include both informal and formal approaches depending on the situation and the context. A baseline cognitive evaluation with a simple test to assess executive function is often useful in capacity evaluation. All capacity evaluations are situation specific, relating to the particular decision under consideration, and are not global in scope. The clinician needs to spend adequate time with the patient and the family allaying their anxieties and also consider the sociocultural context. The area of capacity has considerable overlap with law and the clinician treating patients with dementia should understand the complexities of assessment and the implications of impaired capacity. It is also essential that the clinician be well informed and keep meticulous records. It is crucial to strike a balance between respecting the patient autonomy and acting in his/her best interest.

Awareness of cognitive deficits and clinical competence in mild to moderate Alzheimer's disease: their relevance in clinical practice

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.

Assessment of capacity in an aging society

Over the past 40 years, the assessment and scientific study of capacity in older adults has emerged as a distinct field of clinical and research activity for psychologists. This new field reflects the convergence of several trends: the aging of American society, the growing incidence and prevalence of dementia, and the patient rights, deinstitutionalization, and disability rights movements. Because of these forces, capacity issues now permeate the fabric of everyday life, whether in the form of guardianship petitions, questions of capacity to consent to treatment, the ability to make a new will, or participation in human research. In seeking to resolve these issues, families, clinicians, and legal professionals increasingly turn to psychologists to assess a capacity and to provide empirically supported judgments that properly balance autonomy and protection for the individual. Psychologists have taken a leading role in the development of functional assessment instruments that measure important aspects of the capacity construct. In addition, psychology has been a major contributor to the scientific study of capacity. In collaboration with colleagues from medicine and law, psychologists have articulated crucial theoretical frameworks that integrate legal, clinical, and ethical dimensions of the capacity problem. This article focuses on the evolution of theory, law, science, and practice in the evaluation of capacity in older adults and its recent culmination in a series of interdisciplinary handbooks sponsored by the American Psychological Association and the American Bar Association.

Neuropsychological correlates of capacity determinations in Alzheimer disease: implications for assessment

OBJECTIVES

To explore the neuropsychological correlates of the capacity to consent to research and to appoint a research proxy among persons with Alzheimer disease.

DESIGN, SETTING, AND PARTICIPANTS

Interview study of 77 persons with Alzheimer disease recruited through an Alzheimer disease research center and a memory disorder clinic.

MEASUREMENTS

The capacity to consent to two research scenarios (a drug randomized clinical trial and a neurosurgical clinical trial) and the capacity to appoint a research proxy were determined by five experienced consultation psychiatrists who rendered categorical judgments based on videotaped interviews of the MacArthur Competence Assessment Tool-Clinical Research and the Capacity to Appoint a Proxy Assessment. Mattis Dementia Rating Scale-Second Edition was used to assess neuropsychological functioning.

RESULTS

The capacity to appoint a proxy and to consent to the drug randomized clinical trial, as determined by a majority or greater opinion of the five-psychiatrist panel, was predicted by Conceptualization and Initiation/Perseveration subscales, whereas the capacity to consent to a neurosurgical randomized clinical trial was predicted by the Memory subscale. Furthermore, the more lenient individual psychiatrists' judgments were predicted by the Conceptualization subscale, whereas the stricter psychiatrists' judgments were predicted by the Memory subscale.

CONCLUSIONS

How experienced psychiatrists view the capacity of patients with Alzheimer disease for consenting to research and for appointing a proxy may be related to the patients' conceptualization and memory functioning. More explicit and standardized guidance on the role of short-term memory in capacity determinations may be useful.

Evaluation of the capacity to appoint a healthcare proxy

The appointment of a healthcare proxy is the most common way through which patients appoint a surrogate decision maker in anticipation of a future time in which they may lack the ability to make medical decisions themselves. In some situations, when a patient has not previously appointed a surrogate decision maker through an advance directive, the healthcare team may ask whether the patient, although lacking the capacity to make a healthcare decision, might still have the capacity to appoint a healthcare proxy. In this article the authors summarize the existing, albeit limited, legal and empirical basis for this capacity and propose a model for assessing capacity to appoint a healthcare proxy that incorporates clinical factors in the context of the risks and benefits specific to surrogate appointment under the law. In particular, it is important to weigh patients' understanding and choice within the context of the risks and benefits of the medical and interpersonal factors. Questions to guide capacity assessment are provided for clinical use and refinement through future research.

Temporal stability of receptiveness to clinical research on Alzheimer disease

Research advance directives are a proposed mechanism for ensuring that decisions with regard to research participation adhere to preferences voiced by persons with Alzheimer disease (AD) before losing decisional capacity. Although this approach rests on the assumption that preferences with regard to research participation are consistent over time, little is known about the stability of such preferences. The purpose of this study was to evaluate the temporal stability of older adults' receptiveness to participation in clinical trials, neuroimaging studies, and psychosocial investigations on AD. One hundred and four participants in the University of Pittsburgh Alzheimer Disease Research Center were annually surveyed with regard to their willingness to be contacted with regard to clinical drug trials, neuroimaging studies, and psychosocial research for which they might be eligible. Receptiveness to contact with regard to AD research was compared at 2 time points, 1 year apart. At baseline, most respondents were willing to be contacted with regard to their eligibility for drug trials, imaging studies, and psychosocial research. Thirty-seven percent of respondents voiced a different set of preferences at year 2 as compared with year 1. Differences included both increased and decreased willingness to be contacted. Neither stability of preferences nor direction of change (more vs. less willing) varied by diagnostic group. Bivariate analyses revealed that participation in at least 1 ancillary research study was associated with an overall increase in willingness to be contacted. We conclude that a significant proportion of research-friendly individuals voice different sets of preferences with regard to the possibility of research participation when queried at different points in time. Amenability to participating in clinical research on AD is a relatively dynamic personal attribute that may be influenced by personal experience with research participation. This finding has relevance for the policy debate around research advance directives, an approach which assumes that preferences with regard to research participation are consistent over time.

Predicting functional ability in mild cognitive impairment with the Dementia Rating Scale-2

BACKGROUND

We examined the utility of cognitive evaluation to predict instrumental activities of daily living (IADLs) and decisional ability in Mild Cognitive Impairment (MCI).

METHODS

Sixty-seven individuals with single-domain amnestic MCI were administered the Dementia Rating Scale-2 (DRS-2) as well as the Everyday Cognition assessment form to assess functional ability.

RESULTS

The DRS-2 Total Scores and Initiation/Perseveration and Memory subscales were found to be predictive of IADLs, with Total Scores accounting for 19% of the variance in IADL performance on average. In addition, the DRS-2 Initiation/Perseveration and Total Scores were predictive of ability to understand information, and the DRS-2 Conceptualization helped predict ability to communicate with others, both key variables in decision-making ability.

CONCLUSIONS

These findings suggest that performance on the DRS-2, and specific subscales related to executive function and memory, is significantly related to IADLs in individuals with MCI. These cognitive measures are also associated with decision-making-related abilities in MCI.

The ethics of informed consent in Alzheimer disease research

Clinical research on Alzheimer disease (AD) is much needed but requires the participation of patients with substantial cognitive impairment who have difficulty providing informed consent. Despite decades of debate, policies regulating such research are not well-defined. Although numerous studies have underscored the difficulties of obtaining informed consent for clinical research from patients compromised by AD, there is also increasing evidence that such individuals and their surrogates can make decisions about research participation that are consistent with the patients' values. Policy discussions and future research should consider how the ethical reservations about enrolling incapacitated patients in research could be mitigated by developing ways to promote the congruence between surrogates' decisions and patients' values.

The assessment of decisional capacity

The physician must explain the treatment or procedure in detail including risks, benefits, and alternative options; the patient's choice must be voluntary; the patient must demonstrate his or her ability to understand the risks and benefits of their choice; and the patient must be able to manipulate information in a logical way. These criteria must be met in order for the process of informed consent to be valid.

Variability of judgments of capacity: experience of capacity evaluators in a study of research consent capacity

BACKGROUND

Assessment of decision-making capacity is a common and important function of psychiatric consultants. However, the sources of variability in evaluators' judgments have not been well characterized.

OBJECTIVE

To examine the degree and potential sources of variability in the categorical capacity judgments of experienced psychiatrists.

METHOD

The setting was a study comparing the decision-making capacities of 188 persons with Alzheimer's disease to appoint a research proxy and to consent to two hypothetical randomized controlled trials for dementia (a new drug RCT and a neurosurgical RCT). We compared five experienced consultation psychiatrists' capacity judgments for 555 videotaped capacity interviews. Both quantitative and qualitative data were used.

RESULTS

Pair wise kappa statistics ranged from slight agreement (0.17) to substantial agreement (0.64) with group kappa statistics ranging from fair to moderate agreement (0.40 to 0.45) for the psychiatrists' judgments regarding the three capacities. The sources of variability included varying "strictness" among judges, moderate test-retest reliability within judges, the relative novelty of assessing decision-making capacity for research participation decisions, as well as the limitations of the methods used to obtain capacity judgments in the study.

DISCUSSION

There is considerable variability in capacity judgments of experienced consultation psychiatrists regarding the capacities to appoint a research proxy and to consent to research. The potential sources of variability identified in this study may provide starting points for more effective training in capacity assessment.

The application of the Mental Capacity Act 2005 among geriatric psychiatry patients: a pilot study

BACKGROUND

The Mental Capacity Act 2005 (MCA) was fully implemented in October 2007 in England and Wales. The experience of clinicians working in Old Age Psychiatry, who are likely to have greater experience in the use of MCA, in the early implementation of the MCA was examined.

METHODS

Case-notes of 37 patients in seven different Old Age Psychiatry services in two mental health trusts in west London, who had received at least one assessment of decision-making capacity (DMC) for a specific issue, were examined. A qualitative thematic analysis pertaining to the criteria used for the assessment of DMC, determination of best interests, least restrictive option and unwise decision was used for data analysis.

RESULTS

The main findings were: the criteria used for the assessment of DMC and the determination of best interests were those described in the MCA and the accompanying Code of Practice; and clinicians were developing the concepts of least restrictive option and unwise decision with face validity despite the absence of their definitions in the MCA.

CONCLUSION

Caution should be exercised in extrapolating the findings of this study, which is confined to two Mental Health Trusts in one geographical area and the speciality of Old Age Psychiatry, to other localities and other specialties. Nevertheless, there was evidence that clinicians were following the basic principles of the MCA correctly.

Informed consent to research in long-term care settings

Informed consent to nursing home research is a two-tiered process that begins with obtaining the consent of a long-term care community at the institutional level and progresses to the engagement of individuals in the consent process. Drawing on a review of the literature and the authors' research experiences and institutional review board service, this article describes the practical implications of nurse investigators' obligation to ensure informed consent among participants in long-term care research. Recommendations focus on applying a community consent model to long-term care research, promoting an evidence-based approach to the protection of residents with decisional impairment, and increasing investigators' attention to ethical issues involving long-term care staff.

Research ethics issues in geriatric psychiatry

Progress in geriatric psychiatric research may be impeded by lack of attention to collecting evidence relevant to ethical issues. As has been noted for some time, unless proactive work is done to identify, clarify, and remediate ethical challenges (see Table 2 for research directions), deleterious effects on research can result, including research bans, unduly overprotective stances, or inaccurate weighing of risks and benefits of research by review boards. With regard to proxy consent, a number of issues require further study. These include: how state laws address (or fail to address) research involving cognitively impaired individuals and what effects this has on research conduct; how IRBs define and weigh risks and benefits in considering research involving proxy consent; how various stakeholders, including the general public, people with disorders that may impair decision-making capacity, and proxies themselves view proxy consent for research; and to what degree proxies' research decisions reflect what patients themselves would decide. The use of advanced directives as a stand alone method for future consent is fraught with difficulties around adequate informed consent for a particular study; however, future study may clarify if such directives provide surrogates with improved understanding of their relative's overall views of the research enterprise and possibly the types of studies they would be willing to participate in even if they are no longer able to provide their own consent. In depression and suicide research, further work is needed to develop standard procedures for meeting the ethical demands of research while conducting rigorous, crucial research.

Capacity to make treatment decisions in Chinese older persons with very mild dementia and mild Alzheimer disease

OBJECTIVES

This study aims at assessing mental competence in Chinese patients with mild and very mild dementia with a semistructured assessment method and the impact of repeated presentations of information on patients' mental competence.

DESIGN

Subjects with mild and very mild dementia were compared with cognitively intact subjects.

SETTING

Chinese subjects were recruited from local social centers and residential hostels for the elderly in Hong Kong.

PARTICIPANTS

Sixty-six Chinese community-dwelling older adults (aged from 65 to 87 years) were recruited.

MEASUREMENTS

Clinical diagnosis was made by experienced geriatric psychiatrists. Subjects were assessed with the Mini-Mental State Examination and the Clinical Dementia Rating (CDR). Mental capacity to consent to treatment was assessed by using the Chinese version of the MacArthur Competence Assessment Tool-Treatment (MacCAT-T) and independent clinician ratings based on the definition in the Mental Capacity Act 2005 of the United Kingdom.

RESULTS

Thirty-three (50%) participants were diagnosed with very mild or mild dementia (CDR = 0.5 or 1). In this group, 15 (45.5%) subjects were rated as mentally incompetent in clinician ratings. In the assessment of interrater reliability, the intraclass correlation coefficient of MacCAT-T summary scores among three raters ranged from 0.64 to 0.83. The MacCAT-T summary scores correlated significantly with clinician ratings, years of education, Mini-Mental State Examination score, and CDR. In contrast to the nonimpaired group, repeated presentation of information did not significantly improve capacity in the demented group.

CONCLUSION

Results from this study suggest that even patients with very mild dementia in this population can show substantial deficits in decision-making capacity, and that improved capacity is not likely to result from repeated disclosure of information.

Decisional capacity for research participation in individuals with mild cognitive impairment

OBJECTIVES

To assess decisional capacity performance and the neuropsychological correlates of such performance to better understand higher-level instrumental activities of daily living in individuals with mild cognitive impairment (MCI).

DESIGN

Cross-sectional.

SETTING

Research center, medical center, or patient's home.

PARTICIPANTS

Forty participants with MCI and 40 cognitively normal older controls (NCs) aged 60 to 90 (mean age+/-standard deviation 73.3+/-6.6; 54% female).

MEASUREMENTS

Capacity to provide informed consent for a hypothetical, but ecologically valid, clinical trial was assessed using the MacArthur Competence Assessment Tool for Clinical Research. Neuropsychological functioning was assessed using a comprehensive protocol.

RESULTS

Adjusted between-group comparisons yielded significant differences for most decisional capacity indices examined, including Understanding (P=.001; NC>MCI) and Reasoning (P=.002; NC>MCI). Post hoc analyses revealed that participants with MCI who were categorized as capable of providing informed consent according to expert raters had higher levels of education than those who were categorized as incapable.

CONCLUSION

The findings suggest that many individuals with MCI perform differently on a measure of decisional capacity than their NC peers and that participants with MCI who are incapable of providing informed consent on a hypothetical and complex clinical trial are less educated. These findings are consistent with prior studies documenting functional and financial skill difficulties in individuals with MCI.

Judgment in older adults: development and psychometric evaluation of the Test of Practical Judgment (TOP-J)

This article reports on the development and validation of a novel, objective test of judgment for use with older adults. The Test of Practical Judgment (TOP-J) is an open-ended measure that evaluates judgment related to safety, medical, social/ethical, and financial issues. Psychometric features were examined in a sample of 134 euthymic individuals with mild Alzheimer's disease (AD), amnestic mild cognitive impairment (MCI), or cognitive complaints but intact neuropsychological performance (CC), and demographically-matched healthy controls (HC). Measures of reliability were adequate to high, and TOP-J scores correlated with select measures of executive functioning, language, and memory. AD participants obtained impaired TOP-J scores relative to HCs, while MCI and CC participants showed an intermediate level of performance. Confirmatory factor analyses were consistent with a unidimensional structure. Results encourage further development of the TOP-J as an indicator of practical judgment skills in clinical and research settings. Longitudinal assessments are being performed to examine predictive validity of the TOP-J for cognitive progression in our clinical groups.

Cognitive models of medical decision-making capacity in patients with mild cognitive impairment

This study investigated cognitive predictors of medical decision-making capacity (MDC) in patients with amnestic mild cognitive impairment (MCI). A total of 56 healthy controls, 60 patients with MCI, and 31 patients with mild Alzheimer's disease (AD) were administered the Capacity to Consent to Treatment Instrument (CCTI) and a neuropsychological test battery. The CCTI assesses MDC across four established treatment consent standards--S1 (expressing choice), S3 (appreciation), S4 (reasoning), and S5 (understanding)--and one experimental standard [S2] (reasonable choice). Scores on neuropsychological measures were correlated with scores on each CCTI standard. Significant bivariate correlates were subsequently entered into stepwise regression analyses to identity group-specific multivariable predictors of MDC across CCTI standards. Different multivariable cognitive models emerged across groups and consent standards. For the MCI group, measures of short-term verbal memory were key predictors of MDC for each of the three clinically relevant standards (S3, S4, and S5). Secondary predictors were measures of executive function. In contrast, in the mild AD group, measures tapping executive function and processing speed were primary predictors of S3, S4, and S5. MDC in patients with MCI is supported primarily by short-term verbal memory. The findings demonstrate the impact of amnestic deficits on MDC in patients with MCI.

The association of specific neuropsychological deficits with capacity to consent to research or treatment

Informed consent is key to ethical clinical research and treatment, but partially rests on the ability of individual patients or research participants to use disclosed information to make a meaningful choice. Although the construct of decisional capacity emerged from legal and philosophical traditions, several investigators have begun examining the relationship of specific neuropsychological abilities to decisional capacity. This line of research may foster development of better consent procedures, as well as aid in refining the construct of decisional capacity toward a form that better reflects the underlying neurocognitive processes. We conducted a systematic search of the published literature and thereby identified and reviewed 16 published reports of empirical studies that examined the relationship between specific neuropsychological abilities and capacity to consent to research or treatment. Significant relationships between neuropsychological scores and decisional capacity were present across all the reviewed studies. The degree to which specific neuropsychological abilities have particular relevance to decisional capacity remains uncertain, but the existing studies provide a solid basis for a priori hypotheses for future investigations. These ongoing efforts represent an important conceptual and empirical bridge between bioethical, legal, and neuropsychological approaches to understanding meaningful decision-making processes.

Assessment of decision-making capacity in older adults: an emerging area of practice and research

The convergence of the aging of our society, the increase in blended families, and an enormous intergenerational transfer of wealth has greatly expanded the incidence and importance of capacity assessment of older adults. In this article we discuss the emergence of capacity assessment as a distinct field of study. We review research efforts in two domains: medical decision-making capacity and financial capacity. Existing research in these two areas provides a first pass at many key questions related to capacity assessment, but additional studies that replicate, extend, and improve on this research are urgently needed. An agenda for future is detailed that recommends studies of a wide range of capacity constructs, focusing on clinical markers of diminished capacity, methods to improve clinical assessment, and the many intersections of law and clinical practice.

Empirical advances in the assessment of the capacity to consent to medical treatment: Clinical implications and research needs

The clinical evaluation of capacity to consent to treatment occurs in the medical setting and is based on legal foundations of informed consent and capacity. Clinical judgment is still the "gold standard" for capacity determination, although it can be unreliable. In the past 10 years the empirical basis for these assessments has been advanced considerably by the introduction of a number of instruments designed to assess capacity to consent to treatment. In this paper, we review studies, mostly with older adult populations, that consider the cognitive and non-cognitive correlates of consent capacity, rates of impaired capacity in various patient groups, the relation of instrument-based to clinician-based capacity assessment, and the inter-rater and test-retest reliability of consent capacity assessment. We also overview key research focusing on factors influencing, and procedural and processing variables involved in, medical decision-making. We conclude that these studies have yielded quite varied results, and promote no consensus regarding the reliability and validity of instrument-based consent capacity assessment. Overall, the results of these studies provide some guidance for clinicians, but, at present, practitioners should view these instruments as supplemental resources rather than benchmarks for assessment. However, this first generation of instruments provides a good foundation for future research, which should continue to systematically study aspects of reliability and validity, most especially construct validity, in well-defined patient populations.

Neuropsychological predictors of decision-making capacity over 9 months in mild-to-moderate dementia

BACKGROUND

Older adults with dementia may have diminished capacity to make medical treatment decisions.

OBJECTIVE

To examine rates and neuropsychological predictors of treatment decision making, or consent capacity, among older adults with dementia over 9 months.

DESIGN

Consent capacity was assessed initially and 9 months later in subjects with and without dementia using a longitudinal repeated measures design.

PARTICIPANTS

Fifty-three older adults with dementia and 53 similarly aged adults without dementia.

MEASUREMENTS

A standardized measure MacArthur Competence Assessment Tool-Treatment of 4 legal standards for capacity (Understanding, Appreciation, Reasoning, and Expressing a Choice) and a neuropsychological battery.

RESULTS

In the dementia group, 9.4% had impaired capacity initially, and 26.4% had impaired capacity at 9 months. Mean scores in the dementia group were impaired relative to controls initially and at 9 months for Understanding (initial t=2.49, P=.01; 9-month t=3.22, P<.01) and Reasoning (initial t=2.18, P=.03; 9-month t=4.77, P<.01). Declining capacity over 9 months was attributable to a further reduction in Reasoning (group x time F=9.44, P=.003). Discriminant function analysis revealed that initial scores on naming, delayed Logical Memory, and Trails B were associated with impaired capacity at 9 months.

CONCLUSIONS

Some patients with mild-to-moderate dementia develop a clinically relevant impairment of consent capacity within a year. Consent capacity in adults with mild-to-moderate dementia should be reassessed periodically to ensure that it is adequate for each specific informed consent situation. Interventions that maximize Understanding and Reasoning by supporting naming, memory, and flexibility may help to optimize capacity in this patient group.

Decisional capacity in mental illness and substance use disorders: empirical database and policy implications

Debates on decisional capacity in people with mental illnesses or substance use disorders have tended to be heated. Yet, they are often based not on empirical data but on personal opinions and experiences. The empirical database in this area is quite limited, but has been growing in recent years. The following discussion focuses on relevant clinical investigations. We consider variations across and within different diagnoses, barriers to decision-making, methods for assessing capacity-interview versus instruments, choosing from among different capacity instruments, decisional capacity-is it a state or a trait?, triggers for assessment of decisional capacity, methods for enhancing capacity, and decisional capacity in people with substance use disorders. Finally, we discuss some relevant health policy recommendations.

Impairment and partial recovery of medical decision-making capacity in traumatic brain injury: a 6-month longitudinal study

OBJECTIVE

To investigate empirically change in medical decision-making capacity (MDC) in patients with traumatic brain injury (TBI).

DESIGN

Longitudinal study comparing control and TBI groups at hospitalization and at 6 months postinjury.

SETTING

Inpatient brain injury rehabilitation unit.

PARTICIPANTS

Twenty healthy controls and 24 patients with moderate to severe TBI.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

MDC was measured by using the Capacity to Consent to Treatment Instrument (CCTI). The CCTI evaluates performance on a series of 4 accepted consent abilities, or standards: S1 (evidencing/communicating choice), S3 (appreciating consequences), S4 (reasoning about treatment), and S5 (understanding the treatment situation and choices), and 1 experimental standard [S2] (making the reasonable treatment choice when the alternative choice is unreasonable). In addition, TBI patients were assigned 1 of 3 capacity outcomes (capable, marginally capable, incapable) for each standard.

RESULTS

At hospitalization, TBI patients performed equivalently with controls on standards S1 and [S2] but significantly below controls on S3 ( P <.001), S4 ( P <.02), and S5 ( P <.001). At 6-month follow-up, TBI patients showed significant within-group improvement on these 3 standards (S3, S4, S5) but continued to fall significantly below controls on S3 ( P <.006) and S5 ( P <.001). A group by time interaction emerged on S5 ( P <.02). The TBI group showed increasing proportions of capable outcomes on all standards over the 6 months.

CONCLUSIONS

Patients with TBI showed initial impairment and subsequent partial recovery of MDC over a 6-month period. Complex consent abilities of appreciation, reasoning, and understanding were significantly impaired in hospitalized acute TBI patients. At follow-up, TBI patients showed substantial recovery of reasoning and partial recovery of appreciation and understanding consent abilities. The study suggests the importance in the rehabilitation setting of serial evaluations of MDC in patients with TBI.

Informed consent for medical research by the elderly

Much has been written about the possible lack of capacity of the elderly, especially certain vulnerable populations of older individuals, to give informed consent for medical research. Several small studies have shown a deficit for comprehension of consent material, by the elderly, especially those with less education, but this appears small in comparison to an overall deficit in the general population. A number of investigations have suggested that deficits in executive control functions (ECFs) may be related to lack of capacity to make clinical judgments, but these have yet to be applied to research. Many methods have been piloted to measure capacity and to improve comprehension, some of which may help, although none has been proved conclusively to do either. As the elderly experience significant morbidity and mortality from a vast array of illnesses, the use of the elderly as subjects of medical research is especially important. To prevent older individuals from being coerced into participating or potentially being harmed by scientific investigation, they must give informed consent to their involvement. However, there are many studies to suggest that they are not well informed. A discussion ensued in the 1970s and 1980s about whether or not the elderly deserved special protection as a class of individuals, based on their possible increased risk during medical experimentation, but it was ultimately decided that, because the majority of elderly are perceived to be cognitively intact, they need not receive additional safeguards (High & Doole, 1995, Behavioral Science and Law, 13, 319-335). The U.S. Department of Health and Human Services in 2000 (Federal Registrar Rules and Regulations, 46, 8366-8392) reviewed existing protections for subjects of human research and deemed they were inadequate, issuing new guidelines. This article reviews evidence that differences exist between the ability of young and old in their capacity to give consent. Alterations in methods of obtaining consent may help individuals to give a more informed consent, and even enable subjects who lack the capacity to consent, such as cognitively impaired individuals, to participate in research. However an ideal means of screening or altering the consent process has yet to be devised. Many of these methods are briefly considered.

The prevalence and correlates of capacity to consent to a geriatric psychiatry admission

In the UK the recent House of Lords ruling on the Bournewood case provided a statutory basis for admitting patients into psychiatric beds who lack the capacity to consent, but do not dissent, without recourse to detention under the Mental Health Act. A study to ascertain the prevalence and correlates of the lack of capacity to consent to geriatric psychiatry inpatient admission was undertaken. All consecutive acute inpatient admissions to a geriatric psychiatry unit over a six-month period were examined by an independent research psychiatrist (SM). Data on demography, diagnosis, severity of cognitive impairment, insight, the SM's assessment of capacity to consent to the admission and the consultant psychiatrists' assessment of the capacity to consent to the admission were ascertained. The overall prevalence of lack of capacity to consent to geriatric psychiatry inpatient admission was 48%. It was associated with a diagnosis of dementia, increased severity of cognitive impairment, reduced insight and detention under the Mental Health Act. The kappa concordance between SM's and the consultant psychiatrist's assessment of capacity was modest at 0.6. These findings require replication in a larger multi-centre study, perhaps using standardised instruments to measure capacity. A large number of psychiatric patients are informally admitted despite lacking the capacity to consent to the admission because they do not dissent. These patients do not enjoy the safeguards available under the Mental Health Act.

Legal interventions for persons with dementia in the USA: ethical, policy and practical aspects

The US legal system has developed a number of methods by which the state or private parties may intervene to protect persons, including those with dementia, who lack sufficient cognitive or emotional capacity to make and express autonomous choices about various aspects of their lives. These interventions may be planned and voluntary or unplanned and involuntary. This article explores the ethical and cultural values underlying legal alternatives in the United States and their strengths and weaknesses when measured against those values. The article poses issues about which US policy makers, health and human service practitioners, and attorneys might seek wisdom from the various strategies that other countries have devised to deal with the challenge of protecting, but not overprotecting, their own citizens with dementia.

Capacity to consent: issues and controversies

Capacity to consent has major ethical and legal implications, but it is often poorly understood and inadequately practiced. Varied literature on the subject is reviewed with a view to discuss the legal and clinical aspects and strategies to improve current practice.

Cognitive models of physicians' legal standard and personal judgments of competency in patients with Alzheimer's disease

OBJECTIVES

To investigate measures of patient cognitive abilities as predictors of physician judgments of medical treatment consent capacity (competency) in patients with Alzheimer's disease (AD).

DESIGN

Predictor models of legal standards (LS) and personal competency judgments were developed for each study physician using independent neuropsychological test measures and logistic regression analyses.

SETTING

A university medical center.

PARTICIPANTS

Five physicians with experience assessing the competency of AD patients were recruited to make competency judgments of videotaped vignettes from 10 older controls and 21 patients with AD (10 with mild and 11 with moderate dementia).

MEASUREMENTS

The 31 patient and control videotapes of performance on a measure of treatment consent capacity (Capacity to Consent to Treatment Instrument) (CCTI) were rated by the five physicians. The CCTI consists of two clinical vignettes (A-neoplasm and B-cardiac) that test competency under five LS. Each study physician viewed each vignette videotape individually, made judgments of competent or incompetent under each of the LS, and then made his/her own personal competency judgment. Physicians were blinded to participant diagnosis and neuropsychological test performance. Stepwise logistic regression was conducted to identify cognitive predictors of each physician's LS and personal competency judgments for Vignette A using the full sample (n = 31). Classification logistic regression analysis was used to determine how well these cognitive predictor models classified each physician's competency judgments for Vignette A. These classification models were then cross-validated using physician's Vignette B judgments.

RESULTS

Cognitive predictor models for Vignette A competency judgments differed across individual physicians, and were related to difficulty of LS and to incompetency outcome rates across LS for AD patients. Measures of semantic knowledge and receptive language predicted judgments under less difficult LS of evidencing a treatment choice (LS1) and making the reasonable treatment choice (LS2). Measures of semantic knowledge, short-term verbal recall, and simple reasoning ability predicted judgments under more difficult and clinically relevant LS of appreciating consequences of a treatment choice (LS3), providing rational reasons for a treatment choice (LS4), and understanding the treatment situation and choices (LSS). Cognitive models for physicians' personal competency judgments were virtually identical to their respective models for LS5 judgments. For AD patients, shortterm memory predictors were associated with high incompetency outcome rates (over 70%), a simple reasoning measure was associated with moderately high incompetency outcome rates (60-70%), and a semantic knowledge measure was associated with lower incompetency outcome rates (30-60%). Overall, single predictor models were relatively robust, correctly classifying an average of 83% of physician judgments for Vignette A and 80% of judgments for Vignette B.

CONCLUSIONS

Multiple cognitive functions predicted physicians' LS and personal competency judgments. Declines in semantic knowledge, short-term verbal recall, and simple reasoning ability predicted physicians' judgments on the three most difficult and clinically most relevant LS (LS3-LS5), as well as their personal competency judgments. Our findings suggest that clinical assessment of competency should include evaluation of semantic knowledge, verbal recall, and simple reasoning abilities.

Consistency of physician judgments of capacity to consent in mild Alzheimer's disease

OBJECTIVE

To investigate the agreement of physician judgments of capacity to consent to treatment for normal and demented older adults.

DESIGN

Subjects were individually administered a standardized consent capacity interview. Physicians viewed videotapes of these interviews and made judgments of capacity to consent to treatment.

SETTING

University medical center.

PARTICIPANTS

Subjects assessed for competency (N = 45) were 16 normal older controls and 29 patients with mild Alzheimer's disease (AD). Five medical center physicians with experience assessing the competency of dementia patients were recruited from the specialties of geriatric psychiatry, geriatric medicine, and neurology.

MEASUREMENTS

Subjects were videotaped responding to a standardized consent capacity interview (SCCI) designed to evaluate capacity to consent to treatment. Study physicians blinded to subject diagnosis individually viewed each SCCI videotape and made a judgment of competent or incompetent to consent. Agreement of physician judgments was evaluated using percentage agreement, kappa, and logistic regression.

RESULTS

Competency judgements of physicians showed high agreement for controls but low agreement for AD patients. Physicians as a group achieved 98% judgment agreement for the controls but only 56% judgment agreement for the mild AD patients. The physician group kappa for controls was 1.00 (P < .0001) and differed significantly (P < .0001) from the physician group kappa of .14 (P = .44) for AD patients, indicative of a real difference in the ability of the study physicians to judge consistently competency across the two groups. Similarly, logistic regression analysis showed significant variability in physician judgements for the AD group (chi 2 = 63.8, P < .0001) but not for the control group (chi 2 = 4.1, P = 1.00). Within the Ad group, pairwise analyses revealed significant judgment disagreement (P < .01) for seven of the 10 physician pairs.