Armin R. Azar

Cognitive performance predicts treatment decisional abilities in mild to moderate dementia

Objective: To examine the contribution of neuropsychological test performance to treatment decision-making capacity in community volunteers with mild to moderate dementia. Methods: The authors recruited volunteers (44 men, 44 women) with mild to moderate dementia from the community. Subjects completed a battery of 11 neuropsychological tests that assessed auditory and visual attention, logical memory, language, and executive function. To measure decision making capacity, the authors administered the Capacity to Consent to Treatment Interview, the Hopemont Capacity Assessment Interview, and the MacCarthur Competence Assessment Tool—Treatment. Each of these instruments individually scores four decisional abilities serving capacity: understanding, appreciation, reasoning, and expression of choice. The authors used principal components analysis to generate component scores for each ability across instruments, and to extract principal components for neuropsychological performance. Results: Multiple linear regression analyses demonstrated that neuropsychological performance significantly predicted all four abilities. Specifically, it predicted 77.8% of the common variance for understanding, 39.4% for reasoning, 24.6% for appreciation, and 10.2% for expression of choice. Except for reasoning and appreciation, neuropsychological predictor (β) profiles were unique for each ability. Conclusions: Neuropsychological performance substantially and differentially predicted capacity for treatment decisions in individuals with mild to moderate dementia. Relationships between elemental cognitive function and decisional capacity may differ in individuals whose decisional capacity is impaired by other disorders, such as mental illness.

Neuropsychological Predictors of Decision‐Making Capacity over 9 Months in Mild‐to‐Moderate Dementia

AbstractBACKGROUND: 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 × 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.

Three Methods of Assessing Values for Advance Care Planning: Comparing Persons With and Without Dementia

Advance care planning ideally includes communication about values between patients, family members, and care providers. This study examined the utility of health care values assessment tools for older adults with and without dementia. Adults aged 60 and older, with and without dementia, completed three values assessment tools—open-ended, forced-choice, and rating scale questions—and named a preferred surrogate decision maker. Responses to forced-choice items were examined at 9-month retest. Adults with and without dementia appeared equally able to respond meaningfully to questions about values regarding quality of life and health care decisions. People with dementia were generally as able as controls to respond consistently after 9 months. Although values assessment methods show promise, further item and scale development work is needed. Older adults with dementia should be included in clarifying values for advance care planning to the extent that they desire and are able.

Depressive symptoms after CABG surgery: a meta-analysis.

Learning ObjectivesAfter participating in this educational activity, the reader should be better able to measure the risk of depression before and after coronary artery bypass graft (CABG) surgery; examine the course of depression after CABG; and apply the results of the study to the treatment of patients. ObjectiveDepression is highly comorbid with coronary artery disease. Clinicians face the question of whether patients’ depressive symptoms will improve after coronary artery bypass graft surgery (CABG). The objective of this meta-analysis is to determine the course of depressive symptoms after CABG. MethodsEMBASE, PubMed, and PsycINFO were searched for studies assessing depression before and after CABG. Meta-analyses were performed for depression at early (1–2 weeks), recovery (>2 weeks to 2 months), mid (>2 months to 6 months), and late (>6 months) postoperative time points. Heterogeneity and publication bias were analyzed. ResultsThirty-nine studies were included in the meta-analysis. Twelve reported dichotomous outcomes; 18 reported continuous outcomes; and 9 reported both. Risk of depression was increased early (relative risk [RR] = 1.27; 95% confidence interval [CI], 1.01–1.61). There was a significantly decreased risk of depression at recovery (RR = 0.78; 95% CI, 0.67–0.90), mid (RR = 0.64; 95% CI, 0.58–0.70), and late (RR = 0.68; 95% CI, 0.58–0.79) time points without heterogeneity. All studies reporting continuous depression scales had significant heterogeneity. ConclusionsThe risk of depression decreased post-CABG when depression was measured dichotomously. While depression improves overall and remits for some patients after CABG, the majority of patients will not experience remission of depression. Preoperative and postoperative depression monitoring is important.

Remission in Major Depression: Results from a Geriatric Primary Care Population

While a recent task force report recommended that remission from major depression be defined according to DSM criteria, most previous work has used depressive symptom rating scales. The current study sought to identify baseline factors associated with treatment outcome in major depression, diagnosed according to DSM‐IV criteria.

Race and Vascular Depression Risk in Community-Dwelling Older Adults

OBJECTIVE Authors examined racial differences in cerebrovascular risk factors (CVRFs) and overall depressive symptomatology. METHODS The authors applied a correlational design using a depression inventory, the Center for Epidemiological Studies Depression scale (CES-D) and self-report CVRF data from black and white community-dwelling elderly subjects (N=362). RESULTS Black subjects were more likely than whites to screen positive for depression, but there were no race differences in CVRFs. Across races, greater rates of CVRFs were associated with higher scores on the CES-D. CVRFs and lower education level were independent predictors of positive depression screening on the CES-D. CONCLUSIONS CVRFs were associated with depression in black and white elderly subjects. Future research should examine race differences within vascular depression, utilizing broader measures of CVRFs.