Jennifer Moye

Health Screening and Random Recruitment for Cognitive Aging Research

A survey of 197 cognitive aging studies revealed infrequent use of structured health assessments and random recruitment. In this study, a health screening questionnarie developed to identify subjects with medical problems that might impair cognition was administered to 315 adults aged 60 and older who were recruited by random digit dialing. On the basis of self-reported medical problems, 35% of the subjects were excluded. Those excluded were older (p less than .001) and tended to be male but did not differ in education from those who passed the screening. Subjects who passed the screening and decided to participate in a neuropsychological research project were younger (p less than .001), better educated (p less than .001), and more likely to be male (p less than .001) than nonparticipants. These findings suggest that careful assessment, selection, and description of subjects is needed to aid interpretation of cognitive aging research. Further attention to health status is needed to aid interpretation of cognitive aging research. Although random recruitment of the elderly is feasible, obtaining representative samples may require stratification on demographic variables.

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.

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.

Caregiver outcomes of partners in dementia care: effect of a care coordination program for veterans with dementia and their family members and friends.

The objective is to test the effectiveness of Partners in Dementia Care (PDC), a care‐coordination program that integrates and improves access to medical and nonmedical services, while strengthening the informal care network and providing information, coaching, and emotional support. PDC was delivered via a partnership between Veterans Affairs (VA) Medical Centers (VAMCs) and Alzheimers Association chapters, for caregivers of veterans with dementia living in the community and receiving primary care from the VA. The initial sample was 486 caregivers of 508 veterans with diagnosed dementia. Outcomes were evaluated for 394 and 324 caregivers who completed 6‐ and 12‐ month follow‐up, respectively. PDC had a standardized protocol that included assessment and reassessment, action planning, and ongoing monitoring. It was delivered by telephone and e‐mail for cost efficiency and the ability to handle caseloads of 100 to 125. Care coordinators from VAMCs and Alzheimers Association chapters worked as a team using a shared computerized record. A variety of caregiver outcomes was measured after 6 and 12 months. Intervention group caregivers had significant improvements in outcomes representing unmet needs, three types of caregiver strains, depression, and two support resources. Most improvements were evident after 6 months, with more‐limited improvements from Months 6 to 12. Some outcomes improved for all caregivers, whereas some improved for caregivers experiencing more initial difficulties or caring for veterans with more‐severe impairments. PDC is a promising model that improves linkages between healthcare services and community services, which is a goal of several new national initiatives such as the National Plan to Address Alzheimers Disease and a proposed amendment to the Older Americans Act.

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.

Theoretical frameworks for competency in cognitively impaired elderly adults

Abstract Determinations of a cognilively impaired elderly adults competency to make decisions about self-care, property-care and medical-care occur in clinical and legal domains and obligate clinicians or the state to intervene in the interest of protecting the individual or society. Traditionally, competency assessments utilize expert opinion based on neuropsychological testing, functional evaluation and competency guidelines and scales. These assessments have implications for an individuals autonomy and present significant challenges to the evaluator. Validated construct definitions and assessment techniques are needed to advance knowledge and practice. In this article, current methods and problems of competency evaluations are reviewed. From this, a construct validation approach to the problem is described. Next, three theoretical frameworks related to ontological perspectives for competency constructs are presented to illustrate different ways of conceptualizing competency. These theoretical frameworks can be used to identify assumptions and organize approaches to assessment and research and are presented as starling points to organize future research and practice.

Anxiety in acutely bereaved prepubertal children.

Anxiety symptoms present immediately following parental death and approximately 8 weeks following the death were evaluated in 38 prepubertal children. Comparison groups included 38 hospitalized depressed children and 19 normal children. Bereaved children and parents were administered the Grief Interview and all were administered standard diagnostic interviews (DICA-C/P). While no bereaved children met DSM-III-R criteria for any anxiety disorder, anxiety regarding other family members dying was reported in 55% of bereaved children immediately after death and in 63% approximately 8 weeks later. When DSM-III-R anxiety symptoms were assessed, bereaved children did not report significantly more anxiety symptoms in the approximate 8-week interval post-parental death than normal comparison children, and had significantly fewer anxiety symptoms than depressed children (p < 0.0001). Bereaved children who had the most anxiety symptoms were also likely to have a depressive disorder (p < 0.002). Age and sex of child, sex of surviving parent, anticipation of death, and family history of anxiety or depressive disorders were not significantly associated with increased anxiety.

UPBEAT: the impact of a psychogeriatric intervention in VA medical centers. Unified Psychogeriatric Biopsychosocial Evaluation and Treatment.

Background.The Unified Psychogeriatric Biopsychosocial Evaluation and Treatment (UPBEAT) program provides individualized interdisciplinary mental health treatment and care coordination to elderly veterans whose comorbid depression, anxiety, or alcohol abuse may result in overuse of inpatient services and underuse of outpatient services. Objectives.To determine whether proactive screening of hospitalized patients can identify unrecognized comorbid psychiatric conditions and whether comprehensive assessment and psychogeriatric intervention can improve care while reducing inpatient use. Design.Randomized trial. Subjects.Veterans aged 60 and older hospitalized for nonpsychiatric medical or surgical treatment in 9 VA sites (UPBEAT, 814; usual care, 873). Measures.The Mental Health Inventory (MHI) anxiety and depression subscales, the Alcohol Use Disorder Identification Test (AUDIT) scores, RAND 36-Item Health Survey Short Form (SF-36), inpatient days and costs, ambulatory care clinic stops and costs, and mortality and readmission rates. Results.Mental health and general health status scores improved equally from baseline to 12-month follow-up in both groups. UPBEAT increased outpatient costs by

Preserving Rights for Individuals Facing Guardianship

1,171 (P <0.001) per patient, but lowered inpatient costs by