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

Okonkwo, Ozioma C.; Griffith, H. Randall; Belue, Katherine; Lanza, Sara; Zamrini, Edward; Harrell, Lindy E.; Brockington, John; Clark, David G.; Raman, Rema; Marson, Daniel C.

doi:10.1017/s1355617708080338

Cited by 73 publications

(117 citation statements)

References 49 publications

(71 reference statements)

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“…It is important to note, however, that there is individual variability within both PwMCI and PwD groups. Previous research on awareness in MCI in particular has emphasised that PwMCI vary considerably in levels of awareness and ability to make accurate self-appraisals in various domains [18,19,49]. The present study demonstrates that a minority of PwMCI show a pattern that is more like that of the majority of PwD, and it would be of interest to investigate whether and how this relates to the likelihood of progression to dementia.…”

Section: Discussionmentioning

confidence: 53%

Memory Awareness Profiles Differentiate Mild Cognitive Impairment from Early-Stage Dementia: Evidence from Assessments of Performance Monitoring and Evaluative Judgement

Clare¹,

Whitaker

Roberts³

et al. 2013

Dement Geriatr Cogn Disord

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Background: Measures of memory awareness based on evaluative judgement and performance monitoring are often regarded as equivalent, but the Levels of Awareness Framework suggests they reflect different awareness phenomena. Examination of memory awareness among groups with differing degrees of impairment provides a test of this proposition. Method: Ninety-nine people with dementia (PwD), 30 people with mild cognitive impairment (PwMCI), and their relatives completed isomorphic performance monitoring and evaluative judgement measures of memory awareness and were followed up at 12 and (PwD only) 20 months. In addition to the resulting awareness indices, comparative accuracy scores were calculated using the relatives' data to establish whether any inaccuracy was specific to self-ratings. Results: When making evaluative judgements about their memory in general, both PwD and PwMCI tended to overestimate their own functioning relative to informant ratings made by relatives. When monitoring performance on memory tests, PwD again overestimated performance relative to test scores, but PwMCI were much more accurate. Comparative accuracy scores indicated that, unlike PwD, PwMCI do not show a specific inaccuracy in self-related appraisals. Conclusions: The results support the proposition that awareness indices at the levels of evaluative judgement and performance monitoring should be regarded as reflecting distinct awareness phenomena.

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Section: Discussionmentioning

confidence: 53%

Memory Awareness Profiles Differentiate Mild Cognitive Impairment from Early-Stage Dementia: Evidence from Assessments of Performance Monitoring and Evaluative Judgement

Clare¹,

Whitaker

Roberts³

et al. 2013

Dement Geriatr Cogn Disord

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“…14,[20][21][22][23] Our multivariate regression analyses also illustrate the importance of specific cognitive abilities to treatment consent capacity, in particular short-term verbal memory and semantic knowledge. 13,24,25 However, the degree to which specific vs generalized cognitive impairment is related to decisional capacity in MG still remains an important empirical question. 26 We also investigated the relationships between demographic and clinical variables with performance on the CCTI standards.…”

Section: Resultsmentioning

confidence: 99%

Medical decision-making capacity in patients with malignant glioma

Triebel

Martin²,

Nabors³

et al. 2009

Neurology

108

135

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Objective: Patients with malignant glioma (MG) must make ongoing medical treatment decisions concerning a progressive disease that erodes cognition. We prospectively assessed medical decisionmaking capacity (MDC) in patients with MG using a standardized psychometric instrument.Methods: Participants were 22 healthy controls and 26 patients with histologically verified MG.Group performance was compared on the Capacity to Consent to Treatment Instrument (CCTI), a psychometric measure of MDC incorporating 4 standards (choice, understanding, reasoning, and appreciation), and on neuropsychological and demographic variables. Capacity outcomes (capable, marginally capable, or incapable) on the CCTI standards were identified for the MG group. Within the MG group, scores on demographic, clinical, and neuropsychological variables were correlated with scores on each CCTI standard, and significant bivariate correlates were subsequently entered into exploratory stepwise regression analyses to identify multivariate cognitive predictors of the CCTI standards. Results:Patients with MG performed significantly below controls on consent standards of understanding and reasoning, and showed a trend on appreciation. Relative to controls, more than 50% of the patients with MG demonstrated capacity compromise (marginally capable or incapable outcomes) in MDC. In the MG group, cognitive measures of verbal acquisition/recall and, to a lesser extent, semantic fluency predicted performance on the appreciation, reasoning, and understanding standards. Karnofsky score was also associated with CCTI performance. Conclusions:Soon after diagnosis, patients with malignant glioma (MG) have impaired capacity to make treatment decisions relative to controls. Medical decision-making capacity (MDC) impairment in MG seems to be primarily related to the effects of short-term verbal memory deficits. Ongoing assessment of MDC in patients with MG is strongly recommended. Neurology Malignant gliomas (MGs), which include glioblastoma multiforme (GBM), anaplastic astrocytoma, and anaplastic oligodendrogliomas, are among the deadliest of the primary CNS cancers. Even with the most intensive treatment, the overall median survival of individuals with GBM is only approximately 14.6 months from time of diagnosis.1 Because of the effects of the brain tumor and associated treatments, patients with MG experience a variety of physical, cognitive, and psychiatric changes that cause substantial disability. 2-4Medical decision-making capacity (MDC), also referred to as consent capacity, is a higher-order functional capacity that is relevant for patients with MG and their families and for clinicians involved in their care. Because of their aggressive, often terminal illness, patients with MG and their families must make ongoing and challenging medical decisions in a disease that progressively and rapidly erodes cognition. 5 Clinicians, in turn, are legally and ethically required to ensure that their patients are capable of providing valid consent before initiating ...

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“…8,14,17,21 The selective decline in understanding is, therefore, consistent with the cardinal amnestic deficits of patients with MCI. 4,29,30 This interpretation is supported by longitudinal studies of cognitive change in MCI that have demonstrated greater rates of decline in episodic and semantic memory relative to other cognitive abilities. 27,31 These findings provide insights into how MDC declines in MCI.…”

Section: Effect Of Conversion To Dementia On MDC Trajectorymentioning

confidence: 85%

“…As assessed using the CCTI vignette method, this standard requires comprehensive factual knowledge and understanding of the treatment situation and choices, and, accordingly, relies heavily on intact short-term verbal memory. 8,21,29 The reliance on short-term memory makes it a uniquely challenging standard for persons with AD and related dementias. 8,14,17,21 The selective decline in understanding is, therefore, consistent with the cardinal amnestic deficits of patients with MCI.…”

Section: Effect Of Conversion To Dementia On MDC Trajectorymentioning

confidence: 99%

Medical decision-making capacity in mild cognitive impairment

et al. 2008

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Objective: To investigate longitudinal change in the medical decision-making capacity (MDC) of patients with amnestic mild cognitive impairment (MCI) under different consent standards.Methods: Eighty-eight healthy older controls and 116 patients with MCI were administered the Capacity to Consent to Treatment Instrument at baseline and at 1 to 3 (mean ϭ 1.7) annual follow-up visits thereafter. Covariate-adjusted random coefficient regressions were used to examine differences in MDC trajectories across MCI and control participants, as well as to investigate the impact of conversion to Alzheimer disease on MCI patients' MDC trajectories.Results: At baseline, MCI patients performed significantly below controls only on the three clinically relevant standards of appreciation, reasoning, and understanding. Compared with controls, MCI patients experienced significant declines over time on understanding but not on any other consent standard. Conversion affected both the elevation (a decrease in performance) and slope (acceleration in subsequent rate of decline) of MCI patients' MDC trajectories on understanding. A trend emerged for conversion to be associated with a performance decrease on reasoning in the MCI group. Conclusions: Medical decision-making capacity (MDC) decline in mild cognitive impairment (MCI)is a relatively slow but detectable process. Over a 3-year period, patients with amnestic MCI show progressive decline in the ability to understand consent information. This decline accelerates after conversion to Alzheimer disease (AD), reflecting increasing vulnerability to decisional impairment. Clinicians and researchers working with MCI patients should give particular attention to the informed consent process when conversion to AD is suspected or confirmed. Neurology ® 2008;

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

Cited by 73 publications

References 49 publications

Memory Awareness Profiles Differentiate Mild Cognitive Impairment from Early-Stage Dementia: Evidence from Assessments of Performance Monitoring and Evaluative Judgement

Memory Awareness Profiles Differentiate Mild Cognitive Impairment from Early-Stage Dementia: Evidence from Assessments of Performance Monitoring and Evaluative Judgement

Medical decision-making capacity in patients with malignant glioma

Medical decision-making capacity in mild cognitive impairment

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