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From the Departments of Medicine (Drs. Karlawish, Casarett, and James) and Biostatistics and Epidemiology (Dr. Xie) and Division of Geriatrics (Drs. Karlawish, Casarett, and James), University of Pennsylvania, Philadelphia Veterans Affairs Medical Center (Dr. Casarett), Alzheimer’s Disease Center (Drs. Karlawish, James, and Xie), Center for Bioethics (Drs. Karlawish and Casarett), and Center for Clinical Epidemiology and Biostatistics (Drs. Karlawish and Xie), and Leonard Davis Institute for Health Economics (Drs. Karlawish and Casarett), Philadelphia, PA, and Department of Psychiatry and Bioethics Program and Program for Improving Healthcare Decisions (Dr. Kim), Ann Arbor, MI.
Address correspondence and reprint requests to DrT. Karlawish, Institute on Aging, 3615 Chestnut St., Philadelphia, PA 19104; e-mail: jasonkar{at}mail.med.upenn.edu
Objective: To examine the severity of impairments in the decision-making abilities (understanding, appreciation, reasoning, and choice) and competency to make a decision to use an Alzheimer disease (AD)-slowing medication in patients with AD and the relationships between these impairments, insight, and overall cognition.
Methods: Semistructured in-home interviews were conducted with 48 patients with very mild to moderate AD and 102 family caregivers of patients with mild to severe AD recruited from the Memory Disorders Clinic of an AD center. The interview measured performance on the decision-making abilities and three expert psychiatrists’ judgment of competency based on their independent review of the patient interviews.
Results: There was considerable variation in patients’ performance on the measures of decision-making abilities. Three expert raters found 19 of 48 (40%) of the subjects competent. Competent patients were more likely to show awareness of their symptoms, prognosis, and diagnosis. A sensitivity analysis suggests that a MMSE score is helpful in discriminating capacity from incapacity only when below 19 or above 23.
Conclusions: Persons with mild to moderate Alzheimer disease (AD) have notable impairments in their ability to make an AD treatment decision, especially persons with moderate AD and persons who lack awareness of symptoms, prognosis, or diagnosis.
Editorial, see page 1494
Additional material related to this article can be found on the Neurology Web site. Go to www.neurology.org and scroll down the Table of Contents for the May 10 issue to find the title link for this article.
Supported by National Institute on Aging grants K01-AG00931 and P30-AG01024, a Paul Beeson Physician Faculty Scholars Award, and a Greenwall Faculty Scholar in Bioethics; by a Health Services Research Career Development Award from the Department of Veterans Affairs and a Paul Beeson Physician Faculty Scholars Award (D.J.C.); by National Institute of Mental Health grant K23-MH64172 (S.Y.H.K.); and National Institute on Aging grant P30-AG10124 (S.X.X.).
Received August 10, 2004. Accepted in final form January 20, 2005.
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