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Medical decision-making capacity in patients with mild cognitive impairment

From the Departments of Psychology (O.O.) and Neurology (H.R.G., K.B., S.L., L.E.H., J.C.B., D.C., D.C.M.) and Alzheimer's Disease Research Center (H.R.G., K.B., S.L., L.E.H., J.C.B., D.C., D.C.M.), University of Alabama at Birmingham; Veterans Administration Medical Center (L.E.H., D.C.), Birmingham, AL; Department of Neurology (E.Y.Z.), University of Utah Health Sciences, Salt Lake City; and Department of Family and Preventive Medicine and Neurosciences (R.R.), University of California San Diego.

Address correspondence and reprint requests to Dr. Daniel Marson, Department of Neurology, JT 1216, University of Alabama at Birmingham, Birmingham, AL 35233-7340 dmarson{at}uab.edu.

Objectives: To empirically assess the capacity of patients with amnestic mild cognitive impairment (MCI) to consent to medical treatment under different consent standards (Ss).

Methods: Participants were 56 healthy controls, 60 patients with MCI, and 31 patients with mild Alzheimer disease (AD). Each participant was administered the Capacity to Consent to Treatment Instrument (CCTI) and a comprehensive neuropsychological battery. Group differences in performance on the CCTI and neuropsychological variables were examined. In addition, the capacity status (capable, marginally capable, or incapable) of each MCI participant on each CCTI standard was examined using cut scores derived from control performance.

Results: Patients with MCI performed comparably to controls on minimal consent standards requiring merely expressing a treatment choice (S1) or making the reasonable treatment choice [S2], but significantly below controls on the three clinically relevant standards of appreciation (S3), reasoning (S4), and understanding (S5). In turn, the MCI group performed significantly better than the mild AD group on [S2], S4, and S5. Regarding capacity status, patients with MCI showed a progressive pattern of capacity compromise (marginally capable and incapable outcomes) related to stringency of consent standard.

Conclusions: Patients with amnestic mild cognitive impairment (MCI) demonstrate significant impairments on clinically relevant abilities associated with capacity to consent to treatment. In obtaining informed consent, clinicians and researchers working with patients with MCI must consider the likelihood that many of these patients may have impairments in consent capacity related to their amnestic disorder and related cognitive impairments.

GLOSSARY: AD = Alzheimer disease; ADRC = Alzheimer's Disease Research Center; CCTI = Capacity to Consent to Treatment Instrument; CVLT-II = California Verbal Learning Test, second edition; DRS-2 = Dementia Rating Scale, 2nd edition; GDS = Geriatric Depression Scale; MCI = mild cognitive impairment; MDC = medical decision-making capacity; MMSE = Mini-Mental State Examination; Ss = consent standards; WAIS-III = Wechsler Adult Intelligence Scale, third edition; WMS-III = Wechsler Memory Scale, third edition; WMS-R = Wechsler Memory Scale, revised edition; WRAT-3 = Wide Range Achievement Test, third edition.

Supported by grants 1R01 AG021927 (Marson, PI) and 1P50 AG16582 (Alzheimer's Disease Research Center) (Marson, PI) from the National Institute on Aging.

Disclosure: The capacity outcome measure used in the study is owned by the UAB Research Foundation (UABRF). Dr. Marson and Dr. Harrell receive royalty income through UABRF.

Received February 12, 2007. Accepted in final form April 27, 2007.

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