Do adapted vignettes improve medical decision‐making capacity for individuals with Alzheimer's disease?

Medical decision‐making capacity (MDC) is known to decline in individuals with Alzheimer's disease (AD). The vignette method uses hypothetical information as a prerequisite for measuring the capacity to make well‐informed decisions to clinical trials. Our aim was to investigate if adapted vignettes can help individuals with mild AD to assimilate information, make decisions and express them in an understandable way, compared to corresponding decisions based on linguistically more demanding vignettes, as measured by the Swedish Linguistic Instrument for Medical Decision‐making (LIMD). Two vignettes from LIMD were altered linguistically with the aim to facilitate understanding for individuals with AD. An experimental within‐subject design was used to study the influence on MDC of readability (original/adapted vignettes) and content (two different clinical trials). We included 24 patients with mild AD in this prospective study, which read all four vignettes along with a few other tests. This allowed us to investigate the association between MDC and cognitive function. Adapted vignettes did not yield significant differences regarding MDC as compared with original vignettes using a two‐way repeated measures analysis of variance. A difference was found between the two clinical trials where LIMD score was significantly higher for Kidney disease than hypertension vignettes. Our results indicate that adapted vignettes may not improve MDC for individuals with mild AD. MDC was affected by which clinical trial the vignettes regarded, which implies that other factors affecting MDC need to be investigated, like length of text and vocabulary used.     

The free and cued selective reminding test: Validation for mild cognitive impairment and Alzheimer's disease

The International Working Group on Alzheimer's disease (AD) suggested the free and cued selective reminding test (FCSRT) to assess memory, as it showed high sensitivity and specificity in the differentiation of AD from healthy controls and other dementias. The FCSRT involves the use of selective reminding with semantic cueing in memory assessment. This study aims to validate the FCSRT for mild cognitive impairment (MCI) and AD through the analysis of the diagnostic accuracy and the suggestion of cut‐off scores. Patients were classified into two groups according to standard criteria: MCI (n = 100) and AD (n = 70). A matched control group (n = 101) of cognitively healthy subjects was included. The reliability and the validity of the FCSRT were analysed on the immediate (IR) and delayed (DR) recalls. The Cronbach's alpha was 0.915 for the IR and 0.879 for the DR. The total recall measures revealed good areas under the curve for MCI (IR: .818; DR: .828) and excellent for AD (IR: .987; DR: .991). Furthermore, the MCI group was subdivided with respect to a non‐similar/similar AD pattern of impairment, with almost half of the subjects showing an AD‐like decline. This analysis represents a novel contribution regarding the properties of the FCSRT in illustrating the heterogeneity of MCI at baseline. The FCSRT has proved to be a very useful tool in the characterization of the memory impairment of the AD spectrum.     

Conscious knowledge influences decision‐making differently in substance abusers with and without co‐morbid antisocial personality disorder

Decision‐making impairment, as measured by the Iowa Gambling Task (IGT), is a consistent finding among individuals with substance use disorder (SUD). We studied how this impairment is influenced by co‐morbid antisocial personality disorder (ASPD) and conscious knowledge of the task. Three groups were investigated: SUD individuals without co‐morbid ASPD (n = 30), SUD individuals with co‐morbid ASPD (n = 16), and healthy controls (n = 17). Both SUD and SUD+ASPD participants had poor overall IGT performance. A block‐by‐block analysis revealed that SUD participants exhibited slow but steady improvement across the IGT, whereas SUD+ASPD participants exhibited initial normal improvement, but dropped off during the last 40 trials. Conscious knowledge of the task was significantly correlated to performance for controls and SUD participants, but not for SUD+ASPD participants. Our findings suggest that decision‐making proceeds differently in SUD and SUD+ASPD individuals due to differences in acquisition and application of conscious knowledge.     

Age differences in financial decision making: The benefits of more experience and less negative emotions

The emerging literature on aging and decision making posits that decision‐making competence changes with age, as a result of age differences in various cognitive and noncognitive individual‐differences characteristics. In a national life‐span sample from the United Kingdom (N = 926), we examined age differences in financial decisions, including performance measures of sunk cost and credit card repayment decisions, and self‐report measures of money management and financial decision outcomes. Participants also completed four individual‐differences characteristics that have been proposed as relevant to financial decision making, including two cognitive ones (numeracy and experience‐based knowledge) and two noncognitive ones (negative emotions about financial decisions). First, we examined how age was related to the four financial decision‐making measures and the four individual‐differences characteristics. Older age was correlated to better scores on each of the four financial decision‐making measures, more experience‐based knowledge, less negative emotions about financial decisions, whereas numeracy and motivation were not significantly correlated with age. Second, we found that considering both the two cognitive and the two noncognitive individual‐differences characteristics increased predictions of financial decision making, as compared with considering either alone. Third, we examined how these four individual‐differences characteristics contributed to age differences in financial decision making. Older adults' higher levels of experience‐based knowledge and lower levels of negative emotions seemed to especially benefit their financial decision making. We discuss implications for theories on aging and decision making, as well as for interventions targeting financial decisions.     

Mental capacity and the applied phenomenology of judgement

We undertake to bring a phenomenological perspective to bear on a challenge of contemporary law and clinical practice. In a wide variety of contexts, legal and medical professionals are called upon to assess the competence or capacity of an individual to exercise her own judgement in making a decision for herself. We focus on decisions regarding consent to or refusal of medical treatment and contrast a widely recognised clinical instrument, the MacCAT-T, with a more phenomenologically informed approach. While the MacCAT-T focuses attention on individual cognitive performance criteria, an approach oriented by second-person phenomenology brings into view the complex role of time, others and identity in constituting the capacity for individual autonomous judgement. Our phenomenological analysis has consequences both for the practice of capacity assessments and for further research in this arena. Good practice in capacity assessment must attend to decision communities, distributed capacity, and temporal competence, while research on mental capacity will miss the phenomenon if it trains its focus ‘between the ears.’ We illustrate our approach by considering two recent cases of contested capacity: one involving cognitive disability in a dysfunctional decision community, the second presenting the possibility of competent decision-making under conditions of paranoid schizophrenia.     

Correlation between functional mobility and cognitive performance in older adults with cognitive impairment

Association between cognitive impairment and gait performance occurs in mild cognitive impairment (MCI) and Alzheimer‘s disease (AD), particularly under “divided attention” conditions, leading to a greater risk of falls. We studied 36 controls, 42 MCI, and 26 mild AD patients, using the Timed Up-and-Go test (TUG) under four conditions: TUG single – TUG1; TUG cognitive – TUG2; TUG manual –TUG3; TUG cognitive and manual – TUG4. Cognition was assessed using the MMSE, SKT, Exit25, and TMT (A and B). We found significant correlations between cognitive scores and TUG2 [r values (MMSE: –0.383, TMT-A: 0.430, TMT-B: 0.386, Exit25: 0.455, SKT: 0.563)] and TUG4 [(MMSE: –0.398, TMT-A: 0.384, TMT-B: 0.352,Exit25: 0.466, SKT: 0.525)] in the AD group, and between all TUG modalities and SKT in MCI and AD. Our results revealed that functional mobility impairment in cognitive dual tasks correlated to cognitive decline in AD patients and to attention and memory impairment in MCI.     

Alteration of affective Theory of Mind in amnestic mild cognitive impairment

The concept of amnestic mild cognitive impairment (aMCI) concerns a population of older individuals at high risk of developing probable Alzheimer's disease (AD). Impairments of the cognitive component of Theory of Mind (ToM), that is the inference about other people's beliefs, have been well documented in AD; on the contrary, controversial findings have been reported on the affective component of ToM (inference about other's feelings), a process mainly based on medial portions of the prefrontal cortex. The current study aimed at evaluating the affective component of ToM in aMCI subjects. Twenty aMCI subjects and 20 age‐matched healthy controls (HC) underwent a standard neuropsychological assessment and the assessment of affective ToM with the full 36‐item version of reading the mind in the eyes (RME). Although aMCI subjects had formal impaired performances only in memory tasks, HC outperformed aMCI subjects in several cognitive tasks, including also the RME (mean RME scores 21.7 ± 3.0 vs. 17.0 ± 3.8%; 60.3% of correct answers vs. 47.2%). The lower RME performance of aMCI patients provides the first empirical evidence that aMCI may be associated with difficulties in tasks of affective ToM, in accordance with recent findings of early difficulties of aMCI patients in other processes that are mainly dependent on the medial prefrontal cortex, such as reversal learning and decision making under ambiguity. Findings of the current study need further empirical confirmation in larger samples of aMCI patients and also the investigation of other MCI subtypes is needed.     

Parental rearing behavior prospectively predicts adolescents’ risky decision‐making and feedback‐related electrical brain activity

The present study examined the role of parental rearing behavior in adolescents’ risky decision‐making and the brain's feedback processing mechanisms. Healthy adolescent participants (n = 110) completed the EMBU‐C, a self‐report questionnaire on perceived parental rearing behaviors between 2006 and 2008 (T1). Subsequently, after an average of 3.5 years, we assessed (a) risky decision‐making during performance of the Balloon Analogue Risk Task (BART); (b) event‐related brain potentials (ERPs) elicited by positive (gain) and negative feedback (loss) during the BART; and (c) self‐reported substance use behavior (T2). Age‐corrected regression analyses showed that parental rejection at T1 accounted for a unique and significant proportion of the variance in risk‐taking during the BART; the more adolescents perceived their parents as rejecting, the more risky decisions were made. Higher levels of perceived emotional warmth predicted increased P300 amplitudes in response to positive feedback at T2. Moreover, these larger P300 amplitudes (gain) significantly predicted risky decision‐making during the BART. Parental rearing behaviors during childhood thus seem to be significant predictors of both behavioral and electrophysiological indices of risky decision‐making in adolescence several years later. This is in keeping with the notion that environmental factors such as parental rearing are important in explaining adolescents’ risk‐taking propensities.     

Cognitive deficits of executive functions and decision‐making in obsessive‐compulsive disorder

The nature of cognitive deficits in obsessive‐compulsive disorder (OCD) is characterized by contradictory findings in terms of specific neuropsychological deficits. Selective impairments have been suggested to involve visuospatial memory, set shifting, decision‐making and response inhibition. The aim of this study was to investigate cognitive deficits in decision‐making and executive functioning in OCD. It was hypothesized that the OCD patients would be less accurate in their responses compared to the healthy controls in rational decision‐making on a version of the Cambridge gambling task (CGT) and on the color‐word interference test and on a version of the Tower of Hanoi test (tower test) of executive functioning. Thirteen participants with OCD were compared to a group of healthy controls (n = 13) matched for age, gender, education and verbal IQ. Results revealed significant differences between the OCD group and the healthy control group on quality of decision‐making on the CGT and for achievement score on the tower test. On these two tasks the OCD group performed worse than the healthy control group. The symptom‐dimension analysis revealed performance differences where safety checking patients were impaired on the tower test compared to contamination patients. Results are discussed in the framework of cognition and emotion processing and findings implicate that OCD models should address, specifically, the interaction between cognition and emotion. Here the emotional disruption hypothesis is forwarded to account for the dysfunctional behaviors in OCD. Further implications regarding methodological and inhibitory factors affecting cognitive information processing are highlighted.     

Tool use in neurodegenerative diseases: Planning or technical reasoning?

Recent works showed that tool use can be impaired in stroke patients because of either planning or technical reasoning deficits, but these two hypotheses have not yet been compared in the field of neurodegenerative diseases. The aim of this study was to address the relationships between real tool use, mechanical problem‐solving, and planning skills in patients with Alzheimer's disease (AD, n = 32), semantic dementia (SD, n = 16), and corticobasal syndrome (CBS, n = 9). Patients were asked to select and use ten common tools, to solve three mechanical problems, and to complete the Tower of London test. Motor function and episodic memory were controlled using the Purdue Pegboard Test and the BEC96 questionnaire, respectively. A data‐transformation method was applied to avoid ceiling effects, and single‐case analysis was performed based on raw scores and completion time. All groups demonstrated either impaired or slowed tool use. Planning deficits were found only in the AD group. Mechanical problem‐solving deficits were observed only in the AD and CBS groups. Performance in the Tower of London test was the best predictor of tool use skills in the AD group, suggesting these patients had general rather than mechanical problem‐solving deficits. Episodic memory seemed to play little role in performance. Motor dysfunction tended to be associated with tool use skills in CBS patients, while tool use disorders are interpreted as a consequence of the semantic loss in SD in line with previous works. These findings may encourage caregivers to set up disease‐centred interventions.     

Influence of following vehicle’s tailway and classification on subject driver’s response to the circular yellow indication

Traffic crashes at signalized intersections are frequently linked to driver behavior at the onset of the circular yellow (CY) indication. To better understand behavioral factors that influence a driver’s decision to stop or go at an intersection, this study analyzed the behavior of the driver of a subject vehicle at the onset of the CY indication. Driver performance data from 53 participants were collected in the Oregon State University Driving Simulator, simulating scenarios of driving through high-speed intersections under various conditions. Data included interactions where the driver stopped at the stop line (n = 644) or proceeded through the intersection (n = 628) in response to a CY indication. Data were analyzed as panel data while considering 12 indicator variables related to the driver’s stop/go decision. These indicator variables included time to stop line (TTSL), tailway time, following vehicle type, vehicle speed at the onset of the CY indication, and demographics (age, gender, driving experience, level of education, personal vehicle type, number of times driving per week, number of miles driving last year, participation in previous simulation studies. A random-parameter binary logit model was used to determine contributing factors for driver decision making at the onset of CY indication while accounting for unobserved heterogeneity. Four indicator variables were significantly related to the driver’s stop/go decision, but three factors varied across observations. Findings showed that a driver’s stop/go decision in response to a CY indication was associated with the time to the stop line (TTSL), tailway time to the following vehicle, subject vehicle speed at the onset of the CY indication, and driver’s age (20–36 years), but was not significantly associated with classification of the following vehicle. Also, the findings indicated that a shorter tailway increased a subject driver’s red-light running frequency. These findings provide insights into variables that affect driver decisions in a vehicle-following situation at the onset of the CY indication. This information can help make better decisions in smart traffic control systems such as to extend/decrease the green interval slightly to avoid decisions that are more difficult.     

Neuropsychological predictors of conversion to probable Alzheimer disease in elderly with mild cognitive impairment

In the field of neuropsychology, it is essential to determine which neuropsychological tests predict Alzheimer's disease (AD) in people with mild cognitive impairment (MCI) and which cut‐off points should be used to identify people at greater risk for converting to dementia. The aim of the present study was to analyse the predictive value of the cognitive tests included in a neuropsychological battery for conversion to AD among MCI participants and to analyse the influence of some sociodemographic variables – sex, age, schooling – and others, such as follow‐up time and emotional state. A total of 105 participants were assessed with a neuropsychological battery at baseline and during a 3‐year follow‐up period. For the present study, the data were analysed at baseline. During the follow‐up period, 24 participants (22.85%) converted to dementia (2.79 ± 1.14 years) and 81 (77.14%) remained as MCI. The logistic regression analysis determined that the long delay cued recall and the performance time of the Rey figure test were the best predictive tests of conversion to dementia after an MCI diagnosis. Concerning the sociodemographic factors, sex had the highest predictive power. The results reveal the relevance of the neuropsychological data obtained in the first assessment. Specifically, the data obtained in the episodic verbal memory tests and tests that assess visuospatial and executive components may help to identify people with MCI who may develop AD in an interval not longer than 4 years, with the masculine gender being an added risk factor.     

Visual Imagery Processing and Knowledge of Famous Names in Alzheimer's Disease and MCI

ABSTRACT

The study of memory for famous people and visual imagery retrieval was investigated in patients in the early stages of Alzheimer's disease (AD) and in the prodromal stage of AD, so-called Mild Cognitive Impairment (MCI). Fifteen patients with AD (MMSE ≥23), 15 patients with amnestic MCI (a-MCI) and 15 normal controls (NC) performed a famous names test designed to evaluate the semantic and distinctive physical features knowledge of famous persons. Results indicated that patients with AD and a-MCI generated significantly less physical features and semantic biographical knowledge about famous persons than did normal control participants. Additionally, significant differences were observed between a-MCI and AD patients in all tasks. The present findings confirm recent studies reporting semantic memory impairment in MCI. Moreover, the current findings show that mental imagery is lowered in a-MCI and AD and is likely related to the early semantic impairment.     

Psychometric properties of the Norwegian version of the Childhood Trauma Questionnaire in high‐risk groups

The Childhood Trauma Questionnaire ‐ Short Form (CTQ‐SF) is widely used to measure childhood abuse of all types. In the present study, we examined the psychometric properties of the Norwegian version of the instrument. The participants constituted four subsamples (n = 517): substance abusers (n = 126), psychiatric patients (n = 210), prisoners (n = 109) and adolescents in out‐of‐home placements (n = 72). Confirmatory factor analysis revealed a reasonable fit of the data to the original five‐factor structure of the CTQ‐SF. Measurement invariance was found across gender and the four subsamples. It was concluded that the Norwegian version of the CTQ‐SF has acceptable psychometric properties, with good reliability and satisfactory accuracy, to assess different dimensions of childhood trauma.     

The gap between medical and monetary choices under risk persists in decisions for others

Decisions under risk in the medical domain have been found to systematically diverge from decisions in the monetary domain. When making choices between monetary options, people commonly rely on a decision strategy that trades off outcomes with their probabilities; when making choices between medical options, people tend to neglect probability information. In two experimental studies, we tested to what extent differences between medical and monetary decisions also emerge when the decision outcomes affect another person. Using a risky choice paradigm for medical and monetary decisions, we compared hypothetical decisions that participants made for themselves to decisions for a socially distant other (Study 1) and to recommendations as financial advisor or doctor (Study 2). In addition, we examined people's information search in a condition in which information about payoff distributions had to be learned from experiential sampling. Formal modeling and analyses of search behavior revealed a similarly pronounced gap between medical and monetary decisions in decisions for others as in decisions for oneself. Our results suggest that when making medical decisions, people try to avoid the worst outcome while neglecting its probability—even when the outcomes affect others rather than themselves.     

Decision Pattern Analysis as a General Framework for Studying Individual Differences in Decision Making

This paper investigated decision pattern analysis (DPA) as a general and standard framework for studying individuals' consistent decision making behavior within and between contexts. DPA classifies decisions on the basis of judgement accuracy and the goal orientation of the decided‐upon action. Over repeated decisions, patterns of individuals' decision behavior are described by five variables: competence, optimality, recklessness, hesitancy and decisiveness. A fictitious medical decision making test and three standard cognitive ability tests (extended with confidence ratings and a ‘submit answer for marking’ decision) were used to investigate the psychometric properties of these DPA variables. Internal consistency of the decision patterns ranged from good to excellent. Convergent validity was assessed via cognitive abilities, metacognitive confidence and a control criterion imposed on confidence that determines the decision to be made: the point of sufficient certainty. Personality variables were included to assess discriminant validity. As hypothesised, cognitive abilities showed positive correlations with competence and optimality. High confidence, low points of sufficient certainty and a greater discrepancy between them were associated with higher decisiveness and recklessness, and lower hesitancy. Personality measures showed mixed and generally weak correlations with the DPA variables. These convergent and discriminant results also held after controlling for all variables in regression. The results provide preliminary psychometric support for DPA as a general framework of behavioral decision making. DPA has the potential to be exploited in many contexts for uses that, to date, have been unachievable in a psychometrically valid manner. Copyright © 2015 John Wiley & Sons, Ltd.     

Accepting or Rejecting Medical Treatment: A Comparison of Decisions Made for Self Versus Those Made for a Significant Other1

College students (N= 52) made sets of hypothetical decisions concerning whether to accept or withhold medical treatment for oneself as well as for a significant other. Two sets of decisions were made for the significant other: a set representing what the significant other would want for himself or herself, and a set representing what the potential surrogate would want for the significant other. Results revealed consistent sets of decisions within each decision frame, considerable individual differences in mean judgments, an emphasis on the levels of mental and physical functioning, self‐reported decision weights that differed across the decision frames, and considerable self‐insight into the decision policy used when deciding for oneself.     

Ethical? Toward whom?

Comments on the original article, "Nonrational processes in ethical decision making" by M. D. Rogerson et al (see record 2011-19198-001). Among the many insightful points made by Rogerson, Gottlieb, Handelsman, Knapp, and Younggren (October 2011) regarding nonrational processes in ethical decision making, one deserves further explication: Many of psychologists' ethical decisions lead to actions done to someone. Unfortunately, frameworks and models of ethical decision making frequently neglect this fact by implying that the decisions happen in the abstract, but in truth, these decisions often affect a specific recipient. Importantly, the characteristics of that specific recipient, especially as perceived by the psychologist, can have a powerful impact on the process of ethical decision making (Caughron et al., 2011). It would be wise to add such a hypothetical to the list of specific questions that Rogerson et al recommended psychologists ask themselves: Would I make the same ethical decision if the person(s) toward whom the decision is directed had different characteristics?     

Identifying and Addressing Barriers to Treatment Decision‐making in Bipolar II Disorder: Clinicians’ Perspective

Objective

Treatment decision‐making in bipolar II disorder is complex due to limited evidence on treatment efficacy and potentially burdensome side‐effects of options. Thus, involving patients and negotiating treatment options with them is necessary to ensure that final treatment decisions balance both clinician and patient preferences. This study qualitatively explored clinician views on (a) effective treatment decision‐making, unmet patient needs for (b) decision‐support and (c) information.

Method

Qualitative semi‐structured interviews with 20 practising clinicians (n = 10 clinical psychologists, n = 6 general practitioners, n = 4 psychiatrists) with experience treating adult outpatients with bipolar II disorder were conducted. Interviews were audiotaped, transcribed verbatim and analysed thematically using framework methods. Self‐report professional experience, and clinician preferences for patient decision‐making involvement were also assessed.

Results

Qualitative analyses yielded two inter‐related themes: (a) challenges and barriers to decision‐making and (b) facilitators of clinician decision‐making. Symptom severity, negative family attitudes, system‐based factors, and information gaps were thought to pose challenges to decision‐making. By contrast, decision‐making was supported by patient information, family involvement and patient‐centredness, and a strong therapeutic relationship. Clinician views varied depending on their professional background (medical vs clinical psychologist), patient involvement preferences, and whether the clinician was a bipolar specialist.

Conclusions

Whilst clinicians uniformly recognise the importance of involving patients in informed treatment decision‐making, active patient participation is hampered by unmet informational and decision‐support needs. Current findings inform a number of bipolar II disorder‐specific, clinician‐endorsed strategies for facilitating patient decision‐making, which can inform the development of targeted patient decision‐support resources for use in this setting.     

Appropriateness of decisions as a moderator of the psychology of voice

This paper focuses on the psychology of the voice effect (the effect that people show more positive reactions when they are allowed an opportunity to voice their opinion in the decision‐making process than when they are denied such an opportunity). It is argued that it is important to ask about what decisions people are allowed voice. More specifically, results of two experiments suggest that when participation in decision making is appropriate (i.e. voice is allowed about decisions that are relatively important to participants) the voice effect is found: People's procedural judgements and other reactions are more positive following voice as opposed to no‐voice procedures. However, when participation in decision making is inappropriate (i.e. voice is allowed about decisions that are unimportant to participants) no effect or even a reversal of the voice effect is found. These people do not react differently or even react more negatively following voice as opposed to no‐voice procedures. It is concluded that these results further our insights into the psychology of procedural justice in general and voice in particular. Copyright © 2002 John Wiley & Sons, Ltd.