Decision-making in patients with dementia linked to biological, external factors
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CHICAGO — Impairments in decision-making may be among the earliest signs of cognitive decline, according to a presenter at the 2022 American Neurological Association annual meeting.
“For patients with dementia, decisional impairments can be among the most consequential and catastrophic manifestations,” Winston Chiong, MD, PhD, associate professor at the University of California San Francisco Memory and Aging Center, said. “There’s an interesting statistic that about 40% of the wealth in this country is controlled by people aged 65 and up.”
Age-related decline in decision-making is massively consequential from a policy standpoint, Chiong said, and these types of impairments are often the earliest signals of cognitive decline, with many family members and clinicians initially failing to recognize them as such. While key decisions are not made in a vacuum and instead arise from complex contexts such as family relationships, gender roles, supervision, and vulnerability, data is difficult to obtain.
According to Chiong, many population-based surveys exclude those with dementia, and cases of elder abuse or financial mismanagement are often not reported. The United Kingdom, Singapore, Czech Republic and Ireland have enacted legislation in the last decade to codify criteria for decision-making capacity.
Defining capacity within binary definitions of capable and incapable needs to be addressed as well, Chiong said. Within progression of cognitive decline and onset of dementia, clinicians can rarely pinpoint a time when a patient goes from being able to make decisions for themselves and needing someone to act on their behalf medically and financially.
Clinical tests to measure impulsivity in decision making have been developed and include delay discounting, where individuals suspected of having cognitive difficulty are asked simple questions regarding immediate and long-term financial gains. However, these tests are not clear indicators, Chiong said, and it may not be wise to assume errant discount function is limited to those at risk for dementia.
Differences in decision-making are also complicated by the type of disease, he continued, as cognition related Alzheimer’s disease typically does not affect an individual’s patience or impulsivity but may be related to risk-reward choices. With dementia, suboptimal choosing is likely associated with loss of memory retrieval capabilities.
“The appropriateness of decision support might depend on the specific nature of someone’s decision impairment,” Chiong said. “If people have different preferences about time, or if people just don’t care as much about negative outcomes ... decisional help could be more or less helpful.”