Medical decision-making capacity among geriatric patients with and without dementia : communication-based approaches for assessment and facilitation

Abstract

Introduction: Medical decision-making capacity concerns a patient’s cognitive abilities to make autonomous decisions regarding own person in medical contexts such as to choose treatment or accept/decline participation in research projects. Cognitive communicative functions are needed in order to process information, reach a decision and articulate it. Communication within medical decision-making processes requires receptive, cognitive communicative and expressive language skills. The overall aim of the thesis is to investigate medical decision-making capacity using communication based approaches to facilitation and assessment in geriatric patients with and without dementia.

Methods: Study I investigated whether participants at discharge planning meetings perceived better communication function in geriatric patients with cognitive impairment who had been prepared using the Talking mats method. Study II examined if medical decision-making capacity improved among patients with Alzheimer’s disease if written participant information were presented as linguistically adapted, more readable vignettes. The medical decision-making capacity was measured by Swedish linguistic instrument for medical decision-making. Study III developed a new test to assess medical decision-making capacity: Clinical instrument of medical decision-making capacity. The test was validated by comparing results between three groups: patients with Alzheimer’s disease, patients with Mild cognitive impairment and healthy controls. Test scores were compared to test results on designated linguistic and cognitive tests. Study IV used Clinical instrument of medical decision-making capacity to investigate the prevalence of impaired medical decision-making among geriatric in-patients without known cognitive impairment.

Results: Neither Talking mats nor Adapted vignettes was found to improve geriatric patients’ ability to participate in the specified medical decision-making processes. Clinical instrument of medical decision-making capacity showed good test properties. Positive correlations were found between preserved medical decision-making capacity and longer formal education, well-functioning overall cognition, high premorbid cognitive function, and scores on specific tests assessing e. g. comprehension and vocabulary. An unexpected finding was that the prevalence of impaired medical decision-making capacity was as high among in-patients with somatic conditions as among out-patients in early stage of Alzheimer’s disease.

Conclusions: Medical decision-making processes are difficult to participate in not only for patients with dementia but also for in-patients, regardless of whether a neurodegenerative process is present or not. A flow-chart was constructed from a cognitive communicative perspective. The purpose was to suggest a standardized way to promote the best possible participation and obtain the most accurate perception of the patient’s wishes when asking geriatric patients for informed consent.