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Article
August 1990

Impact of Medical Hospitalization on Treatment Decision-Making Capacity in the Elderly

Arch Intern Med. 1990;150(8):1717-1721. doi:10.1001/archinte.1990.00040031717022
Abstract

A growing population of hospitalized elderly will need to make an increasing number of treatment decisions. No generally accepted criteria currently exist to assess the decision-making capacity of these elders. In this study, three hypothetical clinical vignettes were developed to assess treatment decision-making capacity in 25 presumably competent, medically ill, nondistressed, hospitalized elders and 25 healthy, age- and education-matched controls. The patients' understanding of the vignettes was evaluated and compared with their understanding of a standard consent form; with their performance on a mini-mental state examination; and with physician judgments about their decisional capacity. Vignette results indicate a significant difference between study and control groups in understanding of key treatment issues. Healthy controls demonstrated a better understanding of these issues. Twenty-eight percent of the patients had significant decisional impairments by vignette assessment but were not identified by mental status scores or physician judgments. Results suggest that presumably competent, medically ill elders may be at risk for developing decisional impairments during hospitalization for acute illness. Obtaining informed consent directly from many of these patients may not be feasible.

(Arch Intern Med. 1990;150:1717-1721).

References
1.
Riffer J.  Elderly 21 percent of the population by 2040 .  Hospitals. 1985;59:41-44.
2.
Brody SJ, Persily NA.  Hospitals and the Aged. Rockville, Md: Aspen Systems Corp; 1984.
3.
Davis D.  Aging and the health care systems: economic and structural issues .  Daedalus . 1986;15:227-246.
4.
Kokmen E, Okazaki H,  Schoenberg BS. Epidemiologic patterns and clinical features of dementia in a defined US population .  Trans Am Neurol Assoc. 1980;105:334-336.
5.
Akesson HO.  A population study of senile arteriosclerotic psychoses .  Hum Hered. 1969;19:546-566.Crossref
6.
Broe GA, Akhtar AJ, Andrews GR, Caird FI, Gilmore AJJ, McLennan WJ.  Neurologic disorders in the elderly at home .  J Neurol Neurosurg Psychiatry. 1976;39:362-366.Crossref
7.
Kay DW, Beamish P, Roth M.  Old age mental disorders in NewcastleUpon-Tyne: a study of prevalence .  Br J Psychiatry. 1964;110:146-158.Crossref
8.
Molsa PK, Martilla RJ, Rinne UK.  Epidemiology of dementia in a Finnish population .  Acta Neurol Scand. 1982;65:541-552.Crossref
9.
Rocca WA, Amaducci LA, Schoenberg BS.  The epidemiology of dementia .  Ann Neurol. 1986;19:415-424.Crossref
10.
Kane RL, Kane RA.  Care of the aged: old problems in need of new solutions .  Science. 1978;200:913-919.Crossref
11.
Lee MA, Cassel CK.  The ethical and legal framework for the decision not to resuscitate .  West J Med. 1984;140:117-122.
12.
Rabin DL.  Physician care in nursing homes .  Ann Intern Med. 1981;94:126-127.Crossref
13.
Solon JA, Greenwalt LF.  Physicians' participation in nursing homes .  Med Care. 1971;12:486.Crossref
14.
Steinberg A, Fitten LJ, Kachuck N.  Patient participation in treatment decision-making in the nursing home: the issue of competence .  Gerontologist . 1986;26:362-365.Crossref
15.
Faden RR, Beauchamp TL.  A History and Theory of Informed Consent . New York, NY: Oxford University Press Inc; 1986.
16.
Culver CM, Gert B.  Philosophy in Medicine: Conceptual and Ethical Issues in Medicine and Psychiatry . New York, NY: Oxford University Press Inc; 1982.
17.
Friedman B. Competence,  marginal and otherwise: Concepts and ethics .  Int J Law Psychiatry. 1981;4:53-72.Crossref
18.
Roth LH, Meisel A, Lidz D.  Tests of competency to consent to treatment .  Am J Psychiatry. 1977;134:126-127.
19.
Stanley B, Guido J, Stanley M, et al.  The elderly patient and informed consent .  JAMA. 1984;252:1302-1306.Crossref
20.
Taub HA, Baker MT, Sturr JF.  Informed consent for research: effects of readability, patient age and education .  J Am Geriatr Soc. 1986;34:601-606.
21.
Taub HA.  Informed consent, memory and age.  Gerontologist . 1980;20:686-690.Crossref
22.
Taub HA, Kline G, Baker MT.  The elderly and informed consent: effects of vocabulary level and corrected feedback .  Exp Aging Res. 1981;7:137-146.Crossref
23.
Tymchuck AJ, Ouslander JG, Rahbar B, Fitten LJ.  Medical decisionmaking among elderly people in long term care .  Gerontologist . 1988;28:59-63.Crossref
24.
Fitten LJ, Hamann C, Evans G.  Relationship of cognitive impairment to decision-making competence in nursing home resident: development of a competence assessment protocol .  J Am Geriatr Soc. 1984;32(suppl):519.
25.
Folstein MF, Folstein SE, McHugh PR.  Mini-Mental State: a practical method of grading the cognitive state of patients for the clinician .  J Psychiatr Res. 1975;12:89-198.Crossref
26.
Flesch R.  The Art of Readable Writing . New York, NY: Harper & Row Publishers Inc; 1974.
27.
Drane JF.  Competency to give informed consent .  JAMA. 1984;252:925.Crossref
28.
Drane JF.  The many faces of competency .  Hastings Cent Rep. 1985;15:17-21.Crossref
29.
Sherlock R.  Competency to consent to medical care: toward a general view .  Gen Hosp Psychiatry. 1984;6:71-76.Crossref
30.
Melnik VL.  Senile dementia of the Alzheimer's type (SDAT) and related diseases: ethical and legal issues related to informed consent .  J Am Geriatr Soc. 1983;31:121-123.
31.
Meisel A, Roth LH.  What we do and do not know about informed consent .  JAMA. 1981;241:2473-2477.Crossref
32.
Kloesen S, Fitten LJ, Steinberg A.  Assessment of treatment decisionmaking capacity in a medically ill patient .  J Am Geriatr Soc. 1988;36:1055-1058.
33.
Stanley B.  Senile dementia and informed consent .  Behav Sci Law. 1983;1:57-72.Crossref
34.
Nottingham EJ, Mattson RE.  A validation study of the competency test .  Law Hum Behav. 1981;5:329-335.Crossref
35.
California Uniform Durable Power of Attorney for Health Care Act, CC2400-2423, ch 511 (1981).
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