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December 3, 2018

Aphasic Binary Reversals in Patients With Neurological Disease as a Barrier to Clinical Decision Making

Author Affiliations
  • 1Dementia Research Centre, UCL Queen Square Institute of Neurology, University College London, London, United Kingdom
JAMA Neurol. 2019;76(2):234-235. doi:10.1001/jamaneurol.2018.3790

Assessing capacity and consent is often challenging in patients with aphasia, because they have impaired comprehension or an inability to articulate messages. We have recently encountered a further barrier to medical communication in patients with the nonfluent-agramatic variant of primary progressive aphasia (nfvPPA): binary reversals in which the patient, when required to choose between 2 opposing alternative responses, makes the wrong choice. This most often manifests as reversal of yes and no, but it may extend to other reversals (eg, up and down, his and her) in conversation, writing, or nonverbal gestures (eg, head nodding, head shaking, thumbs up, and thumbs down).1-3 Patients may subsequently correct the unintended response, but their true intentions are easily misinterpreted both in daily life and medical decision making. Supported decision making with patients with aphasia frequently depends on presenting information so that the individual can select a preferred option from binarized alternatives (usually, yes or no); this is a frequent feature of medical pro forma documentation (eg, the checklist of magnetic resonance imaging safety questions).4 Binary reversals render this process particularly problematic. While the problem can sometimes be circumvented by obtaining the information from a friend or family member, it is crucial in other situations to obtain the patient’s own views (for example, during consent to treatment or an assessment of mental capacity).