Even mild Alzheimer’s may impede decision-making

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People with moderate Alzheimer’s disease may have trouble making competent decisions about their treatment, especially if they lack awareness of their symptoms and diagnosis, new research shows.

Impairment in the ability to “understand, appreciate, and reason about taking an Alzheimer’s disease-slowing medicine” is particularly significant among patients with moderate-stage dementia, the researchers report in the medical journal Neurology.

Potential new therapies for Alzheimer’s disease—such as ‘vaccines’ that remove amyloid plaques in the brain—“are quite promising, but they may carry substantial risks and costs,” said Dr. Jason H. Karlawish.

"Getting the patient’s perspective on whether they want to take such treatments is important, but the patient may not be able to make the decision, “ he said. “They are, by definition, demented.”

Karlawish’s team, from the University of Pennsylvania in Philadelphia, gauged the decision-making abilities of 48 adults with very mild to moderate Alzheimer’s disease and 102 family caregivers. During interviews, patients were asked to decide whether or not to take a hypothetical treatment for the disease, based on information they were given about the potential benefits and risks.

Three psychiatrists judged only 19 of the 48 Alzheimer’s patients (40 percent) to be competent in making the decision.

For the most part, “persons with very mild Alzheimer’s disease typically retain the ability to make a decision to treat their own disease, while persons with moderate disease have substantial problems making a treatment decision,” Karlawish said. “In between, we find that mild stage Alzheimer’s disease patients have substantial variability in their abilities.”

The “second key finding” from the study was that patients’ insight into their diagnosis was an important factor in their ability to make a treatment decision, Karlawish noted.

This shows that telling someone that they have the disease, a step that is “feared by some physicians and families as harmful to a patient’s well-being—has a value to preserving a patient’s autonomy,” he stated

Commenting on the study, Dr. Michael McQuillen, a neurologist in Rochester, New York and co-author of an editorial, said this study “shows us that the mere presence of a dementia diagnosis does not preclude the patient from participating in decisions about his or her own care.”

SOURCE: Neurology, May 10, 2005.

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