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Capacity to Vote in Persons with Dementia and the Elderly

Capacity to Vote in Persons with Dementia and the Elderly SAGE-Hindawi Access to Research International Journal of Alzheimer’s Disease Volume 2011, Article ID 941041, 6 pages doi:10.4061/2011/941041 Research Article 1 2 2 Luis Javier Irastorza, Pablo Corujo, and Pilar Banuelos ˜ MHC Arganda, Juan de la Cierva 20, Arganda del Rey, 28500 Madrid, Spain Residencia de Personas Mayores de Arganda, CAM, Arganda del Rey, 28500 Madrid, Spain Correspondence should be addressed to Luis Javier Irastorza, ljirastorza@telefonica.net Received 14 November 2010; Revised 15 April 2011; Accepted 7 June 2011 Academic Editor: Vincenzo Solfrizzi Copyright © 2011 Luis Javier Irastorza et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The capacity to vote in patients with mental illness is increasingly questioned. The objective of this study is to evaluate this capacity in a group of subjects with dementia (Alzheimer’s disease) and other elderly subjects without dementia. With a sample of 68 subjects with dementia and 25 controls living in a senior residence, a transversal study was carried out over 4 months. Subjects were evaluated with the Mini-Mental State Examination (MMSE) and the Competence Assessment Tool for voting (CAT-V). The results were more positive for the Doe criteria (as part of the CAT-V), and a correlation was found with the MMSE in subjects with dementia and, to a lesser degree, in the controls. We conclude that the capacity to vote is related to cognitive deterioration and, within that, is more related to understanding and appreciation. 1. Introduction Our study attempts to resolve these questions in two ways: using the MMSE [6] as a cognitive variable and the Voting is a legal right in many countries. But the exercise of CAT-V as a voting test in two samples: one group of patients this right does not mean that all persons have the capacity with Alzheimer’s dementia living in a senior residence and to vote. There might be cases of people with the competence a second group of persons living in the same residence who to vote, but without the necessary capacity. For this reason, suffer no mental illness. there is increasingly more literature seeking a tool to evaluate the capacity to vote, for patients with dementia as well as 2. Materials and Methods other mental disorders, such as those hospitalized with acute symptoms, and so forth [1–4]. 2.1. Participants. The study included 68 patients residing In the evaluation of the capacity for the act of voting, in the Arganda del Rey Senior Residence, diagnosed with there are 6 questions that evaluate the functional abilities of Alzheimer’s dementia (according to DSM-IV-TR criteria) the person, based on the 4 standard decision-making abil- [7] and 25 subjects living in the same residence, but with ities: understanding, choice, reasoning, and appreciation. a MMSE score greater than 24 and no mental illness, who Some of these questions come from the standard question- participated on a voluntary basis. The severity of dementia naire of a federal court, related to understanding the nature was evaluated using the standard cut-off points in the Mini- of voting, understanding its effect and vote selection in Mental State Examination (MMSE): Mild, 20 to 23; moder- Maine, USA (Doe criteria) [5]. In addition, items have been ate, 12 to 19; severe, <12 [6]. Subjects were evaluated over a added incorporated in the CAT-V test [2]: comparative rea- 4-month period, from August to November 2010. They were soning, consequential reasoning, and appreciation. recruited randomly, given the high percentage of patients This instrument has been used in various studies [2–4]. with various types of dementia living in this residence. All However, doubt persists as to which items to use for screen- spoke Spanish. ing and to which persons. What should be the cutoff point? As a control group, 25 additional subjects were evaluated Should some items be weighted more than others? with the same criteria and lived in the same residence, 2 International Journal of Alzheimer’s Disease Table 1: Characteristics of 68 patients with Alzheimer’s dementia and 25 elderly subjects without mental illness of the Arganda Senior Residence who were evaluated for their capacity to vote. Dementia group Normal group Characteristics N %orrange N %orrange Sex Male 16 23.5 9 36 Female 52 76.5 16 64 Age 70–79 10 14.7 4 16 80–89 35 51.5 16 64 90–99 22 32.4 5 20 Age (M ±SD) 86.4 ± 7 61–99 84.5 ± 6.6 70–98 MMSE score (M±SD) 12.7 ± 6.30–22 26.8 ± 1.6 25–29 Possible scoring for MMSE ranges from 0 to 30, with higher score representing greater cognitive capacity. but were not diagnosed with any type of dementia or any 0 to 2 for consequential. Appreciation was also scored on a other mental illness (according to DSM-IV-TR) which could scale of 0 to 2. confound the results of the study. We used in the comparison of the means of the two groups the Student’s t-test (normal distribution) and the Mann-Whitney U test (abnormal distribution). In order to 2.2. Evaluation Instruments. We used the CAT-V to evaluate measure the association between qualitative variables, the the capacity to vote. The questions used were adapted from Chi-square and Fisher exact tests were used. the criteria for decision making: understanding, choice, reasoning, and appreciation. As previously stated, these are The Spearman correlation coefficient and the Kruskal- the Doe criteria: the voting capacity is applied according Wallis Chi-square tests were used to look at the associations to whether the subject understands the nature and effect of between the CAT-V measurements, and with respect to the the vote, the choice of candidate [2]. Besides, comparative MMSE scoring and sociodemographic characteristics. and consequential reasoning (comparatively reasons about the candidates and reasons the consequences for the voter) 2.4. Human Subject Protections. All participants or their and appreciation of the vote (appreciates the vote weighing caregivers gave verbal informed consent to participate in what candidate is chosen and who would be chosen in the the study. They were assured that the information they gave next election) are added to these Doe criteria in formulating would be used solely for the purposes of this study and they the CAT-V. The scoring of this is 2 if the performance was did not display apprehension in this regard. adequate; 1 if the performance was ordinary or doubtful; 0 if the subject is not capable of considering or answering the 3. Results question. Although our study did not look at interexaminer relia- 3.1. Characteristics of the Subjects. Sixty-eight (68) patients bility, we took into account the experience in another work with dementia and 25 elderly subjects without mental illness completed by the same authors [3], with the same tools. completed the study. Table 1 shows their demographic and After various training sessions on the test (CAT-V), we tried clinical characteristics. According to the MMSE, there were to adapt it to the Spanish voting system: here we do not 27 patients with severe dementia (39.7%), 33 with moderate choose between one candidate and another, as in the USA, dementia (48.5%), and 8 with mild dementia (11.8%) in the but among various political parties. Information was given to group of patients with dementia. There were no significant the participants about which political party would be chosen, differences in age or sex among the two groups, and as not which candidate. expected, there were differences in MMSE (F = 29.4; df = In addition, we used the MMSE [6] to evaluate cognitive 91; P< 0.0001). capacity, with the aforementioned scoring for severity of dementia. The DSM-IV-TR classification criteria were used to diag- 3.2. Development of the CAT-V and Its Subscales. Table 2 nose Alzheimer’s dementia and to exclude possible clinical shows the CAT-V scoring of the study participants. It appears cases in the group of control patients without dementia. that, from the sample of those with dementia, about half understood the nature and effect of the vote; this was not the 2.3. Data Analysis. Scores were given for the Doe criteria for case for the choice itself, in which 75% failed. Forty percent each participant, as a result of adding the points for under- (40%) obtained a 0 in total Doe criteria. The result is also standing of nature and effect of the vote, of 0 to 4 points, plus negative for reasoning, particularly comparative reasoning two for vote choice. In addition, we considered the scoring (0 score in 82%). In appreciation, however, more than 65% for reasoning, of 0 to 2 points for comparative and another achieved good scores. International Journal of Alzheimer’s Disease 3 Table 2: Scoring of the capacity to vote (CAT-V competency assessment tool for voting) of 68 patients with dementia and 25 controls (elderly without dementia). Alzheimer’s Elderly Item and score N % N % Doe criteria Understanding nature of the vote 2 18 26.5 24 96 1 18 26.5 1 4 0 32 46.1 0 — Understanding effect of the vote 26 8.8 18 72 1 24 35.3 7 28 0 38 55.9 0 — Vote choice 2 1 1.5 8 32 1 16 23.5 17 68 051 75 0 — Total Doe score 60 — 7 28 53 4.4 12 48 4 8 11.8 5 20 3 11 16.2 1 4 2 9 13.2 0 — 1 10 14.7 0 — 0 27 39.7 0 — Additional items Comparative reasoning 20 — 7 28 1 12 17.6 18 72 0 56 82.4 0 — Consequential reasoning 21 1.5 14 56 1 23 33.8 11 44 0 44 64.7 0 — Appreciation 2 13 19.1 21 84 1 32 47.1 4 16 0 23 33.8 0 — CAT-V.: test to evaluate the capacity to vote, created by Appelbaum et al., 2005 [2]. Descending order. According to Doe versus Rowe criteria for competence to vote of 2001 [5]. When we compare the CAT-V items in the two groups, associated with better development in MMSE (Figure 1). we observe significant differences: in understanding the The figure shows that all subjects with severe dementia nature of the vote (Chi-square, χ = 35.9; df = 2; P< (MMSE < 12) scored 1 or less on the Doe questions and all 0.0001), understanding the effect of the vote (χ = 42.5; df = those with mild dementia (except for one case that scored 1) 2; P< 0.0001), vote choice (χ = 46.5; df = 2; P< 0.0001), scored 3 or higher on the Doe score. But those with moderate comparative reasoning (χ = 56.4; df = 2; P< 0.0001), dementia had the greatest variability in the Doe, from 0 to 4. consequential reasoning (χ = 50.4; df = 2; P< 0.0001), In the same group of patients with dementia, the correla- and appreciation (χ = 34.1; df = 2; P< 0.0001). tion of MMSE and the CAT-V reasoning items is r = 0.635, N = 68, P< 0. 0001, bilateral sig.; high scores in MMSE 3.3. Relationship between CAT-V Scores and Severity of with greater reasoning development (r = 0.61, N = 68, P< Dementia and Normal Elderly and other Variables. In the 0.0001); except for one exception, all those who scored 2 have group of patients with dementia, there is a correlation be- 16 or more on MMSE. However, there are cases with mild tween the MMSE and the Doe criteria: r = 0.833, N = and moderate dementia that vary between 0 and 2 on the 68,P< 0.0001. High scores on the Doe questions are reasoning criteria. 4 International Journal of Alzheimer’s Disease Comparative reasoning No Doubtful Adequate 10 10 0 1 2 3 4 5 Doe Figure 1: Relation of Mini-Mental State Examination scores to Doe criteria in 68 patients with Alzheimer’s disease. Dementia In dementia’s group, the correlation between MMSE and Elderly appreciation is Kruskal-Wallis test, χ = 39.6; df = 2; P< Figure 2: Relation of Mini-Mental State Examination Scores to 0.0001. All patients with the maximum of 2 in appreciation scores on comparative reasoning for 68 patients with Alzheimer’s obtain a minimum of 15 on the MMSE. Here, moderate disease and 25 controls. dementia varies between 0 and 2 and mild between 1 and 2. Spearman correlations between MMSE and CAT-V items areasfollows. Consequential reasoning No Doubtful Adequate (1) With nature of vote: r = 0.744, P< 0.0001. With effect of vote: r = 0.738, P< 0.001. (2) Correlation between MMSE and the Doe item of vote choice continues to be significant (r = 0.478, P< 0.0001), with high scores in MMSE and in vote choice. However, scoring of moderate dementia varied a great deal (from 0 to 21). (3) With comparative reasoning: r = 0.392, P< 0.001. With consequential reasoning: r = 0.553, P< 0.0001. 17 There is a correlation between age, in the oldest range (90 to 99), and the Doe criteria (Kruskal-Wallis, χ = 12.86, df = 6, P = 0.045); the majority, save exceptions, of patients in this age group achieve scores of 3 or less in these criteria. In all other age ranges, as with sex, there are no significant 27 associations. When we compared the patients with dementia with the controls, elderly without dementia, we observed significant Dementia differences with the Mann-Whitney U statistic in the three Elderly Doe criteria together (U = 69.5, P< 0.0001), the reasoning items (U = 35.5, P< 0.0001), and appreciation item (U = Figure 3: Relation of Mini-Mental State Examination Scores to 252.5, P< 0.0001), affecting all CAT-V criteria (U = 29, scores on consequential reasoning for 68 patients with Alzheimer’s P< 0.0001). disease and 25 controls. Correlation between MMSE and Doe criteria is shown in Figures 2, 3,and 4 (two groups together, dementia and elderly groups). subjects without dementia or any other mental illness, using CAT-V. We observe that patients with dementia understand the 4. Discussion nature and effect of the vote (53% and 44%, resp.), and We believe that this is the first study comparing the capacity appreciate its consequences (66.2%) but do not do as well to vote in patients with Alzheimer’s dementia and in elderly when it is time to make a voting choice (25%) and to MMSE MMSE MMSE International Journal of Alzheimer’s Disease 5 Appreciation when a complete evaluation of capacity is necessary but is No Doubtful Adequate not informative about the specific deficits of capacity. One cognitive screening test is the MMSE, which correlates, as we have seen, with capacity tools, but is not very sensitive 5 or specific [9, 10]. The MMSE has been used to evaluate consent for treat- ment, with similar results [11, 12], or in relation to the loss of autonomy, lack of judgment and capacity to make decisions [13, 14]. But, in other papers, evaluation of the capacity to vote has not been reliable [15, 16]. In our study, we also were unable to obtain a reliable cut-off:itisvalid forsevere dementia, but not as much for mild dementia and even less so for moderate dementia, nor has MMSE correlated with 19 different mental disorders (schizophrenia, mood disorders) or intellectual coefficient [4]. It seems that if we place a high threshold on the voting test, including the reasoning and appreciation items, various subjects remain outside that threshold although they do have the capacity to vote according to the Doe criteria. And if we focus on these, the vote choice item also presents difficulties [4]. We see that it is complicated that some subjects make a good voting choice, as in our study. If we try to interpret Dementia this, we can find other influential factors, such as the sub- Elderly jects’ access to information, proximity to the elections, and Figure 4: Relation of Mini-Mental State Examination Scores to cultural level. scores on appreciation for 68 patients with Alzheimer’s disease and There are studies that show that patients with mild and 25 controls. moderate dementia have a normal score in the subscales of appreciation and reasoning (in the MacArthur Clinical Research test) [17]. This test, which evaluates competency, consequential reasoning (35.3%). There is a correlation has been questioned for showing deterioration, and the among all the items with MMSE, that is, the lower the score, patient was capable of making decisions about treatment. the lower the capacity to vote, and those with mild dementia We also observe cases of normal consequential reasoning and usually retain the capacity to vote. We agree with another appreciation in moderate dementia. study that also used CAT-V and MMSE in patients with The voting test we used, the CAT-V, does correlate with dementia, but with less cognitive deterioration [2]. Other the MMSE in Alzheimer’s dementias, both in our study as in those of other authors [2, 3]. We advocate its use but authors have not found a correlation between the capacity to vote and reasoning [3] or with clinical (psychosis, bipolar with some clarifications: strengthen the vote choice item disorders) and cognitive variables [4]. Within this several with more information. This may be in contradiction with possible voting fraud or misapplication if we focus on im- mental disorder study, the authors verify that patients cor- rectly understand and reason their vote and appreciate its minent elections. But, at the time of the study, we observe associated consequences, like in our elderly control group. that many of the patients made mistakes. Reasoning and, to We observe that Doe scores are lower in the Applebaum study a lesser degree, appreciation are also questionable variables [2], although we agree in the same tendencies of variability in depending on the severity of the dementia. Thus, we could moderate dementia. not define a cutoff point in the CAT-V in relation to these Almost all patients with mild dementia had Doe scores items, particularly in those with moderate dementia and in greater than or equal to 2. We do not agree with the Raad subjects who want to vote. This last factor, not examined in our study, also does not correlate with the MMSE [18]. et al. study [4], with an MMSE higher than in our study, that did not find correlation between high MMSE scores and Nor do we know the cut-off point of the test if we Doe criteria for voting. This could indicate that dementias score more for appreciation than for reasoning. In our study, are more likely to affect the capacity to vote associated with the subjects perform better in terms of appreciation of the cognitive deterioration, and less so in other mental disorders. consequences of an election, the absence of false beliefs There are significant differences in scoring of the MMSE that direct own appreciation [19]. They also obtained better and CAT-V between both groups, as would be expected. results on consequential reasoning. This could be understood that the patients without mental This study has several limitations: not having performed illness, although they are elderly, and without cognitive an interexaminer reliability test and the small sample size. deterioration, have a greater capacity to vote. Therefore, in The first is addressed in part due to the authors’ knowledge this group, the MMSE does not serve as a predictor test of the test from other studies [3]. Patient daily activity and it does in patients with moderate dementia. As observed evaluation (ADL and IADL) was not used, either, searching by Pruchno et al. [8], cognitive screening serves to suggest cognitive deterioration more than functional one. MMSE 6 International Journal of Alzheimer’s Disease Understanding is related to memory, executive capacities Journal of the American Geriatrics Society, vol. 38, no. 10, pp. 1097–1104, 1990. and name comparison in dementia [20]. Appreciation is less associated with neurophysiological tests. Reasoning is related [10] S. Y. H. Kim and E. D. Caine, “Utility and limits of the mini mental state examination in evaluating consent capacity in dementia to working memory and executive functions [3]. in Alzheimer’s disease,” Psychiatric Services, vol. 53, no. 10, Future studies should look at the factor analysis of the pp. 1322–1324, 2002. MMSE items that correlate with the CAT-V, with ADL, and [11] V. Raymont, P. W. Bingley, A. Buchanan et al., “Prevalence IADL and with other sociodemographic variables. of mental incapacity in medical inpatients and associated risk factors: cross-sectional study,” The Lancet, vol. 364, no. 9443, 5. Conclusions pp. 1421–1427, 2004. [12] E. Etchells,P.Darzins,M.Silberfeldetal., “Assessmentof It is important to carry out an evaluation of the capacity to patient capacity to consent to treatment,” Journal of General vote on patients with moderate dementia. The MMSE and Internal Medicine, vol. 14, no. 1, pp. 27–34, 1999. the CAT-V test can be useful to this end. The criteria of un- [13] J. S. Huthwaite, R. C. Martin, H. R. Griffith, B. Anderson, L. derstanding and appreciation are easier for the patients, but E. Harrell, and D. C. Marson, “Declining medical decision- not those of vote choice and reasoning. Cognitive deteriora- making capacity in mild AD: a two-year longitudinal study,” tion, but not age, influences the capacity to vote. Behavioral Sciences and the Law, vol. 24, no. 4, pp. 453–463, [14] J. Karlawish, “Measuring decision-making capacity in cog- Authors’ Contribution nitively impaired individuals,” Neurosignals, vol. 16, no. 1, pp. 91–98, 2008. All authors contributed to the design of the study. P. Corujo and P. Banuelos ˜ identified the participants, did the individual [15] J. Karlawish, “Voting by older adults with cognitive impair- interviews and administered the neuropsychological scales. ments,” LDI Issue Brief, vol. 13, no. 4, pp. 1–4, 2008. L. J. Irastorza contributed to the analysis and interpretation [16] A. Blais, L. Massicotte, and A. Yoshinaka, “Deciding who has the right to vote: a comparative analysis of election laws,” of data, drafted the article and revised. Electoral Studies, vol. 20, no. 1, pp. 41–62, 2001. [17] S. Y. H. Kim, E. D. Caine,G.W.Currier,A.Leibovici,and J. M. Conflict of Interests Ryan, “Assessing the competence of persons with Alzheimer’s disease in providing informed consent for participation in All authors declare that they have no financial interest that research,” American Journal of Psychiatry, vol. 158, no. 5, may be relevant to the submitted work; only we received help pp. 712–717, 2001. for translation of the text by S. A. Andromaco-Grunnenthal. [18] A. Bosquet, A. Medjkane, D. Voitel-Warneke, P. Vinceneux, and I. Mahe, ´ “The vote of acute medical inpatients: a prospec- References tive study,” Journal of Aging and Health, vol. 21, no. 5, pp. 699– 712, 2009. [1] J.H.T.Karlawish andC.M.Clark,“Diagnostic evaluation [19] E. R. Saks, L. B. Dunn, B. J. Marshall, G. V. Nayak, S. of elderly patients with mild memory problems,” Annals of Golshan, and D. V. Jeste, “The California scale of appreciation: Internal Medicine, vol. 138, no. 5, pp. 411–419, 2003. a new instrument to measure the appreciation component of [2] P. S. Appelbaum, R. J. Bonnie, and J. H. Karlawish, “The capacity to consent to research,” American Journal of Geriatric capacity to vote of persons with Alzheimer’s disease,” American Psychiatry, vol. 10, no. 2, pp. 166–174, 2002. Journal of Psychiatry, vol. 162, no. 11, pp. 2094–2100, 2005. [20] M. P. Dymek, P. Atchison, L. Harrell, and D. C. Marson, [3] L.J.Irastorza,P.Corujo,and P. Banuelos, ˜ “The competence to “Competency to consent to medical treatment in cognitively vote in patients with dementia,” Revista de Neurologia, vol. 44, impaired patients with Parkinson’s disease,” Neurology, vol. 56, no. 6, pp. 321–325, 2007. no. 1, pp. 17–24, 2001. [4] R. Raad, J. Karlawish, and P. S. Appelbaum, “The capacity to vote of persons with serious mental illness,” Psychiatric Services, vol. 60, no. 5, pp. 624–628, 2009. [5] Doe v Rowe, 156 F, supplement 2d 35(DMe), 2001. [6] M. F. Folstein, S. E. Folstein, and P. R. McHugh, “Mini—men- tal state”: a practical method for grading the cognitive state of patients for the clinician,” Journal of Psychiatric Research, vol. 12, no. 3, pp. 189–198, 1975. [7] DMS-IV-TR, Manual Diagnostico y Estad´ıstico de los Trastornos Mentales, Masson, Barcelona, Spain, Texto Revisado edition, [8] R. A. Pruchno, M. A. Smyer, M. S. Rose, P. E. Hartman-Stein, andD.L.Henderson-Laribee,“Competence of long-termcare residents to participate in decisions about their medical care: a brief, objective assessment,” Gerontologist, vol. 35, no. 5, pp. 622–629, 1995. [9] L. J. Fitten, R. Lusky, and C. Hamann, “Assessing treatment decision-making capacity in elderly nursing home residents,” MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Alzheimer's Disease Hindawi Publishing Corporation

Capacity to Vote in Persons with Dementia and the Elderly

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Copyright © 2011 Luis Javier Irastorza et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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SAGE-Hindawi Access to Research International Journal of Alzheimer’s Disease Volume 2011, Article ID 941041, 6 pages doi:10.4061/2011/941041 Research Article 1 2 2 Luis Javier Irastorza, Pablo Corujo, and Pilar Banuelos ˜ MHC Arganda, Juan de la Cierva 20, Arganda del Rey, 28500 Madrid, Spain Residencia de Personas Mayores de Arganda, CAM, Arganda del Rey, 28500 Madrid, Spain Correspondence should be addressed to Luis Javier Irastorza, ljirastorza@telefonica.net Received 14 November 2010; Revised 15 April 2011; Accepted 7 June 2011 Academic Editor: Vincenzo Solfrizzi Copyright © 2011 Luis Javier Irastorza et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The capacity to vote in patients with mental illness is increasingly questioned. The objective of this study is to evaluate this capacity in a group of subjects with dementia (Alzheimer’s disease) and other elderly subjects without dementia. With a sample of 68 subjects with dementia and 25 controls living in a senior residence, a transversal study was carried out over 4 months. Subjects were evaluated with the Mini-Mental State Examination (MMSE) and the Competence Assessment Tool for voting (CAT-V). The results were more positive for the Doe criteria (as part of the CAT-V), and a correlation was found with the MMSE in subjects with dementia and, to a lesser degree, in the controls. We conclude that the capacity to vote is related to cognitive deterioration and, within that, is more related to understanding and appreciation. 1. Introduction Our study attempts to resolve these questions in two ways: using the MMSE [6] as a cognitive variable and the Voting is a legal right in many countries. But the exercise of CAT-V as a voting test in two samples: one group of patients this right does not mean that all persons have the capacity with Alzheimer’s dementia living in a senior residence and to vote. There might be cases of people with the competence a second group of persons living in the same residence who to vote, but without the necessary capacity. For this reason, suffer no mental illness. there is increasingly more literature seeking a tool to evaluate the capacity to vote, for patients with dementia as well as 2. Materials and Methods other mental disorders, such as those hospitalized with acute symptoms, and so forth [1–4]. 2.1. Participants. The study included 68 patients residing In the evaluation of the capacity for the act of voting, in the Arganda del Rey Senior Residence, diagnosed with there are 6 questions that evaluate the functional abilities of Alzheimer’s dementia (according to DSM-IV-TR criteria) the person, based on the 4 standard decision-making abil- [7] and 25 subjects living in the same residence, but with ities: understanding, choice, reasoning, and appreciation. a MMSE score greater than 24 and no mental illness, who Some of these questions come from the standard question- participated on a voluntary basis. The severity of dementia naire of a federal court, related to understanding the nature was evaluated using the standard cut-off points in the Mini- of voting, understanding its effect and vote selection in Mental State Examination (MMSE): Mild, 20 to 23; moder- Maine, USA (Doe criteria) [5]. In addition, items have been ate, 12 to 19; severe, <12 [6]. Subjects were evaluated over a added incorporated in the CAT-V test [2]: comparative rea- 4-month period, from August to November 2010. They were soning, consequential reasoning, and appreciation. recruited randomly, given the high percentage of patients This instrument has been used in various studies [2–4]. with various types of dementia living in this residence. All However, doubt persists as to which items to use for screen- spoke Spanish. ing and to which persons. What should be the cutoff point? As a control group, 25 additional subjects were evaluated Should some items be weighted more than others? with the same criteria and lived in the same residence, 2 International Journal of Alzheimer’s Disease Table 1: Characteristics of 68 patients with Alzheimer’s dementia and 25 elderly subjects without mental illness of the Arganda Senior Residence who were evaluated for their capacity to vote. Dementia group Normal group Characteristics N %orrange N %orrange Sex Male 16 23.5 9 36 Female 52 76.5 16 64 Age 70–79 10 14.7 4 16 80–89 35 51.5 16 64 90–99 22 32.4 5 20 Age (M ±SD) 86.4 ± 7 61–99 84.5 ± 6.6 70–98 MMSE score (M±SD) 12.7 ± 6.30–22 26.8 ± 1.6 25–29 Possible scoring for MMSE ranges from 0 to 30, with higher score representing greater cognitive capacity. but were not diagnosed with any type of dementia or any 0 to 2 for consequential. Appreciation was also scored on a other mental illness (according to DSM-IV-TR) which could scale of 0 to 2. confound the results of the study. We used in the comparison of the means of the two groups the Student’s t-test (normal distribution) and the Mann-Whitney U test (abnormal distribution). In order to 2.2. Evaluation Instruments. We used the CAT-V to evaluate measure the association between qualitative variables, the the capacity to vote. The questions used were adapted from Chi-square and Fisher exact tests were used. the criteria for decision making: understanding, choice, reasoning, and appreciation. As previously stated, these are The Spearman correlation coefficient and the Kruskal- the Doe criteria: the voting capacity is applied according Wallis Chi-square tests were used to look at the associations to whether the subject understands the nature and effect of between the CAT-V measurements, and with respect to the the vote, the choice of candidate [2]. Besides, comparative MMSE scoring and sociodemographic characteristics. and consequential reasoning (comparatively reasons about the candidates and reasons the consequences for the voter) 2.4. Human Subject Protections. All participants or their and appreciation of the vote (appreciates the vote weighing caregivers gave verbal informed consent to participate in what candidate is chosen and who would be chosen in the the study. They were assured that the information they gave next election) are added to these Doe criteria in formulating would be used solely for the purposes of this study and they the CAT-V. The scoring of this is 2 if the performance was did not display apprehension in this regard. adequate; 1 if the performance was ordinary or doubtful; 0 if the subject is not capable of considering or answering the 3. Results question. Although our study did not look at interexaminer relia- 3.1. Characteristics of the Subjects. Sixty-eight (68) patients bility, we took into account the experience in another work with dementia and 25 elderly subjects without mental illness completed by the same authors [3], with the same tools. completed the study. Table 1 shows their demographic and After various training sessions on the test (CAT-V), we tried clinical characteristics. According to the MMSE, there were to adapt it to the Spanish voting system: here we do not 27 patients with severe dementia (39.7%), 33 with moderate choose between one candidate and another, as in the USA, dementia (48.5%), and 8 with mild dementia (11.8%) in the but among various political parties. Information was given to group of patients with dementia. There were no significant the participants about which political party would be chosen, differences in age or sex among the two groups, and as not which candidate. expected, there were differences in MMSE (F = 29.4; df = In addition, we used the MMSE [6] to evaluate cognitive 91; P< 0.0001). capacity, with the aforementioned scoring for severity of dementia. The DSM-IV-TR classification criteria were used to diag- 3.2. Development of the CAT-V and Its Subscales. Table 2 nose Alzheimer’s dementia and to exclude possible clinical shows the CAT-V scoring of the study participants. It appears cases in the group of control patients without dementia. that, from the sample of those with dementia, about half understood the nature and effect of the vote; this was not the 2.3. Data Analysis. Scores were given for the Doe criteria for case for the choice itself, in which 75% failed. Forty percent each participant, as a result of adding the points for under- (40%) obtained a 0 in total Doe criteria. The result is also standing of nature and effect of the vote, of 0 to 4 points, plus negative for reasoning, particularly comparative reasoning two for vote choice. In addition, we considered the scoring (0 score in 82%). In appreciation, however, more than 65% for reasoning, of 0 to 2 points for comparative and another achieved good scores. International Journal of Alzheimer’s Disease 3 Table 2: Scoring of the capacity to vote (CAT-V competency assessment tool for voting) of 68 patients with dementia and 25 controls (elderly without dementia). Alzheimer’s Elderly Item and score N % N % Doe criteria Understanding nature of the vote 2 18 26.5 24 96 1 18 26.5 1 4 0 32 46.1 0 — Understanding effect of the vote 26 8.8 18 72 1 24 35.3 7 28 0 38 55.9 0 — Vote choice 2 1 1.5 8 32 1 16 23.5 17 68 051 75 0 — Total Doe score 60 — 7 28 53 4.4 12 48 4 8 11.8 5 20 3 11 16.2 1 4 2 9 13.2 0 — 1 10 14.7 0 — 0 27 39.7 0 — Additional items Comparative reasoning 20 — 7 28 1 12 17.6 18 72 0 56 82.4 0 — Consequential reasoning 21 1.5 14 56 1 23 33.8 11 44 0 44 64.7 0 — Appreciation 2 13 19.1 21 84 1 32 47.1 4 16 0 23 33.8 0 — CAT-V.: test to evaluate the capacity to vote, created by Appelbaum et al., 2005 [2]. Descending order. According to Doe versus Rowe criteria for competence to vote of 2001 [5]. When we compare the CAT-V items in the two groups, associated with better development in MMSE (Figure 1). we observe significant differences: in understanding the The figure shows that all subjects with severe dementia nature of the vote (Chi-square, χ = 35.9; df = 2; P< (MMSE < 12) scored 1 or less on the Doe questions and all 0.0001), understanding the effect of the vote (χ = 42.5; df = those with mild dementia (except for one case that scored 1) 2; P< 0.0001), vote choice (χ = 46.5; df = 2; P< 0.0001), scored 3 or higher on the Doe score. But those with moderate comparative reasoning (χ = 56.4; df = 2; P< 0.0001), dementia had the greatest variability in the Doe, from 0 to 4. consequential reasoning (χ = 50.4; df = 2; P< 0.0001), In the same group of patients with dementia, the correla- and appreciation (χ = 34.1; df = 2; P< 0.0001). tion of MMSE and the CAT-V reasoning items is r = 0.635, N = 68, P< 0. 0001, bilateral sig.; high scores in MMSE 3.3. Relationship between CAT-V Scores and Severity of with greater reasoning development (r = 0.61, N = 68, P< Dementia and Normal Elderly and other Variables. In the 0.0001); except for one exception, all those who scored 2 have group of patients with dementia, there is a correlation be- 16 or more on MMSE. However, there are cases with mild tween the MMSE and the Doe criteria: r = 0.833, N = and moderate dementia that vary between 0 and 2 on the 68,P< 0.0001. High scores on the Doe questions are reasoning criteria. 4 International Journal of Alzheimer’s Disease Comparative reasoning No Doubtful Adequate 10 10 0 1 2 3 4 5 Doe Figure 1: Relation of Mini-Mental State Examination scores to Doe criteria in 68 patients with Alzheimer’s disease. Dementia In dementia’s group, the correlation between MMSE and Elderly appreciation is Kruskal-Wallis test, χ = 39.6; df = 2; P< Figure 2: Relation of Mini-Mental State Examination Scores to 0.0001. All patients with the maximum of 2 in appreciation scores on comparative reasoning for 68 patients with Alzheimer’s obtain a minimum of 15 on the MMSE. Here, moderate disease and 25 controls. dementia varies between 0 and 2 and mild between 1 and 2. Spearman correlations between MMSE and CAT-V items areasfollows. Consequential reasoning No Doubtful Adequate (1) With nature of vote: r = 0.744, P< 0.0001. With effect of vote: r = 0.738, P< 0.001. (2) Correlation between MMSE and the Doe item of vote choice continues to be significant (r = 0.478, P< 0.0001), with high scores in MMSE and in vote choice. However, scoring of moderate dementia varied a great deal (from 0 to 21). (3) With comparative reasoning: r = 0.392, P< 0.001. With consequential reasoning: r = 0.553, P< 0.0001. 17 There is a correlation between age, in the oldest range (90 to 99), and the Doe criteria (Kruskal-Wallis, χ = 12.86, df = 6, P = 0.045); the majority, save exceptions, of patients in this age group achieve scores of 3 or less in these criteria. In all other age ranges, as with sex, there are no significant 27 associations. When we compared the patients with dementia with the controls, elderly without dementia, we observed significant Dementia differences with the Mann-Whitney U statistic in the three Elderly Doe criteria together (U = 69.5, P< 0.0001), the reasoning items (U = 35.5, P< 0.0001), and appreciation item (U = Figure 3: Relation of Mini-Mental State Examination Scores to 252.5, P< 0.0001), affecting all CAT-V criteria (U = 29, scores on consequential reasoning for 68 patients with Alzheimer’s P< 0.0001). disease and 25 controls. Correlation between MMSE and Doe criteria is shown in Figures 2, 3,and 4 (two groups together, dementia and elderly groups). subjects without dementia or any other mental illness, using CAT-V. We observe that patients with dementia understand the 4. Discussion nature and effect of the vote (53% and 44%, resp.), and We believe that this is the first study comparing the capacity appreciate its consequences (66.2%) but do not do as well to vote in patients with Alzheimer’s dementia and in elderly when it is time to make a voting choice (25%) and to MMSE MMSE MMSE International Journal of Alzheimer’s Disease 5 Appreciation when a complete evaluation of capacity is necessary but is No Doubtful Adequate not informative about the specific deficits of capacity. One cognitive screening test is the MMSE, which correlates, as we have seen, with capacity tools, but is not very sensitive 5 or specific [9, 10]. The MMSE has been used to evaluate consent for treat- ment, with similar results [11, 12], or in relation to the loss of autonomy, lack of judgment and capacity to make decisions [13, 14]. But, in other papers, evaluation of the capacity to vote has not been reliable [15, 16]. In our study, we also were unable to obtain a reliable cut-off:itisvalid forsevere dementia, but not as much for mild dementia and even less so for moderate dementia, nor has MMSE correlated with 19 different mental disorders (schizophrenia, mood disorders) or intellectual coefficient [4]. It seems that if we place a high threshold on the voting test, including the reasoning and appreciation items, various subjects remain outside that threshold although they do have the capacity to vote according to the Doe criteria. And if we focus on these, the vote choice item also presents difficulties [4]. We see that it is complicated that some subjects make a good voting choice, as in our study. If we try to interpret Dementia this, we can find other influential factors, such as the sub- Elderly jects’ access to information, proximity to the elections, and Figure 4: Relation of Mini-Mental State Examination Scores to cultural level. scores on appreciation for 68 patients with Alzheimer’s disease and There are studies that show that patients with mild and 25 controls. moderate dementia have a normal score in the subscales of appreciation and reasoning (in the MacArthur Clinical Research test) [17]. This test, which evaluates competency, consequential reasoning (35.3%). There is a correlation has been questioned for showing deterioration, and the among all the items with MMSE, that is, the lower the score, patient was capable of making decisions about treatment. the lower the capacity to vote, and those with mild dementia We also observe cases of normal consequential reasoning and usually retain the capacity to vote. We agree with another appreciation in moderate dementia. study that also used CAT-V and MMSE in patients with The voting test we used, the CAT-V, does correlate with dementia, but with less cognitive deterioration [2]. Other the MMSE in Alzheimer’s dementias, both in our study as in those of other authors [2, 3]. We advocate its use but authors have not found a correlation between the capacity to vote and reasoning [3] or with clinical (psychosis, bipolar with some clarifications: strengthen the vote choice item disorders) and cognitive variables [4]. Within this several with more information. This may be in contradiction with possible voting fraud or misapplication if we focus on im- mental disorder study, the authors verify that patients cor- rectly understand and reason their vote and appreciate its minent elections. But, at the time of the study, we observe associated consequences, like in our elderly control group. that many of the patients made mistakes. Reasoning and, to We observe that Doe scores are lower in the Applebaum study a lesser degree, appreciation are also questionable variables [2], although we agree in the same tendencies of variability in depending on the severity of the dementia. Thus, we could moderate dementia. not define a cutoff point in the CAT-V in relation to these Almost all patients with mild dementia had Doe scores items, particularly in those with moderate dementia and in greater than or equal to 2. We do not agree with the Raad subjects who want to vote. This last factor, not examined in our study, also does not correlate with the MMSE [18]. et al. study [4], with an MMSE higher than in our study, that did not find correlation between high MMSE scores and Nor do we know the cut-off point of the test if we Doe criteria for voting. This could indicate that dementias score more for appreciation than for reasoning. In our study, are more likely to affect the capacity to vote associated with the subjects perform better in terms of appreciation of the cognitive deterioration, and less so in other mental disorders. consequences of an election, the absence of false beliefs There are significant differences in scoring of the MMSE that direct own appreciation [19]. They also obtained better and CAT-V between both groups, as would be expected. results on consequential reasoning. This could be understood that the patients without mental This study has several limitations: not having performed illness, although they are elderly, and without cognitive an interexaminer reliability test and the small sample size. deterioration, have a greater capacity to vote. Therefore, in The first is addressed in part due to the authors’ knowledge this group, the MMSE does not serve as a predictor test of the test from other studies [3]. Patient daily activity and it does in patients with moderate dementia. As observed evaluation (ADL and IADL) was not used, either, searching by Pruchno et al. [8], cognitive screening serves to suggest cognitive deterioration more than functional one. MMSE 6 International Journal of Alzheimer’s Disease Understanding is related to memory, executive capacities Journal of the American Geriatrics Society, vol. 38, no. 10, pp. 1097–1104, 1990. and name comparison in dementia [20]. Appreciation is less associated with neurophysiological tests. Reasoning is related [10] S. Y. H. Kim and E. D. Caine, “Utility and limits of the mini mental state examination in evaluating consent capacity in dementia to working memory and executive functions [3]. in Alzheimer’s disease,” Psychiatric Services, vol. 53, no. 10, Future studies should look at the factor analysis of the pp. 1322–1324, 2002. MMSE items that correlate with the CAT-V, with ADL, and [11] V. Raymont, P. W. Bingley, A. Buchanan et al., “Prevalence IADL and with other sociodemographic variables. of mental incapacity in medical inpatients and associated risk factors: cross-sectional study,” The Lancet, vol. 364, no. 9443, 5. Conclusions pp. 1421–1427, 2004. [12] E. Etchells,P.Darzins,M.Silberfeldetal., “Assessmentof It is important to carry out an evaluation of the capacity to patient capacity to consent to treatment,” Journal of General vote on patients with moderate dementia. The MMSE and Internal Medicine, vol. 14, no. 1, pp. 27–34, 1999. the CAT-V test can be useful to this end. The criteria of un- [13] J. S. Huthwaite, R. C. Martin, H. R. Griffith, B. Anderson, L. derstanding and appreciation are easier for the patients, but E. Harrell, and D. C. Marson, “Declining medical decision- not those of vote choice and reasoning. Cognitive deteriora- making capacity in mild AD: a two-year longitudinal study,” tion, but not age, influences the capacity to vote. Behavioral Sciences and the Law, vol. 24, no. 4, pp. 453–463, [14] J. Karlawish, “Measuring decision-making capacity in cog- Authors’ Contribution nitively impaired individuals,” Neurosignals, vol. 16, no. 1, pp. 91–98, 2008. All authors contributed to the design of the study. P. Corujo and P. Banuelos ˜ identified the participants, did the individual [15] J. Karlawish, “Voting by older adults with cognitive impair- interviews and administered the neuropsychological scales. ments,” LDI Issue Brief, vol. 13, no. 4, pp. 1–4, 2008. L. J. Irastorza contributed to the analysis and interpretation [16] A. Blais, L. Massicotte, and A. Yoshinaka, “Deciding who has the right to vote: a comparative analysis of election laws,” of data, drafted the article and revised. Electoral Studies, vol. 20, no. 1, pp. 41–62, 2001. [17] S. Y. H. Kim, E. D. Caine,G.W.Currier,A.Leibovici,and J. M. Conflict of Interests Ryan, “Assessing the competence of persons with Alzheimer’s disease in providing informed consent for participation in All authors declare that they have no financial interest that research,” American Journal of Psychiatry, vol. 158, no. 5, may be relevant to the submitted work; only we received help pp. 712–717, 2001. for translation of the text by S. A. Andromaco-Grunnenthal. [18] A. Bosquet, A. Medjkane, D. Voitel-Warneke, P. Vinceneux, and I. Mahe, ´ “The vote of acute medical inpatients: a prospec- References tive study,” Journal of Aging and Health, vol. 21, no. 5, pp. 699– 712, 2009. [1] J.H.T.Karlawish andC.M.Clark,“Diagnostic evaluation [19] E. R. Saks, L. B. Dunn, B. J. Marshall, G. V. Nayak, S. of elderly patients with mild memory problems,” Annals of Golshan, and D. V. Jeste, “The California scale of appreciation: Internal Medicine, vol. 138, no. 5, pp. 411–419, 2003. a new instrument to measure the appreciation component of [2] P. S. Appelbaum, R. J. Bonnie, and J. H. Karlawish, “The capacity to consent to research,” American Journal of Geriatric capacity to vote of persons with Alzheimer’s disease,” American Psychiatry, vol. 10, no. 2, pp. 166–174, 2002. Journal of Psychiatry, vol. 162, no. 11, pp. 2094–2100, 2005. [20] M. P. Dymek, P. Atchison, L. Harrell, and D. C. Marson, [3] L.J.Irastorza,P.Corujo,and P. Banuelos, ˜ “The competence to “Competency to consent to medical treatment in cognitively vote in patients with dementia,” Revista de Neurologia, vol. 44, impaired patients with Parkinson’s disease,” Neurology, vol. 56, no. 6, pp. 321–325, 2007. no. 1, pp. 17–24, 2001. [4] R. Raad, J. Karlawish, and P. S. Appelbaum, “The capacity to vote of persons with serious mental illness,” Psychiatric Services, vol. 60, no. 5, pp. 624–628, 2009. [5] Doe v Rowe, 156 F, supplement 2d 35(DMe), 2001. [6] M. F. Folstein, S. E. Folstein, and P. R. McHugh, “Mini—men- tal state”: a practical method for grading the cognitive state of patients for the clinician,” Journal of Psychiatric Research, vol. 12, no. 3, pp. 189–198, 1975. [7] DMS-IV-TR, Manual Diagnostico y Estad´ıstico de los Trastornos Mentales, Masson, Barcelona, Spain, Texto Revisado edition, [8] R. A. Pruchno, M. A. Smyer, M. S. Rose, P. E. Hartman-Stein, andD.L.Henderson-Laribee,“Competence of long-termcare residents to participate in decisions about their medical care: a brief, objective assessment,” Gerontologist, vol. 35, no. 5, pp. 622–629, 1995. [9] L. J. Fitten, R. Lusky, and C. 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