Older adults with mild cognitive impairment may struggle with everyday decision-making

Mild cognitive impairment (MCI) is a form of cognitive ability loss that can precede Alzheimer's disease or other types of dementia. People with MCI have some trouble with memory and thinking, but can largely lead independent lives.

Past research suggests that adults with MCI may have worse judgment than those without when it comes to making financial and health care decisions. But how and when does age-related decline affect day-to-day decision making, and how can families and communities support older adults in balancing autonomy and safety?

A new study has now analyzed decision making more holistically and in a broader population of older adults. The researchers found that participants with MCI performed significantly worse on a test of four types of decision-making abilities compared to older adults who were cognitively healthy. The results are published in the Journal of Alzheimer's Disease.

"This additional evidence helps replicate our earlier studies and makes us more confident that older adults with MCI might have trouble with certain types of decisions," said corresponding author Duke Han, Ph.D., director of neuropsychology in the Department of Family Medicine and a professor of family medicine, neurology, psychology and gerontology at the Keck School of Medicine of USC.

That could indicate that adults with MCI might want to seek support on certain types of decisions, including financial matters or whether it's safe to continue driving. But the researchers note an important caveat: Adults with MCI can still do many things on their own.

"The study does not imply that older adults with MCI are incapable of making good decisions independently," said Laura Fenton, a doctoral student in clinical psychology at the USC Dornsife College of Letters, Arts and Sciences and the paper's first author. "While those with MCI may benefit from additional resources, assistance during decision making or both, it will be important to strike a balance between support and respect for autonomy."

Measuring decision making

To explore the link between MCI and decision-making, the researchers tested participants enrolled in the Advancing Understanding of Transportation Options (AUTO) study, an analysis of decision-making in driving among older adults led by Marian E. Betz, MD, MPH, professor of emergency medicine at the University of Colorado.

The present analysis included data from 301 older adults with an average age of 77.1 years, spread across three sites (Denver, Indianapolis and San Diego). Using data from multiple regions makes the findings more broadly applicable, Han said.

Han and his colleagues tested decision-making with a modified assessment known as the Short Portable Assessment of Capacity for Everyday Decision making (SPACED). Older adults answered questions about a hypothetical scenario: A family member received a past due notice from the electric company and needed to decide whether to pay the bill or leave the country to avoid the problem. The participants were asked to explain the problem and discuss advantages, disadvantages and potential consequences of the two proposed solutions. Trained raters then gave scores for four kinds of decision-making abilities based on the coherence of each answer—understanding, appreciation, comparative reasoning and consequential reasoning.

Participants with MCI scored an average of 2.17 points lower on the SPACED than those without. Among cognitively healthy individuals, 79.9% received a perfect score on the SPACED; among those with MCI, 57.1% scored perfectly.

A broad approach

Because the SPACED assesses multiple components of decision making, the study's findings could have broad implications for choices about finances, health care, end-of-life issues and more.

"One of the main takeaways is that if someone is starting to experience cognitive impairment, it's not a bad idea to seek out additional help in these areas," Han said.

In future research, Han and his colleagues aim to increase the racial and ethnic diversity of participants to ensure that findings accurately capture the experience of older adults across the United States.

In addition to Han, Fenton and Betz, the study's other authors are Carolyn G. DiGuiseppi, Rachel L. Johnson, Ryan A. Peterson, Christopher E. Knoepke and Daniel D. Matlock from the University of Colorado; Nicole R. Fowler from the Indiana University School of Medicine; Linda Hill and Ryan Moran from the University of California San Diego; and Jason Karlawish from the University of Pennsylvania.