Introductory to Issue 41(1): Navigating Thorny Aspects of Dementia Care: Sex, Money, Cars and More

Fellow clinical gerontologists, Providing care for adults with dementia that is compassionate, promotes autonomy, and provides protections when appropriate is critical as the number of adults with dementia worldwide increases in the context of population aging. In this issue of Clinical Gerontologist we tackle some of the thorniest issues in dementia care. Our issue opens with an insightful review by Holdsworth and McCabe (Holdsworth & McCabe, 2017) regarding the impact of dementia on the intimate and sexual relationship of a couple. They perform a qualitative analysis of 13 articles to describe key themes of identity, roles, affection, commitment, reciprocity, sexual activity, and satisfaction. Their efforts to describe and name core aspects of the intimate relationship when one partner has dementia should be helpful as we help couples navigate these issues.

Next are three original research articles related to the topic of capacity and decision-making from three of the major research labs in this area in the United States. Palmer and colleagues (Palmer et al., 2017) describe their considerable efforts with a sample of adults with Alzheimer’s disease and normal controls (N = 248) to enhance the research consent procedure with multimedia and corrective feedback for individuals with mild to moderate Alzheimer’s disease. This study is important for at least two reasons—first, of course, is the need to include adults with dementia in a wide range of studies in a manner that maximizes their opportunities to provide capable and ethical consent. Second, as there is increasing emphasis on supported decision-making it is critical that we delineate which supports help individuals with dementia to gain capacity. On the face of it, almost any enhancements would seem worthwhile, but in this study multimedia enhancement did not improve consent capacity, unlike it has in other patient populations. The authors speculate this is likely related to the difficulty with rapid forgetting of new information even when enhanced with multimedia. This finding is critical as we reach to understand what is the useful range of supports in supportive decision-making.

While we have reproducible models of consent capacity, our conceptual models for other types of capacity are less clear. Our next article by Dan Marson’s research lab (Gerstenecker, Triebel, Eakin, Martin, & Marson, 2017) advances our construct model for financial capacity, by using factor analysis to identify four factors relevant to financial capacity in a large sample (N = 440): (1) Basic Monetary Knowledge and Calculation Skills, (2) Financial Judgment, (3) Financial Conceptual Knowledge, and (4) Financial Procedural Knowledge. I have found the “knowledge, skills, judgment” framework for financial capacity useful clinically but have not found a lot of evidence—for or against—in the literature. With this article we have support for the model, and some finessing by distinguishing the idea of very basic financial skills from more complex procedural knowledge.

Peter Lichtenberg’s lab has advanced our conceptual models of a related concept, financial decision-making and financial exploitation. In the latest contribution from their group (Lichtenberg et al., 2017) they too use factor analysis to provide a conceptual model of financial decision-making using a robust sample of community-dwelling adults (N = 200). Their model considers cognitive elements but also identifies the role of psychological vulnerability and susceptibility. Only recently we evaluated the financial capacity of an older adult who tested well on neuropsychological and financial tests, yet had been a victim of financial exploitation. Such models will help us to understand non-cognitive factors associated with decision-making vulnerability and better incorporate these in our practice.

If there is a topic more fraught than providing good assessments related to financial capacity and exploitation, it just might be the clinician’s role in documenting driving fitness. Vair and colleagues (Vair et al., 2017) examined 516 unique text passages concerning driving in the medical records of 118 persons with dementia treated within the U.S. Department of Veterans Affairs. Documentation described subjective concerns by patients or caregivers, objective risk factors as documented by clinicians, and clinical opinions and recommendations; however, documentation was observed in less than half of the cases. They close by providing recommendations for assessing, documenting and managing driving risk in persons with dementia.

Next are two studies reminding us of the potential role of environment on cognition. Schlemmer and Desrichard (Schlemmer & Desrichard, 2017) explore the impact of environmental press on memory performance, suggesting that lower scores may be obtained in a medical setting. Meyer and colleagues (Meyer et al., 2017) find a relationship between neighborhood socio economic status and rates of cognitive decline in individuals with dementia, consistent with theories of cognitive reserve.

The issue closes with two clinical comments demonstrating the positive role of cognitive evaluation in directing appropriate clinical care. First we have a case presentation of a 56-year-old diagnosed with dementia, subsequently diagnosed with fronto-temporal dementia (Pospos et al., 2016). Next, we have the presentation of two cases in which cognitive assessment during hospitalization was important in maximizing success at home (Pickens, Boss, Ahn, & Jefferson, 2017).

We hope you will find scientifically rigorous and clinically useful as you work to advance the care of adults affected with dementia.

Funding

This material is the result of work supported with resources and the use of facilities at the VA Boston Healthcare System.

Additional information

Funding

This material is the result of work supported with resources and the use of facilities at the VA Boston Healthcare System.