Assessment and Decision-Making Regarding Depression in Dementia - Assignment Example

? Assessment and Decision Making Regarding Depression in Dementia By of Introduction Dementia is a psychological condition characterized by losses or degradation in one’s cognitive abilities. It is however important to note that dementia patients in most cases do not have prior records of cognitive impairments except in aged and aging patients (Lamont, 2004). Dementia, majorly characterized by depression, may be caused by progressive or static injuries to the brain, which ultimately lead to other damages or diseases in the body (Berrios, 1987). That dementia is not a single disease is supported by the many signs and symptoms that characterize it. Among the signs and symptoms of dementia are despaired cognitive capabilities in memory, language, depression and poor problem-solving attention (Wang et al., 2007). The depressive nature of dementia makes it a rather delicate condition, requiring medical practitioners such as psychotherapists and physicians to make certain critical decisions regarding its management and treatment (Weiner et al., 2007). Consequently, guidelines for the evaluation of and decision-making on depression in dementia patients have since been developed. It is the prevalence, the depressive nature of dementia and its increased importance as a psychological concern in the health industry that has prompted stakeholders in psychology to establish certain guidelines for dementia evaluation and decision-making by psychotherapists (Hasegawa et al., 2005). An important aspect of these guidelines is that they conform to the ethical principles and codes of conduct most of the world’s psychological professions and associations such as the American Psychological Association. Decision-making by health care professionals while attending to depressed dementia patients is one of the core areas targeted by the guidelines. In this regard, professional conduct and endeavors by psychotherapists while making decisions on dementia treatment have been emphasized in most of the guidelines (McKellar & Gauthier, 2005). These guidelines on decision-making and engagement with dementia patients are particularly important given the role psychotherapists play in evaluating the memory changes and complaints that are characteristic of dementia (Stanley, 2008). However, the fact that most of the reduced cognitive performances occur in older people does not imply that the performance lapses are more pathological than they are physiological (Fago 2011). Instead, the decreased cognitive performances are directly proportional to the decrease in older peoples’ physiological functions (Wakisaka et al., 2003). Fortunately, psychologists are trained and equipped with skills in decision-making on dementia, supported by specialized neuropsychological tests that evaluate lapses and changes in dementia patients’ cognitive functioning (Barker, 2003). The main objective of the decision-making guidelines, however, remains the identification and specification of the most appropriate cautions, concerns and course of action for all clinicians. While engaging in decision-making on dementia treatment, psychotherapists are also advised to employ their expertise, uphold ethical values and consider patient choices and frames of mind/thought (Anthea & McCabe, 2006). In addition, various decision-making approaches such as categorical and probabilistic reasoning should be applied by psychotherapists when handling dementia patients. This paper thus explores the expertise, values, choices, probabilistic judgment and ethical engagement in decision-making for caring for depressed dementia patients. Decision-Making in Dementia Management Recent times have realized the replacement of the hitherto applied traditional approach of basing all medical decision-making processes on professional paternalism with more viable decision-making methods (Monahan, 2000). In the contemporary medical profession, most decisions made regarding the management of depression in dementia patients have equal input from patients, their loved ones/caretakers and physicians (Chua et al., 2004). In addition, the importance of dementia patients to be informed of the decisions that physicians make and the possible outcomes of the implementation of these decisions are emphasized (Thompson et al., 2007). That is, decisions that concern the treatment or therapy techniques to be applied on a patient and the likely outcomes must have the participation of the patient and/or his/her caregivers or parents. Recent trends have been characterized by dementia patients being engaged in a more central role in determining the treatment techniques of their choice (Bains et al., 2002). However, one of the drawbacks to the incorporation of dementia patients’ input in decision-making processes related to their healthcare is economic forces. The insistence on managed care by employers, health maintenance organizations and insurance companies among other third-party financiers of health services has in effect transferred medical decision-making powers to physicians (Decker et al., 2006). Nevertheless, rebellion has arisen in the healthcare industry against third-party intrusions in decision-making processes on psychological conditions such as dementia (Jaffe et al., 2009). This rebellion, which emphasizes shared decision making processes, also addresses the ethical requirement that dementia patients be fully informed about the risks and benefits of the proposed treatments. Moreover, the rebellion seeks to ensure patients' values and choices are accounted for in decision-making processes (Kahneman & Tversky, 2000). Health decision-making processes on dementia must therefore be scientifically and ethnically sound, particularly pertaining to clinical trials, screening, diagnosis, treatment and prevention. Ethical Engagement in Decision-Making Whether a physician applies the most morally upright and professionally ethical techniques and approaches to decision-making when handling dementia patients depends on the objectives of his/her practices. The first objective that should guide physicians in decision-making for dementia patients is the clear definition and application of virtue, morality, ethics, fairness, justice and the upholding of patients’ rights. To achieve these objectives, it is imperative that a physician gets conversant with the various theories and models of ethical decision-making in psychotherapy. It is not enough to be conversant with these decision-making models and theories; their actual and practical application in the professional handling of dementia patients is of greater importance, more so in dual relationship situations (Goldstein & Beers, 2004). Furthermore, it pays if a physician is in a position to identify and rectify any shortcomings of ethical dilemmas faced while at the same time exploit the strengths of the ethical models of decision-making processes used. Among the most controversial ethical issues in the healthcare provided to dementia patients is consent to medical treatment. In many states, a patient only requires to be 18 years of age to have the legal capacity to consent to health care (Brown, 2009). Otherwise, a doctor/physician must certify that a patient is mentally or physically fit to consent to a medical procedure or therapy. If a patient has some physical, mental disorder, retardation or dementia that may make him/her unable to understand the contents and implications of a medical procedure, he/she loses the legal right to consent to nay treatment. Nonetheless, on the basis of a patient’s mental state, maturity, age and experience, a physician should make an effort to allow such a patient to consent to the health care proposed (Anastasi & Urbina, 1997). In the same manner, a patient of sound mind, good physical health and the right age has the legal capacity and right to withdraw any consent to treatment to which he/she had earlier consented. There are two main methods in which psychotherapists may make decisions on dementia treatment and management: categorical and probabilistic reasoning. Categorical and Probabilistic Engagement That decision-making processes in the medical/psychological profession are a complex and wide subjects is not contested. There are two broad categories of decision-making processes or models that psychotherapists commonly apply while attending to dementia patients. These models are categorical/deterministic decision-making and probabilistic decision-making (Coffey & Hannigan, 2003). It should be appreciated that these two are the extreme ends of decision-making approaches that can be used in the medical profession. Professionals in the medical industry however concur that a judicious combination of the deterministic and the probabilistic approaches is more productive and effective (Drake, 1993). While the deterministic approach to medical decision-making ensures that the context of the decisions made is as narrow as is required, the probabilistic model compares various hypotheses/possibilities, leading to the eventual decision-making (Gregory, 2011). Although questions abound on how psychotherapists make clinical decisions and the techniques they apply, the desire and drive to offer expert and professional medical services has motivated them to indulge in wide consultations on the most appropriate decision-making approaches for different situations. The categorical and the probabilistic approaches to decision-making are largely used by psychotherapists handling dementia patients since in many cases, such decisions are quite straightforward as they only require patient history, routine physical examination, or certain laboratory tests (Triantaphyllou, 2000). To some extent, a physician may only use his/her mastery of the set of routines to respond to a case of dementia since she/he simply has to recognize a situation and know the appropriate response. A vital component of the decision-making process by an expert psychotherapist is thus the use of a set of appropriate rules or norms to a variety of clinical situations (Groth-Marnat, 2009). This type of decision-making is referred to as categorical decision-making. Categorical decisions are therefore made without reservation although they are never absolutely deterministic. Such decisions allow for the possibility of a psychotherapist to withhold full commitment from making conclusions, thereby establishing the flexibility to alter the conclusions and re-think the situation later (Perneger & Agoritsas, 2011). The fact that categorical medical decisions are built on quite a few facts, are simple to make and describe implies that they are easier to judge and give rather unambiguous outcomes. Regrettably, not all decisions pertaining to dementia or any other psychological condition for that matter are easy to make or must be categorical. There are certain decisions for which there are no simple rules used in making decisions (Coon, 1986). In other words, all the available evidences must be weighed carefully before decisions are made. Although it is assumed that all psychotherapists weigh out all the medical possibilities and evidences, it is their manner of weighing out the evidences that counts (Mark, 2009). The probabilistic decision-making is thus one of the effective models with which psychotherapists handle decision-making while treating dementia patients (Williamson et al., 2002). The fact that probabilistic decision-making requires the use of computer schemes implies that physicians using it must be trained to be good at probabilistic reasoning. With proper training therefore, probabilistic reasoning could be an apt component of a computerized medical decision-making method, principally for the difficult decisions for which categorical reasoning is unsuitable (Charles et al., 1965). The reasoning approach applied notwithstanding, there are ethical standards that decision-making in dementia treatment must meet. Ethical Decision-Making Model Since it touches on some of the most private aspects of peoples’ lives, the medical profession is faced with many ethical issues, particularly in relation to decisions and decision-making process (Fletcher, 1984). There are two commonly used decision-making models that uphold the ethics of the medical profession. The first model entails four core principles that cover the entire process of moral action while making decisions on dementia treatment. The components of the model include the recognition that moral issues surround medical decisions; decision-making requires reasoning; the need to choose the moral course of action; and the need to make the morally upright or ethical decision (Veatch, 1988). The second model of ethical decision-making in dementia management is five-dimensional and is based on theories of ethics, professional theoretical premises, professional codes of ethics, the socio-legal parameters, and the personal/professional identity of a physician (Hogan & Cannon, 2007). A five-stage decision-making process has thus been proposed for use by psychotherapists while addressing dementia patients. First, a psychotherapist must ask himself/herself about the social, legal and professional standards for the particular decision to be made. The second stage is the assessment of the need to deviate from the set standards should such a situation present itself. The ethical dilemmas present in the immediate situation should then be identified followed by the fourth stage which is the generation of the possible courses of action. Finally, the psychotherapist has to evaluate whether the course of action opted for is not only implementable but is also ethical (Martinsons, 2001). It is only after this evaluation that the chosen course of action may be implemented. Conclusion Psychologists, like many other medical professionals, are faced with myriad challenges while plying their trade. Decision-making in the management and treatment of psychological disorders such as dementia, characterized by depression, is one such challenging aspect of psychotherapy. Fortunately, guidelines have been developed for psychotherapists to use in decision-making processes. Expertise engagements, value/choice/frame engagement, probabilistic and ethical engagements in decision-making are some of the principles of medical decision-making emphasized in these guidelines. In other words, professional ethics, patient choice, value and frame of mind are some of the core factors that must be accounted for while making decisions on dementia management. References Anastasi, A., and Urbina, S. (1997) Psychological testing, seventh edition. Upper Saddle River (NJ): Prentice Hall. Anthea, I., and McCabe, L. (2006) Evaluation in dementia care, first edition. Jessica Kingsley Publishers. Bains, J. et al. (2002) The Efficacy of Antidepressants in the Treatment of Depression in Dementia. Cochrane Database of Systematic Reviews 1(4), 567. Barker, P. (2003) Psychiatric and mental health nursing the craft of caring. New York, NY: Oxford University Press Inc. Berrios, G. E. (1987) Dementia during the Seventeenth and Eighteenth Centuries: A Conceptual History. Psychological Medicine 17 (4), 837. Brown, C. (2009) Pain, Aging And Dementia: The Crisis Is Looming, But Are We Ready? British Journal of Occupational Therapy 72 (8), 375. Charles, H. K. et al. (1965) The rational manager: a systematic approach to problem solving and decision-making. McGraw-Hill. Chua, E. F. et al. (2004) Dissociating Confidence and Accuracy: Functional Magnetic Resonance Imaging Shows Origins Of The Subjective Memory Experience. Journal of Cognitive Neuroscience, 16, 1131. Coffey, M., and Hannigan, B. (2003) The handbook of community mental health nursing, first edition. Routledge. Coon, D. (1986) Introduction to psychology: exploration and application, fourth edition. St. Paul: West Publishing Company. Decker, S. et al. (2006) Tools for assessment of pain in nonverbal older adults with dementia: a state-of-the-science review. Journal of Pain and Symptom Management 31 (2), 176. Drake, R. A. (1993) Processing Persuasive Arguments: Discounting of Truth and Relevance as a Function of Agreement and Manipulated Activation Asymmetry. Journal of Research in Personality, 27, 196. Fago, J. P. (2011) Dementia: causes, evaluation, and management (hospital practice), first edition. JTE Multimedia. Fletcher, J. F. (1984) Morals and medicine: the moral problems of: the patient's right to know the truth, contraception, artificial insemination, sterilization, euthanasia. Boston: Beacon. Goldstein, G., and Beers, S. (2004) Comprehensive handbook of psychological assessment, volume 1: intellectual and neurological assessment. Hoboken (NJ): John Wiley & Sons. Gregory, R. J. (2011) Psychological testing: history, principles, and applications, sixth edition. Boston: Allyn & Bacon. Groth-Marnat, G. (2009) Handbook of psychological assessment, fifth edition. Hoboken (NJ): Wiley. Hasegawa, K. et al. (2005) Global Prevalence of Dementia: A Delphi Consensus Study. Lancet, 366(9503), 2115. Hogan, T. P., and Cannon, B. (2007) Psychological testing: a practical introduction, second edition. Hoboken (NJ): John Wiley & Sons. Jaffe, S. L. et al. (2009) Early Onset Dementia. International Review of Neurobiology 84: 262. Kahneman, D., and Tversky, A. (2000) Choice, values, frames. The Cambridge University Press. Lamont, P. (2004) Cognitive Decline in a Young Adult with Pre-Existent Developmental Delay – What the Adult Neurologist Needs to Know. Practical Neurology 4 (2), 87. Mark, E. (2009) Psychiatric Co-morbidity in Persons with Dementia: Assessment and Treatment Strategies". Psychiatric Times 26 (4). Martinsons, M. G. (2001) Comparing the Decision Styles of American, Chinese and Japanese Business Leaders. Washington, DC; Best Paper Proceedings of Academy of Management Meetings. McKellar, L., and Gauthier, N. (2005) Instruments for the Assessment of Pain in Older Persons with Cognitive Impairment. Journal of the American geriatrics society 53 (2), 326. Monahan, G. (2000) Management decision making. Cambridge: Cambridge University Press. Perneger, T. V., and Agoritsas, T. (2011) Doctors and Patients' Susceptibility to Framing Bias: A Randomized Trial. Journal of General International Medicine 6(34), 240. Stanley, M. (2008) Anxiety Disorders in Later Life Differentiated Diagnosis and Treatment Strategies. Psychiatric Times 25 (8). Thompson, S. et al. (2007) Efficacy and Safety of Antidepressants for Treatment of Depression in Alzheimer's Disease: A Meta-Analysis. Canadian Journal of Psychiatry 52 (4), 248. Triantaphyllou, E. (2000) Multi-criteria decision making: a comparative study. Dordrecht; The Netherlands: Kluwer Academic Publishers. Veatch, R. M. (1988) A theory of medical ethics. New York: Basic Books. Wakisaka, Y. et al. (2003) Age-Associated Prevalence and Risk Factors of Lewy Body Pathology in a General Population: The Hisayama Study". Acta Neuropathol 106 (4), 382. Wang, J. J. et al. (2007) Pain and Falls in Older People. European Journal of Pain 11 (5): 564. Weiner, D. K. et al. (2007) Pain in Persons with Dementia: Complex, Common, and Challenging. Journal of Pain 8 (5): 375. Williamson, J. et al. (2002) Probability logic: handbook of the logic of argument and inference: the turn toward the practical. Elsevier. Read More