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CLINICAL INVESTIGATIONS

Mild Cognitive Impairment Is Associated with Poorer


Decision-Making in Community-Based Older Persons
S. Duke Han, PhD,* Patricia A. Boyle, PhD,* Bryan D. James, PhD,*|| Lei Yu, PhD,* and
David A. Bennett, MD*

OBJECTIVE: To test the hypothesis that mild cognitive


impairment (MCI) is associated with poorer financial and
healthcare decision-making.
DESIGN: Community-based epidemiological cohort study.
SETTING: Communities throughout northeastern Illinois.
PARTICIPANTS: Older persons without dementia from
the Rush Memory and Aging Project (N = 730).
MEASUREMENTS: All participants underwent a detailed
clinical evaluation and decision-making assessment using a
measure that closely approximates materials used in realworld financial and healthcare settings. This allowed for
measurement of total decision-making and financial and
healthcare decision-making. Regression models were used
to examine whether MCI was associated with a lower level
of decision-making. In subsequent analyses, the relationship between specific cognitive systems (episodic memory,
semantic memory, working memory, perceptual speed,
visuospatial ability) and decision-making was explored in
participants with MCI.
RESULTS: MCI was associated with lower total, financial, and healthcare decision-making scores after accounting for the effects of age, education, and sex. The effect of
MCI on total decision-making was equivalent to the effect
of more than 10 additional years of age. Additional models showed that, when considering multiple cognitive systems, perceptual speed accounted for the most variance in
decision-making in participants with MCI.
CONCLUSION: Persons with MCI may have poorer
financial and healthcare decision-making in real-world situations, and perceptual speed may be an important contributor to poorer decision-making in persons with MCI. J
Am Geriatr Soc 2015.

From the *Rush Alzheimers Disease Center; Departments of

Behavioral Sciences; Neurological Sciences, Rush University Medical


Center, Chicago, Illinois; Mental Health Care Group, Veterans Affairs
Long Beach Healthcare System, Long Beach, California; and ||Department
of Internal Medicine, Rush University Medical Center, Chicago, Illinois.
Address correspondence to S. Duke Han, PhD, Rush Alzheimers Disease
Center, 600 S. Paulina St., Suite 1022, Chicago, IL 60612.
E-mail: Duke_Han@rush.edu
DOI: 10.1111/jgs.13346

JAGS 2015
2015, Copyright the Authors
Journal compilation 2015, The American Geriatrics Society

Key words: decision-making; cognition; mild cognitive


impairment; perceptual speed

ecision-making is a complex process that involves the


ability to generate and evaluate multiple potential
alternatives to make an optimal choice. It is of particular
relevance to older adults, who face important decisions
regarding financial matters such as intergenerational transfers of wealth and appropriation of retirement and pension
funds. Older adults also face important decisions regarding
health care, such as choosing the best medical insurance
plan from among multiple competing options and selecting
end-of-life medical approaches. These real-world decisions
can have a significant effect on maintaining independence
and well-being and on family members, care providers,
and society. Furthermore, there is increasing evidence that
older persons exhibit poorer decision-making than younger
or middle-aged adults,1,2 but the reasons why are poorly
understood. Because of this, the study of decision-making
in old age is an important public health concern.
Although it is known that decision-making is impaired
in older adults with overt dementia,3,4 little is known
about decision-making in persons with mild cognitive
impairment (MCI), which can be a preclinical phase of
dementia. Prior work has shown that MCI is associated
with diminished capacity to complete specific concrete
activities related to monetary exchange (e.g., counting
money, writing a check5,6) and lack of appreciation and
understanding of consent materials for medical treatment,79 but the authors of the current study were not
aware of prior studies examining whether MCI is associated with poorer decision-making on common real-world
financial and healthcare choices that older persons routinely face and that are critical for maintaining independence and well-being in old age. Data from the Rush
Memory and Aging Project, a community-based epidemiological study of chronic conditions of old age, were used
to test the hypothesis that MCI is associated with poorer
financial and healthcare decision-making in communitybased older persons. How the severity and type of

0002-8614/15/$15.00

HAN ET AL.

cognitive impairment affected decision-making in those


with MCI was also explored.

METHODS

2015

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temporal stability.14,15 Performance on the items used


here have been found to be associated with cognition,17
personality (risk aversion preferences16), financial and
healthcare literacy,18 and risk of mortality19 in older
adults without dementia.

Participants
Participants came from the Rush Memory and Aging Project, a clinicalpathological study of aging and dementia.10
Participants are from local residential facilities, including
retirement homes, senior housing facilities, and community
organizations, in and around the greater Chicago metropolitan area and undergo detailed annual clinical evaluations.10
The Rush Memory and Aging Project began in 1997,
and enrollment is ongoing. A decision-making substudy
was added in 2010. At the time of these analyses, 1,671
participants had completed the baseline evaluation for the
parent study; of those, 564 died, and 83 refused further
participation in the parent project before they were able to
complete the baseline decision-making assessment. Of the
remaining 1,024 potentially eligible persons, 802 completed the decision-making baseline, 71 had not yet completed the decision-making baseline, 53 refused the
decision-making assessment, and 98 were not asked to participate because of severe difficulties with language, hearing, vision, or understanding or because they had moved
out of the geographical area. Of the 802 participants who
had completed the decision-making assessment, 41 had
dementia and were excluded, and 31 had missing data in
the variables of interest, leaving 730 eligible for these
analyses.

Clinical Diagnoses
A clinician with expertise in aging diagnosed dementia in
accordance with standard criteria,11 as previously
described.10 Participants with cognitive impairment but no
dementia were deemed to have MCI. This diagnostic characterization of MCI has been used in multiple prior studies.12,13 Clinicians were shielded from the results of the
assessment of decision-making to examine the relationship
between decision-making and cognition.

Assessment of Financial and Healthcare DecisionMaking


Decision-making was measured using a modified performance-based measure specifically designed to represent
actual decisions older adults must make for independence
and wellbeing.14,15 The measure included six items measuring financial decision-making and six items measuring
healthcare decision-making, for a total of 12 items; these
have been described in detail elsewhere.14,16 The items
involve choosing between mutual funds (financial) and
healthcare maintenance organizations (healthcare) based
on a number of prespecified preferences. The items are
of varying levels of difficulty. The total decision-making
score is the number of items answered correctly (range
012). In previous research, this measure has been
shown to have appropriate psychometric properties,
including high interrater reliability and short-term

Assessment of Cognition
Trained technicians supervised by a board-certified clinical
neuropsychologist administered a battery of 21 cognitive
performance tests. Measures of cognitive function were
used to assess a broad range of cognitive abilities.10,20
Two of the 21 tests, the Mini-Mental State Examination
and the Complex Ideational Material, are used for descriptive and clinical diagnostic purposes only. Raw scores on
the remaining 19 tests were converted to z-scores using
means and standard deviations from the baseline evaluation. A global cognition score was calculated by averaging
the z-scores of these 19 measures of cognitive function, as
previously reported.21 Episodic memory measures included
Word List Memory, Recall, and Recognition from the procedures established by the Consortium to Establish a Registry for Alzheimers Disease and immediate and delayed
recall of Logical Memory Story A and the East Boston
Story. Semantic memory measures included Verbal Fluency, Boston Naming, subsets of items from Complex Ideational Material, and the National Adult Reading Test.
Working memory measures included the Digit Span subtests (forward and backward) of the Wechsler Memory
ScaleRevised and Digit Ordering. Measures of perceptual speed included the oral version of the Symbol Digit
Modalities Test, Number Comparison, Stroop Color Naming, and Stroop Word Reading. Measures of visuospatial
ability included Judgment of Line Orientation and Standard Progressive Matrices. A composite score for five cognitive systems (episodic memory, semantic memory,
working memory, perceptual speed, visuospatial ability)
was created by averaging the z-scores of all measures
within a system, as previously reported.21

Other Covariates
Age, sex, and education (years of schooling) were selfreported and included as covariates.

Ethical Statement
All procedures were conducted in accordance with the ethical rules for human experimentation stated in the Declaration of Helsinki and approved by the institutional review
board of Rush University Medical Center.

Statistical Analyses
Descriptive and bivariate statistics were determined for
the two groups (MCI and no cognitive impairment).
Chi-square tests were used for categorical variables and
t-tests for continuous variables. For the t-tests, if variances were found to be different between groups, the
Satterthwaite variance estimate was reported instead of
the pooled variance estimate. Linear regression models
were then used to examine the associations between

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MCI DECISION-MAKING

MCI and decision-making (total, financial, health); persons without cognitive impairment were the reference
group. All models included terms to control for the
potentially confounding effects of age, education, and
sex. Next, a series of linear regression models were conducted only in individuals with MCI to explore the associations between global cognition and decision-making
and between the five cognitive systems (episodic memory, semantic memory, working memory, perceptual
speed, and visuospatial ability) and decision-making.
Analyses were conducted in SAS version 9.3 (SAS Institute, Inc., Cary, NC).

RESULTS
Descriptive Statistics
Mean age was 81.7  7.6, (range 58.8100.8), mean education was 15.2  3.1 years (range 028 years), 75.7%
were female, and 91.9% were non-Hispanic white. Participants with MCI were older on average and had poorer
global cognition (Table 1). Participants with MCI performed significantly worse on total decision-making as
well as financial and healthcare decision-making than
those with no cognitive impairment in all five systems of

Table 1. Descriptive Statistics According to Cognitive Impairment


Characteristic

Mild Cognitive Impairment,


n = 144

No Cognitive Impairment,
n = 586

Female, n (%)
100 (69)
453 (77)
White, n (%)
134 (93)
549 (94)
Age, mean  SD (range)
84.3  6.1 (63.996.4)
81.1  7.8 (58.8100.8)
Education, years, mean  SD (range)
15.4  3.0 (1028)
15.2  3.1 (028)
Episodic memory z-score, mean  SD (range)
0.42  0.66 (1.971.75)
0.53  0.52 (1.021.83)
Wechsler Memory Scale-Revised Logical Memory raw score, mean  SD (range) (range 025)
Immediate recall Ia
8.7  4.2 (020)
13.4  4.0 (324)
Delayed recall IIa
6.4  4.4 (023)
12.0  4.2 (123)
Consortium to Establish a Registry for Alzheimers Disease word list memory, trials 13, raw score
Immediate recall (range 030)
14.6  4.1 (730)
19.6  4.2 (730)
Delayed recall (range 010)
3.1  2.3 (010)
6.5  2.0 (010)
Recognition memory (range 00)
8.6  1.7 (010)
9.9  0.4 (710)
East Boston memory test raw score, mean  SD (range) (range 012)
Immediate recall
8.6  2.1 (212)
10.1  1.8 (012)
Delayed recall
7.8  2.8 (012)
9.7  2.0 (012)
Semantic memory z-score, mean  SD (range)
0.15  0.63 (2.331.35)
0.35  0.55 (2.211.79)
Boston Naming test raw score, mean  SD (range)
13.6  1.4 (915)
14.2  1.0 (815)
(range 015)
Verbal semantic fluency raw score, mean  SD
28.5  9.0 (756)
36.9  8.9 (1470)
(range) (range 075)
National Adult Reading Test word Reading raw score,
12.1  3.1 (215)
12.9  2.6 (115)
mean  SD (range) (range 015)
Working memory z-score, mean  SD (range)
0.24  0.68 (1.831.79)
0.24  0.69 (1.752.22)
Digit Span raw score, mean  SD (range) (range 012)
Forward
7.7  2.0 (212)
8.4  1.9 (412)
Backward
5.5  1.8 (111)
6.5  1.9 (112)
Digit Ordering raw score, mean  SD (range)
6.4  1.6 (210)
7.6  1.5 (213)
(range (014)
Perceptual speed z-score, mean  SD (range)
0.35  0.75 (2.911.10)
0.26  0.76 (2.912.38)
Symbol Digit raw score, mean  SD (range)
33.4  10.1 (854)
41.5  9.6 (1177)
(range 0110)
Number comparison raw score, mean  SD (range)
21.7  7.5 (048)
25.9  6.8 (044)
(range 048)
Stroop raw score, mean  SD (range) (range 0100)
Color naming
15.2  7.7 (041)
20.6  7.2 (045)
Word reading
42.4  14.5 (075)
49.5  13.3 (080)
Visuospatial ability z-score, SD mean  SD (range)
0.14  0.88 (2.911.27)
0.31  0.64 (2.531.27)
Judgment of Line Orientation raw score, mean  SD
9.3  3.4 (115)
10.6  2.9 (015)
(range) (range 015)
Progressive matrices raw score, mean  SD
9.7  2.2 (212)
10.7  1.7 (012)
(range) (range 016)
Global cognitive z-score, mean  SD (range)
0.31  0.43 (1.430.87)
0.38  0.44 (1.191.60)
Total decision-making raw score, mean  SD
6.5  2.8 (012)
8.0  2.7 (012)
(range) (range 012)
Financial decision-making raw score, mean  SD
3.0  1.4 (06)
3.7  1.4 (06)
(range) (range 06)
Healthcare decision-making raw score, mean  SD
3.4  1.7 (06)
4.3  1.5 (06)
(range) (range 06)
SD = standard deviation.

Chi-Square
or T-Value

P-Value

3.89
0.25
5.25
0.81
16.25

.049
.62
<.001
.42
<.001

12.58
14.23

<.001
<.001

12.76
15.68
8.49

<.001
<.001
<.001

7.83
7.83
9.31
5.34

<.001
<.001
<.001
<.001

10.01

<.001

2.95

<.001

7.49

<.001

3.80
5.82
8.08

<.001
<.001
<.001

8.56
8.91

<.001
<.001

6.47

<.001

7.83
5.59
6.89
4.28

<.001
<.001
<.001
<.001

5.36

<.001

16.25
6.06

<.001
<.001

5.26

<.001

5.70

<.001

HAN ET AL.

2015

Table 2. Relationship Between Mild Cognitive Impairment (MCI) and Decision-Making, Adjusted for Age,
Education, and Sex
Model 1
Model Term

Model 2

Estimate (Standard Error) P-Value

Total decision-making
Age
0.11
Education
0.28
Male
0.82
MCI
Financial decision-making
Age
0.06
Education
0.11
Male
0.52
MCI
Healthcare decision-making
Age
0.06
Education
0.16
Male
0.30
MCI

(0.01) <.001
(0.03) <.001
(0.22) <.001

0.10
0.28
0.89
1.35

(0.01)
(0.03)
(0.21)
(0.23)

<.001
<.001
<.001
<.001

(0.01) <.001
(0.02) <.001
(0.12) <.001

0.05
0.12
0.55
0.61

(0.01)
(0.02)
(0.11)
(0.12)

<.001
<.001
<.001
<.001

(0.01) <.001
(0.02) <.001
(0.13) .02

0.05
0.16
0.34
0.74

(0.01)
(0.02)
(0.13)
(0.13)

<.001
<.001
.007
<.001

cognitive function. An analysis of responses to each individual item on the decision-making measure showed that
participants with MCI scored lower on each item than
those with no cognitive impairment. Differences in performance between groups on each item ranged from 7.7% to
16.9% (mean 12.9  53.5%).

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Interaction terms between MCI and age, education, and


sex were included in subsequent models, but no significant
interactions were observed.
Additional analyses were conducted to further characterize how participants with MCI were performing relative
to participants without MCI. The score 1.5 standard deviations below the mean score on the decision-making measure in the participants without MCI was determined and
then used to create binary decision-making measures. The
median score on the decision-making measure in participants without MCI was then determined, and a second
binary decision-making measure was created using the
median split cutoff. The distributions of these binary measures are presented in Table 3 according to MCI diagnosis.
Chi-square statistics showed that a greater proportion of
participants with MCI had total decision-making scores
below each of these cutoffs (P < .01). These associations
remained significant in logistic regression models adjusted
for age, education, and sex (P < .05). The results of these
models are presented in Appendix Table A1. These additional models support the notion that MCI is associated
with statistically different decision-making performances,
although it is unclear whether these statistically poorer
performances constitute impaired performance because
normative data are not available for the decision-making
measure. Nevertheless, these differences may have meaningful real-world implications with respect to decisionmaking in MCI and suggest that persons with mild forms
of cognitive impairment may benefit from strategies to
optimize decision-making.

Relationship Between MCI and Decision-Making


To determine whether MCI was associated with worse
decision-making, a set of linear regression models was
used that examined the relationship between MCI and
decision-making; these and all subsequent analyses controlled for age, education, and sex. MCI was associated
with lower total, financial, and healthcare decision-making
scores (Table 2). To clarify this effect, the magnitude of
the effect of MCI on total decision-making was equivalent
to the effect of more than 10 additional years of age.

Relationship Between Specific Cognitive Abilities and


Decision-Making in Persons with MCI
Given that the clinical diagnosis of MCI was associated
with poor decision-making, the relationship between the
severity of cognitive impairment and decision-making was
examined. Results from a series of linear regression models
examining the relationship between global cognition and
decision-making in participants with MCI are presented in
Table 4. Global cognition was strongly associated with

Table 3. Categorical Relationship Between Mild Cognitive Impairment (MCI) and Decision-Making
Categorical Approach
1.5 Standard Deviations Below Mean of No
Cognitive Impairment
Below
n

Decision-Making

Total
MCI
No cognitive impairment
Financial
MCI
No cognitive impairment
Health
MCI
No cognitive impairment

Above

24
40

120
546

17
44

127
542

24
37

120
549

Median Split of No Cognitive Impairment


Below

Chi-Square

P-Value

14.00

<.001

2.79

16.18

Above
n

106
298

38
288

402
117

184
27

127
435

17
151

.10
<.001

Chi-Square

P-Value

24.22

<.001

9.00

.003

12.72

<.001

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MCI DECISION-MAKING

association between MCI diagnosis and the decision-making measures. Adjusted for age, sex, and education, MCI is
significantly associated with a lower level of total decisionmaking, which explains approximately 3% of its variance.
This association is greatly attenuated after global cognition
is added to the model; MCI explains virtually none of the
variance in total decision-making (~0.2%) in addition to
cognitive function. The results for financial and healthcare
decision-making are similar. Taken together, these results
support the hypothesis that the difference in decision-making measures between subjects with and without MCI is
largely based on differences in cognitive function rather
than other potential differences between the groups.
Results of these analyses are presented in Table 5.
Because impairment in some cognitive systems more
so than others might be driving the association with decision-making, a series of linear regression analyses was conducted to examine the associations between level of
function in the five specific cognitive systems (episodic
memory, semantic memory, working memory, perceptual
speed, visuospatial ability) and decision-making in persons
with MCI. All five cognitive systems were associated with
total decision-making (Table 4); semantic memory, working memory, and perceptual speed were associated with
financial decision-making; and semantic memory, perceptual speed, and visuospatial ability were associated with
healthcare decision-making. Perceptual speed explained the
most variance in decision-making, as indicated by a coefficient of determination change approximately double that
of any other cognitive system measured, but explained
only approximately one-quarter of the variance. To determine whether a particular cognitive system might be driving the association between cognitive abilities any
decision-making, linear regression models adjusted for age,
education, and sex were conducted in participants with
MCI that included all cognitive domains. Perceptual speed

Table 4. Relationship Between Individual Cognitive


Function Measures and Decision-Making in Individuals
with Mild Cognitive Impairment
Cognitive System

Estimate
(Standard Error)

Total decision-making
Global cognition
Episodic memory
Semantic memory
Working memory
Perceptual speed
Visuospatial ability
Financial decision-making
Global cognition
Episodic memory
Semantic memory
Working memory
Perceptual speed
Visuospatial ability
Healthcare decision-making
Global cognition
Episodic memory
Semantic memory
Working memory
Perceptual speed
Visuospatial ability

P-Value

R2 Change

3.20
0.70
1.34
0.65
1.87
0.60

(0.47)
(0.32)
(0.33)
(0.31)
(0.22)
(0.23)

<.001
.03
<.001
.04
<.001
.01

0.16
0.02
0.13
0.02
0.26
0.09

1.61
0.30
0.69
0.49
0.95
0.24

(0.25)
(0.17)
(0.18)
(0.16)
(0.12)
(0.13)

<.001
.08
<.001
.003
<.001
.06

0.14
0.01
0.12
0.04
0.25
0.05

1.59
0.39
0.65
0.16
0.91
0.36

(0.30)
(0.20)
(0.21)
(0.20)
(0.15)
(0.15)

.003
.05
.003
.41
<.001
.02

0.12
0.02
0.09
0.00
0.17
0.06

Estimated from separate linear regression models adjusted for age, sex,
and education. Change in adjusted coefficient of determination (R2) represents the amount of explained variance in the outcome variable associated
with the cognitive variable after accounting for the effects of age, sex, and
education.

total, financial, and healthcare decision-making, suggesting


that the severity of cognitive impairment is related to decision-making in individuals with MCI.
A series of linear regression analyses22 was conducted
to investigate whether global cognition mediated the

Table 5. Relationship Between Mild Cognitive Impairment (MCI), Global Cognition, and Decision-Making
Mediation Model
1

Estimate (Standard Error) P-Value

Model Term

Total decision-making
Age
Education
Male
MCI
Global cognition
Financial decision-making
Age
Education
Male
MCI
Global cognition
Healthcare decision-making
Age
Education
Male
MCI
Global cognition

0.11 (0.01) <.001


0.28 (0.038) <.001
0.82 (0.22) <.001

0.06 (0.04) <.001


0.11 (0.02) <.001
0.52 (0.12) <.001

0.06 (0.01) <.001


0.16 (0.02) <.001
0.30 (0.13) .02

0.10
0.28
0.89
1.35

(0.01)
(0.03)
(0.21)
(0.23)

0.05
0.12
0.52
0.61

(0.01)
(0.02)
(0.11)
(0.12)

0.05
0.16
0.34
0.74

(0.01)
(0.02)
(0.13)
(0.13)

<.001
<.001
<.001
<.001

0.06 (0.01) <.001


0.13 (0.03) <.001
1.10 (0.19) <.001

<.001
<.001
<.001
<.001

0.03 (0.01) <.001


0.05 (0.02) <.001
0.64 (0.11) <.001

<.001
<.001
.007
<.001

0.03 (0.01) <.001


0.08 (0.02) <.001
0.45 (0.11) <.001

2.65 (0.17) <.001

1.21 (0.10) <.001

1.44 (0.11) <.001

0.06
0.12
1.09
0.50
2.89

(0.01)
(0.03)
(0.19)
(0.24)
(0.21)

<.001
<.001
<.001
.04
<.001

0.03
0.04
0.64
0.23
1.32

(0.01)
(0.02)
(0.11)
(0.14)
(0.12)

<.001
<.001
<.001
.08
<.001

0.03
0.08
0.45
0.26
1.57

(0.01)
(0.02)
(0.11)
(0.15)
(0.13)

<.001
<.001
<.001
.07
<.001

HAN ET AL.

was the only cognitive domain that remained significant.


Results of these additional models are presented in Appendix Table A2.

DISCUSSION
In a community-based sample of 730 participants free of
dementia, MCI was associated with poor performance on
a measure of financial and healthcare decision-making that
closely approximates the real-world decisions that independent-living older persons routinely make. Furthermore, in
persons with MCI, poorer decision-making was associated
with more-severe global cognitive impairment. Finally,
after considering multiple specific cognitive systems potentially associated with financial and healthcare decisionmaking, perceptual speed accounted for the most variance.
Altogether, these results support the notion that older
adults with MCI have poorer financial and healthcare decision-making in matters that closely reflect real-world scenarios of significant importance to the maintenance of
independence and well-being, and that the severity and
type of cognitive impairment affects decision-making.
MCI has been previously associated with lack of
insight into financial abilities,23 poor self-care in individuals with heart failure,24 and limited capacity for research
participation.25 Other studies have investigated the association between MCI and capacity to handle specific and
concrete aspects of monetary exchange5,6,23 and consent to
medical treatment.79 The current study is unique in the
use of a measure that closely approximates more-general,
common, real-world choices of significant consequence to
independence and well-being in older adults by asking
questions pertaining to the selection of the best mutual
fund to invest in and the selection of the best health maintenance organization plan from among a number of competing options and considerations. These decisions are
particularly relevant to older adults, who must navigate a
host of complex financial and healthcare decisions and
thus represent a form of real-world decision-making that
previous studies of MCI did not address. Assessment of
these behaviors that are necessary for successfully navigating the complexities of living in the modern world provides a novel approach to obtaining information critical
for the promotion of independence and well-being in older
adults.
This work makes two significant contributions to the
literature. The first is that MCI is associated with poor
financial and healthcare decision-making in matters that
closely simulate real-world choices commonly presented
to independently living older adults. Relevant to the current study, it has been shown that poorer decision-making on this measure is a consequence of cognitive decline
in individuals without dementia or even MCI.17 Furthermore, poorer decision-making in older adults without
dementia is associated with mortality, and this association
is independent of cognition.19 This study extends previous
work by showing that a diagnosis of MCI is associated
with worse decision-making ability in financial and
healthcare matters important for maintaining independence and well-being in old age. Some have conceptualized MCI as a state of cognitive impairment in older
persons that has little to no effect on independent

2015

JAGS

functioning,26 but the results of this study suggest that


people with MCI may exhibit poorer decision-making in
domains that have a significant effect upon independence
and well-being in old age and that are associated with
adverse health outcomes in old age.19 People with poorer
scores on the decision-making measure do not necessarily
have impaired decision-making; there are no normative
data available for the decision-making measure like there
are for cognitive measures. Thus, how to make a determination of clinically relevant impaired decision-making
that would meet accepted criteria for dementia is not
known. The types of functional impairments typically
used in dementia evaluations are of much lower complexity, involving basic or standard instrumental activities of
daily living that are necessary for everyday function. For
example, another recent study found that participants
with MCI had more deficits in instrumental activities of
daily living involving high cognitive demand than cognitively intact older persons.27
The second contribution of the present study is the
finding that multiple systems of cognitive function may be
driving the association between MCI and poorer decisionmaking, although perceptual speed abilities may primarily
drive this. Perceptual speed accounted for approximately
twice the variance in decision-making as other systems of
cognitive abilities but accounted for only approximately
one-quarter of the variance. Some observations can be
made about this. The first is that the ability to cognitively
process multiple aspects of a decision in a rapid manner
allows for a greater amount of time to understand and
evaluate various aspects of the problem and ultimately to
deliberate about an optimal choice. Reductions in perceptual speed can also affect the ability to make mental comparisons and selections between potential choices in a
time-efficient or rapid manner. If older adults with MCI
are not able to process as rapidly as those without MCI,
this would leave less time to fully understand and evaluate
potential choices, particularly if time pressed. Older adults
with MCI might consequently feel inclined to rely more on
simple heuristics, previous experience, or gut instincts in
making choices, which in turn may not lead to the best
decisions.28 Future work is needed to clarify what specific
role a decline in perceptual speed might play in this association. The second observation is that cognitive systems
accounted for only a portion of the variance in decisionmaking. This suggests that, although important, cognition
is not the only factor involved in decision-making, and
based on the results, other factors constitute a substantial
portion of the variance associated with decision-making.
Prior work in this cohort and others has shown that decision-making is a complex function of diverse characteristics that includes not only cognitive function, but also
other factors such as domain-specific knowledge18 and personality traits.16 In addition, amyloid burden, which is
particularly observed in the default network,29 has been
associated with impairment in activities of daily living in
MCI,30 which has been anticorrelated with explicit cognitive brain networks,31 and for this reason might be difficult to determine through cognitive testing. These results
underscore the importance of considering factors other
than cognition when trying to understand the determinants
of poorer decision-making in old age.

JAGS

2015

Strengths of this study include the use of a large, wellcharacterized community-based sample; accurate diagnostic classification; use of a decision-making measure that
closely approximates decisions found in real-world financial and healthcare settings; and incorporation of a battery
of cognitive measures that allowed for global and systemspecific considerations. Weaknesses include the use of a
cross-sectional design, the selected nature of study participants, and not observing the actual choices that participants made regarding health care and finances in their
lives. The results of this study support the notion that
MCI is associated with poorer financial and healthcare
decision-making in matters highly relevant to independence
and well-being. Future studies are needed to explore
whether poor decision-making is associated with subsequent adverse cognitive and neuropathological outcomes.

ACKNOWLEDGMENTS
The authors thank the Rush Memory and Aging Project
staff and participants.
Conflict of Interest: The editor in chief has reviewed
the conflict of interest checklist provided by the authors
and has determined that the authors have no financial or
any other kind of personal conflicts with this paper.
This research was supported by National Institute on
Aging Grants R01AG17917 (DAB), R01AG33678 (PAB),
and K23AG40625 (SDH); the American Federation for
Aging Research (SDH); and the Illinois Department of
Public Health (SDH).
Author Contributions: SDH, PAB, BDJ: conception
and design of the study, interpretation of data, drafting
the article, final approval. LY: analysis and interpretation
of data, revising the article critically for intellectual content, final approval. DAB: conception and design of the
study, acquisition and interpretation of data, revising the
article critically for intellectual content, final approval.
Sponsors Role: None.

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APPENDIX
Table A1. Categorical Relation of MCI to decision making, adjusting for age, education, and sex
1.5 SD Below Mean of NCI
Variable

Model Term

Estimate (standard error, p value)


Total decision making
Age
Education
0.19
Male
0.80
MCI
Financial decision making
Age
Education
0.20
Male
1.11
MCI
Healthcare decision making
Age
Education
0.19
Male
0.91
MCI

(0.05, <0.01)
(0.41, 0.05)
(0.05, <0.01)
(0.46, 0.02)
(0.05, <0.01)
(0.43, 0.03)

Model 1

0.10
0.21
0.90
1.00
0.11
0.20
1.15
0.44
0.10
0.21
1.03
1.10

(0.02,
(0.05,
(0.41,
(0.30,
(0.02,
(0.05,
(0.46,
(0.32,
(0.02,
(0.05,
(0.43,
(0.30,

<0.01)
<0.01)
0.03)
<0.01)
<0.01)
<0.01)
0.01)
0.17)
<0.01)
<0.01)
0.02)
<0.01)

Median Split of NCI


Model 2

0.09 (0.02, <0.01)


0.22 (0.03, <0.01)
0.47 (0.19, 0.01)
0.10 (0.02, <0.01)
0.11 (0.03, <0.01)
0.73 (0.19, <0.01)
0.10 (0.02, <0.01)
0.23 (0.03, <0.01)
0.28 (0.21, 0.20)

Model 1

0.08
0.23
0.55
1.04
0.07
0.12
0.77
0.61
0.05
0.24
0.31
0.97

(0.01,
(0.03,
(0.20,
(0.23,
(0.01,
(0.03,
(0.20,
(0.24,
(0.01,
(0.03,
(0.22,
(0.29,

<0.01)
<0.01)
<0.01)
<0.01)
<0.01)
<0.01)
<0.01)
0.01)
<0.01)
<0.01)
0.15)
<0.01)

Model 2

0.7 (0.01, <0.01)

0.06 (0.01, <0.01)

0.05 (0.01, <0.01)

Table A2. Relation of all cognitive function measures to decision making among individuals with MCI
Factor

Cognitive System

Total Decision Making


Semantic memory
Working memory
Perceptual speed
Visuospatial ability
Financial Decision Making
Semantic memory
Working memory
Perceptual speed
Visuospatial ability
Healthcare Decision Making
Semantic memory
Working memory
Perceptual speed
Visuospatial ability

Episodic memory
0.38
0.12
1.35
0.39
Episodic memory
0.16
0.25
0.69
0.11
Episodic memory
0.22
0.12
0.66
0.28

Estimate

Standard Error

p Value

0.38
0.34
0.28
0.29
0.22
0.15
0.19
0.15
0.16
0.12
0.23
0.24
0.19
0.20
0.15

0.28
0.27
0.66
<0.01
0.07
0.16
0.40
0.11
<0.01
0.36
0.19
0.36
0.52
<0.01
0.06

0.18

Estimated from separate linear regression models adjusted for age, sex, education, and all other cognitive domains.

0.33

0.24