Five Ethical Questions Involving Alzheimer's Disease

Introduction

This article discusses five ethical questions psychiatrists will probably confront when they treat patients who have or may develop Alzheimer's disease (AD). These questions are as follows: 1) Should psychiatrists prescribe antipsychotics to patients with AD? 2) How vigorously should psychiatrists pursue the diagnosis of minimal cognitive impairment (MCI)? 3) Should psychiatrists initiate restricting AD patients' right to drive? 4) Should psychiatrists give anti-androgenic medication to patients who show severely disruptive sexual behavior? and 5) Should psychiatrists encourage patients' loved ones to participate in cognitively stimulating exercises with these patients?

When facing these and other ethical dilemmas, psychiatrists should keep in mind, particularly, that as AD progresses, these patients increasingly gain more joy and meaning from their relationships with others and less from their cognitive capacities. Thus, when psychiatrists consider these ethical issues, they increasingly should consider the choices that will preserve or enhance a patient's relationships with his or her loved ones. This, presumably, is also what these patients would most want for themselves.

Should Psychiatrists Prescribe Antipsychotics to Patients with AD?

The opinion of psychiatrists may differ over when, if ever, they should prescribe AD patients antipsychotic drugs.¹ These drugs may increase these patients' risk of death and cause other serious side effects.^4,5 Yet, they also may effectively reduce these patients' agitation and aggression,⁶ which may mean these patients can continue to relate meaningfully with others. With control of agitation and aggression, loved ones may be able to take care of AD patients at home longer and caregivers in nursing homes may be able to relate to AD patients in a more caring and patient way.⁷ The patient's increased quality of life may be worth the increased risks.

Psychiatrists should discuss possible treatments of agitation and aggression with AD patients and their families early on in the disease process. While a patient with AD may not benefit directly from these discussions due to the progession of the disease, including patients in these discussions demonstrates respect for them as persons, and clinically this may be beneficial.^8–11 These discussions with both the patient and his or her family may also help the family feel better about treatment decisions they make later.

How Vigorously should Psychiatrists Pursue the Diagnosis of MCI?

Patients with MCI may or may not go on to develop AD.¹² The rationale for pursuing this diagnosis is strong, because it is now known that cholinesterase inhibitors can slow the advance of AD once it presents. Thus, once MCI is diagnosed, patients with MCI can be regularly followed so that if and when AD develops, these patients can be treated as early as possible, ultimately improving patient outcomes.^13,14

Notwithstanding this strong rationale, however, some people are so frightened of the possibility of developing AD, especially when there is no treatment for MCI that has yet been proven to be effective in reducing the severity of AD later, that they would prefer not pursuing a diagnosis of MCI, even if the symptoms are there. They believe, quite rightly, that knowing they have MCI, which increases the risk of developing AD, would reduce the quality of their lives.

Again, psychiatrists should discuss the benefits and risks of pursuing an MCI diagnosis with both the patient and his or her family. These discussions may enable patients who do not want to know that they have MCI to help their families and psychiatrists better understand their personal fears and their preference to not know that they have MCI. This may then enable psychiatrists and family members to better respond to the exceptional individual wishes of these patients.

After discussing the risks and benefits of diagnosing MCI, patients may indicate that they still do not want to know this diagnosis, but, rather, they want to know only when and if they develop AD, since AD can and should be treated. Psychiatrists may then give these patients an additional option: Psychiatrists can offer to arrange for another person (ideally someone who works with the psychiatrist) to perform periodic brief cognitive testing on the patient that requires no interpretation of the results. This other person could then inform the psychiatrist only when a predetermined criterion, such as a certain score on the Mini-Mental Status Exam, strongly suggests the presence of AD. This way, neither the psychiatrist nor patient will know whether the patient has MCI; however, if and when the patient develops AD, the patient and psychiatrist would be alerted and the patient could then immediately begin treatment. With this approach, both the psychiatrist and the patient can continue to interact with each other without the psychiatrist having to keep knowledge about the presence of MCI secret from the patient.

Should Psychiatrists Initiate Restricting ad Patients' Right to Drive?

Patients with AD may pose increasing risks when driving, not only to themselves, but also to others, as their illness progresses. Yet the ability to drive may help preserve the quality of their lives.

An important consideration is that even though the ability to drive may become worse in some AD patients, this does not necessarily mean that all AD patients will have more accidents.¹⁵ Some AD patients learn to compensate and increasingly drive more carefully. Ethically, taking away driving licences of all patients with AD is problematic because it is unfair to deprive all AD patients of the opportunity to drive when some patients may not pose an increased risk for accidents.¹⁶

Once again, psychiatrists should discuss the risks and benefits of maintaining the ability to drive with both the patient and his or her family early on in the disease process. Through these discussions, patients may willingly choose not to drive over time, if not for themselves then for the sake of their families.¹⁷ They and their families may agree also to “titrate” their driving over time (e.g., limit driving to just going up the street to a convenience store) before altogether eliminating driving. If AD patients can accept the loss of driving privileges voluntarily, this preserves the trust they have in their psychiatrists.

Should Psychiatrists Give Anti-Androgens?

Patients with AD may become sexually disinhibited, especially in the later stages of AD.¹⁸ Some physicians believe it is ethically obligatory to then give these patients anti-androgens to reduce this behavior, while others may not believe in prescribing this at all.^19–21

Clearly, behavioral interventions should be tried first. However, if these prove ineffective, it may seem optimal to prescribe an anti-androgen so that these patients can continue to have fulfilling relationships with their loved ones.

Psychiatrists should try not to respond to this situation in a way that is overly rigid or reflexive. Ethical principles may warrant exceptions. Psychiatrists should, in these cases, base their decisions on each patient's greatest needs.

Should Psychiatrists Encourage Cognitive Stimulation Exercises in Patients With AD?

Some evidence suggests that cognitive stimulation may help patients with AD.^22,23 These exercises consist of a wide variety of cognitive activities, such as crossword puzzles, that require patients with AD to “use their minds” to a greater extent in the hope that this will prove beneficial to their AD. Loved ones may ask whether or not they should pursue cognitive stimulation exercises with AD patients.

As with any off-label intervention, ethically, psychiatrists should weigh carefully each patient's relative risks and benefits from this form of treatment.²⁴ These interventions may improve a patient's capacity for cognition but harm the patient's self esteem and/or his or her relationship with the loved one who is trying to “treat” the AD in this way. Ethically, these harms may outweigh the possible gains. Loved ones may have the best intentions, but they may do these patients harm by pushing the cognitive training too much. As a result, AD patients may feel shame because they believe that they should be able to do better. They may also believe, rightly or wrongly, that their loved ones are disappointed in how poorly they do. Moreover, these exercises may subtly but insidiously change the nature of the relationship between a loved one and a patient with AD. As a result, the AD patient may feel infantilized and increasingly unequal.

If an AD patient clearly enjoys the exercises, then the psychiatrist should encourage it. Psychiatrists should discuss this intervention with both the patient and his or her loved ones, taking particular care to alert both parties to these risks and potential benefits.

Conclusion

When treating patients with AD, psychiatrists should always keep in mind that what patients with AD generally most want is to be able to continue to relate to their loved ones as harmoniously as is possible for as long as possible. As a final example, I treat a patient with AD who still does a crossword puzzle together every morning with his spouse. This is the favorite part of their day.