The capacity to vote in patients with mental illness is increasingly questioned. The objective of this study is to evaluate this capacity in a group of subjects with dementia (Alzheimer's disease) and other elderly subjects without dementia. With a sample of 68 subjects with dementia and 25 controls living in a senior residence, a transversal study was carried out over 4 months. Subjects were evaluated with the Mini-Mental State Examination (MMSE) and the Competence Assessment Tool for voting (CAT-V). The results were more positive for the Doe criteria (as part of the CAT-V), and a correlation was found with the MMSE in subjects with dementia and, to a lesser degree, in the controls. We conclude that the capacity to vote is related to cognitive deterioration and, within that, is more related to understanding and appreciation.
Voting is a legal right in many countries. But the exercise of this right does not mean that all persons have the capacity to vote. There might be cases of people with the competence to vote, but without the necessary capacity. For this reason, there is increasingly more literature seeking a tool to evaluate the capacity to vote, for patients with dementia as well as other mental disorders, such as those hospitalized with acute symptoms, and so forth [
In the evaluation of the capacity for the act of voting, there are 6 questions that evaluate the functional abilities of the person, based on the 4 standard decision-making abilities: understanding, choice, reasoning, and appreciation. Some of these questions come from the standard questionnaire of a federal court, related to understanding the nature of voting, understanding its effect and vote selection in Maine, USA (Doe criteria) [
This instrument has been used in various studies [
Our study attempts to resolve these questions in two ways: using the MMSE [
The study included 68 patients residing in the Arganda del Rey Senior Residence, diagnosed with Alzheimer’s dementia (according to DSM-IV-TR criteria) [
As a control group, 25 additional subjects were evaluated with the same criteria and lived in the same residence, but were not diagnosed with any type of dementia or any other mental illness (according to DSM-IV-TR) which could confound the results of the study.
We used the CAT-V to evaluate the capacity to vote. The questions used were adapted from the criteria for decision making: understanding, choice, reasoning, and appreciation. As previously stated, these are the Doe criteria: the voting capacity is applied according to whether the subject understands the nature and effect of the vote, the choice of candidate [
Although our study did not look at interexaminer reliability, we took into account the experience in another work completed by the same authors [
In addition, we used the MMSE [
The DSM-IV-TR classification criteria were used to diagnose Alzheimer’s dementia and to exclude possible clinical cases in the group of control patients without dementia.
Scores were given for the Doe criteria for each participant, as a result of adding the points for understanding of nature and effect of the vote, of 0 to 4 points, plus two for vote choice. In addition, we considered the scoring for reasoning, of 0 to 2 points for comparative and another 0 to 2 for consequential. Appreciation was also scored on a scale of 0 to 2.
We used in the comparison of the means of the two groups the Student’s
The Spearman correlation coefficient and the Kruskal-Wallis Chi-square tests were used to look at the associations between the CAT-V measurements, and with respect to the MMSE scoring and sociodemographic characteristics.
All participants or their caregivers gave verbal informed consent to participate in the study. They were assured that the information they gave would be used solely for the purposes of this study and they did not display apprehension in this regard.
Sixty-eight (68) patients with dementia and 25 elderly subjects without mental illness completed the study. Table
Characteristics of 68 patients with Alzheimer’s dementia and 25 elderly subjects without mental illness of the Arganda Senior Residence who were evaluated for their capacity to vote.
Dementia group | Normal group | |||
Characteristics | % or range | % or range | ||
Sex | ||||
Male | 16 | 23.5 | 9 | 36 |
Female | 52 | 76.5 | 16 | 64 |
Age | ||||
70–79 | 10 | 14.7 | 4 | 16 |
80–89 | 35 | 51.5 | 16 | 64 |
90–99 | 22 | 32.4 | 5 | 20 |
Age (M ±SD) | 61–99 | 70–98 | ||
MMSE score (M±SD)a | 0–22 | 25–29 |
aPossible scoring for MMSE ranges from 0 to 30, with higher score representing greater cognitive capacity.
Table
Scoring of the capacity to vote (CAT-Va competency assessment tool for voting) of 68 patients with dementia and 25 controls (elderly without dementia).
Alzheimer’s | Elderly | |||
Item and scoreb | % | % | ||
Doe criteriac | ||||
Understanding nature of the vote | ||||
2 | 18 | 26.5 | 24 | 96 |
1 | 18 | 26.5 | 1 | 4 |
0 | 32 | 46.1 | 0 | — |
Understanding effect of the vote | ||||
2 | 6 | 8.8 | 18 | 72 |
1 | 24 | 35.3 | 7 | 28 |
0 | 38 | 55.9 | 0 | — |
Vote choice | ||||
2 | 1 | 1.5 | 8 | 32 |
1 | 16 | 23.5 | 17 | 68 |
0 | 51 | 75 | 0 | — |
Total Doe score | ||||
6 | 0 | — | 7 | 28 |
5 | 3 | 4.4 | 12 | 48 |
4 | 8 | 11.8 | 5 | 20 |
3 | 11 | 16.2 | 1 | 4 |
2 | 9 | 13.2 | 0 | — |
1 | 10 | 14.7 | 0 | — |
0 | 27 | 39.7 | 0 | — |
Additional itemsa | ||||
Comparative reasoning | ||||
2 | 0 | — | 7 | 28 |
1 | 12 | 17.6 | 18 | 72 |
0 | 56 | 82.4 | 0 | — |
Consequential reasoning | ||||
2 | 1 | 1.5 | 14 | 56 |
1 | 23 | 33.8 | 11 | 44 |
0 | 44 | 64.7 | 0 | — |
Appreciation | ||||
2 | 13 | 19.1 | 21 | 84 |
1 | 32 | 47.1 | 4 | 16 |
0 | 23 | 33.8 | 0 | — |
a CAT-V.: test to evaluate the capacity to vote, created by Appelbaum et al., 2005 [
bDescending order.
cAccording to Doe versus Rowe criteria for competence to vote of 2001 [
When we compare the CAT-V items in the two groups, we observe significant differences: in understanding the nature of the vote (Chi-square,
In the group of patients with dementia, there is a correlation between the MMSE and the Doe criteria:
Relation of Mini-Mental State Examination scores to Doe criteria in 68 patients with Alzheimer’s disease.
In the same group of patients with dementia, the correlation of MMSE and the CAT-V reasoning items is
In dementia’s group, the correlation between MMSE and appreciation is Kruskal-Wallis test,
Spearman correlations between MMSE and CAT-V items are as follows. With nature of vote: Correlation between MMSE and the Doe item of vote choice continues to be significant ( With comparative reasoning:
There is a correlation between age, in the oldest range (90 to 99), and the Doe criteria (Kruskal-Wallis,
When we compared the patients with dementia with the controls, elderly without dementia, we observed significant differences with the Mann-Whitney
Correlation between MMSE and Doe criteria is shown in Figures
Relation of Mini-Mental State Examination Scores to scores on comparative reasoning for 68 patients with Alzheimer’s disease and 25 controls.
Relation of Mini-Mental State Examination Scores to scores on consequential reasoning for 68 patients with Alzheimer’s disease and 25 controls.
Relation of Mini-Mental State Examination Scores to scores on appreciation for 68 patients with Alzheimer’s disease and 25 controls.
We believe that this is the first study comparing the capacity to vote in patients with Alzheimer’s dementia and in elderly subjects without dementia or any other mental illness, using CAT-V.
We observe that patients with dementia understand the nature and effect of the vote (53% and 44%, resp.), and appreciate its consequences (66.2%) but do not do as well when it is time to make a voting choice (25%) and to consequential reasoning (35.3%). There is a correlation among all the items with MMSE, that is, the lower the score, the lower the capacity to vote, and those with mild dementia usually retain the capacity to vote. We agree with another study that also used CAT-V and MMSE in patients with dementia, but with less cognitive deterioration [
Almost all patients with mild dementia had Doe scores greater than or equal to 2. We do not agree with the Raad et al. study [
There are significant differences in scoring of the MMSE and CAT-V between both groups, as would be expected. This could be understood that the patients without mental illness, although they are elderly, and without cognitive deterioration, have a greater capacity to vote. Therefore, in this group, the MMSE does not serve as a predictor test and it does in patients with moderate dementia. As observed by Pruchno et al. [
The MMSE has been used to evaluate consent for treatment, with similar results [
It seems that if we place a high threshold on the voting test, including the reasoning and appreciation items, various subjects remain outside that threshold although they do have the capacity to vote according to the Doe criteria. And if we focus on these, the vote choice item also presents difficulties [
There are studies that show that patients with mild and moderate dementia have a normal score in the subscales of appreciation and reasoning (in the MacArthur Clinical Research test) [
The voting test we used, the CAT-V, does correlate with the MMSE in Alzheimer’s dementias, both in our study as in those of other authors [
Nor do we know the cut-off point of the test if we score more for appreciation than for reasoning. In our study, the subjects perform better in terms of appreciation of the consequences of an election, the absence of false beliefs that direct own appreciation [
This study has several limitations: not having performed an interexaminer reliability test and the small sample size. The first is addressed in part due to the authors’ knowledge of the test from other studies [
Understanding is related to memory, executive capacities and name comparison in dementia [
Future studies should look at the factor analysis of the MMSE items that correlate with the CAT-V, with ADL, and IADL and with other sociodemographic variables.
It is important to carry out an evaluation of the capacity to vote on patients with moderate dementia. The MMSE and the CAT-V test can be useful to this end. The criteria of understanding and appreciation are easier for the patients, but not those of vote choice and reasoning. Cognitive deterioration, but not age, influences the capacity to vote.
All authors contributed to the design of the study. P. Corujo and P. Bañuelos identified the participants, did the individual interviews and administered the neuropsychological scales. L. J. Irastorza contributed to the analysis and interpretation of data, drafted the article and revised.
All authors declare that they have no financial interest that may be relevant to the submitted work; only we received help for translation of the text by S. A. Andromaco-Grunnenthal.