Betting on DBS: Effects of subthalamic nucleus deep brain stimulation on risk taking and decision making in patients with Parkinson's disease.

OBJECTIVE: Concerns persist that deep brain stimulation (DBS) for Parkinson's disease (PD) increases impulsivity or induces excessive reward seeking. We report here the performance of PD patients with implanted subthalamic nucleus electrodes, with stimulation on and off, on 3 laboratory tasks of risk taking and decision making. They are compared with PD patients maintained on medication and healthy participants. METHODS AND RESULTS: In the Game of Dice Task, a test of "risky" decision making, PD patients with or without DBS made highest risk bets more often and ended up with less money than did healthy participants. There was a trend for DBS stimulation to ameliorate this effect. Deal or No-Deal is an "ambiguous" decision-making task that assessed preference for risk (holding on to one's briefcase) over a "sure thing" (accepting the banker's offer). Here, DBS patients were more conservative with stimulation on than with it off. They accepted smaller offers from the banker and won less money in the DBS-on condition. Overall, the 2 PD groups won less money than did healthy participants. The Framing Paradigm assessed willingness to gamble on a fixed (unambiguous) prize depending on whether the reward was "framed" as a loss or a gain. Nonsurgical PD patients tended to be more risk-averse than were healthy participants, whereas DBS patients were more willing to gamble for gains as well as losses both on and off stimulation. CONCLUSIONS: On risky decision-making tasks, DBS patients took more risks than did healthy participants, but stimulation may temper this tendency. In contrast, in an ambiguous-risk situation, DBS patients were more risk-averse (conservative) than were healthy participants, and this tendency was greatest with stimulation.

Internet-based screening for dementia risk.

The Dementia Risk Assessment (DRA) is an online tool consisting of questions about known risk factors for dementia, a novel verbal memory test, and an informant report of cognitive decline. Its primary goal is to educate the public about dementia risk factors and encourage clinical evaluation where appropriate. In Study 1, more than 3,000 anonymous persons over age 50 completed the DRA about themselves; 1,000 people also completed proxy reports about another person. Advanced age, lower education, male sex, complaints of severe memory impairment, and histories of cerebrovascular disease, Parkinson's disease, and brain tumor all contributed significantly to poor memory performance. A high correlation was obtained between proxy-reported decline and actual memory test performance. In Study 2, 52 persons seeking first-time evaluation at dementia clinics completed the DRA prior to their visits. Their responses (and those of their proxy informants) were compared to the results of independent evaluation by geriatric neuropsychiatrists. The 30 patients found to meet criteria for probable Alzheimer's disease, vascular dementia, or frontotemporal dementia differed on the DRA from the 22 patients without dementia (most other neuropsychiatric conditions). Scoring below criterion on the DRA's memory test had moderately high predictive validity for clinically diagnosed dementia. Although additional studies of larger clinical samples are needed, the DRA holds promise for wide-scale screening for dementia risk.

Nonrational processes in ethical decision making.

Most current ethical decision-making models provide a logical and reasoned process for making ethical judgments, but these models are empirically unproven and rely upon assumptions of rational, conscious, and quasilegal reasoning. Such models predominate despite the fact that many nonrational factors influence ethical thought and behavior, including context, perceptions, relationships, emotions, and heuristics. For example, a large body of behavioral research has demonstrated the importance of automatic intuitive and affective processes in decision making and judgment. These processes profoundly affect human behavior and lead to systematic biases and departures from normative theories of rationality. Their influence represents an important but largely unrecognized component of ethical decision making. We selectively review this work; provide various illustrations; and make recommendations for scientists, trainers, and practitioners to aid them in integrating the understanding of nonrational processes with ethical decision making.

Preliminary findings from an internet-based dementia risk assessment.

BACKGROUND: The identification of individuals who are at high risk of dementia may lead to earlier detection and diagnosis. In this study, we describe the development and preliminary validation of a very brief, Internet-based risk assessment tool. METHODS: The Dementia Risk Assessment collected information on demographic, neurologic, and medical risk factors; perceived cognitive functioning; and emotional symptoms. Participants answered questions pertaining to themselves ("patient page") or to a relative or friend ("proxy page"). Patients also completed a novel short-delayed recognition memory test. Subjects received personalized feedback about their risk factors and were advised to seek clinical evaluation for concerning symptoms. By November 2009, 500 respondents completed the patient page. RESULTS: The 352 respondents aged 50 years or older (M = 62 years) included a high percentage of women (72%) and college graduates (67%). Among the respondents, only 10% complained of having severe memory problems, whereas 38% reported having a first-degree relative who experienced severe memory loss. The prevalence of major neurologic risk factors was low. Although the delay interval for the recognition memory test averaged around 2 minutes, there was sufficient variability in performance. Individuals with scores ≤10th percentile were significantly older and more likely to be men, have hypertension, and report having severe memory problems. CONCLUSIONS: History of major dementia risk factors can be ascertained through the Internet, and several of these factors are shown to be moderately predictive of performance on a brief test of episodic memory. These data provide preliminary validation of the Dementia Risk Assessment for identifying current cognitive impairment, and suggest its potential for assessing future dementia risk. Ongoing studies will further establish the validity of these findings against proxy reports of cognitive and functional decline, the results of more detailed cognitive assessments, and formal clinical diagnoses.

A cost utility analysis of interdisciplinary early intervention versus treatment as usual for high-risk acute low back pain patients.

Chronic pain is a costly and debilitating condition that has proven difficult to treat, solely with medical interventions, due to the complex interplay of biological, psychological, and social factors in its onset and persistence. Many studies have demonstrated the effectiveness of interdisciplinary treatment that includes psychosocial interventions for low back pain. Nevertheless, these interventions continue to be under-utilized due to concerns of cost and applicability. The present study utilized a cost utility analysis to evaluate effectiveness and associated costs of interdisciplinary early intervention for individuals with acute low back pain that was identified as high-risk for becoming chronic. Treatment effectiveness was evaluated using a standard pain measure and quality-adjusted life years, and associated medical and employment costs were gathered for 1 year. Results indicated that subjects improved significantly from pretreatment to 1-year follow-up, and that the early intervention group reported fewer health-care visits and missed workdays than the treatment as usual group. The majority of 1,000 bootstrapped samples demonstrated the dominance of the early intervention program as being both more effective and less costly from a societal perspective. The early intervention treatment was the preferred option in over 85% of samples within an established range of acceptable costs. These results are encouraging evidence for the cost-effectiveness of interdisciplinary intervention and the benefits of targeted early treatment.