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J Am Med Dir Assoc. 2015 Nov 1;16(11):957-62. doi: 10.1016/j.jamda.2015.05.014. Epub 2015 Jun 27.

Education and Executive Function Mediate Engagement in Advance Care Planning in Early Cognitive Impairment.

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Department of Neurology, Singapore General Hospital, Singapore.
Department of Psychology, National University of Singapore, Singapore.
Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore.
Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore. Electronic address:



Advance care planning (ACP) is an important component to holistic care for people with early cognitive impairment (ECI) who are generally still mentally capable of making rational decisions. This study explores the willingness of people with ECI to engage in ACP and how clinical and behavioral variables shape their decisions.


Ninety-eight persons with ECI (mild cognitive impairment or early dementia, Clinical Dementia Rating = 0.5/1.0) and assessed to have adequate insight (Clinical Insight Rating Scale) underwent an ACP information session. They were assessed on their knowledge of dementia (Knowledge of Alzheimer Disease) and willingness to engage in ACP, and were interviewed on their beliefs and attitudes toward ACP (Perceived Barriers and Benefits Scale to ACP). Univariate analysis and logistic regression identified factors that predicted persons willing or unwilling to engage in ACP based on their responses to the perceived barriers and benefits of ACP as well as sociodemographic and clinical variables.


Fifty-two persons (54%) were keen on ACP. On univariate analysis, persons with better executive function [Frontal Assessment Battery (FAB)] (t = -3.63, P < .0001), were more educated (t = -2.11, P = .038) and had lower barriers to ACP (t = 2.47, P = .015), particularly less "passive coping" (t = 2.83, P = .006), were more keen on ACP. Logistic regression revealed that the combined predictive model comprising FAB, education, and passive coping as a whole reliably differentiated those unwilling to engage in ACP from those who were willing (χ(2) = 18.995, P = .001 with df = 4). Wald criterion showed that FAB (P = .016) and passive coping (P = .023) contributed most to prediction.


Better education and executive function predict willingness to engage in ACP, and these factors are instrumental in a person's ability to acquire knowledge and process information. Initiating ACP discussions early, increasing efforts at education, and providing tailored information are important interventions that facilitate completion of ACP.


Advanced care planning (ACP); early dementia; education; executive function; mild cognitive impairment

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