Examining Voting Capacity in Older Adults with and without Cognitive Decline^†

Round 1

Reviewer 1 Report

The article addresses a very relevant and interesting topic, justifying the entire ethical and legal aspect of the topic. I find it very interesting for social and medical matters.

Normally, neuropsychological assessments have a weighting regarding the age and education of the subject evaluated in their final result, due to its relevant aspect in cognitive preservation. Does this CAT-V tool consider these aspects in its final assessment?

Table 2 could be transferred to the result item, thus not mixing with the description of the methods used.

Were the results presented covariate for demographics, age and years of education? If not, I suggest inclusion, even in the division of different age groups. I could not understand, if with the separation between age groups or education, if the analyses were covariate by any data.

The study is well designed, but the results lack clarity regarding noise control care, even though it was mentioned in the limitations. A Post Hoc analysis could be included to have a clearer view of the differences.

Figure 1, the axes titles are in low resolution.

Author Response

Dear reviewer, editor,

Below you may find our responses regarding your comments, after the first review. The format below adheres to the format:

(R)eviewer(Reviewer number)(C)omment(Comment number)

(R)eviewer(Reviewer number)/(R)esponse

 

#3 Reviewer’s Comments

R3C1: Normally, neuropsychological assessments have a weighting regarding the age and education of the subject evaluated in their final result, due to its relevant aspect in cognitive preservation. Does this CAT-V tool consider these aspects in its final assessment?

R3R1: According to the original study of the CAT-V and its constructors (Appelbaum at al., 2005), no consideration of the demographic effects on the total score is mentioned and there was no adjustment regarding the age or education. The aim of their study was the investigation of whether the voting capacity would correlate inversely with dementia severity. However, in our study we performed an analysis in order to assess whether demographics, age, and educational level affect the voting capacity of CAT-V’s total score. According to this analysis there was only an age effect on the total CAT-V’s score. Therefore, the calculation of the cutoff scores was adjusted to age. The associated results are presented at page 30 paragraph 4.2 as well as at page 33, table 4 and in figure 2.

R3C2: Table 2 could be transferred to the result item, thus not mixing with the description of the methods used.

R3R2: We thank the reviewer for the comment. We transferred the table 2 as well as a short paragraph that accompanies the table at the Results section. 

R3C3: Were the results presented covariate for demographics, age and years of education? If not, I suggest inclusion, even in the division of different age groups. I could not understand, if with the separation between age groups or education, if the analyses were covariate by any data.

R3R3: We thank the reviewer for the comment. In our analysis there was not a covariation of age and education. Our groups differed according to age and education since they had different cognitive status. As expected, healthy controls were younger and more educated that PwMCI and PwADD. For the needs of the current study all participants were treated as a single group of older adults experiencing different rates of cognitive status. According to the ANOVA analysis the CAT-V total score is age dependent, therefore we adjusted our results according to age. However, there was not an adjustment for education, since education according to ANOVA does not seem to affect in any way the total score of CAT-V. We believe that the use of an age-adjusted normative score approach is advantageous and would provide the clinician with a more accurate assessment.

R3C4: The study is well designed, but the results lack clarity regarding noise control care, even though it was mentioned in the limitations. A Post Hoc analysis could be included to have a clearer view of the differences.

R3R4: We thank the Reviewer for this comment. However, due to the fact that this study was related with discriminant validity of the CAT-V tool, we thought that post hoc analyses could be included in our future endeavors.

R3C5: Figure 3, the axes titles are in low resolution.

R3R5: We thank the reviewer for the comment. We have corrected the axes titles.

 

Author Response File: Author Response.docx

Reviewer 2 Report

The level of cognitive deterioration and/or dementia at which voting ability is compromised is a topic of debate today. The purpose of this study is to determine whether the general cognitive state as people age predicts specific features of voting competence. Methods: 391 participants made up the study sample: 88 senior citizens with good mental health (CH), 150 individuals with mild. 153 people with Alzheimer's disease dementia and 153 people with cognitive impairment (MCI) (ADD). A CAT-V test for voting ability and a Mini Mental State Examination (MMSE) for general cognitive ability were both used in the evaluation. In order to a) determine the MMSE score at which participants are incapable of voting and b) determine if the CATV total score can distinguish individuals with dementia from those without dementia, statistical analysis tools such as ANOVAs and ROC curves were used. Results: Of the six CAT-V questions, one has a low MMSE cutoff score (19.50), excellent sensitivity (92.5%), and excellent specificity (77.20%), while the other five have a higher MMSE cutoff score, good sensitivity (78.4% to 87.6%), and good specificity (75.3% to 81.7%), suggesting that voting difficulties are related to cognitive status. Secondarily, the total CAT-V score distinguishes PwADD from PwtD in the age range of 51–65 years (sensitivity: 93.2%; specificity: 100%); PwADD from PwtD in the age range of 66–75 years (sensitivity: 73.3%; specificity: 97.1%); PwADD from PwtD in the age range of 76–85 years (sensitivity: 92.2%; specificity: 64.7%); and for In conclusion, the MMSE indicates that PwADD lack entire voting capacity, but PwtD appear to have intact voting capacity. Although the results are better but require explaining the following queries before the final recommendation. 

-  It is suggested to add a paragraph that describes the innovation/contribution of the paper.

- The authors need to add more about your future work plan. 

- The format of the references needs to be double-checked.

- The imitation of the work needs to be added for a better interpretation of results that need more research. 

- It is not clear whether the groups were balanced in terms of education or other aspects. Whether significant differences were observed in terms of age? Please report the statistics. 

- The provided link on the page 6 is not working. Please check for its correctness. 

 -It is not evident from the methods section which statistical tools were used to check the differences. Please clarify. 

- Why the authors have not applied the parametric tests instead of non-parametric ones? It can be seen that the dataset was large. Please clarify. 

 

 

 

Author Response

Dear reviewer, editor,

Below you may find our responses regarding your comments, after the first review. The format below adheres to the format:

(R)eviewer(Reviewer number)(C)omment(Comment number)

(R)eviewer(Reviewer number)/(R)esponse

#2 Reviewer’s Comments

R2C1: It is suggested to add a paragraph that describes the innovation/contribution of the paper

R2R1: We thank the reviewer for the comment. We have added a new section at the end of the paper, namely conclusion, where the innovation and contribution of the paper is described.

R2C2: The authors need to add more about your future work plan

R2R2: We have added a paragraph regarding future work plan at the conclusion section.

R2C3: The format of the references needs to be double-checked.

R2R3: We have checked for inconsistencies to the format of the references and we have performed the appropriate changes.

R2C4: The limitation of the work needs to be added for a better interpretation of results that need more research.

R2R4: The limitations of the study are already presented in detail, in a separate section at page 14.

R2C5: It is not clear whether the groups were balanced in terms of education or other aspects. Whether significant differences were observed in terms of age? Please report the statistics.

R2R5: At page 5 at the section of Participants we mention that our groups differed in age, gender, and educational level, with HC to be younger and more educated than MCI and Alzheimer’s disease patients. Moreover, at page 10 in the results section we mention that there was a significant main effect of age group, on the total performance in CAT-V, but not an education or age effect. Therefore, our results were stratified regarding age.

R2C6: The provided link on the page 6 is not working. Please check for its correctness.

R2R6: The link that we have provided at page 6 and refers to the steps of the procedure proposed for tests adaptations, works, since we have re-tested it. We propose to the reviewer to copy the link and paste it to a browser. If the reviewer desires to open it from the Word document he should press Ctrl and perform a click on the link.

R2C7: It is not evident from the methods section which statistical tools were used to check the differences. Please clarify. 

R2R7: At the section Data statistical analysis (pages 7 and 8), we mention in detail the used statistical methods in the current study: a) Analysis of Variance (ANOVA), and b) the ROC curve. We also clarify the reason behind why these analyses were chosen.

R2C8: Why the authors have not applied the parametric tests instead of non-parametric ones? It can be seen that the dataset was large. Please clarify.

R2R8: We have chosen the Analysis of variance, since our data fulfilled the 4 basic assumptions of ANOVA utilization. For further information please see a relevant article “Larson, M. G. (2008). Analysis of variance. Circulation, 117(1), 115-121.”

 

Author Response File: Author Response.docx

Reviewer 3 Report

This is an interesting study examining voting capacity in older adults with and without cognitive decline. The topic is interesting and important. The paper is well-written. I appreciate the methodology and the detailed explanation on how voting capacity is measured. I agree that the paper may have important contribution to the literature. I only have several minor comments to improve the manuscript:

1. I think the authors should minimize the use of abbreviation in the paper (e.g., DCCSH, DCCSJ). It makes the paper very difficult to read.

2. More details are necessary on how the sample is recruited and the sample methodology

3. Information regarding missing data and imputation technique should be provided in the method section.

4. I appreciate the extensive exclusion criteria in the study. Perhaps, the authors should explain how it was assessed and quantified (e.g., behavioral problems, etc)

5. It will be important for the authors to provide a bit more information regarding the diagnosis of minor and major neurocognitive disorders.

6. Figure 1 has poor quality and can be improved

7. I appreciate the careful interpretation in the discussion section. Well done!

Author Response

Dear reviewer, editor,

Below you may find our responses regarding your comments, after the first review. The format below adheres to the format:

(R)eviewer(Reviewer number)(C)omment(Comment number)

(R)eviewer(Reviewer number)/(R)esponse

#1 Reviewer’s Comments

R1C1: I think the authors should minimize the use of abbreviation in the paper (e.g., DCCSH, DCCSJ). It makes the paper very difficult to read.

R1R1: We thank the reviewer for the comment. As known, it is a common practice to not repeat throughout the text concepts that can be abbreviated, since it affects readability. Nevertheless, we performed the following corrections: we tried to fully write terms that the audience is not comfortable with (e.g. DCCSH, DCCSJ etc.) but we kept the commonly used abbreviations in the dementia field (e.g. HC, MCI, AD etc.). We hope this alteration resolves your comment.

R1C2: More details are necessary on how the sample is recruited and the sample methodology

R1R2: The information regarding the sample recruitment is fully presented in page 4, sections 3.1 and 3.1 respectively and also in page 6 which the inclusion/exclusion criteria are also presented. Unfortunately the comment is too generic. If the reviewer considers that something specific is missing, please let us know and we will add it.

R1C3: Information regarding missing data and imputation technique should be provided in the method section

R1R3: Because of the nature of the study and the type assessment (CAT-V), there were no missing data. An extra sentence was added in the last paragraph of the 3.1 section.

R1C4: I appreciate the extensive exclusion criteria in the study. Perhaps, the authors should explain how it was assessed and quantified (e.g., behavioral problems, etc).

R1R4: We thank the reviewer for the comment. We added the data proposed by the reviewer at the participant section on page 6.

R1C5: It will be important for the authors to provide a bit more information regarding the diagnosis of minor and major neurocognitive disorders.

R1R5: We realize the great importance of the diagnosis and we thank the reviewer for the comment. Nevertheless, this information is considered standard knowledge in the dementia field; therefore, we would prefer not to further enlarge the text by providing information that could be easily be found in the basic literature.

R1C6: Figure 1 has poor quality and can be improved

R1R6: We thank the reviewer for the comment. We corrected the figure 1 in order to be easy to be read.

R1C7: I appreciate the careful interpretation in the discussion section. Well done!

R1R7: We thank the reviewer for the comment.

 

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

I believe that with the additions made by the authors in the manuscript, clarifying some points that were not well described and the answers given, the manuscript is suitable for publication

Reviewer 2 Report

The authors have sufficiently improved the quality of the manuscript. It can be accepted in its current form.

Reviewer 3 Report

The authors have addressed my comments well.