Surveys on the voting
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Voting is the basis of all democracy and is fundamental to Western civilization. Yet, as Dr. Sherman's "Get out the demented
vote!" editorial1 conveyed, no data exist concerning the voting capacity of demented patients. Only two American studies, both conducted after
the contentious 2000 U.S. presidential election, have examined factors that influence the participation of cognitively impaired
older adults in national elections.2,3 I want to present the findings of two studies we conducted in Belgium on voter knowledge and participation among demented
older adults. In Belgium, voting in elections is mandatory for adults age 18 and older. Many believe, however, that the majority of older
adults do not vote. Exact figures are lacking and reasons for not voting have yet to be studied. Elections here are considerably
more complicated than in the United States. Unlike in America, where two parties dominate, multiple political parties run
for election, and every party proposes several candidates. Furthermore, voters use a computerized system consisting of a touch-screen/
electronic pen and a magnetic card.
Figure Identifying recent and ancient politicians in Belgium
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In the first study, we investigated the level of knowledge about elected officials in community-dwelling older patients with
cognitive impairment (N=26; age 76.1(64-89); M/F: 10/16). We used a PowerPoint presentation to determine if patients recognized
the photographs of 'ancient' (1960-1990) and 'recent' (>2000) elected officials (eg, the current Prime Minister, see figure).
The results were compared among the Folstein Mini-Mental Status Exam (MMSE: 20.5 (11-28)), basic activities of daily living
(B-ADL: 7.1 (6-13)), instrumental activities of daily living (I-ADL: 17.3 (10-27)) and Global Deterioration Scale (GDS: 4.3
(2-6)). The correlation between test scores and MMSE (ANOVA, p=0.001) and GDS (ANOVA, p <0.001) was significant. However, no relationship was noted between test scores and I-ADL and B-ADL.By compairing the results using a ratio, we found that patients recognized 'ancient' elected officials better than 'recent'
ones. (An ancient/recent-ratio of 1 means 'ancient' officials are recognized as well as 'recent' ones, a ratio >1 means 'ancient'
officials are recognized better than contemporary ones. In the study group, the ratio was 1.41.)
The second study assessed voter participation. In the three months following the Belgian federal elections on May 18, 2003,
demented outpatients (N=41) were asked about their participation in the elections. The majority (28/41) of patients had participated.
Patients living at home with a spouse were more likely to vote (83%) than those who lived alone or with another family member,
eg, sister, son, or daughter, (46%). More than 50% of the participants (15/28) needed the assistance of a family member or
an official of the election bureau to follow the computerized voting procedure. A correlation was shown between voter participation
and the severity of dementia, assessed by the GDS (mean GDS in voters 4.2, in non-voters 5.1; Mann Whitney U test: p<0.001) and decline of praxis, assessed by the I-ADL (mean I-ADL in voters 18.4, in non-voters 14.1; Mann Whitney U test:
p=0.003), but not of pure cognitive decline as assessed by the MMSE (mean MMSE in voters 21.0, in non-voters 18.8, NS).
Of the non-voters, 2 were hospitalized and did not participate, 2 were 'not interested,' and 3 assigned a family member to
fulfill their voter duties. Only one caregiver considered the computerized system a negative influence on participation.
These data indicate that the majority of the cognitively impaired older adults are willing to participate in political elections.
However, the fact that a majority of patients in the study needed assistance using the computerized voting system raises concerns
about the confidentiality of elections. If officials of the election bureau or family members influence the vote of the demented
individual, then who is really voting? Additionally, this need for assistance could imply that voting procedures that are
too "difficult" could negatively influence voter participation.
As Dr. Sherman noted, "there is scant medical, scientific, and technological knowledge that guides government, society, and
physicians on what role demented individuals can and should play in the electoral process." I would argue that, until proven
otherwise, cognitively impaired older adults maintain their right to vote. All adults must be able to participate in elections
and be assured of the confidentiality of the process.
References 1. Sherman FT. Get out the demented vote! The right to vote vs. impaired voting capacity, elder abuse, and fraud. Geriatrics
2004; 59(10):11, 15, 19.
2. Karlawish JH, Casarett DA, James BD, Propert KJ, Asch DA. Do persons with dementia vote? Neurology 2002; 58(7): 1100-2.
3. Ott BR, Heindel WC, Papandonatos GD. A survey of voter participation by cognitively impaired elder patients. Neurology
2003; 60(90):1546-8.
Dr. De Cauwer, a neurologist, is head of KLINA Alzheimer Research Centere, KLINA Regional Hospital, Brasschaat, Belgium.
Disclosure: The author has no real or apparent conflict of interest with the subject under discussion.
