Is opposition to care in elderly people with cognitive impairment may be considered as a refusal of care?

Care or treatment refusal in sick people is a right recognized by law. However, this right is questioned in subjects with cognitive disorders because it is not clear if opposition or refusal to treatment is underpinned by a behavioral disorder, a lack of understanding of the care or treatment, or a refusal to continue living a life heavily impacted by the disease and reflecting a demand for autonomy. Analysis of the literature and our personal experience show that oppositional behaviors in these patients, often described as troublemakers, should be closely analyzed to understand their motivations, and to be attentive to the freedom of choice of the patients, even if their motivations are ambivalent, even contradictory. A major risk for the carers of patients with cognitive disorders is to make decisions ignoring the freedom of choice of the patient, which should be included in the guide lines to improve geriatric care with respect for vulnerable people.