Joshua Grill (Photo by Steve Zylius / UCI)
By Chloe Elmer
Clinicians face an unusual challenge when it comes to diagnosing patients with mild cognitive impairment, commonly called MCI, and what that may or may not mean for their future.
Not all MCI patients develop dementia — some may show no decline over a 10-year period — but the diagnosis can still be helpful. It fosters discussions between physician and patient/family about important issues such as long-term financial planning and expectations.
Meanwhile, recently-approved PET scans can help determine an “elevated risk” of developing Alzheimer’s disease dementia through the identification of amyloid, but clinicians must proceed with caution when discussing these scan results.
These were a few of the comments from researchers in a new guide for clinicians on effective communication with patients and families regarding the diagnosis and possible outcomes of MCI. The 12 recommendations were recently published in the journal “Alzheimer’s Research & Therapy Journal.”
“While MCI has been among the most active areas of research, there remains little guidance for clinicians related to how best to talk to patients and families about the diagnosis,” said Joshua D. Grill, PhD, who organized the group of dementia and MCI experts. “We hoped to develop some guidance, and to spur more study and discussion about this important topic.”
Grill is an Alzheimer’s disease researcher and associate professor of psychiatry and human behavior at the University of California Irvine School of Medicine.
The trademark of MCI is lower cognitive performance than expected for a person’s age and education. The change is recognized by the patient or families but doesn’t affect daily life and doesn’t fulfill the criteria for a diagnosis of dementia.
About 12 to 16 percent of MCI patients progress to dementia per year, but up to 50 percent of MCI patients remain in MCI even 10 years after diagnosis.
Research has refined the understanding of the risk of patients with MCI developing dementia. It may be highest among MCI patients who have Alzheimer’s disease pathology, particularly amyloid plaques, seen on a brain scan or spinal fluid test.
Recently approved PET scans allow clinicians to determine whether a patient with MCI has amyloid. Patients who qualify for this imaging should be given the necessary information and the opportunity to make an informed decision about whether to have the scan, the experts recommended.
Other recommendations included:
- The clinician’s overall assessment of the patient should take into account standard cognitive testing, neuropsychological assessment if necessary, performance on tests of specific cognitive domains, and structural brain imaging. An informant such as a close friend or family member should be present during this process to give an overall picture of the patient’s needs and functioning, as well as to provide emotional support and follow-through.
- Clinicians must set expectations with patients about their impairment and should use the diagnosis of MCI as an opportunity to help patients validate their cognitive complaints. Patients should be given printed literature about their diagnosis and services that they can turn to.
- Expectations should be set before ordering an amyloid scan by discussing the limitations of the scan, possible results, and implications to treatment and well-being.
- Results of the imaging tests should be discussed in person. Showing the actual scan and a contrasting typical positive or negative scan may also help better illustrate the conversation.
- A patient with a negative amyloid scan result should be made aware that although their risk for Alzheimer’s is lower, developing dementia cannot be ruled out, and other underlying brain diseases may be present, such as Lewy Body disease. Positive scan results in MCI patients are associated with higher risk for developing Alzheimer’s, and the physician should discuss possible paths such as continued follow-up and long-term planning.
Recommendations related to amyloid imaging were limited to dementia specialists trained in use of the scan discussing results with patients and families.
The workgroup noted in its summary the importance of including MCI patients and family members in evaluating the system of proposed recommendations, as they hold the key to an important perspective in the process.
The experts also noted that full incorporation of the recommendations may be difficult for busy primary care physicians but maintained the importance of setting appropriate expectations, carefully delivering the diagnosis to both patients and caregivers, as well as having thorough discussions about planning and outcomes.
“Amyloid imaging isn’t perfect,” said Grill, “but it’s clear that the information can make a meaningful difference for clinicians working with patients with memory problems and that patients and families desire this information and often benefit from it.”
“We hope that these recommendations will provide more guidance to enhance that clinical interaction.”