Table 5. Interview themes and exemplar quotes for how patient MCI might influence physician decision-making and recommendations for treatments after stroke and myocardial infarction.
| Theme | Exemplar Quotes |
|---|---|
| Physicians believed that patient MCI influences decision-making and recommendations for acute stroke and acute myocardial infarction treatments with more severe MCI having a greater effect than less severe MCI. | “People with mild cognitive impairment, it kind of depends on where on the spectrum they are and sometimes it’s also how aggressive they want to be. So I mean, it probably factors in, probably not consciously or overtly as much as it would in a patient with dementia.” (physician 7, neurologist) |
| “Yes, it really depends on the severity of the MCI…It might influence whether we do that test at all, whether we do a cardiac cath at all…” (physician 16, internist) | |
| “If there is a clear-cut indication [for oral anticoagulation], it [MCI] shouldn’t matter. Now if you are starting to become closer to dementia then that is another consideration.” (physician 14, neurologist) | |
| “Let’s say if they’re mild cognitive impairment was quite mild then it might be suitable for them to have aggressive treatment by a cardiologist.” (physician 16, internist) | |
| Physicians assumed that patients with MCI have shortened life expectancy and poor prognosis. | “We know that patients with MCI have a reduced lifespan compared to someone who has no cognitive impairment” (physician 10, cardiologist). |
| “I know that many patients with MCI stay in a state of MCI, but there is probably 5% to 10% that progress to dementia per year, so it might make me less likely to do a test that might lead to a more invasive procedure in the future…. do MCI patients generally have the same life expectancy at 70 as someone without cognitive impairment?” (physician 13, neurologist) | |
| Physicians assumed that patients with MCI are frailer and have poorer functional status than cognitively normal patients. | “Their baseline cognitive status in the sense of their baseline functional ability…I think probably the right term is frailty.” (physician 3, internist) |
| “So it’s the function piece that kind of sometimes gets to be concerning.” (physician 7, neurologist) | |
| Regarding the recommendation for intravenous thrombolysis for stroke, “Maybe. So if they have mild cognitive–it’s the same spectrum. Assuming…somebody’s pretty much independent, then no, but if it’s an older, more frail person, then yes.” (physician 3, internist) | |
| Physicians assumed that patients with MCI might not adhere to treatment. | “I worry about patients not complying with the diet or taking too many or not enough of medicines like Warfarin, in particular” (physician 8, internist). |
| Regarding the recommendation for cardiac rehabilitation after AMI, “Can they follow instructions?” (physician 16, internist). | |
| “…the American Heart Association guidelines actually say that if you don’t think a patient is going to be able to comply with dual antiplatelet therapy there’s actually a harm associated with putting a stent in their coronary arteries and so the stakes are fairly high with figuring out is somebody going to be able to take their medications. And I think people with mild cognitive impairment, that’s a big question that’s much more difficult to answer.” (physician 8, internist) | |
| “I might reconsider whether if somebody had a lot of memory problems if memory was a big component and they were forgetting their medicines, the more complicated medicine with higher risk may not be a good choice so Coumadin.” (physician 14, neurologist) | |
| Physicians made assumptions that MCI is associated with patient/family preferences for less intensive treatment. | “…well informed patients …who have an extremely high priority on their cognitive function and if they’re aware they have cognitive impairment based on a number of things—based on, let’s say, geriatrics, based on the feelings of their spouse about how they’re repeating themselves or certain things about asking the same questions, and they’re aware of cognitive impairment, they’re aware the imaging of their brain by CT or MRI was not perfect, and if they were to think about getting bypass surgery they might be aware that we’re not sure if something about bypass surgery or the sedation that’s required in bypass surgery affects that. That might make them more reluctant to consider that option.” (physician 16, internist) |
| “I just have concerns, frankly, that the patient and family would choose against it [surgery] because they don’t understand what it means" (physician 12, internist). | |
| Physicians worried that patients with MCI have greater risks or burdens from treatment. | “Invasive procedures, I think there’s a gray spectrum there and for that reason, I think those are conversations where I would want to take into account a patient’s baseline cognitive status and their family and their living situation before making a decision.” (physician 3, internist) |
| “I suppose that I might be more inclined to consult PM&R earlier in somebody’s hospital stay if they had a new acute focal weakness from a stroke and the complete absence of any cognitive deficits, versus if they had MCI, I might be more inclined to wait to hear what PT and OT thought, and if they thought that the person would be a good candidate for rehab, then consult them. …I probably am more inclined to consult PM&R more quickly if somebody has normal cognition and has a new neurological deficit than if they have impaired cognition and a new neurologic deficit.” (physician 4, neurologist) |
Abbreviations: PM&R is Physical Medicine and Rehabilitation. PT is physical therapy. OT is occupational therapy.