Physician Diagnosis and Knowledge of Mild Cognitive Impairment

Abstract

Background:

People with mild cognitive impairment (MCI) receive fewer guideline-concordant treatments for multiple health conditions than cognitively normal older adults. Reasons for this disparity are unclear.

Objective:

To better understand this disparity, we describe physician understanding and experience with patient MCI, particularly physician identification of MCI, ability to distinguish between MCI and dementia, and perspectives on education and training in MCI and dementia.

Methods:

As part of a mixed-methods study assessing the influence of patient MCI on physician recommendations for acute myocardial infraction and stroke treatments, we conducted a descriptive qualitative study using semi-structured interviews of physicians from three specialties. Key question topics included participants’ identification of MCI, impressions of MCI and dementia awareness within their practice specialty, and perspectives on training and education in MCI.

Results:

The study included 22 physicians (8 cardiologists, 7 neurologists, and 7 internists). We identified two primary themes: There is 1) a lack of adequate understanding of the distinction between MCI and dementia; and 2) variation in physician approaches to identifying whether an older adult has MCI.

Conclusion:

These findings suggest that physicians have a poor understanding of MCI. Our results suggest that interventions that improve physician knowledge of MCI are needed.

Introduction

Up to 1 in 5 older adults (65+), more than 5.4 million Americans, have mild cognitive impairment (MCI), and this number is expected to triple by 2050 [1]. MCI is characterized by measurable cognitive impairment that does not severely affect daily functioning. Many older adults with MCI live an average of 10 years or more with good quality of life [2, 3], and so face competing health risks of aging. However, evidence suggests that older adults with MCI are less likely than those with normal cognition to receive guideline-concordant treatments for co-morbid conditions including cardiovascular disease (CVD) [5–7].

The reasons for treatment disparities between older adults with MCI and normal cognition are unclear, but earlier studies conducted by our team suggest that incorrect physician assumptions about MCI contribute to physicians recommending less intensive care to (i.e., undertreat) older adults with MCI than to those with normal cognition [7–9]. Although many older adults with MCI do not progress to dementia (conversion rates range from 3% to 15% per year) and others remain stable or revert to normal cognition (14% to 55%) [10–12], preliminary research has shown that physicians might conflate MCI with dementia [8, 9]. Previous studies show that physicians frequently recommend significantly less intensive care to older adults with dementia [13, 14]. Therefore, it is possible that conflation of MCI with dementia might lead physicians to recommend less treatment to people with MCI than people with normal cognition.

Previous studies have examined physician practice patterns associated with diagnostic evaluations of people with suspected MCI among selected groups of physicians who report managing older adults with dementia or cognitive decline (e.g., primary care physicians, neurologists, geriatricians, psychiatrists) and have required physicians to evaluate a certain number of older adults per month (i.e., 5–10) [15–17]. Less is known about how the broader group of physicians in primary care and neurology and physicians in other specialties, such as cardiologists, identify MCI. Cardiologists view cognitive impairment as a contraindication to invasive interventions and might identify MCI in their practice [18]. Although we know that inadequate training in MCI and dementia is a barrier to the identification of MCI in primary care physicians [4, 8], we know less about how neurologists and cardiologists perceive their training in MCI and dementia. The goal of this paper was to examine physician understanding of MCI as a potential factor in physicians treating older adults with MCI differently than cognitively normal older adults. In particular, the current study looks at physicians’ fundamental understanding of MCI by exploring physician identification of MCI, physician ability to distinguish between MCI and dementia, and physician training in MCI and dementia.

Methods

Study Design, Sampling, and Recruitment

We conducted a descriptive qualitative study using semi-structured interviews with physicians. These interviews were a component of a larger mixed-methods study that assessed the influence of MCI on physician treatment recommendations as well as patient and family preferences for CVD treatments [8, 19, 20]. Specifically, this larger study used surveys and interviews to assess how a person’s MCI diagnosis affects physician treatment recommendations for acute myocardial infarction (AMI) and acute ischemic stroke (AIS). We used criterion sampling [21] and purposefully sampled physicians who practiced in three specialties (cardiology, neurology, or internal medicine) from three hospital systems and affiliated private practices, but not the research team’s institution, in the state of Michigan. Although the current manuscript does not focus on CVD, we recruited physicians from cardiology, neurology, and internal medicine as they treat AMI and AIS most often and AMI and AIS were the main focus of the larger parent study. The senior author (DAL) contacted department leaders in the three specialties at each institution who identified physician champions for recruitment. Physician champions provided a list of all attending and fellow physicians in their specialties and recruited eligible physicians by email and telephone. We did not include physicians at our institution because they might have been exposed to our pilot study on the topic [7]. We aimed to interview a minimum of 3 physicians in each specialty at each site. Physicians received a $100 honorarium after completing the interview. The University of Michigan Institutional Review Board approved the study.

Data Collection

A trained qualitative research consultant (CK) conducted the interviews either in person or by videoconference. Participants did not previously know the interviewer. The interviewer informed participants she was a qualitative research consultant and not a medical professional. The interview duration was approximately 60 minutes. All participants provided informed consent.

The interviewer used an interview guide to conduct the interviews (Online Supplement A). Our multidisciplinary research team consisting of an internal medicine physician (DAL), a neurologist (DBZ), a qualitative research expert (JF), a neuropsychologist (BG), a professional interviewer (CK), and a project manager (BKR) developed the interview guide using an iterative approach. The team based original interview questions on both clinical understanding and the literature, including results from our pilot study. The research team pilot tested interview guides with two physicians, a cardiologist, and a neurologist at the research team’s institution and revised. The interview guide (Online Supplement A) covered the following domains: MCI identification (diagnosis) in practice, treatment recommendations for AMI/AIS in a clinical scenario, reflection on prior data suggesting AMI/AIS treatment disparities in the MCI patient population, assumptions about MCI, clinical experience with people with MCI, and knowledge on MCI. This manuscript focuses on MCI identification in practice and knowledge of MCI. We use the term MCI identification rather than MCI diagnosis because some participants’ approaches represent identifying rather than diagnosing MCI.

First, the interviewer read definitions of MCI and dementia: “Mild cognitive impairment or MCI is defined as objective cognitive impairment that is not severe enough to cause significant difficulties with activities of daily living. In a typical older adult with MCI, his family reports mild difficulty remembering recent conversations, dates, and appointments. He functions independently. He does not require help with dressing, bathing, grocery shopping, or taking medicines, but he uses reminders more. In contrast, dementia is defined as objective cognitive impairment that is severe enough to cause significant difficulties with activities of daily living. In a typical person with early-stage dementia, his family reports moderate difficulty remembering recent conversations, dates, and appointments. He is not able to function independently. He requires help with one or more of: dressing, bathing, grocery shopping, or taking medicines. While the distinction between MCI and early-stage dementia can be fuzzy at times, please try to distinguish between MCI and dementia in our conversation as best as you can.” Then the interviewer asked participants the following question regarding their experience caring for people with MCI: “Do you think of MCI in your older patients? How do you know if your patient has MCI?” After participants responded, the interviewer then asked these follow-up questions: “What are some of the informal approaches you use to determine that your patient has MCI? What are some of the formal approaches you use to determine that your patient has MCI? In what ways do you find these approaches to be helpful?”. Next, the interviewer shared with participants that “In the previous study interviewing doctors, some doctors were unaware of the definition of MCI and conflated MCI with dementia. For example, one cardiologist asked, ‘What’s the difference?’”. The interviewer asked participants: “Do you agree or disagree that some doctors in your specialty conflate MCI with dementia? Why do you think that some doctors in your specialty might think that MCI is similar to dementia?”. All interviews were audio-recorded, professionally transcribed, de-identified, and uploaded into the Dedoose web application [22].

Data Analysis

We used a descriptive qualitative methodology grounded in a naturalist philosophy, wherein the goal is to be “data-near”, reporting findings in their everyday terms, rather than more highly theorized [23]. The underlying epistemology is pragmatist, which emphasizes the “practical meaning of knowledge in specific contexts” and largely subjectivist that is, the belief that knowledge of reality is socially constructed by participants and researchers [24, 25]. We accepted data as representing our participants’ subjective perceptions and saw our role as researchers as co-constructing knowledge (through interaction with participants and influencing the analysis process), and as using our skills to describe the phenomenon based on our interpretations of participants’ perceptions as described by them. This approach supports our goal of producing concrete findings for real-world practice [24].

We identified unifying and recurrent themes using a qualitative content analysis approach that included both deductive and inductive elements [26]. The coding team consisted of a vascular neurologist (DBZ), an internal medicine physician (DAL), qualitative researchers (JF, CK), and study staff (EMB, BKR, and research associates). The analysis proceeded in two stages. In the first stage, the coding team read through the first several transcripts, coding using free codes corresponding to interview domains and questions and developing a coding tree that included parent and sub-codes. Most sub-codes corresponded to interview questions, follow-up questions or probes (e.g., formal and informal methods used to describe MCI) and some were developed using an inductive approach (e.g., specific methods used to identify MCI). To produce the final codebook, the team then independently coded additional transcripts and held regular meetings to discuss and resolve discrepancies and refine code definitions. The remaining transcripts were then each coded by one of 4 coders (EMB, BKR, and two research assistants). To ensure coding reliability, each coder achieved a kappa score of >=0.80 compared to a “gold standard” sample of interview excerpts that had been coded by the senior project manager (BKR) and senior author (DAL) using a consensus process. To maintain coding reliability throughout the coding process, one third of transcripts were coded by two coders and the entire coding team discussed discrepancies in bi-weekly meetings.

In the second stage, after coding was complete, the team reviewed the data organized under each code and developed themes and sub-themes in each domain through discussion. For example, we developed an overall theme statement for the domain “MCI Identification in Practice” and question, “How do you know if your patient has MCI?”. To develop sub-themes, we created a code for each method that participants used to identify MCI, categorized each as formal or informal, developed a sub-theme on the use of formal vs. informal methods, and described specific methods under each sub-theme. We similarly developed an overall theme statement and sub-themes for the domain, “Knowledge of MCI”.

Results

Enrollment was stopped after 22 participants (eight cardiologists, seven neurologists, and seven internists) completed interviews as thematic saturation was achieved, meaning that no further themes were revealed through continued interviews (flow diagram in Appendix B). Table 1 presents the characteristics of the participants. Findings did not differ across the three physician specialties.

Table 1:

Characteristics of Physician Participants

Characteristics	Interviewed Physicians (N=22)
Race, n (%)
Caucasian	7 (31.8)
Asian	8 (36.4)
Middle Eastern or Arab-American	7 (31.8)
Women, n (%)	8 (36.4)
Age, mean (25th-75th interquartile range)	36 (range 30–59)
Specialty, n (%)
Cardiology	8 (36.4)
Internal Medicine	7 (31.8)
Neurology	7 (31.8)
Board certification, n (%)	22 (100)
Fellow, n (%)	7 (31.8)
Family member or friend with dementia, n (%)	8 (36.4)
Inpatient work, n (%)	22 (100)
Outpatient work, n (%)	18 (81.8)
Affiliated medical school, n (%)
Wayne State University	11 (50)
Michigan State University	11(50)
Primary medical center, n (%)
Henry Ford Hospital	3 (14.3)
Detroit Medical Center	6 (28.6)
Sparrow Health System	11 (50)
John D. Dingell VA Medical Center	1 (4.8)

Interview Themes

We identified two major themes related to physicians’ identification and knowledge of MCI. There is 1) a lack of adequate understanding of the distinction between MCI and dementia; and 2) variation in physician approaches to identifying whether a patient has MCI. These two themes appeared in interview transcripts of participants in all three physician specialty groups. Representative quotations from the participant interviews are in the text and Table 2.

Table 2:

Representative Quotations Supporting Study Themes

Theme	Representative Quotes
Lack of adequate understanding of the distinction between MCI and dementia	Participant Equation of MCI with Dementia “We probably would tend to think of everything on like a dementia spectrum, so we might think MCI means like mild dementia.” (Physician 11, Internist) “Unless if you have formal training in the various definitions, it’s easy to get skewed into thinking it’s all one thing.” (Physician 1, Neurologist) Avoidance of MCI Diagnosis “MCI is not familiar waters - we just talk about maybe early dementia versus full blown dementia.” (Physician 5, Internist) Colleagues Conflate MCI with Dementia “It’s a problem and I think we should be better equipped to deal with mild cognitive impairment versus dementia because they are two very different things with two very different prognoses that don’t get talked about enough.” (Physician 22, Cardiologist) Lack of Training in MCI and Dementia “I don’t know if there is good training at the level of the residency. I think there is very little emphasis from the medical school on cognitive aspects of the neurology residency training.” (Physician 18, Neurologist) “I’m even trying to remember back to like specific, like neurology-based training experiences, and I’m not even remembering that we talked so much about this.” (Physician 11, Internist) “Well, if I say we are very well educated [on MCI], that’s not true.” (Physician 14, Internist)
Variation in physician approaches to identifying whether a patient has MCI	“I typically will assess our older patients’ functionality…it’s easier in a snapshot to assess, you know, the ADLs (activities of daily living) and asking, you know, the family if they function and those types of things than potentially to be able to easily assess a cognitive impairment.” (Physician 11, Internist) “You know, usually in getting to know the patient and their living circumstances, and what they do and how I have to tailor my speech to them, that is usually how I judge.” (Physician 18, Neurologist) “We always ask I mean the kind of common things as part of a physical exam…where you are or, you know, what the date is and things like that. But that’s usually probably beyond a little bit of a mild cognitive impairment. I would think if you can’t remember the day or the place.” (Physician 17, Cardiologist) “One of the first things that would make me think about mild cognitive impairment in a patient would be sometimes just when you initially start talking to a patient, sometimes they can have a blank look on their face at times, and they can have trouble fully comprehending the things that you’re saying to them as you even begin to interview them in a patient interview setting.” (Physician 13, Neurologist)

Theme 1: Lack of Adequate Understanding of the Distinction Between MCI and Dementia

When asked about experience in identifying MCI, and distinguishing between MCI and dementia in practice, many participants conveyed a lack of adequate understanding of the distinction between MCI and dementia. Within this overall theme, there were four subthemes: participant equation of MCI with dementia in their clinical practice; avoidance of an MCI diagnosis; belief that colleagues conflate MCI and dementia; and expressed lack of training in MCI and dementia.

When asked about identifying MCI in practice, some participants reported equating MCI and dementia, that is, treating them the same in practice despite knowing that the two are in fact different. For example, one internist admitted that they typically do not consider the possibility of MCI in their patients, stating, “I jump into dementia first, to be honest. Mild cognitive impairment – I know it is an established entity, but for me, I just think about dementia. Early dementia versus advanced dementia.” (Physician 5, Internist). Others combined MCI and early dementia, believing that they were in fact the same thing: “I think honestly MCI can be construed as an early form of dementia.” (Physician 1, Neurologist)

Regarding avoidance of an MCI diagnosis, a participant stated that they generally don’t try to diagnose MCI because it may be transient: “So, but, you know, when the patients are normal, they don’t have a diagnosis, but if they are going through some treatment, we do notice that the patient has some cognitive impairment. But we usually don’t do the Mini-Mental Status Exam or to go further down to see if the patient really had mild cognitive impairment because, you know, we feel this is a transient, or it may, it may come back…so I don’t diagnose them with mild cognitive impairment or early-stage dementia, usually.” (Physician 14, Internist).

Many participants agreed that their colleagues frequently equate or conflate MCI and dementia. Participants noted that the difference between the two diagnoses frequently gets overlooked by physicians. For example, a neurologist said, “I’m pretty sure there are some neurologists out there who equate MCI with dementia” (Physician 2, Neurologist). Another participant stated, “They [some neurologists] don’t mind the difference between MCI and dementia, or they’re not aware of the difference between MCI and dementia.” (Physician 4, Neurologist).

Most participants felt that physicians might lack adequate understanding of the distinction between MCI and dementia because they receive inadequate training in the definitions, criteria, and diagnostic approach to MCI and dementia. Neurologists in our sample responded similarly to other specialists in suggesting a need for better training in MCI in neurology and neurology subspecialties. One participant stated, “You know – it’s easy to get confused between MCI and dementia. I don’t think we receive good training in this regard.” (Physician 20, Cardiologist). Participants described lack of time spent on learning about cognitive impairment in all phases of training: medical school, residency, and post-residency. One participant stated, “It’s not part of medical education… It’s really abysmal.” (Physician 14, Internist). Participants also said that, after residency, most physicians never get the opportunity to learn about cognitive impairment. A participant said, “If you [physicians] don’t learn it in residency, it’s unlikely you will learn it ever.” (Physician 9, Internist). Some participants believed that only physicians that work in geriatric care have adequate knowledge of MCI and dementia.

Theme 2: Variation in Physician Approaches to Identifying Whether a Person Has MCI

Two of the 22 participants stated they did not identify MCI routinely because they worked in the acute care setting where prioritization of other health issues is necessary. These participants reported not having enough time to identify cognitive status due to the nature of their clinical work. The remaining participants described identifying MCI in older adults in the following ways: use of clinical gestalt, use of family reports, use of formal cognitive testing, and use of referral to a specialist. Among the participants who identified MCI, many reported primarily using informal methods, namely a clinical gestalt and family reports of the person’s cognitive difficulties.

Of those participants who relied on clinical gestalt, some participants identified MCI based on initial impressions at the beginning of the visit. One participant explained that they identified MCI using a “doorway test”, saying it is “a gestalt thing. It’s not a measured thing in our office that I use.” (Physician 22, Cardiologist). Another participant similarly reported, “What do they look like when I walk in the doorway? Are they conversant?” (Physician 20, Cardiologist). A second way participants described identifying MCI through clinical gestalt was during the patient interview and history. One participant stated, “I get an idea of how they do on their own, you know, whether they are dependent on someone or not. That usually gives me a good idea of their status.” (Physician 7, Cardiologist). Another participant reported, “Usually during the history-taking we can determine if a patient is a good historian or a poor historian…this does impact my decision.” (Physician 1, Neurologist) Some participants explicitly contrasted relying on informal assessment using clinical gestalt to formal cognitive testing of older adults. One participant stated, “Honestly, in cardiology, we rarely use the MoCA [Montreal Cognitive Assessment] exam. You can usually gauge based on your clinical sense.” (Physician 8, Cardiologist).

A second informal method that participants reported using to identify MCI was family members’ or other care partners’ reports of a person’s cognitive problems. For example, a neurologist stated, “I personally spend some time talking to the people who they kind of live with or deal on a day-to-day basis with…to find out, you know, if his lifestyle is still the same. Have they noticed anything? Is he missing like familiar exits when he’s driving the same expressway which he has been doing for years? Or is he forgetting his specific, you know memories, like if somebody needs to remember a specific day, like a birthday; he’s forgetting that. Or if he’s forgetting familiar faces. Or he’s not as sharp with the activities.” (Physician 4, Neurologist). One participant stated that it is helpful when family members call attention to memory problems, but family members may not consistently report cognitive decline of the person: “Usually if someone is with them, they may mention difficulties, sometimes they do sometimes they don’t…” (Physician 19, Neurologist).

Of the participants who identify MCI in their practice, less than half (7/18) reported using formal methods such as cognitive testing and referral to specialists. Some participants said that they perform cognitive testing in the office, using cognitive screening tests like the Mini Mental Status Exam. One participant stated, “In clinic I’ll do the MoCA exam.” (Physician 19, Neurologist). Other formal methods used by participants included referral for neuropsychological assessment or consultation with a geriatrics or cognitive disorders specialist. For example, one participant stated, “If I suspect any kind of cognitive impairment, I refer the patient to a cognitive clinic, I do not make the determination myself.” (Physician 11, Internist). Another participant reported, “If we are suspecting something like either MCI or early dementia, we do consult geriatrics.” (Physician 10, Internist)

Discussion

In this qualitative study of internists, cardiologists, and neurologists from three medical centers, we identified two themes: There is 1) a lack of adequate understanding of the distinction between MCI and dementia; and 2) variation in physician approaches to identifying whether a person has MCI. Some participants reported routinely identifying MCI using informal methods such as a clinical gestalt, including “the doorway test”, rather than formal methods. Participants also felt that physicians in their specialty often equate or conflate MCI and dementia because physicians do not receive adequate training in MCI and dementia in medical school and residency.

Our results provide evidence that some physicians are not properly diagnosing MCI. Clinical guidelines recommend using formal methods to diagnose MCI, including a history with a report of objective cognitive decline by patient/care partner, physical examination, laboratory evaluation, brain imaging, and cognitive testing [27]. However, some participants reported routinely using informal methods rather than formal methods. While some simple and brief methods for diagnosing cognitive impairment have been shown to have value [28], the physicians in this study described using informal methods that have not undergone rigorous testing. Previous evidence suggests that some physicians lack confidence in their ability to perform cognitive tests and interpret their results [16], which may contribute to the frequent use of informal methods to identify patient MCI. Another concern is the time formal methods to diagnose MCI require. Some participants in our sample reported not diagnosing MCI in their practice due to time constraints and prioritization of other health issues. While cognitive screening instruments such as the Mini-Mental State Examination and the MoCA are relatively brief [29], physicians are increasingly pressed for time in busy practices, and time spent on formal cognitive screening leaves less time to address other important health issues [30].

These results may be explained by physicians’ training in MCI. Many physicians reported not receiving adequate training in MCI. Without adequate training, some physicians may not be equipped to properly identify MCI using formal diagnostic methods [31]. After completing residency training, physicians have difficulty in obtaining adequate education in MCI and dementia, as one participant in our study noted. A lack of training could also contribute to physicians’ tendency to conflate MCI with dementia. In an American survey, the majority of primary care physicians (65%) reported that medical school and residency programs in primary care offer very limited training related to dementia [4]. Depending on their specialty, some physicians might not routinely diagnose MCI or other neurocognitive disorders in their clinical practice; therefore, they might not be familiar with the definitions, criteria, and diagnostic approach to these disorders. Our results suggest a need for clearer clinical guidelines and protocols for providers’ training in the diagnosis of MCI.

Our study has several strengths. The sample included a racially diverse group of male and female physicians who had a range of ages. We included early-career physicians still in training (fellows) and later-career attending physicians. Participants practiced in a range of settings, including academic, community-based, private, or Veterans Health Affairs settings. We continued interviews until we achieved thematic saturation. Although we kept our sample to three specialties (cardiology, neurology, and internal medicine), our sample included physicians with a wide range of clinical experience. Neurologists included physicians with specialized training in cognition, and internists included physicians in geriatrics and family medicine. Participants’ perspectives from varied demographic groups, career stages, settings, and clinical specialties contributed to the data’s scope and richness.

Our study has limitations. We did not capture the perspectives of physicians in all specialties that care for older adults with MCI. Nevertheless, participants were in three of the most common specialties that care for the population with or at risk for MCI. We did not collect information on neurology subspecialty of participants; however, we did not exclude any neurology subspecialties during recruitment. We did not have a sufficient sample size to rigorously assess differences in perspectives by specialty and hospital; however, our analysis emphasized common themes across specialties. We do not have information on the characteristics of physicians who were eligible for the study but not recruited. Although physicians with academic affiliations may differ from those without academic ties, it is plausible that physicians in the two groups have comparable experiences with older adults with MCI.

Understanding physician identification and knowledge of MCI has valuable implications for the clinical care of older adults and the training of physicians. An inadequate understanding of MCI might cause a physician to misidentify a patient’s cognitive status. Physicians’ use of informal methods to identify MCI, such as “the doorway test”, might lead to cognitively normal people with less education, literacy, or numeracy being misidentified as having MCI or dementia. Physicians might also misclassify a person with MCI as having dementia by overestimating the severity of cognitive dysfunction or having difficulty distinguishing between MCI and dementia diagnoses. Incorrect physician diagnosis of dementia in people with MCI might contribute to underuse of effective treatments because physicians frequently offer less care to people with dementia [13]. Our results that physicians conflate MCI with dementia, coupled with the findings of our parent study that physicians are less likely to recommend guideline-concordant treatments to people with MCI [8, 19], suggest sub-optimal physician understanding of MCI plausibly contributes to the underuse of effective treatments for co-morbid conditions in the MCI population. Alternatively, physicians might miss the presence of MCI and not take the extra time to explain treatments to older adults with MCI, assess their understanding of the benefits and risks of treatments, provide reminders, and involve loved ones in the treatment decision-making process. These results suggest the need for improving physicians’ training in MCI and dementia. Although the percentage of primary care physicians receiving training in dementia is improving [4], our results suggest that the quality of the training could be further improved in internal medicine, cardiology, and neurology. Future studies should address whether education interventions to improve physician diagnosis and knowledge of MCI eliminate inappropriate under-treatment of co-morbid conditions in the large and growing population of older adults with MCI.

Conclusions

This qualitative study found that some physicians routinely identify MCI using informal methods and may conflate MCI with dementia, at least in part, due to inadequate training in MCI and dementia.

Figure 1.