How to talk to patients and their family after a diagnosis of mild cognitive impairment

Mild cognitive impairment (MCI) is a transitional clinical stage between normal aging and demen­tia. Together with aging, it is considered the most significant risk factor for developing dementia, often the Alzheimer’s type.¹

MCI is a challenging neuropsychiat­ric diagnosis to discuss with patients and their family because it is characterized by overlapping features of normal aging and because of its heterogeneity of etiol­ogy, clinical presentation, and outcome.^2,3 The evolution to dementia and the lack of effective treatments for preventing or forestalling this outcome can be difficult to address—particularly when the patient is in good health and has been leading a productive life.

Successful communication is key
You can take steps to communicate in a helpful way, build a strong treatment alli­ance, and reduce the potential for the iat­rogenic effects of disclosing this diagnosis and its prognostic implications.

Clarify that your findings are consistent with the patient’s or family’s report of sustained and concerning change in cog­nition and, depending on the patient, concurrent alterations in affect, behavior, or both. Emphasize that these changes are disproportionately severe relative to expectations for the patient’s age and are not caused by psychiatric or clear-cut medical factors.

Highlight contexts in which the patient’s symptoms are likely to become more dis­ruptive and impaired, and situations in which the patient can be expected to func­tion more effectively.

Provide evidence-based support for the rate of progression of symptoms and func­tional impairment.³

Emphasize that major lifestyle adjust­ments usually are unnecessary in the absence of progression, especially for patients who are retired or not involved in endeavors that involve significant cogni­tive and executive functioning demands.

Discuss the role that cognition-enhancing medications might play in managing symptoms.⁴

Address indications for additional services, including formal psychiatric care for patients who have concomitant affec­tive or behavioral symptoms and who are highly distressed by the diagnosis. Pair these services with longitudinal monitor­ing for possible exacerbation of symptoms.

Identify psychiatric, medical, and life­style factors that can increase the risk of dementia. Depending on the patient’s history, this might include diabetes, hypertension, elevated lipid levels, obe­sity, smoking, head trauma, depres­sion, physical inactivity, and lack of intellectual stimulation.

Review compensatory strategies. In MCI predominantly amnestic type, for example, having the patient make system­atic lists for shopping and other activities of daily living, as well as establishing rou­tines for organizaton, can bolster success­ful coping.

If psychometric testing was not utilized to establish the diagnosis, discussion can include the value of performing such an assessment for a more finely tuned profile of preserved and impaired neurobehavioral functions. Such a profile can include test patterns that 1) have prognostic value with regard to the likelihood of progression to dementia and 2) establish a baseline against which you can assess stability or progression over time.⁵

Disclosure
Dr. Pollak reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Mild cognitive impairment (MCI) is a transitional clinical stage between normal aging and demen­tia. Together with aging, it is considered the most significant risk factor for developing dementia, often the Alzheimer’s type.¹

MCI is a challenging neuropsychiat­ric diagnosis to discuss with patients and their family because it is characterized by overlapping features of normal aging and because of its heterogeneity of etiol­ogy, clinical presentation, and outcome.^2,3 The evolution to dementia and the lack of effective treatments for preventing or forestalling this outcome can be difficult to address—particularly when the patient is in good health and has been leading a productive life.

Successful communication is key
You can take steps to communicate in a helpful way, build a strong treatment alli­ance, and reduce the potential for the iat­rogenic effects of disclosing this diagnosis and its prognostic implications.

Clarify that your findings are consistent with the patient’s or family’s report of sustained and concerning change in cog­nition and, depending on the patient, concurrent alterations in affect, behavior, or both. Emphasize that these changes are disproportionately severe relative to expectations for the patient’s age and are not caused by psychiatric or clear-cut medical factors.

Highlight contexts in which the patient’s symptoms are likely to become more dis­ruptive and impaired, and situations in which the patient can be expected to func­tion more effectively.

Provide evidence-based support for the rate of progression of symptoms and func­tional impairment.³

Emphasize that major lifestyle adjust­ments usually are unnecessary in the absence of progression, especially for patients who are retired or not involved in endeavors that involve significant cogni­tive and executive functioning demands.

Discuss the role that cognition-enhancing medications might play in managing symptoms.⁴

Address indications for additional services, including formal psychiatric care for patients who have concomitant affec­tive or behavioral symptoms and who are highly distressed by the diagnosis. Pair these services with longitudinal monitor­ing for possible exacerbation of symptoms.

Identify psychiatric, medical, and life­style factors that can increase the risk of dementia. Depending on the patient’s history, this might include diabetes, hypertension, elevated lipid levels, obe­sity, smoking, head trauma, depres­sion, physical inactivity, and lack of intellectual stimulation.

Review compensatory strategies. In MCI predominantly amnestic type, for example, having the patient make system­atic lists for shopping and other activities of daily living, as well as establishing rou­tines for organizaton, can bolster success­ful coping.

If psychometric testing was not utilized to establish the diagnosis, discussion can include the value of performing such an assessment for a more finely tuned profile of preserved and impaired neurobehavioral functions. Such a profile can include test patterns that 1) have prognostic value with regard to the likelihood of progression to dementia and 2) establish a baseline against which you can assess stability or progression over time.⁵

Disclosure
Dr. Pollak reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Mild cognitive impairment (MCI) is a transitional clinical stage between normal aging and demen­tia. Together with aging, it is considered the most significant risk factor for developing dementia, often the Alzheimer’s type.¹

MCI is a challenging neuropsychiat­ric diagnosis to discuss with patients and their family because it is characterized by overlapping features of normal aging and because of its heterogeneity of etiol­ogy, clinical presentation, and outcome.^2,3 The evolution to dementia and the lack of effective treatments for preventing or forestalling this outcome can be difficult to address—particularly when the patient is in good health and has been leading a productive life.

Successful communication is key
You can take steps to communicate in a helpful way, build a strong treatment alli­ance, and reduce the potential for the iat­rogenic effects of disclosing this diagnosis and its prognostic implications.

Clarify that your findings are consistent with the patient’s or family’s report of sustained and concerning change in cog­nition and, depending on the patient, concurrent alterations in affect, behavior, or both. Emphasize that these changes are disproportionately severe relative to expectations for the patient’s age and are not caused by psychiatric or clear-cut medical factors.

Highlight contexts in which the patient’s symptoms are likely to become more dis­ruptive and impaired, and situations in which the patient can be expected to func­tion more effectively.

Provide evidence-based support for the rate of progression of symptoms and func­tional impairment.³

Emphasize that major lifestyle adjust­ments usually are unnecessary in the absence of progression, especially for patients who are retired or not involved in endeavors that involve significant cogni­tive and executive functioning demands.

Discuss the role that cognition-enhancing medications might play in managing symptoms.⁴

Address indications for additional services, including formal psychiatric care for patients who have concomitant affec­tive or behavioral symptoms and who are highly distressed by the diagnosis. Pair these services with longitudinal monitor­ing for possible exacerbation of symptoms.

Identify psychiatric, medical, and life­style factors that can increase the risk of dementia. Depending on the patient’s history, this might include diabetes, hypertension, elevated lipid levels, obe­sity, smoking, head trauma, depres­sion, physical inactivity, and lack of intellectual stimulation.

Review compensatory strategies. In MCI predominantly amnestic type, for example, having the patient make system­atic lists for shopping and other activities of daily living, as well as establishing rou­tines for organizaton, can bolster success­ful coping.

If psychometric testing was not utilized to establish the diagnosis, discussion can include the value of performing such an assessment for a more finely tuned profile of preserved and impaired neurobehavioral functions. Such a profile can include test patterns that 1) have prognostic value with regard to the likelihood of progression to dementia and 2) establish a baseline against which you can assess stability or progression over time.⁵

Disclosure
Dr. Pollak reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.