How to Help Worried Patients Better Understand Dementia Risk
by Lauren LeBano
For many older patients, forgetting their car keys or struggling to remember a name is more than a passing annoyance. These patients may have watched family members decline from Alzheimer disease or another form of dementia, and any memory concern that could signal the beginning of that pathological process is, naturally, frightening.
Sometimes, though, patients seeking clarity from a health care professional are left confused by the encounter. In a Q&A with Consultant360, Michael Gordon, MD, shared his clinical advice for better engaging with patients who have cognitive concerns ranging from subjective cognitive impairment to dementia. Dr. Gordon is a geriatrician and ethicist with extensive experience treating older patients, assessing their cognition, and communicating with them about their risk of dementia.
What are some common pitfalls clinicians should guard against when evaluating patients’ concerns about cognitive problems?
Older individuals often go to the doctor with concerns about not functioning as well as they believe they should be functioning. Often, these patients will be given a standard battery of cognitive tests, and the results all indicate that the patient’s cognitive function is normal.
However, there is a problem with this approach. The tests we commonly use, including the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Exam, are screening tests. The screens are designed to catch anyone with a significant amount of cognitive impairment, but conversely, they may not catch someone with a lesser amount of impairment.
Thus, people with subjective cognitive impairment often appear normal on the screens. In addition, normal interaction with these patients shows they are fine, and people accompanying them to the appointment frequently say they are fine, too.
For example, years ago, I had a patient who was a mathematician and had a cerebral event.1 The patient had previously seen a neurologist who had reassured him that his cognitive function was normal.
The patient told me that the health professionals assessing him kept asking him to do simple arithmetic, such as subtracting 7 from 100. He could do simple subtraction without a problem. However, the patient told me that the conclusion that he was normal was absurd, because he performs higher mathematics. He looked at me and said, “I can’t do differential equations. Do you know what differential equations are?”
In other words, he was comparing his current cognitive performance to his own, personal standard. He was reporting subjective cognitive impairment, in which the individual feels something is wrong, but the problem is not obvious. In cases like this, it is important for the clinician to carefully listen to the patient’s story and take it seriously. Patients may still experience impairment even if it is not detectable on typical tests.
How should clinicians approach the patient conversation when someone shows impairment on screening tests and is diagnosed as having mild cognitive impairment (MCI)?
If a patient is further along the spectrum and has MCI, then some impairment is evident on a screening test. Maybe the patient was unable to subtract 7 from 100, but the overall score indicates that cognitive function is still good, and that the patient is managing his or her life despite having some mild impairments.
MCI can be a reassuring diagnosis because it means the individual does not currently have dementia, and in many cases, individuals with MCI will not progress to dementia.2 However, most people are terrified by an MCI diagnosis and do not understand what it means. Recently, one of my patients received an MCI diagnosis and came to me wondering if that meant he already had dementia.
When I talked with the patient further, I found out that the neuropsychologist who had administered the cognitive testing had given him the diagnosis and then did what we all do as professionals—quoted statistics. This approach is a problem because most people do not understand statistics.
Can you elaborate on the assumptions we may make about patients’ knowledge of statistics?
Odds and risk may be familiar words to most people, but we cannot assume that a passing familiarity with the terms means that a patient will be able to interpret such a number alone.
I frequently hear residents, interns, and other health professionals explaining percentages to older people and quoting the literature. However, the literature often consists of experiments that tell us about what happened to 1,000 people, but not to the individual sitting in our office. As a clinician, it is very important to translate our practice of science to the art of medicine.
The art of medicine is going beyond the numbers by helping patients to answer 2 important questions: “What does the diagnosis mean for my life?” and “What can I do?”
What are some tips for practicing the art of medicine and better communicating the implications of statistics to patients?
My own opinion is that statistics are complicated but that it is still important to give patients a sense of what they mean. When patients are diagnosed as having MCI, I tell them the numbers and then point out that what we really want to know is whether they have a reasonable chance of getting through the next 5 years being able to do all the activities they enjoy now. Sometimes the answer is “yes, probably.” Other times, the answer may be “no, probably not.”
We next focus on what we can do to improve function. In some cases, I might recommend lifestyle changes. However, the problem with dementia illnesses is that most of what we can recommend with confidence comes from the heart disease world, in terms of lifestyle. This is often confusing for patients. A patient may come in and express worry about forgetting the words they need to do their work, and I may say to try exercising. At this point, the patient may look at me as if I am crazy and say, “What does that have to do with the brain?” However, if you carefully explain the lifestyle changes, and if the patient trusts you, he or she may actually make changes.
How do you best explain other therapeutic options to patients? (Continued on next page)
In some cases, patients may have evidence of dementia or more advanced cognitive impairment, and I may recommend medications or nonpharmacologic modalities. Depending on the individual case, I may prescribe cholinesterase inhibitors.
It is important to carefully explain to patients that cholinesterase inhibitors are not a cure. I tell patients that these medications may improve function with some side effects, but that the disease will ultimately still progress. I might give patients an example, such as “Maybe the medication won’t improve your function to the point where you could play Scrabble again, but it might improve your function to the point where you could sit around the table while other people play Scrabble, and you could still talk with them and enjoy it.”
I frequently use nonpharmacologic therapies, too. One of the best types of these therapies is music therapy.3 One of my patients and his family recently discovered that playing YouTube videos of his favorite singers would calm his agitation.
I am also an advocate of pet therapy. Animals have a marvelous affect on individuals with dementia, and they are especially good at calming agitation.4 Every pet works, but tactile pets are best. If you’ve never owned a cat, you don’t know the magic of a purr.
What other advice do you wish more clinicians would convey to patients?
Sometimes patients have a condition that appears to be dementia but that is actually caused by something external, or by another medical condition. Most commonly the cause is medication. Older people are often taking medications that can aggravate mental functions.
Many of these drugs are obtained over the counter (OTC). Anybody can go into a pharmacy and buy a cold remedy that makes them behave like a person with mid-range dementia. I often tell my older patients that they should only buy an OTC medication after speaking with the pharmacist who usually fills their prescriptions, who knows them and their medications.
Michael Gordon, MD, MSc, FRCPC, FACP, FRCPEdin, is a geriatrician, ethicist, educator, speaker, and author. He is currently Professor of Medicine in the Division of Geriatrics at the University of Toronto, consultant to Palliative Care, and Former Vice President of Medical Services and Head of Geriatrics and Internal Medicine, at Toronto’s Baycrest Health Sciences. Dr. Gordon holds Canada’s first certificate issued by the Royal College of Physicians and Surgeons in the field of Geriatric Medicine. He was awarded a fellowship in the Royal College of Physicians of Edinburgh in 2004.
References
1. Gordon M. Is subjective cognitive impairment a harbinger of dementia risk? Consultant. 2014;54(4):248-250.
2. Mitchell AJ, Shiri-Feshki M. Rate of progression of mild cognitive impairment to dementia--meta-analysis of 41 robust inception cohort studies. Acta Psychiatr Scand. 2009;119(4):262-265.
3. Fukui H, Arai A, Toyoshima K. Efficacy of music therapy in treatment of the patients with Alzheimer’s disease. Intl J Alzheimers Dis. 2012;2012:531646.
4. Cherniack EP, Cherniack AR. The benefit of pets and animal-assisted therapy to the health of older individuals. Curr Gerontol Geriatr Res. 2014;2014:623203.