“When should we ask for a third person in the room?” The lecturer posed this question in the context of a patient visit.
A typical visit involves only two people: the healthcare professional and the patient. But when should we ask for someone to accompany the patient?
As I pondered his question, I thought back to my early rotations in medical school. My first was with the obstetrics/labor and delivery team — the very first interaction a newborn has with healthcare. Later, the growing child is often accompanied to the pediatrician. It is generally not until their late teenage years that a patient seeks healthcare unaccompanied. But what if we suspect that our patient doesn’t have the capacity to participate in shared decision-making?
We do not need to wait until the white hairs start filling in to see differences in thinking and cognition. There is evidence that certain cognitive abilities start declining very early in life. Cognitive reasoning, spatial visualization, memory, and speed all peak in our twenties; vocabulary, however, continues to improve with age. But most people are juggling careers and families well beyond their cognitive peak. So, what are some signs that your patient’s cognition is worse than what comes with normal aging?
When to Suspect Mild Cognitive Impairment?
Between the cognitive decline of normal aging and dementia is the intermediate phase, mild cognitive impairment (MCI). It is defined as objective evidence of lower performance in at least one cognitive domain than what would be expected for someone of that age and educational background. This evolves into dementia when at least two cognitive domains are affected and the decline now interferes with the person’s ability to carry out their usual activities.
One way to assess for MCI is cognitive screening tools like the Montreal Cognitive Assessment and the Mini-Mental State Examination, or the more formal neuropsychological assessment. Another approach is to think about when someone needs help with their instrumental activities of daily living, or IADLs. Examples of IADLs include managing finances, shopping for groceries, household chores, managing medications, and preparing a meal. While you can often get a sense of a patient’s independence in the interview and history, there are also formal questionnaires and checklists that can help assess these skills.
A diagnosis of MCI does not inevitably lead to dementia. Community-based studies reveal that many people with MCI remain stable or even improve with treatment of other medical conditions. But there is certainly a high risk for progression, and an estimated 5% to 15% of people with MCI develop dementia every year.
Decision-making capacity is often impaired in patients with MCI. Broadly speaking, to have capacity for any decision, a patient must be able to understand the information presented, appreciate why it is relevant to them, use the given information to make a choice, and be consistent with that choice.
Patients with MCI often can make a choice, but they have difficulty expressing the risks and benefits of the presented options to navigate which choice is best for them. Tools to help assess this include the Capacity to Consent to Treatment Instrument and the Assessment of Capacity for Everyday Decision-Making. Once someone demonstrates difficulty with any aspect of capacity, it would be ideal to have a family/friend who knows the patient well accompany them to their medical appointments.
When to Test for MCI
When should clinicians consider employing this plethora of questionnaires and assessments?
One answer is when a patient complains of changes in memory, attention, concentration, language, or personality. Studies show that patients with subjective memory impairment have a higher risk for progression to MCI, especially if they report difficulty following group conversations or navigating their neighborhood, as opposed to losing their train of thought (which was not associated with MCI).
However, loss of insight into one’s cognitive challenges is common in both MCI and dementia. Consequently, many patients present with subjective cognitive impairments at the behest of (and usually accompanied by) their loved ones. Multiple studies show a stronger association between MCI and dementia with informant-reported complaints compared with self-reported complaints, highlighting the benefit of having this “third person” accompany the patient.
Other patients may present with self-neglect, looking disheveled or unkempt, or they may miss appointments when they previously did not. This should prompt the clinician to pursue a more thorough cognitive workup.
There are certain diseases and risk factors that portend a higher risk of developing MCI and dementia, such as prior stroke or transient ischemic attack; we should keep a particularly close eye on these patients’ cognitive abilities.
Aging Population
Our population is aging, with new dementia cases expected to double by 2060. Thus, it is critical to start looking for early signs of cognitive decline. If present, it may be helpful to ask for a caregiver/family member/friend to accompany the patient to their appointments, especially to help in shared decision-making. Primary care practitioners are especially poised to identify these changes early, given their longitudinal relationships with patients.
Before, I had not fully appreciated how many facets of a person’s life are affected by the evolution of dementia and the potential for intervention between MCI and progression. Since pondering the lecturer’s question, I have become more proactive about reducing risk factors for dementia progression; for example, I have started counseling patients I see for stroke follow-up, on ways to maintain their cognitive health.
In an ideal setting, longer appointments would facilitate this collaboration. Having a good baseline relationship should make it easier when you have to broach the topic of inviting a third person into the room.
Noor F. Shaik, MD, PhD, is a neurology resident physician at the Hospital of the University of Pennsylvania. She has published academic research and patient-facing articles on the prevention of and recovery after neurologic injuries such as stroke and traumatic brain injury. The opinions expressed in this article do not necessarily represent those of the University of Pennsylvania Health System or the Perelman School of Medicine.
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