For the first time, a major professional organization, the American Academy of Neurology (AAN), is recommending that physicians perform an annual assessment of cognitive health in all patients 65 years or older. The recommendation is one of several issued by the AAN-organized Mild Cognitive Impairment Quality Measurement Workgroup and published in the journal, Neurology.
Attention to cognitive health issues thus should not ignored, put off, or chalked up to the normal process of aging, conclude the authors of a new paper. A team that included physicians as well as representatives of patient groups studied, discussed, and worked up the issue of MCI over nearly a two-year period.
MCI is a condition characterized by difficulties with memory, thinking, language, and/or judgment, beyond what is expected for one's age, but not to the point that it can be called dementia. The condition is extremely common, affects one's quality of life, and can be a prelude to the later onset of Alzheimer disease. Affecting 6.7% of individuals from the ages of 60 to 64 years, MCI is increasingly prevalent as age goes up. It is present in 8.4 percent of people aged 65 – 69 years, and for people 85 years and up, the prevalence of MCI reaches 37.6%. But the connection between MCI and age is not necessarily direct. Nor is MCI a reason for a patient, family, and physician to throw up their hands.
In many cases, MCI could be the result of a mood disorder, such as depression, a sleep disorder, a systemic condition, such as high blood pressure, or — quite frequently — medication, particularly when a patient is taking a drug with known anticholinergic effects. This means that the drug inhibits what are called parasympathetic nerve impulses, causing multiple symptoms including mental disturbances.
When the problem is a drug side effect, the solution can be as simple as switching the patient to a different medication. Consequently, one of the six standards detailed in the new paper is that physicians must assess all drugs that any patient with memory complaints is taking, particularly those with anticholinergic effects. But the first standard on the list is recognizing MCI in the first place.
"Physicians often defer, deflect, and delay when confronted with patients' memory complaints," says Norman Foster, MD, director of the Center for Alzheimer's Care, Imaging and Research at University of Utah Health "The working group has said that this situation should change and look for memory problems early and consistently." Foster is also a fellow in the AAN, Chair of the MCI Working Group and senior author on the new paper.
The working group also recommends that physicians confronted with MCI must work up the case to determine the cause, be it medication or a medical condition. In addition to assessing medical treatment that the patient is receiving, they must account for a range of factors that could be contributing to cognitive symptoms, such as medications, stressful life events, or sleep issues. Finally, health care providers should provide education to the patient's family.
Depending on where the patient is being seen, the last measure can be tricky. Spouses and other family members are not always permitted to be present at a patient's exam. Utah, where Foster spearheaded the study, has invested $45,000 in an effort to boost MCI awareness among health providers — called Age Happy, Age Healthy, Age Well — but there are a variety of laws across states, he notes. And laws, like office visit traditions, can take a long time to change.
- Written by David Warmflash, MD