Survey findings suggested that neurologists regularly see patients with cognitive symptoms of mild severity, with over 88% of respondents reporting at least monthly encounters. Practitioners preferred the MCI label for describing these patients, with 90% recognizing it as a clinical diagnosis (including over 80% who recognized its amnestic vs nonamnestic subtype) and 70% reporting they had already used the MCI code for diagnostic or billing purposes. Alternate terms (e.g., AAMI, CIND) and other diagnostic codes (e.g., memory loss, cognitive disorder NOS) were recognized and used by some respondents, with the frequency of such use varying by respondent practice type and subspecialty training status. Taken together, these findings suggest that the MCI concept has gained acceptance as a clinical category among neurologists treating this patient population.
Clinicians reported regularly addressing several topics when educating and counseling patients with mild cognitive symptoms and their family members. Most emphasized the need for monitoring and follow-up and discussed potential risks for dementia. Yet over 40% of respondents said they never or only rarely used quantitative estimates when discussing dementia risk. Fewer than half reported routinely addressing issues including driving, advance planning, and support services. Only 15% routinely provide a written summary letter of findings for patients and families (with this rate even lower among private practice respondents), and fewer than 10% routinely refer such patients to the Alzheimer's Association. The variable frequency with which clinicians reported addressing these key topics suggests a need for guidelines and supplementary educational materials in this area, and the AAN is currently revising its MCI evidence-based medicine practice parameter for clinicians. The development of standardized education and counseling tools tailored for MCI populations may be appropriate to accompany these professional guidelines. For example, a growing body of literature on other diseases might be drawn upon to support the development of empirically validated tools for risk communication and decision support.21,22
Such materials may be particularly helpful for a population facing important decisions regarding future planning and treatment options while contending with symptoms that might potentially affect their decisional capacity.23,24
Notably, respondents prescribe a variety of medications to treat patients with cognitive symptoms of mild severity, including cholinesterase inhibitors (70% sometimes or routinely), memantine (nearly 40% sometimes or routinely), and other agents including vitamin E and Ginkgo biloba
. In addition, two-thirds of respondents reported sometimes or routinely counseling patients about vitamin and supplement use, although none are proven to reduce risk of dementia in patients with MCI. Although our data do not allow us to comment on the appropriateness of treatment in a given case, the frequency of reported medication use (particularly among private practice respondents) is striking given that there are no medications that are approved by the Food and Drug Administration specifically for the treatment of MCI. Although several clinical trials have been conducted with MCI populations, to date none have achieved their primary outcomes. One of the largest trials, sponsored by the National Institute on Aging and Pfizer, Inc. through the Alzheimer's Disease Cooperative Study Group, examined the treatment effects of donepezil and vitamin E on an amnestic MCI population in a multicenter randomized clinical trial.7
Participants in the donepezil group had a reduced risk of progressing to AD for 12 months and for up to 24 months in the APOE
4 carrier subset. No treatment effect occurred in the vitamin E group.
Our data on reported medication use are consistent with a recent study of nearly 600 patients with MCI treated across 10 AD research centers of California, which found that almost 30% of patients were receiving anti-AD medications “off-label.”25
It may be that clinicians consider some patients with MCI to already be in the early stages of AD (e.g., 30% of respondents have used the AD billing code for patients with mild cognitive symptoms) and therefore appropriate for use of cholinesterase inhibitors and memantine. Nevertheless, given these potential trends toward overutilization of medications to treat MCI, as well as numerous “brain health” products being marketed over-the-counter to individuals with concerns about their cognitive functioning,26,27
it will be important to educate practitioners and patients alike on the benefits and limitations of emerging treatment options in MCI.
Overall, respondents believed that the benefits of a clinical diagnosis of MCI outweighed its potential drawbacks and limitations. These findings suggest that clinicians generally find the MCI concept a useful diagnostic tool to inform treatment, education, and advance planning with patients and families. In open-ended responses, some respondents also expressed the view that an MCI diagnosis was reassuring to patients and families by labeling “what they already know” and allowing them “to do their homework and explore the problem on their own.” The most commonly endorsed limitation was that MCI is too difficult to diagnose accurately or reliably. This finding among one-quarter of specialty providers suggests that incorporating MCI into primary care may pose diagnostic challenges. Relatively few respondents believed a MCI diagnosis would cause unnecessary worry among patients and families, a notion supported by recent psychological studies in the area.28
The strongest beliefs about drawbacks were expressed in open-ended responses by neurologists who objected to the notion of MCI as a formal clinical category, implying that MCI is often better characterized as early dementia. These views reflect the sometimes contentious nature of the debate about MCI.
Limitations to this study include that survey responses are subject to self-report recall biases and do not provide information about the quality of provider interactions with patients with MCI and their family members. Future studies should seek more objective measures of outcomes such as billing codes used and medications prescribed. Exploration of patient–provider communication and treatment decision-making (e.g., via audiorecording of clinical encounters) may also be warranted. While respondents were similar to nonrespondents on key demographic characteristics, they may differ from the general population of neurologists seeing patients with MCI in terms of their usual practices or attitudes. For example, the use of the MCI term in survey recruitment materials may have attracted respondents more inclined to use this category and view it in strong terms (favorable or unfavorable). The overall response rate, while not ideal, was typical for surveys of practicing physicians, who tend to respond less frequently to survey requests than other groups.29
This survey primarily involved neurologists, but other medical professionals (e.g., geriatricians, internists, allied health professionals) often encounter MCI and should therefore be queried in future research (of note here, a recent survey of 163 geriatricians in Australia and New Zealand also found that MCI was being commonly used in clinical practice, but pharmacologic treatment was reported less frequently in this study than ours).30
Given the brief survey format used, we could not collect data on all patient and provider characteristics of interest. We plan in future analyses of this dataset to examine correlations between provider demographics (e.g., years of experience) and reported attitudes and practices. Consideration could be given in future research to examining other practice groups, as well as practice patterns in other countries.