Practice guidelines needed for MCI diagnosis
Penn researchers present findings from survey
According to a recent survey of neurologists, "clinicians vary greatly in the education and support they provide or recommend for people with MCI [mild cognitive impairment], suggesting that there is a need for practice guidelines in this area."
Researchers from the University of Pennsylvania presented the findings at the Alzheimer's Association 2009 International Conference on Alzheimer's Disease (ICAD 2009). The survey was completed by members of the American Academy of Neurology to determine how neurologists are diagnosing and treating patients with mild cognitive symptoms, according to a Penn news release.
"Mild cognitive impairment and early Alzheimer's disease, whatever terms you use to describe late-life cognitive impairment, are really ultimately economic problems," says one of the researchers, Jason Karlawish, MD, associate professor of medicine and medical ethics at the University of Pennsylvania School of Medicine in Philadelphia.
One of the chief risk factors for developing early Alzheimer's is chronologic age, he notes.
"So, if you put those two facts together, you begin to see projections that tally into the millions to tens of millions of individuals who could potentially have these disorders in the next 10, 20, 30 years," Karlawish says.
"That, frankly, is the economic urgency with which we have to think about how best to diagnose these people, and how best to treat them in a way that obviously gets back to making the patients feel better, but also does it in a way that respects the economic challenges that this disease presents," he says.
Another aspect of the urgency for developing diagnosis and treatment guidelines that would culminate in a standard of care for patients with MCI is that most of these patients will go on to develop Alzheimer's disease. But there is a distinction between MCI and Alzheimer's disease, Karlawish notes.
"Mild cognitive impairment describes a clinical condition that can be caused by a variety of different diseases," he says. "In contrast, Alzheimer's disease is a specific disease that causes a stereotypical pattern of clinical problems with pathologic findings," he says.
Patients, family notice cognitive changes
Patients with MCI have a level of severity of cognitive problems that are just that — "mild." In contrast, a patient diagnosed with Alzheimer's disease would be described as having "cognitive problems of greater severity that meet criteria where an expert person would judge that person to be demented. And demented is a term that simply describes a severity of cognitive impairment that interferes with a person's ability to perform their usual and everyday activities," Karlawish says.
The most common cognitive symptom that patients report is a decline in short-term memory, according to Karlawish.
"Oftentimes, this is noted by the individual . . .it may also be noted by someone who is familiar or close to the patient and sees them on a semi-regular basis and can notice this change in cognition," Karlawish says.
Shelley Bluethmann, MA, MPH, director of early-stage initiatives at the Chicago-based Alzheimer's Association, says it is important for individuals who may be experiencing any of the warnings signs of Alzheimer's disease to get diagnosed early. That way, patients can get their families involved, not only in care but in legal planning "to allow the person with dementia to continue to be very active in defining how they would want their care to be all along the way."
Key finding was variability in practices
One of the key findings from the survey was that there is variability in practices among neurologists who treat both MCI and Alzheimer's disease.
"Once you find variability as a researcher, the next step is to explain that variability," Karlawish says. "And our survey doesn't explain the variability, but the first step to doing that, obviously, is to identify it and describe it."
Among the other findings from the survey was that neurologists "regularly see and treat people with MCI, despite the fact that the medications they are prescribing are not FDA-approved," according to a Penn news release on the survey findings and presentation at ICAD 2009.
"I think the next step is to investigate what criteria physicians use to decide that they will or won't offer these medications; and how do they engage in discussions with patients about this; and probably more importantly, from a policy perspective, what are the criteria for deciding if the drugs are making any difference or not," Karlawish says.
The individuals likely to be affected by both MCI and Alzheimer's comprise a large segment of the population, adding even more urgency to "the policy issue that's at stake."
"Depending on how many are on these drugs and for how long they're on these drugs, that's a cost — a cost either to the patient out of their own pocket, or to their prescription plans that are paying for the drugs," Karlawish says.
Karlawish suggests two things need to occur toward developing standard practice — or achieving consensus in diagnosing and treating MCI.
"Number one: gathering better evidence; and number two, expert clinicians — free of bias and conflicts of interest that can sway how they perceive evidence — getting together and deciding what the evidence says we ought to do," he notes. "Now, that's a dream of reason, meaning right now there are patients walking around with memory complaints showing up at the neurologist's office, saying, 'Help me. I'm sick."
Until clinicians reach this point, Karlawish says his approach to such patients is to take a patient's complaints and symptoms "very seriously." If a patient indicates that he or she is having problems with memory, he is "inclined to try one of the cognitive-enhancing drugs."
"But my criteria are: to have clear consensus over how we'll decide over the course of the next several weeks that the person is less symptomatic, and therefore, has benefited," Karlawish says. "Because if after several weeks of treatment, they're just as symptomatic and haven't felt that they've benefited, I would stop the treatment."
Sources
- Alzheimer's Association, Chicago. For additional information about the association, visit www.alz.org.
- Jason Karlawish, MD, Associate Professor of Medicine and Medical Ethics, University of Pennsylvania School of Medicine, Philadelphia. E-mail: [email protected]. For additional information on Alzheimer's research at Penn, visit www.pennadc.org.
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