Physician decision-making and recommendations for stroke and myocardial infarction treatments in older adults with mild cognitive impairment

Abstract

Evidence suggests that older adults with mild cognitive impairment (MCI) might not receive evidence-based treatments. We explored the impact of patient MCI on physician decisionmaking and recommendations for acute ischemic stroke (AIS) and acute myocardial infarction (AMI) in a pilot concurrent mixed-methods study of physicians recruited from one academic center. The mailed survey included a clinical vignette of AIS or AMI where the patient cognitive status was randomized (normal cognition, MCI, or early-stage dementia). The primary outcome was a composite summary measure of the proportion of guideline-concordant treatments recommended. Linear regression compared the primary outcome across patient cognition groups adjusting for physician characteristics. Semi-structured interviews done with 18 physicians (4 cardiologists, 9 neurologists, 5 internists) using a standard guide. Survey response rate was 72% (82/114) (49/61 neurologists; 33/53 cardiologists). As patient cognition worsened, neurologists recommended less guideline-concordant treatments after AIS (P trend <0.001 across patient cognition groups). Cardiologists did not after AMI (P trend = 0.11) in adjusted analyses. Neurologists' recommendation of guideline-concordant treatments after AIS was non-significantly lower in patients with MCI (composite measure, 0.13 points lower; P = 0.14) and significantly lower in patients with early-stage dementia (0.33 points lower; P<0.001) compared to cognitively normal patients. Interviews identified themes that may explain these findings including physicians assumed patients with MCI, compared with cognitively normal patients, have limited life expectancy, frailty and

Treatment preferences among adults with normal cognition and cognitive impairment

“…36,37 Some providers may assume that patients with cognitive impairment prefer less treatment due to perceived lower life expectancy or worsened quality of life. 35 However, our findings are consistent with previous studies suggesting that those with cognitive impairment do not prefer fewer life-extending treatments. 23 Education efforts may be necessary to improve providers' understanding of cognitive impairment prognosis and treatment preferences associated with cognitive impairment.…”

“…Studies have found that patients with preexisting MCI have a lower probability of receiving evidence‐based treatments following acute myocardial infarction or acute ischemic stroke 36,37 . Some providers may assume that patients with cognitive impairment prefer less treatment due to perceived lower life expectancy or worsened quality of life 35 . However, our findings are consistent with previous studies suggesting that those with cognitive impairment do not prefer fewer life‐extending treatments 23 .…”

Factors affecting physician decision-making regarding antiplatelet therapy in minor ischemic stroke

“…The incidence of cerebral hemorrhage in the loading dose group was significantly higher than that in the group without a loading dose. This may reflect the complexity and uncertainty of clinical decision-making ( 28 ) and a higher risk of ischemic and bleeding incidence in the real world ( 29 ). However, a larger sample of data is needed to confirm this hypothesis.…”

The Influence of Cognitive Impairment on Postoperative Outcomes

“…18 Another possible explanation for patients with MCI receiving elective surgical care less often could be that primary care providers who commonly refer patients for elective surgery may be less likely to refer patients with MCI, believing that they are at higher risk for surgery and may not participate in follow up care as consistently compared with patients with normal cognition. 19…”