Patient and Care Partner Perspective on Potential Undertreatment of Patients With Mild Cognitive Impairment for Cardiovascular Disease

Abstract

Background and Objectives: Mild cognitive impairment (MCI) affects up to 22% of US older adults aged 65 and older. Research suggests that physicians may recommend less cardiovascular disease (CVD) treatment for older adults with MCI due to assumptions about their preferences. To delve into the disparity between patient preferences and physician assumptions in CVD treatment recommendations, we conducted a multi-site qualitative study to explore the underlying reasons for this discrepancy, providing insights into potential communication barriers and strategies to enhance patient-physician relationships. Research Design and Methods: Employing a descriptive qualitative approach, we conducted interviews with 20 dyads, comprising older adults with MCI (n = 11) and normal cognition NC (n = 9), and their respective care partners. During these interviews, participants were prompted to reflect on physicians recommending fewer guideline-concordant CVD treatments to older adults with MCI than those with NC and physicians presuming that older adults with MCI desired less care or treatment in general than those with NC. Results: We identified three primary themes: (1) Most participants had negative reactions to the data that physicians might undertreat patients with MCI for CVD; (2) Participants suggested that physicians may undertreat patients with MCI due to physician assumptions about treatment effectiveness, patient prognosis, value, and treatment adherence, and (3) Participants proposed that physicians may elicit less input from patients with MCI about treatments because of negative physician assumptions about patient decision-making capacity and physician time limitations. Discussion and Implications: This study underscores the pressing need for person-centered communication and involvement of older adults with MCI and their care partners in the decision-making process to ensure that decisions are well-informed, reflecting patients' genuine preferences and values. Addressing these concerns has the potential to substantially enhance the quality of care and treatment outcomes for this vulnerable population, ultimately promoting their overall well-being.

Keywords

mild cognitive impairment decision-making treatment aging

What this paper adds

• Insight into Disparities in Treatment Recommendations: The study sheds light on a significant disparity between the treatment recommendations made by physicians and the actual preferences of older adults with mild cognitive impairment (MCI).

• Challenging Assumptions About MCI Patient Desires: It highlights that the assumption among physicians that MCI patients desire less care, particularly in the context of cardiovascular disease (CVD), is unfounded and can lead to inadequate treatment.

• Emphasizing the Need for Patient-Centered Communication: The research underscores the critical need for more patient-centered communication and the active involvement of MCI patients and their caregivers in the decision-making process.

Applications of study findings

• Improving Physician-Patient Dialogue: The findings can be used to enhance the dialogue between physicians and MCI patients, ensuring that medical advice is better tailored to the specific needs and preferences of each patient.

• Training and Guidelines Development: This study can inform the development of training programs and guidelines that encourage physicians to avoid assumptions about patient care preferences and instead, engage in thorough discussions with patients and care partners.

• Policy and Healthcare System Improvements: The insights from this research can contribute to policy changes and improvements in healthcare systems, promoting a more inclusive and patient-oriented approach to the treatment of MCI and associated conditions like CVD.

• Longer Appointment Times: The study underscores the complexity of decision-making for patients with MCI and suggests that healthcare systems may need to allot longer appointment times for older patients.

Introduction

Mild cognitive impairment (MCI) affects up to 22% of older adults (65+) in the U.S. (Manly et al., 2022). The number of older adults with MCI is projected to almost double by 2050 (Ortman et al., 2014). MCI is a clinical diagnosis defined as a measurable impairment of cognitive function that does not impair an individual’s ability to carry out everyday activities (Petersen et al., 2018). It is an intermediate stage of cognitive decline between the expected cognitive decline of aging and the more severe decline of dementia (Peterson et al., 2010). Although those diagnosed with MCI have an increased risk of dementia, MCI does not always progress to dementia (Mitchell & Shiri‐Feshki, 2009; Mooldijk et al., 2022; Ready et al., 2004; Roberts et al., 2014). Patients with MCI can live years with good quality of life, and so face competing health risks including cardiovascular disease (CVD), the leading cause of death and disability in older adults (Kimmel et al., 2022).

Findings from our previous studies indicate that physicians may recommend less treatment to older adults with MCI than their counterparts with normal cognition (NC) (Blair et al., 2020). Physicians in this study offered a range of explanations, often based on unsubstantiated assumptions, for this difference in treatment recommendations, including the belief that older adults with MCI want less CVD treatment than those with NC. However, in another study, older adults with MCI reported wanting the same treatments as those with NC (Blair et al., 2022). The disparity in perspectives on CVD treatment between physicians and older patients with MCI might be due to issues such as physician-patient communication and relationships. Further, patient-centered communication is increasingly recommended for a wide range of treatments in older adults including those with cognitive impairment (Backman et al., 2020),

To identify the potential discrepancies between patient preferences and what they perceive as physician assumptions regarding these preferences, our multi-site, qualitative study interviewed older adults with MCI and NC, and their care partners. Participants were invited to share their perceptions on why they believe physicians might recommend fewer guideline-concordant CVD treatments to those with MCI than their NC counterparts. The findings are intended to enable physicians to better understand and consider patients’ and their care partners’ viewpoints, which, in turn, can help improve effective physician-patient communication and inform strategies for enhancing the patient-physician relationship.

Methods

We used a descriptive qualitative approach and interviewed 20 dyads of participants with MCI (n = 11) or NC (n = 9) and their care partners at the University of Michigan and Duke University (See Table 1). These interviews were part of a larger mixed-methods study of the influence of patient MCI on physician CVD treatment recommendations and patient and surrogate preferences for CVD treatment. Interviews and analysis methods followed the consolidated criteria for qualitative research reporting (Tong et al., 2007).

Table 1.

Interview Participant Characteristics.

	Patient with MCI (n = 11)	Care partners for patients with MCI (n = 11)	Patients with NC (n = 9)	Care partners for patients with NC (n = 9)
Recruitment site
University of Michigan	5	5	3	3
Duke University	6	6	6	6
Female sex	4	8	7	4
Relationships to study partner
Spouse	10	10	5	5
Family	-	-	2	2
Friend	1	1	1	1
Other	-	-	1	1
Race
Black	2	1	1	2
White	9	9	8	7
Bi-racial	-	1	-	-
Age, median age, years	72	70	72	72

Note. MCI: mild cognitive impairment; NC: normal cognition.

Participant Selection

We used purposeful sampling to select participants with MCI and NC, and their care partners. We recruited all participants in collaboration with the Alzheimer’s Disease Research Centers (ADRC) at the University of Michigan and Duke University.

Participants were recruited from the University of Michigan longitudinal cohort, which enrolls adults 55 and older with NC and MCI. The University of Michigan recruits participants from the Cognitive Disorders Clinic in the Department of Neurology, the Neuropsychology Section, or from the community via newspaper advertisements, community outreach programs, the ADRC website, or word of mouth. At the Duke University study site, participants with MCI and their care partners were recruited from the Memory Disorders Clinic and the Geriatric Evaluation and Treatment Clinic using chart review. At both sites, the diagnosis of MCI was based on cognitive testing, clinical examinations, and expert clinician diagnosis following the 2011 National Institute on Aging–Alzheimer’s Association (NIA-AA) diagnostic guidelines for MCI. The University of Michigan and Duke University Institutional Review Boards approved the study. Patients with NC and their care partners were recruited from the established Alzheimer’s Disease Prevention Registry, ADRC outreach and educational events, and other ADRC studies that allow for re-contacting participants and care partners for future studies.

All participants were required to be 65 or older, read and speak English, self-identify as having Black or White race, and have a diagnosis of MCI or NC within the last 12 months to limit the probability of conversion to dementia. Participating care partners were required to be 18 or older and were defined as a friend or family member involved in the patient’s medical care.

Data Collection

Trained qualitative interviewers (CDK and JW) conducted in-person interviews with the participants. Interviewers and participants did not know each other before the study. Participants and their care partners were interviewed separately in a private workspace at the ADRCs.

The interviewers used standardized interview guides for participants and their care partners (Britten, 1995; Forman et al., 2008). The interview used a clinical vignette that depicted a fictional patient who suffered an acute ischemic stroke and had a pre-existing diagnosis of MCI (Figure 1). The interviewer read the definition of stroke. The interview began by eliciting patient and care partner preferences for stroke treatments for the fictional patient. The interviewer next presented the following data from our previous study (Blair et al., 2022) on the impact of patient MCI on physician decision-making recommendations for CVD treatment: (1) physicians recommended some guideline-concordant treatments for stroke less frequently to patients with MCI than patients with NC and (2) physicians thought that patients with MCI would want less care or treatment in general than patients with NC and (3) some physicians expressed that they were less likely to ask MCI patients for input on treatment decisions (See Supplemental Material for full interview guide). The current report focuses on participant reactions to the presented physician study data (See Figure 1).

Figure 1.

Clinical vignette.

A professional transcriptionist transcribed the interviews. De-identified transcripts were uploaded into Dedoose (Dedoose, 2018) to facilitate analysis. Data collection was continued until thematic saturation was achieved based on the inductive approach (Saunders et al., 2018).

Data Analysis

The qualitative analysis team consisted of a stroke neurologist with expertise in decision-making (DBZ), an internal medicine physician with expertise in MCI (DAL), qualitative researchers (JF and CDK), and study staff (BKR and EMB). The team performed qualitative content analysis to code the interview data (Elo & Kyngäs, 2008; Forman et al., 2008). The initial round of coding consisted of organizing the data around responses to specific questions in the interview guide. We systematically examined the pre-coded excerpts focusing on the questions, carefully scrutinizing the context and content of each excerpt. We referred to participants’ original quotes wherever more context was needed. Patterns, themes, and relationships between codes were noted in analysis to develop ideas about themes and interpretation. Discussions among members of the team continued until consensus was reached regarding the themes and interpretations.

Rigor

Multiple strategies were used to establish qualitative rigor (Morse, 2015). To ensure coding reliability, each coder achieved a kappa score of 0.80 or higher compared to a “gold standard” sample of interview excerpts that had been coded by the senior project manager (BKR) and senior author/principal investigator (DAL) using a consensus process. After coding was complete, the team reviewed the data organized under each code and discussed themes that emerged. For credibility, we engaged other team members to review and challenge our interpretations. For dependability, we kept summaries and memos of all the discussion among members of the coding team to keep track of the interpretation.

Results

We asked participants to share their reactions to (1) physicians recommending fewer guideline-concordant treatments for stroke to patients with MCI than patients with NC and (2) physicians thinking that patients with MCI would want less care or treatment in general than patients with NC. We identified three primary themes from participant reactions relating to physician data presented in the interview: (1) Most participants had negative reactions to the data that some physicians undertreat patients with MCI for CVD; (2) Participants suggested that physicians may undertreat patients with MCI due to physician assumptions about treatment effectiveness, and patient prognosis, value, and treatment adherence, and (3) Participants proposed that physicians may elicit less input from patients with MCI about treatments because of negative physician assumptions about patient decision-making capacity and physician time limitations.

Theme 1: Most Participants had Negative Reactions to the Data that Some Physicians Undertreat Patients With MCI for CVD

Over three-quarters of participants reacted negatively to physicians recommending fewer stroke treatments to patients with MCI than to patients with NC. Participants said that patients with MCI should not be denied treatment that is beneficial and that their quality of life is “worth living.” Participants thought it was unreasonable to undertreat patients with MCI and even those with mild dementia, though it might be reasonable to undertreat those with more advanced dementia. They also expressed negative attitudes towards physicians who would recommend less treatment to patients with MCI than patients with NC.

“That’s pretty surprising to me because all of those treatments have benefits, major benefits. That’s wild. I’m kind of disappointed in the doctors.”(participant with NC)

“I don’t agree because even with mild dementia, if you can stop everything and get medication and rehab, there can be a quality of life that’s worth living.” (participant with MCI)

“I don’t see why that should be distinguished between no memory problems and mild memory. Dementia, yes, I can understand that.” (Care partner of participant with MCI)

Participants' differentiation between MCI and dementia is noted. One participant highlighted the importance of differentiating between mild memory problems and dementia, emphasizing that treatments should be considered in context. Another participant indicated that he would be inclined to provide more treatment for stroke if there was a good chance that patients would not progress to dementia.

“I would want as much protection as possible because a) mild memory might just be aging and not ever go here to dementia, or someone may find a cure for dementia ten years down the road and what if you had not given me every chance when I was just mildly affected.” (participant with NC)

In contrast, less than one quarter of the participants thought that it may be reasonable for physicians to recommend fewer stroke treatments to patients with MCI, citing the complexity of medical decision-making and trust in physicians to take the patient’s quality of life into account.

“I’m not surprised. I think it’s complex, trying to decide treatments for patients. There’s a lot of factors to consider. I guess some people might think that it’s callous to discount people with mild dementia but then I guess medical ethics is so involved.” (participant with NC)

More than three-quarters of participants also reacted negatively to physicians thinking that patients with MCI would want less treatment than patients with NC. Participants expressed negative attitudes towards these physicians and the belief that patients with MCI want and deserve treatment. Many of these reactions were conveyed with strong negative emotions.

“It’s stupid. I’m having a hard time believing this. These doctors that thought that- are not thinking straight. (Participant with MCI)

“I would think everybody – if they have something wrong with them – everyone wants to get better. They may be not able to get that across to the doctors, but I think that they would want a cure just like everybody else. Those people definitely need an advocate to help them, to speak up for them.”(Participant with MCI)

In contrast, the remaining participants thought that it may be reasonable for physicians to think that patients with MCI would want less treatment, citing physician training.

“Well, I know how I feel. But yet the doctor has been to school and learned all of that stuff, and maybe he knows how I feel too. And I think he would be the one to recommend.” (Participant with NC)

Theme 2: Participants Suggested that Physicians May Undertreat Patients With MCI due to Physician Assumptions About Treatment Effectiveness, and Patient Prognosis, Value, and Treatment Adherence

When asked why they thought physicians might recommend less treatment to older patients with MCI, some participants, often hesitantly, proposed reasons. Most participants regarded these reasons negatively.

Reason 1: Treatment Would Not be Effective or Would Cause Harm

Some participants proposed that physicians may have recommended less treatment because these treatments would be less effective for patients with MCI than for NC patients.

“it seems like they think that it would be less effective giving the treatments to [patients with MCI and]…more effective if they give the treatments to those with no memory problems” (Paricipant with MCI).

Other participants expressed the possibility that treatment would cause harm, such as furthering the patient’s cognitive decline or prolonging suffering.

“I assume they’ve done some research, and maybe if you already have mild memory problems, the treatment isn’t all that – in fact, it could cause more harm than good, or something like that. They’ve done research. So I would trust them.” (Care partner of participant with NC)

Further, some participants thought that patient age and medical history may influence physicians' determination of treatment ineffectiveness or potential for harm.

“they [physicians] look at the person's history – their family history, their age… when you don't recommend a procedure, part of it is you know…the effects of that on a person – so that may figure into the doctor's decision not to do it. Maybe he thinks that this would not be in the best interest of that person, given where that person is in his or her own life”. (Care partner of participant with MCI)

Reason 2: Patients With MCI Have a Poor Prognosis

Some participants suggested that physicians may not recommend treatment because physicians believed that older patients with MCI would have poor outcomes regardless of intervention. One patient with NC alluded to treatment being a pointless endeavor for older patients with MCI who were already expected to have a decline in health:

“I think they do play a big role in the age of the patient and where they might see the patient going in the future. Especially if they have a memory issue. And they see that okay, so, maybe the person can't remember the day of the week or the time of day, but then eventually it doesn’t recognize people, which too me is more severe. And they see that, they might say, “Oh well that person is already 70, 80, whatever. It’s just going to get worse.” (pariticipant with NC)

“..it sounds like what they’re thinking is, well, these people are on a downhill slide anyway. Let’s help them just get out of here as fast as they can.”(care partner of participant with MCI)

Reason 3: Physicians Devalue the Lives of Patients With MCI

Some participants believed that physicians did not value the life of a patient with MCI, and so may not think it was worth investing the resources towards providing treatment to them. For example, one care partner with NC seemed to generalize that physicians had a callous attitude and implied that they pursued medicine for financial purposes rather than helping others.

“Working with doctors, I don't think they're always the most compassionate people on the face of this earth… I don't know why they go into medicine or want to help people. They don't – not all of them have – they like money…[they think] this patient, it's not going anywhere. It's going down and I'm not interested in caring for that person anymore.” (participant with NC)

Similarly, other participants theorized that physicians wanted to allocate resources to patients with NC rather than those with MCI. One MCI care partner, among others, believed that it would be wiser to offer the treatment and resources to patients with the potential for a higher quality of life.

“It's going to be expensive and this person's life expectancy is not not very long –if you can provide that for another person that has… more quality life, then that's a decision you make”.(care partner of participant with MCI)

Reason 4: Patients With MCI Would Not be Able to Adhere to Treatment

Some participants speculated that some physicians thought MCI patients would have difficulties adhering to treatment because of poor memory, especially if they lacked a proper support system. For example, a patient with NC said, “I would think that they would be concerned about what kind of support system the patient had because maybe they need to do medications and they’re concerned that they would [not]remember to do it or that they could follow the directions after the treatment”. (participant with NC)

Theme 3: Participants Proposed That Physicians May Elicit Less Input from Patients With MCI About Treatments Because of Negative Physician Assumptions About Patient Decision-Making Capacity and Physician Time Limitations

Reason 1: Negative Assumptions About MCI Patients' Cognitive Capacity for Understanding Treatments and Decision-Making

These participants suggested that MCI made it difficult for patients to participate in treatment discussions. One participant proposed that physicians might have preconceived notions of MCI patient behaviors that were not substantiated and that decreased their motivation to discuss treatment options with these patients. This participant with NC said that physicians might assume that patients with MCI cannot comprehend what their doctor is saying: “[the doctor might be thinking] this person with memory problem, isn’t paying attention to me. This person doesn’t value what I’m saying. This person doesn’t even know what I’m saying, let alone follow my reasoning or my recommendations…Why bother that person with all these options…when the person clearly is having trouble connecting with me right now.” Another participant said, “I imagine they [physicians] would just think that they don’t have the cognitive skills to fully participate in the conversation…maybe they were thinking that they’re further along in the dementia, the memory problems, than they are”. Similarly, other participants implied or explicitly expressed how frustrating and pointless it can be to explain concepts to someone with memory problems. One participant with NC said, “[if] you have a person that has [memory] problems, it’s hard to explain anything to them and sometimes it’s frustrating. So I almost think it might be a waste to go through a lot of explanation”.

Reason 2: Assumption That Patients Will not be Able to Adhere to Treatment Would Lead Some Physicians not to Discuss Treatment with Patients

Some participants said that physicians may not ask patients with MCI for input on treatment decisions because physicians may assume that they would not adhere to treatment. One participant with MCI proposed that physicians could ascertain inability to adhere through interactions with a patient with MCI, and would not offer treatment: “I would trust a doctor. If he’s going to spend enough time with a patient, and sometimes everybody can’t do that much, but he’s going to pick up pretty quick what a patient is going to be able to do and isn’t…I think at the end of the day, if you’re not taking that medicine, you’re no better off than a guy who wasn’t given it.” (participant with MCI)

Another view was that if the physician did not believe a patient with MCI would be able to adhere to treatment, they would discuss treatment and supporting the patient with the patient’s care partner instead. For example, a participant with NC said, “Maybe they feel that the patient with mild memory problems might have more trouble remembering to take their medication. Maybe they feel like that person’s family member is more responsible for helping the patient remember to take their medication.” (participant with NC)

Reason 3: Physicians are Rushed due to Systems Issues

Some participants said that physicians do not have the time to question their perceptions of MCI or involve patients with MCI in decision-making because they work in a rushed and stressful environment. One participant with MCI felt that doctors have to see too many patients in too short a time and implied that discussing treatment options with patients with MCI would take more time than with patients with NC. This participant said, “I know that doctors today are very stressed and overworked. It’s not, there’s so many dictates on their jobs and they have to justify what they do left and right and at an incredible pace. Every ten minutes, a new patient or whatever…that’s your regular office visits. Yeah, it’s unfortunate, I think, that they aren’t taking more time to discuss it with patients, especially with only mild memory problems or mild dementia, but I couldn’t, I would hesitate to pass judgment on them for doing that.” (Participant with MCI)

Discussion

In this study, we identified three significant themes from participant responses on the influence of a patient’s MCI diagnosis on physicians’ recommendations for CVD treatments: (1) Most participants had negative reactions to the data that some physicians undertreat patients with MCI for CVD; (2) Participants suggested that physicians may undertreat patients with MCI due to physician assumptions about treatment effectiveness, and patient prognosis, value, and treatment adherence, and (3) Participants proposed that physicians may elicit less input from patients with MCI about treatments because of negative physician assumptions about patient decision-making capacity and physician time limitations.

This study makes significant contributions to the existing literature by providing unique insights into patients’ and care partners’ perspectives regarding physician decision-making and treatment recommendations in MCI patients. Comparing the findings in the current study to that of our prior studies (Blair et al., 2020, 2022, 2023), there is a convergence of insights into the disparities in CVD treatment recommendations for patients with MCI versus those with NC. However, each study provides unique perspectives that collectively enhance our understanding of this issue. Prior studies identified reasons for fewer CVD treatments based on physician beliefs about MCI patients' prognoses, treatment complication risks, cognitive ability to consent, and perceived benefits. They suggest a need for improved physician understanding of MCI to reduce treatment disparities. The current study underscores the discrepancy between physician assumptions and the actual preferences and values of patients, revealing a critical gap in patient-physician communication and the significance of patient input in decision-making. It highlights the importance of bridging the gap between physician assumptions and patient preferences, thereby advocating for a more inclusive, informed, and empathetic approach to care for this vulnerable population.

Existing research has explored patient and care partner perspectives on physician decision-making and treatment recommendations, highlighting the importance of involving patients in decision-making and tailoring treatments to individuals (Dillworth et al., 2019; Ishikawa et al., 2013; Taylor et al., 2018). However, there is limited research focusing on patients with MCI and their unique challenges in receiving appropriate care. In this study, participants identified several factors that influenced physician decision-making and treatment recommendations. They inferred that physicians often hold misconceptions about MCI patients' functional status, their treatment adherence, and their impaired decision-making ability, which could contribute to undertreatment of patients with MCI and less patient involvement in treatment decisions. These findings shed light on the barriers faced by patients with MCI in receiving evidence-based and patient-centered care. This study underscores the needs of MCI patients and care partners for more comprehensive conversations, care partner involvement, and accurate assessment of patients' decision-making capacity to ensure appropriate and patient-centered care. These findings align with previous research that emphasizes the importance of evaluating patients beyond their MCI diagnosis to fully understand their decision-making capacity (Larson & Stroud, 2021; Levine et al., 2022; Levine et al., 2021; Parmigiani et al., 2022; Pruzin et al., 2023). It underscores the necessity of tailored approaches, increased communication, and physician education to enable patients to receive guideline-concordant care.

Participant responses also raised concerns over patient rights and emphasized the importance of having person-centered and adequate communication with patients and their care partners to avoid patient distrust and improve physician-patient relationships. Some participants assumed the lack of freedom to make treatment decisions equated to physicians having “given up” on MCI patients. Studies have found associations of patient distrust with poor physician professionalism which demonstrates less humanity and less clinical competency (Gabay, 2019). Patient distrust was also associated with poor preservation of patient self-worth when physicians neglected emotional aspects to only focus on their disease. Our study results are consistent as participants questioned physicians’ perspectives on the worth of patients with MCI. This is concerning as patient trust is associated with positive health outcomes, whereas lack of communication and patient involvement in decision-making extend patient distrust and jeopardize the effectiveness of stroke interventions (Birkhäuer et al., 2017; Gabay, 2019). The participants’ comments raised a subtle yet significant presence of ageism in clinical decision-making. There is a suggestion that chronological age, rather than the biological fitness or quality of life of the individual, may unduly influence the withholding of treatment. This point invites a deeper examination of how age-related biases might impact the care provided to older adults, and the importance of assessing each patient’s unique circumstances, preferences, and potential for treatment benefit (Torke et al., 2014; Vick et al., 2018).

Our analysis revealed a variability in participant views concerning dementia and its impact on treatment eligibility. Some participants did not differentiate between stages of dementia, viewing any form of dementia as an exclusionary factor for treatment. Conversely, others recognized a distinction between MCI and dementia. This variation underscores the need for clearer communication regarding how different stages of cognitive impairment may influence treatment decisions. Some participants noted that given the MCI patients’ higher risks of stroke and progression to dementia, there might be a stronger, not lesser, impetus for their treatment. Such insights raise questions about the trust placed in clinicians and whether the evidence is effectively guiding treatment decisions. The conversation regarding financial incentives, introduced by a participant, adds a nuanced aspect to our comprehension of treatment decisions. It raises more expansive concerns about how the mechanisms of physician compensation, even within publicly funded healthcare frameworks, might inadvertently influence the standard and fairness of care provided to patients across the spectrum of cognitive abilities.

This study has limitations. As with any qualitative study, we chose qualitative methods to obtain an in-depth understanding of participants’ views that a quantitative study could not produce. It is possible that the views of patients and care partners in medical settings other than academic medical centers may differ from those of our participants. However, the strengths of our study were purposeful sampling of information-rich patients and care partners from two sites, and rigorous interviewing and data analysis procedures that enhance the validity of our results, which provide clinically useful information and suggest areas for further study.

This study has implications for clinical practice and policy. We revealed several plausible deficiencies in communication and shared decision-making with patients with MCI and their care partners, and the need for better initiatives to address problems identified from participant responses. Participants assumed that the potential treatment disparities between patients with MCI and NC could be attributed to several factors ranging from inability to develop meaningful relationships, sub-optimal communication of the available treatment options, or physicians deciding without patient input. While there have been initiatives recommending shared decision-making between patients, care partners, and providers (Farrell & Héritier, 2004; Vahdat et al., 2014), our results highlight the need to ensure that patients with MCI have the opportunity to voice their preferences and values and suggest that healthcare systems may need to allocate longer clinic times for older patients. Additionally, it emphasizes the importance of providing written information in an accessible format and having in-depth discussions with providers regarding treatment purposes, risks, and benefits. Professionals have also reported that they value the personal rewards and see patient involvement as a means to manage consultations more effectively (Farrell & Héritier, 2004). Adopting a patient-centered approach demonstrates equity and accountability which will enhance health outcomes, patient satisfaction, and cost-effective services (Vahdat et al., 2014; Sepucha et al., 2014). Our results suggest a scientific need to identify effective strategies for patient-centered communication about CVD treatments between patients with MCI, their care partners, and providers. Further research will be needed to determine tools that will best address the issues raised in our study. Better tools in the decision-making process and awareness through physician education of MCI can help physicians assess, rather than assume, the severity and decision-making capacity of patients with MCI.

Conclusion

Overall, most participants expressed negative reactions towards the undertreatment of patients with MCI, citing multiple reasons for this phenomenon, including a lack of involvement of patients with MCI in treatment decision-making. The current study suggested the need to facilitate person-centered communication and more involvement of patients with MCI and their care partners in treatment decision-making. It provided meaningful reasoning for creating a framework of effective communication between the health care team, patients with MCI, and care partners to ensure informed decision-making that reflects patients’ preferences and understanding and ultimately ensures safe and high-quality care.

Supplemental Material

Supplemental Material - Patient and Care Partner Perspective on Potential Undertreatment of Patients With Mild Cognitive Impairment for Cardiovascular Disease

Supplemental Material for Patient and Care Partner Perspective on Potential Undertreatment of Patients With Mild Cognitive Impairment for Cardiovascular Disease by ing Wang, Emilie M. Blair, Jane Forman, Darin B. Zahuranec, Bailey K. Reale, Zihao Cao, Brenda L. Plassman, Kathleen A. Welsh-Bohmer, Colleen D. Kollman, and Deborah A. Levine in Journal of Applied Gerontology

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institutes of Health (NIH)/NIA grant R01 AG051827 (Dr. Levine, PI).

Institutional Review Board (IRB)

University of Michigan Medical School (HUM00118584)

University of Duke #Pro00075422

ORCID iD

Jing Wang

Supplemental Material

Supplemental material for this article is available online.

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