Mild Cognitive Impairment: How “Mild”?

The devastating toll of Alzheimer’s Disease and Related Dementias (ADRD) – both human and economic – is well documented. Our society is particularly susceptible because Americans are living longer and are wealthier than ever before. Advanced age remains the number one known risk factor for ADRD. Cognitive impairment can affect judgment and decision-making capacity, including those about finances. This makes cognitively impaired elders especially vulnerable to fraud and exploitation.

The nation has responded with a growing emphasis on earlier detection of impairment, even before symptoms manifest, with hopes of earlier intervention. But while this may be a wise approach for certain diseases like cancer, early detection is particularly complex when addressing cognitive disorders, which often have few clear biologic markers, and many ethical, legal, and psychosocial implications. For many older Americans and their families, these well-intended efforts can lead to unintended consequences.

Evidence: What are the real effects of mild cognitive impairment
Mild Cognitive Impairment (MCI) has been a popular research topic for more than two decades. Professional organizations continue to host MCI conferences and the diagnosis was recently included in the Diagnostic and Statistical Manual of Mental Disorders. But while mild neurocognitive disorder, as MCI is now called, is touted as a precursor of dementia, research shows it usually is not. Instead, most data from around the world show a common pattern, namely, 2/3 of people diagnosed with MCI either remain at a mild level of impairment over time, or return to their normal level of functioning. In fact, a recent synthesis of evidence from 41 different studies concluded that most people diagnosed with MCI do not dement even after 10 years.1

Psychology: A disconnect between beliefs and behavior
While data generally do not show MCI to be a sign of dementia, they do show it is correlated with other psychological factors. These include symptoms of depression and anxiety, as well as personality characteristics such as the tendency to voice somatic complaints or worry excessively about one’s overall health. Further, numerous studies have shown people are not accurate at assessing their own memory or cognitive function, and subjective complaints often do not correlate with objective deficits. Many of those experiencing true cognitive decline often feel they are not, while many who are not experiencing decline often feel they are. This complicated reality is nothing new, as psychologists have theorized and measured the link between beliefs (stigma, stereotypes, confidence, anxiety) and behavior for decades.

Workforce: The need to integrate biomedical and psychosocial healthcare
Differentiating these and other psychological factors is made difficult by the nation’s longstanding failure to integrate biomedical and psychosocial healthcare. Despite calls to correct this for more than a half century,2 the U.S. system remains disproportionately biomedical, relying primarily on non-psychiatrist physicians and nurses. Largely absent from this system are psychiatrists and psychologists who, by law, are the only behavioral health specialists licensed and trained at the doctoral level. Notably, legal and financial professionals have stepped up to develop protections to mitigate the risk of exploitation and create policies for notifying appropriate authorities such as adult protective services. But while increased vigilance of non-clinician professionals is important, it is only the beginning.

Solutions: The path forward
My own efforts toward integrated senior care have included authoring an evidence-based guide to clinical decisions in MCI management with a geriatric neurologist,3 and more recently, creating a team of geriatric physicians and psychologists to publish an evidence-based text focused on integrated care of our aging population.4 But geriatrics extends beyond healthcare. Legal and financial professionals play a vital role. And while emerging laws and policies aimed at protection are needed, it is important to avoid heavy handedness. This would threaten seniors’ autonomy and, ironically, can backfire, causing client defensiveness, denial of problematic symptoms, and ruptured relationships with those trying to help (families, attorneys/advisers). Relevant psychological variables are often subtle and nuanced. Aging stereotypes and related bias shape our perceptions and assumptions.5 Senior investors’ decision-making is inseparable from their perception of their declining function, growing dependence, and potential for becoming a burden to others. When it comes to mild degrees of cognitive impairment, a licensed behavioral health professional’s recognition of these factors can help differentiate changes due to impairment vs normal aging. Consultation with qualified psychologists who apply validated assessment tools and diagnostic interviews is appropriate when cognitive capacity needs to be evaluated and when strained interpersonal family dynamics must be understood and managed.

Often, when investor finances and autonomy are at stake, perception is reality. Perceived relationship quality and family history may impact asset distribution more than logic. Consultation can help uncover these issues and tackle hard-to-answer questions such as those involving ethics and the legality of whether senior clients are entitled to make seemingly rash decisions. Late life is difficult. Indeed, senior investors’ ability to make financial decisions for themselves can be their sole remaining source of power and control, serving as a protective buffer to the growing threats often associated with the aging process.

Benjamin A. Bensadon, Ed.M., Ph.D.
Associate Director, Internal Medicine Residency – Geriatrics & Palliative Care Rotation
Assistant Professor of Integrated Medical Science
Charles E. Schmidt College of Medicine, Florida Atlantic University

Dr. Bensadon is a licensed psychologist. He provides clinical training to medical students and residents in inpatient, outpatient, and specialty settings; geriatrics and behavioral health consultation to memory and long-term care facilities; and direct clinical services to individuals, groups, and family caregivers via his independent practice, Bensadon Medical Psychology & Geriatrics, PLLC.