Identifying sources and mechanisms for missed opportunities in discussing cognition and capacity among older adults with advanced cancer, their caregivers, and physicians.
Authors: Kyi Kaitlin , Digiovanni Grace , Kelly Jeremy M. , Tylock Rachael , Wells Megan , Gilmore Nikesha , Loh Kah Poh , Kadambi Sindhuja G. , Kehoe Lee , Anand Maya , Lin Ann , Berkhof Lucia , Griggs Lorraine , O'Rourke Mark Allen , Bearden James D. , Bradley Thomas Paul , Mohile Supriya Gupta , Magnuson Allison 
Published: June 2023

e24019 Background: Impaired cognition increases the risk of treatment-related toxicity and adverse cancer outcomes. Thus, communication about cognition is essential for informed decision making, particularly for patients with abnormal cognitive screening results (e.g. Mini-Cog). We aimed to qualitatively explore missed opportunities in discussing cognition and capacity in oncology clinical encounters for patients with an impaired Mini-Cog score. Methods: This secondary analysis examined audio recordings of clinical encounters from a nationwide, multi-center, cluster-randomized trial (NCT02054741; PI: Mohile; funding NCI UG1CA189961). Eligible patients were age 70 years or older with at least one geriatric assessment (GA) domain impairment, either receiving or considering cancer treatment for incurable cancer. Patients were randomly assigned to usual care or GA-guided communication intervention (GA summary with recommendations was provided to patient, caregiver, oncologist). Clinical encounters in both arms were audio-recorded and transcribed. A sample size of 75 patients with impaired Mini-Cog was utilized to meet thematic saturation. Transcribed interviews were open-coded by 2-4 independent coders using a constant comparative method to simultaneously code and analyze for thematic elements. Missed opportunity for cognitive or capacity conversations was identified when a cognitive or capacity concern was mentioned but not acknowledged and/or addressed by other participants in the conversation, or when concerns were alluded to but not described in sufficient detail. Results: A total of 74 patients were evaluated with mean age 78.7 years (SD 6.0). The majority were male (53.3%), white (86.7%), non-Hispanic (100%), with gastrointestinal (26.7%) or lung (25.3%) cancer. Overall, 48 missed opportunities were identified across the 75 clinical encounters (cognition 39 [81.3%]; capacity 9 [18.8%]); oncologists, patients, and caregivers all contributed as sources of missed opportunities to discuss cognition/capacity (63%, 24%, 13% respectively). Mechanistically, when oncologists were the source of the missed opportunity, it was due to: 1) a lack of response to either caregiver or patient’s concern, or 2) not allowing space for the patient or caregiver to elaborate or clarify. When patients were the source of a missed opportunity, it was due to: A) cognitive impairment preventing meaningful conversation, B) minimization or deflection of concern by the patient, or C) lack of engagement in conversation. Conclusions: We identified several underlying mechanisms of missed opportunities in discussing cognition/capacity in oncology clinical encounters. Discussing cognition/capacity in the context of oncology is critical and future work should develop interventions to enhance communication about cognition. Clinical trial information: NCT02054741 .