Geriatric Psychiatry In-Patient Perspectives on the Diagnosis of Dementia/Major Neurocognitive Disorder (MNCD)

Introduction According to recent estimates, there are approximately 5.8 million Americans age 65 and older living with the most prevalent type of MNCD, Alzheimer's dementia (Hebert 2013). The number of new and existing cases of Alzheimer's dementia and other MNCDs is expected to increase in the next decades as the older population in the United States grows (Alzheimer's Association 2020; US Census Report 2016). Despite the increasing prevalence of MNCDs, there is significant variability in clinical practice regarding the communication of this diagnosis to patients and families. This has significant ethical and practical implications in the care provided to individual patients, as well as on the public perception of these conditions. Published literature worldwide recommends disclosure of dementia/MNCD, based on evidence that patients want to know their diagnosis (Abe, Michiko, et al. 2019) and clinical considerations regarding respect of patient autonomy, improved adherence to treatment and the ability to provide support to patients and families (Carpenter, Brian, et al. 2004). However, a systematic review found that only 34% of general practitioners reported disclosing the diagnosis to patients (Low, Lee-Fay, et al. 2018). Reasons why providers chose not to disclose the diagnosis included diagnostic uncertainty, perceived futility given limited treatment options, concern for the patient's ability to comprehend or remember the diagnosis and concerns for the psychological impact of disclosure (Carpenter, Brian, et al. 2004). Studies have suggested that disclosing the diagnosis of MNCD is associated with an increased risk of suicide (Erlangsen et. al. 2008; Annor et. al. 2019). Clinicians’ fear of provoking or worsening depression symptoms and/or increasing suicide risk in patients may be a potential reason behind decisions to withhold the diagnosis of MNCD. The aim of this study is to assess the beliefs and attitudes regarding the diagnosis of MNCD of patients in an urban inpatient geriatric psychiatry unit, and specifically, to ascertain whether these patients believed that such disclosure would cause them to feel depressed or suicidal. Such information potentially can aid clinicians, patients and their caregivers to develop additional strategies to manage the disclosure of MNCD. Methods Retrospective chart review. Results Preliminary results from this ongoing study revealed the following: The sample consisted of 7 males and 8 females, with an average age of 72.5+/-8.71 years and with 60% self-identifying as Caucasian. 66.67% of patients reported completing high school. Montreal Cognitive Assessment (MoCA) scores were available for 8 participants and ranged from 6 to 26, with an average of 17.25+/-8.24, suggesting a range of mild to severe cognitive impairment in the sample. Geriatric Depression Screening (GDS) scores ranged from 0-14, with an average of 4.08 +/-3.95, suggesting that the sample as a whole was not depressed. The average number of comorbid mental and physical conditions was 2.2+/-1.15 and 10.87+/-7.03, respectively, and 53.33% of the patients carried a diagnosis of MNCD prior to admission. 60% (n=9) of patients in the study reported having memory problems. Only one patient reported receiving a diagnosis of dementia/MNCD by a physician, while another patient reported that the diagnosis had been shared with a family member, but not with the patient directly. Of the patients interviewed, 53.33% (n=8) reported that it would be helpful for them to receive the diagnosis if they had it. They cited validation of their symptoms and prompt access to treatment as the main reasons for this. Regarding the psychological impact of disclosure, participants described potential feelings of disbelief, frustration, hopelessness, acceptance and determination to overcome. 20% (n=3) of patients indicated that seeking non-pharmacologic help for MNCD would be most helpful to them. Of interest, only 20% (n=3) of the patients reported that they would feel depressed if the diagnosis of MNCD was revealed to them. Only 13.33% (n=2) of the patients interviewed stated they may feel suicidal, and of these two, one provided a history of having been diagnosed previously with dementia/MNCD. Conclusions We found that the beliefs and attitudes regarding the diagnosis of MNCD of patients in an urban inpatient geriatric psychiatry unit ranged from hopelessness to acceptance of memory impairments. Of note, 20% (n=3) of the patients interviewed believed that disclosure of a diagnosis of MNCD would cause them to feel depressed and 13.33% (n=2) believed that it would make them feel suicidal. Limitations of this preliminary study include the small sample size and subjective nature of the interview which relied on patients’ impressions at one point in time. Further research is being conducted to expand on these findings in hopes that such information can aid clinicians, patients and their caregivers to develop additional strategies to manage the disclosure of MNCD. Funding Not applicable.