Dementia rates are rising. Data from a recent UK study showed that 42% more people than previously forecast will be diagnosed with some form of the disease by 2040. And physicians are just as much at risk as the general population.

 

An argument for cognitive screenings

 

An article in Clinical Ethics presents the compelling report of an 80-year-old pulmonologist.

Fortunato JT, Menkes DL. The aging physician: A practical approach to protect our patients. Clinical Ethics. 2019;14(1):46–49.

This physician, who had multiple comorbidities and past depression, presented with troubling symptoms of short-term memory impairment. After serial cognitive assessments, he was presumptively diagnosed with senile dementia of the Alzheimer's type. 

 

This intriguing case sparks a critical dialogue: Are physicians (along with the general population) aging well, and what implications does this have for patient care?

 

An aging physician population

 

Recent projections by an AAMC report indicate that over the next decade, more than 2 out of 5 currently active physicians will reach age 65 or older.

The Complexities of Physician Supply and Demand: Projections From 2019 to 2034. Association of American Medical Colleges. 2021.

 

 

 

Studies have also found evidence supporting a decline in physician performance as they age, challenging the notion that accumulated experience compensates for cognitive decline. 

Doctors' abilities may initially deteriorate in terms of strength, followed by vision, dexterity, and cognition. Impairment manifests earlier in surgeons, whose necessary competencies include physical prowess, visual acuity, and manual dexterity. 

Let's look at the numbers here:

• Around 28% of the approximately 95,000 actively licensed US physicians aged 70 and above have some form of mild cognitive impairment (21%) or dementia (7%), according to a report in Neurology Clinical Practice.

  Devi G, Gitelman DR, Press D, et al. Cognitive impairment in aging physicians: current challenges and possible solutions. Neurol Clin Pract. 2021;11(2):167–174.

   

• An article in the NEJM reported that roughly 11,000 have amnestic mild cognitive impairment (MCI), a precursor to Alzheimer's, while 9,400 have non-amnestic MCI, a precursor to cognitive disorders affecting areas other than memory. Additionally, approximately 7% of physicians enrolled in New York's physician health program annually receive referrals for cognitive issues. Most of them are allowed to continue working under restrictions and supervision.

  Devi G. Alzheimer’s disease in physicians—assessing professional competence and tempering stigma. N Engl J Med. 2018;378(12):1073–1075.

   

   

• Recently, a study found that after age 70, the incidence of dementia in physicians reached 20.2% (compared with 17.5% in the general population).

  Vassilaki M, Syrjanen JA, Kremers WK, et al. Medical doctors and dementia: a longitudinal study. J Am Geriatr Soc. 2020;68(6):1250–1255.

   

   

 

Factors affecting retirement age

 

The AAMC report cites burnout as a key reason for physicians to expedite their retirement. 

 

 

In contrast to countries such as Finland, Japan, China, and India, there is no obligatory retirement age for physicians in the United States. This means that some doctors may continue practicing despite cognitive decline. Potential issues, such as misdiagnoses, medication errors, or reduced care quality, could impact patient safety and well-being. 

 

Underreporting issues

 

 

According to the Clinical Ethics authors, research has shown that physicians have limited ability to evaluate their own competency. Interestingly, while most physicians endorse their ethical responsibility to report colleagues' impairment, many fail when they themselves are faced with these situations.

The common method for detecting cognitive issues in doctors is reactive evaluation, which only takes action after an error or a report from someone like an institution, patient, or coworker. This approach misses many impaired doctors and can lead them to conceal their issues.

Younger doctors often hesitate to report issues in older doctors because of the hierarchical apprenticeship model. In a US survey, more than one-third of physicians didn’t believe it was their duty to report impaired colleagues. Another third felt unprepared to deal with such colleagues. 

The AMA suggests that doctors aged 70 or older should get regular neurocognitive tests.

Competency and the Aging Physician. Report 5 of the Council on Medical Education (A-15). American Medical Association. 2015.

 

 

 

 

Practical solutions

 

One solution is establishing a standardized test for surgeons' physical skills and for cognitive assessments for all physicians. The American Academy of Surgeons suggests surgeons undergo confidential physical and visual tests and regular re-evaluations between 65 and 70.

Statement on the Aging Surgeon. American College of Surgeons. January 1, 2016.

 

 

Some health systems are introducing age-based cognitive tests, ranging from simple assessments, like the Mini-Mental State Examination, to more extensive neurocognitive evaluations.

A simplified, multi-domain approach has been proposed by the authors writing in Neurology Clinical Practice. It suggests starting cognitive screening at age 65, with further evaluation triggered when a doctor scores at least two standard deviations below the mean. Those scoring within one standard deviation should be retested every 5 years, and those between one and two standard deviations below the mean might require testing every 2 years. 

However, resistance from older doctors and legal concerns related to the Age Discrimination Act of 1975 could limit the effectiveness of such protocols. An alternative approach could involve screening doctors in mid-adulthood, well before expected dementia onset, addressing age discrimination concerns.