1. Mild Cognitive Impairment
Dr. Sridhar Vaitheswaran

2. Plan What is MCI? What is the prevalence?
Will MCI progress to dementia?
Can we treat MCI?
How to manage MCI?
In primary care settings
In secondary care settings

3. What is MCI? Age Associated Cognitive Decline
Age Associated Memory Impairment
Age Consistent Memory Impairment
Age Related Cognitive Decline
Benign Senescent Forgetfulness
Cognitive Impairment No Dementia
Limited Cognitive Disturbance
Mild Cognitive Decline
Moderate Cognitive Decline
Mild Cognitive Disorder
Mild Cognitive Impairment
Amnestic
Non-amnestic
Multiple
Minimal Dementia
Mild Neurocognitive Disorder
Self-reported memory complaint
Questionable Dementia
Stephan et al 2007

4. Modified from Peterson & Smith 1999
What is MCI?
Subjective complaint of memory loss (or single cognitive function domain)
Objective evidence of memory impairment (or single cognitive function domain)
Generally preserved other cognitive ability
Preserved basic day-to-day functioning
No other obvious medical, neurologic or psychiatric cause for memory problem
Does not meet criteria for dementia
Modified from Peterson & Smith 1999

5. Prevalence of MCI Varies according to definition
Reported values: 0.1% - 42% (Stephan et al 2007)
MCI (amnestic): 2.5%
Self reported memory impairment: 42%
In Grampian (85,000 X 0.42) 35,700 older subjects

6. What is dementia?
Impairment in at least 2 or more cognitive domains (memory, language, recognition, praxis, executive function)
Impairment in ADL
No other obvious medical, neurological or psychiatric cause

7. Natural history of cognitive decline
“Normal”
“MCI”
Dementia

8. What is the conversion rate?
Mean annual conversion rate to dementia
Lonie et al 2010: 11% for aMCI
Grundman et al 1996: 15%
25% did not convert to dementia after 10 years (Chertkow et al 2001)

9. Can we predict conversion?
APOE e4 load (Petersen et al 1995), Homocysteine levels (Lehmann et al 1999), LDL/HDL ratio (Corrada et al 2002), Interleukin 6 levels (Yaffe et al 2002)
Neuroimaging: Hippocampal volumes, fMRI, PET, SPECT
Neuropsychology
Others: Smell test, CSF Tau, CSF Amyloid β 42

10. Points to note
Cognitive impairment often noted in persons before they develop dementia
MCI group are at increased risk of converting to dementia
A significant group of MCI do not convert to dementia & some also revert back to “normal”

11. Treatment for MCI Non-pharmacological Cognitive interventions
Physical exercise

12. Treatment for MCI-Pharmacological
Massoud et al 2007

13. Treatment recommendations
Mental stimulation & Physical exercise
No hard evidence for MCI but no harm!
Pharmacological
No evidence to support any intervention

14. So….
When a 75-year-old farmer from NE of Scotland complains of subjective memory loss…..

15. Screen for & manage Treatable physical conditions
Vascular & other modifiable risk factors
Other mental disorders
Presence of dementia
Multiple cognitive impairment
Impaired ADL
Fitness/willingness for physical exercise
Feasibility & willingness to try mental activity

16. Then…
If in doubt refer….

17. What can secondary service offer?
Clinical assessment to rule out dementia/other disorders
Imaging
Neuropsychology
Follow-up????

19. References
Corrada M, Kawas C. Plasma total cholesterol, LDL, HDL levels and the risk of Alzheimer disease: the Baltimore Longitudinal Study of Aging. Neurology 2002;58:A106
Graham JE, Rockwood K, Beattie BL, Eastwood R, Gauthier S, Tuokko H, et al. Prevalence and severity of cognitive impairment with and without dementia in an elderly population. Lancet 1997; 349: 1793 – 1796
Grundman M, Petersen RC, Morris JC. ADSC Cooperative Study: rate of dementia of the Alzheimer type (DAT) in subjects with mild cognitive impairment. Neurology 1996;46:A403
Lehmann M, Gottfries CG, Regland B. Identification of cognitive impairment in the elderly: homocysteine is an early marker. Dement Geriatr Cogn Disord 1999;10:12–20
Lonie JA, Parra-Rodriguez MA, Tierney KM, et al. Predicting outcome in mild cognitive impairment: 4-year follow up study. British Journal of Psychiatry 2010; 197: 135 – 140
Massoud F, Belleville S, Bergman H, Kirk J et al. Mild cognitive impairment and cognitive impairment, no dementia: Part B, therapy. Alzheimer’s & Dementia 2007: 3:
Petersen RC, Smith GE, Ivnik RJ, Tangalos EG, Schaid DJ, Thibodeau SN, et al. Apolipoprotein E status as a predictor of the development of Alzheimer’s disease in memory-impaired individuals [published erratum appears in JAMA 1995;274:538]. JAMA 1995;273:1274–1278
Petersen RC, Smith GE, Waring SC, Ivnik RJ, Tangalos EG, Kokmen E. Mild cognitive impairment: clinical characterization and outcome. Arch Neurol 1999; 56: 303 – 308
Stephan BCM, Mathews FE, McKeith IG, Bond J, Brayne C. Early cognitive change in the general population: how do different definitions work? J Am Geriatr Soc 2007; 55: 1534 – 1540