Mild Cognitive Impairment

Mild Cognitive Impairment
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Author: Heather S Anderson, MD; Chief Editor: Michael Hoffmann, MBBCh, MD, FCP(SA), FAAN, FAHA
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Updated: Sep 23, 2013
Practice Essentials
In mild cognitive impairment (MCI), the changes in cognition exceeds the normal, expected changes related to age.
In one classification of MCI, the amnestic form is distinguished from the nonamnestic form. The amnestic form often
precedes Alzheimer disease.
Essential update: Fornix (not hippocampal) changes may be first biologic sign of cognitive
decline
In a study of 102 cognitively normal elderly subjects, fornix body volume and axial diffusivity on t1-weighted MRI
were found to predict cognitive changes, raising the possibility that deterioration in this region of the brain is the first
[1, 2]
biologic sign of cognitive decline.

Of the 102 participants, 20 converted to MCI (18 participants) or Alzheimer
disease (AD; 2 participants). The average time to conversion was 3 years. The 20 "converters" were followed up for
an average of 4.4 years, the 82 "nonconverters" for an average of 3.8 years.
Fornix white-matter volume was independently associated with risk for conversion (mean hazard ratio [HR], 0.47;
[2]
95% confidence interval [CI], 0.24-0.89; P =.02). Fornix axial diffusivity was also associated with risk for conversion
(mean HR, 1.25; 95% CI, 1.02-1.46; P =.005). Hippocampal gray-matter volume was not a significant predictor of
cognitive decline but showed a significant association with fornix body volume and axial diffusivity (P =.004).
Signs and symptoms

Symptoms of mild cognitive impairment (MCI) are often vague and include the following:
Memory loss
Language disturbance (eg, difficulty in finding words)
Attention deficit (eg, difficulty in following or focusing on conversations)
Deterioration in visuospatial skills (eg, disorientation in familiar surroundings in the absence of motor and
sensory conditions that would account for the complaint)
Ronald C. Petersen postulated that the defining element of MCI is a single sphere of slowly progressive cognitive
impairment that is not attributable to motor or sensory deficits and to which other areas of involvement may
eventually be added, before social or occupational impairment supervenes (because this occurrence marks the
[3]
onset of dementia).
Diagnosis
Although no single feature of the general physical examination characterizes MCI, the following should be included
in the overall assessment of the patient:
Evaluation of mental status
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Examination for the presence of potential causative comorbid conditions

Examination for the presence of sensory and/or motor deficits as potential causes or exacerbating factors
No specific diagnostic studies exist for mild cognitive impairment. However, most clinicians perform a basic workup
at minimum to exclude potential treatable causes (eg, thyroid disease, cobalamin deficiency). Research is ongoing in
the search for biologic markers that may help differentiate between the large number of conditions that may progress
from MCI to full dementia.
Brain imaging with magnetic resonance imaging (MRI) or computed tomography (CT) is often performed in patients
with MCI. In general, MRI is preferred, as whole brain and hippocampal volume on MRI can predict progression from
[4]
MCI to Alzheimer disease (AD). However, there are no established parameters to integrate this finding into the
routine diagnosis and management of MCI. In addition, there is also some preliminary evidence for the use of
[5]
baseline FDG-PET of the brain in conjunction with episodic memory assessment to predict conversion to AD.
There are no stipulated neuropsychological tests for patients with MCI, nor are there predetermined cutoff points (eg,
1.0, 1.5, or 2 standard deviations below the mean). However, clinicians use the results from standardized memory
and cognitive tests to determine whether these data represent significant changes from a patients presumed
baseline. In general, serial testing is required to establish whether the patients cognitive function is improving,
staying stable, or progressing to full-blown clinical dementia.
Alzheimers Association recommendations
The Alzheimer's Association guidelines, including an algorithm, help clinicians in the primary care setting detect
cognitive impairment and determine whether referral or further testing is needed.
[6, 7]
following components
[6, 7]
The algorithm includes the
Review of patient health risk assessment (HRA) information

Patient observation
Use of unstructured queries
Use of structured cognitive assessment tools for patients and informants
[8, 9]
The following 3 cognitive assessment tools are recommended for routine use by primary care physicians
General Practitioner Assessment of Cognition (GPCOG)

Mini-Cog
Memory Impairment Screen (MIS)
Additionally, the Alzheimers Association recommends the following 3 cognitive assessment tools for use with the
[8, 9]
patient's spouse, family, or friends
Informant General Practitioner Assessment of Cognition (informant GPCOG)

AD 8-Question Screen (AD8)
Short Informant Questionnaire on Cognitive Decline in the Elderly (short IQCODE)
Management
Although no established treatment exists for MCI, donepezil delays the progression to AD in MCI patients with
depression without affecting their depressive symptoms, and some evidence suggests that cognitive interventions
[10]
may have a positive effect.
Cholinesterase inhibitors have not been found to delay the onset of AD or dementia in
[11]
MCI.
Identify and monitor patients with MCI, because of their increased risk for AD (and, to a lesser extent, other
dementing conditions). In addition, to the extent possible, correct any sensory and motor manifestations that
compound their cognitive symptoms.
Diet and activity may have some positive effects in patients with MCI. The risk of developing MCI is lower in
[12]
individuals who consume a Mediterranean diet,
and interactive, mentally challenging activities as well as

[13]
moderate exercise have the potential to be helpful in MCI.
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Overview
Various terms have been employed to characterize the cognitive decline associated with aging, including benign
[6, 7, 14]
senescent forgetfulness, age-associated memory impairment, and age-associated cognitive decline.

The term
mild cognitive impairment (MCI) is intended to represent an intermediate stage between normal aging and the
[7]
development of pathologic aging and dementia (eg, malignant senescent forgetfulness
).
Other terms with connotations similar to those of MCI include isolated memory impairment, incipient dementia, and
dementia prodrome. However, these terms are not nearly as widely accepted as MCI and should not be considered
exact synonyms.
Of the normal memory functions, some decline substantially with increasing age, and some do not. Memory
functions that remain relatively stable with increasing age include the following:
Semantic memory - Facts and general knowledge about the world; although this function generally remains
[15]
stable with age, especially if the information is used frequently,

names) typically declines
retrieval of highly specific information (eg,

[15]
Procedural memory Acquisition and later performance of cognitive and motor skills
Memory functions that decrease with age include the following:
Working memory - Holding and manipulating information in the mind, as when reorganizing a short list of
[15]
words into alphabetical order
; verbal and visuospatial working speed, memory, and learning, with

[16]
visuospatial cognition more affected by aging than verbal cognition

Episodic memory Personal events and experiences
[15]
[17]
Processing speed
Prospective memory The ability to remember to perform an action in the future (eg, remembering to fulfill an
[15]
appointment or take a medication

)
Ability to remember new text information, to make inferences about new text information, to access prior
knowledge in long-term memory, and to integrate prior knowledge with new text information
Recollection
[18]
[19]
To demonstrate that a patients cognitive function is worse than would normally be expected for his or her age,
neuropsychological testing is necessary so that the patients performance can be compared with that of an
age-matched (and, ideally, education-matched) control group.
Mild degrees of cognitive impairment, particularly when self-reported by patients, pose a substantial challenge to the
clinician. The physician may be dealing with a patient with a mild or transient condition, a drug-induced adverse
effect, or a depressive disorder; the patient may be in the early stages of a condition that will eventually lead to a
dementia; or the complaint may be due to a psychological condition rather than an organic brain disorder.
Because a variety of conditions may result in a complaint of cognitive impairment, an individualized workup for such
conditions and a consensus on a therapeutic approach should be sought. To date, no medications have been
approved by the US Food and Drug Administration (FDA) for the treatment of MCI.
For patient education resources, see the Dementia Center, as well as Possible Early Dementia.
Pathophysiology
In mild cognitive impairment (MCI), cognitive impairment exceeds the normal expected age-related changes, but
[3]
functional activities are largely preserved; thus, MCI does not meet the criteria for dementia. Different subtypes of
MCI are recognized. One common classification distinguishes between amnestic and nonamnestic forms of MCI.
Amnestic MCI, in which memory impairment predominates, is often a precursor of clinical Alzheimer disease (AD).
Nonamnestic forms of MCI are characterized by a variety of cognitive impairments, the most common of which is
probably impaired executive function. A substantial number of patients with MCI may be judged to have normal
cognition on follow-up visits.
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The pathophysiology of MCI is multifactorial. Most cases of amnestic MCI result from pathologic changes of AD that
have not yet become severe enough to cause clinical dementia.
[20]
At least in specialty research populations,

[21]
autopsies done on amnestic MCI patients have found the neuropathology to be typical of AD.
Nonamnestic MCI
may be associated with cerebrovascular disease, frontotemporal dementias (as a precursor), or no specific
pathology.
Etiology
Mild cognitive impairment (MCI) is heterogeneous both in its clinical manifestations and in its etiology. Given that
amnestic MCI often results from Alzheimer disease (AD) pathology, it is not surprising that most patients with
amnestic MCI progress to clinical AD within 6 years. Nonamnestic forms of MCI may be due to cerebrovascular
disease, Lewy body dementia, Parkinson disease, frontotemporal dementias, atypical Alzheimer disease, or no
specific underlying pathology.
Mood disorders, medical illness, and medications may affect cognition in such a way that a patient will meet criteria
for MCI (usually nonamnestic MCI). Many such patients have normal neuropsychological test results when
reevaluated a year later.
Epidemiology
Annual prevalence estimates for mild cognitive impairment (MCI) in the United States range from 3% to 4% in the
[22]
eighth decade
in the general population. Among community-dwelling African Americans, the estimated prevalence
is 19.2% for those aged 65-74 years, 27.6% for those aged 75-84 years, and 38% for those aged 85 years and
[23]
older.
The prevalence of mild cognitive impairment increases with age. The prevalence is 10% in those aged 70-79 years
[24]
and 25% in those aged 80-89 years.

Many studies indicate that the risk of Alzheimer disease (AD) is significantly
higher in women than in men, and it is therefore presumed that the likelihood of developing MCI is greater in women
than in men. Virtually nothing is known about cultural and racial factors influencing the clinical manifestations of MCI.
Clinical Presentation
Patient history
Patients with mild cognitive impairment (MCI) often present with vague and subjective symptoms of declining
cognitive performance, which may be difficult to distinguish from the typical performance decline in healthy older
individuals. The most common symptom is said to be memory loss, in keeping with the prevalent view that amnestic
MCI is the most common type. However, some authorities affirm that the most common form of MCI affects multiple
spheres of cognition.
Less common presentations of MCI include language disturbance (eg, difficulty in finding words), attention deficit
(eg, difficulty in following or focusing on conversations), and deterioration in visuospatial skills (eg, disorientation in
familiar surroundings in the absence of motor and sensory conditions that would account for the complaint).
Dissociating purely cognitive symptoms from those attributable to various degrees of sensory deprivation (eg,
hearing loss or loss of visual acuity) that tend to coexist in the same patient population is often difficult and may be
compounded by motor deficits that also beset the same individuals.
In any case, the defining element of MCI, as postulated by Petersen, is a single sphere of slowly progressive
cognitive impairment that is not attributable to motor or sensory deficits and to which other areas of involvement may
eventually be added, before social or occupational impairment supervenes (because this occurrence marks the
[3]
onset of dementia). Virtually nothing is known about the average duration of these manifestations before they are
brought to medical attention (if they ever are).
Clinicians should rely on their own judgment in deciding when safety-related questions that are appropriate for
patients with dementiafor example, about weapons, driving, and possible home fires involving cigarettes, stoves,
or fireplacesshould also be asked of patients with MCI.
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Physical examination
No feature of the general physical examination is characteristic of MCI. Nevertheless, a thorough physical
examination should be performed as part of the general evaluation in an effort to determine whether any conditions
capable of causing MCI (eg, thyroid disease, cobalamin deficiency, or venereal disease) are present and whether
there are any sensory and motor deficits that could explain or compound the symptoms. Mental status examination is
also important for documenting the degree of cognitive dysfunction.
Differential Diagnosis
Mild cognitive impairment (MCI) may result from virtually any disorder that causes brain dysfunction. Common
causes include the following:
Alzheimer disease (AD)
Cerebrovascular disease
Parkinson disease
Frontotemporal degenerations
Thyroid disease
HIV infection
Depression
[25]
Metabolic and endocrine disease

Adverse central nervous system effects of drugs and toxicants
Cerebral infection
Traumatic brain injury
Cognitive adverse effects of sleep disorders
Cobalamin deficiency
Chronic psychological stress
According to an analysis of 5150 patients aged 65 years or older from the Cardiovascular Health Study, patients with
atrial fibrillation (AF) reach clinical thresholds for cognitive impairment and dementia at an earlier age than patients
without AF, even in the absence of clinical stroke.
[26, 27]
Depressive disorders are particularly prevalent in older adults (approximately 15%), who frequently exhibit vague
somatic symptoms and anxiety and report inability to concentrate and poor memory. These patients typically deny a
sad mood but often admit to sleep symptoms, lack of interest in things they used to enjoy, loss of appetite, and lack
of motivation. Depression may certainly be accompanied by cognitive dysfunction that abates with successful
treatment of the depression.
The association between depression and AD and other dementias is likely to be complex, and depression may be
misdiagnosed in the realm of dementia. Framingham data have helped bolster the epidemiologic association,
[28]
documenting a 50% increase in AD and dementia in those who were depressed at baseline.
During a 17-year
follow-up period, a total of 21.6% of participants who were depressed at baseline developed dementia, compared
with 16.6% of those who were not depressed.
In another related study, recurrent depression was noted to be particularly pernicious: having 1 depression episode
conferred an 87-92% increase in dementia risk, whereas having 2 or more episodes nearly doubled the dementia
[29]
risk (but did not increase the risk of incident MCI).
Laboratory Studies
No specific laboratory studies are indicated for mild cognitive impairment (MCI). Most practitioners perform at least a
basic workup to rule out treatable conditions that may cause dementia, such as thyroid disease and cobalamin
deficiency. These assessments are not mandatory, however.
A search for biologic markers of MCI that may help distinguish among the many conditions that lead from MCI to
full-blown dementia is ongoing. As yet, however, no unanimous agreement has been reached, and potentially useful
markers, such as functional and structural abnormalities found on imaging studies (eg, hippocampal atrophy and
cerebral hypoperfusion) and putative biochemical markers (eg, apolipoprotein E epsilon 4 allele), remain
controversial.
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Imaging Studies
No specific laboratory studies are indicated for mild cognitive impairment (MCI). Most practitioners perform at least a
basic workup to rule out treatable conditions that may cause dementia, such as thyroid disease and cobalamin
deficiency. These assessments are not mandatory, however.
A search for biologic markers of MCI that may help distinguish among the many conditions that lead from MCI to
full-blown dementia is ongoing. As yet, however, no unanimous agreement has been reached, and potentially useful
markers, such as functional and structural abnormalities found on imaging studies (eg, hippocampal atrophy and
cerebral hypoperfusion) and putative biochemical markers (eg, apolipoprotein E epsilon 4 allele), remain
controversial.
Neuropsychological Testing
Neuropsychological testing is required in instances of mild cognitive impairment (MCI) to demonstrate that the
patient is below some cutoff point on standardized memory tests (as well as other cognitive tests). However, the
exact cutoff point (be it 1.0, 1.5, or 2 standard deviations below the mean) and the particular neuropsychological
tests to be used are not stipulated.
Because few MCI patients have undergone baseline testing on these measures before the onset of the impairment,
the clinician will have to determine whether a particular score represents a significant change from a patients
presumed baseline. Such determinations are inexact, and serial testing eventually will be needed to establish
whether the patients cognitive function is improving, staying stable, or progressing to full-blown clinical dementia.
The Alzheimer's Association released guidelines, including an algorithm, to help clinicians in the primary care setting
[5]
detect cognitive impairment and determine whether referral or further testing is needed.
[4, 5]
following components
The algorithm includes the
Review of patient health risk assessment (HRA) information

Patient observation
Use of unstructured queries
Use of structured cognitive assessment tools for patients and informants
[7]
The following 3 cognitive assessment tools are recommended for routine use by primary care physicians
General Practitioner Assessment of Cognition (GPCOG)

Mini-Cog
Memory Impairment Screen (MIS)
Additionally, the Alzheimers Association recommends the following 3 cognitive assessment tools for use with the
[6, 7]
patient's spouse, family, or friends
Informant General Practitioner Assessment of Cognition (informant GPCOG)

AD 8-Question Screen (AD8)
Short Informant Questionnaire on Cognitive Decline in the Elderly (short IQCODE)
Treatment & Management

Medical care
At present, no established treatment exists for mild cognitive impairment (MCI). Cholinesterase inhibitors have not
been found to delay the onset of Alzheimer disease (AD) or dementia in individuals with MCI; however, donepezil
has been found to delay the progression to AD in MCI patients with depression without affecting their symptoms of
[11]
depression.
[10]
There is some evidence to suggest that cognitive interventions may have a positive effect.
A practice parameter recommendation by the American Academy of Neurology states that patients with MCI should
be identified and monitored because of their increased risk for AD and, to a lesser extent, other dementing
conditions. Obviously, correcting (to the extent possible) any sensory and motor manifestations compounding the
cognitive symptoms is important for minimizing their impact on MCI.
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Particular attention should be given to the need to make a legal statement about the competency of patients to
handle their own affairs. Because patients with MCI are by definition not demented, they usually do not need to
assign power of attorney to anyone elseunlike patients with AD, who eventually will need such help.
The results of a study that included 361 subjects with AD, vascular dementia, or mixed dementias suggested that
centrally acting angiotensin-converting enzyme inhibitors (CACE-Is) may reduce the rate of cognitive decline in
[30, 31]
patients with dementia, regardless of blood pressure levels at the time of their hypertension diagnosis.
of cognitive change was slowed in the first 6 months after dementia patients started taking these drugs.
The rate
Diet
Roberts et al found that the risk of developing MCI is lower in individuals who consume a Mediterranean diet, which
is high in vegetables and unsaturated fats.
[12]
A randomized, double-blind, placebo-controlled trial involving 25 elderly subjects with MCI determined that dietary
supplementation with an oily emulsion of docosahexaenoic acid (DHA)-phospholipids containing melatonin and
tryptophan yielded significant improvements in several measures of cognitive function as compared with
[32]
supplementation with the placebo.
Activity
Because physical, social, and mental activity are often recommended for patients with AD and because MCI often
heralds AD, many experts have suggested that mentally challenging activities (eg, crossword puzzles and brain
teasers) may be helpful for patients with MCI. Although there is no definitive proof that these exercises are
efficacious, recommending them to patients with MCI seems advisable.
Such exercises should be kept to a level of difficulty that is reasonable for the patient. Ideally, they should be
interactive rather than passive, and they should be administered in a fashion that does not cause excessive
frustration. If an activity is not enjoyable or stimulating for the patient, it is unlikely to offer much cognitive benefit. In
such cases, searching for other similar cognitive activities may be beneficial.
Social isolation can be minimized through referral to senior community centers or a day treatment program.
Cognitive retraining and rehabilitative strategies offer considerable promise in MCI
explored.
[33]
and are therefore being
A growing body of evidence suggests that physical activity and exercise are beneficial for brain health. A prospective
study suggested that engaging in moderate exercise of any frequency in midlife or late life was associated with
[13]
reduced odds of having MCI.
Prognosis
Many patients with mild cognitive impairment (MCI) eventually experience progressive deterioration in their abilities
to perform activities of daily living, cognition, and behavior.
Subtypes of MCI progress to Alzheimer disease (AD) at different rates. A study by Rountree et al showed that the
conversion rate to AD was 56% for amnestic MCI, 50% for amnestic-subthreshold MCI, and 52% for nonamnestic
[34]
MCI.
For all MCI subtypes, the 4-year conversion rate to dementia was 56% (14% annually), and that to
Alzheimer disease was 46% (11% annually).In comparison, healthy elderly individuals develop AD at a rate of 1-2%
per year.
Boyle et al reported that patients with MCI are almost 7 times more likely to develop AD than are older individuals
[35]
without cognitive impairment.

Of patients with MCI, 80% are said to progress to dementia after approximately 6
years. This is a significant finding, given that AD is often cited as the fourth leading cause of death in the United
States.
At least one well-designed study has shown MCI, as identified by the Short Portable Mental Status Questionnaire, to
[36]
be an independent predictor of mortality.

Wilson et al reported that in both African American and white patients,
the risk of death was increased by about 50% among individuals with MCI and was nearly 3 times higher among
[37]
those with AD.
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Ultimately, long-term follow-up and eventual autopsy are necessary to distinguish between patients experiencing
MCI due to preclinical AD and patients experiencing MCI due to less frequently occurring conditions. However, there
are some factors that can be helpful in predicting the likelihood of progression.
The severity of memory impairment is predictive of progression to AD: patients with more severe memory impairment
are more likely to progress. Whole brain and hippocampal volume on magnetic resonance imaging (MRI) has been
[4]
shown to predict progression from MCI to AD,

not recommended for routine clinical use.
[38]
as has apolipoprotein E (ApoE) status
; however, ApoE testing is
Contributor Information and Disclosures

Author
Heather S Anderson, MD Associate Professor, Staff Neurologist, Department of Neurology, University of Kansas
Alzheimer's Disease Center
Heather S Anderson, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.
Chief Editor
Michael Hoffmann, MBBCh, MD, FCP(SA), FAAN, FAHA Professor of Neurology, University of Central Florida
College of Medicine; Director of Cognitive Neurology, Director of Stroke Program, James A Haley Veterans Affairs
Hospital
Michael Hoffmann, MBBCh, MD, FCP(SA), FAAN, FAHA is a member of the following medical societies:
11/26/2013 8:36 PM
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American Academy of Neurology, American Headache Society, American Heart Association, and American
Society of Neuroimaging
Additional Contributors
Richard J Caselli, MD Professor, Department of Neurology, Mayo Medical School, Rochester, MN; Chair,
Department of Neurology, Mayo Clinic of Scottsdale
Richard J Caselli, MD is a member of the following medical societies: American Academy of Neurology, American
Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, American
Neurological Association, and Sigma Xi
Joseph Quinn, MD Assistant Professor, Department of Neurology, Portland VA Medical Center, Oregon Health
Sciences University
Joseph Quinn, MD is a member of the following medical societies: American Academy of Neurology, Society for
Neuroscience, and Society for Pediatric Radiology
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College
of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
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