At Risk of Dementia:
Mild Cognitive Impairment
and Other Non-Dementia Diagnoses
Declaration of Interests
NHS:
GP East Surrey
SCN SE Coast Clinical Lead Dementia
Honorary Research Fellow Wolfson Institute King’s College London
Co-developer of MoodHive (Depression Anxiety Pathway) Royal College of General Practitioners
Clinical Champion Dementia
Chair Learning Disability Special Interest Group
Member Dementia Roadmap Steering group
Consultancy / Advisory Boards / Speakers Bureau:
Alzheimer’s Society, Cerestim Ltd, Chase Pharmaceuticals, Edmund de Rothschild, Eli Lilly, Ono, Otsuka, Pfizer, Roche, Servier, Wellcome Trust
At Risk of Dementia: Questions ?
What percentage of people who are referred to a Memory assessment service are NOT given a dementia diagnosis?
What diagnoses are they given?
How should people who are identified as being “at risk of dementia be
Managed ?
Reviewed ?
Supported ?
Diagnosing Dementia
Dementia is a clinical diagnosis that should consider all available information :
Degree of functional impairment
Neuropsychological profile
Neuroimaging findings
Cognitive Impairment: Contributions –
Not all Dementia
Cognitive Impairment Age Depression Dementia Cerebro Vascular disease Medications Physical Illness
Risk Factors for Dementia
Age: ↑ risk with advanced age.
Alcohol use: drinking large amounts of alcohol ↑ risk
Moderate alcohol may be protective Atherosclerosis:
Lipids and cholesterol + inflammatory process
↑ low-density lipoprotein (LDL) ↑ risk for vascular dementia & Alz Dis Diabetes general ↑ risk for dementia
Well-proven risk factor for stroke, CV events, ↑ risk vascular dementia Hypertension
linked to cognitive decline, stroke, and types of dementia that affect the white matter regions of the brain.
Mental illness. Depression has been associated with mild mental impairment and cognitive function decline.
Mild Cognitive Impairment
Cognitive decline is a common and feared aspect of aging.
Mild cognitive impairment (MCI) is defined as the
symptomatic pre- dementia stage on the continuum of
cognitive decline, characterized by objective impairment in cognition that is not severe enough to require help with usual activities of daily living
Mild Cognitive Impairment (MCI)
Marks a transitional stage between healthy aging and dementia, BUT the understanding of MCI in the general population is limited
Is not a unified disease but heterogeneous disorder with subtypes yet to be fully defined.
Can no longer be assumed to always be a simple
transitional state between normal aging and dementia.
Some underlying causes such as psychiatric disorders remain poorly described but are likely to have a distinct phenomenology and course.
Mild Cognitive Impairment
Subtypes1:
Amnestic (aMCI), non-amnestic (nmMCI), multi-domain (mMCI)
Simplified Consensus Criteria2
Moderate cognitive deficits, short of dementia
Self-reported and ⁄ or informant reported cognitive complaints
Impairment on objective clinical cognitive tests
Preserved basic activities of daily living & minimal impairment in complex instrumental functions
Refs: 1. Petersen, J Intern Med 2004; 2. Mitchell Acta Psychiatr Scand 2009 adapted from Winbald 2004 and Porter 2006
Rotterdam Study
Investigated determinants, MRI-correlates, and prognosis of MCI within the population-based Rotterdam Study
Apo E4 status, waist circumference, hypertension, diabetes mellitus, total and HDL-cholesterol levels, smoking, stroke
4,198 participants were compared at baseline and 7 yrs prior to baseline
Followed for 7 to 12 years
Results (baseline)
Of 4,198 participants, 417 had MCI
163 amnestic, 254 non-amnestic MCI
Older age, ApoE4 status, lower total cholesterol levels, and stroke were associated with MCI
HDL-cholesterol levels and smoking were related to MCI when assessed 7 years prior to baseline
Rotterdam Study
Results baseline MCI subset
MCI (especially non-amnestic MCI) compared with cognitively healthy had specific MRI correlates of cerebrovascular disease :
Larger white matter lesion volumes
Higher prevalence of lacunes,
MCI was associated with:
a four fold ↑ risk of dementia
HR 3.98, 95%; CI 2.97;5.33, Alz dis (HR 4.03, 95% CI 2.92;5.56)
↑ mortality HR 1.54, 95% CI 1.28;1.85).
Mild Cognitive Impairment: Findings
The prevalence of MCI in adults aged ≥ 65 years:
Is 10% to 20%
Risk increases with age
Men appear to be at higher risk than women.
In older patients with MCI, clinicians should consider factors that ↑ risk for cognitive impairment and other negative outcomes:
Depression
Polypharmacy
Uncontrolled cardiovascular risk factors
Mild Cognitive Impairment: Findings
Currently, no medications have proved effective for MCI;
Treatments and interventions should be aimed at:
↓ cardiovascular risk factors and prevention of stroke.
Aerobic exercise, mental activity, and social engagement may help ↓ risk of further cognitive decline.
Although patients with MCI are at ↑ risk for developing dementia there is currently substantial variation in risk estimates depending on the population studied.
from <5% to 20% annual conversion rates
Current research targets improving early detection and treatment of MCI, particularly in patients at high risk for progression to dementia.
Subjective Memory Complaints (SMCs)
Are much more common in later life than the objective problems that suggest minor cognitive impairment or dementia
Not a characteristic of the “worried well”, should be taken seriously
Associated with depression, older age, female sex, low educational attainment
Depression is itself a risk factor for dementia, making the diagnostic task even more difficult
A poor predictor of dementia syndrome by themselves When deciding whether to refer to specialist services,
practitioners need to rely on rules of thumb to evaluate the extent and possible significance of symptoms or subjective memory loss
Diagnosing Dementia: MCI and / or SMC
The key feature that differentiates people with SMC and MCI from those with dementia is the lack of association of the memory complaint with functional impairment
Therefore, it seems appropriate that the review of people with SMC and MCI both at the first presentation at a MAS and subsequently either in primary care of in the MAS should include both a cognitive and a functional
MIMIC: Mnemonic for Characterisation of
Patients with Memory Problems
Memory loss
What Type?
Informant history:
Use GPCog OR global assessment of early dementia
Mood:
Depressed mood, now or in the past; PHQ-9 score
Individual:
Age, sex, education, other long term
Psychological problems (anxiety, personality type)
Cognitive function test results:
6CIT, GPCog
Characterisation of Memory Impairments
Episodic memory - memory of specific past events that involved the person;
forgetting a wedding anniversary is qualitatively different from forgetting that you are married.
Semantic memory - the store of facts and general knowledge:
e.g., knowing the answer to the question “who is the monarch?” Implicit memory - the non-conscious part of memory that uses
past experience to shape current behaviour.
Inhibitions may be lost and much offence caused by someone whose manners and social behaviour had been impeccable
Executive functioning - the forms of thinking necessary for goal directed behaviour.
Anticipation of / adaptability to new situations are reduced
Thinking becomes concrete rather than conceptual and abstract.
E.g., driving on an unfamiliar route becomes problematic, proverbs lose their meaning Ref :
Recommendations: Assessment of MCI:
Clinical Dementia Rating Scale
Early Dementia: Global assessment of
Behaviour and Function
The patient is impaired by their loss of memory for recent events
They may forget that they have already collected their repeat prescription and argue with the receptionist about it)
Some variable disorientation occurs in time and place, but not in relation to people
Gets lost easily; turns up for an appointment days late or early Some difficulty with complex problems:
Understanding what a letter / form is telling / requiring them to do Engagement in some social activities:
The individual may appear normal because they retain the ability to conduct “small talk”; cannot sustain a serious conversation
More difficult tasks and hobbies are abandoned:
Bills go unpaid, the garden is neglected
Some prompting needed for personal care:
Clothes are not washed, baths are missed
Brief Dementia Screening Indicator
for Primary Care
Recommendations: Management of MCI
Communication to Primary care about the outcome of referrals to a MAS should include:
For people with dementia:
Dementia subtype diagnostic code (READ / CTV)
Advice about follow-up, treatment (including involvement in post-diagnosis group interventions) and whether referred to local dementia support/adviser service.
For people with SMC or MCI
Diagnostic code
Risk categorization for conversion
Guidance about longitudinal assessment of cognition and function
Advice about non-pharmacological interventions and lifestyle
For Atypical cases:
Recommendations: Management of MCI
MAS should ensure:
Concordance between staff for cognitive and functional assessments
All relevant data are considered when making a diagnosis
Either review non-dementia diagnoses regularly or hold a “team meeting” to agree classification of SMC / MCI and risk for conversion
Provide data about the outcome of referrals that includes percentages of dementia, SMC and MCI diagnoses
Publish / Document specific criteria used for MCI diagnosis used in their MAS
Recommendations: Management of SMC /
MCI and Atypical Presentations
Commissioners need to ensure that pathways and service specifications for the evaluation of people with cognitive impairment include provision for:
Atypical cases that are likely to require:
Sub-specialist or neurologist review
Specialist investigations
o Additional structural imaging (CT or MRI), HMPAO-SPECT,
18-FDG-PET, Dopamine Transporter (DAT) scan, amyloid PET for younger individuals according to agreed pathway
o Cerebrospinal fluid evaluation
Pathway for review of people with SMC / MCI
Evidence-based non-pharmacological interventions for SMC and MCI
Recommendations: Review MCI
Review of people with MCI both at the first presentation at a MAS and subsequently either in primary care OR in the
MAS should include both a Cognitive and Functional
assessment
Review period determined by “Risk for Conversion”:
6 mth high risk
12 mths low risk
Refer for a further dementia assessment if there is cognitive impairment AND a decline in function
ONE point on the GP-Cog
Recommendations: Review MCI
Classify patients according to their individual “Risk” for conversion to dementia.
Age
Metabolic and vascular risk factors
Specific MRI correlates of cerebrovascular disease
ApoE status (usually research at present)
Future:
Other biomarkers e.g inflammation
Longitudinal follow-up on MRI, neuropsychology
Recommendations:
Key Points – Mild Cognitive Impairment
Heterogeneous group of pts BUT important to recognise / document in a formal way as has implications for:
QoL, mortality, ↑ risk for dementia
Current evidence supports the following interventions:
Aerobic Exercise, Mental activity, CV risk factor control What is good for the Heart if good for the Brain
Need a process for categorisation of important subgroups of MCI:
Depression, high risk of conversion to dementia
Definition of review process
Assessment of MCI – cognition & function
Responsibility for review – Primary / Secondary care
