MCI REVIEW 2013

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MILD COGNITIVE IMPAIRMENT

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  • refer to multiple cognitive domains presumed to decline in normal ageing
  • “ Subjective and objective”
    “Consistent and Converging”
    Threshold for functional disability and social impairment
    Confounding disorders delirium, depression, intercurrent medical illnesses
    Thresholds of raters, centers, countries
  • Let’s review the important points from today’s discussion.
    Dementia is progressive, but with adequate and timely treatment it can be slowed, if not completely reversed.
    Alzheimer’s disease, the most common cause of dementia, can now be diagnosed by healthcare providers with 80% to 90% accuracy using a battery of evaluations and tests.
    The current quality of life of the affected individual can be maintained by incorporating treatment and certain behavioral changes into everyday life.
    Remember that as a caregiver, you are not alone. Caregiver support is widely available from support groups and educational programs.
  • Let’s review the important points from today’s discussion.
    Dementia is progressive, but with adequate and timely treatment it can be slowed, if not completely reversed.
    Alzheimer’s disease, the most common cause of dementia, can now be diagnosed by healthcare providers with 80% to 90% accuracy using a battery of evaluations and tests.
    The current quality of life of the affected individual can be maintained by incorporating treatment and certain behavioral changes into everyday life.
    Remember that as a caregiver, you are not alone. Caregiver support is widely available from support groups and educational programs.
  • MCI REVIEW 2013

    1. 1. Mild cognitive impairment [MCI] Prof Ashr af A bdou Neuropsychiatry dept Alexandria univ
    2. 2. Objectives • The concept of MCI • Criteria for diagnosis • Controversies about MCI • Prevalence of MCI • Outcome of MCI • Trials for treatment of MCI
    3. 3. Cogntive abilities and age Cognition: means of acquiring and processing information about our selves and our world Includes memory and other functions Cognitive abilities peak in 30s Plateau through 50s, 60s Slow decline late 70s
    4. 4. Dementia Memory deficit + At least 1 other cognitive area affected + Interfere with daily activity
    5. 5. Mrs Um Alsaad a 60-yrs old lady, housewife describing her cognitive health as good till 2 yrs ago she and her children noticed her difficulty recalling where she place objects, her forgetfulness about recent conversations and difficult in remembering names. She can do all her duties outside and inside the home. Her MMSE 27
    6. 6. Development of the concept of MCI • Kral 1962; Benign senescent forgetfulness. • NIMH 1986; Age-associated memory impairment (AAMI) • Int Psychogeriatric association 1994; Age-associated cognitive decline (AACD) • CSHA 1997; Cognitive impairment nodementia (CIND) • AAN 2001; Mild cognitive impairment (MCI)
    7. 7. 13000 publications till now in pubmed
    8. 8. MCI is Prodromal Dementia Normal Cognition Dementia Reversible Prodromal Dementia Brain Aging Mild Cognitive Impairment Stable Or Reversible Impairment Alzheimer’s Disease Other Dementias Mixed Vascular Dementia Mixed
    9. 9. MCI criteria 1. Memory complaint, preferably corroborated by an informant 2. Objective memory impairment for age 3. Normal general cognitive function 4. Intact activity of daily living 5. Not demented
    10. 10. Application of MCI criteria First criteria refers to the subjective memory complaint. What if the patient didn’t complaint?
    11. 11. Application of MCI criteria Second criteria refers to an objective memory impairment for age. –score 1-2 SD below their agemates MMSE low sensitivity for MCI Montreal cognitive assessment [MoCA] http://www.Mocates t.org
    12. 12. Application of MCI criteria general intellectual function. • Third criteria regarding - General intellectual function (other nonmemory cognitive domains, e.g. language, executive function, visuospatial skills ) - no specific instruments or cutoff scores - Neuropsychological testing can be very useful
    13. 13. Application of MCI criteria • Fourth: Activities of daily living The criterion requires that the No functional impairment can be difficult to determine in older sub jects who may have several medi cal comorbidities and physical li mitations. • Last criteria, 'not demented', is also made on the basis of the clin ician's best judgement.
    14. 14. Prevalence Prevalence of mild cognitive impairment vary from 1% to 34% •Increase with age •Different assessment tools
    15. 15. Prevalence of MCI Author (year) Graham (1997) N 1800 Age Study Prevalence (%) >65 CSHA 5.3 Larrieu (2002) 1265 70-90 PAQUID 2.8 Hanninen (2002) 806 60-76 KUPIO 5.3 Lopez (2003) 2470 >75 CHS 6.0 Fisk (2003) 1790 >65 CSHA 1-3 Ganguli (2004) 1248 >65 MoVIES 3-4
    16. 16. Clinical Spectrum • Typical MCI patient is one who has a memory impairment beyond what is felt to be normal for age but is relatively intact in other cognitive domains. • The concept of MCI has been expanded to include other types of cognitive impairment beyond memory
    17. 17. Classification of MCI MCI Amnestic Single domain Multiple domain Non-amnestic Single domain Multiple domain
    18. 18. Clinical subtypes of mild cognitive impairment
    19. 19. Flow chart of decision process for making diagnosis of subtypes of MCI   Journal of Internal Medicine Vol 256 Issue 3 Page 183, Sep2004
    20. 20. Exclusion of systemic or brain diseases that can cause cognitive decline  Depression - Memory function may improve with treatment of depression  Metabolic disturbance - Memory function may improve if corrected  Traumatic injury - Memory function often stabilizes after a period of recovery  Vascular disease - Memory function may stabilize or progress
    21. 21. Cognitive Decline Outcome of MCI MCI AD Age
    22. 22. Outcome The annual rate of conversion to AD 10 – 15% per year
    23. 23. Conversion to AD Normal MCI Amnestic Type Function Point of conversion Probable AD Definite AD Age
    24. 24. Outcome Mayo Alzheimer's Disease Research Center - 220, mean age 79 yrs, F/U 3-6 yrs - Progressed from normal to dementia at a rate of 12% per year • Followed for up to 6 years approximately 80% of them will have converted to dementia
    25. 25. Mild Cognitive Impairment (MCI) MCI →AD 12%/yr Control→AD 1-2%/yr 100 100 90 90 80 80 70 70 60 60 50 50 Initial exam 12 24 36 Months 48 Initial exam 12 24 36 Months 48 Petersen RC et al: Arch Neurol 56:303-308, 1999
    26. 26. Outcome Clinical severity Type; multiple domain vs single domain Genetics: Apolipoprtein E-4 carrier Biomarkers Radiological CSF
    27. 27. Neuroimaging Essential part of general evaluation in MCI subject - Identifying specific and treatable cause of cognitive impairment (DDx) - Markers for prediction of conversion to AD
    28. 28. Neuroimaging Predict future development of AD - Atrophy Hippocampus & entorhinal cortex ( MRI ) - Evidence deficits in - regional cerebral blood flow as measured by SPECT - regional cerebral glucose as measured by FDG-PET
    29. 29. Arrow highlights the body of the hippocampus. Image on right is from a patient with atrophy.
    30. 30. Arrows mark the entorhinal cortex on MRI.
    31. 31. (CSF) biomarkers • Invasive procedure • Lack of normative data no change of these CSF markers with age • Effect of drugs on change in CSF markers
    32. 32. (CSF) biomarkers 3 cerebrospinal fluid (CSF) biomarkers - total-tau (T- ) - phospho-tau (P- ) - 42 amino acid form of βamyloid (Aβ42)
    33. 33. TREATMENT
    34. 34. Treatment • Dopenzil-Vit E-Placebo study 2005 • Galantamine trial; 2004 • Rivastigmine trial; 2004 • Rofecoxib trial; 2005 • Ginko biloba; 2008 • Folic acid vitamin B12 trial; 2004 • Lithium; some benefit 2011 Fail to show any benefit
    35. 35. What to do? • Exercise • Healthy food • Cognitive stimulating activities • Stop smoking • Control; DM, HTN, Dyslipedemia • Treat depression
    36. 36. Tying it all together!  MCI is a widely accepted term for diagnosis of memory impairment not fulfilling the criteria of dementia  Diagnostic criteria need to be standardized, to include it in the current classifications.
    37. 37. Tying it all together!  Biomarkers are the main focus of research now  Current treatment options are control of risk factors and healthy lifestyle

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