2. Learning Objectives
• Understand various definitions of MCI
• Learn about clinical presentations
• Consider various investigations
• Learn About Predictors of MCI
• Understand current treatment options
• Discuss future of the concept of MCI
3. MCI
• It’s a clinically relevant concept
• The concept is continuing to evolve
• We can use some reliable criteria
• The main focus is on prediction of outcome
and conversion
• NOT NORMAL, NOT DEMENTED and
• can we Treat????
4. History
• 1962 - benign senescent forgetfulness”
• 1986 - age-associated memory impairment”
(AAMI)
• age-associated cognitive decline by IAGP
• Late 80s Reisberg et al Mild Cognitive
Impairment
6. CASE EXAMPLE
JOHN – 75 Retired Teacher
• Forgetful
• Gets frustrated when
dealing with various bills
• Enjoys Bridge
• Independent in all ADL skills
• Wife does not see this as a
problem
• John is worried if he is
developing AD
TOM – 78 Retired Bus Driver
• Forgetful
• Threads of conversation
and telephone messages
• Looks after grand children
collects them from school
• President of local club
organises events etc
• Daughters are worried
about his memory he is not
specifically concerned
8. Concern regarding a change in
cognition
• There should be evidence of concern about a
change in cognition, in comparison with the
person’s previous level.
• This concern can be obtained from the
patient, from an informant who knows the
patient well, or from a skilled clinician
observing the patient.
9. Impairment in one or more cognitive
domains
• There should be evidence of lower
performance in one or more cognitive
domains that is greater than would be
expected for the patient’s age and educational
background.
10. Preservation of independence in
functional abilities
• Persons with MCI commonly have mild problems
performing complex functional tasks which they
used to perform previously, such as paying bills,
preparing a meal, or shopping
• They may take more time, be less efficient, and
make more errors at performing such activities
than in the past.
• Nevertheless, they generally maintain their
independence of function in daily life, with
minimal aids or assistance.
11. Not demented
• These cognitive changes should be sufficiently
mild that there is no evidence of a significant
impairment in social or occupational
functioning
12. Etiology
• There is heterogeneity in Presentation and
possibility of multiple etiologies
• The predicted outcome of MCI can have a link
to the etiology in a particular presentation
13. Mild cognitive impairment – beyond controversies, towards a consensus: report of the International
Working Group on Mild Cognitive Impairment
Journal of Internal Medicine
Volume 256, Issue 3, pages 240-246, 20 AUG 2004 DOI: 10.1111/j.1365-2796.2004.01380.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2004.01380.x/full#f1
14. Pathophysiology
• In autopsy of MCI
– Amnestic MCI – Similar changes like AD
– Non Amnestic – CVD, FTD or no pathology
• Lab Studies
– Biomarkers as Apolipoprotein E ????
• Neuroimaging
– Hippocampal atrophy???
– Hypoperfusion on functional imaging???
15. Baseline Tests
• Neuropsychological Assessment – Baseline
– Below normal cut off (1,1.5,2 SD is debatable)
• Neuroimaging
– No Specific Predictive Parameters
– Some evidence that whole hippocampal volume
on MRI predicting progression of MCI to AD
(Risacher et al)
– PET imaging + episodic memory impairment may
predict conversion (Landau SM et al)
16. CASE EXAMPLE
JOHN – 75 Retired Teacher
• Hypertensive on treatment
had MI 8 years ago
• MMSE 27/30
• CT Scan Normal
• SPECT – Mild temporal
hypoperfusion on the left
TOM – 78 Retired Bus Driver
• Not on any regular
medication apart from
painkiller for arthritis as
required
• MMSE 28/30
• CT – Age related
involutional change
• SPECT – Normal
17. Treatment
• Currently no established drug treatment
available
• Trials have proven negative in use of Choline
esterase inhibitors
• Diet: Vascular risk factors
• Activity: Physical exercise and social
stimulation
No evidence for cognitive exercise puzzles etc
20. Prognosis
• Many patients with MCI eventually progress
to AD
• Research quotes variable figures on rates of
conversion ( average of 15% annually)
• Patients with MCI 7 times more likely to
develop AD
• 80% of patients diagnosed with MCI are said
to progress to AD by 6 years (Boyle et al)
21. Prognosis - Predictors
• Severity of Memory Impairment
• Whole Brain and Hippocampal volume on MRI
• ApoE Status (Not recommended for routine
clinical use)
22. CASE EXAMPLE after 18 months
JOHN – 75 Retired Teacher
• More forgetful now unable
to do banking
• Not able to go to unfamiliar
places
• Difficulty in playing bridge
• CT medial temporal atrophy
bilaterally
• MMSE 23/30
TOM – 78 Retired Bus Driver
• Remains forgetful
• No major changes
• Still drives no concerns
• Had a DVLA assessment and
passed
• MMSE 25/30
• Daughter continues to
express concerns
23. Conclusion
• MCI is becoming an increasingly important
clinical entity
• The focus remains on amnestic MCI which
may be a prodrome/precursor of AD
• NOT NORMAL, NOT DEMENTED
• Will Need Monitoring
• No current evidence of specific treatment
24. References
• Risacher SL, Saykin AJ, West JD, Shen L, Firpi HA, McDonald BC;
Alzheimer's Disease Neuroimaging Initiative (ADNI). Baseline MRI
predictors of conversion from MCI to probable AD in the ADNI
cohort.Current Alzheimer Research. Aug 2009;6(4):347-61.
• Landau SM, Harvey D, Madison CM, Reiman EM, Foster NL, Aisen PS.
Comparing predictors of conversion and decline in mild cognitive
impairment. Neurology. Jul 20 2010;75(3):230-8.
• Boyle PA, Wilson RS, Aggarwal NT, et al. Mild cognitive impairment: risk
of Alzheimer disease and rate of cognitive decline. Neurology. Aug 8
2006;67(3):44
