Psych · Consultation-liaison psychiatry
Mild cognitive impairment
Also known as MCI · Mild neurocognitive disorder · Mild NCD · Cognitive impairment no dementia · Amnestic MCI
Exam-exhaustive fellowship topic on mild cognitive impairment and mild neurocognitive disorder — Petersen/Winblad criteria, DSM-5-TR mild NCD, amnestic vs non-amnestic subtypes, conversion risk and reversion, MoCA vs MMSE, work-up for reversible causes, differential from ageing/depression/major NCD/delirium, lifestyle and risk-factor care (Lancet Commission, FINGER), and why cholinesterase inhibitors are not routine for MCI (AAN, Cochrane, Petersen 2005, InDDEx). FRANZCP-primary, globally tagged.
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FRANZCPMRCPsychABPNMD-DNBNEET-SS
Red flags
- Acute or fluctuating cognitive change — treat as delirium until proven otherwise; do not label MCI in an acute confusional state
- Interference with independence in IADLs/ADLs — this is major NCD/dementia territory, not MCI
- Rapid progression over weeks to months — widen organic differential (autoimmune, infection, space-occupying, CJD, medication)
- Starting a cholinesterase inhibitor solely 'to prevent conversion' without counselling that trials do not support routine use in MCI
- Missed depression, B12/thyroid deficiency, anticholinergic or benzodiazepine burden as treatable contributors
- Unsafe driving or financial exploitation dismissed because the person is 'not demented'
- Young-onset or atypical cognitive profile — specialist memory/neurology pathway and expanded work-up
Meet the patient
A 68-year-old retired schoolteacher arrives with his wife and a printout from the internet. For two years he has been losing names, walking into rooms without knowing why, and writing lists for things he never used to write down.[1][9]
He still drives, still cooks, still does the tax return — though his wife now checks it. His MoCA is 23/30, weak on delayed recall, normal on everything else. He wants to know whether he has Alzheimer's disease, and whether he should be on "the tablet".[13][9]
Two questions sit on the desk and examiners test both. Has he crossed the independence line? And what will you actually offer him? The second question is where most candidates lose the marks.[8][10]
References28ShowHide
- [1]Petersen RC, Smith GE, Waring SC, et al. Mild cognitive impairment: clinical characterization and outcome Arch Neurol, 1999.PMID 10190820
- [2]Petersen RC, Doody R, Kurz A, et al. Current concepts in mild cognitive impairment Arch Neurol, 2001.PMID 11735772
- [3]Winblad B, Palmer K, Kivipelto M, et al. Mild cognitive impairment--beyond controversies, towards a consensus: report of the International Working Group on Mild Cognitive Impairment J Intern Med, 2004.PMID 15324367
- [4]Gauthier S, Reisberg B, Zaudig M, et al. Mild cognitive impairment Lancet, 2006.PMID 16631882
- [5]Albert MS, DeKosky ST, Dickson D, et al. The diagnosis of mild cognitive impairment due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease Alzheimers Dement, 2011.PMID 21514249
- [6]McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease Alzheimers Dement, 2011.PMID 21514250
- [7]Sperling RA, Aisen PS, Beckett LA, et al. Toward defining the preclinical stages of Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease Alzheimers Dement, 2011.PMID 21514248
- [8]Sachdev PS, Blacker D, Blazer DG, et al. Classifying neurocognitive disorders: the DSM-5 approach Nat Rev Neurol, 2014.PMID 25266297
- [9]Langa KM, Levine DA The diagnosis and management of mild cognitive impairment: a clinical review JAMA, 2014.PMID 25514304
- [10]Petersen RC, Lopez O, Armstrong MJ, et al. Practice guideline update summary: Mild cognitive impairment [RETIRED]: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology Neurology, 2018.PMID 29282327
- [11]Mitchell AJ, Shiri-Feshki M Rate of progression of mild cognitive impairment to dementia--meta-analysis of 41 robust inception cohort studies Acta Psychiatr Scand, 2009.PMID 19236314
- [12]Cooper C, Sommerlad A, Lyketsos CG, et al. Modifiable predictors of dementia in mild cognitive impairment: a systematic review and meta-analysis Am J Psychiatry, 2015.PMID 25698435
- [13]Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment J Am Geriatr Soc, 2005.PMID 15817019
- [14]Folstein MF, Folstein SE, McHugh PR "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician J Psychiatr Res, 1975.PMID 1202204
- [15]Petersen RC, Thomas RG, Grundman M, et al. Vitamin E and donepezil for the treatment of mild cognitive impairment N Engl J Med, 2005.PMID 15829527
- [16]Feldman HH, Ferris S, Winblad B, et al. Effect of rivastigmine on delay to diagnosis of Alzheimer's disease from mild cognitive impairment: the InDDEx study Lancet Neurol, 2007.PMID 17509485
- [17]Russ TC, Morling JR Cholinesterase inhibitors for mild cognitive impairment Cochrane Database Syst Rev, 2012.PMID 22972133
- [18]Tricco AC, Soobiah C, Berliner S, et al. Efficacy and safety of cognitive enhancers for patients with mild cognitive impairment: a systematic review and meta-analysis CMAJ, 2013.PMID 24043661
- [19]Russ TC Cholinesterase inhibitors should not be prescribed for mild cognitive impairment Evid Based Med, 2014.PMID 24482151
- [20]Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission Lancet, 2020.PMID 32738937
- [21]Livingston G, Sommerlad A, Orgeta V, et al. Dementia prevention, intervention, and care Lancet, 2017.PMID 28735855
- [22]Ngandu T, Lehtisalo J, Solomon A, et al. A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial Lancet, 2015.PMID 25771249
- [23]Butters MA, Young JB, Lopez O, et al. Pathways linking late-life depression to persistent cognitive impairment and dementia Dialogues Clin Neurosci, 2008.PMID 18979948
- [24]Taylor WD, Aizenstein HJ, Alexopoulos GS The vascular depression hypothesis: mechanisms linking vascular disease with depression Mol Psychiatry, 2013.PMID 23439482
- [25]Appelbaum PS, Grisso T Assessing patients' capacities to consent to treatment N Engl J Med, 1988.PMID 3200278
- [26]Jack CR Jr, Bennett DA, Blennow K, et al. NIA-AA Research Framework: Toward a biological definition of Alzheimer's disease Alzheimers Dement, 2018.PMID 29653606
- [27]Petersen RC Mild Cognitive Impairment Continuum (Minneap Minn), 2016.PMID 27042901
- [28]Ismail Z, Smith EE, Geda Y, et al. Neuropsychiatric symptoms as early manifestations of emergent dementia: Provisional diagnostic criteria for mild behavioral impairment Alzheimers Dement, 2016.PMID 26096665