- Mild Cognitive Impairment (MCI) is a condition in which the patient transitions from the normal aging process to Alzheimer’s or to another type of dementia
- Most prevalent symptoms of MCI include forgetfulness, inability to focus and impaired judgement
- MCI is considered a prime dementia risk
- The clearest risk factors for MCI are old age and genetic predispositions
- There are three cognitive fields that comprise a fundamental test for MCI: Episodic memory, Executive function and Processing speed
- MCI is a condition; Dementia is a syndrome
- There is currently no specific treatment for MCI
Mild Cognitive Impairment (MCI) is a condition best defined as the patient transition period from the normal aging process to Alzheimer’s disease or to another type of dementia. This intermediate phase is elusive and slow, with the patient’s first emerging signs of mental disorder barely discernable. It is akin to a battery that loses its power in an unhurried and drawn-out period in between natural aging and the gradual dimming of significant cognitive faculties.
There is some loss of memory in this “pre-symptomatic” phase, as well as a slight diminishing of language and judgment abilities, though not sufficient to interfere with normal social functioning, or with the patient’s independence and skills in performing activities of daily living (ADLs).
Another name given to this phase is “pre-clinical”, and although it is often a precursor to Alzheimer’s or other type of dementia disorder, it does not necessarily lead to further neurological decline. In fact, people with the MCI type of disorder may stay with condition for years, while others may fully recover from it. Naturally, these statements depend to a large degree on the person’s coexisting health problems and other disorders.
With advancing age, the brain sustains wear and tear as well, mostly as a result of oxidative damage, also known as oxidative stress, which results from the effect of “free radicals” or oxidants over time. Typically, we may start forgetting names or recent events, though this forgetfulness is hardly more than a nuisance.
Comes a point however where some people experience more than simple forgetfulness. They may forget things more often, even appointments or important commitments they made, or they may lose the ability to focus on any task on hand, their thought processes easily distracted. Those could be the early signs of the MCI type of mental disorder.
In addition, many people with MCI get easily overwhelmed by chores or developments that had previously not caused any concern. Planning a multi-step activity also becomes too strenuous, and they may even experience difficulties finding their way around familiar grounds. Judgment is also impaired, causing embarrassment, frustration and a loss of self-confidence, which in turn at times lead to irritability, withdrawal and depression.
These signs and symptoms cause considerable anxiety, not just for the sufferers, but also for their families and support people who can’t but observe that something beyond normal aging is happening, right in front of everybody’s eyes.
Less prevalent symptoms of the MCI disorder include language challenges such as:
- Struggling to find words or construct full and coherent sentences
- Focus and concentration challenges, for example in following a trend of thought or a conversation
- And weakening of visual and spatial acumen, or disorientation in familiar surroundings
People with MCI have a heightened risk of developing dementia-type disorders. For the population as a whole, up to 2 percent of older adults develop dementia every year. Among older adults with Mild Cognitive Impairment however, research studies have indicated that up to 15 percent develop dementia every year. As such, MCI is considered as a prime dementia risk.
Assessments every 15 months of a group of more than 2,700 elderly residents of a county in Minnesota revealed that when they were first tested, 534 persons had MCI. The researchers recognized that based on prior research, individuals with MCI break into three categories:
- Some show no change over time, i.e. neither recovery nor decline into dementia
- Approximately 40 percent recover to normal cognitive functioning
- Others develop dementia after a few years
The key finding however was that five years down the line, of those who recovered to normal cognitive functioning, 65 percent did develop Mild Cognitive Impairment. This was roughly 6 times the ratio of those who, when first examined, had not shown any signs of Mild Cognitive Impairment.
The significance of that particular study is that it shed light on the elderly who, given other relatively good health, nowadays routinely live well into their 80s and beyond. At those advanced ages, memory issues are so prevalent that, more often than not, they are merely considered part of the aging process. That implies that many people with Mild Cognitive Impairment skip that phase and jump from old age to dementia, never having been diagnosed with Mild Cognitive Impairment.
The challenge in that scenario of skipping the MCI diagnosis is that had there been such a diagnosis, many with treatable underlying causes may have been prevented from declining into dementia. Not to mention that the care such individuals require also catapults from a relatively small amount of care, to more or less suddenly requiring arduous care.
At another level, there are typical cases that heighten the likelihood of progressing from Mild Cognitive Impairment to Alzheimer’s. For example, when there is an actual diagnosis, or even merely validation of memory difficulties “beyond the ordinary” by a credible or well-informed source, such as a spouse or other care provider. In cases like that, confirmation of issues beyond the ordinary include disruptions in performing daily living tasks, and inability to handle complex multi-step tasks or emergencies, requiring, again, more helping care.
Age, lifestyles and genetics seem to be all that we have from research studies as risk factors for Mild Cognitive Impairment, with a person’s genes perhaps being the most prominent among those. Furthermore, researchers are still investigating whether other conditions such as hypertension, high levels of cholesterol or diabetes may also be underlying causes.
Even sleep apnea, or sleep-disordered breathing (SDB), are under consideration as potential risk factors. It is thought that the interruption in breathing patterns during sleep may reduce blood oxygen levels and create risk factors for cognitive decline, much like they do in causing daytime sluggishness and heightened risk of vascular complications.
Mental acuity and stimulation at an early age, such as for example advancing from high school to years in college, are known to reduce the risk of cognitive decline as we age. Similarly, some mentally demanding careers, such as in accounting or engineering, can also produce the same effect of reducing or delaying the risk of cognitive decline with older age.
At another level, current evidence highlights the fact that there are times when Mild Cognitive Impairment develops from more or less the same types of brain changes seen in Alzheimer’s disease or other forms of dementia. Some of these changes have been identified in autopsy studies and include abnormal clumps of plaques and tangles in the brain typical of Alzheimer’s disease.
To sum up, the clearest risk factors for Mild Cognitive Impairment are old age and genetics of the type that predispose individuals to MCI. Diabetes, smoking, lack of exercise, hypertension, depression and other lifestyle issues are also thought to be risk factors.
Mild Cognitive Impairment may be assessed in individuals as young as 50, yet people in the 50 to 70 range are often averse to subjecting themselves to tests about “a little forgetfulness”. These concerns are more apt to be shared not so much with family physicians, but with friends and family members, and that is where the process commonly stops.
This is a considerable impediment to individuals finding out if they have developed MCI. For those who are more open-minded and willing to undergo tests, licensed specialists in the field of psychometric assessments have been around for many years, although mostly in the past for corporate employers.
Diagnosing Mild Cognitive Impairment is a relied upon process that can lead to evaluating a person’s risk for eventually developing one or more of the types of dementia. There are three cognitive fields that comprise a fundamental test for Mild Cognitive Dementia:
- Episodic memory: This involves the cognitive process of gaining, storing, and recovering new information, and spontaneously evoking that information after a lapse of some time. It can be of the verbal type, as in remembering the details of last night’s dinner, or nonverbal, as in visualizing a past experience or scenes from a movie watched a few days earlier.
Delayed recall memory is thus a subtle test for early Alzheimer’s. The first findings can then be followed by other assessments that fully engage the person’s concentration, thus moving from spontaneity to focused attention.
- Executive function: This reflects on the ability to plot, outline, and observe the completing of behaviors that are purposefully framed with a focus on specific objectives. Executive function also includes a sign coordinating test which necessitates decision-making in selecting the right answer in a more multifaceted way than tests that measures speed.
- Processing speed: This reflects on mental dexterity by measuring the time span required to cover a set number of givens. The most significant influence on speed tests have been shaped by Timothy Salthouse, PhD and Professor of Psychology at the University of Virginia, who produced a simple “paper and pencil” test in which participants are asked to process 20 questions as quickly as they can. The results of Salthouse’s test can then be computerized to promptly derive results.
A partnership between The Alzheimer’s Association and the National Institute on Aging (NIA) assembled proficient workgroups to update the diagnostic criteria for Mild Cognitive Impairment that has Alzheimer’s as the underlying disease.
It has to be noted that our current scientific knowledge advises that in preclinical Alzheimer’s, i.e. in Mild Cognitive Impairment, brain changes caused by Alzheimer’s may commence many years before actual symptoms are discerned.
Furthermore, clinically, Mild Cognitive Impairment at best represents only a physician’s conclusion about what underlies an individual’s symptoms. When the physician has little confidence in such conclusions, brain imaging and cerebrospinal fluid tests may be performed to further ascertain whether or not the individual has MCI with Alzheimer’s as the underlying disease.
A medical assessment for Mild Cognitive Impairment would consist of the following basic components:
- A medical history which includes a thorough documentation of the person’s symptoms, previous illnesses, and any family history of advanced memory issues or dementia
- Input from knowledgeable and reliable individuals who are close to the participant and who can add contextual perspectives on the development to date of cognitive function
- An evaluation of performance with everyday tasks, focusing on the possible recent deterioration in the execution of those activities
- An evaluation of the person’s mental functioning using brief in-office tests aimed at assessing memory, planning multi-faceted tasks, decision-making, and ability to adequately combine visual and spatial elements with the thinking process
- A physical examination to measure the function of reflexes, coordination, mobility, balance, and sensory sharpness
- And, finally, laboratory tests including brain imaging and blood tests
When a methodical assessment of this type doesn’t yield a clear outcome, the physician may recommend neuropsychological testing, such as has been described in the above section.
We first have to differentiate between normal aging and Mild Cognitive Impairment. We’re all acquainted with what happens to us as we age: although our intelligence remains constant, our brain and body slow down, and we take additional time to sort things out, and the names of people and places don’t come to us as easily as before.
In Mild Cognitive Impairment, we start having newly aggravating issues with memory or some other cognitive function. Although not serious enough to significantly hamper our performance in everyday living, these issues in turn become noticeable to the people around us. But the worst part is that—not all, but many—people with Mild Cognitive Impairment become increasingly prone to develop Alzheimer’s or another type of dementia, such as Lewy Body, vascular, or other.
As for dementia, it has to be repeated that dementia is not a disease, but rather an umbrella term that depicts symptoms that may be caused by a number of different diseases. These symptoms commonly involve mental decline severe enough to disrupt daily life. High on the list of such symptoms are recent memory, articulating disturbances, visuospatial function, and executive function, i.e. the ability to plan and execute on complicated matters.
There is today no specific treatment for Mild Cognitive Impairment. With worldwide resources currently attempting to find more effective pharmaceutical drugs and better therapeutic interventions for Alzheimer’s, the results from such efforts are bound to be tried on patients with Mild Cognitive Impairment.
Once the scientific evidence points to positive outcomes from such efforts, the significance of diagnosing Mild Cognitive Impairment early in its progression will acquire new urgency.
In the meantime, we do well to remember that many drugs currently in use have dire side effects on memory and other cognitive function. These drugs include Valium, Ativan, and over-the-counter drugs like Tylenol, Advil, and several other that we see advertised on our screens on a daily basis.
At 70, and living in the dainty city of Bennington, Vermont, Brenda L. had the beginnings of old age issues. She at times grappled with trying to remember the first or last names of even some of her accustomed television newscasters and, when speaking, she would get stuck with recalling just the word her mind sought for what she was saying.
Those, one might say, were minor issues that would at worst cause her a little frustration and realistic recognition that she was getting on in age. But it wasn’t all that harmless, for Brenda was experiencing precisely the same type of forgetfulness that her husband Jerry exhibited going back some ten years.
Today, Brenda had to give up her job and become Jerry’s full-time caregiver.
Jerry had been a brilliant mechanical engineer and inventor. By the time he was in his 60s, he headed the new product division of a Fortune 500 auto parts company. He had been instrumental in obtaining sixty different patents for his employer.
He got up one day to give a talk to some 50 employees from other divisions of the company only to draw a complete blank, forcing him to read from quickly jotted notes. He had relied entirely on winging the speech, as he’d done successfully on prior occasions.
“A senior moment” Brenda thought, although Jerry admitted to great embarrassment during the event. “It’s just your aging brain, darling,” she told her husband, with a wink and a smile. They were both reasonably confident individuals, and this would soon be forgotten.
But it wasn’t. As the months rolled by, his memory declined rapidly, and Jerry started talking incoherently, stopping for long pauses as he raked his brain for the right words that just simply wouldn’t materialize. His general practitioner knew little about cognitive decline, but he knew enough to urge Brenda and Jerry to seek help from a dementia specialist, which they did.
After conducting some tests of Jerry’s memory at his office, the specialist ordered brain imaging and more tests. Sure enough, the diagnosis came back of mild cognitive impairment. “We cannot be certain of any of that,” the doctor told Brenda, “but that is my judgment, based on having seen those symptoms and tests in other patients.” After prodding him for a prognosis, he admitted that Jerry was at high risk for developing Alzheimer’s.
Four years later, Jerry’s cognitive function had declined to the point where he recognized Brenda not as his lifetime partner, but as a kind and familiar face, or something close to that.
All this unfolded as Brenda herself was going through episodes of forgetfulness that reminded her painfully of how Jerry’s weakening mental faculties had developed at the beginning. Was she destined for Alzheimer’s too? Who would look after Jerry? Who would look after both of them, if that became her predicament as well? And how long could she keep Jerry at home, if and when she herself embarked on the downhill path to dementia?
Tough questions with no redeeming resolutions. Transitioning from old age to mild cognitive impairment phases raises fears of immeasurable proportions, particularly for people who had been exposed at close range to the full wrath of a spouse’s Alzheimer’s.