Saturday, December 8, 2012

Mild Cognitive Impairment (MCI)

Photo by Flood
As people get older, they experience age-related changes to their memory: i.e., they take longer to store and retrieve information, their attention is compromised when multitasking, and they take longer to retrieve the desired name, date, place or specialized word.

Sometimes older adults too readily fear that they are in an early stage of Alzheimer's disease (AD). Usually, these changes to memory are just normal signs of aging.

But what if the memory problems seem more serious?  Is it Alzheimer's disease?  Maybe, maybe not.

Yes, as people age, their risk for AD and other forms of dementia does increase. About 5% of those ages 65 to 74 have AD; the rate increases to about 50% for those 85 plus. Yes, symptoms of AD can often mask as normal changes to memory. Some disregard atypical memory changes, which postpones a diagnosis until people move beyond the early stage and into the mid-stage of the disease.

(For a fuller overview of various stages of memory performance,
see this list at alz.org.)

However, older adults with memory problems should first consider the possibility they have Mild Cognitive Impairment (MCI).

The Alz.org document 2012 Alzheimer's Disease Facts and Figures reports this prevalence: "Studies indicate that as many as 10 to 20 percent of people age 65 and older have MCI" (p. 9).  Furthermore, only a small percentage (15%) seek medical advice about MCI. Of those who do seek treatment, half will develop dementia in 3-4 years.

Clearly, older adults and their loved ones need a greater awareness of MCI as a distinct diagnosis.

MCI is a diagnosis that indicates greater memory problems than those associated with normal aging but fewer memory problems than required for a diagnosis of dementia (Alzheimer's disease being the most common form of dementia).   MCI is an "in between" diagnosis of sorts.

It's important to note that the majority of those with  MCI do not progress to dementia.

In combined studies (see Mitchell et al 2009) over a 10 year period, only 1/3 of those with MCI progressed to dementia.  The others either maintained the MCI diagnosis or returned to normal memory capabilities for their age and education.  By another measure, the annual conversion rate from MCI to dementia falls between 5% and 10%. 

People suspect AD over MCI primarily because Alzheimer's disease was established over a century ago as a clinical diagnosis in 1906.  Many haven't heard of MCI yet. Or MCI is ignored as a possibility until major memory problems appear.

Today's most employed definition of MCI began in the 1990s when Dr. Ronald C. Petersen and colleagues established the Petersen guidelines for diagnosing MCI.

MCI has many causes and is still coming into focus for the medical community. Consequently, the diagnostic guidelines are still in flux.  Here is a list of symptoms by Ghetu et al from their 2010 article appearing in Clinical Geriatrics. The authors constructed this list by looking at the available scholarship on defining MCI and presenting the most commonly recurring criteria:  
  • Self-reported memory complaint, preferably corroborated by an informant
  • Objective memory impairment
  • Preserved general cognitive function
  • Intact activities of daily living (ADL) with minimal impairment in instrumental functions
  • Not meeting criteria for dementia 
When someone has MCI, they are a little more confused a little more often than others with the same age and education level, but they can still meet the day-to-day demands of self-care and social function.

Examine this list that shows MCI-type concerns but recognizing that these are not as severe as a dementia symptom:
  • Losing items more often, but not showing paranoia that others are stealing these items.  
  • Taking longer to recall information, but eventually finding the right word, even an hour later. 
  • Forgetting a doctor's appointments, but remembering where the office is located. 
  • Getting off track when interrupted, but eventually returning to the task. 
  • Needing to take notes more often, but remembering to consult those notes. 
  • Confusion at times about the day of the week, but knowing the season and the year.  
  • Forgetting some minor details of a day trip to the next county, but remembering going on a trip. 
  • Struggling to manage more complex financial matters, but managing to balance a checkbook. 
If a few "senior moments" from the above list seem familiar, dementia is probably not the problem. But if several of these milder memory problems appear together and with more frequency, there is cause to suspect MCI. 

If you are concerned about changes to memory for you or a loved one, work with a doctor.  Diagnosing memory problems involves a combination of tools:

  1. Observations by a family member or someone with day-to-day contact (called an informant by clinicians)
  2. Short cognition tests such as the Mini Cog or the MMSE that can be performed in a doctor's office in a few minutes
  3. More involved cognition tests such as the Wechsler Adult Intelligence Scale (WAIS) performed by a memory specialist
  4. Blood tests

With mild memory problems, doctor's rarely order images of the brain such as an MRI, PET or CT scan unless there is a family history of AD  or another exceptional reason.

There's a lot to manage as people age, but memory concerns can be a little tricky to diagnose.  It's difficult to distinguish these phenomena: 1) age-related changes, 2) symptoms of mild cognitive impairment 3) signs of pre-dementia, and 4) cognition problems due to other factors such as depression, infection, side effects from medications, etc. Memory experts especially value the role of taking the same clinically established cognitive tests (such as the MMSE) over a period of months and years.

Consider asking your general practitioner for a baseline cognition test by age 65 even if it only establishes normal cognition levels. Having that baseline score can help diagnose more serious memory problems that might appear later. 

Related:

On the Tip of the Tongue
Is It Delirium or Dementia
Hospital-Induced Delirium
Age-Related Changed to How We Write
Prevalence of Dementia and Diagnosis Tools

3 comments:

  1. Karen, I thought this was very interesting. My next question would be "what can be done if it is diagnosed?" If nothing can be done, why are we fretting about forgotten car keys?

    In my case, I am doing a lot of the things you describe but have always done those things. I probably have a MCI condition. But I function at a very high level and have learned to compensate for a lot of my inaptitude.

    Just a thought.

    b+

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    1. Barbara, I totally agree that people should maximize compensation strategies. It's super smart! Because I read research reports but I also talk to a lot of individuals, I experience a gulf in between the research that focuses on patterns of thousands of people and then the day-to-day reality of an individual. The epidemiologists who are churning out the data above have only been working on this for about 15 years. They aren't quite sure what they are seeing and what it means. But I think it's great for them to keep on measuring cognition even if what we know is sketchy. In the mean time, you are doing a brilliant job problem solving your specific situation. I have a few memory issues, too. So it's great to know that you are working around things. It gives me hope for managing my own issues now and later. Hugs to you!

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    2. Thank you for your reply Karen. The research is very interesting for me. I watch those around me seem to fail and then recover totally. I find that I don't need to worry about them yet.

      I liked the idea that not all forgetfulness or senior moments are signs of something dire in the future. Women in particular are afraid because they cannot recall people's name and will awake in the night with that information. We do support each other and I suppose that a group of friends can be a great comfort. I picture us all in the nursing home searching for each other's glasses!

      I think that I have always been a little wonky but it has not been a problem that cannot be overcome. We all are different I suppose and that is why putting people into pigeon holes is not a good thing. I do like the information that MCI

      Be well.

      b+

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