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MCI and Dementia

  • Objective evidences of low performance in one or more cognitive domain
    • Does not SUBSTANTIALLY interfere daily activities though complex task may take more time or are performed less efficiently
  • 5 Cognitive Domains (Each corresponding their cerebral localization) 
    • Learning and Memory
    • Language
    • Visuospatial
    • Executive (if affected, patients are disorganized, and unconcerned; frontosubcortical structures)
  • Psychomotor (Sympathy and empathy involves  temporal lobe of non-dominant hemispheres, Insular Cortex, Orbitofrontal Cortex, and Ventral Striatum; Hyperorality and loss of response to internal signals such as satiety or nausea are highly typical of involvement of the right frontoinsular cortex or hypothalamus; Constellation of compulsive behaviors, apathy, and disinhibition is associated with diminished function in the circuits of the anterior cingulate, insular, and orbitofrontal cortexes that drive and regulate behavior  (Case 9-2015). 

    Posterior brain region is associated with  memory, language and spatial function (Affected in AD)
    • Broard categories of diagnosing MCI
      • Amnestic MCI (related to Memory)
      • Non-Amnestic MCI (Other than Memory in above 5 cognitive domain)
      • Multi-domain MCI (More than one cognitive domain is affected)
  • Diagnosis:
    • History:
      • Functional Activity Questionnaire (See NEJM 2011 Supplement)
      • Mental Status Examination (Montreal Cognitive Assessment; The Short test of Mental Status; (See NEJM 2011 Supplement) Note: MMSE is insensitive
      • Referral for neuro-cognitive assessment (In certain situations)
    • Labs and Imaging (To define the cause of MCI / Dementia)
      • Non Contrast MRI / CT
      • B12, TSH
      • DDx
        • Depression
        • Multiple Medical Co-morbidities
        • Drugs / Medications
  • DEMENTIA  (Is a Syndrome; How to APPROACH it?):
  • 2 or more cognitive domain is affected causing significant impairment in function but not alertness or attention
  • Confirm Diagnosis of Dementia (History, Labs and Imaging, DDx as above in MCI) MCI, Delirium, Pseudo-dementia due to depression, Medications, 
  • Rule out treatable causes (i.e B12 deficiency and Thyroid Status) 
    • Consider HIV associated Dementia, Neurosyphilis, Thiamine Deficiency, Chronic Alcohol use, and Toxins
    • Please see Annals 2014 Appendix Table 1 for Full List of DDx of Cognitive Decline
  • Assess the severity of Dementia (MMSE)
  • Assess the associated symptoms that needs treatment (Depression, Anxiety, Sleep Problems, Agitation, Psychosis etc)
  • Identify the TYPE of dementia (2 Major subtypes)
  • Alzheimeirs Dementia
    • Donepezil (Aricept)
    • Rivastigmine (Exelon)
    • Galantamine (Razadyne)
    • Mementine (Namenda)
Early Alzheimer’s Disease NEJM 2010
Alzheimer’s Disease NEJM 2004 
Vitamin E, Memantine, and Alzheimer Disease (Editorial) JAMA 2014
Pharmacologic Treatment of Dementia: ACP/AAFP Guidelines Annals 2008
More on Pharmacology
Cognitive Loss and Dementia (Medical Letter) 2010
Additional References