MCI: - 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)
- A. Alzheimer's Dementia (Please see Table 1 of Annals 2014)
- Probable AD
- Possible AD
- Definite AD
Note: Affects posterior brain region associated with memory, language and spatial function
- B. Non-AD (3 major subtypes)
- 1. NPH Dementia
- 2. Neurodenerative Dementia (NDGD) (3 major subtypes)
- i) Diffuse Lewy Body Disease
- ii) Prion Disease
- iii) Frontotemporal Dementia (Least common cause of NDGD (6 major syndromes)
- 3. Vascular Dementia
- 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
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