P1252428419jCNiV

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Dementias 2006 23rd 24th February 2006 Savoy
Place London
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Mild cognitive impairment is not a useful concept

• Roy Jones
• Research Institute for the Care of the Elderly,
  Bath
• and
• School for Health, University of Bath

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Mild Cognitive Impairment

• O thou! whatever title suit theeAuld Hornie,
  Satan, Nick or CloutieBurns (Rabbie not
  Alistair)

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Introduction

• There is usually a period between appearance of
  first symptoms and a clinical diagnosis of
  dementia
• e.g. Subjects who report subjective memory loss
  more likely to develop AD1

1Tyas et al, 2001
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The transition from normal ageingto dementia
Cognitive Performance
Normal
Grey Area
Dementia
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The transition from normal ageingto dementia
Cognitive Performance
Normal
Grey Area
Dementia
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Pre-dementia syndromes

• Benign Senescent Forgetfulness (BSF)
• Age Associated Memory Impairment (AAMI)
• Age Related Memory Decline (ARMD)
• Age Related Cognitive Decline (ARCD)
• Cognitive Impairment No Dementia (CIND)
• Subclinical cognitive impairment
• Memory Impairment
• Mild Cognitive Disorder/ Mild Cognitive
  Dysfunction (MCD)
• Mild Cognitive Impairment (MCI)
• Mild Neurocognitive Disorder (MND)
• Questionable dementia (QD)

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Mild Cognitive Impairment
Cognitive Performance
Normal
MCI
Dementia
MCI refers to the state of cognition and
functional ability between normal aging and very
mild AD (Petersen, 2001)
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Problems with criteria

• Multiple definitions
• Heterogenous criteria eg subjective, objective
• Vary in content and amount of detail eg which
  tests to use

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Amnestic MCI (Petersen, 1995)

• Cognitive complaint, usually memory
• Cognitive screening test in normal range for age
  (eg MMSE)
• 1.5 SDs below age-appropriate norms on memory
  tests or memory component of other cognitive
  tests
• ADLs not significantly affected
• Not meeting DSM dementia criteria

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MCI same name, different criteria
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Differences between syndromes

• Memory Impairment

• Some require interview based clinician judgement
• e.g. Questionable Dementia CDR 0.5
• Mild Cognitive Decline GDS 3

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Differences between syndromes

• Other cognitive domains

• Associated mood disturbance
• MCD - yes, AAMI MCI - no,
• others - not stated

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Differences between syndromes

• Impaired Activities of daily living

• Recommended cognitive tests

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Natural History
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Out-patient clinic samples
1Visser et al, 2000 2Bozoki et al, 2001
3Goldman et al, 2001 4Jack et al, 1999 5Jelic
et al, 2000 6Visser et al, 2002 7Flicker et al,
1991
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Community samples
1Ritchie et al, 2001 2Petersen et al, 1995
3Daly et al, 2000 4Bennett et al, 2002
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The evolution of MCI and similar concepts

• AAMI (1.5y f/u) Helkala et al 1997
• 12 no problems, 22 improved cognition
• AAMI (3.6y f/u) Hanninen et al 1995
• 5 no longer problems, further 8 no longer
  qualified as AAMI
• Questionable dementia
• 15 improved at 3y, 29 stable (Daly et al 2000)
• 44 improved at 2.5y to no dementia (Devanand
  et al 1997)
• MCI
• 19.5 improved at 2.7y, 61 stable (Wolf et al
  1998)
• Only 7-17 with baseline MCI retained diagnosis
  at 1y (Ritchie et al 2001)

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The evolution of MCI and similar concepts

• A number of studies have followed people over
  periods of up to 5 y
• Outcomes
• Cognitive decline and/or progression to dementia,
  or specifically AD
• Death
• Improvement in cognitive functioning
• Stability
• Results vary considerably

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The evolution of MCI and similar concepts

• Why do the results vary so much?
• Criteria vary widely in the literature
• Specific measurement tools rarely suggested (eg
  for Petersens criteria)
• Populations vary enormously
• Memory clinics (12/year) vs population based
  samples (11 in 3 years)
• Some focus on all outcomes including death
  others only report on those alive at follow-up

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Predictors of conversion are predictors of AD

• For example
• Increasing age
• ApoE
• Hippocampal atrophy
• Medial temporal lobe loss
• Reduced perfusion on SPECT

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MCI Diagnostic validity

• Predictive power
• and practical utility

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Mild Cognitive Impairment
Cognitive Performance
Normal
MCI
Dementia
MCI refers to the state of cognition and
functional ability between normal aging and very
mild AD (Petersen, 2001)
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MCI concepts
Cognitive Performance
Normal
MCI
Dementia
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Pre-dementia
Cognitive Performance
Normal
Dementia
Prodrome
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Pre-dementia
Cognitive Performance
Normal
AD
Prodrome
Prodromes?
VaD, LBD, FTD
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Kendalls criteria1

• Validating clinical syndromes
• 1. Identification description
• 2. Demonstration of boundaries or points of
  rarity between related syndromes
• 3. Establish a distinct course or outcome
• 4. Establish a distinct treatment response
• 5. Establish the syndrome breeds true
• 6. Association with more fundamental abnormality

??
?
?
?
?
??
1Kendall et al, 1989
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Conclusions

• MCI and other pre-dementia syndromes are
  heterogenous
• Higher risk of dementia
• Predictors of conversion similar to AD
• Validity questionable
• Specificity not known
• ? No syndrome obviously superior to others though
  perhaps higher rates of conversion using clinical
  interviews

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Is MCI a useful concept to GPs, patients and
their families?

• It is assumed that earlier diagnosis is better
  but the assumption has not been tested
• May have a stigma, effect on self esteem, create
  depression/anxiety
• Family issues
• Driving/insurance issues
• Can be a difficult concept to discuss especially
  when prognosis is so varied (some decline, some
  are stable and some improve?)

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Mild cognitive impairment is not a useful concept

• It produces a lot of papers for researchers and
  gives Alistair and me something to debate
• BUT there is a danger it will restrict our
  thinking and we think it is a disease in its own
  right
• It is not particularly useful for clinicians in
  routine practice because the prognosis is too
  difficult to predict and it doesnt cover people
  in the grey area where we dont want to give a
  diagnosis of AD or dementia yet
• Its hard to explain the label or the outcome to
  GPs, patients or their families and is not a
  useful concept for them

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And finally..(especially for those who suffered
Latin)

• Virgil et al, Aeneid 19(BC) IV 335
• Nec me meminisse pigebit Alistair Burnus
• Dum memor ipse mei, dum spiritus hos regit artus
• Nor will the thought of Alistair Burns be bitter
  to me
• So long as I have memory, and breath control
  these limbs

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Dementias 2006 23rd 24th February 2006 Savoy
Place London