Clinicians assessing patients for cognitive impairment should use a validated cognitive assessment tool and monitor changes over time, according to guideline

Updated guidelines for assessing mild cognitive impairment (MCI) released early in 2018 by the American Academy of Neurology (AAN) offer a fresh perspective on the subject of cognitive aging. In the practice guideline for clinicians, the authors outline why diagnosing MCI is important and explain how to assess and manage the condition.

Diagnosis of MCI is important to rule out reversible causes of impairment and to allow patients to make life choices

The summary of the AAN practice guideline, “Update: Mild Cognitive Impairment,” states, “For patients for whom the patient or a close contact voices concern about memory or impaired cognition, clinicians should assess for MCI and not assume the concerns are related to normal aging.”

Diagnosing MCI is important in order to rule out reversible causes of cognitive impairment and give patients the ability to plan ahead for the possibility that their MCI progresses to dementia.

Examples of reversible causes of cognitive impairment include “medication side effects, sleep apnea, depression, and other medical conditions.” If an MCI diagnosis is made, clinicians should perform a medical evaluation for modifiable risk factors.1

Physicians should use validated assessment tools and not rely solely on patient reports

Assessing and diagnosing MCI and dementia

In the U.S., Medicare Annual Wellness Visits require an assessment of cognitive impairment.2 The “Recommendations for Assessing Mild Cognitive Impairment (MCI)” section of the practice guideline update spells out what clinicians should do:

“For patients for whom screening or assessing for MCI is appropriate, clinicians should use validated assessment tools to assess for cognitive impairment.”

Since most assessment tools are calibrated to maximize sensitivity, if a patient tests positive on a brief assessment, clinicians should perform a more formal neurocognitive assessment in order to diagnose MCI.1 It is also important to distinguish between MCI and dementia, and clinicians should do that by assessing for functional cognitive impairment, which would indicate dementia.

Tracking cognitive status over time

The guideline states, “For patients diagnosed with MCI, clinicians should perform serial assessments over time to monitor for changes in cognitive status.”

MCI can improve, remain stable, or progress into dementia, and changes in cognitive status could affect diagnosis and management approach.

Management of MCI

Addressing modifiable factors

The “Recommendations for Management of MCI” section of the guideline states, “For patients diagnosed with MCI, clinicians should wean patients from medications that can contribute to cognitive impairment (where feasible and medically appropriate) and treat modifiable risk factors that may be contributing.”

No effective medications, unfortunately

Clinicians should counsel patients and families that at this time there are no medications or supplements shown to improve cognitive symptoms of MCI. No medications are FDA-approved for this purpose, although off-label prescriptions are sometimes given.

Lifestyle and behavioral interventions

Lifestyle interventions are effective. Exercise twice per week and treatment of behavioral and neuropsychiatric symptoms (e.g., depression, anxiety, or insomnia) in MCI is important.1 Cognitive training may be effective, and it certainly can’t hurt.

Long-term planning

Although prognosis is uncertain and MCI symptoms may remain stable or even improve, many cases of MCI progress to dementia. For patients diagnosed with MCI, “clinicians should counsel patients and families to discuss long-term planning topics such as advance directives, driving safety, finances, and estate planning.”

References

  1. Peterson, R.C., Lopez, O., Armstrong, M.J., et al. (2018). Practice guideline update summary: mild cognitive impairment: report of the guideline development, dissemination, and implementation subcommittee of the American Academy of Neurology. Neurology, (90)3, 1-10. doi: https://doi.org/10.1212/WNL.0000000000004826.
  2. Association AM. MLN Matters News Flash: Annual wellness visit (AWV), including personalized prevention plan services (PPPS). (2009). Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm7079.pdf.