Discussing Mild Cognitive Impairment

Mild cognitive impairment (MCI) can be a challenging diagnosis to discuss with patients for many reasons, including its overlapping symptoms with normal aging, heterogenous presentation, variable outcomes, and lack of effective treatments. Such discussions will become more common as the older adult population continues to increase in the coming decades. Cognitive decline is one of the more feared aspects of aging. Although the concept of MCI is often distressing to patients and their families, the diagnosis can provide validation of cognitive complaints and justification for the patient’s abilities and behaviors (1). Currently, there are no established guidelines for universal screening; such screening, however, would likely facilitate increased awareness and earlier detection and set the stage for a better initial discussion regarding the diagnosis. Early diagnosis can provide increased opportunity for better care, earlier interventions to potentially improve outcomes, more time to plan, and more opportunity to participate in clinical trials. Clear and direct communication, in a supportive manner, can assist with fostering a strong therapeutic alliance and allay concerns about the diagnosis of MCI and its prognostic implications.

Explain the Diagnosis and Prognostic Uncertainty

MCI is a clinical stage that falls between normal aging and early dementia (2). The diagnostic criteria include concern regarding a change in cognition, abnormal cognitive function in one or more domains, preservation of functional abilities, and absence of dementia. Prevalence estimates of MCI in older adults over age 60 range from 6.7% to 25.2%, depending on the population studied and the cutoff scores used to determine MCI (1–4). Risk increases with age and lower education and is more prevalent among men (3, 4). Compared with the general population, patients with MCI are at greater risk of developing dementia, often of the Alzheimer’s type (5). The annual rate of progression to dementia is approximately 5%−20%, with substantial variation depending on the population studied (6).

Established biomarkers associated with progression from MCI to Alzheimer’s disease include a positive amyloid positron emission tomography (PET) scan, apolipoprotein E4 genotype, abnormal cerebrospinal fluid tau levels, and a positive PET scan due to tau deposition into the lateral temporal lobe structures (3). The discussion with patients to pursue further evaluation to determine more specific risk should be based on the patient’s personal and family history and should involve a cognitive specialist familiar with interpreting these tests and their limitations. Because diagnostic testing for MCI can be associated with significant financial costs, emotional distress, and social stigma for patients and their families, some patients may decline diagnostic evaluation entirely (1).

The diagnosis of MCI can cause patients to feel overwhelmed with uncertainty about the future and concern for functional loss that may make them increasingly dependent on others. In addition to cognitive symptoms, or perhaps because of them, patients with MCI can develop neuropsychiatric symptoms, such as depression, anxiety, apathy, and irritability, that can be associated with greater functional impairment and increased risk of progression to dementia (7, 8).

In discussions with patients and their families, it is important to emphasize that MCI is not synonymous with dementia. MCI does not always progress to dementia; the cognitive condition of many individuals with MCI remains stable over time and sometimes even improves.

Identify and Address Modifiable Risk Factors

Because there are currently no pharmacological interventions proven effective for MCI, it is essential to identify modifiable medical, psychiatric, and lifestyle factors that can increase risk for cognitive impairment. The same modifiable risk factors for dementia can be discussed with MCI patients: midlife hearing loss, lower education level, traumatic brain injury, hypertension, physical inactivity, diabetes, excessive alcohol consumption, obesity, smoking, depression, social isolation, and exposure to air pollutants (9).

For older patients with MCI, polypharmacy should also be considered a modifiable risk factor for cognitive impairment and other negative outcomes. Attempts should be made to reduce or eliminate use of anticholinergic medications and other medications with cognitive side effects.

Discuss Treatment Recommendations and Strategies

There are no FDA-approved medications for MCI. Moreover, to our knowledge, no high-quality, long-term studies have identified specific pharmacologic or dietary agents that can improve or delay progression in patients with MCI (4).

Clinicians should assess and treat for reversible causes of cognitive impairment. Patients should be reasonably weaned off medications that can contribute to cognitive impairment. Clinicians should regularly advise patients on reducing modifiable risk factors for cognitive impairment. The use of cholinesterase inhibitors for MCI is considered off label; studies so far have shown no benefit on cognitive outcomes or reduction in conversion rates from MCI to dementia (4).

Optimizing physical and mental health can decrease overall risk for cognitive decline and can maintain quality of life for patients with MCI. Patients should be educated and encouraged to keep physically, mentally, and socially active. Although no long-term studies are available, 6-month studies have suggested the benefit of twice-weekly aerobic exercise for cognition among individuals with MCI (4). In addition, many studies have demonstrated the benefits of mental activity and social engagement in preventing or slowing cognitive decline and in improving mental health (4, 7, 10). Neuropsychiatric symptoms of those with MCI should be monitored and treated with pharmacologic and/or nonpharmacologic interventions. Psychotherapy, such as cognitive-behavioral therapy, has high value for helping patients cope with the psychological distress that can be brought about by cognitive impairment in daily life (11).

Treatment discussions should also include opportunities to participate in clinical trials. With no pharmacologic treatments currently available, these opportunities become more important. Patients may be interested in participating in studies to identify or test new treatment options. Clinicians should provide information to these patients to help connect them to clinical trials (e.g., subspecialty centers, Trial Match, ClinicalTrials.gov) (4).

Provide Close Monitoring and Ongoing Support

Due to the uncertainty regarding the prognosis of MCI, patients should have serial assessments approximately every 6 to 12 months to monitor for changes in cognitive and functional status (4, 10). Close monitoring also allows for more opportunities to discuss prognostic possibilities and any newly available treatments, provide ongoing education to patients and their families, and assess the need for increased support. Patients should be strongly encouraged to seek additional support when needed. Patients and their families should be made aware of community resources and support groups in their area.

Encourage Advance Care Planning

The diagnosis of MCI can have many important implications for patients and their families. It is critical that all patients are encouraged early in treatment to consider decisions about long-term care while they remain cognitively stable enough to participate in planning and able to make their wishes known to others.

Advance care planning is important for all patients with MCI, irrespective of potential progression. Patients should be urged to prepare advance directives, living wills, power of attorney designations, estate plans, etc. They should also be advised to directly discuss their preferences with those they want involved in their care.

Additionally, patients with MCI and their families should be encouraged to develop plans for how they would address high-risk situations that may arise, such as driving safety, firearm safety, susceptibility to financial scams, and incorrect use of medications. These kinds of discussions can also assist patients and their families with establishing a sound plan for “aging in place” as well as lay down a framework to better ensure that their wishes and desires are respected and upheld (1).