Mild cognitive impairment: Individualising screening and treatment

Lynnette Hoffman

writer

Lynnette Hoffman

Managing Editor

Dr Diem Pham

writer

Dr Diem Pham

GP

 

Half of patients with MCI develop dementia within five years — Here’s how we can help change that trajectory.

Early recognition of mild cognitive impairment can slow the rate of decline, improve quality of life, and ultimately lead to fewer aged care admissions, says Dr Mark Hohenberg, a geriatrician from the Salus Clinic.

“It is important to recognise that losing memory is not a routine part of ageing, and more often than not, it represents the symptoms of a disease,” Dr Hohenberg says.

If someone has signs of cognitive impairment, but doesn’t meet the DSM-V criteria for a diagnosis of dementia, they might have mild cognitive impairment. They can still independently perform daily activities—but they are at increased risk of developing dementia, which is why early identification and intervention is so important to reduce that risk.

The research literature highlights that 9-10% of those with mild cognitive impairment will progress to dementia over one year or around 50% over five years. But early, effective management can slow decline and improve these odds.

After cognitive changes are perceived by patients or those around them, GPs can establish a diagnosis of mild cognitive impairment through comprehensive assessment. Initially this involves a thorough history and examination and exclusion of potential reversible causes. Dr Hohenberg stresses that seeking collateral history from family and close friends should be part of this process and any abnormalities followed up with investigations and further assessments.

Choosing the most appropriate screening test

When deciding on a screening test, it’s important to consider the person’s age, education level and any potential language barriers. Screening tests may include the well-known Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Clock Drawing Test (CDT), Rowland Universal Dementia Assessment Scale (RUDAS) and the ACE-III or ACE-R.

The MMSE does not test frontal lobe function, so Dr Hohenberg recommends further tests to assess frontal lobe function, such as the clock drawing test, proverb interpretation or the Luria-3 step challenge.

The RUDAS is an excellent choice for people from culturally and linguistically diverse backgrounds or with low levels of educational achievement.

The MoCA is considered more appropriate for people with slightly higher than average levels of educational achievement, and incorporates frontal lobe testing.

The Addenbrooke’s Cognitive Examination (ACE) is considered one of the best screening tests as it can differentiate between the different areas of brain function, though it generally takes 20 minutes to complete, so it is used less in general practice.

While these screening tests are not diagnostic in themselves, they can alert to the need for further evaluation.

Making a diagnosis of MCI

To evaluate signs of possible mild cognitive impairment, Dr Hohenberg recommends reviewing the current Australian MCI guidelines which recommend:

  • Requesting brain imaging and pathology tests to rule out reversible causes such as infections, electrolyte disturbances, nutritional deficiencies and anaemia.
  • Assessing for and treating mental health conditions, such as depression.
  • Reviewing for medications that can adversely affect cognition such as amitriptyline, solifenacin and tramadol.
  • Exploring substance dependency, such as alcohol and benzodiazepine dependence, which can be associated with cognitive impairments.
  • Checking for and addressing sensory deficits (e.g. deafness).

Dr Hohenberg recommends referring to a specialist if the diagnosis is uncertain, if there’s concern that frontotemporal dementia or other less common forms of dementia are involved, or if the patient experiences rapid deterioration or has other unexpected features.

Once the diagnosis is confirmed, there’s much that can be offered.

Managing mild cognitive impairment

Studies have shown three key priorities that patients with mild cognitive impairment say are the most important to them.

  • Firstly, patients want to be informed about the diagnosis as early as possible so they can take ownership.
  • Secondly, they want their supporters and carers to be able to maintain good quality of life.
  • Lastly, they want to maintain independence and stay as healthy as possible.

Dr Hohenberg says it’s crucial to learn the wishes and concerns of the patient and their family, and empower them to understand the condition and available options.

He says integrative care has the best evidence for achieving patient satisfaction.

It’s particularly important to address vascular risk factors (e.g. hypertension, diabetes etc) to reduce the overall risk of dementia developing. He recommends offering all patients who’ve been diagnosed with MCI a GP Management Plan, as working collaboratively with other healthcare professionals such as physiotherapists, occupational therapists and dieticians provides the best chance for patients to remain independent and improve or maintain their condition.

Good sleep hygiene and treating sleep apnoea are also important to optimise brain function.

Dr Hohenberg advises patients and families that there is currently no evidence to support using any medications that are currently available in Australia, including cholinesterase inhibitors (used for Alzheimer’s Dementia) or dietary agents—though good nutrition is important.

Evidence also supports cognitive interventions that challenge areas of the brain that the person might otherwise neglect. For example, encourage people who are naturally stronger at logic-based thinking to undertake creative hobbies or activities.

Support to maintain social connections is also extremely important— it’s another way to keep the brain active.

Dr Hohenberg recommends the resources from Dementia Australia (www.dementia.org.au) especially, and says every patient diagnosed with mild cognitive impairment should have their link and request a copy of their excellent Dementia Guide.

The federal government also supports the free ‘Staying at Home’ program which can greatly improve a person’s chances of remaining at home for longer. This can be accessed by calling 1800 699799.

Dementia Support Australia and the Dementia Behaviour Management Advisory Service also offer support for those dealing with more challenging behaviours.

Dr. Hohenberg will be sharing more about this important topic in the upcoming webcast on Tuesday 19th September. Register here to attend.

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Lynnette Hoffman

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Lynnette Hoffman

Managing Editor

Dr Diem Pham

writer

Dr Diem Pham

GP

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