There’s no doubt Mild Cognitive Impairment (MCI) is a difficult topic to discuss with patients, but as geriatrician Associate Professor Mark Yates says, you just have to dive right in.
Associate Professor Yates has been involved in national advisory committees on dementia and mild cognitive impairment and helped develop nationally approved recommendations for the management of MCI. He says doctors may fear they’re opening a Pandora’s box of issues, but often it can be the opposite.
“I think we have to bite the bullet,” when a patient presents with memory concerns, he says. “The first thing is say, ‘really? I’m really interested. … What made you think there was a problem for you? What was your concern?’ So, you have immediately adapted and embrace the patient’s problem, so it’s not shunned away.”
MCI is often not progressive
Associate Professor Yates says it’s important to remember that a diagnosis of MCI can have a very different trajectory to dementia. In fact, 60% of people with MCI do not progress further and in many cases, effective management of comorbidities can lead to improvements.
That’s when it becomes an opportunity, he says.
Associate Professor Yates gives the example of George, a 73-year-old, who is on the board of his own successful business but is worried that lately he’s missed a few meetings and isn’t handling technology as well as he used to.
George hasn’t been in for 18 months. He has diabetes, high blood pressure, is overweight and has sleep apnoea.
He suggests ordering bloods including a FBC, HBAC1, thyroid function and B12 to make sure there’s nothing underlying contributing the George’s concerns.
Medications to be aware of
He also recommends doing a medications review.
Medications to look out for include some older style antidepressants like amitriptyline, and other anticholinergic medications like oxybutynin. These can have a cumulative effect, so using tools to evaluate their anticholinergic burden is helpful.
And don’t forget the anticholinergic patches, he warns.
“Other specialists are still into using oxybutynin patches, which are potently anticholinergic,” he says. Patients often forget them and he has to have a look on their body.
“And then you’ve got to add antipsychotics and the benzodiazepines, be aware of all of those, both short and long acting,” he says.
And then there are the antidepressants that have an antihistamine effect that may be used as sleep aides: “Low dose Mirtazapine at 15 milligrams is really an antihistamine which has significant anticholinergic properties as well,” he says.
The role of lifestyle
Associate Professor Yates says this is a good time to reassure the patient that lifestyle plays a significant role in memory and cognitive ability and addressing risk factors may improve or remove the issue. Regular exercise and a healthy diet are important in their own right, and can also impact on poor sleep and depression, which can both contribute to MCI.
Treating depression can often see memory and cognitive function improve. Likewise, resolving the underlying causes of poor sleep may also see improvements.
As for alcohol, Associate Professor Yates says drinking within the recommended guidelines is unlikely to be a significant cause of MCI. For those with established MCI /ABI or dementia any alcohol will not be helpful.
In essence, he says: “You’re saying, ‘let’s get you right first before we look at your memory issues.”
What is the functional impact?
Assessment tools can help differentiate between MCI and dementia, but often what’s most important is how the memory symptom impacts on day-to-day life and whether the patient can use strategies such as calendar reminders. Family feedback using the Lawton Instrument of Activities of Daily living Scale can help.
To assess if there is progression of memory or cognition problems, he suggests assessment tests such as an MMSE with the clock drawing test, and the informant questionnaire of cognitive decline, at the initial consultation and assuming they are OK then comparing the results again a year later, as recommended in the Dementia Clinical Guidelines
If the results are worse at the review and you suspect dementia, time is generally on your side with an average of 19 years between the development of amyloid plaques and dementia onset.
“There has to be a period of time in the middle when people are emerging from ‘normal’ to dementia, and that’s what we call MCI. But the reality of that is that 60% of people with mild cognitive impairment when you see them in your practice will either stay the same or get better.”
If they are not improving, or their MMSE score or CDT is concerning, it’s time to refer on, he says, making sure that CT scans and standard bloods are done.
Associate Professor Yates says there are a number of memory clinics open that can provide support for patients and GPs.
He notes that GPs do not need to report MCI to driving authorities, and people in George’s position are under no obligation to report MCI to their board of directors either.
When someone presents with MCI, it’s an opportunity to discuss enduring powers of attorney, medical care treatment and end-of-life plans and to improve overall health. The recommendation recently published also say that when MCI is present that we discuss the use of Souvinaid with our patients.
To hear more from Associate Professor Yates, listen to his recent Healthed podcast here.
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