Differences

Last edited on January 2, 2024

This shows you the differences between two versions of the page.

--- cl:3-mild-neurocog-disorder [on March 20, 2019]
+++ cl:3-mild-neurocog-disorder [on January 2, 2024]
psychdb [Subtypes]
@@ Line 1: / Line 1: @@
 ====== Mild Neurocognitive Disorder / Mild Cognitive Impairment (MCI) ======
+{{INLINETOC}}
 ===== Primer =====
-**Mild Neurocognitive Disorder** (also known as **Mild Cognitive Impairment**, or MCI) is a condition in which individuals demonstrate cognitive impairment with minimal impairment of instrumental activities of daily living (IADLs). Although it can be the first cognitive sign of [[geri:dementia:alzheimers|]], it can also be secondary to other disease processes (e.g. - neurologic, other neurodegenerative disorders, systemic, infectious, or psychiatric disorders). When there is //significant// impairment to daily function, a [[cl:2-major-neurocog-disorder|major neurocognitive disorder]] needs to be considered instead.
+**Mild Neurocognitive Disorder** (also known as **Mild Cognitive Impairment**, or MCI) is a condition in which individuals demonstrate cognitive impairment with minimal impairment of instrumental activities of daily living (IADLs). Although it can be the first cognitive sign of [[geri:dementia:alzheimers|]], it can also be secondary to other disease processes (e.g. - neurologic, other neurodegenerative disorders, systemic, infectious, or psychiatric disorders). When there is //interference// with independence in everyday activities, a [[cl:2-major-neurocog-disorder|major neurocognitive disorder]] needs to be considered instead.
-===== Diagnostic Criteria =====
+<HTML>
+<script async src="https://pagead2.googlesyndication.com/pagead/js/adsbygoogle.js"></script>
+<!-- Leaderboard -->
+<ins class="adsbygoogle"
+     style="display:block"
+     data-ad-client="ca-pub-8020066590182443"
+     data-ad-slot="1227446251"
+     data-ad-format="auto"
+     data-full-width-responsive="true"></ins>
+<script>
+     (adsbygoogle = window.adsbygoogle || []).push({});
+</script>
+</HTML>
+== Epidemiology ==
+  * Prevalence is between 10-20% in adults over 65 years.
+== Prognosis ==
+  * Anywhere between 3 to 13% of patients with mild neurocognitive disorder will progress to a major neurocognitive disorder (dementia) each year.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2863139/|Farias, S. T., Mungas, D., Reed, B. R., Harvey, D., & DeCarli, C. (2009). Progression of mild cognitive impairment to dementia in clinic-vs community-based cohorts. Archives of neurology, 66(9), 1151-1157.]])]
+  * Not all individuals with MCI will go on to develop a dementia!
+    * This is a highly heterogeneous group with variable rates of conversion to dementia.
+    * For example, having multiple domain MCI appears to increase the risk of future dementia.
+== Comorbidity ==
+  * Neuropsychiatric symptoms will be present in 35-75% of cases.
+== Risk Factors ==
+  * Higher age, the presence of at least one ApoE4 allele, and medicated hypertension are independent risk factors for MCI.[([[https://pubmed.ncbi.nlm.nih.gov/14739544/|Tervo, S., Kivipelto, M., Hänninen, T., Vanhanen, M., Hallikainen, M., Mannermaa, A., & Soininen, H. (2004). Incidence and risk factors for mild cognitive impairment: a population-based three-year follow-up study of cognitively healthy elderly subjects. Dementia and geriatric cognitive disorders, 17(3), 196-203.]])]
+  * Higher education is a protective factor for MCI.
+===== DSM-5 Diagnostic Criteria =====
 <WRAP group>
 <WRAP half column>
 == Criterion A ==
-Evidence of **//modest//** cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual motor, or social cognition) based on:
+Evidence of **//modest//** cognitive decline from a previous level of performance in ''1'' or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual motor, or social cognition) based on:
   - Concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and
   - A substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment.
+</WRAP>
+<WRAP half column>
 == Criterion B ==
-The cognitive deficits **//do not interfere with capacity for independence in everyday activities//** (i.e., complex instrumental activities of daily living such as paying bills or managing medications are preserved, but greater effort, compensatory strategies, or accommodation may be required).
+The cognitive deficits **//do not interfere with capacity for independence in everyday activities//** (i.e. - complex instrumental activities of daily living such as paying bills or managing medications are preserved, but greater effort, compensatory strategies, or accommodation may be required).
 == Criterion C ==
-The cognitive deficits do not occur exclusively in the context of a delirium.
+The cognitive deficits do not occur exclusively in the context of a [[cl:1-delirium|delirium]].
 == Criterion D ==
 The cognitive deficits are not better explained by another mental disorder (e.g., [[mood:1-depression:home|major depressive disorder]], [[psychosis:schizophrenia-scz|schizophrenia]]).
 </WRAP>
-<WRAP half column>
+</WRAP>
-== Specifiers ==
+==== Specifiers ====
-<accordion collapsed="false">
+<WRAP group>
+<WRAP half column>
 <panel icon="fa fa-search-plus" size="xs" title="Etiology Specifier">
   * Major or Mild Neurocognitive Disorder Due to [[geri:dementia:alzheimers|Alzheimer’s Disease]]
@@ Line 38: / Line 73: @@
   * Unspecified Neurocognitive Disorder
 </panel>
+</WRAP>
+<WRAP half column>
 <panel icon="fa fa-signal" size="xs" title="Behaviour Specifier">
 **Specify:**
-  * **Without behavioral disturbance**: If the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance.
+  * **Without behavioural disturbance**: If the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance.
-  * **With behavioural disturbance** (//specify disturbance//): If the cognitive disturbance is accompanied by a clinically significant behavioural disturbance (e.g., psychotic symptoms, mood disturbance, agitation, apathy, or other behavioural symptoms).
+  * **With behavioural disturbance** (//specify disturbance//): If the cognitive disturbance is accompanied by a clinically significant behavioural disturbance (e.g. - psychotic symptoms, mood disturbance, agitation, apathy, or other behavioural symptoms).
 </panel>
-</accordion>
+</WRAP>
+</WRAP>
-</WRAP></WRAP>
+===== Subtypes =====
+The DSM-5 criteria notably do not provide additional sub-typing of MCI beyond the specifier criteria. Outside of the DSM-5, a total of ''4'' MCI subtypes have been proposed, depending on whether the presentation is amnestic/non-amnestic, and single/multiple domain:[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2929315/|Rapp, S. R., Legault, C., Henderson, V. W., Brunner, R. L., Masaki, K., Jones, B., ... & Thal, L. (2010). Subtypes of mild cognitive impairment in older postmenopausal women: the Women’s Health Initiative Memory Study. Alzheimer disease and associated disorders, 24(3), 248.]])]
+  - **Amnestic MCI, Single Domain (a-MCI-sd)**\
+    * **a-MCI-sd** involves primarily memory impairment with no or minimal involvement of the other cognitive domains.
+  - **Amnestic MCI, Multiple Domain (a-MCI-md)**
+    * **a-MCI-md** involves memory impairment as the primary domain affected, but other cognitive domains (e.g. - executive function, attention, language, decision-making, judgment, visuospatial) are also impaired.
+  - **Non-Amnestic MCI, Single Domain (na-MCI-sd)**
+    * **na-MCI-sd** involves impairment of a single, non-memory cognitive domain, such executive function, attention, language, or visuospatial skills.
+  - **Non-Amnestic MCI, Multiple Domain (na-MCI-md)**
+    * **na-MCI-md** involves impairment of two or more cognitive domains, neither of which involves memory impairment.
+===== Differential Diagnosis =====
+<alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">
+See main article: **[[geri:dementia:home|]]**
+</alert>
+  * Some cases of MCI are actually reversible causes of cognitive impairment. This is a broad differential diagnosis that includes medication side effects, [[sleep:breathing:1-osa|obstructive sleep apnea]], [[mood:1-depression:geriatric|depression]] (pseudodementia), and other medical conditions. Medications such as [[meds:benzos:home|benzodiazepines]] may also contribute to cognitive impairment and so [[meds:benzos:deprescribe-tapering|deprescribing]] may also be an important factor to consider.
 ===== Management =====
-See [[https://www.ncbi.nlm.nih.gov/pubmed/29282327|Petersen, Ronald C., et al. 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 (2018): 126-135.]]
+<alert type="info" icon="fa fa-book fa-lg fa-fw">
+See also: **[[https://www.ncbi.nlm.nih.gov/pubmed/29282327|Petersen, Ronald C., et al. 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 (2018): 126-135.]]**
+</alert>
+==== Monitoring and Counselling ====
+  * Clinicians should counsel patients with MCI and their families to discuss long-term planning topics such as advance directives, driving safety, finances, and estate planning.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5772157/|Petersen, R. C., Lopez, O., Armstrong, M. J., Getchius, T. S., Ganguli, M., Gloss, D., ... & Rae-Grant, A. (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), 126-135.]])]
+  * For patients diagnosed with MCI, clinicians should perform serial cognitive assessments over time (e.g., a [[cognitive-testing:moca|MoCA]] every 6 to 12 months) to monitor for changes in cognitive status.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5772157/|Petersen, R. C., Lopez, O., Armstrong, M. J., Getchius, T. S., Ganguli, M., Gloss, D., ... & Rae-Grant, A. (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), 126-135.]])]
+  * [[geri:dementia:1-bpsd|Neuropsychiatric symptoms]] should also be serially assessed for, as these may be more functionally impairing than the cognitive symptoms.
+==== Exercise ====
+  * [[teaching:exercise-prescription|Exercise]] at least twice weekly of moderate intensity may provide benefits in cognition for individuals with MCI.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5772157/|Petersen, R. C., Lopez, O., Armstrong, M. J., Getchius, T. S., Ganguli, M., Gloss, D., ... & Rae-Grant, A. (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), 126-135.]])]
-===== Treatment =====
+==== Pharmacologic ====
-== Vitamin D ==
+  * There are no high-quality, long-term studies suggesting that either pharmacologic or dietary agents can improve cognition or delay progression in patients with MCI.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5772157/|Petersen, R. C., Lopez, O., Armstrong, M. J., Getchius, T. S., Ganguli, M., Gloss, D., ... & Rae-Grant, A. (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), 126-135.]])]
-Improvements in cognition and lipid levels are seen in individuals with long-term supplementation of Vitamin D.[([[https://www.ncbi.nlm.nih.gov/pubmed/30279214|Fujishiro, H. (2018). Vitamin D3 as a potentially modifiable factor in mild cognitive impairment. J Neurol Neurosurg Psychiatry, jnnp-2018.]])]
+  * [[meds:dementia:home|Acetylcholinesterase inhibitors]] as a class have shown **no benefit** on cognitive outcomes or reduction in progression from MCI to dementia (although some studies could not entirely exclude a positive effect). In addition to lacking efficacy, the side effects of cholinesterase inhibitors can be significant.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5772157/|Petersen, R. C., Lopez, O., Armstrong, M. J., Getchius, T. S., Ganguli, M., Gloss, D., ... & Rae-Grant, A. (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), 126-135.]])] If an individual is prescribed an acetylcholinesterase inhibitor, they should be counselled that this is off-label.