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cl:3-mild-neurocog-disorder [on December 8, 2018]
cl:3-mild-neurocog-disorder [on January 2, 2024] (current)
psychdb [Subtypes]
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 +====== 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 //​interference//​ with independence in everyday activities, a [[cl:​2-major-neurocog-disorder|major neurocognitive disorder]] needs to be considered instead.
  
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 +
 +== 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 ''​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).
 +
 +== Criterion C ==
 +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>​
 +
 +==== Specifiers ====
 +<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]]
 +  * Major or Mild [[geri:​dementia:​frontotemporal|Frontotemporal Neurocognitive Disorder]]
 +  * Major or Mild Neurocognitive Disorder With [[geri:​dementia:​lewy-body|Lewy Bodies]]
 +  * Major or Mild [[geri:​dementia:​vascular|Vascular Neurocognitive Disorder]]
 +  * Major or Mild Neurocognitive Disorder Due to [[:​cl:​tbi|Traumatic Brain Injury]]
 +  * [[cl:​psychiatric-side-effects-of-medications|Substance/​Medication-Induced]] Major or Mild Neurocognitive Disorder
 +  * Major or Mild Neurocognitive Disorder Due to [[cl:​hiv|HIV Infection]]
 +  * Major or Mild Neurocognitive Disorder Due to [[geri:​dementia:​creutzfeldt-jakob-disease-cjd|Prion Disease]]
 +  * Major or Mild Neurocognitive Disorder Due to [[geri:​dementia:​parkinsons|Parkinson’s Disease]]
 +  * Major or Mild Neurocognitive Disorder Due to [[cl:​huntingtons-disease|Huntington’s Disease]]
 +  * Major or Mild Neurocognitive Disorder Due to Another Medical Condition
 +  * Major or Mild Neurocognitive Disorder Due to Multiple Etiologies
 +  * Unspecified Neurocognitive Disorder
 +</​panel>​
 +</​WRAP>​
 +<WRAP half column>
 +<panel icon="​fa fa-signal"​ size="​xs"​ title="​Behaviour Specifier">​
 +**Specify:​**
 +  * **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).
 +</​panel>​
 +</​WRAP>​
 +</​WRAP>​
 +
 +===== Subtypes =====
 +The DSM-5 diagnostic criteria notably do not provide additional sub-typing of MCI beyond the specifier criteria or how [[cognitive-testing:​memory|cognitive domains]] are specifically involved. 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 =====
 +<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.]])]
 +
 +==== Pharmacologic ====
 +  * 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.]])]
 +  * [[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.