​Kembara Xtra - Medicine - Mild Cognitive Impairment

​Kembara Xtra - Medicine - Mild Cognitive Impairment 
According to common memory tests, mild cognitive impairment (MCI) is considerable cognitive decline without dementia:
- Concerns about cognitive change - Maintenance of independence in daily living (ADL)
- Impairment in one or more cognitive areas, including language, executive function, memory, attention, and visuospatial disorder.
- other words for MCI that are mentioned in the literature:
Mild cognitive dysfunction; cognitive impairment but not dementia (CIND). Some of these ailments do not develop into dementia. The "mild neurocognitive disorder" (mNCD), which shares many characteristics with MCI and may be an early sign of Alzheimer's disease, is mentioned in the DSM-5.
Compared to age-matched populations, older persons with MCI are 3 times more likely to develop dementia in 2 to 5 years.

 Incidence
Male is more prevalent than female.
Predominant age: 12 to 15/1,000 person-years in those under 65; 50 to 75/1,000 person-years in those over 75; higher in older people and in those with less education.
Prevalence
In the US, MCI is more common than dementia (12–18%) among people under the age of 60. 25% for people 80–84 years old. With age and for people with lesser educational levels, prevalence rises.


Pathophysiology and Etiology 

There are four different subtypes of MCI: single-domain amnestic, multiple-domain amnestic, single-domain nonamnestic, and multiple-domain nonamnestic
The amnestic subtype has a higher risk of developing into Alzheimer's.
Vascular, neurodegenerative, traumatic, metabolic, psychological, or any combination of these conditions
Genetics
Consideration must be given to the apolipoprotein (APO) E4 genotype in particular subsets of MCI where the disease will advance to Alzheimer dementia: There are numerous routes that can lead to amyloid deposition and buildup, which is thought to be related to dementia.

Risk factors include smoking, sleep apnea, the APO E4 genotype, low levels of education, depression, and a sedentary lifestyle in addition to diabetes, hypertension, hyperlipidemia, and cerebrovascular illness.

Prevention 

Improve vascular risk factors while putting an emphasis on a fit, active lifestyle.

Diagnosis 
Pay attention to cognitive dysfunction and impairments. MCI is intended to represent a change in cognition rather than a permanent impairment.
Review all prescription drugs that can impair cognition, paying special attention to anticholinergic drugs because some patients taking them might be incorrectly diagnosed with MCI.
 Discard depression. Compared to age-matched populations, MCI patients have a higher rate of depression.
 Examine daily function (ADLs, instrumental ADLs), as well as any subtle alterations (such in the job).
 Affects social interactions and caregiver stress
Assess the vascular risk factors, including cerebrovascular disease, hypertension, diabetes, and hyperlipidemia.
 Evaluate alterations in behavior.
Olfactory impairment may be linked to the development of Alzheimer dementia and amnestic MCI. This can be quickly assessed in patients with memory loss. 

clinical assessment 
A neurologic examination to rule out reversible CNS causes of cognitive impairment or other causes of cognitive impairment; a general examination concentrating on clinical clues to indicate vascular illness (e.g., bruits, abnormal BP); and office tests of cognitive function, depression, and functional status.

Differential Diagnosis: Aging normally (including age-related cognitive decline and age-related memory decline)
Depression, dementia, and delirium
Cognitive impairment that is "reversible" - Drugs (anticholinergics and drugs having anticholinergic characteristics)
Take into account sleep disorders that might affect cognition, particularly sleep apnea and hypothyroidism. Also investigate vitamin B12 insufficiency.

Laboratory Results 
Formal screening using standardized cognitive tests (such as the Montreal Cognitive Assessment [MoCA] and Saint Louis University Mental Status [SLUMS]) is crucial; the MoCA may be more sensitive for identifying and monitoring MCI.
Testing for neuropsychological disorders is advised for all patients with MCI.
Initial examinations (lab, imaging)
Thyroid-stimulating hormone, a comprehensive metabolic profile, a complete blood count, and vitamin B12
When there are rapid or abnormal presentations, focal neurologic impairments, or both, imaging tests can be useful:
- Cognitive impairment-causing structural CNS disorders can be found using a CT scan:
 Cerebrovascular accident; subdural hematoma; normal pressure hydrocephalus; metastatic disease
- Vascular, infectious, neoplastic, and inflammatory diseases are further evaluated by MRI.

Tests in the Future & Special Considerations

 Record the development of comorbid disorders, such as concomitant depression, cognitive deterioration, and functional impairment.
 Careful preparation while the patient is still able
 Early instruction of carers in matters of security, upholding order, controlling stress, and future planning
Concentrate on your driving skills and safety.
Work-related concerns ought to be looked into and optimized to the fullest extent possible.
Depending on subjective concerns and the continuous diagnosis of MCI, neuropsychological testing should be performed every one to two years.
Interpretation of Tests
Due to the variability of the population investigated and the paucity of longitudinal investigations, little is known about the pathology of MCI.
Pathophysiology of Alzheimer's disease:
- Hippocampal neurofibrillary tangles
- Amyloid buildup in senile plaques - Neuronal degeneration
Amnestic MCI is associated with white matter hyperintensity volume on MRI, whereas nonamnestic MCI is associated with infarcts. Those with MCI have intermediate amounts of pathologic findings of Alzheimer disease with amyloid deposition and neurofibrillary tangles in the mesial temporal lobes.

Management Aggressive treatment is necessary for atherosclerotic risk factors.

Medication 
There is no evidence linking the use of cholinesterase inhibitors (ChEIs) in MCI to a delay in the onset of dementia or Alzheimer's disease. Furthermore, the safety profile demonstrated that there are sizable dangers related to ChEIs. ChEIs are therefore not often advised.


Referral 
To assess and distinguish between distinct subtypes of MCI and particular cognitive abnormalities, think about referring the patient to a memory specialist (e.g., a geriatrician, neurologist, geropsychiatrist, or neuropsychologist).

Further Treatments 

With cognitive training and physical activity, there may be an advantage in terms of performance on tests for global cognitive functioning. Six months of exercise training is probably going to boost cognitive tests.

Alternative Therapies 
Vitamin E has not been found to be effective in the prevention or treatment of MCI, and long-term usage of Ginkgo biloba extract has not been shown to slow the progression of MCI to dementia. Additionally, ginkgo biloba may raise your risk of bleeding, especially CNS bleeds.


Delirium is more frequent in hospitalized individuals with all types of cognitive impairment.
 Steer clear of drugs including anticholinergics, antihistamines, and sedatives that could exacerbate or hasten cognitive impairment.
Patients could be quite sensitive to the hospital setting; the ideal stimulation level is moderate.
- Avoid being sensory-deprived. Ensure that patients may obtain eyeglasses and hearing aids.
- Use regular cues, and wherever feasible, have the patient's relatives or caretakers present.
- orient patients to the time and date frequently.

Take Action 

Every six to twelve months, reassess to see if the symptoms are getting worse.
patient observation
Along with a clinical history and exam, appropriate cognitive and functional tests should be utilized to assess improvement. Patients should be monitored more often after starting a medicine to assess efficacy, adverse effects, dose titration, and other factors. Clinicians should actively monitor and counsel patients and families to look out for signs of declining executive function, which may be an early sign of MCI progressing to dementia. ADL function impairments are a good indicator of dementia development from MCI.
Weaning efforts should be performed for drugs that may affect cognition.

Diet 
It is important to prioritize diet in order to reduce atherosclerotic risk factors.

Education of Patients 

Discuss subjects related to long-term planning, such as advanced directives, firearm safety, driving safety, finances, and estate preparation.
Encourage a change in lifestyle:
- Exercise, such as walking for 30 minutes every day or most days of the week, has been shown in some studies to modestly improve various measures of cognition.
- It is important to promote mental activity that enhances language development and physical coordination.
Activities like playing video games, reading books, making crafts, doing crossword puzzles, and using computers may reduce the risk of developing MCI.
Treatment of vascular risk factors (hypertension, diabetes, cerebrovascular disease, and hyperlipidemia) is important in lowering risk of progression to dementia (e.g., intensive blood pressure lowering in the Sprint Mind Study reduced incidence of MCI with target SBP of 120 mm Hg). Cognitive rehabilitation strategies may be helpful in helping with daily activities relating to memory tasks in MCI.
Currently, there are no dietary supplements or drugs with FDA approval that have been proven to be helpful for MCI.
Compliance with CPAP therapy improves cognition in people with sleep apnea.
Maintaining good dental hygiene and frequent dental exams is essential. Significant periodontal disease is linked to MCI, and excessive alcohol use that exceeds advised limits deteriorates cognition.

The likelihood that older persons with MCI will develop dementia in the next two to five years is three times higher.
The majority of MCI amnestic subtypes will eventually develop dementia.
In specialized settings, neuropsychological testing methods, cerebrospinal fluid (CSF) biomarkers, and neuroimaging studies are utilized to forecast the development of dementia. These are not frequently utilized because they are not extensively used or cost-effective.
Women are more prone to develop dementia than males.
Olfactory impairment may increase the likelihood of dementia developing.
Patients who have neuropsychiatric symptoms like anxiety or sadness are more likely to develop Alzheimer disease. This could be useful in identifying MCI patients who are at increased risk.