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Prevalence and Classification of Mild Cognitive Impairment in the Cardiovascular Health Study Cognition Study Part 1

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Prevalence and Classification of Mild Cognitive Impairment in the Cardiovascular Health Study Cognition Study Part 1 ORIGINAL CONTRIBUTION Prevalence and Classification of Mild Cognitive Impairment in the Cardiovascular Health Study Cognition Study Part 1 Oscar L. Lopez, MD; William J. Jagust; Steven T. DeKosky, MD; James T. Becker, PhD; Annette Fitzpatrick, PhD; Corinne Dulberg, PhD; John Breitner, MD; Constantine Lyketsos, MD; Beverly Jones, MD; Claudia Kawas, MD; Michelle Carlson, PhD; Lewis H. Kuller, MD Objective: To examine the prevalence of mild cogni- was classified as either MCI amnestic-type or MCI mul- tive impairment (MCI) and its diagnostic classification tiple cognitive deficits–type. in the Cardiovascular Health Study (CHS) Cognition Study. Results: The overall prevalence of MCI was 19% (465 of 2470 participants); prevalence increased with age from Design: The CHS Cognition Study is an ancillary study 19% in participants younger than 75 years to 29% in those of the CHS that was conducted to determine the pres- older than 85 years. The overall prevalence of MCI at the ence of MCI and dementia in the CHS cohort. Pittsburgh center was 22% (130 of 599 participants); prevalence of the MCI amnesic-type was 6% and of the Setting: Multicenter population study. MCI multiple cognitive deficits–type was 16%. Patients: We examined 3608 participants in the CHS Conclusions: Twenty-two percent of the participants who had undergone detailed neurological, neuropsycho- aged 75 years or older had MCI. Mild cognitive impair- logical, neuroradiological, and psychiatric testing to iden- ment is a heterogenous syndrome, where the MCI am- tify dementia and MCI. nestic-type is less frequent than the MCI multiple cog- nitive deficits–type. Most of the participants with MCI Main Outcome Measures: The prevalence of MCI was had comorbid conditions that may affect their cognitive determined for the whole cohort, and specific subtypes functions. of MCI were examined in detail only at the Pitts- burgh, Pa, center (n=927). Mild cognitive impairment Arch Neurol. 2003;60:1385-1389 LDER PERSONS can de- The prevalence rates for MCI and re- velop demonstrable cog- lated conditions have ranged from 3.2% to nitive impairment, espe- 53.8%,6,11-15 reflecting differences in co- cially memory deficits, hort characteristics, and the criteria used to without crossing the define MCI. The prevalence of age- Othreshold for dementia. This condition has associated cognitive impairment seems been termed “mild cognitive impair- higher than that of age-associated memory ment” (MCI), and these patients have an impairment. This is, in part, attributed to increased risk of developing dementia, es- the fact that the concept of age-associated pecially Alzheimer disease.1-3 Because cognitive impairment involves a broader memory deficits are the clinical hallmark range of cognitive deficits, including iso- of Alzheimer disease, most of the criteria lated memory impairment.14,16 In the pres- ent study, we report the prevalence of MCI See also page 1394 in the Cardiovascular Health Study (CHS) Cognition Study using diagnostic criteria developed to characterize MCI require the that encompass a range of clinical manifes- presence of memory deficits in isola- tations of MCI. The prevalence of MCI was tion.4-8 However, other researchers be- determined after a multistage adjudication lieve this to be too restrictive, as it does process. not capture other cognitive problems that 9,10 often occur in elderly persons. For ex- METHODS ample, age-associated cognitive decline de- Author affiliations are listed at scribes those individuals with a wider The characteristics of the 5888 CHS partici- the end of this article. range of cognitive deficits.9 pants have been described previously.17 Begin- (REPRINTED) ARCH NEUROL / VOL 60, OCT 2003 WWW.ARCHNEUROL.COM 1385 ©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 ning in 1988-1989, all participants completed the Modified Mini- Neurological Examination Mental State Examination (3MSE)18 and the Digit Symbol Test19 at their annual visits; the Benton Visual Retention Test was added The neurological examination included detailed assessments for those tested between 1994 and 1998.20 The Telephone In- of motor and sensory functions,25 as well as a mental status ex- terview for Cognitive Status was used when participants did amination (ie, immediate and delayed recall of 3 words, verbal not come to the clinic.21 Further information on cognition was fluency, similarities, clock drawing test, and the Luria 3-hand obtained from proxies using the Informant Questionnaire for test of sequencing). After the mental status examination, the Cognitive Decline in the Elderly,22 and the Dementia Ques- neurologist asked the participant about his or her perfor- tionnaire.23 Symptoms of depression were measured with the mance on these tests, and the response was graded on a 4-point modified version of the Center for Epidemiologic Studies– scale of awareness of cognitive deficits. Depression Scale.24 Between 1991 and 1994, 3608 partici- pants underwent magnetic resonance imaging (MRI) of the brain. DIAGNOSIS OF DEMENTIA A second MRI of the brain was taken during the 1-year period of 1997-1998. The CHS staff also obtained information from The diagnosis of dementia was based on a deficit in perfor- participants and next-of-kin regarding the circumstances of the mance in 2 or more cognitive domains that were of sufficient illness, the history of dementia, and the functional status, as severity to affect the participants’ activities of daily living and well as information about pharmaceutical drug use and alco- on a history of normal intellectual function before the onset of hol consumption.25 cognitive abnormalities. An abnormal domain was present when the results of at least 2 tests of the same domain were abnor- THE CHS COGNITION STUDY mal. The dementia criteria were designed to identify subjects with syndromes that could include relatively preserved memory In 1998-1999 the CHS attempted to identify all participants who functions (eg, frontotemporal dementia), and, thus, a memory had either prevalent dementia at the time of the MRI scan taken deficit, was not required for the diagnosis of dementia.25 between 1991 and 1994, or subsequent incident dementia in 1998-1999; the sample was limited to the 3608 participants who CHS COGNITION STUDY MCI CRITERIA had an MRI scan between 1991 and 1994.25 The participants were classified as high risk for dementia MCI Amnestic-Type (MCI-AT) if they had any of the following characteristics: (1) a 3MSE score of less than 80 at 1 of their last 2 clinic visits, (2) a 5-point de- These subjects had impairments in delayed verbal or nonverbal cline in the 3MSE from the time of MRI to last contact, (3) a recall, and the cognitive deficits must represent a decline from a Telephone Interview for Cognitive Status score less than 28, previous level of functioning, detected with the annual CHS (4) an Informant Questionnaire for Cognitive Decline in the neuropsychological testing, and normal performance in other Elderly score of more than 3.6, (5) an incident stroke, (6) were cognitive function. This diagnosis did not exclude individuals currently residing in a nursing home, or (7) had a diagnosis of with mild defects on instrumental activities of daily living. dementia found on medical record review. In 3 of the clinics (Sacramento, Calif; Winston-Salem, NC; MCI Multiple Cognitive Deficits–Type (MCI-MCDT) and Hagerstown, Md) only the high-risk white participants, but all of the African American participants, were evaluated for the These subjects had deterioration in at least 1 cognitive do- diagnosis of dementia. This was done to increase the power of main (not including memory), or 1 abnormal test result in at the analysis within the African American group, and to in- least 2 other domains, without sufficiently severe cognitive func- crease the overall power of the study. The examination of all tion impairment, or loss of instrumental activities of daily liv- Pittsburgh, Pa, participants allowed us to estimate the “misses” ing to constitute dementia. These cognitive deficits may or may among the low-risk participants at the other centers. not affect instrumental activities of daily living and represent a decline from a previous level of functioning, detected with CLINICAL EXAMINATION the annual CHS neuropsychological testing. Psychiatric Examination PROBABLE AND POSSIBLE MCI In addition to the Center for Epidemiologic Studies– The degree of certainty of the diagnosis of MCI was graded as prob- Depression Scale 10-item version, we administered the Neu- able or possible based on the amount of information available for ropsychiatric Inventory26 to expand the psychiatric informa- the diagnosis and the presence of comorbid conditions. tion. Probable MCI Neuropsychological Examination Participants were classified as having probable MCI if they met The neuropsychological battery included tests of 6 cognitive the following criteria: (1) participants or their families re- domains: premorbid intelligence, memory, language, ported cognitive problems and (2) there were no neurologi- visuoconstructional/visuospatial, executive functions, and cal, psychiatric, or systemic illnesses that could explain their motor functions.25 The results of the neuropsychological bat- presence of cognitive deficits. tery were classified as normal or abnormal (Ͼ1.5 SDs below individuals of comparable age and educational level) based on Possible MCI normative data collected from a sample of 250 unimpaired subjects in Pittsburgh. In 3 of the centers, participants with 2 Participants were classified as having possible MCI if they met abnormal test results were referred for a neurological exami- the following criteria: (1) neither participants nor their fami- nation and further clinical evaluation. In the Pittsburgh cen- lies reported cognitive problems; or (2) there were neurologi- ter, all of the available participants had a neurological exami- cal, psychiatric, or systemic illnesses that might explain the pres- nation regardless of the results of the neuropsychological ence of cognitive deficits; or (3) there was an incomplete battery.
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