6/6/18 Assessment, Identification, and Management of Mild Cognitive Impairment (MCI) and Dementias in Your Clinical Practice Mark Hogue, Psy.D. Donald McAleer, Psy.D., ABPP Northshore Neurosciences Overview • MCI • Definitions, Subtypes, Screening/ assessment • Dementias • Definitions, Subtypes, Screening / Assessment • Management of Cognitive issues for the general clinician • Referrals/ treatments • Family • Legal / Driving 1 6/6/18 Erie Times-News June 3, 2018 Dementia and Mild Cognitive Impairment • Globally, the number of people diagnosed with dementia is increasing every year at an alarming rate. There are currently over 46.8 million people living with dementia and this is estimated to rise to 131.5 million people by 2050. (Tozer, 7/5/17) • Dementia • A loss of cognitive processes from a prior level of cognitive processes, as compared to age-mates, and due to a pathophysiological process. • MCI • An intermediate step between normal cognition and dementia • A measurable deficit in at least one domain, absent dementia and showing no appreciable deficit in ADL functioning 2 6/6/18 Mild Cognitive Impairment • Diagnos(c concepts to describe cogni(ve change in aging • Benign senescent forge-ulness (BSF) – Kral, 1962 • Mild Cogni?ve Impairment (MCI) – Reisberg et al., 1982 • Age-Associated Memory Impairment (AAMI) – CooK et al., 1986 • Late-life forge-ulness (LLF) – BlacKford & La Rue, 1989 • Age-Associated Cogni?ve Decline (AACD) – Levy et al., 1994 • Cogni?ve Impairment No Demen?a (CIND) – Graham et al., 1997 • Amnes?c Mild Cogni?ve Impairment (aMCI) – Petersen et al., 1999 • Age Related Cogni?ve Decline (ARCD) – DSM IV • Mild Cogni?ve Disorder (MCD) – ICD-10 • Prodromal AD – Dubois et al., 2010 • MCI due to AD – NIA-AA criteria; Albert et al., 2011 • Mild Neurocogni?ve Disorder (MNCD) – DSM-5 Mild Cognitive Impairment • Typical clinical/cognitive problems in MCI • Changes in memory (more dependent on reminders, notes, diaries; misplacing things; etc.) • More difficulties with multi tasking • Changes in attention and executive functions (more easily distracted; less flexible; new difficulties with problem solving; less skilled or interested in planning ahead (e.g. traveling) • Changes in language (word-finding difficulties) • Changes in visuospatial function • Often slower or more stressed (routines change) • Limited insight can occur (what is their theory?) • Often increase in conflict with significant others (new safety concerns from family members; change of roles in family) • ADLs can be impacted (new difficulties with driving in challenging situations; subtle new problems with managing finances; cog. decline in skills; e.g. bridge, golf etc.) • Holsinger et al., 2007; Lautenschlager & Kurz, 2010; McCarten et al., 2013 Management of SMC and MCI 3 6/6/18 Mild Cognitive Impairment Normal Aging MCI Dementia Mild Cognitive Impairment • Subtypes • Amnestic • Most Common?* ? Precursor to SDAT • Non- Amnestic • Impairment in a single or multiple non-memory domain • Language, executive functioning, spatial skills • Depending: could progress to Fronto-Temporal Dementia (FTD), Vascular Dementia (VD), Primary Progressive Aphasia (PPA), Diffuse Lewy Body Dementia (DLB). *Mark has issues with this! 4 6/6/18 Heterogeneity of MCI & possible multiple etiologies Clinical Presenta-ons Possible E-ologies MCI Degenera-ve Amnes-c Vascular MCI Metabolic Mul-ple Domains Trauma-c MCI Single Psychiatric Non-memory Domain Others? Mild Cognitive Impairment • Rate of progression from MCI to dementia: 2 to 20% • Risk factors: • age, race, lower education • HTN, DM, sleep disorders • Apolipiprotein E- epsilon 4 genotype • h/o CVA and h/o cardiac disease have more chance of amnestic than non- amnestic MCI • Pathology: predominantly, MCI autopsy samples show AD pathology ie, tau distribution in medial temporal lobes 5 6/6/18 The aging process Brain Amyloid-β Burden Is Associated with Disrup9on of Intrinsic Func9onal Connec9vity within the Medial Temporal Lobe in Cogni9vely Normal Elderly Zhuang Song, Philip S. Insel, Shannon Buckley, Seghel Yohannes, Adam Mezher, Alix Simonson, Sarah Wilkins, Duygu Tosun, Susanne Mueller, Joel H. Kramer, Bruce L. Millerand Michael W. Weiner Journal of Neuroscience 18 February 2015, 35 (7) 3240-3247; DOI: hTps://doi.org/10.1523/JNEUROSCI.2092- 14.2015 Alzheimer’s Process: Destruction of Cortex 6 6/6/18 Alzheimer’s Process: Destruc3on of Cortex Agreement of new perspectives • Currently, biomarkers, esp. CSF markers can be used as research tool • POSSIBLY: identifying persons @ risk of progressing to AD • Findings from small # of studies from selected clinical samples cannot be generalized (as yet) to the general population 7 6/6/18 Genetics • MCI is a gene+cally complex condi+on and there are currently no major genes known to be involved. • Each of the disorders that my possibly underlay MCI (Eg: AD, vascular pathology, depression) may par+ally have some gene+c components. • Consequently, different genes could underlie e+ologies, and gene+c, environmental, health history, drug/etoh abuse likely creates even a more complex and heterogeneous picture. Mild Cognitive Impairment • Cogni&ve: • Neuropsychiatric: depression, irritability, anxiety, aggression, apathy, dysphoria • Olfactory changes • Gait slowing: motoric cogni&ve risk 8 6/6/18 Mild Cognitive Impairment • If patient or a close contact • MCI can reflect a pathological voices concern about memory or disease that may progress to impaired cognition, assess for dementia. MCI and not assume the • Assessment can rule out concerns are related to normal reversible cause, help pt and aging family to understand cause of cognitive decline and prognosis Recommenda)ons for General Criteria: MCI • General Criteria for MCI Not normal, not demented (Does not meet criteria (DSM IV, ICD 10) for a dementia syndrome Cognitive Decline - Self and/or informant report - and impairment on objective cognitive tests And/or: -Evidence of decline over time on objective cognitive tests Preserved basic activities of daily living (ADLs) / or minimal impairment in complex instrumental functions. 9 6/6/18 Cognitive Complaint Not normal for age Not demented Cognitive decline Essentially normal functional activities Mild Cognitive Impairment Impairment in Memory? Only in Memory? More than one domain? YES NO YES NO YES NO MULTIDOMAIN MULTIDOMAIN AMNESTIC Single non- MCI MCI MCI memory MCI AMNESTIC Non-AMNESTIC Mild cognitive Impairment • should not rely on historical • Subjective cognitive complaints report alone of subjective alone can result in both over- memory concerns when and under-diagnosis of MCI and assessing for MCI thus are insufficient • To screen for MCI - should use a brief, validated cognitive assessment instrument in addition to eliciting patient and informant history regarding cognitive concerns 10 6/6/18 Mild Cognitive Impairment • Should use validated assessment • Various instruments have tools acceptable diagnos:c accuracy but none is superior to another. • For pts who test positive, perform a more formal clinical • Because brief cogni:ve assessment assessment tests are more sensi:ve than specific, pa:ents who test posi:ve for MCI should then have further assessment Mild Cognitive Impairment • Assess for the presence of • Diagnosing dementia functional impairment related to prematurely can lead to negative cognition before diagnosing of consequences for patients and dementia. families. • Cooking, water running, • Assess for evidence of functional misplacing food/ incidentals, impairment limiting need to replace lost items, independence in daily activities financial management, driving/ • A requirement for all dementia directional issues, medication diagnoses, to help distinguish errors, gets lost in stores between MCI and dementia 11 6/6/18 Mild Cognitive Impairment • Clinicians who themselves lack • Perform a medical evalua<on for the necessary experience should MCI risk factors that are refer these patients to a poten<ally modifiable specialist with experience in • Some cases of MCI cognition are reversible, including medica<on adverse events, • Remember the possible sleep apnea, depression, anxiety disorders, NPH, Infec<on, reversible causes Vitamin B12, D deficiencies, various metabolic disorders (chronic UTIs, chronic infec<ons) Mild Cognitive Impairment •Clinicians should •MCI can improve, perform serial remain stable, or assessments over progress over time, time to monitor for which can change changes in cognitive diagnosis and status approach 12 6/6/18 Assessments for MCI (incomplete lists) • Cognitive Assessment Toolkit • Saint Louis University Mental (Alzheimer’s Association) Status (SLUMS). • General Practitioner Assessment of • Cognistat Cognition (GPCOG) • Memory Impairment Screen (MIS) • Cognistat Assessment System: Web based • Mini-Cog • Cognistat Paper • Informant Questionnaire • Cognistat AcOve Form- • Mini Mental Status Exam (MMSE) • Montreal Cognitive Assessment (MoCA) • Now APP for iPhone Cognitive Assessment Toolkit (Medicare Wellness Visit) 13 6/6/18 Cognitive Assessment Toolkit (Medicare Wellness Visit) Mini Cog Validity and Reliability • Validity and Reliability • The primary validation of the Mini-Cog© was tested in studies of accuracy in detecting the presence of dementia, now termed major neurocognitive disorder. Most studies included mainly individuals with Alzheimer type and mixed degenerative/vascular dementias. The recommended cut score for dementia screening (0-2 = positive; 3-5 = negative) was derived empirically to optimize the balance of sensitivity