A Reference Guide for Mild Cognitive Impairment

Survey of Mild Cognitive

Impairment Resources

Evelyn Smith

 MS in Library Science, University of North Texas (2012)

This survey begins on a very personal note since this author’s mother received the chilling diagnosis of mild cognitive disorder in August 2000 after showing symptoms of memory decline. Since that time, the syndrome gradually progressed through the stages of Alzheimer’s so that a once vibrant and accomplished woman is now enduring the final stage of Alzheimer’s in the hospice ward of an Alzheimer’s care center. Along the way, this researcher has wondered if there was anything more she could have done to delay her mother’s descent into dementia.  Accordingly, this sampling of research chronicles an accurate assessment of current MCI research that should help other caregivers and potential caregivers cope with what psychiatry now views as the earliest stage of Alzheimer’s.

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Overview

The following sources obtained through Web of Science, ScienceDirect, and PubMed give summarizes of what medical science currently knows about mild cognitive disorder from different points of view.  The many articles available through PubMed also point out how much information is available Online about mild cognitive disorder and Alzheimer’s disease.

 Mild Cognitive Impairment. (2010, November 17).  Alz.org/Alzheimer’s Association. Retrieved from http://www.alz.org/alzheimers_disease_mild_cognitive_impairment.asp

The Alzheimer’s Association defines mild cognitive impairment as problems with memory, language, and mental functioning significant enough to be noticeable, but not crucial enough to interfere with simple activities of daily living (ADLs) (2010, November 17).  The Association further recognizes that a diagnosis of amnestic MCI increases the risk of developing Alzheimer’s, but not everyone who shows evidence of MCI will go on to develop Alzheimer’s (Alzheimer’s, 2010, November 17, para. 3 and 4).  The Association then dispenses the current take on treatment: The daily dose of 10 milligrams of donepezil (Aricept) can delay the progression to Alzheimer’s for about a year, but all benefits disappear within three years.  Razdyne and vitamin E also do not reduce the risk (Alzheimer’s, 2010, November 17, para. 6-7).

Mild Cognitive Impairment. (2011). Alzheimer’s Disease Center. NYU Medical Center/NYU School of Medicine. Retrieved from http://www.med.nyu.edu/adc/forpatients/cognitiveimpair.html

Making the best of a bad situation, the Alzheimer’s Center at the New York Medical Center defines mild cognitive impairment as a “comparatively mild cognitive problem that is worse than expected due to aging” (2011, para. 1).  Memory, concentration, and orientation decline along with decaying functional abilities that often correspond with pathological changes in certain parts of the brain (Alzheimer’s Center, 2011, para. 2). Neurological and psychiatric testing and a review of the patient’s past medical history and current symptoms make up the diagnostic procedure, although both MCI and Alzheimer’s technically can only be confirmed by an autopsy (Alzheimer’s Center, 2011, para. 4).  Non-pharmacological treatments, including memory enhancement programs and counseling for depression may help MCI patients (Alzheimer’s Center, 2011, para. 7).  However, at this point, an elder care attorney should prepare a living will as well as documents conferring power of attorney, and take steps towards ensuring the MCI-diagnosed client’s financial security (Alzheimer’s Center, 2011, para. 8). A neurologist also needs to monitor symptoms and periodically re-evaluate the MCI patient as the syndrome progresses (Alzheimer’s Center, 2011, para. 10).

Mild Cognitive Impairment (MCI). (2010, August 26).  Mayoclinic.com Retrieved from http://www.mayoclinic.com/health/mild-cognitive-impairment/DS00553

The Mayo Clinic sets the standards for Alzheimer’s and mild cognitive impairment research, so its overview accords respect.  This summary is similar to other sources, but the difference lies in the details, even though the Mayo Clinic is not afraid to pronounce that MCI is the intermediate stage between dementia and the loss of cognitive function that results from normal aging (2011, para. 1).  Later it specifies that MCI often, but not always, causes the same brain changes found in Alzheimer’s and other types of dementia as brain imaging shows the shrinking of the hippocampus, the region that is responsible for memory, as well as plaques of beta amyloid protein, and the enlargement of the ventricles of the brain (2011, para. 5). The Mayo Clinic web site also describes MCI symptoms in simple terms, for example, “forgetting appointments, and losing trains of thought”  as well as noting how to prepare for an appointment with a neurologist that might confirm MCI.  Its list of risk factors additionally breaks down into those that are uncontrollable—age and the presence of the APOE-e4 gene linked to Alzheimer’s—as well as less clear-cut but possibly preventable risk factors: diabetes, smoking, depression, high blood pressure, lack of physical exercise, and elevated cholesterol levels (Mayo Clinic, 2011, para. 5). Always practical, the synopsis concludes that no drugs specifically for treating MCI are approved by the Food and Drug Administration (para. 15), but patients whose main symptom is memory loss might benefit from cholinesterase inhibitors (para. 16).  If the caretakers and family of MCI patients can read only one source on MCI, it ought to be the Mayo Clinic web site.

Rabin, P.. V. (n.d.). Mild Cognitive Impairment. Practice guidelines for treatment of patients with Alzheimer’s disease and other dementias. APA (American Psychiatric Association) Practice Guidelines. (DSM-IV). 2nd ed. Retrieved from http://www.psychiatryonline.com/

Since most in depth literature on mild cognitive impairment refers back to the American Psychiatric Association’s DSM-IV-TM, readers will find a look at its assessment of MCI helpful. The APA defines mild cognitive syndrome as “a modest but detectable decline in cognitive function” (n.d., para. 18). that it also categorizes as the prodromal, or transitional stage, between normal aging and Alzheimer’s whereupon it gives the most widely accepted characteristics of MCI: 1) subjective cognitive decline; 2) cognitive function that falls below an individual’s age and level of education as evidenced through standard neuropsychological testing, 3) intact daily functioning, 4) proof of cognitive decline from previous levels, and 5) not meeting the criteria of dementia (APA, n.d., para. 18). The APA further divides MCI into subtypes whereupon it notes that amnestic MCI, which is marked by short term memory loss, may be the prodromal stage of Alzheimer’s (n.d., para. 19).

Rosenberg, P. B., and Lyketsos, C. G. (2008).  Mild Cognitive Impairment: Searching from the prodrome of Alzheimer’s disease. World Psychiatry, 7:72-78.  Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2430721/pdf/wpa020072.7

Rosenberg (2008) is a little behind the times since this overview notes that mild cognitive impairment represents a risk group rather than a widely accepted diagnosis (p. 72).  Nevertheless, Rosenberg’s descriptive  jives with the Mayo Clinic one: 1) Neither cognitively normal nor dementia, but performing 1.5 deviation below age and educational norms on at least one cognitive test; 2) no impairment in activities of daily living, although Rosenberg admits that MCI may be more noticeable in someone still employed (2008, p. 72). Rosenberg  (2008) further divides MCI into amnestic and non-amnestic versions as well as single domain and multiple domain while noting that those MCI patients with worse verbal memory and executive function skills remain at the greatest risk of further cognitive decline (p. 73), which is also signaled by “subtle changes in Instructional [complex] Activities of Daily Living (IADLs)”, rate of brain atrophy, including losses in the hippocampus and an increase in ventricle size, depression, and anxiety (p. 73).  After detailing how the MCI diagnosis is made, including mention of the currently woefully inadequate Mini-Mental State Exam (MMSE) (Rosenberg, 2008, p. 74), Rosenberg details management of the syndrome, including lifestyle strategies—cognitive activity and regular moderate exercise—and the use of acetyl-cholinesterase inhibitors that offer symptomatic benefits (p. 76).  Overall, Rosenberg offers a detailed, practical view that may help MCI patients and their caregivers understand this syndrome.

Torpy, J. (2009, July).  Mild Cognitive Impairment. JAMA patient page. Journal of the American Medical Association. Retrieved from http://jama.ama-assn.org/content/302/4/452.full.pdf

Torpy (2009, July) reassures readers that while MCI can be the first step on the way to Alzheimer’s and other dementias (para. 1), it can also be the result of other conditions including stroke, brain injury, tumors, central nervous system infections, open heart surgery as well as the obsessive use of drugs or alcohol (para. 2).  He then details the diagnosis, beginning with gathering a medical of history of mental lapses, a physical exam and possibly computer tomography (CT) scans, magnetic resonance imaging (MRI), blood tests, a lumbar puncture, or spinal tap, as well as neuropsychological testing (Torpy, 2009, July, para. 3). Finally, without going into specifics, Torpy recommends the following habits that might prevent—or perhaps delay—the onset of Alzheimer’s: No smoking, a diet that emphasizes the consumption of fish as well as five serving of fruits and vegetables daily, regular physical exercise, mental activity, social contacts, and managing chronic illness (2009, July, para. 4).  The reader, however, may long for more detailed information since the JAMA offers the bare minimum of knowledge anyone would want to know.

Werner, P. and Korczyn, A. D. (2008, September).  Mild cognitive impairment: Conceptual, assessment, ethical, and social issues. Clinical Interventions in Aging. 3(3): 413-420. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2682374/pdf/CIA-3-413.pdf

Werner (2008, September) gives a very specific historical and diagnostic account of mild cognitive disorder along with the usual defining details—memory complaints, memory impairment beyond that expected for the patient’s age and education, normal general cognitive function, intact activities of daily living (ADLs), and not demented (p. 414), before delimiting MCI to newly developed cognitive decline, which Werner (2008) concludes may be treated temporarily with cholinesterase inhibitors (p. 414). Then after reviewing the clinical diagnostic exam, Werner (2008) brings up some ethically issues—the patient’s need to know versus withholding distressing information as well as the stigmatization that affects MCI-diagnosed patients and their caregivers—before finishing up with financial problems related to long-term care, and the necessity of support groups, memory training, and relaxation techniques (p. 417). Although Werner includes all the expected information in this overview, readers will also appreciate the thoughtful discussion of ethical, social, and economic issues.

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Diagnosis

Albert, M. S., DeKosky, S. T., Dickson, D., Dubois, B., Feldman, H., Fox, H., Nick, C., Gamst, A., Holtzman, D. M., Jagust, W. J., Petersen, R. C., Snyder, P. J., Carrillo, M. C., Thies, B., and Phelps, C. H. (2011, in press).  The diagnosis of mild cognitive impairment due to Alzheimer’s disease: Recommendations from the National Institute on Aging and Alzheimer’s Association Workgroup. Alzheimer’s and Dementia, 1-10. doi:10.1016/j.alz.2011.03.008  Retrieved from http://www.alzheimersanddementia.com/article/PIIS155252601100104X/fulltext

This working group urges the inclusion of MCI as one of the stages of Alzheimer’s since this stage of gradual cognitive decline results in the accumulation of Alzheimer’s disease brain pathology (Albert, 2011, p. 2).  Thus, they recommend that 1) the diagnosis of MCI should be used in clinical setting only where it can be applied broadly without the need of specialized tests, and 2) separate clinical research criteria must also include biomarkers to be used only in research (Albert, 2011, p. 2)

Diagnostic criteria for this MCI syndrome should also include

• Concern regarding a change in cognitive abilities relative to previous levels;

• Impairment in one or more of the cognitive domains—memory, executive function, language, visual-spatial skills, episodic memory, and the ability to learn new information;

• Preservation of independence in performing Instrumental [or complex] Activities of Daily Living, for example, shopping or paying bills;

• No evidence of dementia.

(Albert, 2011, p. 3)

They further urge that MCI-diagnosed patients receive assessments over time and that they be given tests that are culturally, educationally, and age-wise appropriate as clinicians seek to discover the cause of their cognitive dysfunction. If, and only if, the autosomal dominant form of Alzheimer’s is present then MCI is likely a prodrome, or precursor of Alzheimer’s.  Biomarkers reflecting chemical changes may then indicate if the MCI is highly, somewhat likely, or not at all likely to progress to Alzheimer’s (Albert, 2011, p. 5).  Such knowledge would relieve family members or else spur them on to plan for the worst consequences.

Goldberg, T. E, Koppel, J., Keehlisen, L., Christen, E., Dreses-Werringloer, U., Conejero-Goldberg, C., Gordon, M. L., and Davies, P. (2010, April 1).  Performance-based measurement of everyday function in mild cognitive impairment. American Journal of Psychiatry Online, 167(7), 845-53. doi: 10.1176/appi.ajp.2010.09050692  Retrieved from http://www.psychiatryonline.com/content.aspx?aID=152608

MCI-diagnosed individuals skewed significantly lower than their cognitively stable controls on the University of California, San Diego Performance-Based Skills Assessment that  measures real world activities, such as writing checks or planning a route for a trip, and their scores in speed of processing episodic memory, semantic processing and fluency accounted for this variation (Goldberg, 2010, April 1, p. 4).  Thus, while the MCI-diagnosed patient may still be able to feed and dress him or herself and perform other simple activities of daily living, the ability to perform more complex functions,or instrumental activities of daily living (ADLs), is “subtly impaired”. This inability corresponds with neuropathlogical findings that indicate that MCI appears to be a transitional state between normal aging and Alzheimer’s (Goldberg, 2010, April 1, p.1).  The stress occasioned by the MCI-diagnosed individual is graphically depicted by chronicling the medical history of a 76-year-old woman diagnosed with MCI at the end of the article. 

Kesler, A., Vakhapova V., Korczyn, A. D., Natalie, E., Neudorfer, M. (2011, in press).  Retinal thickness in patients with mild cognitive impairment and Alzheimer’s disease. Clinical Neurology and Neurosurgery.  doi: 10.10161j.clineuro.2011.02.014  Retrieved from http://library.tasmc.org.il/Staff_Publications/publications%202011/Kesler.pdf

A decreased thickness of the retinal optic nerve fiber layer ordinary reflects the loss the retinal neuronal ganglion cells in the fiber layer of the optic nerve (RNFL), so it should come as no surprise that optical examinations show that MCI-diagnosed patients also have reduced RNFL thickness compared to their cognitively healthy peers. Using non-invasive optical coherence tompgraphy (OCT), this study thus sought to determine whether loss of RNFL fibers is global or is more marked in certain areas of the optic nerve by comparing Alzheimer’s and MCI subjects with cognitively normal controls (Kesler, 2011, para. 4).  By comparing 78 subjects, researchers found that  the RNFL was significantly thinner in the 24 MCI-diagnosed subjects than in the 24 controls just as these cells were thinner still in the 30 Alzheimer’s patients (Kesler, 2011, para. 4).  RNFL thinness was most pronounced in the inferior quadrant for MCI-diagnosed individuals and in the superior quadrant for Alzheimer’s patients (Kesler, 2011, para. 8). Even so, researchers contend that tracking RNFL thinning most probably is not likely to be helpful in monitoring the progress of dementia even as they acknowledge that it is related to early signs of it (Kesler, 2011, para. 9). 

Perneczky, R., Pohl, C., Sorg, C., Hartmann, J. Komossa, K. Alexopoulos, P., Wagenpfeil, S., and Kurz, A. (2006, May).  Complex activities of daily living with mild cognitive impairment: Conceptual and diagnostic issues. Age and Ageing, 35(3), 240-245. doi: 10.1093/ageing1afj654  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21454010

Perneczky’s diagnosis criteria for mild cognitive impairment differs from the Mayo Clinic’s definition since the Mayo definition does not require any subjective memory complaints while Perneczky’s does, nor does it mention the MCI patient’s possible inability to  handle the instrumental activities of daily living (IADLS).  Furthermore, in the Perneczky model of MCI, memory impairment may be absence if at least one other cognitive domain is significantly affected (2006, May, p. 242). The results of this study, therefore, furnish proof that the inability to complete IADLs, such as meal preparation, taking medication, managing money, shopping, telephone use, and using technology, means that cognitive deterioration has occurred.  Moreover, since Perneczky’s study indicates that patients with MCI perform significantly worse than their controls in the IADLs, a strong link exists between an MCI patient’s cognitive performance and the ability to undertake these tasks (2006, May, p. 243).  Thus, if an older adult has trouble scrambling eggs while broiling the toast, this might indicate that he or she can no longer safely live independently.

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Coping & Custodial Care

Family members, caregivers, and friends need to understand that a purpose in life delays or prevents the onset of mild cognitive impairment while the very label and the problems that go along with it, most notably the inability to handle one’s own finances, add to the MCI-diagnosed individual’s stigma and shame.  While those so diagnosed need to be given a truthful assessment of their syndrome, they also need to be assured that they will not lose the love and support of their significant others.

Boyle, P. A., Buchman, A. S., Barnes, L. L. and Bennett, D. A. (2010, March).  Effect of a purpose in life on risk of incident Alzheimer’s disease and mild cognitive impairment in community-dwelling older persons. Archives of General Psychiatry, 67(3), 304-310.  doi: 10.1001/archgenpsychiatry.2009.208 Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2897172/

This Chicago study compared MCI-diagnosed individuals’ purpose in life as derived by using a ten-item scale taken from Ryff’s Scales of Psychological Well-being with a battery of 21 tests assessing cognitive functioning, including episodic, semantic, and working memory as well as perceptual speed and visual-spatial ability (Boyle, 2010, March, p. 305). Individuals diagnosed with MCI who went on to develop Alzheimer’s had a lower purpose in life as well as more depressive symptoms while a reason for living reduced the risk of Alzheimer’s (Boyle, 2010, March, p. 307).  Since purpose in life is a potentially modifiable factor, caregivers, loved ones and friends need to help older adults identify meaningful activities and goal-directed behaviors (Boyle, 2010, March, p.309).  Apathy, on the other hand, equates with loss of cognitive function (Boyle, 2010, March, p.309).

Garand, L., J. H., Conner, K. O., and Dew, M. A. (2009, April).  Diagnostic labels, stigma, and participation in research related to dementia and mild cognitive impairment. Research in Gerontological Nursing, 2(2), 112-21. doi: 10.3928/19404921-20090401-04 Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2864081/

While the mild-cognitive impairment label allows clinical researchers and medical personnel to easily identify patients, it also stigmatizes these individuals and so may either interfere with their willingness to seek care or participate in research trials (Garand, 2009, April, p.3-4). Stereotyping MCI-diagnosed individuals encourages a negative self image as well as the belief that others will reject them (Garard, 2009, April, p.3) that, in turn, reinforces their isolation and low self-esteem.  Earlier research has documented the stigma associated with Alzheimer’s and its destructive effect on personal relationships; however, the stigma experienced by MCI-diagnosed individuals is less well known.  Even so, interviews conducted at the study participants’ homes or at location of their choosing revealed that they and their caretakers need time to accept this diagnosis as well as psychological support that includes active listening as MCI-diagnosed individuals vent their feelings even as they receive factual information about their diagnosis (Garard, 2009, April, p. 5).  Researchers further recommend using terms like “changes in thinking” and other value-neutral terms when discussing cognitive changes. Similarly, caregivers need support and understanding from family and friends (Garand, 2009, April, p.7).

Triebel, K. L., Martin, R., Griffith, H. R., Marceaux, J., Okonkwo, O. C., Harrell, L., Clark, D., Brockington, J., Bartolucci, A., and Marson, D. C. (2009, September). Declining financial capacity in mild cognitive impairment: A one-year-longitudinal study. Neurology, 73(12), 928-934. doi: 10.1212.WNL.0b01ze3181687971 Retrieved from  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2754335/

Both amnestic-MCI and non-amnestic (non-converter) MCI-diagnosed individuals performed significantly worse than healthy controls in their ability to perform financial skills, although both MCI groups performed equivalently in their understanding of basic monetary skills, checkbook balancing, financial judgment, and investment decisions  (Triebel, 2009, September, para. 14).  Moreover, amnestic MCI-diagnosed individuals performed much worse than both the cognitively healthy controls and MCI non-converters.  Trouble with managing finances thus can be seen as a sign of cognitive decline and the onset of dementia (Triebel, 2009, September, p.25). The findings of this study are particularly important since MCI-diagnosed individuals are often preyed upon by the unscrupulous. 

Weston, A. L., Weinstein, A. M., Barton, C., Yoffe, K. (2010, March).  Potentially inappropriate medication use in older adults with mild cognitive impairment, Journal of Gerontology: MEDICAL SCIENCES. 65A (3), 318-321. doi: 10.1093/Gerona/glp158  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19843646

Potentially inappropriate medications to be avoided by MCI-diagnosed patients include barbiturates, muscle relaxants, central nervous stimulants, benzodiazepines and sedative hypnotics (Weston, 2010, p. 319).  The extent of this prescription drug abuse among MCL-diagnosed patients is staggering: 20.8 percent of MCI patients surveyed were currently taking inappropriate medications; moreover, 15.7 percent were taking one PIM while 4.1 percent were taking two or more.  The most common PIMS taken by MCI-diagnosed patients were anticholinergics (35.7 percent), benzo-diazepines (31.5 percent), sedative-hypnotics (22.4 percent), barbiturates (16.8 percent), and muscle relaxants (10.5 percent) (Weston, 2010, p. 19).  Moreover, both caregivers and patients alike need to be warned that anticholinergics increase non-degenerative cognitive impairment while the use of two drug types may contribute to further cognitive decline. Thus, taking inappropriate medications may mean that MCI symptoms are caused by the patient’s medicine rather than by the progressive decline of the MCI syndrome (Weston, 2011, p. 320).

Woodard, J. L., Seidenberg, M., Nielson, K. A., Antuono, P., Guidotti, L., Durgerian, S., Zhang, O., Lancaster, M., Hantke, N., Butts, A., and Rao, S. M. (2009, June 10). Semantic memory activation in amnestic mild cognitive impairment. Brain, 132 (Part 8), 2068-2078. doi: 10.1093/brain/awp157 Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2904596/

Individuals diagnosed with MCI compensate for loss of semantic, or contextual, memory with still functional regions of the brain according to a study that required MCI-diagnosed and genetically at risk participants to distinguish between the names of famous individuals and not so famous ones whereupon their responses were compared with those of cognitively healthy similarly-aged individuals while functional magnetic resonance imaging documented the changes in brain activity: Participants made a right-finger key press if a name was famous and a middle finger key press if the name was unfamiliar one when a name flashed on the computer screen for four seconds whereupon the computer recorded accuracy and reaction time.  Sixty names, in turn, randomly appeared, interspersed with 30 3-w trails that  the participants fixed with a single central placed crosshair (Woodard, 2009, June 10, p. 271). No statistical difference occurred in the percentage of correct answers or reaction time between the groups, although a Discriminability Index did reveal a slight difference (Woodard, 2009, June 10, p. 272).  For the most part, MCI-diagnosed individuals and at risk individuals activated the same brain regions, although the left hippocampus were activated in the at risk group, but not in the MCI-diagnosed participants (Woodard, 2009, June 10, p. 2077). Thus, the study implies that regional brain activity increases as brain atrophy increases (Woodward, 2009, June 10, p. 2076).

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Prevention & Amelioration Exercise

 

Studies show that regular, daily, sustained, aerobic exercise can improve cognitive function in individuals diagnosed with Mild Cognitive Impairment as well as with Alzheimer’s can simultaneously improve their cerebral and cardiovascular fitness.  Even so, aerobic exercise should always be a pleasurable activity that older adults look forward to doing. These sessions also have an added benefit since they allow MCI-diagnosed individuals to socialize with their peers.  Ideally, knowledge of these findings will inspire groups to sponsor aerobic exercise programs geared to these special needs older adults. However, spouses and/or adult children may also need to exercise along with their loved ones to ensure that they take part in regular moderate exercise. Middle-aged adults should also take note that a regular moderate exercise program in middle age can delay the onset of MCI and Alzheimer’s. 

Baker, L. D., Frank, L. L., Foster-Schubert, K., Green, P. S., Wilkinson, C. W., McTiernan, A., Plymate, S. R., Fisher, M. A., Watson, G. S., Cholerton, B. A., Duncan, G. E., Mehta, P. D., and Craft, S. (2010, January).  Effects of aerobic exercise on mild cognitive impairment: A controlled trial.  Archives of Neurology, 67(1), 71-79.  doi: 10.1008/archneurol.2009.307  Retrieved from http://archneur.ama-assn.org/cgi/reprint/67/1/71.pdf

This University of Washington study emphasizes that aerobic exercise improves selective attention, search efficiency, processing speed, and cognitive flexibility most particularly in women just as a similar Canadian study found that aerobic exercise for Alzheimer’s patients reduces brain atrophy (Baker, 2010, January, p. 7).  Aerobic exercise simply does a better job of sending blood into the regions of the brain that control executive function and memory (Baker, 2010, January, p. 2) as shown in controlled trials over a six-month period: Sedentary MCI diagnosed individuals took part in an experiment where half of the 33 subjects participated in aerobic exercise four days per week for 45 minutes to an hour while the controls took part in stretching sessions (Baker, 2010 January, p. 3). The duration and intensity of the aerobic exercise gradually increased until the aerobic exercisers were using 75 to 85 percent of their heart rate reserve, using YMCA treadmills, stationary bicycles, and elliptical trainers, while the control group maintained a HR 50 percent below reserve level (Baker, 2010, January, p. 6).  While aerobic exercise significantly improved the men’s cardiovascular health, it did not significantly improve their cognitive function (Baker, 2010, January, p. 7). 

Geda, Y. E., Roberts, R. O., Knopman, D. S. Christianson, T. J., Pankratz, V. S., Ivnik, R. H., Boeve, B. F., Tangalos, E. G., and Petersen, R. C. (2010, January). Physical exercise, aging, and mild cognitive impairment: a population-based study.  Archives of Neurology, 67(1), 80-86. doi: 10.1001/archneurol.209.297  Retrieved from http://archneur.ama-assn.org/cgi/reprint/67/1/80

This proactive Mayo Clinic study asked a random sample of older respondents from Olmsted County, Minnesota, to recall exercise performed within the past year as well as exercise performed between the ages of 50 to 65 whereupon researchers equated mid-life moderate exercise with a 39 percent reduction in mild cognitive disorder while they linked late-life moderate exercise with a 32 percent reduction in MCI (Geda, 2010, January, p. 82).   Here moderate exercise includes brisk walking, hiking, aerobic, strength training, swimming, tennis doubles, martial arts, weight lifting, golfing without a golf cart, and the extended use of exercise machines (Geda, 2010, January, p.81). Although physicians have long credited physical exercise with the reduced risk of cardiovascular disease, type 2 diabetes, and some cancers, it may also protect against MCI and dementia (Geda, 2010, January, p. 80, 82, 84). Researchers further theorize that taking part in regular physical exercise possibly shows a similar sense of discipline in dietary habits, accident prevention, and other healthy behavior (Geda, 2010, January, p.85).  Thus, it is never too early—or too late—to delay the onset of MCI.

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Cognitive Training & Intervention

Challenging mental stimulation over a period of time can help delay cognitive decline.  This training may address specific skills that influence the activities of daily living, but computerized games, listening to audio books, reading newspapers, and using the Internet will also help the MCI-diagnosed individual to delay mental dysfunction.

Barnes, D. E., Yaffe, K., Belfor, N., Jagust, W. J., DeCarli, C., Reed, B., R. and Kramer, J. H. (2009, July-September).  Computer-based cognitive training for mild cognitive impairment: Results from a pilot randomized controlled trial. Alzheimer Disease and Associated Disorders, 23(3), 205-210.  doi: 10.1097/wAD.0b013e31819c6137  Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760033/

Barnes and company have inadvertently documented the effectiveness of surfing the Net by comparing a computer-based training program designed to improve processing speed and accuracy in the auditory cortex, based on sound recognition, with a control group that used computers performing various tasks—listening to audio books, reading online newspapers, or playing visual-spatial online games.  MCI-diagnosed volunteers recruited from memory disorder or university clinics in the San Francisco area self-reported their computer use five days a week for 100 to 90 minutes respectively whereupon no significant difference was discovered in the cognitive processing of either group, although more positive measurements occurred in the control group (Barnes, 2009, July-September, p.   5). The researchers confess that their active control may have been too active, resulting in domain-specific cognitive improvement (Barnes, 2009, July-September, p.6).   While an intensive, computer-based training program may be possible for some MCI-diagnosed individuals, others are just as likely to benefit from daily Internet usage.

Faucounau, V., Wu, Y. H., Boulay, M., De Rotrou, J., and Rigaud, A. S. (2010, January).  Cognitive intervention programmes on patients affected by mild cognitive impairment: A promising intervention tool for MCI? The Journal of Nutrition, Health, and Aging, 14(1), 31-35. Retrieved from http://springerlink.com/content/nm05127305536p6r/fulltext.pdf 

“Cognitive intervention” can for a time forestall mental decline in MCI-diagnosed individuals as well as improve the awareness, judgment and reasoning capacity for early stage Alzheimer’s patients.  However, under this rather wide umbrella, three different levels of training exist:

1. General cognitive stimulation increases cognitive and social functioning in a non-specific manner;
2. Cognitive training in a set of standardized skills specifically addresses memory, language, attention, or executive functions and uses teaching strategies that allow spared cognitive abilities to compensate for impaired ones;
3. Cognitive rehabilitation focuses on specific activities of daily living—feeding, bathing, and dressing oneself, toileting, transferring, and continence;
4. Preserved basic activities of daily living with minimal impairment of complex functions (IADs).

(Faucounau, 2010, January, p. 31)

No proven, guaranteed therapies exist to combat MCI cognitive decline; nevertheless, studies document the effectiveness of cognitive training in slowing mental decay as long as individuals have the ability to learn new skills and apply them.  In traditional training programs, an instructor provides opportunities for practice and feedback while computer-based stimulation programs prod attention, memory, perception, visual-spatial cognition, language, and non-verbal intelligence (Faucounau, 2010, January, p. 32).  However, cost-effective computer-based training programs are better able to individualize training to meet specific needs (Faucounau, 2010, January, p. 35).

Jean, L., Bergeron, M. E., Thivierge, S., and Simard, M. (2010, April). Cognitive  intervention programs for individuals with mild cognitive impairment. American Journal of Geriatric Psychiatry, 18(4), 281-296. doi: 10.1097/JGP.0b013e3181c37ce9  Retrieved from http://recherche.univ-lyon2.fr/emc/IMG/pdf/Jean_et_al._2010-AJGP-Review.pdf

In a survey of 20 randomized trials dealing with cognitive intervention and/or training, French researchers found that individualized cognitive training programs with between six and 20 sessions improve the episodic recall skills and task repetition of MCI-diagnosed individuals while programs over 12 weeks did not show any appreciable improvement in memory (Jean, 2010, April, p. 292-294). Nevertheless, they also observed that “cognitive intervention” achieves greater success in improving the subjective perception of improved memory than in actually increasing the objective measure of various cognitive domains (Jean, 2010, April, p. 293). Researchers find these preliminary findings encouraging, but they also note that they need to be verified with larger sampling sizes (Jean, 2010, April, p. 292). They additionally recommend the necessity of conducting longitudinal trials with randomized, double-blind placebo and control groups (Jean, 2010, April, p. 295), even as they coincide that it would be unethical to withhold intervention training to anyone if there is any evidence of its documented favorable long-term results (Jean, 2010, April, p. 292). 

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Diet & Nutrition

Pass the broccoli: Recent findings tout the value of a low fat, low cholesterol diet and the high intake of folic acid, vitamin B6, and B12 since keeping cholesterol levels in check and consuming high levels of Vitamin B delays cognitive decline in MCI diagnosed individuals as well as improving cardiovascular health and preventing the onset of type 2 diabetes. Healthy home cooking, dining with others regularly, and shopping for groceries with a friend or family member will also probably increase the changes that MCI-diagnosed individuals are eating a well-balanced diet.

Smith, A. D., Smith, S. M., de Jager, C.A., Whitbread, P., Johnston, C., Oulhaj, A., A., Bradley, K. M., Jacoby, R., and Refsum H. (2010, September 8).  Homocysteine-lowering by B vitamins slows the rate of accelerated brain atrophy in mild cognitive impairment: A randomized controlled trial. PLoS One, 5(9), 1-10. doi: 10.1371.journal.pone.0012244  Retrieved from http://www.plosone.org/article/info:doi%2F10.1371%2Fjournal.pone.0012244

Elevated Homocysteine (tHcy) levels correspond with an increased risk of stroke, cardiovascular disease, and bone fracture.   Similarly, this Oxford University study confirms earlier findings that raised tHcy levels accelerate shrinkage in the medial temporal lobe in individuals with MCI (Smith, 2010, September 8, p. 1): Researchers gave one group of test subjects supplements of folic acid, pyridoxine (B6) and cyanocobalmin (B12) while dispensing a placebo to a control group, and then took baseline cranial MRI scans of both and compared them with scans taken at the end of the two-year study.  Vitamin B supplements taken during this time significantly slowed cognitive decline in individuals with MCI (Smith, 2010, September 8, p. 6).  Conversely, participants whose intake of folic acid or Vitamin B 12 declined risked increased brain atrophy. Moreover, supplemental B vitamin treatment proved most effective in those participants with an already high level of Vitamin B intake. Thus, researchers reason that high dosages of Vitamin B might slow down or prevent the conversion of MCI to Alzheimer’s (Smith, 2010, September, 8, p. 7).

Sparks, D. L., Kryscio, R. J., Connor, D. J., Sabbagh, M. N., Sparks, L. M., Lin, Y, and Liebsack, C. (2010). Cholesterol and cognitive performance in normal controls and the influence of elective statin use after conversion to mild cognitive impairment. Neurodegenerative Diseases, 7(1-3), 183-186. doi: 10.1159/000295660 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2859238/

Comparing a control group of cognitively healthy older adults with individuals diagnosed with MCI reveals a positive correlation between High Density Lipoprotein, or good cholesterol, and adequate brain function while confirming a decline in learning and memory that accompanies increased total and Low Density Lipoprotein, or bad cholesterol.   MCI patents thus suffer a small—but noteworthy—decrease in brain function with a rise in over all cholesterol levels (p. 184). Accordingly, after the onset of MCI, elective statin use positively affects clinical cognition measures (p. 185).  Paradoxically, however, while previously compiled data suggests that statin use may reduce the risk of Alzheimer’s, it does not reduce the risk of MCI, even if it does improve brain function after its onset.  Nevertheless, this study backs up the supposition that control of cholesterol through diet and exercise delays memory loss ordinarily associated with aging. 

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Putting this Information to Use

After reading this research guide, caregivers might also wish to take advantage of the following sources available furnished by accessing USA.gov, which has proven to be an excellent source for obtaining current information on mild cognitive disorder.  More importantly, it also emphasizes just how much information is available to the general public that can help the MCI-diagnosed individual and his or her family and care givers make the best of a bad situation.

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Elder Exercise Guide

Exercise and physical activity:  (2010, October 20). Your Everyday Guide from the National Institute of Health.  U.S. National Institutes of Health.  Retrieved April 26, 2011, from http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide/

Geared towards seniors, this very complete guide explains the difference between physical activity and exercise as well as giving sample endurance (aerobic), strength, balance, and flexibility exercises.  The site also contains a chapter on healthy eating and answers frequently asked questions.  

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Brain-growing Activities

This following collection gives older adults plenty of opportunities to train their brain online:

Exercise your brain! (2011). My Senior Site. Retrieved April 26, 2011, from http://www.myseniorsite.ca/justfun-games_brainex.htm

This Canadian site includes a selection of quizzes that challenge various cognitive domains as well as links with useful and entertaining information on popular hobbies like gardening and cooking.  Canadian seniors might also appreciate the links detailing Canadian genealogy and travel.  Thankfully, the link to lotteries is disabled.

Happy neuron. (2011). Retrieved April 26, 2011, from http://www.happy-neuron.com

Created by a neurologist, this site claims that its activities will help users improve their memory.  The site supposedly offers individual coaching and performance tracking.

Games for the brain. (n.d.).  Retrieved April 26, 2011, from http://www.gamesforthebrain.com

Bookmark this site for a collection of both single-player and multiple player online games including solitaire, Sudoku, Chinese checkers, and chess. 

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Senior Meal Planning

Nutrition for seniors. (2011, April 8). Medline Plus.  U.S. National Library of Medicine. Retrieved April 26, 2011, from http://www.hlm.hih.gov.medlineplus/nutritionforseniors.htm.

This entertaining and informative site includes lots of links geared to seniors including tutorials and videos.

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Addendum

August 28, 2015

The Mini-Mental Exam may ask the test taker to draw a clock.

Morley, John E., Morris, John C. Berg-Weger, Marla, et al. (2015, September 1).  Brain health: The importance of recognizing cognitive impairment: An IAGG consensus conference. Journal of Post-Acute and Long-term Care Medicine. 16(9), 731-739. doi: http://dx.doi.org/10.1016/j.jamda.2015.06.017 [Abstract only].  Retrieved from http://www.jamda.com/article/S1525-8610%2815%2900438-7/abstract

Early diagnosis of cognitive decline is a right owed every older adult.  Moreover, recognizing early symptoms of Mild Cognitive Impairment allows for appropriate diagnosis and treatment that also allows for individual to participate in the decision-making process about his or her future:  Additionally, 1) screening tests take only 3 to 7 minutes to administer;  2)  consultation with both individual and family member or friends who suspect that his or her cognitive powers are declining is an appropriate approach to take; 3) MCI may have treatable aspects, and 4) a combination of medical and lifestyle interventions may delay or prevent cognitive decline.

The medical links furnished on this Web page represent the opinions of their authors, so they complement—not substitute—for a physician's advice.