比较MoCA和MMSE在卒中后认知功能筛查中的应用

目的：比较蒙特利尔认知评估量表（Montreal Cognitive Assessment,MoCA）和简易智能量表（mini-mental state examination,MMSE）在急性缺血性脑卒中后认知损害筛查中的应用。方法：对65例缺血性脑卒中患者在发病14天内应用简易精神状态检查量表（Mini-mental State Examination,MMSE）和MoCA进行神经心理评估。其中12例患者在发病3-6个月后应用MMSE、MoCA和神经心理成套测验进行神经心理评估。以MMSE〈23分、MoCA〈21为分界值,受教育年限小于12年加1分,文盲加2分。结果：MMSE的平均分值为25.2±4.3,MoCA的平均分值为18.6±5.7。37例患者MoCA评分显示有认知损害,但其中19例患者（29%）MMSE评分显示正常。28例MoCA评估显示认知正常的患者的MMSE评分均显示认知正常。视空间与执行功能、注意和语言重复测试受损最常见,定向和命名受损较少。在3-6个月的随访期内,12例患者中1例诊断为血管性痴呆患者的MoCA的分值上升1分,MMSE分值无变化;5例认知正常患者、3例轻度认知损害无痴呆的患者和3例中度认知损害无痴呆的患者MMSE和MoCA平均分值均有不同程度的上升,视空间与执行功能平均得分值在2次检测中无明显变化。结论：MoCA较MMSE检出血管性认知功能障碍患者敏感性更高,对认知变化更为敏感。     

长期住院老年精神疾病患者营养状况与认知功能的相关性研究

目的:了解长期住院老年精神疾病患者营养状况及与认知功能的相关性,为临床提供指导。方法:对住院3个月及以上的123例老年精神疾病患者采用简易精神状态检查量表(MMSE)评估认知功能,采用简易微型营养评定精简版(MNA-SF)评估营养状况,并采集一般资料、相关营养生化指标,应用Pearson相关分析MNA-SF评分与MMSE评分的相关性。结果:123例患者中,营养不良风险者67例(54.47%),营养不良者37例(30.08%),营养正常者19例(15.44%)。有认知障碍患者的营养不良发生率显著高于无认知障碍患者营养不良发生率(P<0.05),重度认知障碍者营养不良发生率显著高于轻、中度认知障碍者(P<0.05)。与无认知障碍者比较,中度、重度认知障碍者MNA-SF评分显著降低(P<0.05);与轻度、中度认知障碍者比较,重度认知障碍者MNA-SF评分显著降低(P<0.05)。营养不良者MMSE 6个认知领域评分和认知总评分均显著低于营养不良风险/正常者(P<0.05),Pearson相关分析显示:长期住院老年精神疾病患者MNA-SF评分与MMSE评分呈正相关(r=0.486, P=0.023<0.05)。结论:长期住院老年精神疾病患者营养不良发生率高,且与认知功能密切相关。临床部门需加强老年精神疾病患者,特别是有认知损害老人的营养关切。     

Evidence for cognitive impairment in mastocytosis: prevalence, features and correlations to depression

Mastocytosis is a heterogeneous disease characterized by mast cells accumulation in one or more organs. We have reported that depression is frequent in mastocytosis, but although it was already described, little is known about the prevalence and features of cognitive impairment. Our objective was to describe the prevalence and features of cognitive impairment in a large cohort of patients with this rare disease (n?=?57; mean age?=?45) and to explore the relations between memory impairment and depression. Objective memory impairment was evaluated using the 3(rd) edition of the Clinical Memory scale of Wechsler. Depression symptoms were evaluated using the Hamilton Depression Rating Scale. Age and education levels were controlled for all patients. Patients with mastocytosis presented high levels of cognitive impairment (memory and/or attention) (n?=?22; 38.6%). Cognitive impairment was moderate in 59% of the cases, concerned immediate auditory (41%) and working memory (73%) and was not associated to depression (p≥0.717). In conclusion, immediate auditory memory and attention impairment in mastocytosis are frequent, even in young individuals, and are not consecutive to depression. In mastocytosis, cognitive complaints call for complex neuropsychological assessment. Mild-moderate cognitive impairment and depression constitute two specific but somewhat independent syndromes in mastocytosis. These results suggest differential effects of mast-cell activity in the brain, on systems involved in emotionality and in cognition.     

Medical Decision-Making Incapacity among Newly Diagnosed Older Patients with Hematological Malignancy Receiving First Line Chemotherapy: A Cross-Sectional Study of Patients and Physicians

Background

Decision-making capacity to provide informed consent regarding treatment is essential among cancer patients. The purpose of this study was to identify the frequency of decision-making incapacity among newly diagnosed older patients with hematological malignancy receiving first-line chemotherapy, to examine factors associated with incapacity and assess physicians’ perceptions of patients’ decision-making incapacity.

Methods

Consecutive patients aged 65 years or over with a primary diagnosis of malignant lymphoma or multiple myeloma were recruited. Decision-making capacity was assessed using the Structured Interview for Competency and Incompetency Assessment Testing and Ranking Inventory-Revised (SICIATRI-R). Cognitive impairment, depressive condition and other possible associated factors were also evaluated.

Results

Among 139 eligible patients registered for this study, 114 completed the survey. Of these, 28 (25%, 95% confidence interval [CI]: 17%-32%) were judged as having some extent of decision-making incompetency according to SICIATRI-R. Higher levels of cognitive impairment and increasing age were significantly associated with decision-making incapacity. Physicians experienced difficulty performing competency assessment (Cohen’s kappa -0.54).

Conclusions

Decision-making incapacity was found to be a common and under-recognized problem in older patients with cancer. Age and assessment of cognitive impairment may provide the opportunity to find patients that are at a high risk of showing decision-making incapacity.     

Espasticidad tras ictus: ¿la edad es un factor de riesgo? Estudio observacional de la espasticidad en pacientes neurovasculares en una serie retrospectiva de dos centros

ObjectiveApproximately one third of patients who have suffered a stroke develop spasticity. Since clinical observations that spasticity in the elderly population is lower after stroke, and disagreement about risk factors between different authors, an analysis is performed on the variables that influence the development of spasticity.The objective of the study is to determine the how many factors influence spasticity outcome, and the prevalence of spasticity in patients who have suffered a stroke and require intensive rehabilitation treatment.MethodA retrospective assessment was carried out on a total of 554 patients from two neurorehabilitation centres. A record was made of sociodemographic data, aetiology, type and location of stroke, motor and sensory deficits, language and swallowing impairment, incontinence, cognitive and mood state. Spasticity levels at admission and at the third month were studied in 462 patients using the Ashworth scale. Multivariate regression analyses were used to assess the risk factors for spasticity present at the third month after stroke.ResultsThe mean age of the patients was 67.3 years, of which 67.1% were men, and with ischemic aetiology in 76.5%. On admission 31.4% of patients had spasticity, and this increased to 54.8% at the 3^rd month. The absolute risk factor for spasticity was motor index (OR 1.04; 95% CI 1.03-1.05). When this factor was omitted, the variables with predictive ability were: age less than 75 years (OR 0.52; 95% CI 0.30-0.90), sensory impairment (OR 0.66; 95% CI 0.37-1.20), and lower Barthel index score (OR 1.02; 95% CI 1.01-1.03). There was no significant relationship for gender, physiopathological mechanism (ischaemic/haemorrhagic), stroke location, aphasia, or cognitive impairment.ConclusionThe prevalence of spasticity in stroke at third month of follow-up was 54.8%. Motor index is the independent predictor of spasticity. Patients younger than 75 years old, with sensory impairment and low Barthel index score are more likely to develop spasticity.     

Longitudinal Assessment of Tau Pathology in Patients with Alzheimer’s Disease Using [18F]THK-5117 Positron Emission Tomography

The formation of neurofibrillary tangles is believed to contribute to the neurodegeneration observed in Alzheimer’s disease (AD). Postmortem studies have shown strong associations between the neurofibrillary pathology and both neuronal loss and the severity of cognitive impairment. However, the temporal changes in the neurofibrillary pathology and its association with the progression of the disease are not well understood. Tau positron emission tomography (PET) imaging is expected to be useful for the longitudinal assessment of neurofibrillary pathology in the living brain. Here, we performed a longitudinal PET study using the tau-selective PET tracer [¹⁸F]THK-5117 in patients with AD and in healthy control subjects. Annual changes in [¹⁸F]THK-5117 binding were significantly elevated in the middle and inferior temporal gyri and in the fusiform gyrus of patients with AD. Compared to patients with mild AD, patients with moderate AD showed greater changes in the tau load that were more widely distributed across the cortical regions. Furthermore, a significant correlation was observed between the annual changes in cognitive decline and regional [¹⁸F]THK-5117 binding. These results suggest that the cognitive decline observed in patients with AD is attributable to the progression of neurofibrillary pathology. Longitudinal assessment of tau pathology will contribute to the assessment of disease progression and treatment efficacy.     

肥厚型心肌病患者认知功能障碍的发生及影响因素分析

目的:探讨肥厚型心肌病(HCM)患者认知功能障碍的发生及影响因素。方法:收集2018年4月至2019年7月期间空军军医大学第一附属医院超声医学科HCM患者198例。综合北京版蒙特利尔认知评估(MoCA)量表结果及教育程度,判断患者认知功能:文盲且MoCA得分14分、1年≤教育年限≤6年且MoCA得分20分、或教育年限6年且MoCA得分25分为认知功能障碍组(n=37),其余为认知功能正常组(n=161)。比较两组患者一般资料、超声心动图检查结果及认知功能评估结果。采用多因素logistic回归分析筛选HCM患者认知功能障碍的可能危险因素。结果:HCM患者认知功能障碍的发生率为18.7%(37/198)。与认知功能正常组相比,认知功能障碍组HCM患者年龄较大(P0.05),受教育年限较短(P0.05),心功能分级及左心室舒张功能较差(P0.05),激发左心室流出道压差较高(P0.05)。认知功能障碍组HCM患者MoCA得分较低(P0.05),尤其在视空间与执行功能和延迟回忆(P0.05)两项上得分较差。多因素logistic回归分析结果表明,调整年龄(OR=14.435, 95%CI:4.476-46.550; P0.001)和教育年限(OR=5.274, 95%CI:2.024-13.744; P=0.001)后,激发左心室流出道压差(OR=3.844, 95%CI:1.551-9.524; P=0.004)是HCM患者认知功能障碍的独立危险因素。结论:激发左心室流出道压差可以增加HCM患者认知功能障碍的发生风险。     

Cognitive function in growth hormone deficiency and growth hormone replacement

There is converging evidence from neuropsychological studies that growth hormone (GH) is associated with cognitive function. The aim of the current study was to review the existing neuropsychological literature for studies in which cognitive assessment had been conducted in patients with GH deficiency (GHD), and where change in cognitive function had been assessed following treatment with GH. Studies that have investigated relationships between GH and cognitive function and those that have developed methodological and statistical approaches that could be useful in future GH studies were identified. In this review, GH levels were found to be associated with cognitive function. Untreated individuals with GHD showed reliable impairment in memory and attentional functions when compared with matched controls. Appropriately designed prospective studies also indicated that cognitive function improved with GH treatment. It was concluded that individuals with GHD do show cognitive impairment and that this is ameliorated to some extent by GH treatment. It is now important to establish the clinical importance of these findings, and further work is required to understand better the nature, magnitude and meaning of GH-related cognitive impairments and improvements.     

维持性腹膜透析患者认知功能障碍与营养状况的关系研究

摘要 目的：探究维持性腹膜透析患者认知功能障碍与营养状况的关系。方法：前瞻性纳入2019年1月至2020年6月在济宁医学院附属医院就诊的172例维持性腹膜透析患者，收集患者一般资料。采用蒙特利尔认知评估量表（MoCA）评估患者的认知功能，根据MoCA评分分为认知功能正常组及认知功能障碍组。采用微型营养评估量表（MNA）评估患者营养状态，以MNA评分分为营养正常组、潜在营养不良组、营养不良组，比较认知功能正常组及认知功能障碍组营养状况占比情况，分析维持性腹膜透析患者认知功能与营养状况的相关性及影响认知功能的相关因素。结果：与认知功能正常组比较，认知功能障碍组患者透析时间明显延长，MNA总分、MoCA总分明显降低（P<0.05）。与认知功能正常组比较，认知功能障碍组患者营养正常者比例明显降低，营养不良者比例明显升高（P<0.05），潜在营养不良者比例有所升高但差异无统计学意义（P>0.05）。经Pearson相关性检验分析显示，维持性腹膜透析患者MoCA总分与MNA总分呈明显正相关（P<0.05）。经Logistic回归分析显示，透析时间（延长）、营养不良均为维持性腹膜透析患者认知功能障碍的危险因素（P<0.05）。结论：维持性腹膜透析认知功能障碍患者营养不良发生率明显升高，且患者认知功能障碍与营养状况具有明显相关性，加强患者的营养状况有助于降低认知功能障碍的发生风险。     

Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial

ObjectiveTo determine the effectiveness of multifactorial intervention after a fall in older patients with cognitive impairment and dementia attending the accident and emergency department.DesignRandomised controlled trial.Participants274 cognitively impaired older people (aged 65 or over) presenting to the accident and emergency department after a fall: 130 were randomised to assessment and intervention and 144 were randomised to assessment followed by conventional care (control group).SettingTwo accident and emergency departments, Newcastle upon Tyne.ResultsIntention to treat analysis showed no significant difference between intervention and control groups in proportion of patients who fell during 1 year''s follow up (74% (96/130) and 80% (115/144), relative risk ratio 0.92, 95% confidence interval 0.81 to 1.05). No significant differences were found between groups for secondary outcome measures.ConclusionsMultifactorial intervention was not effective in preventing falls in older people with cognitive impairment and dementia presenting to the accident and emergency department after a fall.

What is already known on this topic

Multifactorial intervention prevents falls in cognitively normal older people living in the community and in those who present to the accident and emergency department after a fallFall prevention strategies have not been tested by controlled trials in patients with cognitive impairment and dementia who fall

What this study adds

No benefit was shown from multifactorial assessment and intervention after a fall in patients with cognitive impairment and dementia presenting to the accident and emergency departmentThe intervention was less effective in these patients than in cognitively normal older people     

From multidimensional neuropsychological outcomes to a cognitive complication rate: The International Subarachnoid Aneurysm Trial

Background

The neuropsychological arm of the International Subarachnoid Aneurysm Trial (N-ISAT) evaluated the cognitive outcome of 573 patients at 12 months following subarachnoid haemorrhage (SAH). The assessment included 29 psychometric measures, yielding a substantial and complex body of data. We have explored alternative and optimal methodologies for analysing and summarising these data to enable the estimation of a cognitive complication rate (CCR). Any differences in cognitive outcome between the two arms of the trial are not however reported here.

Methods

All individual test scores were transformed into z-scores and a 5^th percentile cut-off for impairment was established. A principal components analysis (PCA) was applied to these data to mathematically transform correlated test scores into a smaller number of uncorrelated principal components, or cognitive 'domains'. These domains formed the basis for grouping and weighting individual patients' impaired scores on individual measures. In order to increase the sample size, a series of methods for handling missing data were applied.

Results

We estimated a 34.1% CCR in all those patients seen face-to-face, rising to 37.4% CCR with the inclusion of patients who were unable to attend assessment for reason related to the index SAH. This group demonstrated significantly more self and carer/relative rated disability on a Health Related Quality of Life questionnaire, than patients classified as having no functionally significant cognitive deficits.

Conclusion

Evaluating neuropsychological outcome in a large RCT involves unique methodological and organizational challenges. We have demonstrated how these problems may be addressed by re-classifying interval data from 29 measures into a dichotomous CCR. We have presented a 'sliding scale' of undifferentiated individual cognitive impairments, and then on the basis of PCA-derived cognitive 'domains', included consideration of the distribution of impairments in these terms. In order to maximize sample size we have suggested ways for patients who did not complete the entire protocol to be included in the overall CCR.

ISAT trial registration

ISRCTN49866681     

NADPH-oxidase activation and cognition in Alzheimer disease progression

Superoxide production via NADPH-oxidase (NOX) has been shown to play a role in a variety of neurological disorders, including Alzheimer disease (AD). To improve our understanding of the NOX system and cognitive impairment, we studied the various protein components of the phagocytic isoform (gp91^phox, or NOX2) in the frontal and temporal cortex of age- and postmortem-matched samples. Individuals underwent antemortem cognitive testing and postmortem histopathologic assessment to determine disease progression and assignment to one of the following groups: no cognitive impairment (NCI), preclinical AD, mild cognitive impairment (MCI), early AD, and mild-to-moderate AD. Biochemical methods were used to determine overall NOX activity as well as levels of the various subunits (gp91^phox, p67^phox, p47^phox, p40^phox, and p22^phox). Overall enzyme activity was significantly elevated in the MCI cohort in both cortical regions compared to the NCI cohort. This activity level remained elevated in the AD groups. Only the NOX cytosolic subunit proteins (p67^phox, p47^phox, and p40^phox ) were significantly elevated with disease progression; the membrane-bound subunits (gp91^phox and p22^phox) remained stable. In addition, there was a robust correlation between NOX activity and the individual's cognitive status such that as the enzyme activity increased, cognitive performance decreased. Collectively, these data show that upregulated NADPH-oxidase in frontal and temporal cortex suggests that increases in NOX-associated redox pathways might participate in early pathogenesis and contribute to AD progression.     

Neuropsychiatric symptoms in patients with aortic aneurysms

Background

Emerging evidence suggests that vascular disease confers vulnerability to a late-onset of depressive illness and the impairment of specific cognitive functions, most notably in the domains of memory storage and retrieval. Lower limb athero-thrombosis and abdominal aortic aneurysm (AAA) have both been previously associated with neuropsychiatric symptoms possibly due to associated intracerebral vascular disease or systemic inflammation, hence suggesting that these illnesses may be regarded as models to investigate the vascular genesis of neuropsychiatric symptoms. The aim of this study was to compare neuropsychiatric symptoms such as depression, anxiety and a variety of cognitive domains in patients who had symptoms of peripheral athero-thrombosis (intermittent claudication) and those who had an asymptomatic abdominal aortic aneurysm AAA.

Methodology/Principal Findings

In a cross-sectional study, 26 participants with either intermittent claudication or AAA were assessed using a detailed neuropsychiatric assessment battery for various cognitive domains and depression and anxiety symptoms (Hamilton Depression and Anxiety Scales). Student t test and linear regression analyses were applied to compare neuropsychiatric symptoms between patient groups. AAA participants showed greater levels of cognitive impairment in the domains of immediate and delayed memory as compared to patients who had intermittent claudication. Cognitive dysfunction was best predicted by increasing aortic diameter. CRP was positively related to AAA diameter, but not to cognitive function. AAA and aortic diameter in particular were associated with cognitive dysfunction in this study.

Conclusions/Significance

AAA patients are at a higher risk for cognitive impairment than intermittent claudication patients. Validation of this finding is required in a larger study, but if confirmed could suggest that systemic factors peculiar to AAA may impact on cognitive function.     

Body Mass Index and Decline of Cognitive Function

Background

The association between body mass index (BMI) and cognitive function is a public health issue. This study investigated the relationship between obesity and cognitive impairment which was assessed by the Korean version of the Mini-mental state examination (K-MMSE) among mid- and old-aged people in South Korea.

Methods

A cohort of 5,125 adults, age 45 or older with normal cognitive function (K-MMSE≥24) at baseline (2006), was derived from the Korean Longitudinal Study of Aging (KLoSA) 2006~2012. The association between baseline BMI and risk of cognitive impairment was assessed using multiple logistic regression models. We also assessed baseline BMI and change of cognitive function over the 6-year follow-up using multiple linear regressions.

Results

During the follow-up, 358 cases of severe cognitive impairment were identified. Those with baseline BMI≥25 kg/m² than normal-weight (18.5≤BMI<23 kg/m²) were marginally less likely to experience the development of severe cognitive impairment (adjusted odds ratio [aOR] = 0.73, 95% CI = 0.52 to 1.03; P_trend = 0.03). This relationship was stronger among female (aOR = 0.63, 95% CI = 0.40 to 1.00; P_trend = 0.01) and participants with low-normal K-MMSE score (MMSE: 24–26) at baseline (aOR = 0.59, 95% CI = 0.35 to 0.98; P_trend<0.01). In addition, a slower decline of cognitive function was observed in obese individuals than those with normal weight, especially among women and those with low-normal K-MMSE score at baseline.

Conclusion

In this nationally representative study, we found that obesity was associated with lower risk of cognitive decline among mid- and old-age population.     

Efectos del Modelo de Atención Centrado en la Persona en la calidad de vida de personas con deterioro cognitivo de centros gerontológicos

Introduction

The Model of Person Centered Care has attracted increasing interest for use in gerontology centers. Therefore, the contributions about its impact are scarce in our context. The objective of this paper is to establish the impact that the interventions associated with the Model of Person Centered Care in the «Etxean Ondo» Project have on the quality of life of residents with cognitive impairment.

Material and methods

One hundred and ninetten residents with cognitive impairment were selected: 59 in the control group and 60 in the experimental group. Subjects in each group were sorted by cognitive impairment: mild or severe. Changes were implemented in the physical and organizational environments for the promotion of autonomy and wellbeing. Quality of life was assessed before and 6 months after intervention using the Fumat Scales (mild cognitive impairment) and Qualid (severe cognitive impairment). The t-Student test was used for comparison of means.

Results

In intergroup comparisons, significant differences in the Fumat Scale for the control group with mild cognitive impairment were initially identified. These differences were not recorded in the post assessment. The experimental group with severe cognitive impairment was significantly improved in the Qualid Scale post assessment. In intragroup comparisons, significant improvements were evident in the quality of life of experimental subjects, both with severe cognitive impairment (Qualid) and mild (Fumat).

Conclusions

The findings support the effectiveness of the interventions and identify methodological and conceptual issues that have been considered to analyze the Model of Person Centered Care efects.     

Effects of emotion-oriented care on elderly people with cognitive impairment and behavioral problems in residential homes

This study investigates the effects of emotion-oriented care on the behavior of elderly people with cognitive impairment and behavioral problems. This approach is mainly based on the validation approach, but uses also insights from other approaches like reminiscence and sensory stimulation. Sixteen homes for the aged with structured day care units were randomly allocated to an intervention or control group. 151 Residents with cognitive impairment and behavioral problems were included in the study. The eight intervention homes received a training program with regard to emotion-oriented care. In the eight control homes usual care was continued. Measurements were performed at baseline and after three, six and twelve months of follow-up (assessment by caregivers and relatives). The primary outcome measure was the change in behavior of the residents. The results of multilevel analyses (overall, subgroup and per protocol) showed no statistically significant, nor clinically relevant effects in favor of the intervention group on the behavioral outcome measures. A possible reason for this is that the intervention did not result in significant contrast between the study groups. There is insufficient scientific evidence yet to justify the implementation of emotion-oriented care in residential homes, for residents with moderate to severe cognitive impairment and behavioral problems, on a large scale. Additional studies are needed in which special attention should be given to the implementation process.     

Efficacy and safety of cognitive enhancers for patients with mild cognitive impairment: a systematic review and meta-analysis

Background:

Cognitive enhancers, including cholinesterase inhibitors and memantine, are used to treat dementia, but their effectiveness for mild cognitive impairment is unclear. We conducted a systematic review to examine the efficacy and safety of cognitive enhancers for mild cognitive impairment.

Methods:

Our eligibility criteria were studies of the effects of donepezil, rivastigmine, galantamine or memantine on mild cognitive impairment reporting cognition, function, behaviour, global status, and mortality or harms. We identified relevant material by searching electronic databases (e.g., MEDLINE, Embase), the references of included studies, trial registries and conference proceedings, and by contacting experts. Two reviewers independently screened the results of the literature search, abstracted data and appraised risk of bias using the Cochrane risk-of-bias tool.

Results:

We screened 15 554 titles and abstracts and 1384 full-text articles. Eight randomized clinical trials and 3 companion reports met our inclusion criteria. We found no significant effects of cognitive enhancers on cognition (Mini–Mental State Examination: 3 randomized clinical trials [RCTs], mean difference [MD] 0.14, 95% confidence interval [CI] −0.22 to 0.50; Alzheimer’s Disease Assessment Scale — cognition subscale: 3 RCTs, standardized MD −0.07, 95% CI−0.16 to 0.01]) or function (Alzheimer’s Disease Cooperative Study activities of daily living inventory: 2 RCTs, MD 0.30, 95% CI −0.26 to 0.86). Cognitive enhancers were associated with higher risks of nausea, diarrhea and vomiting than placebo.

Interpretation:

Cognitive enhancers did not improve cognition or function among patients with mild cognitive impairment and were associated with a greater risk of gastrointestinal harms. Our findings do not support the use of cognitive enhancers for mild cognitive impairment. Older adults experiencing memory and cognition deficits without substantial limitations in activities of daily living may be given a diagnosis of mild cognitive impairment. ¹ These patients often present with subjective memory loss, impairment of cognitive function and no change in their basic daily functioning. Mild cognitive impairment has recently been recognized as a distinct condition, with a prevalence that ranges from 3% to 42% and increases with age. ² Because of the growing proportion of older adults worldwide, the prevalence of this condition will only increase in the future. ³ Each year, 3%–17% of people with mild cognitive impairment experience progression to dementia, ^{4 – 6} a rate that increases to between 11% and 33% by 2 years after the initial diagnosis. ⁷ More than 4.6 million new cases of dementia are diagnosed each year, ³ and efforts to reduce this public health burden are essential. Strategies to delay the progression of mild cognitive impairment are being sought to meet this challenge. One strategy that has been hypothesized to delay the progression from mild cognitive impairment to dementia is the use of cognitive enhancers, agents that are often used to treat dementia. These medications include cholinesterase inhibitors (e.g., donepezil, rivastigmine and galantamine) and the N -methyl- d -aspartic acid receptor antagonist memantine. ⁸ Donepezil, rivastigmine and galantamine increase the concentration of acetylcholine at neurotransmitter sites, ⁹ enhancing the brain’s cholinergic function. Galantamine also influences activity at nicotinic receptors, ⁹ whereas memantine modulates the neurotransmitter glutamate. ⁹ In many countries, cognitive enhancers are not widely available for patients with mild cognitive impairment. However, in some countries, including Canada, these drugs can be obtained through special authorization, ¹⁰ and patients and their families are increasingly requesting their use. Although a Cochrane review on this topic exists, ¹¹ it does not provide information on the use of memantine for mild cognitive impairment or provide data on function or global status, nor does it distinguish between overall harms and treatment-related harms. We sought to examine the efficacy and safety of cognitive enhancers for mild cognitive impairment.     

Review: Diagnosis and treatment of dementia: 3. Mild cognitive impairment and cognitive impairment without dementia

Background

Mild cognitive impairment and cognitive impairment, no dementia, are emerging terms that encompass the clinical state between normal cognition and dementia in elderly people. Controversy surrounds their characterization, definition and application in clinical practice. In this article, we provide physicians with practical guidance on the definition, diagnosis and treatment of mild cognitive impairment and cognitive impairment, no dementia, based on recommendations from the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, held in March 2006.

Methods

We developed evidence-based guidelines using systematic literature searches, with specific criteria for study selection and quality assessment, and a clear and transparent decision-making process. We selected studies published from January 1996 to December 2005 that had mild cognitive impairment or cognitive impairment, no dementia, as the outcome. Subsequent to the conference, we searched for additional articles published between January 2006 and January 2008. We graded the strength of evidence using the criteria of the Canadian Task Force on Preventive Health Care.

Results

We identified 2483 articles, of which 314 were considered to be relevant and of good or fair quality. From a synthesis of the evidence in these studies, we made 16 recommendations. In brief, family physicians should be aware that most types of dementia are preceded by a recognizable phase of mild cognitive decline. They should be familiar with the concepts of mild cognitive impairment and of cognitive impairment, no dementia. Patients with these conditions should be closely monitored because of their increased risk for dementia. Leisure activities, cognitive stimulation and physical activity could be promoted as part of a healthy lifestyle in elderly people and those with mild cognitive impairment. Vascular risk factors should be treated optimally. No other specific therapies can yet be recommended.

Interpretation

Physicians will increasingly see elderly patients with mild memory loss, and learning an approach to diagnosing states such as mild cognitive impairment is now warranted. Close monitoring for progression to dementia, promotion of a healthy lifestyle and treatment of vascular risk factors are recommended for the management of patients with mild cognitive impairment.

Articles to date in this series

• Chertkow H. Diagnosis and treatment of dementia: Introduction. Introducing a series based on the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia. CMAJ 2008;178:316-21.
• Patterson C, Feightner JW, Garcia A, et al. Diagnosis and treatment of dementia: 1. Risk assessment and primary prevention of Alzheimer disease. CMAJ 2008;178:548-56.
• Feldman HH, Jacova C, Robillard A, et al. Diagnosis and treatment of dementia: 2. Diagnosis. CMAJ 2008;178:825-36.