Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly

Cognitive Decline

Patient history

Patients with mild cognitive impairment (MCI) often present with vague and subjective symptoms of declining cognitive performance, which may be difficult to distinguish from the typical performance decline in healthy older individuals.

The most common symptom is said to be memory loss.

Dissociating purely cognitive symptoms from those attributable to various degrees of sensory deprivation (eg, hearing loss or loss of visual acuity) that tend to coexist in the same patient population is often difficult and may be compounded by motor deficits that also beset the same individuals.

Clinicians should rely on their own judgment in deciding when safety-related questions that are appropriate for patients with dementia (for example, about weapons, driving, and possible home fires involving cigarettes, stoves, or fireplaces) should also be asked of patients with MCI.

Physical examination

No feature of the general physical examination is characteristic of MCI.

Nevertheless, a thorough physical examination should be performed as part of the general evaluation in an effort to determine whether any conditions capable of causing MCI (eg, thyroid disease, cobalamin deficiency, or venereal disease) are present and whether there are any sensory and motor deficits that could explain or compound the symptoms.

Mental status examination is also important for documenting the degree of cognitive dysfunction.

Cognitive Decline is one of 4 sub-domains of the

Psychological Assessment

The Psychological Assessment is one of 8 domains of the

 Comprehensive Geriatric Assessment (CGA)

Psychological Assessmen
Psychological Assessmen
Psychological Assessmen

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Comprehensive Geriatric Assessment
Comprehensive Geriatric Assessment
Comprehensive Geriatric Assessment

Differential Diagnosis

Mild cognitive impairment (MCI) may result from virtually any disorder that causes brain dysfunction. Common causes include the following:

  • Alzheimer disease (AD)

  • Cerebrovascular disease

  • Parkinson disease

  • Frontotemporal degenerations

  • Thyroid disease

  • HIV infection

  • Depression

  • Metabolic and endocrine disease [23]

  • Adverse central nervous system effects of drugs and toxicants

  • Cerebral infection

  • Traumatic brain injury

  • Cognitive adverse effects of sleep disorders

  • Cobalamin deficiency

  • Chronic psychological stress

 

patients with atrial fibrillation (AF) reach clinical thresholds for cognitive impairment and dementia at an earlier age than patients without AF (Jeffrey S, 2013), even in the absence of clinical stroke (Thacker EL, 2013).

Treatment

 

Medication

At present, no established treatment exists for mild cognitive impairment (MCI).

Cholinesterase inhibitors have not been found to delay the onset of Alzheimer disease (AD) or dementia in individuals with MCI; however, donepezil has been found to delay the progression to AD in MCI patients with depression without affecting their symptoms of depression (Panza F, 2010).

There is some evidence to suggest that cognitive interventions may have a positive effect (Simon SS, 2012).

 

Medico-legal

Particular attention should be given to the need to make a legal statement about the competency of patients to handle their own affairs.

Because patients with MCI are by definition not demented, they usually do not need to assign power of attorney to anyone else—unlike patients with AD, who eventually will need such help.

 

Diet

The risk of developing MCI is lower in individuals who consume a Mediterranean diet, which is high in vegetables and unsaturated fats.(Roberts RO, 2010).

There is evidence that dietary supplementation with an oily emulsion of docosahexaenoic acid (DHA)-phospholipids containing melatonin and tryptophan yielded significant improvements in several measures of cognitive function (Mariangela R, 2011).

 

Activity

Because physical, social, and mental activity are often recommended for patients with AD and because MCI often heralds AD, many experts have suggested that mentally challenging activities (eg, crossword puzzles and brain teasers) may be helpful for patients with MCI. Although there is no definitive proof that these exercises are efficacious, recommending them to patients with MCI seems advisable.

Such exercises should be kept to a level of difficulty that is reasonable for the patient. Ideally, they should be interactive rather than passive, and they should be administered in a fashion that does not cause excessive frustration.

If an activity is not enjoyable or stimulating for the patient, it is unlikely to offer much cognitive benefit. In such cases, searching for other similar cognitive activities may be beneficial.

 

Social isolation can be minimized through referral to senior community centers or a day treatment program.

Cognitive retraining and rehabilitative strategies offer considerable promise in MCI (Galante E, 2010).

 

A growing body of evidence suggests that physical activity and exercise are beneficial for brain health.

Engaging in moderate exercise of any frequency in midlife or late life was associated with reduced odds of having MCI (Geda YE, 2010).

Prognosis

Many patients with mild cognitive impairment (MCI) eventually experience progressive deterioration in their abilities to perform activities of daily living, cognition, and behavior.

 

Patients with MCI are almost 7 times more likely to develop AD than are older individuals without cognitive impairment.[33]

Of patients with MCI, 80% are said to progress to dementia after approximately 6 years (Boyle PA, 2006).

 

MCI is an independent predictor of mortality (Sachs GA, 2011).

The risk of death is increased by about 50% among individuals with MCI and was nearly 3 times higher among those with AD (Wilson RS, 2009).

 

The severity of memory impairment is predictive of progression to AD: patients with more severe memory impairment are more likely to progress.

Whole brain and hippocampal volume on magnetic resonance imaging (MRI) has been shown to predict progression from MCI to Alzheimer's Disease (Risacher SL, 2009).

Apolipoprotein E (ApoE) status[36] is also a predictor of progression to AD, however, ApoE testing is not recommended for routine clinical use (Boyle PA, 2006).