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Mild Cognitive Impairment: What Caregivers Need to Know

MCI can be a precursor to dementia, but experts say it is often treatable

living in old people's home: senior woman gets attention - hand on shoulder
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You see an actor on TV and have trouble remembering her name — that “tip of the tongue” sensation. Or you walk into a room to retrieve something only to forget what it was you came to get, a phenomenon known as the doorway effect. These sorts of things happen to most of us as we get older.

Mild cognitive impairment (MCI) is a stage between cognitive changes associated with normal aging and the more serious decline of dementia.

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“MCI is an umbrella term for an early stage of loss of cognitive, or thinking, ability,” says Tamar Gefen, a neuropsychologist at Northwestern Memorial Hospital. “An individual does not lose their ability to carry out their typical activities of daily living. They have cognitive problems but can still work, can still drive. No one would necessarily from the outside know that there’s anything wrong with their thinking.”  

The changes, however, are serious enough to be noticed by the person affected and by family caregivers and others who know them well. Ardeshir Hashmi, M.D., section chief of the Center for Geriatric Medicine at the Cleveland Clinic, likens MCI to borderline diabetes, a condition that develops before a person gets type 2 diabetes. 

“That is what MCI is to memory impairment,” he says. “You don’t have dementia at the time but are you borderline or at risk of developing it in the future. It’s sort of a warning stage.”

There are two categories of mild cognitive impairment. 

Amnestic MCI affects memory. A person may start to forget information they would have recalled easily before, such as the contents of a recent conversation, an appointment they’ve been reminded of multiple times or a recurring event like a close relative’s birthday. 

Non-amnestic MCI affects other thinking skills. You can remember things, but other ways you engage your brain become more difficult. These might include: 

• Your ability to make sound decisions or understand instructions.

• Spatial ability — you have trouble navigating through your environment or gauging distances.

• Language — losing your train of thought or forgetting familiar words when speaking.

• Calculation — difficulty with anything that involves math, for example. 

What’s behind the brain fog?

According to the Alzheimer’s Association, 12 to 18 percent of people age 60 or older are living with mild cognitive impairment. An estimated 10 to 15 percent of individuals with MCI develop dementia each year. 

“Some people [with MCI] will be in the early stages of a neurodegenerative process, such as Alzheimer’s disease,” says C. Munro Cullum, a neuropsychologist at the UT Southwestern O’Donnell Brain Institute. “Others may be experiencing cognitive decline or memory loss due to vascular risk factors, such as a series of small mini-strokes or hyper-cholesterol building up over many years, leading to reduced blood flow through blood vessels in the brain.” 

“There are people who have MCI and remain stable, and some actually get better and revert back to normal cognition,” Hashmi says. “Depending on the underlying cause, it may be a treatable thing.” 

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Case in point: Cullum has one patient he’s followed for close to 20 years. “He had a diagnosis of MCI for 15 of those years and never got worse. He’s had little ups and downs, but he’s stable.” 

Indeed, MCI can often be reversed if a general health condition is behind the brain fog. 

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“The list of what causes MCI is very long,” says Sarah Kremen, M.D., director of the neurobehavior program at Cedars-Sinai Medical Center’s Jona Goldrich Center for Alzheimer’s and Memory Disorders. “It could be anxiety or depression, it could be a thyroid problem, it could be multiple medications interacting with each other and causing cognitive difficulties.”

Other possible culprits include vision or hearing loss

“Vision and hearing are sensory nourishment to the brain,” Hashmi says. “The more sensory input the brain gets from your external world, in terms of what you’re able to see and hear, the more connections in the brain are formed, the better your memory. If that starts to get compromised, the less sensory input there is, and the connections in the brain are negatively impacted.” 

Likewise, sleep apnea — a disorder in which breathing stops and starts as you doze, preventing your brain from getting enough oxygen — can also lead to cognitive slippage, resulting in memory loss.

“I have patients who say, ‘I have Alzheimer’s disease, I can’t remember a thing, I’m disoriented, I’m confused,’ and it turns out they have a vitamin D or B12 deficiency and urinary tract infection, and they’re depressed — all of these different factors,” Gefen says. “You treat the UTI, the vitamin deficiency and the depressive symptoms and it resolves.”

That MCI may be caused by something treatable and reversible “is so important,” she adds. “There are people walking around thinking they have something like Alzheimer’s disease, but it’s not.”

Still, there is a subset of people whose condition never improves. 

“Every year they’re getting worse, and eventually they progress to dementia,” Kremen says. “At the beginning, it may not be easy to tease those people apart. Obviously, the goal is to be able to figure out who those people are, as early as possible, to begin to initiate proper treatment.” 

Diagnosis: MCI or normal aging?

Our brains don’t think as fast at 80 as when we were 30. But when a change in memory or cognition becomes a worry that is shared by others, that may be a sign it’s time to see your primary care physician or geriatrician. 

Your doctor might encourage you to get a specialized evaluation with a neurologist or a neuropsychologist, who will want to review your medical and psychiatric history, your symptoms and their course. (Did the memory issues crop up a week ago or have they been happening for years? How have they changed over time?) 

“These details are important,” Gefen says. 

The doctor might also administer brief cognitive screening tests, such as the Short Test of Mental Status or the Montreal Cognitive Assessment, to assess memory and measure changes in problem-solving, comprehension, reasoning and other cognitive skills. 

“What we try to do with neuropsychological evaluation is distinguish normal aging and what may look like pathological aging,” Cullum says.

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If there’s evidence of impairment, a neurologist will perform additional tests to figure out if the cause is reversible. 

“First, you have to rule out all of the reversible possibilities,” Gefen says. “The doctor will take a blood test, get a urine sample, measure blood pressure — all the vitals — and hopefully find a reversible cause. If everything is clean, we start to consider irreversible causes, say, a neurodegenerative disorder” such as Alzheimer’s or Parkinson’s disease

Part of the workup might be getting a brain MRI to detect vascular changes, which may eventually progress to Alzheimer’s disease.

Eat healthy, stay connected

If testing determines that a treatable medical condition underlies MCI, the patient can be treated for that condition. “There is robust evidence that there are things one can do to prevent — and actually improve — MCI,” Hashmi says. 

For example, a CPAP machine can ease sleep apnea. Depression can be treated with medication, therapy or a combination of both. Dietary changessupplements or injections can reverse a vitamin B12 deficiency. 

Since MCI is more likely to progress to dementia if you have hypertension, high cholesterol or diabetes, managing these conditions with appropriate medication is crucial. Then there are commonsense measures, such as maintaining a healthy weight, not smoking and avoiding excessive drinking

The FINGER study, an ongoing randomized controlled trial initiated in Finland in 2009 and since expanded worldwide, has demonstrated that it is possible to prevent cognitive decline with lifestyle interventions. One component is following the Mediterranean diet, which includes lots of plant-based foods (vegetables, fruits, whole grains, legumes and nuts) and seafood, particularly fatty fish such as salmon. 

Another is exercise — “not the intensity of it, but the regularity,” Hashmi says. For example, walk, swim or run two to five times a week. 

Try activities that engage the mind, like learning a new language or skill, or playing mentally challenging games such as chess or sudoku. “That plus staying busy and active with things that you love and enjoy that are your passions, especially volunteering your time,” Hashmi recommends. “Research shows that when you volunteer your time, your memory stays sharp. The Japanese have a word for it: ikigai. A reason for being.”

Social interaction, both in person or connecting with friends and relatives via video platforms like Zoom, may also be helpful in maintaining cognition later in life. 

“One of our theories is that the brain loves new things,” Cullum says. “If you’re doing the same thing — say, watching Perry Mason reruns — day and night and never leave your house, you’re at greater risk for more significant and more rapid mental decline than someone who is getting out and socializing. Social interactions are a form of mental stimulation.” 

‘The key word is change’

How can older adults and caregivers tell when MCI is progressing into dementia? It’s a matter of degrees, Cullum says. 

“Some people’s ability to perform their daily tasks tends to start slipping,” he says. “If Grandma was an awesome cook and suddenly she’s messing up recipes — in isolation those things may be meaningless. But when you start seeing these events occurring with greater frequency, they can be warning signs.”

“The key word is change. Does it represent a change from the person’s typical baseline functioning?” Gefen says. “For example, I get lost everywhere. That’s who I am — I’m not good at navigating. When I’m 85 and still have trouble with navigating, it’s not going to alarm me. But if suddenly I forget to speak and can’t comprehend things properly or I’m not writing as well, that’s a change for me. That’s concerning.”

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