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Mild Cognitive Impairment (MCI) – How do we detect it and does it go on to dementia?
Michelle M. Mielke, PhD Associate Professor of Epidemiology and Neurology
19th Congress of the Australasian Menopause Society September 25, 2015
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• Definition(s) of MCI • MCI Subtypes
• Epidemiology of MCI • Incidence and prevalence • Progression to dementia • Reversion
• Risk factors for progression • DSM-V: Mild Neurocognitive Disorder (NCD)
Outline
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Mild Cognitive Impairment
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Cognitive Spectrum
MCI
Cognitive Normal
Dementia
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Dementia
10%
AD vascular dementia Alzheimer’s disease (AD)
53%
8%
Vascular dementia
8% Fronto-
temporal dementia
6% Other
5%
DLB 10%
AD + dementia with Lewy bodies (DLB)
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Core Clinic Criteria of MCI
• Self- or informant-reported cognitive complaint
• Objective cognitive impairment • Preserved independent in functional
abilities • No dementia
Petersen, 2004, 2014
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Mild Cognitive Impairment
CP1265413-4
Non-amnestic MCI Single domain
Non-amnestic MCI
Single non-memory cognitive domain
impaired?
Non-amnestic MCI Multiple domain
Amnestic MCI Single domain
Cognitive complaint
Not normal for age Not demented
Cognitive decline Essentially normal functional activities
Amnestic MCI
MCI
Memory impaired?
Memory impairment only?
Amnestic MCI Multiple domain
Petersen, 2004, 2014
Yes
Yes Yes
No
No No
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CP1265413-6
AD
AD
FTD AD
DLB AD
Depr
Depr
VCI
VCI
Single domain
Multiple domain
Single domain
Multiple domain
Clin
ical
cla
ssifi
catio
n Amnestic MCI
Non- amnestic
MCI
Etiology Degen- erative Vascular Psychiatric Med Cond
Mild Cognitive Impairment
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Introduction to the Recommendations from the National Institute on
Aging-Alzheimer’s Association Workgroups on Diagnostic Guidelines
for Alzheimer’s Disease Clifford R. Jack, Jr, Marilyn S. Albert, David S. Knopman,
Guy M. McKhann, Reisa A. Sperling, Maria C. Carrillo, Bill Thies, Creighton H. Phelps
Alz and Dementia, 2011
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Hypothetical Model of Dynamic Biomarkers of the Alzheimer’s Pathological Cascade
Jack et al: Lancet Neurol 2010
Normal
Bio
mar
ker m
agni
tude
Aβ Tau-meditated neuronal injury and dysfunction Brain structure Abnormal
Clinical disease stage
Cognitively normal MCI Dementia
Memory Clinical function
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Biomarkers for AD
• Early Biomarkers (Amyloid) • Amyloid PET imaging • CSF Amyloid
• Later Biomarkers (Neurodegeneration) • Structural MRI • FDG-PET • CSF tau
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The Diagnosis of Mild Cognitive Impairment Due to Alzheimer’s Disease: Recommendations from the National Institute on Aging-Alzheimer’s Association Workgroups on Diagnostic Guidelines for Alzheimer’s
Disease
Marilyn S. Albert, Steven T. DeKosky, Dennis Dickson, Bruno Dubois, Howard H. Feldman, Nick C. Fox, Anthony Gamst, David M.
Holtzman, William J. Jagust, Ronald C. Petersen, Peter J. Snyder, Maria C. Carrillo, Bill Thies, Creighton H. Phelps
Alz and Dementia, 2011
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MCI due to AD
• 2 sets of criteria • Core clinical for health care providers • Criteria based on biomarkers – used only in
the research setting or clinical trials • Clinic Criteria
• Essentially the same as the Petersen criteria and previous MCI criteria, with extra focus on memory
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Intermediate Positive Untested
MCI Criteria Incorporating Biomarkers Biomarker Neuronal probability Aβ injury (tau,
Diagnostic category of AD etiology (PET or CSF) FDG, sMRI)
Conflicting/indeterminant Untested
Uninformative
MCI – unlikely due to AD
MCI due to AD – intermediate likelihood
MCI due to AD – high likelihood
MCI
Highest Positive Positive
Lowest Negative Negative
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Epidemiology of MCI
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Incidence and Prevalence: Any MCI
• Average prevalence ≥ 65 years = 18.5% • Average incidence ≥ 65 years = 47.9/1000 p-
years • Both increase with age • Men may have a higher prevalence and incidence
• Estimates vary considerably, depending on: • Source of participants (epidemiological; clinical) • Definition (use of strict cognitive cut-points on 1 or
more tests versus more of a clinical judgment)
Petersen, RC et al., 2014
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MCI Annual Progression Rates
• Epidemiological studies: 7-9%
• Clinical settings: 10-15%
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Stability of MCI diagnosis: Rate of reversion from MCI to normal
Normal
Any MCI
Dementia 37.7% 26.0%
36.3%
- Median 5.1 years of follow-up - 65% who reverted from MCI to Normal, again developed MCI/dementia
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Cumulative Incidence of Dementia by MCI status
Roberts et al., 2014
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Predictors HR 95% CI p FAQ ≥5 2.86 1.94-4.23 <.0001 Apathy 2.02 1.26-3.24 .004 Depression 1.83 1.21-2.76 .004 Stroke 1.72 1.12-2.61 .01 Slow gait 1.57 1.00-2.46 .05 APOE ε4 1.23 0.81-1.85 .33
Risk factors for progression from MCI to dementia
Roberts et al., 2014
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Transition to DSM 5 – Neurocognitive Disorder (NCD)
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Mild Neurocognitive Disorder (MCI)
1. Cognitive decline
2. Single cognitive domain impaired (usually)
3. Preservation of independence
1. Cognitive decline
2. Significant cognitive impairment in one or more often multiple cognitive domains
3. Loss of independence
Major Neurocognitive Disorder (Dementia)
Independence
Cognition
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MCI due to AD
Mild Cognitive Impairment
Plus biomarker for Aβ or tau/Aβ Prodromal AD
Plus biomarker for Aβ MRI or FDG PET or tau § High AND
Plus biomarker for Aβ MRI or FDG PET or tau OR § Intermediate
No or conflicting Aβ or MRI or FDG PET or tau § Uncertain
Mild Neurocognitive Disorder DSM-5
No
Non-amnestic MCI
Cognitive complaint
Not normal for age Not demented
Cognitive decline Essentially normal functional activities
Yes
Amnestic MCI
MCI
Memory impaired?
Non-amnestic MCI Single domain
Non-amnestic MCI Multiple domain
Amnestic MCI Single domain
MCI Criteria Key Symposium JIM, 2004
Amnestic MCI Multiple domain
Petersen et al., J Int Med, 2013
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Conclusions and Discussion • MCI is an intermediate phase between
cognitively normal and dementia • Not everyone with MCI develops dementia • While there is instability, the vast majority of
individuals with a diagnosis of MCI in the community go on to develop dementia
• Notice of new criteria for both clinical and research
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Thank You!
Questions & Discussion