Half of patients with MCI develop dementia within five years — Here’s how we can help change that trajectory.

Early recognition of mild cognitive impairment can slow the rate of decline, improve quality of life, and ultimately lead to fewer aged care admissions, says Dr Mark Hohenberg, a geriatrician from the Salus Clinic.

“It is important to recognise that losing memory is not a routine part of ageing, and more often than not, it represents the symptoms of a disease,” Dr Hohenberg says.

If someone has signs of cognitive impairment, but doesn’t meet the DSM-V criteria for a diagnosis of dementia, they might have mild cognitive impairment. They can still independently perform daily activities—but they are at increased risk of developing dementia, which is why early identification and intervention is so important to reduce that risk.

The research literature highlights that 9-10% of those with mild cognitive impairment will progress to dementia over one year, or around 50% over five years. But early, effective management can slow decline and improve these odds.

This point is also made in the 2023 Australian Dementia Network (ADNeT) Registry annual report released last month, which includes data from 4,280 participants, 37% of whom have mild cognitive impairment (MCI).

“People with MCI are at a greater risk of developing dementia. However, not everyone with MCI develops dementia, and in many cases, the symptoms of MCI may stay the same or even improve over time,” the ADNeT report states.

Comprehensive assessment

Timely diagnosis is crucial – but ADNeT’s data shows that many people wait years.

“Among the participants living with MCI, 41% had symptoms related to cognitive impairment for more than two years at the time of initial appointment, and the percentage increased to 56% among the participants living with dementia,” the report said.

It’s important to do a comprehensive assessment if patients or their loved ones perceive cognitive changes. Initially this involves a thorough history, including collateral history from family and close friends, and examination and exclusion of reversible causes, following up any abnormalities.

Choosing the most appropriate screening test

When deciding on a screening test, consider the person’s age, education level and any potential language barriers. Screening tests may include the well-known Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Clock Drawing Test (CDT), Rowland Universal Dementia Assessment Scale (RUDAS) and the ACE-III or ACE-R.

MMSE

The MMSE does not test frontal lobe function, so Dr Hohenberg recommends further tests to assess frontal lobe function, such as the clock drawing test, proverb interpretation or the Luria-3 step challenge.

RUDAS

The RUDAS is an excellent choice for people from culturally and linguistically diverse backgrounds or with low levels of educational achievement.

MoCA

The MoCA is considered more appropriate for people with slightly higher than average levels of educational achievement, and incorporates frontal lobe testing.

ACE

The Addenbrooke’s Cognitive Examination (ACE) is considered one of the best screening tests as it can differentiate between the different areas of brain function, though it generally takes 20 minutes to complete, so it is used less in general practice.

While these screening tests are not diagnostic in themselves, they can alert to the need for further evaluation.

Making a diagnosis of MCI

To evaluate signs of possible mild cognitive impairment, the Australian MCI guidelines recommend:

• Requesting brain imaging and pathology tests to rule out reversible causes such as infections, electrolyte disturbances, nutritional deficiencies and anaemia.
• Assessing for and treating mental health conditions, such as depression.
• Reviewing for medications that can adversely affect cognition such as amitriptyline, solifenacin and tramadol.
• Exploring substance dependency, such as alcohol and benzodiazepine dependence, which can be associated with cognitive impairments.
• Checking for and addressing sensory deficits (e.g. deafness).

Refer to a specialist if the diagnosis is uncertain, if there’s concern that frontotemporal dementia or other less common forms of dementia are involved, or if the patient experiences rapid deterioration or has other unexpected features, Dr Hohenberg says.

Once the diagnosis is confirmed, there’s much that can be offered.

Managing mild cognitive impairment

Studies have shown three key priorities that patients with mild cognitive impairment say are the most important to them.

• Firstly, patients want to be informed about the diagnosis as early as possible so they can take ownership.
• Secondly, they want their supporters and carers to be able to maintain good quality of life.
• Lastly, they want to maintain independence and stay as healthy as possible.

The ADNeT report notes that most participants living with MCI “did not require a walking aid, were independent in both basic and instrumental activities of daily living and were recorded as driving at the time of diagnosis.” In fact, 93% were able to independently do basic activities and 68% could independently do instrumental ones, while 66% were currently driving.

Dr Hohenberg says it’s crucial to learn the wishes and concerns of the patient and their family, and empower them to understand the condition and available options.

Integrative care has the best evidence for achieving patient satisfaction, he says.

It’s particularly important to address vascular risk factors (e.g. hypertension, diabetes etc) to reduce the overall risk of dementia developing. He recommends offering all patients who’ve been diagnosed with MCI a GP Management Plan, as working collaboratively with other healthcare professionals such as physiotherapists, occupational therapists and dieticians provides the best chance for patients to remain independent and improve or maintain their condition.

Good sleep hygiene and treating sleep apnoea are also important to optimise brain function.

There is no evidence to support using any medications that are currently available in Australia, including cholinesterase inhibitors (used for Alzheimer’s Dementia) or dietary agents—though good nutrition is important.

“The TGA are reviewing lecanemab as a biological treatment,” Dr Hohenberg adds, noting that although it will likely be approved, it’s unlikely to go onto the PBS “due to marginal benefit and high cost, and very significant logistics needed (multiple MRIs and PET scans).”

Evidence also supports cognitive interventions that challenge areas of the brain that the person might otherwise neglect. For example, encourage people who are naturally stronger at logic-based thinking to undertake creative hobbies or activities.

Support to maintain social connections is also extremely important— it’s another way to keep the brain active.

Dr Hohenberg recommends the resources from Dementia Australia (www.dementia.org.au) especially, and says every patient diagnosed with mild cognitive impairment should have their link and request a copy of their excellent Dementia Guide.

The federal government also supports the free ‘Staying at Home’ program which can greatly improve a person’s chances of remaining at home for longer. This can be accessed by calling 1800 699799.

Dementia Support Australia and the Dementia Behaviour Management Advisory Service also offer support for those dealing with more challenging behaviours.