Mild cognitive impairment: a practice guideline update

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According to the guideline, clinicians should recommend that patients with MCI exercise regularly as part of an overall approach to managing their symptoms.
According to the guideline, clinicians should recommend that patients with MCI exercise regularly as part of an overall approach to managing their symptoms.

Exercising twice a week may improve thinking ability and memory in patients with mild cognitive impairment (MCI), according to a practice guideline update released by the American Academy of Neurology and published in Neurology.

The guideline authors updated the recommendations after reviewing all available studies on MCI. According to the guideline, clinicians should recommend that patients with MCI exercise regularly as part of an overall approach to managing their symptoms. Although long-term studies have not been conducted, 6-month studies suggest that twice-weekly workouts may improve memory.

Recommendations for assessing mild cognitive impairment are as follows:

  • For patients (or a close contact of patients) who voice concern about memory or impaired cognition, clinicians should assess for MCI and not assume the concerns are related to normal aging. (Level B)
  • When performing a Medicare Annual Wellness Visit, clinicians should not rely on historical report of subjective memory concerns alone when assessing for cognitive impairment. (Level B)
  • For patients for whom screening or assessing for MCI is appropriate, clinicians should use validated assessment tools to assess for cognitive impairment. (Level B)
  • For patients who test positive for MCI, clinicians should perform a more formal clinical assessment for diagnosis of MCI. (Level B)
  • For patients with MCI, clinicians should assess for the presence of functional impairment related to cognition before giving a diagnosis of dementia. (Level B)
  • For patients suspected to have MCI, clinicians who themselves lack the necessary experience should refer these patients to a specialist with experience in cognition. (Level B)
  • For patients diagnosed with MCI, clinicians should perform a medical evaluation for MCI risk factors that are potentially modifiable. (Level B)
  • For patients and families asking about biomarkers in MCI, clinicians should counsel that there are no accepted biomarkers available at this time. (Level B)
  • For interested patients, clinicians may discuss the option of biomarker research or refer patients or both, if feasible, to centers or organizations that can connect patients to this research. (Level C)

Recommendations for the management of mild cognitive impairment are as follows:

  • For patients diagnosed with MCI, clinicians should wean patients from medications that can contribute to cognitive impairment (where feasible and medically appropriate) and treat modifiable risk factors that may be contributing. (Level B)
  • For patients diagnosed with MCI, clinicians should counsel the patients and families that there are no pharmacologic or dietary agents currently shown to have symptomatic cognitive benefit in MCI and that no medications are FDA-approved for this purpose. (Level B)
  • For patients diagnosed with MCI, clinicians may choose not to offer cholinesterase inhibitors. (Level B)
  • If clinicians choose to offer cholinesterase inhibitors, they must first discuss with patients the fact that this is an off-label prescription not currently backed by empirical evidence. (Level A)
  • For patients diagnosed with MCI who are interested in pharmacologic treatment, clinicians may inform these patients of centers or organizations that can connect patients to clinical trials. (Level C)
  • For patients diagnosed with MCI, clinicians should recommend regular exercise (twice per week) as part of an overall approach to management. (Level B)
  • For patients diagnosed with MCI, clinicians should discuss diagnosis and uncertainties regarding prognosis. Clinicians should counsel patients and families to discuss long-term planning topics such as advance directives, driving safety, finances, and estate planning. (Level B)
  • Clinicians should assess for behavioral and neuropsychiatric symptoms in MCI and treat with both pharmacologic and non-pharmacologic approaches when indicated. (Level B)
  • In patients with MCI, clinicians may recommend cognitive interventions. (Level C)

“If you or others have noticed that you are forgetful and are having trouble with complex tasks, you should see your [clinician] to be evaluated and not assume that it is just part of normal aging,” stated Ronald C. Petersen, MD, PhD, of the Mayo Clinic in Rochester, Minn. “Sometimes memory problems are a side effect of medications, sleep disturbances, depression, or other causes that can be treated. It is important to meet with your [clinician] to determine the root cause. Early action may keep memory problems from getting worse.”

References

  1. Petersen RC, Lopez O, Armstrong MJ, et al. Guideline: Exercise may improve thinking ability and memory. Neurology. December 27, 2017. Accessible at: https://www.aan.com/Guidelines/home/GuidelineDetail/881
  2. Petersen RC, Lopez O, Armstrong MJ, et al. Practice guideline update summary: Mild cognitive impairment: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2017 Dec 27. doi: 10.1212/WNL.0000000000004826
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