Resources

  1. Practice guideline update summary: Mild cognitive impairment. Ronald C. Petersen, Oscar Lopez, Melissa J. Armstrong, Thomas S.D. Getchius, Mary Ganguli, David Gloss, Gary S. Gronseth, DanielMarson, Tamara Pringsheim, Gregory S. Day, Mark Sager, JamesStevens, Alexander Rae-Grant. Neurology Dec 2017, 10.1212/WNL.0000000000004826; DOI:10.1212/WNL.0000000000004826. 

Transcript

Dr. Frank Domino:
KR's mother, Ellen, is a 73-year-old female with history of hypertension. She's always taken excellent care of herself, stayed fit, didn't smoke, but has recently been diagnosed with mild cognitive impairment. Today, we're going to discuss what we can do to possibly help her. Hi, this is Frank Domino, Professor in the Department of Family Medicine and Community Health. And joining me today is Robert Baldor, Professor and Senior Vice Chair in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School. Welcome to the show, Bob.

Robert A. Baldor, MD, FAAFP:
Thanks, Frank. Great to be back.

Dr. Frank Domino:

Thank you. Well, we're gonna continue our discussion around the American Academy of Neurology's guidelines on mild cognitive impairment, and we have Ellen here who has recently been diagnosed. Can you talk a little bit about how screening and diagnosis should be done?

Robert A. Baldor, MD, FAAFP:
Certainly, our last segment we went into that quite a bit, and I just wanna remind people that the guidelines call for use of a validated instrument for screening something like the MoCA or the Mini-Mental Status Exam, but that's a screening instrument. So if you have a patient that fails that they really should undergo a formal neuropsych testing just to sort of get a sense as to, is this a real diagnosis or not? So that's a key piece of what needs to be done.

Dr. Frank Domino:
Thanks, Bob, for that. Can you remind us a little bit about what are the secondary causes of mild cognitive impairment and how we should consider working that up?

Robert A. Baldor, MD, FAAFP:

Well, that's a good point because I think a lot of it we're worried about this being a dementia or aging process, that's not the case, but clearly when you do have somebody who has a mild cognitive impairment, the first thing you wanna look for is what medications they're on that may be causing some cognitive impairment for them. That's number one. There are things that may be clouding their ability to think straight and so on or memory, and can you wean them off of it? Can you take them off those meds? The second thing is the two biggest issues that relate to this from a medical perspective are sleep, and folks who have difficulty with sleep are gonna then have problems with their cognitive function the next day. It's pretty clear that that's out there.

And who has depression, so folks that are depressed they're gonna have problems with cognitive impairment as well. So those are the things you need to think about before really starting to worry about dementia or something else going on, and going after that those can be correctable. About 15% of those who've been diagnosed with mild cognitive impairment over the age of 65 will go on to develop dementia, 15%. The other 85% will stay static or improve. So we wanna have as many people improve as possible, and that's attending to those issues.

Dr. Frank Domino:
Well, that's really interesting. I think most of us think of dementia as sort of a terminal diagnosis, but it's great to know that there are alterable risk factors or secondary causes like sleep, like anxiety, like depression that we should probably get a little bit more aggressive about treating. And I really like the thought that we need to look at the medications we use, especially in seniors. Polypharmacy is a huge issue, and we probably cause problems that can appear as dementia.
Alright, well, let's say we've screened them, we've diagnosed them, we've eliminated the possible secondary causes, we've done a workup to look for B12 and thyroid dysfunction, and it looks like the person has mild cognitive dysfunction. What are the pharmacologic and non-pharmacologic approaches that the guidelines support?

Robert A. Baldor, MD, FAAFP:
Well, I will say that as the most surprising thing for me was what they were saying in their conclusions. They actually, just to go to this first then I'll come back around, it says, "Clinicians may choose not to offer cholinesterase inhibitors. If offering, they must first discuss lack of evidence for efficacy." So that was fascinating to hear this.

Dr. Frank Domino:
Wow. So even before we begin, they make the use of cholinesterase inhibitors as something that's optional based upon its limited database.

Robert A. Baldor, MD, FAAFP:
Yeah. Clearly for mild cognitive impairment, there's just no evidence out there to support that. All of the known treatments for cognitive impairments and mild cognitive impairments, there's still other things that can be done. The other thing they recommend, interestingly enough, is exercise. So looking at the recommendations they say long-term studies are unavailable, but six-month studies have actually shown a benefit from twice weekly exercise program. I constantly talk to people about exercise, and getting out, and moving for a whole host of things, and here's just another reason to be out there. And if you're worried about dementia in your family or you're worried about your memory or whatever, another reason to get out there and get active twice a week. I think it's not an unreasonable thing to be thinking about.

Dr. Frank Domino:
When I think about the social isolation that seniors develop and trying to get them more integrated, I would love to think that you could take a senior and recommend they join a group that does exercise two, three times a week, and you address two issues with one very healthy and simple intervention. So that's great exercise as a first approach. Other thoughts?

Robert A. Baldor, MD, FAAFP:
Well, there is recommendation for cognitive interventions. So what are cognitive interventions? Some of this is there's some data out there that there are these various learning strategies. Some of it is to minimize one's ability to sort of function and thinking a little bit about what are the tools you can be using to help you think better to organize your thoughts should be taking notes, should be using pictures to be thinking about things from that perspective. And the data out there is a little... That it's by help for people to function probably not improving, but it helps them to function better.

The other thing, there are some evidence out there for repeatedly practicing cognitive skills so that you retrain your brain. And the data from there really comes from folks who've had traumatic brain injury or post stroke, and those folks seem to respond to really repeated cognitive skills so you're almost re-memorizing something. Less so here, the people have recommended something that people can do. There's lot of tools out there, different apps you can use on your smartphones and so on. Not a lot of data out there to show that you're beneficial with it, but it is something that people wanna be doing something, this is something to try to work with those memory enhancing tools and types of apps and programs that are there.

Dr. Frank Domino:
So I think that's very interesting. I like the idea of notes and pictures. I actually have a patient who does this, who has posted by the door to her house a sign that says, "Don't forget your keys and know where you're going before you leave." She told me this and I thought that was fantastic. I do find it fascinating that for at least the last few years we've had a fair number of advertisements for web-based and phone-based tools to try to prevent dementia. And it's been at least somewhat reassuring to see that doing Sudoku and doing crossword puzzles are great, but they don't necessarily stave off the syndromes associated with dementia.

Robert A. Baldor, MD, FAAFP:

Yeah, it is frustrating 'cause I do all those myself and what can you do to go with it? So I wanna just talk a little about medications. We talked about the acetylcholinesterase inhibitors. What's really interesting in this guideline is they went through all kinds of recommended therapies that have been out there to sort of say, is there evidence out there to support this? And so they're saying these are probably... So again, the acetylcholinesterase inhibitors probably ineffective in reducing progression to dementia. That's basically the language that they're using here. But what about flavonoid-containing drinks? Right? Lots of flavonoid-containing drinks. I said, "Well, you know what? Insufficient evidence to support or refute the cognitive benefits from a drink with high dose of flavonoid." So no data to support that.

Dr. Frank Domino:
What's a drink that's high in flavonoid?

Robert A. Baldor, MD, FAAFP:
Well, that would be my daily glass of wine, Frank.

Dr. Frank Domino:
Why? There's no evidence to support or refute... So I'm gonna drink some wine.

[overlapping conversation]

Robert A. Baldor, MD, FAAFP:
So I'm drinking. How about...

[laughter]

Dr. Frank Domino:
That's fine.

Robert A. Baldor, MD, FAAFP:
One glass a night probably is the best thing to do for that. Homocysteine and B vitamins, again, insufficient evidence to support or refute the use of homocysteine-lowering therapies with B vitamins. It's just interesting as they go through... Vitamin E, possibly ineffective for reducing progression and so on. So in many ways, it's a little sad that we don't have something that can be helpful for our patients. Something we can't prescribe or recommend for them from a pharmacologic point of view because patients come in and they want us to write a prescription and that's a lot of what I do. On the other hand, it's really helpful to have this evidence and this guideline saying, don't put people on these medications 'cause it's really not gonna be benefiting 'em. Instead, getting 'em out, to get them exercising, getting social interaction, keeping them moving.

Dr. Frank Domino:
Bob, this is... Well, as you say, this guideline didn't find great evidence for treatment using pharmacologic agents. It gave us a clear direction on what we should be doing with regard to exercise and other cognitive interventions, and I think that the benefit there is huge and something that we as primary care folks need to really respect. Thanks for bringing this forward today, Bob.

Robert A. Baldor, MD, FAAFP:
Thanks. Pleasure being here, Frank.

Dr. Frank Domino:
Practice pointer: After you make the diagnosis of mild cognitive impairment, the two most effective methods to slow the progression to full dementia are exercise twice a week and cognitive interventions like reminding the patients to take notes and use pictures to help guide their activities. Join us next time when we review the CASTLE-AF trial, which looked at using catheter ablations on our patients with heart failure and atrial fibrillation. This trial found an improved mortality rate by this aggressive treatment with very little adverse effects.