Opinion statement
It is increasingly evident that early identification of cognitive impairment in older adults presents opportunities for interventions that aim to mitigate the impact of cognitive symptoms on daily function and that attempt to delay (or ultimately prevent) progression from mild cognitive impairment (MCI) to dementia. To date, no intervention has proven protective in ultimately preventing conversion to dementia. However, several lifestyle, dietary, and pharmacologic interventions have suggested symptomatic benefit for those having MCI. A number of diet and lifestyle recommendations have been associated with decreased risk of dementia both in cognitively intact older adults and in those having mild cognitive impairment. Thus, these recommendations may be appropriate for both people presenting with subjective cognitive concerns and for those having objective evidence of memory problems. It remains less certain whether adopting these lifestyle habits in later life confers the benefits seen in epidemiological cohorts (where people have likely practiced them for many years). Discussion of starting on a cholinesterase inhibitor is appropriate for those having MCI, particularly those in whom the MCI is thought to have a vascular etiology or to represent the prodromal stage of a neurodegenerative disease. Recent meta-analyses exploring the use of cholinesterase inhibitors in patients having MCI have concluded that there is no evidence to support this practice. Although meta-analytic techniques seemingly strengthen the confidence in a recommendation via the incorporation of a large number of subjects analyzed, the technique is not capable of overcoming any inherent weaknesses of the individual studies included in the analysis. It is arguable whether studies in MCI may have employed endpoints poorly adapted to investigating effect of cholinesterase inhibitors. Most studies have used cognitive screening examinations, all of which stretch their detection ability to identify subjects with MCI, let alone discriminate subtle differences between them. Some have used conversion from MCI to dementia as an endpoint, which may not be the best measure for a symptomatic treatment. Further, once conversion to dementia has occurred, a cholinesterase inhibitor would be started in most (if not all) clinical settings, a reality not well reflected in most study designs. Additionally, several large studies have not permitted subject stratification by APOE carrier status, another important defect in assessing outcome. In clinical practice, our center typically does recommend cholinesterase inhibitors for patients having MCI. Despite the modest effect size, many patients do wish to start on treatment. It appears that this is a generally accepted practice and experience, as most clinical trials for prodromal Alzheimer’s disease specify that participants should be taking a cholinesterase inhibitor.
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Petersen RC. Clinical practice. Mild cognitive impairment. N Engl J Med. 2011;364:2227–34. Discusses clinical operationalization and utility of the diagnosis of mild cognitive impairment.
Petersen RC, Smith GE, Waring SC, Ivnik RJ, Tangalos EG, Kokmen E. Mild cognitive impairment: clinical characterization and outcome. Arch Neurol. 1999;56:303–8.
Fleisher AS, Sowell BB, Taylor C, et al. Clinical predictors of progression to Alzheimer disease in amnestic mild cognitive impairment. Neurology. 2007;68:1588–95.
Gauthier S, Reisberg B, Zaudig M, et al. Mild cognitive impairment. Lancet. 2006;367:1262–70.
Ferman TJ, Smith GE, Kantarci K, et al. Nonamnestic mild cognitive impairment progresses to dementia with Lewy bodies. Neurology. 2013;81:2032–8.
Roberts RO, Geda YE, Knopman DS, et al. The Mayo Clinic Study of Aging: design and sampling, participation, baseline measures and sample characteristics. Neuroepidemiology. 2008;30:58–69.
Albert MS, DeKosky ST, Dickson D, et al. 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. Alzheimers Dement J Alzheimers Assoc. 2011;7:270–9. Most recent consensus on diagnosis and research implications of mild cognitive impairment due to Alzheimer’s disease including discussion of biomarkers.
Petersen RC, Caracciolo B, Brayne C, Gauthier S, Jelic V, Fratiglioni L. Mild cognitive impairment: a concept in evolution. J Intern Med. 2014;275:214–28. Provides historical context and discusses future implications of the diagnostic category “mild cognitive impairment.”.
Whitwell JL, Wiste HJ, Weigand SD, et al. Comparison of imaging biomarkers in the Alzheimer disease neuroimaging initiative and the Mayo Clinic study of aging. Arch Neurol. 2012;69:614–22.
Donohue MC, Sperling RA, Salmon DP, et al. The preclinical Alzheimer cognitive composite: measuring amyloid-related decline. JAMA Neurol. 2014;71:961–70.
Lourida I, Soni M, Thompson-Coon J, et al. Mediterranean diet, cognitive function, and dementia: a systematic review. Epidemiology. 2013;24:479–89. Reviews available data pertinent to the association between cognitive function and Mediterranean style diet.
van Uffelen JG, Chinapaw MJ, van Mechelen W, Hopman-Rock M. Walking or vitamin B for cognition in older adults with mild cognitive impairment? A randomised controlled trial. Br J Sports Med. 2008;42:344–51.
Petersen RC, Thomas RG, Grundman M, et al. Vitamin E and donepezil for the treatment of mild cognitive impairment. N Engl J Med. 2005;352:2379–88.
Quinn JF, Raman R, Thomas RG, et al. Docosahexaenoic acid supplementation and cognitive decline in Alzheimer disease: a randomized trial. JAMA. 2010;304:1903–11.
Gray SL, Anderson ML, Crane PK, et al. Antioxidant vitamin supplement use and risk of dementia or Alzheimer's disease in older adults. J Am Geriatr Soc. 2008;56:291–5.
Sattler C, Toro P, Schonknecht P, Schroder J. Cognitive activity, education and socioeconomic status as preventive factors for mild cognitive impairment and Alzheimer's disease. Psychiatry Res. 2012;196:90–5.
Valenzuela M, Brayne C, Sachdev P, et al. Cognitive lifestyle and long-term risk of dementia and survival after diagnosis in a multicenter population-based cohort. Am J Epidemiol. 2011;173:1004–12.
Wilson RS, Hebert LE, Scherr PA, Barnes LL, Mendes de Leon CF, Evans DA. Educational attainment and cognitive decline in old age. Neurology. 2009;72:460–5.
Rapp SR, Espeland MA, Manson JE, et al. Educational attainment, MRI changes, and cognitive function in older postmenopausal women from the Women's Health Initiative Memory Study. Int J Psychiatry Med. 2013;46:121–43.
Stern Y. Cognitive reserve and Alzheimer disease. Alzheimer Dis Assoc Disord. 2006;20:112–7.
Dufouil C, Pereira E, Chene G, et al. Older age at retirement is associated with decreased risk of dementia. Eur J Epidemiol. 2014;29:353–61.
Hall L, Orrell M, Stott J, Spector A. Cognitive stimulation therapy (CST): neuropsychological mechanisms of change. Int Psychogeriatr / IPA. 2013;25:479–89.
Woods B, Aguirre E, Spector AE, Orrell M. Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database Syst Rev. 2012;2:CD005562.
Patterson C, Feightner JW, Garcia A, Hsiung GY, MacKnight C, Sadovnick AD. Diagnosis and treatment of dementia: 1. Risk assessment and primary prevention of Alzheimer disease. CMAJ Can Med Assoc J J Assoc Med Can. 2008;178:548–56.
Vogel T, Brechat PH, Lepretre PM, Kaltenbach G, Berthel M, Lonsdorfer J. Health benefits of physical activity in older patients: a review. Int J Clin Pract. 2009;63:303–20. Discussion and review of cognitive and health benefits of regular physical activity in older adults.
Forbes D, Forbes SC, Blake CM, Thiessen EJ, Forbes S. Exercise programs for people with dementia. Cochrane Database Syst Rev. 2015;4:CD006489.
van Uffelen JG, Chin APMJ, Hopman-Rock M, van Mechelen W. The effect of walking and vitamin B supplementation on quality of life in community-dwelling adults with mild cognitive impairment: a randomized, controlled trial. Qual Life Res Int J Qual Life Asp Treat Care Rehab. 2007;16:1137–46.
Venturelli M, Scarsini R, Schena F. Six-month walking program changes cognitive and ADL performance in patients with Alzheimer. Am JAlzheimers Dis Other Dement. 2011;26:381–8.
Hughes TF, Flatt JD, Fu B, Chang CC, Ganguli M. Engagement in social activities and progression from mild to severe cognitive impairment: the MYHAT study. Int Psychogeriatr/ IPA. 2013;25:587–95.
Fratiglioni L, Paillard-Borg S, Winblad B. An active and socially integrated lifestyle in late life might protect against dementia. Lancet Neurol. 2004;3:343–53. Review of the importance of physical and social stimulation in decreasing he risk of dementia and cognitive decline.
Fratiglioni L, Wang HX, Ericsson K, Maytan M, Winblad B. Influence of social network on occurrence of dementia: a community-based longitudinal study. Lancet. 2000;355:1315–9.
Neuvonen E, Rusanen M, Solomon A, et al. Late-life cynical distrust, risk of incident dementia, and mortality in a population-based cohort. Neurology. 2014;82:2205–12.
Nikmat AW, Hawthorne G, Al-Mashoor SH. The comparison of quality of life among people with mild dementia in nursing home and home care--a preliminary report. Dementia. 2015;14:114–25.
Parsaik AK, Lapid MI, Rummans TA, et al. ApoE and quality of life in nonagenarians. J Amer Med Dir Assoc. 2012;13:704–7.
Gorelick PB, Scuteri A, Black SE, et al. Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the american heart association/american stroke association. Stroke J Cereb Circ. 2011;42:2672–713. This paper underscores the importance of vascular risk factors (and likely cerebrovascular pathology) in the risk of all-cause dementia in older adults.
Boeve BF. Evidence for cholinesterase-inhibitor therapy for dementia associated with Parkinson's disease. Lancet Neurol. 2005;4:137–8.
Maidment I, Fox C, Boustani M. Cholinesterase inhibitors for Parkinson's disease dementia. Cochrane Database Syst Rev. 2006:CD004747.
McKeith IG, Dickson DW, Lowe J, et al. Diagnosis and management of dementia with Lewy bodies: third report of the DLB Consortium. Neurology. 2005;65:1863–72.
Russ TC, Morling JR. Cholinesterase inhibitors for mild cognitive impairment. Cochrane Database Syst Rev. 2012;9:CD009132.
Roberts JS, Karlawish JH, Uhlmann WR, Petersen RC, Green RC. Mild cognitive impairment in clinical care: a survey of American Academy of Neurology members. Neurology. 2010;75:425–31.
Weinstein AM, Barton C, Ross L, Kramer JH, Yaffe K. Treatment practices of mild cognitive impairment in California Alzheimer's Disease Centers. J Am Geriatr Soc. 2009;57:686–90.
Reisberg B, Doody R, Stoffler A, et al. Memantine in moderate-to-severe Alzheimer's disease. N Engl J Med. 2003;348:1333–41.
Schneider LS, Dagerman KS, Higgins JP, McShane R. Lack of evidence for the efficacy of memantine in mild Alzheimer disease. Arch Neurol. 2011;68:991–8.
Prvulovic D, Hampel H. Amyloid beta (Abeta) and phospho-tau (p-tau) as diagnostic biomarkers in Alzheimer's disease. Clin Chem Lab Med CCLM / FESCC. 2011;49:367–74.
Ewers M, Mattsson N, Minthon L, et al. CSF biomarkers for the differential diagnosis of Alzheimer's disease. A large-scale international multicenter study. Alzheimers Dement J Alzheimers Assoc. 2015.
Molinuevo JL, Blennow K, Dubois B, et al. The clinical use of cerebrospinal fluid biomarker testing for Alzheimer's disease diagnosis: a consensus paper from the Alzheimer's Biomarkers Standardization Initiative. Alzheimers Dement J Alzheimers Assoc. 2014;10:808–17.
Holtzman DM. CSF biomarkers for Alzheimer's disease: current utility and potential future use. Neurobiol Aging. 2011;32 Suppl 1:S4–9. An excellent review of CSF biomarkers for Alzheimer’s disease and discussion of possible future clinical and research use for these biomarkers.
van Rossum IA, Vos S, Handels R, Visser PJ. Biomarkers as predictors for conversion from mild cognitive impairment to Alzheimer-type dementia: implications for trial design. J Alzheimers Dis JAD. 2010;20:881–91.
Herholz K. PET studies in dementia. Ann Nucl Med. 2003;17:79–89.
Foster NL, Heidebrink JL, Clark CM, et al. FDG-PET improves accuracy in distinguishing frontotemporal dementia and Alzheimer's disease. Brain J Neurol. 2007;130:2616–35.
Shivamurthy VK, Tahari AK, Marcus C, Subramaniam RM. Brain FDG PET and the diagnosis of dementia. AJR Am J Roentgenol. 2015;204:W76–85.
Herholz K. Cerebral glucose metabolism in preclinical and prodromal Alzheimer's disease. Expert Rev Neurother. 2010;10:1667–73.
Drzezga A. Diagnosis of Alzheimer's disease with [18F]PET in mild and asymptomatic stages. Behav Neurol. 2009;21:101–15.
Zhang S, Han D, Tan X, Feng J, Guo Y, Ding Y. Diagnostic accuracy of 18 F-FDG and 11 C-PIB-PET for prediction of short-term conversion to Alzheimer's disease in subjects with mild cognitive impairment. Int J Clin Pract. 2012;66:185–98.
Adlard PA, Tran BA, Finkelstein DI, et al. A review of beta-amyloid neuroimaging in Alzheimer's disease. Front Neurosci. 2014;8:327.
Carome M, Wolfe S. Florbetapir-PET imaging and postmortem beta-amyloid pathology. JAMA. 2011;305:1857. author reply 1857-1858.
Chetelat G, La Joie R, Villain N, et al. Amyloid imaging in cognitively normal individuals, at-risk populations and preclinical Alzheimer's disease. NeuroImage Clin. 2013;2:356–65.
Clark CM, Schneider JA, Bedell BJ, et al. Use of florbetapir-PET for imaging beta-amyloid pathology. JAMA. 2011;305:275–83.
Curtis C, Gamez JE, Singh U, et al. Phase 3 trial of flutemetamol labeled with radioactive fluorine 18 imaging and neuritic plaque density. JAMA Neurol. 2015;72:287–94.
Richards D, Sabbagh MN. Florbetaben for PET imaging of beta-amyloid plaques in the brain. Neurol Ther. 2014;3:79–88.
Greenaway MC, Hanna SM, Lepore SW, Smith GE. A behavioral rehabilitation intervention for amnestic mild cognitive impairment. Am J Alzheimers Dis Other Dement. 2008;23:451–61.
Greenaway MC, Duncan NL, Smith GE. The memory support system for mild cognitive impairment: randomized trial of a cognitive rehabilitation intervention. Int J GeriatrPsychiatry. 2013;28:402–9.
Solfrizzi V, Panza F. Plant-based nutraceutical interventions against cognitive impairment and dementia: meta-analytic evidence of efficacy of a standardized Gingko biloba extract. J Alzheimers Dis JAD. 2015;43:605–11.
DeKosky ST, Williamson JD, Fitzpatrick AL, et al. Ginkgo biloba for prevention of dementia: a randomized controlled trial. JAMA. 2008;300:2253–62.
Snitz BE, Saxton J, Lopez OL, et al. Identifying mild cognitive impairment at baseline in the Ginkgo Evaluation of Memory (GEM) study. Aging Ment Health. 2009;13:171–82.
Schneider LS, DeKosky ST, Farlow MR, Tariot PN, Hoerr R, Kieser M. A randomized, double-blind, placebo-controlled trial of two doses of Ginkgo biloba extract in dementia of the Alzheimer's type. Curr Alzheimer Res. 2005;2:541–51.
Gavrilova SI, Preuss UW, Wong JW, et al. Efficacy and safety of Ginkgo biloba extract EGb 761 in mild cognitive impairment with neuropsychiatric symptoms: a randomized, placebo-controlled, double-blind, multi-center trial. Int J Geriatr Psychiatry. 2014;29:1087–95.
Ha GT, Wong RK, Zhang Y. Huperzine a as potential treatment of Alzheimer's disease: an assessment on chemistry, pharmacology, and clinical studies. Chem Biodivers. 2011;8:1189–204.
Little JT, Walsh S, Aisen PS. An update on huperzine A as a treatment for Alzheimer's disease. Expert Opin Invest Drugs. 2008;17:209–15.
Rafii MS, Walsh S, Little JT, et al. A phase II trial of huperzine A in mild to moderate Alzheimer disease. Neurology. 2011;76:1389–94.
Yang G, Wang Y, Tian J, Liu JP. Huperzine A for Alzheimer's disease: a systematic review and meta-analysis of randomized clinical trials. PLoS One. 2013;8:e74916.
Giurgea C. The "nootropic" approach to the pharmacology of the integrative activity of the brain. Cond Reflex. 1973;8:108–15.
Croisile B, Trillet M, Fondarai J, Laurent B, Mauguiere F, Billardon M. Long-term and high-dose piracetam treatment of Alzheimer's disease. Neurology. 1993;43:301–5.
Flicker L, Grimley Evans G. Piracetam for dementia or cognitive impairment. Cochrane Database Syst Rev. 2001:CD001011.
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Brendan J. Kelley declares no conflict of interest.
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Kelley, B.J. Treatment of Mild Cognitive Impairment. Curr Treat Options Neurol 17, 40 (2015). https://doi.org/10.1007/s11940-015-0372-3
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DOI: https://doi.org/10.1007/s11940-015-0372-3