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AAN guideline for patients with mild cognitive impairment
Clinical Question
How should clinicians manage patients with mild cognitive impairment?
Bottom line
Mild cognitive impairment (MCI) follows a variable course: not all patients progress to dementia. The data on pharmacologic interventions are limited and, so far, not very encouraging. Of the nonpharmacologic interventions, the best, albeit limited, data support exercise. 5
Reference
Study design: Practice guideline
Funding: Foundation
Setting: Outpatient (any)
Synopsis
This guideline development panel was convened by the American Academy of Neurology (AAN). The panel used a systematic review of the literature to address 4 broad areas important to managing patients with MCI: prevalence, prognosis, pharmacologic management, and nonpharmacologic management. Overall, 62 studies informed the panel's recommendations. One of the challenges the panel faced is the variability in definition of MCI. Their best guess is that MCI becomes more prevalent with advancing age (approximately 7% in adults aged 60 years to 64 years; 8% for 65- to 69-year olds; 10% for 70- to 74-year olds; 15% for 75- to 79-year olds; and 25% for those 80 and older). Additionally, for adults older than 65 years with MCI, approximately 15% will develop dementia after 2 years. Among the few studies that report the natural history of MCI, between 15% and 38% of patients with MCI regress to normal. The panel identified 3 studies that assessed donepezil (Aricept), but could not pool data because of variable duration and variable outcome measures. These studies found little likelihood that donepezil prevents progression from MCI to Alzheimer dementia. Two studies assessed galantamine (Razadyne), and similarly failed to provide evidence that it slows progression to dementia. Only one trial evaluated rivastigmine (Exelon). After 4years the rate of progression from MCI to dementia was similar for placebo-treated patients. A single trial evaluated a flavonoid-containing beverage, but that study duration was only 8 weeks, so we can't really conclude much. Additional studies with limited data included homocysteine-lowering vitamin B, nicotine patches, piribedil (an anti-Parkinson agent sold under many trade names), rofecoxib (Vioxx), growth hormone–releasing hormones, and various other vitamins. Most studies either showed the treatments were ineffective, or were too short or too limited to have much faith in their results. The panel identified 7 studies of nonpharmacologic interventions. Only exercise seemed to show any short-term improvements. Cognitive interventions were too variable in scope, quality, and generalizability to recommend widespread adoption. Although this guideline was funded by the AAN, most of the panelists had financial ties to industry.
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI
Comments
Dr. Dale Bredesen, " the end of Alzheimer's"
Dr. Mary Newport, 'what if there was a cure?"
Here is a link to 178 and counting published papers: http://www.greenmedinfo.com/disease/alzheimers-disease
Good poem. Thanks for highlighting ties to industry among panel members.
Good poem
As an increasingly forgetful 60 year old, I am reassured that descent into marked dementia is not a certainty!
Good to learn that medications are not as robust as we had hoped they were.
I am a strong believer in physical activity, when possible.
I wonder if music along with the activity would provide for more benefit
Medication don't work for decline which results from a lifetime of hyperinsulinemia from following the soya / seed oil & sugar industry funded SAD, for either "Standard American Diet" or more correctly "Sick and Demented". Hyperinsulinemia affects many organs. In 1965 (I was in diapers) it had already been observed that those who were obese, hypertensive, or had myocardial infarctions, had elevated fasting insulin levels. This was before Economist / fish physiologist Angel Keyes convinced the world that saturated animal fats were the enemy.
Dementia has been clearly associated with hyperinsulinemia. Insulin crosses into the CSF via transporter proteins and stimulates receptors in the hypothalamus. Insulin stimulates immune system cells and when chronically elevated has a pro-inflammatory effect. Insulin stimulates cells involved in atheroma formation. Insulin promotesthe production of large Triglyceride rich VLDL, which become small dense atherogenic LDL.
Mildly Demented seniors switched from porridge to eggs & sausage or bacon (from high carbohydrate to ketogenic) diets showed improved memory after a few months, in a 2015 study.
The solution to hyperinsulinemia is simple, reduce the ingestion of sugary & starchy foods.
Interesting that 15-30 % of patients with MCI return to normal. Also this study confirms that there is no clear evidence for the use of pharmaceuticals for MCI.