Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
2 April 2008

WHAT IS MILD COGNITIVE IMPAIRMENT?

            The word cognitive has to do with a person’s ability to know or to think or to figure out.  Impairment means that something doesn’t work as well as it should. Thus, cognitive impairment has to do with a person not thinking as well as that person should.   The medical use of the term “mild cognitive impairment” implies that the person is not thinking as well as they used to.

 The critical point has to do with “that person”.  Not everyone thinks as well as the next person (husbands and wives debate this every day).  Just because someone can’t figure out Einstein’s theory of relativity doesn’t mean that person is cognitively impaired.          

            There is a huge concern at this time about “baby boomers” reaching age 65 and after.  The average age of the population in the United States is growing older every year.  The concern about the ability of an elderly person to think and take care of themselves is reaching epidemic proportions.  The condition we call “dementia” in which the person is no longer able to care for themselves is the in point when a person needs a constant caregiver or a nursing facility to take care of them.  Dementia is a much feared condition.  It has been recognized for many years that “mild cognitive impairment” is one of the stages along the road to dementia. 

            The process of diagnosing a person with cognitive impairment is very complex.  The test to determine this with any meaning takes the better part of an hour.  The most common tool used in the medical setting is the “mini-mental state exam” which is a standardized test first published in 1975.  This is a very crude and not particularly accurate test but it does give an index of a person’s ability to think.  Questions involve the person’s ability to draw a clock and put the hands of the clock to show a certain time and the ability to remember three objects, the date, among many other questions.  This test can be scored from 1-30.  Scores below 28 suggest some cognitive impairment.  Scores below 20 suggest dementia.  Scores below 15 are highly correlated with a diagnosis of dementia. 

            The causes of cognitive impairment or dementia are highly varied.  A severely depressed individual can appear to be cognitively impaired.  A person with a major medical illness can appear to be cognitively impaired.  A person under an extremely stressful situation can appear to be cognitively impaired.  But what the tests and examinations are really looking for is whether the person has the ability to care for themselves and remain safe in their own environment. 

            When persons are seen in the clinic in regard to questions of cognitive impairment or dementia, the patient or their family wants to know the cause of the problem.  Once major medical illness or depression or high stress situations are ruled out, the belief is that there is some “cause”.  Most of the time, we don’t have any kind of cause.  The belief that some day a cause is going to be found to be due to specific virus or other type problem is in no way believable.  Instead, cognitive impairment and dementia in most people results from progressive deterioration of metabolic and blood vessel function secondary to high blood pressure, high blood cholesterol, diabetes, cigarette abuse, and alcoholism or drug abuse.  The hope that cognitive impairment or dementia can be reversed once it begins is rarely realized.  The condition maybe stabilized and medications may improve function briefly but the idea that the condition can be reversed to normality is just not a realistic expectation. 

            The reason for this article has to do with two recent publications.  One of these appeared in the Annals of Internal Medicine in March of this year and had to do with what percent of our population has cognitive impairment and what is happening to these people in regard to progression to dementia.  The striking numbers indicate that about 1 in 5 individuals (20%) of the population over age 70 has significant cognitive impairment.  Of those that are cognitively impaired but without dementia, 10% per year progress to dementia.  The good news is that 90% do not. 

            I see a number of patients each week that have questions and concerns about cognitive impairment and dementia.  The first step in the evaluation has to do with whether or not there is additional medical conditional (diabetes, heart failure, low thyroid, etc) causing the thinking problem.  About 1 in 4 patients will have a significant medical condition that can stabilize or reverse their thinking problem.

            Of the 75% who don’t have a medical condition, the problem invariably has to do with how to stabilize their condition and prevent progression.  Products such as Aricept, or Reminyl or Exelon may stabilize the person’s condition for several years but these products do have side effects that can be a problem.  A product such as Namenda with one of the previous mentioned drugs can have a significant improvement in function for a year or more.  Providing a more supportive environment can be a big help in maintaining the individuals safety and viability at home. 

            An additional article that appeared in the Journal of Neurology in March of 2008 has to do with a “pot belly” and its effect on dementia.  The epidemic of obesity in the United States at this time involves one in three individuals. The article in Neurology points out that those with a “pot belly” in their 40 to 60 year age group develop dementia 3 times faster than the general population. The most important step in dealing with cognitive impairment and dementia is to maintain general health avoiding hypertension, diabetes, high cholesterol, cigarettes and excessive alcohol.  When a person reaches age 60-70 with these risk factors, the sad truth is that there is very little way back. 

This and other columns available at www.macpierre.com.