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Mild cognitive impairment

Definition
MCI is defined as a cognitive decline greater than expected for an individual's age and education level, but that does not interfere notably with activities of daily life.
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Pathophysiology
The pathophysiology of MCI is not fully understood, but it is thought to involve both neurodegenerative and vascular factors.
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Epidemiology
The prevalence of MCI increases with age, with reported prevalence rates of 6.7% in patients aged 60-64 years, 10.2% in patients aged 70-74 years, and up to 37.6% in patients aged ≥ 85 years.
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Disease course
The clinical course of MCI is progressive, with individuals experiencing a decline in cognitive function over time. There are two main types of MCI: amnestic, primarily affecting memory, and non-amnestic, affecting other cognitive skills such as language, attention, and visuospatial skills.
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Prognosis and risk of recurrence
The prognosis of MCI is variable. While many individuals with MCI progress to dementia (more than half within 5 years), particularly Alzheimer's disease, others may remain stable or even revert to normal cognitive function. The amnestic subtype of MCI carries a high risk of progression to Alzheimer's disease.
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Key sources
The following summarized guidelines for the evaluation and management of mild cognitive impairment are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024; 2018), the American Diabetes Association (ADA 2024), the American Academy of Sleep Medicine (AASM 2023), the World Falls Guidelines (WFG 2022), the Canadian Consensus Conference on Diagnosis and Treatment of Dementia (CCCDTD 2020), the U.S. Preventive Services Task Force (USPSTF 2020), the Canadian Neurological Sciences Federation (CNSF 2019), the American Academy of Neurology (AAN 2018), the American College of Preventive Medicine (ACPM/PCNA/ABC/ASPC/ASH/AAPA/AGS/AHA/NMA/ACC/APhA 2018), the British Association for Psychopharmacology (BAP 2017), and the Canadian Task Force on Preventive Health Care (CTFPHC 2016).
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Guidelines

1.Screening and diagnosis

Indications for screening: as per AAFP 2024 guidelines, insufficient evidence to recommend screening asymptomatic older adults for cognitive impairment.
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  • Indications for testing

  • Screening tools

2.Diagnostic investigations

Initial assessment: as per CCCDTD 2020 guidelines, consider obtaining dual-task gait testing in specialized clinics (memory clinics) in older adult patients with MCI to help identify those at higher risk of progression to dementia if time/resources are available.
C

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  • Laboratory tests

  • Diagnostic imaging

3.Medical management

General principles: discontinue medications that can contribute to cognitive impairment (where feasible and medically appropriate) in patients with MCI and treat modifiable risk factors that may be contributing.
B
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  • Cholinesterase inhibitors

  • Memantine

  • Management of sleep disturbances

4.Nonpharmacologic interventions

Physical activity: as per WFG 2022 guidelines, offer an exercise program to prevent falls in community-dwelling older adults with MCI or mild-to-moderate dementia.
A

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  • Cognitive interventions

  • Vitamin E

5.Specific circumstances

Patients with vascular mild cognitive impairment: use standardized criteria (such as the VAS-COG criteria, DSM-V-TR, the VICCCS, or the AHA consensus statement) for the diagnosis of vascular MCI and vascular dementia.
B

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  • Patients with Parkinson's disease

6.Patient education

General counseling
Counsel patients and families that there are no pharmacologic or dietary agents currently shown to have symptomatic cognitive benefit in MCI.
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Discuss diagnosis and uncertainties regarding prognosis with patients with MCI. Advise patients and families to discuss long-term planning topics, such as advance directives, driving safety, finances, and estate planning.
B

7.Preventative measures

Management of hypertension: as per CCCDTD 2020 guidelines, recognize that an SBP treatment target of < 120 mmHg in middle-aged and older patients being treated for hypertension with associated vascular risk factors may be associated with a decreased risk of developing MCI.
B

8.Follow-up and surveillance

Follow-up: obtain serial assessments over time to monitor for changes in cognitive status in patients with MCI.
B