Mild cognitive impairment: Most people are unaware they have condition

• Mild forgetfulness is largely seen by many people as well as doctors as part of normal aging.
• However, experts say mild forgetfulness can also be symptomatic of mild cognitive impairment, which can be an early sign of Alzheimer’s disease.
• They say people should specifically ask doctors about excessive forgetfulness, otherwise doctors may just minimize the problem.

Small, everyday forgetfulness – not remembering why you walked into a room or not being able to find your phone – may seem to many like the normal process of aging.

However, these lapses can sometimes be symptomatic of mild cognitive impairment (MCI), which itself can be an early sign of Alzheimer’s disease.

Since it’s considered normal by many – including some doctors – people who have MCI don’t always know it and miss out on taking preventative measures or getting treated, according to two new studies published in parallel by researchers at the USC Dornsife College of Letters, Arts and Sciences in Los Angeles.

In one study, researchers looked at data from 40 million Medicare beneficiaries, 65 years and older, and compared the proportion diagnosed with MCI with the rate expected in this age group. They reported that fewer than 8% of expected cases were actually diagnosed.

That means that of the 8 million individuals predicted to have MCI based on their demographic profile – which includes age and gender – more than 7 million went undiagnosed.

“This study is meant to raise awareness of the problem,” said Soeren Mattke, director of the Brain Health Observatory at USC Dornsife’s Center for Economic and Social Research, which led the investigations, in a statement.

“We want to say ‘Pay attention to early changes in cognition and tell your doctor about them. Ask for an evaluation.’ We want to reach physicians to say, ‘There’s a measurable difference between aging and pathologic cognitive decline and detecting the latter early might identify those patients who would benefit from recently approved Alzheimer’s treatments,” he added.

What can cause mild cognitive impairment

Researchers said MCI is influenced by socioeconomic and clinical factors.

People with cardiovascular disease, diabetes, hypertension, and other health issues are at higher risk of cognitive decline, including dementia.

The team said such health issues appear more among members of historically disadvantaged groups, such as those with less education as well as Black and Hispanic Americans, among which the detection of MCI was even lower in the study.

Mattke said the overall appearance of disease in those populations is higher.

“So, they’re hit twice: They have higher risk and yet lower detection rates,” he said.

Doctors and cognitive decline diagnoses

In the second study, researchers reported that 99% of 200,000 primary care clinicians under-diagnosed MCI.

“There’s really just a tiny fraction of physicians in a position to diagnose MCI who would find these cases early enough for maximum therapeutic potential,” Mattke said.

The team said, by definition, MCI doesn’t cause disability, whereas dementia is a disabling condition.

MCI’s challenges to everyday functioning tends to be more sporadic, said Soo Borson, a clinical professor of family medicine at Keck School of Medicine of USC and co-lead of the BOLD Center on Early Detection of Dementia, in a statement.

Borson, who was not involved in the studies, said forgetfulness is the most familiar form of MCI. Another is an executive form, which mainly affects efficiency in getting things done and difficulty with tasks that used to be easier, such as paying bills. There’s also a behavioral form, in which mild changes in personality may predominate. The various forms often coexist.

The researchers said it’s important to understand MCI is a level of cognitive functioning and not a specific disease state. Recent advances in the treatment of the most common cause of MCI — Alzheimer’s disease — lends new urgency to improving detection of MCI, they said

Researchers said there are several reasons MCI might be so widely underdiagnosed in the United States. A person may not be aware of or bring up their concern. In addition, a physician might not notice subtle signs of difficulty. Or, a clinician might notice but not correctly enter the diagnostic code in a patient’s medical record.

Researchers also said time may not be set aside during a clinical visit to discuss or assess brain health unless the visit was planned to include it.

Why early diagnosis of mild cognitive impairment is important

Mattke said risk-based MCI detection, which focuses attention on people at greater risk, would help identify more cases because time and resources could be focused on those people. Digital tests administered before a medical visit could also aid in detection efforts.

Early treatment is vital because the brain is limited in its ability to recover. Lost brain cells don’t grow back and damage can’t be repaired, researchers noted.

“For MCI caused by Alzheimer’s disease, the earlier you treat the better your outcomes,” Mattke said. “This means even though the disease may be slowly progressing, every day counts.”

Dr. David Merrill, a geriatric psychiatrist and the director of the Pacific Neuroscience Institute’s Pacific Brain Health Center in California who was not involved in the study, told Medical News Today he found it surprising that 99% of primary care doctors under-diagnose MCI.

But he also said it fits with stories he’s heard.

“I’ve heard from the patients in our specialty brain health center that when they’d asked their primary care doctor for help with mild memory changes, they were offered false reassurances about there not being a memory problem,” Merrill said. “Or worse, if a problem is acknowledged, the falsehood is stated that there’s nothing worth trying or doing to change the memory loss.”

Merrill said doctors underestimating what can be done makes patients vulnerable to putting off addressing suboptimal health risk factors or making lifestyle changes and not seeking treatments until it’s too late.

“Once dementia is diagnosed, many of the brain cells in critical areas for memory formation are already dead,” Merrill said. “Treatment is best started as early as possible, before irreversible loss of brain cells.

How family, friends can notice cognitive decline

Dr. Lauren Bennett, a clinical neuropsychologist at Hoag’s Pickup Family Neurosciences Institute in the Los Angeles area, who was not involved in the study, told Medical News Today it’s usually other people who first notice a person’s minor cognitive impairment.

“On average, family members notice the first symptoms of cognitive change two years before the first health professional consultation regarding the cognitive decline,” Bennett said. “This statistic highlights the importance of regular cognitive screening for older adults and seeking input from loved ones whenever possible.”

Bennett said people who believe they may have MCI should invite loved ones to share feedback with care providers if they note any declines in cognitive functioning.

“Seek out annual cognitive screening from the age of 55 on (and) talk openly with your primary care provider about any cognitive concerns and request regular cognitive assessments,” Bennett said.

How a person can advocate for themselves

Dennis Fortier is the president of Embic Corporation, which has sold cognitive evaluation technology for more than 20 years. He told Medical News Today his company has confronted this problem constantly.

“MCI is very similar in outward appearance to subtle declines that occur naturally as we age,” said Fortier, who was not involved in the studies. “The difficulty in distinguishing between the two means that the ‘wait and see’ approach is often adopted and the opportunity to intervene against emerging conditions is often lost. Historically, identifying underlying conditions that might be impairing cognition was an invasive and/or expensive proposition but non-invasive digital technologies offer pragmatic solutions.”

Fortier said “the other side of this coin” is older adults have become hyper-sensitive to the prospect of cognitive conditions.

“They are increasingly entering the healthcare system and demanding evaluation when they notice shorter working memory or slower processing speed, but are still cognitively normal for their age,” Fortier said. “For this reason, it is equally important for the healthcare system to identify ‘normal aging’ without overburdening healthcare resources.”

What action can be taken

Merrill added that doctors are getting closer to finding ways of identifying reversible causes of memory loss early on in the process.

“We find that many patients have chronic low-level inflammation, insulin resistance, nutritional deficiencies, or elevated levels of various toxins,” he said. “Though the work is not done by any means, our studies to date support the idea that improving overall health serves to preserve and protect brain function with aging.”

Merrill said examples of significant modifiable risk factors for dementia include poor diet quality, low physical exercise levels, hearing loss or uncorrected vision changes, exposure to toxins or pollution, and high levels of chronic stress.

“Even without clinical tests or doctor visits, there’s so much we can start working on today to improve the brain health of ourselves and our loved ones,” he said. “It’s never too early, or too late, to start working on your brain health – every day is the right day to start.”

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