Finding Mild Cognitive Impairment Quickly in Primary Care

Javier Cotelo, MD

July 10, 2023

MADRID — Primary care is the ideal setting to screen for mild cognitive impairment. Screening can be performed in under 10 minutes using brief cognitive assessment tools. When it comes to treatment, deprescribing is a priority, as many drug interactions contribute to cognitive disorders. Drugs also influence the value of nondrug therapies.

At the XXIX National Congress of General and Family Medicine of the Spanish Society for General and Family Physicians (SEMG) in Granada, Spain, Alberto Freire, MD, a family doctor and head of the society's neurology group, presented a way to detect cognitive impairment in a few minutes during a primary care office visit. He also presented a stepwise algorithm for diagnosing and treating the disease, which is highly prevalent and underdiagnosed.

The specialist dismissed the idea that "memory problems are associated with age," though it is true that in normal aging, "cognitive frailty develops, and some processes will move a little slower. But there won't be significant functional impairment." Mild cognitive impairment falls between normal aging and dementia, and both conditions can be stabilized.

"Primary care is essential for screening for mild cognitive impairment due to its high level of accessibility, proximity, and continuity, but most of all due to its longitudinal perspective, which differentiates it from other specialties," said Freire. He pointed out that screening is not the same as diagnosis because screening merely indicates probability or well-founded suspicion that can then be confirmed in secondary care.

He also highlighted the need for assessment of cognitive function using brief cognitive tests, as well as the need for functional assessment of activities of daily living. Many cognitive function tests are available, some of which are patient-oriented and some caregiver-oriented.

"The patient initially comes to see us due to memory loss that he or she, or that some reliable reporter, has detected," said Freire. He indicated that 18.5% of consultations for cognitive impairment are prompted by subjective perceptions of memory complaints, which represent the most common subtype of the condition: mild amnestic cognitive impairment.

Quick Cognitive Tests

Freire was in favor of picture-based tests, which he strongly recommended. "These are the most-studied tests in Spain for detecting neurocognitive impairment and they eliminate the reading factor. They're quick, they're easy to use and interpret, and are well-accepted by patients. Also, they assess executive function (verbal fluency) and memory." Freire stressed the importance of referencing categories when showing the pictures, as well as the fact that the test is available for free online.

He also questioned whether the Mini-Mental State Examination is dead because "there's an abbreviated version that the author rejects, and the author's permission is required to use it. It's very appropriate for Alzheimer's disease, but not for cognitive impairment."

Another notable test is the episodic test (a test that avoids interfering with working memory). It has been validated for amnestic mild cognitive impairment and Alzheimer's disease, but a reliable caregiver is required to verify patient responses.

For caregiver-oriented tests, Freire pointed to AD8, which, when paired with any brief cognitive test, significantly increases detection of cognitive impairment.

He also recommended a useful website for everyday consultations created by several scientific societies, including the Spanish Society of General and Family Physicians. The site includes the AD8 and Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) questionnaires that can be completed online. "It produces a score that indicates the likelihood that the patient has cognitive impairment, and it can be filled out by family members or caregivers to get the result during the consultation," he said.

Functional Assessment

"Functional assessment of the patient's level of independence for their life in society is what conceptually differentiates mild cognitive impairment from dementia," explained Freire. "There are several types of activities of daily living. The instrumental activities (cooking, laundry, talking on the phone, using transportation, managing finances, taking medications, etc) are the activities that truly distinguish between mild cognitive impairment and dementia. They allow the person to adjust to their environment and retain their independence within the community."

There are multiple tools for assessing activities of daily living, but Freire singled out the Mongil test (from Spain), which covers basic, instrumental, and advanced activities. The higher the score, the worse the patient's condition, so the goal is to lower the score. On the other hand, grouping certain items together helps determine whether there is a risk of falling, sarcopenia, depression, or suicide, among other outcomes. "So, it's not only useful for diagnosis and treatment but also detects geriatric problems and syndromes. That is, it's useful for prevention and allows planning of preventive and therapeutic medical interventions," he explained.

Reversible Dementia

Freire presented a diagnostic and therapeutic algorithm for cognitive impairment to be used when brief cognitive tests are positive. "The first thing is to perform a clinical assessment because, although many cases of cognitive impairment go undiagnosed, 10% of the cases of symptomatic dementia are potentially reversible. We shouldn't overlook these." These cases of dementia may be brought on by medication use, alcoholism, chronic meningoencephalitis, toxins, normal pressure hydrocephalus, certain brain tumors, hypothyroidism, and nutritional deficits, among other causes. Functional assessment follows, using the scales mentioned above.

Interactions and Deprescribing

"As to polypharmacy, there is underuse of good, evidence-backed medications with no major contraindications. But care must also be taken with inappropriate or off-label medications, overtreatment, drug interactions, and adherence," said Freire.

"We need to start deprescribing because the chemical basis of cognitive impairment traces back to reduced cholinergic activity, increased dopaminergic activity in the brain, or both. There are many commonly prescribed drugs with anticholinergic interactions that can cause cognitive disorders. These could be psychotropics, hypnotics, analgesics (nonsteroidal anti-inflammatory drugs), first-generation antihistamines, antihypertensives, antiarrhythmics, H2 blockers, and even antibiotics like penicillin and quinolones, among many others," he emphasized.

The next step is to perform comprehensive laboratory testing to rule out vitamin and mineral deficiencies, diabetes, thyroid disorders, kidney failure, liver diseases, urinary infections, and infections of the central nervous system. After that, neuroimaging should be performed. MRI is the preferred method because it allows quantification of atrophy and volumetric measurements.

Strict Cardiovascular Control

"At this point, treatment can be started, and the patient can be referred to secondary care," said Freire, as he proceeded through a therapeutic algorithm following diagnosis of the patient. Regular exercise increases coordination synapses, prevents disease onset, improves executive function, and delays the onset of dementia. "The problem lies in not knowing how much time should be spent daily and weekly on exercise to achieve these goals.

"It is known that a Mediterranean diet and omega-3 fatty acids improve cognitive impairment. However, care should be taken with omega-3s as they are no longer helpful in dementia that has already been established." The importance of strictly controlling cardiovascular risk factors must also be kept in mind, as backed by validated studies; it has been shown that blood pressure levels below 128 mmHg make mild cognitive impairment and dementia worse, atrial fibrillation increases the risk of dementia by a factor of 1.4 to 2.4, diabetes is a risk factor for developing amnestic mild cognitive impairment, tobacco use also leads to cognitive impairment — even in individuals exposed to second-hand smoke — and statins do not change the risk in cases of dyslipidemia.

Nondrug Treatment

Freire also highlighted the importance of multiple nondrug therapies in this field, such as cognitive training and rehabilitation, reminiscence, music therapy, cognitive behavioral psychotherapy, and sensory interventions, among others. He also recommended patient groups for these individuals.

He added: "In mild cognitive impairment, there is currently no drug that is an improvement over nondrug therapies."

The drugs aim to improve memory loss, prevent or delay the onset of mild cognitive impairment, and treat initial symptoms of dementia if applicable. The most commonly prescribed drugs are citicoline alone in vascular disease and memory loss, EGb 761 (which is the only approved dose-dependent drug), and others such as phosphatidylserine, nimodipine, and memantine combined with galantamine or piracetam, Freire concluded.

Freire had declared receiving funding as a student in training and outreach activities for popular science sponsored by Ferrer, and on the topic of pain by Esteve, Grünenthal Pharma, and Menarini. He has also reported being a consultant for GSK, Lilly, and Pfizer.

Follow Javier Cotelo, MD, of Medscape Spanish Edition on Twitter @Drjavico.

This article was translated from the Medscape Spanish Edition.


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