Making Sense of MCI

Alzheimer’s and dementia are often the first concerns to come to mind regarding age-related mental health. But mild cognitive impairment (MCI) is different – and while it should be taken seriously, it’s not necessarily indicative of something worse to come.

EDITOR’S NOTE: Sunday, Oct. 3 marked the start of a weeklong observance of Mental Health Awareness Week. Sponsored by the National Alliance on Mental Health (NAMI), the designation focuses attention on the fact that millions of Americans face the reality of living with some form of mental health condition. In light of this, ICD10monitor publisher Chuck Buck conducted an online interview with Dr. H. Steven Moffic, award-winning author and considered to be one of the nation’s most prominent psychiatrists. An edited version of that interview appears below.

BUCK: Dr. Moffic, the Mayo Clinic defines mild cognitive impairment (MCI) as “the stage between the expected cognitive decline of normal aging and the more serious decline of dementia. It’s characterized by problems with memory, language, thinking, or judgment.”

In my own life, from time to time, I can’t remember names, or dates, or even where I left my glasses. Sometimes, too, I’ll be in the kitchen and I’ll say to myself, “now, why did I come in here?”

Is this a precursor to something more serious, such as Alzheimer’s disease?

MOFFIC: Chuck, although according to our ethical Goldwater Rule in psychiatry, I am not supposed to diagnose someone who I have not examined nor received permission to comment publicly on, I can tell from my interactions with you, live and online, that your personal memory examples seem normal for your age. It better be, because the same things are happening to me and my wife!

I very much commend you for asking about MCI for this Mental Health Awareness Week, because the attention usually goes to the more common psychiatric problems, and this one more concerns the elderly and fits sort of in between psychiatry and neurology. Currently, we think that the general prevalence of MCI is 7 percent of the population in ages 60-64; 10 percent in ages 70-74; and 25 percent in ages 80-84.

So, it is not uncommon at all.

As to the Mayo Clinic definition of MCI, who am I to question Mayo, but their definition of MCI is much more stringent than other definitions, in the sense of always going on to a “serious decline of dementia.” That does not always seem to be the case. Nevertheless, such concerns as yours need to be taken seriously, because they could be part of a precursor to something more serious, including Alzheimer’s disease. You are insightfully honing in on an area of concern that has much uncertainty and paradox, thereby sometimes needing the expertise of a geriatric neurologist or psychiatrist to adequately assess.

BUCK: What are the symptoms for MCI?

MOFFIC: The answer to that question should help distinguish MCI from normal aging, or a more serious loss of memory. The trouble and challenge here is that there is no firm line of demarcation or technology to be sure, one way or another. Even so, there are some guidelines. In MCI, the patient and/or loved ones can notice a decline in overall cognitive mental abilities – that is, not only memory, but also thinking skills, compared to others of the same age. More importantly, in MCI, these changes are not severe enough to interfere with normal, everyday life. Of course, comparison with others of similar age is tricky, because when do you have enough of an adequate comparison group?

With MCI, the patient frequently forgets conversations and information such as appointments and planned events. Usually, there are not the personality changes consistent with Alzheimer’s disease.

BUCK: If I’m suffering from MCI, what else might I experience?

MOFFIC: If you have MCI, other than those broad cognitive symptoms I just mentioned, there is little else other than your own reaction to the changes. That may include anxiety and fear of what is happening mentally. Sometimes that leads to complete denial that anything is wrong. In full-blown Alzheimer’s disease, you usually lose the ability to know that something is wrong, mentally, but that is from physical brain changes rather than a psychological defense mechanism.

BUCK: You and I have talked extensively about burnout – especially burnout among physicians. Could burnout have a causative effect on MCI? Also, could the current healthcare environment contribute to stressors that might lead to MCI among hospital staff, including nurses, cleaning, and maintenance personnel?

MOFFIC: Those are good questions about burnout and stress, Chuck. Because we still don’t know the cause of some dementias, and because burnout is such a new societal problem, we really don’t know if burnout can have a causative impact on developing MCI. However, burning out can have some temporary negative cognitive impact itself.

Certainly and currently, in part because of the pandemic, among the highest-stress and burning-out jobs are those of hospital personnel. The good news here is that if and when the health systems improve in enhancing the wellness of employees, then the burning out and stress can dissipate.

BUCK: And what about other medical conditions or lifestyle factors that might contribute to MCI?

MOFFIC: This question is leading us into the essential area of ruling out other conditions that may cause some similar symptoms. Most importantly, most of these are treatable, so that the symptoms could go away. However, this is such a challenging task, and too much personal or family “research” on the Internet is potentially misleading and dangerous. Start with your family doctor. Here are some of the conditions that need to be ruled out:

• Depression, stress, anxiety, and burnout;
• Thyroid, kidney, and liver problems;
• Sleep apnea;
• Blood flow problems to the brain;
• Low vitamin 12 levels;
• Eye or hearing problems;
• Infection;
• Medication and street drugs, especially those with anticholinergic effects; and
• Alcoholism

BUCK: Is there a linear progression from MCI to Alzheimer’s or other forms of dementia?

MOFFIC: MCI is often the beginning stage of Alzheimer’s disease, as well as other dementias like Parkinson’s disease, lewy body dementia, vascular dementia, and frontotemporal dementia. However, sometimes MCI stays the same, or remits for reasons not well-understood.

BUCK: Is there a cure for MCI? And, finally, what could I and others of my generation do to protect themselves from MCI?

MOFFIC: Unfortunately, if MCI is an early manifestation of a more severe dementia, there is no cure. Still, one potential advantage to recognizing MCI in that process is that as psychologically worrisome as it is, it does give time for future planning, as the evolution is usually relatively slow.

But that brings us to a major current controversy. Despite an advisory committee recommendation to the contrary, the U.S. Food and Drug Administration (FDA) approved the drug aducanumab, sold as Aduhelm, in July 2021 for patients with mild cognitive deterioration (that is, MCI). This is the first new drug since 2003 that has been approved for the possibility of slowing down the progress of Alzheimer’s disease. In the decision-making, however, several members of that committee resigned after the decision, feeling that there was undue financial influence of the drug company on the FDA. Many experts feel that this drug is not effective, very expensive (over $56,000 a year), and has common significant side effects like brain swelling.

Since it was approved under an accelerated approval, it still has to be studied as part of a Phase 4 confirmation process. Therefore, it is not yet generally available to the public.

On the other hand, activist groups like the Alzheimer’s Association want the drug available ASAP. That fits the “right to try” movement that we have seen with COVID-19. Psychologically, also as with the pandemic, there is so much desperation about Alzheimer’s disease that many are willing to try such a new drug anyway. Such desperation also means not taking the risk of trying other drugs or over-the-counter substances that can actually worsen MCI.

Lifestyle-wise, the usual recommendation to the elderly is to exercise enough to improve brain blood flow, which is appropriate here. That means averaging 15-30 minutes a day of moderate exercise. Reducing any alcohol use is recommended. The role of marijuana is still unknown. Caffeine can still help focus somewhat. Despite no clear-cut, proven link that adhering to the following advice will slow memory and thinking decline, these are some more typical recommendations:

• Maintain good blood pressure, cholesterol level, and blood glucose level;
• Stop smoking;
• Follow a healthy diet;
• Maintain appropriate body weight;
• Reduce stress;
• Get an adequate amount of sleep;
• Engage in social activities; and
• Exercise the brain with puzzles, quizzes, and new learning.

Most importantly, the elderly should be checked every 6-12 months by their doctor for changes in memory or thinking skills.

Programming Note:Listen to Dr. H. Steven Moffic’s live report on mental health today on Talk Ten Tuesdays, 10 a.m. EST.