You Just Received a Diagnosis of Mild Cognitive Impairment — What Happens Now?

What is Mild Cognitive Impairment? How is It Diagnosed?

Mild Cognitive Impairment (MCI) lies between normal cognitive aging, where one might experience subtle changes in thinking, and the dementia syndrome, in which cognitive impairment is severe enough to interfere with one's ability to do the things one usually does. 

In other words, MCI causes more cognitive trouble than normal cognitive aging but much less trouble than Alzheimer's disease and related dementias (ADRD). People who have MCI remain functionally independent for the most part, meaning they still drive, manage finances and medications, cook, do laundry, and engage in their usual leisure activities. People with ADRD have lost the ability to accomplish most or all these tasks. 

MCI may or may not involve memory impairment (see Figure below). When it involves memory, it is likely caused, at least in part, by underlying pathological brain changes related to Alzheimer's disease (AD). In other words, MCI involving memory is possibly a precursor to AD. 

When memory is unaffected, the possible underlying causes of the MCI can be quite variable (see the Figure below). 

Specific predictions cannot yet reliably be made about whether, and if so, when, a given person might be likely to transition from MCI to ADRD. On average, people with MCI involving memory have approximately a 12-15% chance each year to progress to AD. 

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What Does the MCI Diagnosis Mean?

MCI is an intermediate stage between the subtle cognitive changes expected in normal aging and the more severe decline that occurs in ADRD. 

In other words, MCI is an intermediate, but not necessarily or always transitional, cognitive state between normal cognition and ADRD. 

MCI is an invented diagnosis, one that was derived empirically based on clinical patterns. 

About 30 years ago, an exceptional neurologist at the Mayo Clinic (Dr. Ronald Petersen) had the critical insight that nobody goes to sleep on, say, a Monday night only to wake up on Tuesday morning with full-blown AD.¹ That might happen with the flu, but it does not happen with a dementing disease, where pathology usually accumulates for decades before symptoms emerge. 

Dr. Petersen defined MCI as an intermediate and transitional stage between normal cognitive aging and ADRD characterized by four criteria:

1. A subjective cognitive complaint (eg, “Doc, my memory is shot”).

2. An objective impairment in at least one area of thinking (usually found through detailed cognitive testing, known as a neuropsychological evaluation).

3. Normal “general cognition” (ie, unimpaired performance on a cognitive screening test).

4. “No dementia,” meaning no notable decline in functional abilities (eg, driving, managing finances and medications, and other complex activities needed for independent living) due to the cognitive complaints.

You can live a happy and active life with MCI, although you may have to make some minor changes each day to help yourself adjust. 

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‍How can I Prevent or Delay Further Decline?

‍Medications for MCI

Until recently, no medications had been formally approved by the U.S. Federal Drug Administration (FDA) to treat MCI.^2,3 Sometimes, medications for AD were prescribed, but in the past, this use was always in an “off-label” fashion, meaning in the absence of formal FDA approval. 

In July 2023, everything changed when the FDA granted full approval to a new type of medication—the monoclonal antibody drug class, known as the mAbs— to treat MCI involving memory and early AD.^4,5 Engineered in the laboratory, a mAb is a molecule specifically designed to recognize and bind to specific proteins that contribute to the pathology of AD, facilitating their clearance from the brain tissue. Two mAbs have received FDA approval: lecanemab (brand name Leqembi) and donanemab (brand name Kisunla). Other mAbs are still in the clinical trial pipeline.

Given every 2-4 weeks by intravenous infusion, in the clinical trials that led to FDA approval, the mAbs demonstrated mild slowing in cognitive decline in addition to their ability to clear the brain of toxic deposits of amyloid proteins. The mAbs have notable adverse effects, including infusion-related reactions and amyloid-related imaging abnormalities (ARIA).

The mAbs for AD are unprecedented and paradigm-shifting. Although their use has yet to become widespread, it is expected to expand in the coming weeks and months. (Watch this space for more information as things develop!)

Lifestyle Changes for MCI

Some lifestyle elements have growing scientific evidence supporting their usefulness in keeping your brain healthy. 

• Hearing loss is a risk factor for cognitive decline and dementia. If you or your loved ones notice any diminished hearing at some point in the future, it is essential to act on it immediately. This means getting your hearing tested (audiologists most commonly do this) and, if hearing loss is found, taking recommended steps to mitigate it (most commonly, this means hearing aids, which these days are practically invisible!). 

• Similarly, it is crucial to attend to visual health. Doing this will also help thinking remain strong. 

• Eat as much of a Mediterranean-style diet as possible. This diet is high in vegetables, legumes, fruits, nuts, cereals, fish, and olive oil. Find out more here: https://www.healthline.com/nutrition/mediterranean-diet-meal-plan.

• Try to exercise three or more times per week or, if you can, do vigorous exercise for one hour per week. Walking daily is absolutely good enough! 

• Maintaining a broad and robust social network is a good way to stay engaged with the people and places around you, which is an excellent source of emotional support and cognitive stimulation. 

• Finally, do cognitively stimulating daily activities like crossword puzzles or Sudoku. For cognitively stimulating activities, the more different things you do and the greater the variety in your activity, the better off you will be. (As an example, a daily cognitively stimulating “vitamin” might include word games, number games, matching games, card games, jigsaw puzzles, writing and journaling, gardening, reading a book in a new genre, ballroom dancing, plus a crossword puzzle). Always remember that it is most important that you do a variety of activities; the particular content of your cognitively stimulating activities is much less critical. 

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What Should I Do If I'm Diagnosed with MCI?

Even though the medications approved to date for MCI are new and not yet widely adopted, there are absolutely steps you can take right now to help ensure you are living your best possible life with MCI. 

First, you want to work with your medical care team to “optimize the optimizable.” Maximizing control of vascular conditions impacting cognition, including atherosclerosis, coronary artery disease, diabetes, high blood pressure, and high cholesterol, is crucial. 

You will also want to work with your medical care team to review your prescribed medications. The goal of the review is to remove any medications that could be making MCI worse. If removal is impossible, ensuring that you are taking the lowest possible effective dose is also a good step. 

Getting the best possible sleep, exercising regularly to maintain aerobic capacity, strength, and flexibility, and eating a primarily Mediterranean diet with less than 25% of your diet from “ultra-processed” foods⁶ are also key lifestyle steps to take or continue if you are already doing them. 

Taking immediate steps to address symptoms of depression and anxiety if they occur is essential, as these conditions can adversely affect happiness and quality of life in addition to cognition, and they are treatable conditions. 

In general, if a doctor or other healthcare professional wants to prescribe any new medicine for you, ask them AND your pharmacist these questions: 

• Is this medication okay for people with AD? Many of the medicines that can worsen symptoms of AD may also worsen memory in people with MCI. 

• Will this medication have any anticholinergic side effects? An older adult with memory problems should avoid this class of side effects whenever possible because it can worsen memory problems. 

• Is this medication on the Beers’ List of medications that older adults should avoid? The American Geriatrics Society publishes this list annually to help keep older adults as safe from the adverse effects of medication as possible.⁷ 

Finally, if you need to attend to long-range planning, this is an excellent time to do so. Long-range care plans include both health care and financial planning. Advance directives for end-of-life care include a “Living Will” enumerating the medical care that you do not want and what you do want at the end of your life, along with the designation of a Health Care Representative (sometimes called a “proxy”) who will make medical decisions for you should there be a time when you cannot speak for yourself. 

If you are wondering about MCI or if you have been diagnosed with MCI, Sunday Health can help support and guide you throughout your journey with this condition. 

You are never alone. 

Do you have another question that the Sunday Health brain health experts can answer? We invite you to send your questions to hello@sundayhealth.com.

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References

1. https://www.adrc.wisc.edu/dementia-matters/our-evolving-understanding-mild-cognitive-impairment
2. Petersen RC, Lopez O, Armstrong MJ, Getchius TSD, Ganguli M, Gloss D, Gronseth GS, Marson D, Pringsheim T, Day GS, Sager M, Stevens J, Rae-Grant A. Practice guideline update summary: Mild cognitive impairment: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2018 Jan 16;90(3):126-135. doi: 10.1212/WNL.0000000000004826. Epub 2017 Dec 27.2.
3. Fink HA, Jutkowitz E, McCarten JR, Hemmy LS, Butler M, Davila H, Ratner E, Calvert C, Barclay TR, Brasure M, Nelson VA, Kane RL. Pharmacologic Interventions to Prevent Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer-Type Dementia: A Systematic Review. Ann Intern Med. 2018 Jan 2;168(1):39-51. doi: 10.7326/M17-1529. Epub 2017 Dec 19.
4. van Dyck CH, Swanson CJ, Aisen P, Bateman RJ, Chen C, Gee M, Kanekiyo M, Li D, Reyderman L, Cohen S, Froelich L, Katayama S, Sabbagh M, Vellas B, Watson D, Dhadda S, Irizarry M, Kramer LD, Iwatsubo T. Lecanemab in Early Alzheimer's Disease. N Engl J Med. 2023 Jan 5;388(1):9-21. doi: 10.1056/NEJMoa2212948. Epub 2022 Nov 29.
5. Sims JR, Zimmer JA, Evans CD, Lu M, Ardayfio P, Sparks J, Wessels AM, Shcherbinin S, Wang H, Monkul Nery ES, Collins EC, Solomon P, Salloway S, Apostolova LG, Hansson O, Ritchie C, Brooks DA, Mintun M, Skovronsky DM; TRAILBLAZER-ALZ 2 Investigators. Donanemab in Early Symptomatic Alzheimer Disease: The TRAILBLAZER-ALZ 2 Randomized Clinical Trial. JAMA. 2023 Aug 8;330(6):512-527. doi: 10.1001/jama.2023.13239.
6. Gomes Gonçalves N, Vidal Ferreira N, Khandpur N, Martinez Steele E, Bertazzi Levy R, Andrade Lotufo P, Bensenor IM, Caramelli P, Alvim de Matos SM, Marchioni DM, Suemoto CK. Association Between Consumption of Ultraprocessed Foods and Cognitive Decline. JAMA Neurol. 2023 Feb 1;80(2):142-150. doi: 10.1001/jamaneurol.2022.4397.
7. https://www.americangeriatrics.org/media-center/news/many-older-adults-take-multiple-medications-updated-ags-beers-criteriar-will-help