2018 Top Stories in Primary Care: New Practice Guidelines on Mild Cognitive Impairment

This year’s practice guideline update on mild cognitive impairment (MCI) by the American Academy of Neurology was a major story.¹ I will briefly summarize the major recommendations by level of evidence here and add at the end pertinent information that has come out this year on dementia.

• Acetylcholinesterase inhibitors (AchEl)

  • The lack of evidence for AchEI should be discussed with the patient/family before offering the drugs; level A.

  • Clinicians may choose not to offer these medications; level B. Even in people with dementia, the benefits of AchEI are statistically significant but not clinically relevant.²

• MCI

  • The physician should assess for MCI when patients or family members voice concern about memory, and not assume that memory loss is due to normal aging; level B.

  • The physician should assess for MCI with validated tools in appropriate scenarios; level B.

  • The cognitive status of patients with MCI should be monitored over time; level B.

  • The physician should evaluate patients with MCI for modifiable risk factors, assess for functional impairment, and assess for and treat behavioral/neuropsychiatric symptoms; level B.

  • Cognitively impairing medications are to be discontinued when possible, and behavioral symptoms should be treated; level B. Major offending medications include anticholinergic medications and many more that are listed in the newest version of the Beers Criteria. 

• Regular exercise; level B.

• Diagnosis, prognosis, long-term planning, and the lack of effective medicine options should be discussed with the patient/family; level B.

• Cognitive training may be recommended; level C.

• Biomarker research may be discussed with the patient/family; level C. 

These guidelines give us hope that exercise and managing risk factors, such as removing inappropriate medications, can make a difference in preventing MCI and dementia.

In addition to blood pressure control, the AHA Life’s Simple 7, have been shown to decrease cognitive decline.^3,4

• No smoking

• Maintaining body weight

• Physical activity

• Diet

• Cholesterol control

• Glucose control

• Blood pressure control

  • Although intensive blood pressure control has increased orthostatic hypotension, it has not increased the risk of falls.⁵ So, there should be no fear of controlling blood pressure aggressively in robust patients who can tell us about side effects.

Using hearing aids can attenuate the progression of memory loss.⁶

Daily intellectual activity is associated with a lower risk of dementia.

A number of medication groups have been shown to increase the risk of dementia:

• Anticholinergics ^7,8

• Benzodiazepines⁹

• Possibly proton pump inhibitors¹⁰ and alpha blockers¹¹