Home > Diagnosis, Early recognition, Stages of dementia, Types of dementia > New Diagnostic Criteria for Mild Cognitive Impairment

New Diagnostic Criteria for Mild Cognitive Impairment

As a speech pathologist, I receive a magazine called “The ASHA Leader,” published by the American Speech-Language-Hearing Association.  In the Dec. 18, 2012, edition, I read an article that got me quite excited.  It reports new diagnostic criteria for Mild Cognitive Impairment or, more specifically, for helping to determine increased risk for development of Alzheimer’s disease.

As it stands now, the term “mild cognitive impairment” is most often used to describe individuals who display cognitive deficits that are not severe enough to be labelled as full-blown dementia.  It can be ascribed to a number of different causalities including traumatic head injury, substance abuse, or even normal aging.  However, in this context it is used to refer to those persons who are in the symptomatic predementia phase of Alzheimer’s.  Typically, these persons exhibit progressive cognitive decline more than what might be expected as a result of “normal” aging, as well as preserved functional abilities.

The National Institute of Neurological and Communicative Disorders and Stroke, and the Alzheimer’s Disease and Related Disorders Association, first published clinical diagnostic criteria for Alzheimer’s in 1984.  However, our understanding of the disease has increased tremendously since that time, and by 2009 professionals began to call for an updating of these criteria.  As a result, the National Institute on Aging and Alzheimer’s Association formed three interdisciplinary working groups in order to collaborate toward this end.  The overall goal was to give health care providers better means for screening, identifying, and treating at an earlier stage than previously.

According to results published in a series of articles in Alzheimer’s and Dementia,” the diagnosis of mild cognitive impairment remains as before — a clinical judgment by trained professionals following various cognitive and functional examinations.  There are no laboratory tests or neuroimaging studies that can definitively pronounce the presence of either MCI or Alzheimer’s, short of autopsy.  (However, great strides in both of these areas are being made through the research of talented professionals.)  The working group did propose some core clinical criteria for distinguishing between the different types of cognitive decline.  These include:

–  “Concern about a change in cognition reported by the patient, someone who knows the patient well, or a skilled clinician observing the patient.

–  “Evidence of lowered performance in one or more cognitive domains (attention, memory, language, visuospatial skills, executive function) that is greater than would be expected for the patient’s age and educational background.

—  “Reported or documented decline in episodic memory, found to be significantly predictive of Alzheimer’s development.

—  “No difficulty with everyday functional activities.

—  “Decreased efficiency or accuracy in performing more complex tasks, such as paying bills or shopping.”

Two of the key components of the screening and assessment of MCI include longitudinal documentation of the cognitive decline, and formal cognitive testing to establish the degree of decline.  In other words, standardized testing must be administered on multiple occasions over time to determine how much the individual has declined, and how function has decreased over time.  There are several different tools available for that purpose, which the skilled professional can choose from depending on the needs of the patient.  Some of these include:

—  The Mini-Mental Status Examination

—  Repeatable Battery for the Assessment of Neuropsychological Status

—  Montreal Cognitive Assessment

—  Saint Louis University Mental Status Examination

—  Brief Cognitive Assessment Tool

In skilled nursing facilities, there is another useful tool that can be used as part of the professional’s arsenal.  That is the resident’s Minimum Data Set, the assessment mandated by the federal government, and which is completed by several departments in the facility.  Speaking from personal experience, I have on a number of occasions been referred to a resident by the facility’s Social Services director, after she has administered the cognitive screening required to be given periodically as part of the MDS process.

Persons with MCI will usually score between 1.0 and 1.5 standard deviations below the mean for their age and education, on formal cognitive assessments.  Episodic memory is another important component in the diagnostic process, and the working group recommended several tests for this purpose.  Other domains of cognitive function should be measured as well, using appropriate formal tests and informal observations.  For some time now, those of us working in long-term care have been told that Medicare is increasingly demanding formal test results, rather than just clinical descriptions of behaviors, in determining whether to reimburse for coverage.  And, truly, such measures are preferred for a number of reasons.

One problem is, however, that many of these instruments are expensive.  And so, those of us in the trenches sometimes must convince facilities that it is cost effective to spend what may sometimes be hundreds of dollars to buy these materials.  So, sometimes we must use what we have — thankfully there are some good tools available free of charge (such as the MoCA and the SLUMS), and supplement that with detailed anecdotal reporting.

It remains unclear, at this time, how much these recommendations will be utilized by Medicare and the U.S. health care system.  It is also not certain how much the American Medical Association has made use of these diagnostic criteria.  Documentation and reimbursement are additional unknowns.  But I look forward to seeing how the face of dementia care will change in the future, as a result of these and many other advancements.

  1. Shirley Sigmund
    December 23, 2012 at 2:41 PM

    Very helpful, timely, and practical information! I am sharing your blog with colleagues, and we are grateful for your commentary and for sharing updates in research. Happy Holidays to you and your loved ones!

    • December 24, 2012 at 7:04 AM

      Thank you, as always, for your kind words. A very Merry Christmas to you as well.

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