Running head: PATIENT MANAGEMENT PAPER 1

Treatment of Mild Cognitive Impairment

Janice Krug, BSN, RN

University of Texas Health Science Center at San Antonio

NURS 6623 PMHNP Diagnosis and Management Clinical Application I

March 26, 2018

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Introduction

The aim of this paper is to analyze a treatment guideline as it relates to a recent clinical

experience. Mild neurocognitive impairment (MCI) is the selected psychiatric disorder for this

treatment guidelines analysis.

The patient in this interesting case is a married, 60 year-old male Veteran of the U.S. Army

who presented to the Veteran’s Administration Hospital GEM clinic with a ten-year history of

progressive memory loss and word-finding difficulty. He was referred by his primary care physician

(PCP). He had been started on bupropion 50mg, for smoking cessation, about 4 weeks prior to the

visit. Recent laboratory studies revealed low vitamin B12 level of 44ng/L and his MRI of the brain

revealed both parietal and frontotemporal region volume loss. During this GEM clinic visit, a full

mental health evaluation was completed along with three screening tools administered, the Lawton

Instrumental Assessment of Daily Living (IADL), Montreal Cognitive Assessment (MoCA) and

Geriatric Depression Scale (GDS). Results of these screening evaluations were: MoCA 24/30 and

GDS 6/15. He displayed minimal deficits related to the IADL screening. During the interview the

patient demonstrated mild word finding difficulty and memory impairment. After careful review of

past, present and collateral information, the patient was diagnosed with mild cognitive impairment.

Review of Treatment Guideline/Evidence

Clinical practice guidelines are statements that include recommendations to clinicians

intended to optimize patient care. They contain a systematic review of research and assessment of

the benefits and risks of treatment options. The American Academy of Neurology (AAN) practice

guideline for the treatment of Mild Cognitive Impairment (2016) is an update from their 2001 MCI

guideline and was selected for application to this case because it provides the most current

recommendations for screening, diagnosis and treatment. The AAN guidelines are based on Class I
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thru Class III clinical research and include Level A thru Level C recommendations to clinicians on

assessing and diagnosing MCI. The AAN (2016) clinical practice guidelines are also the foundation

for MCI treatment in UpToDate. Furthermore, they are endorsed by the Alzheimer’s Association.

The guideline was retrieved from the internet on the AAN website.

The AAN practice guideline for MCI is broken down into four sections: prevalence,

prognosis of progression to dementia, pharmacologic and non-pharmacologic treatment options.

They begin by discussing the prevalence of MCI in populations aged 60 and older:

 6.7% aged 60-64 (patient 123 in this group)

 8.4% aged 65-69

 10.17% aged 70-74

 14.8% 75-79

 25.2% aged 80-84

 37.6% aged 85 and older

Of great concern for patients, families and clinicians is the prognosis of MCI to dementia.

Identification of reversible causes of MCI as well as prevention to dementia above all else is the

objective in treatment. Class I evidence reports persons 65 and older with MCI have a 14.9% higher

risk of progressing to dementia compared to age-matched controls (AAN, 2016).

The U.S. Food and Drug Administration (FDA) approved one class of medication for

treatment of MCI. Cholinesterase inhibitors prevent the breakdown of acetylcholine, a chemical

messenger important for learning and memory. Class II evidence illustrates use of donepezil is

possibly ineffective for reducing the chances of progression to dementia or Alzheimer’s dementia as

well as galantamine and rivastigmine. Patient 123 was not placed on an anticholinesterase inhibitor

at this time based on his symptoms. Should clinicians choose to offer cholinesterase inhibitors,
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they must first discuss with patients the fact that this is an off-label prescription not currently

backed by empirical data (AAN, 2016).

The AAN mentions Class II evidence of flavanoid-containing drinks, homocysteine-

lowering B vitamin therapies, piribedil and rofecoxib. There is insufficient evidence to support or

refute the cognitive benefits of any such treatment and rofecoxib could possibly increase the risk of

progression to dementia (AAN, 2016). Flavanoid containing drink mixes have garnered much

attention in the media for their antioxidant protective benefits however as mentioned in the practice

guideline there is a lack of evidence to support these claims. Homocysteine-lowering B therapies,

including folate, are not supported as an evidence-based treatment practice. Piribedil, a dopamine

receptor agonist used in Parkinson’s disease, and rofecoxib, an anti-inflammatory, both lack

evidence to support a positive effect on cognitive measures in MCI. Data on Vitamin E and

Vitamin C are insufficient to support an effect on MCI however; one Class II study demonstrates

some possible cognitive improvement with tesamorelin growth hormone injections over a 20 week

period (AAN, 2017). Patient 123 is currently on none of these medications nor any over-the-

counter supplements for cognitive enhancement.

Non-pharmacologic treatments discussed by the AAN include Class II evidence on exercise

and cognitive interventions. Twice weekly physical exercise as an intervention demonstrates

evidence likely to improve cognition and also provides overall health benefits (AAN, 2016).

Patient 123 continues to be physically active however his body mass index (BMI) is 27.4 per the

National Institute of Health (NIH) which deems him overweight (NIH, 2018). He does not engage

in any type of formal cognitive training interventions such as memory-recall tests nevertheless,

Class II evidence does not support nor refute the use of any individual cognitive intervention

strategy (AAN, 2016).

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Recommendations from the AAN stress the importance of assessing individuals with MCI.

Level B recommendations for assessing MCI include:

 Clinicians should not assume concerns about memory or impaired cognition voiced

by the patient or close relatives with whom the patient is in contact are related to

normal aging deficits.

 Clinicians should not rely on historical reporting of memory concerns alone when

assessing for cognitive impairment during Medicare Annual Wellness Visits.

 Clinicians should use validated assessment tools to assess for cognitive impairment

and for patient who test positive for MCI, clinicians should perform a more formal

clinical assessment for diagnosis of MCI.

 Patients with MCI should be assessed for the presence of functional impairment

related to cognition before giving a diagnosis of dementia.

 Clinical should perform a medical evaluation for MCI risk factors that are

potentially modifiable.

 Clinicians should perform serial assessments over time to monitor for changes in

cognitive status.

 Clinicians may discuss the option of biomarker research.

To summarize the pharmacologic and non-pharmacologic treatment guidelines, there is low

confidence in the pharmacologic treatments with cholinesterase inhibitors donepezil, galantamine

and rivastigmine in the possible progression to dementia. Flavanoid-containing drinks,

homocysteine-lowering B vitamin therapies, piribedil and rofecoxib research is limited on positive

effects on MCI as well. There is also little evidence to support the use of cognitive interventions

however; twice-weekly exercise for six months does seem to show improvement in cognitive
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measures. Patient 123 is currently not being treated per any of the AAN pharmacologic or

nonpharmacological guidelines since he is in the early phase of his diagnosis and the AAN stresses

the importance of assessing and identifying the possible underlying contributing factors for

individuals with MCI as judicious part of the treatment plan. Patient 123 received a thorough

medical evaluation, screening with three validated assessment tools and will be follow up serially at

the GEM clinic as part of his treatment plan in accordance with the AAN (2016) practice guidelines

for MCI.

Application of Guideline

The goal of treatment is to identify any modifiable risk factors as well as to limit and

potentially reverse progression to dementia. The patient’s treatment plan will also include a

combination of pharmacotherapy for treatment of suspected depression and non-pharmacotherapy.

Depression—According to Larson (2017), multiple studies suggest that a history of depression is

associated with an increased risk for dementia. Patient 123 was placed on buproprion for smoking

cessation. This medication has dual benefits of treatment for both smoking cessation and

depressive symptoms. Bupropion 50mg daily will be continued. This medication is also continued

due to its favorable side effect profile of decreased sexual dysfunction compared to SSRIs (Rigotti,

2018).

Hearing loss—The patient has a history of hearing loss. A growing number of studies suggest that

peripheral hearing loss may be a risk factor for the development of dementia, independent of age

and other potential confounding factors and greater annual rates of cognitive decline than those

without baseline hearing loss (Larson, 2017). It is important for the patient to follow up with his

audiologist and obtain hearing aids if necessary.

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Head trauma—Patient 123 has been diagnosed with multiple concussions throughout his lifetime.

Risk factors for chronic cognitive impairment after head injury are not well recognized although

this remains a possible contributing factor to cognitive impairment for the patient (Larson, 2017). It

is important for him to maintain a safe environment in order to prevent further head trauma by

decreasing potentially dangers such as climbing ladders, working with heavy equipment or

preventing falls in the home.

Vitamin B 12 deficiency- Although the AAN practice guidelines demonstrate insufficient evidence

use of homocysteine-lowering therapies they also do not refute the treatment. There is some

evidence that elevated serum homocysteine and/or low serum levels of folate, vitamin B6, and

vitamin B12 may be associated with impaired cognition and risk of dementia (Press and Alexander,

2018). Correction of low vitamin B12 levels can be accomplished over a short period of time using

over the counter supplements or a eating a well balanced diet.

Hypertension-- Although the relationship between blood pressure and dementia risk is complex,

most evidence suggests that hypertension is associated with an approximate 1.5-fold increase in the

relative risk of dementia, especially when present in midlife (Larson, 2017). Vital signs will be

monitored as part of the routine office visit with his mental health provider and recommendations to

follow up with his PCP if necessary for blood pressure management.

Smoking—First-line pharmacologic therapy for smoking cessation, approved by the Food and Drug

Administration, is bupropion. Patients with MCI have a higher-than-expected prevalence of

atherosclerosis risk factors. There are long documented risks to cardiovascular health associated

with atherosclerosis and smoking (Rigotti, 2017).

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Hypercholesterolemia—Hypercholesterolemia may increase the risk of dementia especially

vascular dementia however, there remains inconclusive data as to whether it plays a significant part

in increasing or decreasing risk for dementia (Larson, 2017). Continued treatment of

hypercholesterolemia is warranted since prevention of atherosclerosis is a contributing factor for

cerebrovascular disease. The patient will be referred to his PCP for evaluation of

hypercholesterolemia.

Apolipoprotein E4 (APOE 4) — APOE is a lipoprotein in the brain involved in cholesterol

homeostasis. APOE 4 is a susceptibility gene not a determinative gene in that individuals with two

copies of the APOE 4 allele are at the highest risk of acquiring Alzheimer’s dementia (Sherva and

Kowall, 2017). Patient 123 will be referred to the VA laboratory for serum blood work to include

APOE 4 genetic testing.

Short-Term Outcomes: 6 weeks

Remission of Depression--Rescreening with the GDS and during the interview assessing mood and

neurovegitative symptoms to evaluate response to antidepressant therapy is an essential part of the

treatment plan.

Treatment of Vitamin Deficiency--Laboratory studies to evaluate serum Vitamin B-12 deficiency

will be evaluated during follow up visits.

Long-Term Outcomes: 1 year

Prevent Conversion to Dementia—Patient 123 will not experience a decline in neurocognitive

symptoms in the next year.

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Follow-Up Care—Continue to follow up at the GEM clinic and annually screen the patient using

the MoCA, IADL, EXIT-16, CLOX1, CLOX2 to evaluate improvement or decline in MCI.

Exercise Plan—Have the patient develop and engage in an exercise program to lower his BMI to

NIH healthy standards (BMI 18.5-24.9) for cardiovascular health and as an adjunct to treatment of

depressive symptoms.

Cognitive Interventions—Discuss with the patient use of cognitive rehabilitation exercises as part

of treatment such as memory training. Multiple small studies have demonstrated short-term

improvements in various cognitive domains after cognitive training programs compared with a

control condition, the benefits tend to be small, and studies that have measured long-term outcomes

generally demonstrate waning effects over time (McDade & Peterson, 2018).

Alternative Therapeutic Modalities

Transdermal nicotine—Transdermal nicotine (15mg/d) trials have demonstrated possible

improvement in cognitive test performance in patients with MCI (Larson, 2017). It would be

beneficial to include this in the treatment plan for patient 123 should bupropion be ineffective.

Anticipatory Guidance

Anticipating needs for patients and caregivers with MCI can be challenging. The most

important need would include ongoing discussions to help the patient and family understand the

potential causes and contributing factors of MCI and to discuss the possibilities of converting from

mild to major cognitive impairment in the future. Failure to discuss this possibility and balancing
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the anxiety of such a reality will take time. This type of information is not given to the patient in a

single visit but as the therapeutic relationship builds these conversations will be necessary.

Referrals/Consultations

Neuropsychological evaluation is an assessment that involves the integration of multiple

sources of information about the patient, including data collected from an interview, collateral

information and an individual’s performance on standardized psychometric measures that can

complement the clinician’s assessment and assist with MCI diagnosis (Larson, 2018).

Continuity of Care

Collaborating with his PCP regarding the diagnosis of MCI and the treatment plan is

imperative. Requesting data from previous health records, laboratory findings, and physical

examinations is information that can be shared between providers in order to formulate an

individualized and comprehensive treatment plan.

Critical Analysis

Patients and caregivers of individuals with MCI and dementias face a multitude of obstacles.

In 2016, the economic impact of MCI and dementia was astronomical with regard to unpaid

caregivers at 18.2 billion unbilled hours at an average of $12.65/hour equating to $230.1 billion

dollars in the U.S. alone (Alzheimer’s Association, 2017). These estimates are expected to rise

dramatically as the number of adults aged 65 and older in 2025 reaches about 60% (U.S.

Department of Commerce, 2014). This financial burden is not lost within the workplace either,

with caregivers contributing less working hours per week due to coming in late or leaving early,

leave of absence, switching from full to part-time or leaving the workforce all together accounting

for almost $470 billion dollars in 2013 (Family Caregiving Alliance, 2016).
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The social impact of individuals with MCI or dementias has an impact on the use of health

care services. People with cognitive impairment have twice as many hospital stays per year than

older adults without MCI or dementia. Furthermore, the use of health care services by people with

other serious medical conditions is strongly affected by the presence or absence of cognitive

impairment or dementia resulting in longer hospital stays with a potential lack of resources to

distribute throughout communities (Alzheimer’s Association, 2017).

There is also a shortage of professionals who are specialized in treating older adults.

The American Geriatrics Society states “due to the increase in older Americans and the stagnation

in the number of new geriatric professionals trained in the past decade, the differential will increase

to one geriatrician and one geriatric psychiatrist for every 4,484 and 20,448 older Americans, by the

year 2030” (Alzheimer’s Association, 2017). In addition, less than 1 percent of registered nurses,

physician assistants and pharmacists identify themselves as specializing in geriatrics (Alzheimer’s

Association, 2017). This could create a potential moral burden on society if mental health

professionals are not available for older populations.

Opportunities for Teaching Needs and Quality of Care Improvement

 Educating patients and families to anticipate problems with accomplishing daily tasks,

short-term memory, concentration, or language are expected (McDade and Peterson, 2018).

 Educating patients and families that trials of anticholinesterase inhibitors have been found to

not prevent the progression of MCI to dementia and are not routinely recommended

(McDade and Peterson, 2018).

 Education regarding support groups (i.e. Alz. Connected) for caregiver needs would be

provided during treatment should symptoms progress to help prevent caregiver burnout (Alz.

Org, 2018).
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Summary

In summary, care of a patient with mild cognitive impairment is complicated. As future

psychiatric nurse practitioners it is imperative to understand that evidenced based guidelines are

established and are meant to assist with developing a comprehensive and sound treatment plan.

Nurse practitioners are best suited in patient-family centered care when educating about MCI by

incorporating a comprehensive treatment plan that includes safety needs, activities of daily living,

pharmacologic interventions and collaborating with members of the patient’s health care team.
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References

Alzheimer’s Association. (2017). 2018 Alzheimer’s disease facts and figures. Alz.Org. Retrieved

from: https://www.alz.org/facts/overview.asp

American Academy of Neurology. (2016). Mild cognitive impairment: report of the guideline

development, dissemination, and implementation subcommittee of the American Academy

of Neurology. Retrieved from:

https://www.aan.com/Guidelines/home/GetGuidelineContent/887

Family Caregiver Alliance. (2016). Caregiver statistics. Family Caregiver Alliance. Retrieved from:

https://www.caregiver.org/caregiver-statistics-demographics

Larson, E. B. (2017). Risk factors for cognitive decline and dementia. UpToDate. Retrieved from:

https://www.uptodate.com/contents/risk-factors-for-cognitive-decline-and-dementia

Larson, E.B. (2018). Evaluation of cognitive impairment and dementia. UpToDate. Retrieved from:

https://www.uptodate.com/contents/evaluation-of-cognitive-impairment-and-dementia

McDade, E.M. & Peterson, R.C. (2018). Mild cognitive impairment: prognosis and treatment.

UpToDate. Retrieved from: https://www.uptodate.com/contents/mild-cognitive-

impairment-prognosis-and-treatment

National Institute of Health [NIH]. 2018. Calculate your body mass index. National Institute of

Health. Retrieved from:

https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Peterson, R.C., Lopez, O., Armstrong, M.J., Getchius, T.S.D., Ganguli, M., Gloss, D., …Rae-Grant,

A. (2018). Practice guideline update summary: mild cognitive impairment. Neurology,

90(3), 126-135
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Press, D. & Alexander, M. (2018). Prevention of dementia. UpToDate. Retrieved from:

https://www.uptodate.com/contents/prevention-of-dementia

Rigotti, N. (2017). Overview of smoking cessation management in adults. UpToDate. Retrieved

from: https://www.uptodate.com/contents/overview-of-smoking-cessation-management-in-

adults

Sherva, R. & Kowall, N. W. (2017). Genetics of Alzheimer disease. UpToDate. Retrieved from:

https://www.uptodate.com/contents/genetics-of-alzheimer-disease