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- What Do You Want to Know About Dementia?
- Dementia: Symptoms, stages, and types
- What Do You Want to Know About Dementia?
- Mild Cognitive Impairment and Dementia: Definitions, Diagnosis, and Treatment
Dementia occurs as a set of related symptoms when the brain is damaged by disease. Dementia has a significant effect on the individual, relationships and caregivers. Causative subtypes of dementia may be based on a known potential cause such as Parkinson's disease , for Parkinson's disease dementia ; Huntington's disease for Huntingtons disease dementia; vascular disease for vascular dementia ; brain injury including stroke often results in vascular dementia; or many other medical conditions including HIV infection for HIV dementia ; and prion diseases.
What Do You Want to Know About Dementia?
Mild cognitive impairment part 1 : clinical characteristics and predictors of dementia. Orestes V. Forlenza 1. Breno S. Antonio L. Wagner F. Gattaz 1. To critically review and evaluate existing knowledge on the conceptual limits and clinical usefulness of the diagnosis of mild cognitive impairment MCI and the neuropsychological assessment and short- and long-term prognosis thereof.
We conducted a systematic search of the PubMed and Web of Science electronic databases, limited to articles published in English between and Based on the search terms mild cognitive impairment or MCI and epidemiology or diagnosis, we retrieved 1, articles, of which were critically eligible cross-sectional and longitudinal studies ; the abstracts of the remaining 1, articles were also reviewed.
A critical review on the MCI construct is provided, including conceptual and diagnostic aspects; epidemiological relevance; clinical assessment; prognosis; and outcome. The distinct definitions of cognitive impairment, MCI included, yield clinically heterogeneous groups of individuals. Those who will eventually progress to dementia may present with symptoms consistent with the definition of MCI; conversely, individuals with MCI may remain stable or return to normal cognitive function.
On clinical grounds, the cross-sectional diagnosis of MCI has limited prognostic relevance. The characterization of the transition between normal cognitive aging and the earliest manifestations of dementing disorders, particularly Alzheimer's disease AD , has been an area of major interest in the last decades. Individuals diagnosed with MCI have an increased risk of progression to dementia, AD being the putative outcome. However, the experience accumulated in the last few years supports the notion that MCI is by no means a synonym of incipient dementia.
Considering the insidious and progressive nature of most neurodegenerative disorders, we can assume that most patients who will progress to dementia will exhibit symptoms compatible with MCI at the earlier stages of the disease.
We retrieved 1, articles, of which were reviews. We reviewed the abstracts of the remaining 1, articles and critically summarized the most relevant publications in the following sections.
A number of overlapping definitions have been proposed since the s to describe the transition between normal cognitive aging and pathological cognitive decline. These definitions developed from the concept of benign and malignant senescent forgetfulness described by Kral 1 more than 50 years ago and the age-related memory impairment described by Crook and Larrabee 2 in the late s.
Table 1 reviews the most commonly used terms and definitions, along with their major limitations. The term mild cognitive impairment itself was firstly used by researchers at New York University 9 to refer to a specific stage of cognitive deterioration identified through the Global Deterioration Scale GDS.
A grade 3 in this scale, which ranges from 1 to 7, indicates that an individual has cognitive complaints and shows subtle cognitive decline, but performance of usual occupational duties and social activities is preserved. In addition to the CDR classification, subjects may be also classified according to the degree of overall functional impairment, as measured by the CDR sum of boxes SoB , ranging from 0 to 18 points.
A higher SoB score is indicative of more severe functional impairment. In several studies, a CDR 0. In the late s, a group led by Ronald Petersen at the Mayo Clinic 5 , 12 proposed five operational criteria for the clinical diagnosis of MCI Table 2.
In the original study, 5 patients classified as having amnestic MCI showed a significant increase in the risk of progression to dementia largely AD during follow-up i. In subsequent years, the criteria for MCI were revised to encompass other patterns of cognitive impairment in addition to memory per se. However, the core aspect of MCI has been preserved, i. Figure 1 illustrates the distinct MCI subtypes according to the number and type of cognitive deficits within the core construct.
A recent task force, led by the U. These objectives would be achieved by a systematic evaluation of established disease biomarkers e. In the second part of this review, we will address in detail the role of these biomarkers in the diagnosis and classification of AD. Despite a wealth of data on the epidemiology of dementia, little information is available regarding its prodromal stages in the Brazilian population.
Given the different definitions and conceptualizations that describe the cognitive dysfunction observed in the elderly, it is important to ascertain which is more suitable to illustrate the clinical framework of prodromal dementia. A notable analysis on how varied definitions work to detect early cognition changes in the general population was published in , based on data from a large-scale multicenter study conducted in the United Kingdom, with a cohort of over 13, individuals aged 65 or older.
As a consequence, prevalence estimates can vary between 0. Such wide variance could be explained by fundamental differences in the operationalization of the MCI diagnosis, including the requirement of objective measurement of cognitive decline as opposed to self-reported complaints , the inclusion of cognitive functions other than episodic memory in the diagnostic workup, and the magnitude of cognitive impairment that delimits caseness e.
Hence, heterogeneity in methodological approaches may be the reason for the large variance in prevalence estimates, such as the definition of cognitive decline and diagnosis criterion employed; average age and educational level, among other demographic features; the coverage and sensitivity of batteries for cognitive testing; procedures for patients recruitment and the research setting i.
The clinical procedures for the diagnosis of MCI are complex and, in many instances, cognitive deficits are very mild, requiring more sophisticated cognitive assessments.
In this scenario, a comprehensive neuropsychological evaluation may be considered a gold standard for the identification of patients with MCI.
Thus, there is a need for development of assessment strategies that are cost-effective, easy to administer and that generate results that are easy to interpret, while maintaining good sensitivity and specificity to identify MCI cases. Ultimately, these strategies should be widely available to all clinical settings. Many different approaches have been developed, with promising results. The mini-mental state examination MMSE is the most widely used cognitive screening test in clinical and research settings.
In a previous study, we showed that subjects with MCI had worse performance in specific MMSE subtests, according to their neuropsychological classification, despite having a similar total test score. As with other tests, they did not show good accuracy for the diagnosis of MCI, even when higher than usual cutoff scores were evaluated.
These issues may limit its broad applicability in primary and secondary clinical settings. In a recent study by our group, Aprahamian et al. The combination of scores on two or more tests is a common strategy for increasing the accuracy of dementia diagnosis in clinical practice.
In general, this yields better sensitivity and specificity to distinguish dementia from normal aging. Abreu et al. This combination did not significantly improve the sensitivity and specificity of each test alone in recognizing MCI cases as compared with healthy elderly subjects. In another study, Ladeira et al.
None of the chosen strategies were able to significantly improve the accuracy to differentiate MCI vs. These results are similar to previous studies with elderly populations. Although some of the currently used cognitive screening tests yield good results for recognizing subjects with MCI, they still have important limitations, mainly because they were designed for the diagnosis of established dementia, not of its prodromal and milder manifestations.
Therefore, it is important to develop new, more specific tools to tackle the challenge of identifying, with high accuracy, subjects with mild cognitive deficits. Indeed, some promising strategies have been developed are being tested in several populations.
The MoCA Montreal Cognitive Assessment is a brief cognitive test specifically developed to screen for mild cognitive deficits and has been regarded as a suitable test for initial workup of subjects with suspected MCI. Another interesting assessment strategy is the use of computer-based cognitive tests. Several computer-based batteries have been developed, e. This technology seeks to provide accurate and timely identification of MCI cases.
In the seminal work of Petersen et al. As the conceptual framework for MCI and its subtypes evolved, it was hypothesized that specific MCI subtypes would be associated with distinct outcomes.
Pure amnestic MCI would be associated with higher risk of progression to AD, since impairment of episodic memory is considered the most common prodromal clinical symptom of AD.
Non-amnestic MCI, which is manifested by the involvement of one or more cognitive functions other than memory, would indicate higher risk of progression to frontotemporal dementia FTD , primary progressive aphasia, or other non-dementia outcomes, e. Despite this reasonable hypothetical foundation, the findings of several clinical and epidemiological studies did not corroborate the association between specific MCI subtypes and distinct outcomes. A large proportion of subjects classified as having MCI can resume normal cognitive function backconversion or diagnostic instability or maintain stable cognitive deficits, not progressing to dementia even on long-term follow-up.
In this study, the best predictors of diagnostic instability were younger age and better global cognitive performance at baseline. These results were also observed in other studies. Another key point when assessing individuals with MCI is to ascertain the predictors of conversion to dementia and AD. This finding highlights the importance of careful assessment of other cognitive domains beyond memory in these individuals. Despite the importance of characterizing the cognitive profile of MCI subjects and understanding the predictors of conversion to dementia, this provides little or no information on the trajectories from normal cognitive aging to MCI and, finally, to dementia.
Therefore, we sought to determine the most common paths from normal cognition to AD. Similar results were also found in large community-based epidemiological studies. Where lies the threshold between MCI and incipient dementia?
The importance of functional assessment. The progression from MCI to dementia requires cognitive decline to be severe enough to impair one's ability to perform ADLs. According to the most recent criteria, MCI patients, unlike those with dementia, must have preserved global cognitive function, with no or minimal functional impairment, enabling them to perform ADLs independently.
However, when comes the time to decide whether a patient with MCI meets the diagnostic criteria for dementia on follow-up assessment i. The objective assessment of functional status is not a routine procedure when evaluating subjects with suspected cognitive impairment; rather, it usually relies on the subjective appraisal of a relative or caregiver, or even on the patient's self-judgment, rendering this information inaccurate and subject to several sources of bias, including the informant's personality, mood, and cognitive state.
Also, the objective assessment of functional status not only helps to establish the threshold at which cognitive decline significantly impact ADL performance, but enables the investigation of which functional abilities are more sensitive to such alterations. Although patients with dementia commonly exhibit neuropsychiatric symptoms such as depression, anxiety, irritability, agitation, disinhibition, sleep disorders, and apathy, these occurrences have been consistently associated with faster cognitive decline and with increased risk of progressing to dementia across individuals with MCI.
Despite wide acceptance by researchers and clinicians of the MCI construct as an important step toward understanding of the prodromal stages of dementia, others have harshly criticized the validity of this concept in light of the heterogeneity of its clinical setting and prognosis.
Nonetheless, given the insidious progressive nature of most neurodegenerative diseases, including AD, it is reasonable to assume that most of the patients who tend to develop dementia will exhibit, at the earliest stages, symptoms consistent with MCI. However, the reverse may not be true, since many individuals who do meet the criteria for MCI in a given assessment resume normal cognitive function or do not progress to dementia at all.
Given the foregoing, is there an urgent need for improvement of the predictive accuracy of clinically defined MCI to aid the selection of subjects at risk of progressing to dementia? On clinical grounds, the best approach is to perform longitudinal reassessment of individuals diagnosed with MCI.
Characterization of the cognitive signs and symptoms that pertain to the natural history of the disease is undoubtedly an important aid to the early diagnosis of AD and other dementias. Massive efforts have been dedicated to increasing the accuracy of cross-sectional diagnosis of pre-dementia AD, and definite progress has been achieved in the development of biomarkers which reflect the core changes observed in the disease.
In the future, the association of clinical and biological markers may help increase the specificity of MCI criteria, thus enabling identification of patients at actual risk of progression. Indeed, the use of biomarkers has been included in the most recent revisions of the diagnostic criteria for AD and MCI.
Kral VA. Senescent memory decline and senile amnestic syndrome. Am J Psychiatry.
Dementia: Symptoms, stages, and types
Arch Neurol. Where definitions focused on memory impairment and on multiple cognitive domains, higher proportions progressed and lower proportions reverted on the CDR. Proportions of participants progressing to dementia are lower and proportions reverting to normal are higher than in clinical populations. Memory impairments and impairments in multiple domains lead to greater progression and lesser improvement. Research criteria may benefit from validation at the community level before incorporation into clinical practice. Mild cognitive impairment MCI , the cognitive state intermediate between normal cognition and dementia, is interesting because of the potential for MCI to eventually develop into full-blown dementia. The original Mayo Clinic criteria for amnestic MCI 1 focused on deficits in and complaints about memory.
Dementia is a collective term used to describe various symptoms of cognitive decline, such as forgetfulness. It is a symptom of several underlying diseases and brain disorders. Dementia is not a single disease in itself, but a general term to describe symptoms of impairment in memory, communication, and thinking. An analysis of the most recent census estimates that 4. This article discusses the potential causes of dementia, the various types, and any available treatments. Some symptoms they may notice themselves, others may only be noticed by caregivers or healthcare workers. To discover more evidence-based information and resources for healthy aging, visit our dedicated hub.
Request PDF | On Nov 1, , Kevin Duff published Mild Cognitive Impairment and Dementia: Definitions, Diagnosis, and Treatment | Find.
What Do You Want to Know About Dementia?
Dementia is a decline in cognitive function. To be considered dementia, mental impairment must affect at least two brain functions. Dementia may affect:.
Mild Cognitive Impairment and Dementia: Definitions, Diagnosis, and Treatment
So, you want to enter the lucrative world of dementia evaluations, but it has been a long time since you saw anyone under 65? Then this contribution by Glenn Smith and Mark Bondi might just be the ticket to get you headed in the right direction. Mild Cognitive Impairment and Dementia: Definitions, Diagnosis, and Treatment is another volume in the American Academy of Clinical Neuropsychology series that follows a strong tradition of authoritative texts that appeal to graduate students and seasoned professionals and all neuropsychologists in between. Smith and Bondi are so extensively published and widely known for their work in aging and dementia that you could not find more qualified experts to guide you through the literature and offer their views on the late life continuum of cognitive disorders. As evident in the introductory chapter, the labels and criteria used to identify various stages of cognitive decline in the elderly have undergone dramatic shifts over the past three decades, with the speed of these changes rapidly increasing.
Mild cognitive impairment part 1 : clinical characteristics and predictors of dementia. Orestes V. Forlenza 1.
It seeks to promote medical-scientific writing and thereby support research and creativity in Medicine. The journal aims as well to support the medical-biological sciences related to health as to have a space for history, philosophy and ethics. Medical writing without relation to science is promoted: anecdotes, stories and short stories of doctors and patients. In recent years the term MCI has been recognized as a pre-dementia state, raising an important subject for investigation in the prevention of dementia. There are various terms related to pre-dementia MCI, such as isolated memory complaint and pre-Alzheimer's disease; most of them do not comprise all the areas related to MCI.
So, you want to enter the lucrative world of dementia evaluations, but it has been a long time since you saw anyone under 65? Then this contribution Mild Cognitive Impairment and Dementia: Definitions, Diagnosis, and Treatment. Mild Cognitive Impairment PDF; Split View. Views. Article contents.
So, you want to enter the lucrative world of dementia evaluations, but it has been a long time since you saw anyone under 65? Then this contribution by Glenn Smith and Mark Bondi might just be the ticket to get you headed in the right direction. Mild Cognitive Impairment and Dementia: Definitions, Diagnosis, and Treatment is another volume in the American Academy of Clinical Neuropsychology series that follows a strong tradition of authoritative texts that appeal to graduate students and seasoned professionals and all neuropsychologists in between. Smith and Bondi are so extensively published and widely known for their work in aging and dementia that you could not find more qualified experts to guide you through the literature and offer their views on the late life continuum of cognitive disorders. Oxford University Press is a department of the University of Oxford.
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