Age Associated Cognitive Decline and Mild …

1 Age Associated Cognitive Decline and mild Cognitive Impairment (MCI)Mike R. Schoenberg, PhD, ABPP-CNDiplomate, American Board of Clinical NeuropsychologyLicensed PsychologistDepartments of Psychiatry and Behavioral Sciences and NeurologyUniversity of South Florida College of MedicineDisclosuresAdvisory Board/Panel: UCB Pharma, and Co-Editor of Black Book of Neuropsychology: A syndrome based approach Receive financial support from USF and the Florida Alzheimer s Disease Research Center, National Institutes of HealthObjectivesRationale for Neuropsychological AssessmentNeuropsychological Evaluation in Growing Older Age appropriate Decline in Cognitive function Abnormal agingDementias mild Cognitive ImpairmentNeuropsychology Crucial?

2 ConclusionsFuture DirectionsRationale for Neuropsychological AssessmentAging and Brain disorders manifested by changes in Cognitive and behavioral functionDementia is Decline in previously acquired Cognitive and behavioral abilities which leads to deficits in ability to functionMild Cognitive Impairment is abnormal Decline in Cognitive function greater than expected for assessment is only way to measure alterations in Cognitive and behavioral AgingExtensive Data indicate aging is Associated with Cognitive decline292724051015202530 MMSE18-5555-7071-85 Normal AgingWhat, When and How Much Cognitive Decline occurs with aging varies.

3 Numerical ability/arithmetic and processing speed- beginning about age 25 Memory (Episodic or Declarative)- Late 30 s or 40 s perhaps as late as 50 s to 60 s Seattle study found about age 53 Reasoning, verbal ability, and Visuoperceptual skills- Beginning in 50 s and 60 s Word knowledge, vocabulary, word reading-Stable into late adulthood (70 s+)Longitudinal change in cognition with normal agingFrom Schaie (1996) Cognitive Changes in Normal Aging:Simple Attention and Complex AttentionAttention: Simple TaskAttention / Processing Speed: Difficult TaskCognitive Changes in Normal AgingLanguageObject naming: Easy ItemObject Naming: Difficult ItemCognitive Changes in Normal AgingMemoryVerbal MemoryBatCannonChairFloorOrangeMayorBusP layCornerSaladLeverSquareVisual (non-verbal) memoryCognitive Changes in Normal Aging:Visuoperceptual/Visual Reasoning012345678910 Score60708090 AgeSpatial Pe rce ptionVis ualReasoningVisuospatial Perception:Spatial PerceptionCognitive Changes in Normal Aging.

4 Reasoning012345678910 Score60708090 AgeVe rbalReasoningVis ualReasoningVerbal ReasoningEasywWood and Coal HardwPlatypus and StorkObjectivesNeuropsychological EvaluationRationale of AssessmentNeuropsychological Evaluation in Growing Older Age appropriate Decline in Cognitive function Abnormal agingDementias mild Cognitive ImpairmentNeuropsychology Crucial?ConclusionsFuture DirectionsCognitive Decline : Dementia and mild Cognitive ImpairmentExtensive terms and research to defining where normal aging stops and pathology beginsAge-appropriate memory Impairment (AAMI)SenilityBenign semnescent forgetfulnessCognitive Impairment No Dementia (Canada) mild Cognitive DisorderMild Cognitive Impairment (MCI) mild Neurocognitive DisorderQuestionable dementiaDefining Impairment Theoretical Progression from normal to dementiaFrom Petersen, 2003 Gross Pathology.

5 Normal Coronal ViewGross Pathology: Alzheimer s DiseaseHow to define where pathology begins?Defining Impairment:DementiaDementia is broadly defined as a Decline in Cognitive function from a previous level of ability severe enough to interfere with work, school, social activities, etc. that is not due to delirium or encephalopathyDSM-IV TR defines dementia more specifically as requiring a deficit in memory and at least one other Cognitive , Aphasia, Agnosia, Apraxias, executive functionsANDI mpairment in ability to work, attend school, complete ADLs, to measure memory loss and Cognitive or behavioral impairmentIdentifying Cognitive ImpairmentMethods to define impairment in neuropsychological function for dx of dementiaClinical interview with pt (and collateral source)

6 MMSEC linical Dementia Rating scale (CDR)Neurologic/neurobehavioral examClinical neuropsychological evaluationStructure of CNS does NOT allow for dx of dementiaMRI, CT, PET study can NOT identify Cognitive impairment for dx of dementiaWhen is Impaired Actually ImpairedThreshold for impairment can vary from diagnostician to diagnosticianWhen is MMSE score impaired?MMSE score 25/30?MMSE score 23/30?MMSE score 18/30?Neuropsychological criteria for defining impairment< 16thpercentile (< SD below average = possible impairment)< 7thPercentile (< SD below average = MCI)2ndPercentile (< SD below average = dementia)Neuropsychologic Profile of DementiasSo-called cortical dementiasMemory loss (impaired recall without benefit of recognition cues)

7 With other cortical findings such as agnosias, aphasias, and/or is Dementia of Alzheimer s typeSo-called subcortical dementiasslowed processing speed, with deficits in attention, memory (poor spontaneous retrieval but intact recognition), visuospatial skills, and executive functions (initiation, planning, behavioral apathy).Prototype is Vascular dementia or Parkinson s disease dementiaAlzheimer s DiseaseEarly deficitsEarly and profound impairment in memoryDeficient consolidation and rapid forgettingRetention rate over 20-30 minutes < 50 %Attention/working memory intactSocial withdraw (common early)Verbal fluency (semantic < phonemic) and dysnomiaVisuoconstructional apraxiaExecutive function (impulsivity, indifference, poor insight)

8 Later stage deficitsIQ, attention, behavioral apathy, agitation, delusionsVascular DementiaEarly deficitsMemory impairedPoor spontaneous recall, but recognition intactAttention (divided attention/working memory)Visuoperceptual/Visuoconstruction al apraxiaExecutive function (reasoning, sequencing, apathy)Verbal fluency (semantic > phonemic)Social withdraw, depressionFocal neurological deficitsLater stage deficitsIQ, agitation, delusionsLewy Body DementiaEarly deficitsEarly and profound impairment in AttentionImmediate memory/working memory impairedVisuoperceptual/Visuoconstructio nal apraxiaExecutive function (reasoning, sequencing, poor insight)

9 Fluctuating mental status, visual hallucinationsMemory not severely impairedLater deficitsMemory, IQ, language/speech, agitation, delusionsFrontotemporal DementiaEarly deficits (considerable variability)Executive function (impulsivity, reasoning, sequencing, apathy, disinhibition, poor insight)Behavioral/Mood (Early and profound changes)Attention (divided attention/working memory)Verbal fluency (phonemic < semantic) naming deficitsPrimary progressive aphasias have early and profound language deficitsMemory ( mild deficits only)Later deficitsMemory, IQ, visuoperceptual, agitation, echolalia, mutism, stimulus bound behaviorsObjectivesNeuropsychological EvaluationRationale of AssessmentNeuropsychological Evaluation in Growing Older Age appropriate Decline in Cognitive function Abnormal agingDementiasMild Cognitive ImpairmentNeuropsychology Crucial?

10 ConclusionsFuture DirectionsMild Cognitive Impairment (MCI)Term to describe Pts with Cognitive impairment, but do NOT meet diagnostic criteria for dementiaPeterson et al. (Mayo Clinic) defined MCI as: Subjective memory complaint Objective memory deficit compared to age-matched peers ( or more standard deviations below average) Otherwise cognitively intact Otherwise intact daily functioning- Patient may use adaptations for memory loss Not dementedWho Cares? Why MCI is ImportantEarliest cut-point distinguishing normal aging from abnormal aging Controversy Unique disease entity?