Guidelines: AAN Recommends Exercise, Cautious Prescribing for Patients With Mild Cognitive Impairment

Physical and cognitive exercise, using caution when prescribing cholinesterase inhibitors, and assessment of modifiable risk factors are among the new recommendations from the American Academy of Neurology (AAN) guideline for the management of patients with mild cognitive impairment (MCI), which was published in Neurology.

In an effort to update the AAN guideline on MCI, investigators systematically reviewed class I (n=20) and class II (n=14) studies to examine the prevalence of MCI, its prognosis, and the effect of various treatment options for CI.

A lower education level was associated with higher MCI prevalence in 8 of the class I studies. Additionally, the prevalence of MCI rose with increasing age: ages 60 to 64 (6.7%), 65 to 69 (8.4%), 70 to 74 (10.1%), 75 to 79 (14.8%), and 80 to 84 (25.2%). In patients with MCI >65 years of age who were followed for 2 years, the cumulative incidence of dementia was 14.9%.

According to the investigators, there was no high-quality evidence available in the recent literature to suggest a significant benefit of pharmacologic treatment for MCI. For this reason, the investigators recommend discussing the lack of reliable evidence to support the use cholinesterase inhibitors in patients with MCI. Available evidence did suggest, however, a likely benefit associated with 6-month exercise and cognitive training on cognitive improvement in patients with MCI, indicating regular exercise should be recommended for this patient population.

Based on the available literature, the major recommendations made in the updated AAN guideline include clinician assessment of modifiable risk factors, evaluation of functional impairment, and assessment and treatment of neuropsychiatric and/or behavioral symptoms for patients with MCI. In addition, long-term monitoring of cognitive function in patients with MCI is recommended, and the investigators of this update also suggest the discontinuation of medications that might impair cognition. Clinicians should also be encouraged to discuss biomarker research with patients with MCI.

Variation in the definitions used for MCI in the reviewed studies represents a possible limitation to this analysis. The investigators involved in this update also did not consider the psychological distress associated with a diagnosis of MCI, a potential limitation of this review that might be important to address in future reviews/updates.

In addition to the major treatment and management recommendations for the new AAN guideline, the investigators also recommend that, “referral to appropriate specialists is an important part of the treatment paradigm” of patients with MCI, particularly if clinicians are not experienced in managing the behavioral/psychiatric or cognitive needs of this population.

Reference

Petersen RC, Lopez O, Armstrong MJ, et al. Practice guideline update summary: mild cognitive impairment: report of the guideline development, dissemination, and implementation subcommittee of the American Academy of Neurology [published online December 27, 2017]. Neurology. doi:10.1212/WNL.0000000000004826