Mild Cognitive Impairment (MCI): Is It Normal Ageing?

Becoming more forgetful, losing your train of thought mid-conversation, misplacing items from time to time - are these part and parcel of ageing? If they are not, is dementia looming? How do we know if and when a visit to the doctor is necessary? 

These questions might arise as you notice changes in memory and behaviour in yourself or your senior loved ones. This article aims to shed light on such concerns by addressing Mild Cognitive Impairment (MCI), a condition that is frequently mistaken for normal ageing and therefore overlooked and undiagnosed. Dementia - the most severe form of cognitive decline associated with ageing is covered in separate articles on our blog here. 

First, let us find out what mild Cognitive impairment is and how it is different from dementia. 

1. What is Mild Cognitive Impairment (MCI)? 

Mild cognitive impairment is defined as a slight but noticeable decline in memory and thinking experienced by the person himself/herself or others interacting with them. The memory ‘slip’ does not significantly interfere with daily life activities. The person affected is often able to manage routine activities well with the help of notes and reminders. 

Globally, mild cognitive impairment is estimated to affect 12-18% people aged 60 and above. Prevalence in Singapore is lower than global figures, which could be partly due to low awareness and underdiagnosis. What is worrying is that despite the low incident rate, seniors with MCI in Singapore are found to experience marked disability, depression and anxiety.  

MCI may sound like a mild case of dementia but it is not always the pre-stage of dementia. Approximate one in three people with MCI develops dementia within five years. Another one in three does not experience further cognitive and memory decline. And the good news is that the remaining one in three may improve their condition when the underlying cause of MCI is addressed. These causes may include insomnia, sleep apnea, depression and anxiety, nutrient deficiency, stroke, cardiovascular diseases, head injury and the side effects of other medications. 

Mild cognitive impairment is estimated to affect 12-18% people aged 60 and above, whereby 1 in 3 develops dementia within 5 years.

2. MCI vs Dementia

Mild cognitive impairment and dementia both affect a person’s memory, thinking and other cognitive abilities. The biggest difference is that MCI does not cause disruptions to a person’s daily life while dementia will gradually undermine a senior’s ability to be independent in their basic daily activities. Dementia will progressively worsen but MCI may improve, stabilise or further develop into dementia, depending on the underlying causes. 

As such, it is crucial to visit a doctor for professional assessment when you notice ‘memory lapses’ that are more serious than people of the same age, or deteriorating quickly. The doctor will conduct detailed cognitive and neurological testing to determine if the memory decline is due to normal ageing, an underlying condition, some other medications or indeed an early stage of dementia. 

In some cases, the test and examination results are not clinically evident for the doctor to establish whether the case is MCI or not. This does not mean assessment is not helpful. Results are still important as an important baseline for future monitoring. Evaluation by professional medical personnel may also reveal other underlying conditions such as sleep apnea or anxiety. If MCI is a symptom of other diseases, treatment of primary causes will improve or mitigate MCI. 

3. Will MCI lead to dementia?

Mild cognitive impairment is not a sign that Alzheimer’s or other type of dementia is looming. As noted above, there are reversible causes of MCI other than dementia. Sometimes, a simple change in medications can resolve the memory loss issue for the patient. In other cases, MCI will stabilise and the patient will adapt to managing their life with MCI efficiently. It is therefore important for the affected elderly to go through the clinical evaluation process to identify possible causes and how to address them. 

However, as noted above, one third of people with MCI are found to develop dementia within 5 years. For them, MCI is indeed the stage in-between normal ageing and dementia. A research study conducted by the American Academy of Neurology indicates that people with mild cognitive impairment above 65 years will progress to dementia as follow: 

• Approximately 7.5 percent of people with mild cognitive impairments will progress to dementia within one year after they are diagnosed with MCI. 
• About 15 percent will progress to dementia within two years after they are diagnosed with MCI. 
• Approximately 30 percent of people will progress to dementia within five years after they are diagnosed with MCI. 

4. Signs and Symptoms of MCI

MCI may affect memory and/or the ability to reason, think and make decisions. As such, someone with mild cognitive impairments may experience any or all of the following memory and thinking problems.

• Memory loss: A person with MCI may start to forget important information that he or she had no trouble recalling previously, such as appointments, recent happenings, or conversations. Occasionally, they may repeat the same questions after they are being answered or telling the same stories over and over again.
• Language problems: People with MCI may face trouble with finding words for conversation or writing. They may also have difficulty in understanding complex verbal speech and ask the person they are conversing with to repeat or explain things repeatedly. 
• Attention: Loss of focus and early distractions are common symptoms of MCI. A task that was once easy such as preparing a new dish or following instructions now takes longer or becomes challenging to complete. A person with MCI may lose their train of thought mid-sentence or mid-conversation.
• Reasoning and Judgement: Complex problem solving, planning and hard decision-making becomes difficult when a person is affected by MCI. This may manifest as unsound or reckless decisions by someone known among family and friends as a rational and responsible person.

These symptoms may get noticed by the person him or herself, or his family and close friends. Most healthy people experience a gradual decline in mental functioning with increasing age such as a pause to remember words or names from time to time. It is critical to be able to tell whether the decline is age appropriate or signalling medical attention. An important hint is whether the forgetfulness occurs with very familiar details such as names of loved ones, very common words, or directions to go home, and whether the behavioural changes are out of character for the affected senior. 

Below table illustrates the differences in symptoms experienced by an elderly with mild cognitive impairment vs. dementia vs. normal ageing.

Is it mild cognitive impairment (MCI), dementia or just normal ageing?

5. How is MCI diagnosed?

The diagnosis of mild cognitive impairment is relatively complex. No single test can confirm if a person has or does not have MCI. The doctor thus needs to conduct a clinical diagnosis based on the symptoms a patient experiences along with a series of tests and investigations to make the best judgement if MCI is present as well as its possible causes. 

5.1. Clinical examination:

• Examination of general health and medical history 
• Memory assessment such as interviewing the elderlies themselves and/or their close family members for a view of memory function and how severe memory loss is.
• Evaluation of memory mental functioning compared to age and education, including pen and paper tests to determine the mental status of the patient, such as Mini-Mental state examination (MMSE) or Montreal Cognitive Assessment (MoCA). 

5.2. Neurological examinations such as reflexes, eye movements, walking, and balance are performed. 

5.3. Lab tests including blood tests to check for vitamin B-12 deficiency, thyroid functions, and other biomarkers; ECG or sleep analysis, etc are performed to rule out other medical conditions and causes.

5.4. Radiological investigations such as specialised Magnetic Resonance Imaging (MRI) and Positron emission tomography (PET) scans are performed to check for brain and blood vessel abnormalities. 

Note that some patients may not receive a conclusive result even after thorough memory and function assessment. Thus, seniors and their families are recommended to consult a doctor for an appropriate level of testing and examination.. Learn more about memory and cognitive assessment services in Singapore here.

6. Treatment for MCI

Treatment for MCI depends on the underlying causes. If sleep apnea or insomnia is diagnosed, the doctor may prescribe medications or measures to treat the sleep disorders while monitoring memory and cognitive function of the patient. If the elderly suffers from a stroke or a vascular disease that may affect memory, focus can be placed on treating the vascular condition or recovery from the stroke. 

When MCI is the primary condition, i.e., there are no other known causes, or when it is evidently caused by Alzheimer’s or other dementia, medical interventions aim to monitor, stabilise the condition and slow down its possible progress to dementia. The doctor may prescribe medications used to treat Alzheimer’s. Patients will need to follow up regularly, often every six months, to be reevaluated if symptoms have progressed. They are also encouraged to be socially and physically active, maintain a sufficient and nutritious diet, and engage in a healthy lifestyle to be generally fit and prevent other conditions that are linked to neurological damages such as diabetes, cardiovascular diseases and mental disorders.

7. How to care for an elderly loved one with MCI?

Being diagnosed with mild cognitive impairment can be devastating news. Although the risk of developing dementia is higher in seniors diagnosed with MCI, it is important to note and remind your loved one with MCI that MCI does not always mean dementia is on the horizon. By definition, people with MCI can go about their daily activities independently without any compromises. In fact, being active and socially engaged can help them reserve their memory and cognitive abilities and prevent conditions that may trigger MCI. 

Below are important aspects of a holistic care plan that seniors with MCI and their families should pay attention to:

• Medical care for MCI: This includes self-monitoring of symptoms, adhering to the check-up schedule recommended by the doctor, and taking medications as required, if medications are prescribed. 
• Treatment and prevention of causes that may trigger or worsen MCI: This depends on an individual’s risk factors and medical history and may involve management or prevention of
  • Cardiovascular diseases such as high blood pressure (hypertension), high cholesterol, stroke, etc (More about cardiovascular risk from our dedicated article here)
  • Mental disorders such as depression, anxiety, etc (Find out how mental health is linked to cardiovascular health and brain here)
  • Diabetes (More about how diabetes can cause neurological damage here)
  • Sleep disorders (Find out how insomnia can cause brain decline here)
• Diet: Studies show that a diet rich in antioxidants, omega-3 fatty acids, vitamins and low glycemic index foods are beneficial for preventing brain and cognitive decline. On the contrary, high consumption of diets rich in saturated fats, refined sugars and low intake of fruits and vegetables can negatively affect brain functions. As elderlies may struggle to consume sufficient calories and nutrition due to poor appetite or chewing difficulties, it is important to address dental and appetite issues and plan out nutritious meals for them. Check out tips on how to overcome loss of appetite for the elderlies here.
• Exercise: Exercising 3 times a week for 1 hour per session has been proven to improve cognitive performance in older adults both with and without MCI. Exercises can involve aerobics or resistance training, or other mind-body exercises. In addition to brain and memory benefits, being physically active helps seniors fight sarcopenia (i.e., muscle loss due to ageing) and many other health problems. Check out suggestions for exercises for seniors of different health and mobility status in our article here. 
• Other non-pharmacological therapies: Activities like meditation, yoga, learning to play a musical instrument, using the computer and other brain stimulation are also increasingly recognised as cognitive enhancers. Find or help your senior loved ones find an activity that they like could improve both their brain health and mental health.
• Lifestyle habits: Avoiding smoking and limit alcohol consumption has a boosting effect on overall health, cognitive health as well as chronic disease management. Being socially engaged also helps, as it requires seniors to practise their cognitive functions such as communication, thinking, reasoning and decision-making skills. 

8. Living with Mild Cognitive Impairment

Memory lapses and cognitive decline associated with MCI occur gradually and often do not cause significant troubles for a senior’s daily life. 

As family members, you can help your elderly loved one make use of notes, reminders, calendars in paper or electronic form to manage their daily activities better. Establishing routine, setting up fixed locations at home for items such as keys and handphones reduce the pressure to memorise things for your elderly. Memory slips happen to everyone every now and then, even with tools and support. Be sure to be extra patient when your loved one is diagnosed with MCI. Do not say things such as ‘How can you forget..’ which could be hurtful to someone with MCI. 

If you are dealing with MCI yourself, remember that MCI is not a disability. It can be managed and it does not always equate dementia. You can still make the most of your golden years despite having MCI. When you go for MCI evaluation or even being diagnosed with MCI, you are taking your brain health matters in your hands for the best possible outcome.

9. How to Prevent Mild Cognitive Impairment?  

There is no sure way to prevent MCI among elderlies. However, we can actively manage risk factors such as preventing or managing cardiovascular diseases, diabetes, sleep disorders, mental health disorders, etc to keep MCI at bay as much as we can. 

Lifestyle improvement and home remedies recommended in the treatment of MCI section also works as preventive measures. It is never too early, or too late, to engage in a healthy lifestyle to improve our overall physical and cognitive health. 

10. Takeaway Message

It can be devastating to witness memory loss and cognitive decline in yourself or your elderly loved ones. While a part of it is due to usual ageing, cognitive impairment may signal a medical condition that needs professional care. These include insomnia, sleep apnea, cardiovascular diseases, mental health conditions, or a form of dementia. 

We hope the article brings attention to the problem of mild cognitive impairment (MCI) among elderlies. Different from dementia, MCI is manageable or even treatable in many cases. Being aware of the early signs and getting professional memory and cognitive assessment is the first step you can take to preserve or improve your brain health in the golden years.