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This is an academic presentation given at IPA2008 re the progression of mild memory impairment to more severe impairment (dementia)
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Relative Risk of Progression of MCI to Dementia
Pooled and Meta-Analysis of 39 Robust Inception Cohort Studies
Alex MitchellConsultant & Hon SnR Lecturer in Liaison Psychiatry, Leicester
Moj FeshkiStR in Psychiatry
Srini MalladiConsultant in Old Age Psychiatry, Northampton
IPA, Dublin 2008
What is MCI?
The Natural History of Dementia
PRE-SYMPTOMATIC
PRE-CLINICAL
CLINICAL
Pathological Burden
Dis
ease
Sev
erit
y
Time in Years
T0
T-5 T+10
T-10 T+5
(Bra
in V
olu
me
/ In
trac
ran
ial V
olu
me)
80%
85%
90%
75%
70%
Severe Dementia
Moderate Dementia
Mild Dementia
Mild Cognitive Impairment
23v24
30
20v21
9v10
Dia
gnos
is
Dea
th
11v12
MM
SE
Stages of Dementia
VI(Cortical association
areas)
All38+6-730-11Severe Alzheimer’s disease
V(Basal cortex)
Semantic MemoryVisuospatial awarenessOrientation
21-375212-20Moderate Alzheimer’s disease
III/IV(Amygdala & Thalamus)
Recognition MemorySpatial Episodic MemoryExecutive Dysfunction
13-204121-23Early Alzheimer’s disease
II(CA1 field of
hippocampus)
Verbal Episodic Memory(Delayed Recall)
1-1330.521-29Mild Cognitive Impairment
II(CA1 field of
hippocampus)
Verbal Episodic Memory (Extended Recall)
1-1220.524-29Age-Associated Memory Impairment
I(Transentorhinal
area)
No Problems01030Healthy Elderly
Braak StagingCognitive PerformanceADAS-Cog
GDSCDRMMSEStage
1. Subjective Memory complaintSpontaneous or affirmed?
2. Normal activities of daily livingNormal or near normal?
3. Memory impaired for age1.5SD?
4. No dementiaQuestionable dementia?
Simple Definition Peterson (Mayo Defn) 1997/1999/2001
Winblad B, Palmer K, Kivipelto M, et al. Mild cognitive impairment—beyond controversies, towards a consensus: report of the International Working Group on Mild Cognitive Impairment. J Intern Med 2004;256:240–6.
Portet F, Ousset PJ, Visser PJ, Frisoni GB, Nobili F, Scheltens P, Vellas B, Touchon J . Mild cognitive impairment (MCI) in medical practice: a critical review of the concept and new diagnostic procedure. Report of the MCI Working Group of the European Consortium on Alzheimer's Disease. Journal Of Neurology Neurosurgery And Psychiatry 2006;77 (6): 714-718 .
Author (year) N Age Study Prev (%)
Graham (1997) 1800 >65 CSHA 5.3
Larrieu (2002) 1265 70-90 PAQUID 2.8
Hanninen (2002) 806 60-76 KUPIO 5.3
Lopez (2003) 2470 >75 CHS 6.0
Fisk (2003) 1790 >65 CSHA 1-3
Ganguli (2004) 1248 >65 MoVIES 3-4
Prevalence of MCI
What is the Risk of Dementia in MCI?
Progression, Peterson, 1999
Petersen RC et al: Arch Neurol 56:303, 1999
MCI → AD 12%/yr
50
60
70
80
90
100
Initial 12 24 36 48exam Months
Control → AD 1-2%/yr
50
60
70
80
90
100
Initial 12 24 36 48exam Months
100
88
76
64
52
40
28
16
40
0
10
20
30
40
50
60
70
80
90
100
Baseline Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9
ExtrapolationCrude Mayo MCI Model
Rivastigmine InDDEX Study
Rivastigmine InDDEX Study
Cochrane Review
AChE for MCI?
Pooled Effect of Ache for MCIRR Meta-analysis (fixed effects)
ACR for MCI to Dementia by Intervention
6.3%
8.0%
9.9%
0
1
2
3
4
5
6
7
8
9
10
Drug Placebo VitE
n=4 n=4 n=1
Pooled Analysis
Pooled Analysis - Methods
• Systematic search + appraisal + extraction
• Focus on robust studies– Follow-up 3yrs+– Sample n > 50
• Expecting ?20 papers– 65 studies– 15 long term– Sample = 11,756
4x
2x
10x
9x
17x
AD
13926xAACD
23085xCIND
9022xCDR
464412xPartial
251110xClassical
N=DementiaType
0
2
4
6
8
10
12
4 5 6 7 8 9 10
Years of Observation
Annual Rate of Conversion (%)
Hansson et al (2007)
Bozoki et al (2001)
Visser & Verhey (2008)
Devanand et al (2007) Annerbo et al (2006)Visser et al (2006)
Ganguli et al (2004)
Tyas et al (2004)
Hogan & Ebly (2000)
Ishikawa & Ikeda (2007)
Grober et al (2000)
Larrieu et al (2002)
Dickerson et al (2007) Aggarwal et al (2005)
Busse et al (2006)
Triangle = Specialist Centres (clinical)Square = Community Studies (non-clinical)
Long Term Studies 5yrs+
y = -5.9607Ln(x) + 16.633R2 = 0.1857
0
2
4
6
8
10
12
14
16
18
20
2 3 4 5 6 7 8 9 10
Years of Observation
ACRMedium+Long Term Studies 3yrs+
Triangle = DementiaSquare = Alzheimer’s disease
ACR to AD
0.08
0.04
0.07
0.09
0.04
0.09
0.05
0.06
0.09
0.04
0.00
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
0.09
0.10
Classical MCI Partial MCI CDR=0.5 CIND AACD
All
Specialist Settings
Long Term Studies 3yrs+
Weakness in Model?
• 1-2% Die per year
• 2-5% Recover per year
• ? Lost to follow-up
• => Inception vs Completer studies
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
CP1183493-10
Years after enrollment
Alive (%)
NormalsNormalsAll amnestic MCIAll amnestic MCI
P<0.0001
Mayo Data Survival (Kaplan-Mayer)
0
1
2
3
45
67
89
10
17
0
2
4
6
8
10
12
14
16
1922
20
100
85
7465
5750
4337
3124
18
8
0
10
20
30
40
50
60
70
80
90
100
Baseline Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10 Year 15
MCI-StableRecoveredDiedDementia
ExtrapolationAdvanced All Case MCI Model
Extras
Non-Amnestic MCISingle Domain
Yes
Amnestic MCISingle Domain
Yes
Cognitive complaint
Not normal for age
Modest Objective Cognitive decline
Normal instrumental function
Yes
Amnestic MCI
MCI
Memory impaired? No
Non-Amnestic MCI
Single non-memorycognitive domain
impaired?
Memoryimpairment only? No
Non-Amnestic MCIMultiple Domain
No
Amnestic MCIMultiple Domain
Petersen: J Int Med, 2004
Credits / Acknowledgments
For more slides www.psycho-oncology.info/slides
Alex J Mitchell © 2008