deterioro cognitivo
TRANSCRIPT
Caso CliacutenicoDeterioro Cognitivo
Leve
(DCL)Seccioacuten de Geriatriacutea
Cliacutenica Meacutedica
Hospital Alemaacuten
Caso Cliacutenico Mujer de 81 antildeos que concurre para Valoracioacuten Geriaacutetrica Integral derivada por
su medico de cabecera por trastornos mneacutesicos Recibe Donepecilo por ldquoolvidosrdquo desde hace 2 antildeos
Olvidos citas nombres y nuacutemeros de teleacutefono
Orientada en tiempo y espacio Concurre sin acompantildeante niega episodios de desorientacioacuten sin antecedentes familiares de enfermedad neurocognitiva
Antecedentes HTA (Losartan 50mg diacutea)
Ultima TAC y laboratorio completo normales
ACE 81100 (86 punto corte)
MMT 2330 (escolaridad secundaria completa)
Independiente para AVD
Parcialmente dependiente para el manejo de dinero (la controla la hija)
Preguntas
iquestDeterioro Cognitivo Leve (DCL) vs anciano
sano
iquestUtilidad de medidas de estimulacioacuten cognitiva
en DCL
iquestReevaluacioacuten de progresividad
iquestInicio de medicacioacuten antidemencial en DLC
ldquoContinuumrdquo del rendimiento
cognitivo
DCLDemenciaNormalidad
Zona gris Zona gris
Deterioro Cognitivo Leve DLC Siacutendrome amneacutesico que
denota una etapa de transicioacuten entre
el envejecimiento y la demencia
(especialmente demencia por AD)
Los criterios revisados para DCL
1) Cambio en la cognicioacuten reconocida
por el individuo o los observadores
del afectado
2) Deterioro objetivo en uno o maacutes
dominios cognitivos
3) Independencia en las actividades
funcionales
4) Ausencia de demenciaArch Neurol 2012 June 69(6) 700ndash708Revised Criteria for Mild Cognitive
Impairment May Compromise the Diagnosis of Alzheimer Disease DementiaJohn
C Morris MD
Criterios de Petersen
DLC ndash Clasificacioacuten de la funcioacuten cognitiva
bull Enfermedad de AlzheimerDCL
Amneacutesico
bull Enfermedad de Alzheimer
bull Envejecimiento normal
DCL muacuteltiple dominio
bull D Frontotemporal
bull Demencia C Lewy
bull Demencia vascular
bull Demencia Alzheimer
DCL dominio uacutenico no memoria
Ann Neurol 2008 April 63(4) 494ndash506Frequency and Course of Mild
Cognitive Impairment in a Multiethnic Community
10517 personasantildeos
21 de Sano a DLC
(Incidencia anual = 51 95
CI = 46ndash56)
218 de DCL a AD
(Incidencia anual = 54 95
CI = 47ndash63)
47 permanecioacute sin cambios
y 31 revertioacute a normal
Aquellos con MCI tuvieron 28
veces mas probabilidad de
desarrollar AD comparado con
ancianos normales
MCI con alteracioacuten de la
memoria y al menos otro
dominio cognitivo se asocioacute
con mayor riesgo de AD
Queja cognitiva referida por el paciente o conviviente
Deterioro en uno o mas dominios cognitivos comparado por
edadnivel educacional El deacuteficit en memoria episoacutedica (la habilidad
para aprender y retener nueva informacioacuten) es el dominio mas
afectado en DLC de los pacientes que progresan a AD
Independencia en AVD pero puede existir compromiso en
actividades complejas como manejo de dinero cocinar y
comprar las cuales pueden llevar mas tiempo ser menos
eficientes o mas errores al realizarlas
Alzheimers Dement 2011 May 7(3) 270ndash279
The diagnosis of mild cognitive impairment due to Alzheimerrsquos diseaserecommendations from the National
Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for Alzheimerrsquos disease
Arch Gen Psychiatry 2011 June 68(6) 617ndash626
Functional impairment in elderly patients with mild cognitive impairment and mild Alzheimers disease
Deterioro Cognitivo Leve
Actividades Instrumentales
de la vida diaria Nuevos criterios para el deterioro cognitivo leve
Revisioacuten retrospectiva de 17535 pacientes con la cognicioacuten normal DCL o Demencia AD evaluados en los Centros de la Enfermedad de Alzheimer
Casi todos ( 998 ) de los pacientes con diagnoacutestico de Demencia AD muy leve y la gran mayoriacutea ( 927 ) con diagnostico de Demencia leve AD pueden ser reclasificados como DCL con los criterios revisados
Arch Neurol 2012 June 69(6) 700ndash708
Revised Criteria for Mild Cognitive Impairment May Compromise the Diagnosis of Alzheimer Disease Dementia
Deacuteficit AIVD DLC amneacutesico vs no amneacutesico
Dement Geriatr Cogn Disord 2010 November 30(3) 189ndash197
Subtle Deficits in Instrumental Activities of Daily Living in Subtypes of Mild Cognitive Impairment
Trastornos conductuales en DCL
Estudio InDDEX (n=1000) con dg de DLC 59 presentoacute alguacuten
trastorno neuropsiquiaacutetrico
(depresioacuten ansiedad apatiacutea irritabilidad) Estos pacientes
exhibiacutean mayor alteracioacuten cognitiva y funcional que aquellos
que no teniacutean trastornos de conducta asociados
Feldman H Scheltens P Scarpini E Hermann N Mesenbrink P Mancione L et al
Behavioral symptoms in mild cognitive impairment Neurology 2004621199- 201
Estudio grupo UCLA (n=51) seguimiento 23 meses demostroacute
que los siacutentomas neuropsiquiaacutetricos (NPI) como depresioacuten y
apatiacutea se asocian a mayor riesgo de conversioacuten
Teng E Lu PH Cummings JL Neuropsychiatric symptoms are associated with
progression from mild cog- nitive impairment to Alzheimerrsquos disease Dement Geriatr
Cogn Disord 200724253-9
DLC
Mayo Clinic criteria para DLC amneacutesico deacuteficit y queja cognitiva
International Working Group deacuteficit objetivo y subjetivo de cualquier
dominio
Clinical Dementia Rating (CDR) focaliza en declinacioacuten cognitiva en las funciones de la vida diaria mas que en el deacuteficit cognitivo objetivo
Hipoacutetesis la prevalencia de DCL varia considerablemente seguacuten la definicioacuten
Estudios de
cohorte
indican al igual
que estudios
previos que el
DCL es una
entidad
heterogeacutenea a
nivel de
poblacioacuten
Arch Neurol 2011 June 68(6) 761ndash767
Outcomes of mild cognitive impairment depend on definition a
population study
Olvidos leves constantes
Orientado pero con leve dificultad
para las relaciones temporales
Leve dificultad para resolver
problemas similitudes y diferencias
Leve dificultad en las actividades
fuera de la casa
Aficiones e intereses intelectuales
algo limitados
Capaz de cuidarse por si mismo
Detection of Dementia Page 4
age-associated cognitive decline (AACD) have been used They are distinct from the concept of mild cognitive
impairment as used in the current article Age-associated memory impairment refers to the concept of increasing memory
impairment with age and references memory function in the elderly cohort to young normal adult subjects As such there
can be an overinclusion of neurologically normal individuals in this concept and it has been critiqued as such13 Age-
associated cognitive decline refers to the concept of mild impairments in multiple cognitive domains but not of sufficient
severity to constitute the diagnosis of dementia This is a useful concept however few longitudinal studies have been
conducted using this nomenclature and this classification scheme also includes many normal elderly persons Each of
these terms either includes a segment of the normal population and represents extremes of normal aging andor is more
inclusive than the current definition of mild cognitive impairment As such they are not directly germane to the current
discussion Individuals with mild cognitive impairment meet criteria similar to those shown in table 1 There are
differences in the literature with respect to the sources of subjects age education and criteria but a general pattern of
clinical progression has emerged These studies are summarized in table 5 The conversion criteria refer to either the
development of dementia or AD
Table 5 Studies demonstrating outcome of persons with mild cognitive impairment (MCI) or similar condition
Study
Subjects
no
Mean age
y Source Criteria
Duration
follow-
up y
Annual
conversion
rate to
dementia or
AD Class
Mayo2 66 81 Community practice MCI 4 12 II
Toronto1415 107 74 Family practice Memory impairment 2 14 II
Columbia16 127 66 Memory disorders clinic Questionable dementia 27 15 II
MGH17 123 72 Community advertising CDR 05 3 6 II
Seattle18 21 74 Health Maintenance
Organization
Isolated memory loss 38 12 III
NYU19 32 71 Dementia clinic GDS 3 22 25 III CDR = Clinical Dementia Rating GDS = Global Deterioration Scale
In a Class II US study from the Mayo Clinicrsquos longitudinal study of aging and dementia subjects were recruited
from a primary care practice which served the residents of Rochester MN2 Subjects were enrolled if they expressed a
concern about their cognitive function a family member appreciated a change in cognitive function or the primary care
physician indicated a concern These were community-dwelling individuals and the mean age at the time of enrollment
was 81 years The subjects were classified as having mild cognitive impairment if they met criteria similar to those shown
in table 1 When the subjects were followed for up to 4 years they converted to AD at a rate of 12 per year2 By 6 years
approximately 80 of the individuals had developed AD10
In another Class II Canadian study from a similar setting in Toronto 107 subjects with a memory impairment without
dementia were followed for 2 years1415 Subjects were referred to the study by family physicians and the mean age of the
subjects was 74 years During the 2-year follow-up 29 (approximately 28) developed AD for an approximate annual
conversion rate of 14
A Class II US study exploring the natural history of subjects from a memory disorders clinic at Columbia University
evaluated 127 consecutive subjects with questionable dementia However these subjects did not meet criteria for
dementia16 This group represented subjects seen in a referral setting with a mean age of 66 years Approximately 40 of
the subjects were not followed for various reasons During the course of 27 years 413 of the subjects who were
followed became demented for an annual conversion rate of approximately 15
In a recent US Class II study from Massachusetts General Hospital persons were recruited from the community
through media advertisements17 A total of 123 persons with a Clinical Dementia Rating (CDR) of 05 (questionable
dementia) were followed for 3 years During this time frame 23 individuals converted to probable AD for an annual rate
of approximately 6
In a US Class III study from a large health maintenance organization in Seattle a group of memory impaired
subjects were followed18 Of 811 subjects with a mean age of 74 years who had been recruited through a registry for
cognitive complaints 21 subjects with a severe isolated memory loss were followed for a mean of 48 months During this
time period 48 developed dementia for an annual conversion rate of approximately 12 per year
Investigators at New York University in a Class III study using the Global Deterioration Scale as a measure to assess
impairment followed individuals with a Global Deterioration Scale rating of 3 which represented mild cognitive
impairment for these investigators19 They found that 16 of 32 of these individuals had progressed to a diagnosis of AD
over 22 years (25 per year)19 and concluded that mild cognitive impairment was a risk factor for subsequent
development of dementia
Conclusions Taken together these studies indicate that individuals characterized as being cognitively impaired but
not meeting clinical criteria for dementia or AD (mild cognitive impairment) have a high risk of progressing to dementia
or AD If the figures for incident AD from the general population are used from table 4 one can see that the rates range
by on August 22 2010 wwwneurologyorgDownloaded from
Factores de riesgo de conversioacuten
ldquoReserva Funcionalrdquo
Baja escolaridad
Menor nivel intelectual
Edad
Inactividad laboral
Bajo nivel cultural
Estudio longitudinal de una poblacioacuten en riesgo de demenciaSeguimiento 50 mesesAllegri
No todo DCL evoluciona a demencia la bibliografiacutea reporta desde un12 a un 2 Los pacientes que presentariacutean mayor riesgo seriacutean losque presentan afeccioacuten de la memoria mas otro dominio
In various studies a substantial percentage (11 to 40) of patients with MCIimprove even to normal over a one to three-year follow-up time
Faltariacutea aun el punto de corte de normalidad y anormalidad
Descartar depresioacuten
La persistencia de los cambios en evaluaciones sucesivas
En el DLC puede existir dependencia parcial en AIVD
El diagnostico de DCL es cliacutenico cognitivo y funcional
Llamadas de atencioacuten en el perfil neuropsicoloacutegico
Fallas en la memoria episoacutedica semaacutentica (estrategia de asociacioacuten semaacutentica en elaprendizaje de palabras) y diferida
Presencia de intrusiones (produccioacuten equivocada del nombre de un objeto) A mayornumero de intrusiones mayor riesgo de AD
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
Caso Cliacutenico Mujer de 81 antildeos que concurre para Valoracioacuten Geriaacutetrica Integral derivada por
su medico de cabecera por trastornos mneacutesicos Recibe Donepecilo por ldquoolvidosrdquo desde hace 2 antildeos
Olvidos citas nombres y nuacutemeros de teleacutefono
Orientada en tiempo y espacio Concurre sin acompantildeante niega episodios de desorientacioacuten sin antecedentes familiares de enfermedad neurocognitiva
Antecedentes HTA (Losartan 50mg diacutea)
Ultima TAC y laboratorio completo normales
ACE 81100 (86 punto corte)
MMT 2330 (escolaridad secundaria completa)
Independiente para AVD
Parcialmente dependiente para el manejo de dinero (la controla la hija)
Preguntas
iquestDeterioro Cognitivo Leve (DCL) vs anciano
sano
iquestUtilidad de medidas de estimulacioacuten cognitiva
en DCL
iquestReevaluacioacuten de progresividad
iquestInicio de medicacioacuten antidemencial en DLC
ldquoContinuumrdquo del rendimiento
cognitivo
DCLDemenciaNormalidad
Zona gris Zona gris
Deterioro Cognitivo Leve DLC Siacutendrome amneacutesico que
denota una etapa de transicioacuten entre
el envejecimiento y la demencia
(especialmente demencia por AD)
Los criterios revisados para DCL
1) Cambio en la cognicioacuten reconocida
por el individuo o los observadores
del afectado
2) Deterioro objetivo en uno o maacutes
dominios cognitivos
3) Independencia en las actividades
funcionales
4) Ausencia de demenciaArch Neurol 2012 June 69(6) 700ndash708Revised Criteria for Mild Cognitive
Impairment May Compromise the Diagnosis of Alzheimer Disease DementiaJohn
C Morris MD
Criterios de Petersen
DLC ndash Clasificacioacuten de la funcioacuten cognitiva
bull Enfermedad de AlzheimerDCL
Amneacutesico
bull Enfermedad de Alzheimer
bull Envejecimiento normal
DCL muacuteltiple dominio
bull D Frontotemporal
bull Demencia C Lewy
bull Demencia vascular
bull Demencia Alzheimer
DCL dominio uacutenico no memoria
Ann Neurol 2008 April 63(4) 494ndash506Frequency and Course of Mild
Cognitive Impairment in a Multiethnic Community
10517 personasantildeos
21 de Sano a DLC
(Incidencia anual = 51 95
CI = 46ndash56)
218 de DCL a AD
(Incidencia anual = 54 95
CI = 47ndash63)
47 permanecioacute sin cambios
y 31 revertioacute a normal
Aquellos con MCI tuvieron 28
veces mas probabilidad de
desarrollar AD comparado con
ancianos normales
MCI con alteracioacuten de la
memoria y al menos otro
dominio cognitivo se asocioacute
con mayor riesgo de AD
Queja cognitiva referida por el paciente o conviviente
Deterioro en uno o mas dominios cognitivos comparado por
edadnivel educacional El deacuteficit en memoria episoacutedica (la habilidad
para aprender y retener nueva informacioacuten) es el dominio mas
afectado en DLC de los pacientes que progresan a AD
Independencia en AVD pero puede existir compromiso en
actividades complejas como manejo de dinero cocinar y
comprar las cuales pueden llevar mas tiempo ser menos
eficientes o mas errores al realizarlas
Alzheimers Dement 2011 May 7(3) 270ndash279
The diagnosis of mild cognitive impairment due to Alzheimerrsquos diseaserecommendations from the National
Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for Alzheimerrsquos disease
Arch Gen Psychiatry 2011 June 68(6) 617ndash626
Functional impairment in elderly patients with mild cognitive impairment and mild Alzheimers disease
Deterioro Cognitivo Leve
Actividades Instrumentales
de la vida diaria Nuevos criterios para el deterioro cognitivo leve
Revisioacuten retrospectiva de 17535 pacientes con la cognicioacuten normal DCL o Demencia AD evaluados en los Centros de la Enfermedad de Alzheimer
Casi todos ( 998 ) de los pacientes con diagnoacutestico de Demencia AD muy leve y la gran mayoriacutea ( 927 ) con diagnostico de Demencia leve AD pueden ser reclasificados como DCL con los criterios revisados
Arch Neurol 2012 June 69(6) 700ndash708
Revised Criteria for Mild Cognitive Impairment May Compromise the Diagnosis of Alzheimer Disease Dementia
Deacuteficit AIVD DLC amneacutesico vs no amneacutesico
Dement Geriatr Cogn Disord 2010 November 30(3) 189ndash197
Subtle Deficits in Instrumental Activities of Daily Living in Subtypes of Mild Cognitive Impairment
Trastornos conductuales en DCL
Estudio InDDEX (n=1000) con dg de DLC 59 presentoacute alguacuten
trastorno neuropsiquiaacutetrico
(depresioacuten ansiedad apatiacutea irritabilidad) Estos pacientes
exhibiacutean mayor alteracioacuten cognitiva y funcional que aquellos
que no teniacutean trastornos de conducta asociados
Feldman H Scheltens P Scarpini E Hermann N Mesenbrink P Mancione L et al
Behavioral symptoms in mild cognitive impairment Neurology 2004621199- 201
Estudio grupo UCLA (n=51) seguimiento 23 meses demostroacute
que los siacutentomas neuropsiquiaacutetricos (NPI) como depresioacuten y
apatiacutea se asocian a mayor riesgo de conversioacuten
Teng E Lu PH Cummings JL Neuropsychiatric symptoms are associated with
progression from mild cog- nitive impairment to Alzheimerrsquos disease Dement Geriatr
Cogn Disord 200724253-9
DLC
Mayo Clinic criteria para DLC amneacutesico deacuteficit y queja cognitiva
International Working Group deacuteficit objetivo y subjetivo de cualquier
dominio
Clinical Dementia Rating (CDR) focaliza en declinacioacuten cognitiva en las funciones de la vida diaria mas que en el deacuteficit cognitivo objetivo
Hipoacutetesis la prevalencia de DCL varia considerablemente seguacuten la definicioacuten
Estudios de
cohorte
indican al igual
que estudios
previos que el
DCL es una
entidad
heterogeacutenea a
nivel de
poblacioacuten
Arch Neurol 2011 June 68(6) 761ndash767
Outcomes of mild cognitive impairment depend on definition a
population study
Olvidos leves constantes
Orientado pero con leve dificultad
para las relaciones temporales
Leve dificultad para resolver
problemas similitudes y diferencias
Leve dificultad en las actividades
fuera de la casa
Aficiones e intereses intelectuales
algo limitados
Capaz de cuidarse por si mismo
Detection of Dementia Page 4
age-associated cognitive decline (AACD) have been used They are distinct from the concept of mild cognitive
impairment as used in the current article Age-associated memory impairment refers to the concept of increasing memory
impairment with age and references memory function in the elderly cohort to young normal adult subjects As such there
can be an overinclusion of neurologically normal individuals in this concept and it has been critiqued as such13 Age-
associated cognitive decline refers to the concept of mild impairments in multiple cognitive domains but not of sufficient
severity to constitute the diagnosis of dementia This is a useful concept however few longitudinal studies have been
conducted using this nomenclature and this classification scheme also includes many normal elderly persons Each of
these terms either includes a segment of the normal population and represents extremes of normal aging andor is more
inclusive than the current definition of mild cognitive impairment As such they are not directly germane to the current
discussion Individuals with mild cognitive impairment meet criteria similar to those shown in table 1 There are
differences in the literature with respect to the sources of subjects age education and criteria but a general pattern of
clinical progression has emerged These studies are summarized in table 5 The conversion criteria refer to either the
development of dementia or AD
Table 5 Studies demonstrating outcome of persons with mild cognitive impairment (MCI) or similar condition
Study
Subjects
no
Mean age
y Source Criteria
Duration
follow-
up y
Annual
conversion
rate to
dementia or
AD Class
Mayo2 66 81 Community practice MCI 4 12 II
Toronto1415 107 74 Family practice Memory impairment 2 14 II
Columbia16 127 66 Memory disorders clinic Questionable dementia 27 15 II
MGH17 123 72 Community advertising CDR 05 3 6 II
Seattle18 21 74 Health Maintenance
Organization
Isolated memory loss 38 12 III
NYU19 32 71 Dementia clinic GDS 3 22 25 III CDR = Clinical Dementia Rating GDS = Global Deterioration Scale
In a Class II US study from the Mayo Clinicrsquos longitudinal study of aging and dementia subjects were recruited
from a primary care practice which served the residents of Rochester MN2 Subjects were enrolled if they expressed a
concern about their cognitive function a family member appreciated a change in cognitive function or the primary care
physician indicated a concern These were community-dwelling individuals and the mean age at the time of enrollment
was 81 years The subjects were classified as having mild cognitive impairment if they met criteria similar to those shown
in table 1 When the subjects were followed for up to 4 years they converted to AD at a rate of 12 per year2 By 6 years
approximately 80 of the individuals had developed AD10
In another Class II Canadian study from a similar setting in Toronto 107 subjects with a memory impairment without
dementia were followed for 2 years1415 Subjects were referred to the study by family physicians and the mean age of the
subjects was 74 years During the 2-year follow-up 29 (approximately 28) developed AD for an approximate annual
conversion rate of 14
A Class II US study exploring the natural history of subjects from a memory disorders clinic at Columbia University
evaluated 127 consecutive subjects with questionable dementia However these subjects did not meet criteria for
dementia16 This group represented subjects seen in a referral setting with a mean age of 66 years Approximately 40 of
the subjects were not followed for various reasons During the course of 27 years 413 of the subjects who were
followed became demented for an annual conversion rate of approximately 15
In a recent US Class II study from Massachusetts General Hospital persons were recruited from the community
through media advertisements17 A total of 123 persons with a Clinical Dementia Rating (CDR) of 05 (questionable
dementia) were followed for 3 years During this time frame 23 individuals converted to probable AD for an annual rate
of approximately 6
In a US Class III study from a large health maintenance organization in Seattle a group of memory impaired
subjects were followed18 Of 811 subjects with a mean age of 74 years who had been recruited through a registry for
cognitive complaints 21 subjects with a severe isolated memory loss were followed for a mean of 48 months During this
time period 48 developed dementia for an annual conversion rate of approximately 12 per year
Investigators at New York University in a Class III study using the Global Deterioration Scale as a measure to assess
impairment followed individuals with a Global Deterioration Scale rating of 3 which represented mild cognitive
impairment for these investigators19 They found that 16 of 32 of these individuals had progressed to a diagnosis of AD
over 22 years (25 per year)19 and concluded that mild cognitive impairment was a risk factor for subsequent
development of dementia
Conclusions Taken together these studies indicate that individuals characterized as being cognitively impaired but
not meeting clinical criteria for dementia or AD (mild cognitive impairment) have a high risk of progressing to dementia
or AD If the figures for incident AD from the general population are used from table 4 one can see that the rates range
by on August 22 2010 wwwneurologyorgDownloaded from
Factores de riesgo de conversioacuten
ldquoReserva Funcionalrdquo
Baja escolaridad
Menor nivel intelectual
Edad
Inactividad laboral
Bajo nivel cultural
Estudio longitudinal de una poblacioacuten en riesgo de demenciaSeguimiento 50 mesesAllegri
No todo DCL evoluciona a demencia la bibliografiacutea reporta desde un12 a un 2 Los pacientes que presentariacutean mayor riesgo seriacutean losque presentan afeccioacuten de la memoria mas otro dominio
In various studies a substantial percentage (11 to 40) of patients with MCIimprove even to normal over a one to three-year follow-up time
Faltariacutea aun el punto de corte de normalidad y anormalidad
Descartar depresioacuten
La persistencia de los cambios en evaluaciones sucesivas
En el DLC puede existir dependencia parcial en AIVD
El diagnostico de DCL es cliacutenico cognitivo y funcional
Llamadas de atencioacuten en el perfil neuropsicoloacutegico
Fallas en la memoria episoacutedica semaacutentica (estrategia de asociacioacuten semaacutentica en elaprendizaje de palabras) y diferida
Presencia de intrusiones (produccioacuten equivocada del nombre de un objeto) A mayornumero de intrusiones mayor riesgo de AD
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
Preguntas
iquestDeterioro Cognitivo Leve (DCL) vs anciano
sano
iquestUtilidad de medidas de estimulacioacuten cognitiva
en DCL
iquestReevaluacioacuten de progresividad
iquestInicio de medicacioacuten antidemencial en DLC
ldquoContinuumrdquo del rendimiento
cognitivo
DCLDemenciaNormalidad
Zona gris Zona gris
Deterioro Cognitivo Leve DLC Siacutendrome amneacutesico que
denota una etapa de transicioacuten entre
el envejecimiento y la demencia
(especialmente demencia por AD)
Los criterios revisados para DCL
1) Cambio en la cognicioacuten reconocida
por el individuo o los observadores
del afectado
2) Deterioro objetivo en uno o maacutes
dominios cognitivos
3) Independencia en las actividades
funcionales
4) Ausencia de demenciaArch Neurol 2012 June 69(6) 700ndash708Revised Criteria for Mild Cognitive
Impairment May Compromise the Diagnosis of Alzheimer Disease DementiaJohn
C Morris MD
Criterios de Petersen
DLC ndash Clasificacioacuten de la funcioacuten cognitiva
bull Enfermedad de AlzheimerDCL
Amneacutesico
bull Enfermedad de Alzheimer
bull Envejecimiento normal
DCL muacuteltiple dominio
bull D Frontotemporal
bull Demencia C Lewy
bull Demencia vascular
bull Demencia Alzheimer
DCL dominio uacutenico no memoria
Ann Neurol 2008 April 63(4) 494ndash506Frequency and Course of Mild
Cognitive Impairment in a Multiethnic Community
10517 personasantildeos
21 de Sano a DLC
(Incidencia anual = 51 95
CI = 46ndash56)
218 de DCL a AD
(Incidencia anual = 54 95
CI = 47ndash63)
47 permanecioacute sin cambios
y 31 revertioacute a normal
Aquellos con MCI tuvieron 28
veces mas probabilidad de
desarrollar AD comparado con
ancianos normales
MCI con alteracioacuten de la
memoria y al menos otro
dominio cognitivo se asocioacute
con mayor riesgo de AD
Queja cognitiva referida por el paciente o conviviente
Deterioro en uno o mas dominios cognitivos comparado por
edadnivel educacional El deacuteficit en memoria episoacutedica (la habilidad
para aprender y retener nueva informacioacuten) es el dominio mas
afectado en DLC de los pacientes que progresan a AD
Independencia en AVD pero puede existir compromiso en
actividades complejas como manejo de dinero cocinar y
comprar las cuales pueden llevar mas tiempo ser menos
eficientes o mas errores al realizarlas
Alzheimers Dement 2011 May 7(3) 270ndash279
The diagnosis of mild cognitive impairment due to Alzheimerrsquos diseaserecommendations from the National
Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for Alzheimerrsquos disease
Arch Gen Psychiatry 2011 June 68(6) 617ndash626
Functional impairment in elderly patients with mild cognitive impairment and mild Alzheimers disease
Deterioro Cognitivo Leve
Actividades Instrumentales
de la vida diaria Nuevos criterios para el deterioro cognitivo leve
Revisioacuten retrospectiva de 17535 pacientes con la cognicioacuten normal DCL o Demencia AD evaluados en los Centros de la Enfermedad de Alzheimer
Casi todos ( 998 ) de los pacientes con diagnoacutestico de Demencia AD muy leve y la gran mayoriacutea ( 927 ) con diagnostico de Demencia leve AD pueden ser reclasificados como DCL con los criterios revisados
Arch Neurol 2012 June 69(6) 700ndash708
Revised Criteria for Mild Cognitive Impairment May Compromise the Diagnosis of Alzheimer Disease Dementia
Deacuteficit AIVD DLC amneacutesico vs no amneacutesico
Dement Geriatr Cogn Disord 2010 November 30(3) 189ndash197
Subtle Deficits in Instrumental Activities of Daily Living in Subtypes of Mild Cognitive Impairment
Trastornos conductuales en DCL
Estudio InDDEX (n=1000) con dg de DLC 59 presentoacute alguacuten
trastorno neuropsiquiaacutetrico
(depresioacuten ansiedad apatiacutea irritabilidad) Estos pacientes
exhibiacutean mayor alteracioacuten cognitiva y funcional que aquellos
que no teniacutean trastornos de conducta asociados
Feldman H Scheltens P Scarpini E Hermann N Mesenbrink P Mancione L et al
Behavioral symptoms in mild cognitive impairment Neurology 2004621199- 201
Estudio grupo UCLA (n=51) seguimiento 23 meses demostroacute
que los siacutentomas neuropsiquiaacutetricos (NPI) como depresioacuten y
apatiacutea se asocian a mayor riesgo de conversioacuten
Teng E Lu PH Cummings JL Neuropsychiatric symptoms are associated with
progression from mild cog- nitive impairment to Alzheimerrsquos disease Dement Geriatr
Cogn Disord 200724253-9
DLC
Mayo Clinic criteria para DLC amneacutesico deacuteficit y queja cognitiva
International Working Group deacuteficit objetivo y subjetivo de cualquier
dominio
Clinical Dementia Rating (CDR) focaliza en declinacioacuten cognitiva en las funciones de la vida diaria mas que en el deacuteficit cognitivo objetivo
Hipoacutetesis la prevalencia de DCL varia considerablemente seguacuten la definicioacuten
Estudios de
cohorte
indican al igual
que estudios
previos que el
DCL es una
entidad
heterogeacutenea a
nivel de
poblacioacuten
Arch Neurol 2011 June 68(6) 761ndash767
Outcomes of mild cognitive impairment depend on definition a
population study
Olvidos leves constantes
Orientado pero con leve dificultad
para las relaciones temporales
Leve dificultad para resolver
problemas similitudes y diferencias
Leve dificultad en las actividades
fuera de la casa
Aficiones e intereses intelectuales
algo limitados
Capaz de cuidarse por si mismo
Detection of Dementia Page 4
age-associated cognitive decline (AACD) have been used They are distinct from the concept of mild cognitive
impairment as used in the current article Age-associated memory impairment refers to the concept of increasing memory
impairment with age and references memory function in the elderly cohort to young normal adult subjects As such there
can be an overinclusion of neurologically normal individuals in this concept and it has been critiqued as such13 Age-
associated cognitive decline refers to the concept of mild impairments in multiple cognitive domains but not of sufficient
severity to constitute the diagnosis of dementia This is a useful concept however few longitudinal studies have been
conducted using this nomenclature and this classification scheme also includes many normal elderly persons Each of
these terms either includes a segment of the normal population and represents extremes of normal aging andor is more
inclusive than the current definition of mild cognitive impairment As such they are not directly germane to the current
discussion Individuals with mild cognitive impairment meet criteria similar to those shown in table 1 There are
differences in the literature with respect to the sources of subjects age education and criteria but a general pattern of
clinical progression has emerged These studies are summarized in table 5 The conversion criteria refer to either the
development of dementia or AD
Table 5 Studies demonstrating outcome of persons with mild cognitive impairment (MCI) or similar condition
Study
Subjects
no
Mean age
y Source Criteria
Duration
follow-
up y
Annual
conversion
rate to
dementia or
AD Class
Mayo2 66 81 Community practice MCI 4 12 II
Toronto1415 107 74 Family practice Memory impairment 2 14 II
Columbia16 127 66 Memory disorders clinic Questionable dementia 27 15 II
MGH17 123 72 Community advertising CDR 05 3 6 II
Seattle18 21 74 Health Maintenance
Organization
Isolated memory loss 38 12 III
NYU19 32 71 Dementia clinic GDS 3 22 25 III CDR = Clinical Dementia Rating GDS = Global Deterioration Scale
In a Class II US study from the Mayo Clinicrsquos longitudinal study of aging and dementia subjects were recruited
from a primary care practice which served the residents of Rochester MN2 Subjects were enrolled if they expressed a
concern about their cognitive function a family member appreciated a change in cognitive function or the primary care
physician indicated a concern These were community-dwelling individuals and the mean age at the time of enrollment
was 81 years The subjects were classified as having mild cognitive impairment if they met criteria similar to those shown
in table 1 When the subjects were followed for up to 4 years they converted to AD at a rate of 12 per year2 By 6 years
approximately 80 of the individuals had developed AD10
In another Class II Canadian study from a similar setting in Toronto 107 subjects with a memory impairment without
dementia were followed for 2 years1415 Subjects were referred to the study by family physicians and the mean age of the
subjects was 74 years During the 2-year follow-up 29 (approximately 28) developed AD for an approximate annual
conversion rate of 14
A Class II US study exploring the natural history of subjects from a memory disorders clinic at Columbia University
evaluated 127 consecutive subjects with questionable dementia However these subjects did not meet criteria for
dementia16 This group represented subjects seen in a referral setting with a mean age of 66 years Approximately 40 of
the subjects were not followed for various reasons During the course of 27 years 413 of the subjects who were
followed became demented for an annual conversion rate of approximately 15
In a recent US Class II study from Massachusetts General Hospital persons were recruited from the community
through media advertisements17 A total of 123 persons with a Clinical Dementia Rating (CDR) of 05 (questionable
dementia) were followed for 3 years During this time frame 23 individuals converted to probable AD for an annual rate
of approximately 6
In a US Class III study from a large health maintenance organization in Seattle a group of memory impaired
subjects were followed18 Of 811 subjects with a mean age of 74 years who had been recruited through a registry for
cognitive complaints 21 subjects with a severe isolated memory loss were followed for a mean of 48 months During this
time period 48 developed dementia for an annual conversion rate of approximately 12 per year
Investigators at New York University in a Class III study using the Global Deterioration Scale as a measure to assess
impairment followed individuals with a Global Deterioration Scale rating of 3 which represented mild cognitive
impairment for these investigators19 They found that 16 of 32 of these individuals had progressed to a diagnosis of AD
over 22 years (25 per year)19 and concluded that mild cognitive impairment was a risk factor for subsequent
development of dementia
Conclusions Taken together these studies indicate that individuals characterized as being cognitively impaired but
not meeting clinical criteria for dementia or AD (mild cognitive impairment) have a high risk of progressing to dementia
or AD If the figures for incident AD from the general population are used from table 4 one can see that the rates range
by on August 22 2010 wwwneurologyorgDownloaded from
Factores de riesgo de conversioacuten
ldquoReserva Funcionalrdquo
Baja escolaridad
Menor nivel intelectual
Edad
Inactividad laboral
Bajo nivel cultural
Estudio longitudinal de una poblacioacuten en riesgo de demenciaSeguimiento 50 mesesAllegri
No todo DCL evoluciona a demencia la bibliografiacutea reporta desde un12 a un 2 Los pacientes que presentariacutean mayor riesgo seriacutean losque presentan afeccioacuten de la memoria mas otro dominio
In various studies a substantial percentage (11 to 40) of patients with MCIimprove even to normal over a one to three-year follow-up time
Faltariacutea aun el punto de corte de normalidad y anormalidad
Descartar depresioacuten
La persistencia de los cambios en evaluaciones sucesivas
En el DLC puede existir dependencia parcial en AIVD
El diagnostico de DCL es cliacutenico cognitivo y funcional
Llamadas de atencioacuten en el perfil neuropsicoloacutegico
Fallas en la memoria episoacutedica semaacutentica (estrategia de asociacioacuten semaacutentica en elaprendizaje de palabras) y diferida
Presencia de intrusiones (produccioacuten equivocada del nombre de un objeto) A mayornumero de intrusiones mayor riesgo de AD
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
ldquoContinuumrdquo del rendimiento
cognitivo
DCLDemenciaNormalidad
Zona gris Zona gris
Deterioro Cognitivo Leve DLC Siacutendrome amneacutesico que
denota una etapa de transicioacuten entre
el envejecimiento y la demencia
(especialmente demencia por AD)
Los criterios revisados para DCL
1) Cambio en la cognicioacuten reconocida
por el individuo o los observadores
del afectado
2) Deterioro objetivo en uno o maacutes
dominios cognitivos
3) Independencia en las actividades
funcionales
4) Ausencia de demenciaArch Neurol 2012 June 69(6) 700ndash708Revised Criteria for Mild Cognitive
Impairment May Compromise the Diagnosis of Alzheimer Disease DementiaJohn
C Morris MD
Criterios de Petersen
DLC ndash Clasificacioacuten de la funcioacuten cognitiva
bull Enfermedad de AlzheimerDCL
Amneacutesico
bull Enfermedad de Alzheimer
bull Envejecimiento normal
DCL muacuteltiple dominio
bull D Frontotemporal
bull Demencia C Lewy
bull Demencia vascular
bull Demencia Alzheimer
DCL dominio uacutenico no memoria
Ann Neurol 2008 April 63(4) 494ndash506Frequency and Course of Mild
Cognitive Impairment in a Multiethnic Community
10517 personasantildeos
21 de Sano a DLC
(Incidencia anual = 51 95
CI = 46ndash56)
218 de DCL a AD
(Incidencia anual = 54 95
CI = 47ndash63)
47 permanecioacute sin cambios
y 31 revertioacute a normal
Aquellos con MCI tuvieron 28
veces mas probabilidad de
desarrollar AD comparado con
ancianos normales
MCI con alteracioacuten de la
memoria y al menos otro
dominio cognitivo se asocioacute
con mayor riesgo de AD
Queja cognitiva referida por el paciente o conviviente
Deterioro en uno o mas dominios cognitivos comparado por
edadnivel educacional El deacuteficit en memoria episoacutedica (la habilidad
para aprender y retener nueva informacioacuten) es el dominio mas
afectado en DLC de los pacientes que progresan a AD
Independencia en AVD pero puede existir compromiso en
actividades complejas como manejo de dinero cocinar y
comprar las cuales pueden llevar mas tiempo ser menos
eficientes o mas errores al realizarlas
Alzheimers Dement 2011 May 7(3) 270ndash279
The diagnosis of mild cognitive impairment due to Alzheimerrsquos diseaserecommendations from the National
Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for Alzheimerrsquos disease
Arch Gen Psychiatry 2011 June 68(6) 617ndash626
Functional impairment in elderly patients with mild cognitive impairment and mild Alzheimers disease
Deterioro Cognitivo Leve
Actividades Instrumentales
de la vida diaria Nuevos criterios para el deterioro cognitivo leve
Revisioacuten retrospectiva de 17535 pacientes con la cognicioacuten normal DCL o Demencia AD evaluados en los Centros de la Enfermedad de Alzheimer
Casi todos ( 998 ) de los pacientes con diagnoacutestico de Demencia AD muy leve y la gran mayoriacutea ( 927 ) con diagnostico de Demencia leve AD pueden ser reclasificados como DCL con los criterios revisados
Arch Neurol 2012 June 69(6) 700ndash708
Revised Criteria for Mild Cognitive Impairment May Compromise the Diagnosis of Alzheimer Disease Dementia
Deacuteficit AIVD DLC amneacutesico vs no amneacutesico
Dement Geriatr Cogn Disord 2010 November 30(3) 189ndash197
Subtle Deficits in Instrumental Activities of Daily Living in Subtypes of Mild Cognitive Impairment
Trastornos conductuales en DCL
Estudio InDDEX (n=1000) con dg de DLC 59 presentoacute alguacuten
trastorno neuropsiquiaacutetrico
(depresioacuten ansiedad apatiacutea irritabilidad) Estos pacientes
exhibiacutean mayor alteracioacuten cognitiva y funcional que aquellos
que no teniacutean trastornos de conducta asociados
Feldman H Scheltens P Scarpini E Hermann N Mesenbrink P Mancione L et al
Behavioral symptoms in mild cognitive impairment Neurology 2004621199- 201
Estudio grupo UCLA (n=51) seguimiento 23 meses demostroacute
que los siacutentomas neuropsiquiaacutetricos (NPI) como depresioacuten y
apatiacutea se asocian a mayor riesgo de conversioacuten
Teng E Lu PH Cummings JL Neuropsychiatric symptoms are associated with
progression from mild cog- nitive impairment to Alzheimerrsquos disease Dement Geriatr
Cogn Disord 200724253-9
DLC
Mayo Clinic criteria para DLC amneacutesico deacuteficit y queja cognitiva
International Working Group deacuteficit objetivo y subjetivo de cualquier
dominio
Clinical Dementia Rating (CDR) focaliza en declinacioacuten cognitiva en las funciones de la vida diaria mas que en el deacuteficit cognitivo objetivo
Hipoacutetesis la prevalencia de DCL varia considerablemente seguacuten la definicioacuten
Estudios de
cohorte
indican al igual
que estudios
previos que el
DCL es una
entidad
heterogeacutenea a
nivel de
poblacioacuten
Arch Neurol 2011 June 68(6) 761ndash767
Outcomes of mild cognitive impairment depend on definition a
population study
Olvidos leves constantes
Orientado pero con leve dificultad
para las relaciones temporales
Leve dificultad para resolver
problemas similitudes y diferencias
Leve dificultad en las actividades
fuera de la casa
Aficiones e intereses intelectuales
algo limitados
Capaz de cuidarse por si mismo
Detection of Dementia Page 4
age-associated cognitive decline (AACD) have been used They are distinct from the concept of mild cognitive
impairment as used in the current article Age-associated memory impairment refers to the concept of increasing memory
impairment with age and references memory function in the elderly cohort to young normal adult subjects As such there
can be an overinclusion of neurologically normal individuals in this concept and it has been critiqued as such13 Age-
associated cognitive decline refers to the concept of mild impairments in multiple cognitive domains but not of sufficient
severity to constitute the diagnosis of dementia This is a useful concept however few longitudinal studies have been
conducted using this nomenclature and this classification scheme also includes many normal elderly persons Each of
these terms either includes a segment of the normal population and represents extremes of normal aging andor is more
inclusive than the current definition of mild cognitive impairment As such they are not directly germane to the current
discussion Individuals with mild cognitive impairment meet criteria similar to those shown in table 1 There are
differences in the literature with respect to the sources of subjects age education and criteria but a general pattern of
clinical progression has emerged These studies are summarized in table 5 The conversion criteria refer to either the
development of dementia or AD
Table 5 Studies demonstrating outcome of persons with mild cognitive impairment (MCI) or similar condition
Study
Subjects
no
Mean age
y Source Criteria
Duration
follow-
up y
Annual
conversion
rate to
dementia or
AD Class
Mayo2 66 81 Community practice MCI 4 12 II
Toronto1415 107 74 Family practice Memory impairment 2 14 II
Columbia16 127 66 Memory disorders clinic Questionable dementia 27 15 II
MGH17 123 72 Community advertising CDR 05 3 6 II
Seattle18 21 74 Health Maintenance
Organization
Isolated memory loss 38 12 III
NYU19 32 71 Dementia clinic GDS 3 22 25 III CDR = Clinical Dementia Rating GDS = Global Deterioration Scale
In a Class II US study from the Mayo Clinicrsquos longitudinal study of aging and dementia subjects were recruited
from a primary care practice which served the residents of Rochester MN2 Subjects were enrolled if they expressed a
concern about their cognitive function a family member appreciated a change in cognitive function or the primary care
physician indicated a concern These were community-dwelling individuals and the mean age at the time of enrollment
was 81 years The subjects were classified as having mild cognitive impairment if they met criteria similar to those shown
in table 1 When the subjects were followed for up to 4 years they converted to AD at a rate of 12 per year2 By 6 years
approximately 80 of the individuals had developed AD10
In another Class II Canadian study from a similar setting in Toronto 107 subjects with a memory impairment without
dementia were followed for 2 years1415 Subjects were referred to the study by family physicians and the mean age of the
subjects was 74 years During the 2-year follow-up 29 (approximately 28) developed AD for an approximate annual
conversion rate of 14
A Class II US study exploring the natural history of subjects from a memory disorders clinic at Columbia University
evaluated 127 consecutive subjects with questionable dementia However these subjects did not meet criteria for
dementia16 This group represented subjects seen in a referral setting with a mean age of 66 years Approximately 40 of
the subjects were not followed for various reasons During the course of 27 years 413 of the subjects who were
followed became demented for an annual conversion rate of approximately 15
In a recent US Class II study from Massachusetts General Hospital persons were recruited from the community
through media advertisements17 A total of 123 persons with a Clinical Dementia Rating (CDR) of 05 (questionable
dementia) were followed for 3 years During this time frame 23 individuals converted to probable AD for an annual rate
of approximately 6
In a US Class III study from a large health maintenance organization in Seattle a group of memory impaired
subjects were followed18 Of 811 subjects with a mean age of 74 years who had been recruited through a registry for
cognitive complaints 21 subjects with a severe isolated memory loss were followed for a mean of 48 months During this
time period 48 developed dementia for an annual conversion rate of approximately 12 per year
Investigators at New York University in a Class III study using the Global Deterioration Scale as a measure to assess
impairment followed individuals with a Global Deterioration Scale rating of 3 which represented mild cognitive
impairment for these investigators19 They found that 16 of 32 of these individuals had progressed to a diagnosis of AD
over 22 years (25 per year)19 and concluded that mild cognitive impairment was a risk factor for subsequent
development of dementia
Conclusions Taken together these studies indicate that individuals characterized as being cognitively impaired but
not meeting clinical criteria for dementia or AD (mild cognitive impairment) have a high risk of progressing to dementia
or AD If the figures for incident AD from the general population are used from table 4 one can see that the rates range
by on August 22 2010 wwwneurologyorgDownloaded from
Factores de riesgo de conversioacuten
ldquoReserva Funcionalrdquo
Baja escolaridad
Menor nivel intelectual
Edad
Inactividad laboral
Bajo nivel cultural
Estudio longitudinal de una poblacioacuten en riesgo de demenciaSeguimiento 50 mesesAllegri
No todo DCL evoluciona a demencia la bibliografiacutea reporta desde un12 a un 2 Los pacientes que presentariacutean mayor riesgo seriacutean losque presentan afeccioacuten de la memoria mas otro dominio
In various studies a substantial percentage (11 to 40) of patients with MCIimprove even to normal over a one to three-year follow-up time
Faltariacutea aun el punto de corte de normalidad y anormalidad
Descartar depresioacuten
La persistencia de los cambios en evaluaciones sucesivas
En el DLC puede existir dependencia parcial en AIVD
El diagnostico de DCL es cliacutenico cognitivo y funcional
Llamadas de atencioacuten en el perfil neuropsicoloacutegico
Fallas en la memoria episoacutedica semaacutentica (estrategia de asociacioacuten semaacutentica en elaprendizaje de palabras) y diferida
Presencia de intrusiones (produccioacuten equivocada del nombre de un objeto) A mayornumero de intrusiones mayor riesgo de AD
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
Deterioro Cognitivo Leve DLC Siacutendrome amneacutesico que
denota una etapa de transicioacuten entre
el envejecimiento y la demencia
(especialmente demencia por AD)
Los criterios revisados para DCL
1) Cambio en la cognicioacuten reconocida
por el individuo o los observadores
del afectado
2) Deterioro objetivo en uno o maacutes
dominios cognitivos
3) Independencia en las actividades
funcionales
4) Ausencia de demenciaArch Neurol 2012 June 69(6) 700ndash708Revised Criteria for Mild Cognitive
Impairment May Compromise the Diagnosis of Alzheimer Disease DementiaJohn
C Morris MD
Criterios de Petersen
DLC ndash Clasificacioacuten de la funcioacuten cognitiva
bull Enfermedad de AlzheimerDCL
Amneacutesico
bull Enfermedad de Alzheimer
bull Envejecimiento normal
DCL muacuteltiple dominio
bull D Frontotemporal
bull Demencia C Lewy
bull Demencia vascular
bull Demencia Alzheimer
DCL dominio uacutenico no memoria
Ann Neurol 2008 April 63(4) 494ndash506Frequency and Course of Mild
Cognitive Impairment in a Multiethnic Community
10517 personasantildeos
21 de Sano a DLC
(Incidencia anual = 51 95
CI = 46ndash56)
218 de DCL a AD
(Incidencia anual = 54 95
CI = 47ndash63)
47 permanecioacute sin cambios
y 31 revertioacute a normal
Aquellos con MCI tuvieron 28
veces mas probabilidad de
desarrollar AD comparado con
ancianos normales
MCI con alteracioacuten de la
memoria y al menos otro
dominio cognitivo se asocioacute
con mayor riesgo de AD
Queja cognitiva referida por el paciente o conviviente
Deterioro en uno o mas dominios cognitivos comparado por
edadnivel educacional El deacuteficit en memoria episoacutedica (la habilidad
para aprender y retener nueva informacioacuten) es el dominio mas
afectado en DLC de los pacientes que progresan a AD
Independencia en AVD pero puede existir compromiso en
actividades complejas como manejo de dinero cocinar y
comprar las cuales pueden llevar mas tiempo ser menos
eficientes o mas errores al realizarlas
Alzheimers Dement 2011 May 7(3) 270ndash279
The diagnosis of mild cognitive impairment due to Alzheimerrsquos diseaserecommendations from the National
Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for Alzheimerrsquos disease
Arch Gen Psychiatry 2011 June 68(6) 617ndash626
Functional impairment in elderly patients with mild cognitive impairment and mild Alzheimers disease
Deterioro Cognitivo Leve
Actividades Instrumentales
de la vida diaria Nuevos criterios para el deterioro cognitivo leve
Revisioacuten retrospectiva de 17535 pacientes con la cognicioacuten normal DCL o Demencia AD evaluados en los Centros de la Enfermedad de Alzheimer
Casi todos ( 998 ) de los pacientes con diagnoacutestico de Demencia AD muy leve y la gran mayoriacutea ( 927 ) con diagnostico de Demencia leve AD pueden ser reclasificados como DCL con los criterios revisados
Arch Neurol 2012 June 69(6) 700ndash708
Revised Criteria for Mild Cognitive Impairment May Compromise the Diagnosis of Alzheimer Disease Dementia
Deacuteficit AIVD DLC amneacutesico vs no amneacutesico
Dement Geriatr Cogn Disord 2010 November 30(3) 189ndash197
Subtle Deficits in Instrumental Activities of Daily Living in Subtypes of Mild Cognitive Impairment
Trastornos conductuales en DCL
Estudio InDDEX (n=1000) con dg de DLC 59 presentoacute alguacuten
trastorno neuropsiquiaacutetrico
(depresioacuten ansiedad apatiacutea irritabilidad) Estos pacientes
exhibiacutean mayor alteracioacuten cognitiva y funcional que aquellos
que no teniacutean trastornos de conducta asociados
Feldman H Scheltens P Scarpini E Hermann N Mesenbrink P Mancione L et al
Behavioral symptoms in mild cognitive impairment Neurology 2004621199- 201
Estudio grupo UCLA (n=51) seguimiento 23 meses demostroacute
que los siacutentomas neuropsiquiaacutetricos (NPI) como depresioacuten y
apatiacutea se asocian a mayor riesgo de conversioacuten
Teng E Lu PH Cummings JL Neuropsychiatric symptoms are associated with
progression from mild cog- nitive impairment to Alzheimerrsquos disease Dement Geriatr
Cogn Disord 200724253-9
DLC
Mayo Clinic criteria para DLC amneacutesico deacuteficit y queja cognitiva
International Working Group deacuteficit objetivo y subjetivo de cualquier
dominio
Clinical Dementia Rating (CDR) focaliza en declinacioacuten cognitiva en las funciones de la vida diaria mas que en el deacuteficit cognitivo objetivo
Hipoacutetesis la prevalencia de DCL varia considerablemente seguacuten la definicioacuten
Estudios de
cohorte
indican al igual
que estudios
previos que el
DCL es una
entidad
heterogeacutenea a
nivel de
poblacioacuten
Arch Neurol 2011 June 68(6) 761ndash767
Outcomes of mild cognitive impairment depend on definition a
population study
Olvidos leves constantes
Orientado pero con leve dificultad
para las relaciones temporales
Leve dificultad para resolver
problemas similitudes y diferencias
Leve dificultad en las actividades
fuera de la casa
Aficiones e intereses intelectuales
algo limitados
Capaz de cuidarse por si mismo
Detection of Dementia Page 4
age-associated cognitive decline (AACD) have been used They are distinct from the concept of mild cognitive
impairment as used in the current article Age-associated memory impairment refers to the concept of increasing memory
impairment with age and references memory function in the elderly cohort to young normal adult subjects As such there
can be an overinclusion of neurologically normal individuals in this concept and it has been critiqued as such13 Age-
associated cognitive decline refers to the concept of mild impairments in multiple cognitive domains but not of sufficient
severity to constitute the diagnosis of dementia This is a useful concept however few longitudinal studies have been
conducted using this nomenclature and this classification scheme also includes many normal elderly persons Each of
these terms either includes a segment of the normal population and represents extremes of normal aging andor is more
inclusive than the current definition of mild cognitive impairment As such they are not directly germane to the current
discussion Individuals with mild cognitive impairment meet criteria similar to those shown in table 1 There are
differences in the literature with respect to the sources of subjects age education and criteria but a general pattern of
clinical progression has emerged These studies are summarized in table 5 The conversion criteria refer to either the
development of dementia or AD
Table 5 Studies demonstrating outcome of persons with mild cognitive impairment (MCI) or similar condition
Study
Subjects
no
Mean age
y Source Criteria
Duration
follow-
up y
Annual
conversion
rate to
dementia or
AD Class
Mayo2 66 81 Community practice MCI 4 12 II
Toronto1415 107 74 Family practice Memory impairment 2 14 II
Columbia16 127 66 Memory disorders clinic Questionable dementia 27 15 II
MGH17 123 72 Community advertising CDR 05 3 6 II
Seattle18 21 74 Health Maintenance
Organization
Isolated memory loss 38 12 III
NYU19 32 71 Dementia clinic GDS 3 22 25 III CDR = Clinical Dementia Rating GDS = Global Deterioration Scale
In a Class II US study from the Mayo Clinicrsquos longitudinal study of aging and dementia subjects were recruited
from a primary care practice which served the residents of Rochester MN2 Subjects were enrolled if they expressed a
concern about their cognitive function a family member appreciated a change in cognitive function or the primary care
physician indicated a concern These were community-dwelling individuals and the mean age at the time of enrollment
was 81 years The subjects were classified as having mild cognitive impairment if they met criteria similar to those shown
in table 1 When the subjects were followed for up to 4 years they converted to AD at a rate of 12 per year2 By 6 years
approximately 80 of the individuals had developed AD10
In another Class II Canadian study from a similar setting in Toronto 107 subjects with a memory impairment without
dementia were followed for 2 years1415 Subjects were referred to the study by family physicians and the mean age of the
subjects was 74 years During the 2-year follow-up 29 (approximately 28) developed AD for an approximate annual
conversion rate of 14
A Class II US study exploring the natural history of subjects from a memory disorders clinic at Columbia University
evaluated 127 consecutive subjects with questionable dementia However these subjects did not meet criteria for
dementia16 This group represented subjects seen in a referral setting with a mean age of 66 years Approximately 40 of
the subjects were not followed for various reasons During the course of 27 years 413 of the subjects who were
followed became demented for an annual conversion rate of approximately 15
In a recent US Class II study from Massachusetts General Hospital persons were recruited from the community
through media advertisements17 A total of 123 persons with a Clinical Dementia Rating (CDR) of 05 (questionable
dementia) were followed for 3 years During this time frame 23 individuals converted to probable AD for an annual rate
of approximately 6
In a US Class III study from a large health maintenance organization in Seattle a group of memory impaired
subjects were followed18 Of 811 subjects with a mean age of 74 years who had been recruited through a registry for
cognitive complaints 21 subjects with a severe isolated memory loss were followed for a mean of 48 months During this
time period 48 developed dementia for an annual conversion rate of approximately 12 per year
Investigators at New York University in a Class III study using the Global Deterioration Scale as a measure to assess
impairment followed individuals with a Global Deterioration Scale rating of 3 which represented mild cognitive
impairment for these investigators19 They found that 16 of 32 of these individuals had progressed to a diagnosis of AD
over 22 years (25 per year)19 and concluded that mild cognitive impairment was a risk factor for subsequent
development of dementia
Conclusions Taken together these studies indicate that individuals characterized as being cognitively impaired but
not meeting clinical criteria for dementia or AD (mild cognitive impairment) have a high risk of progressing to dementia
or AD If the figures for incident AD from the general population are used from table 4 one can see that the rates range
by on August 22 2010 wwwneurologyorgDownloaded from
Factores de riesgo de conversioacuten
ldquoReserva Funcionalrdquo
Baja escolaridad
Menor nivel intelectual
Edad
Inactividad laboral
Bajo nivel cultural
Estudio longitudinal de una poblacioacuten en riesgo de demenciaSeguimiento 50 mesesAllegri
No todo DCL evoluciona a demencia la bibliografiacutea reporta desde un12 a un 2 Los pacientes que presentariacutean mayor riesgo seriacutean losque presentan afeccioacuten de la memoria mas otro dominio
In various studies a substantial percentage (11 to 40) of patients with MCIimprove even to normal over a one to three-year follow-up time
Faltariacutea aun el punto de corte de normalidad y anormalidad
Descartar depresioacuten
La persistencia de los cambios en evaluaciones sucesivas
En el DLC puede existir dependencia parcial en AIVD
El diagnostico de DCL es cliacutenico cognitivo y funcional
Llamadas de atencioacuten en el perfil neuropsicoloacutegico
Fallas en la memoria episoacutedica semaacutentica (estrategia de asociacioacuten semaacutentica en elaprendizaje de palabras) y diferida
Presencia de intrusiones (produccioacuten equivocada del nombre de un objeto) A mayornumero de intrusiones mayor riesgo de AD
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
DLC ndash Clasificacioacuten de la funcioacuten cognitiva
bull Enfermedad de AlzheimerDCL
Amneacutesico
bull Enfermedad de Alzheimer
bull Envejecimiento normal
DCL muacuteltiple dominio
bull D Frontotemporal
bull Demencia C Lewy
bull Demencia vascular
bull Demencia Alzheimer
DCL dominio uacutenico no memoria
Ann Neurol 2008 April 63(4) 494ndash506Frequency and Course of Mild
Cognitive Impairment in a Multiethnic Community
10517 personasantildeos
21 de Sano a DLC
(Incidencia anual = 51 95
CI = 46ndash56)
218 de DCL a AD
(Incidencia anual = 54 95
CI = 47ndash63)
47 permanecioacute sin cambios
y 31 revertioacute a normal
Aquellos con MCI tuvieron 28
veces mas probabilidad de
desarrollar AD comparado con
ancianos normales
MCI con alteracioacuten de la
memoria y al menos otro
dominio cognitivo se asocioacute
con mayor riesgo de AD
Queja cognitiva referida por el paciente o conviviente
Deterioro en uno o mas dominios cognitivos comparado por
edadnivel educacional El deacuteficit en memoria episoacutedica (la habilidad
para aprender y retener nueva informacioacuten) es el dominio mas
afectado en DLC de los pacientes que progresan a AD
Independencia en AVD pero puede existir compromiso en
actividades complejas como manejo de dinero cocinar y
comprar las cuales pueden llevar mas tiempo ser menos
eficientes o mas errores al realizarlas
Alzheimers Dement 2011 May 7(3) 270ndash279
The diagnosis of mild cognitive impairment due to Alzheimerrsquos diseaserecommendations from the National
Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for Alzheimerrsquos disease
Arch Gen Psychiatry 2011 June 68(6) 617ndash626
Functional impairment in elderly patients with mild cognitive impairment and mild Alzheimers disease
Deterioro Cognitivo Leve
Actividades Instrumentales
de la vida diaria Nuevos criterios para el deterioro cognitivo leve
Revisioacuten retrospectiva de 17535 pacientes con la cognicioacuten normal DCL o Demencia AD evaluados en los Centros de la Enfermedad de Alzheimer
Casi todos ( 998 ) de los pacientes con diagnoacutestico de Demencia AD muy leve y la gran mayoriacutea ( 927 ) con diagnostico de Demencia leve AD pueden ser reclasificados como DCL con los criterios revisados
Arch Neurol 2012 June 69(6) 700ndash708
Revised Criteria for Mild Cognitive Impairment May Compromise the Diagnosis of Alzheimer Disease Dementia
Deacuteficit AIVD DLC amneacutesico vs no amneacutesico
Dement Geriatr Cogn Disord 2010 November 30(3) 189ndash197
Subtle Deficits in Instrumental Activities of Daily Living in Subtypes of Mild Cognitive Impairment
Trastornos conductuales en DCL
Estudio InDDEX (n=1000) con dg de DLC 59 presentoacute alguacuten
trastorno neuropsiquiaacutetrico
(depresioacuten ansiedad apatiacutea irritabilidad) Estos pacientes
exhibiacutean mayor alteracioacuten cognitiva y funcional que aquellos
que no teniacutean trastornos de conducta asociados
Feldman H Scheltens P Scarpini E Hermann N Mesenbrink P Mancione L et al
Behavioral symptoms in mild cognitive impairment Neurology 2004621199- 201
Estudio grupo UCLA (n=51) seguimiento 23 meses demostroacute
que los siacutentomas neuropsiquiaacutetricos (NPI) como depresioacuten y
apatiacutea se asocian a mayor riesgo de conversioacuten
Teng E Lu PH Cummings JL Neuropsychiatric symptoms are associated with
progression from mild cog- nitive impairment to Alzheimerrsquos disease Dement Geriatr
Cogn Disord 200724253-9
DLC
Mayo Clinic criteria para DLC amneacutesico deacuteficit y queja cognitiva
International Working Group deacuteficit objetivo y subjetivo de cualquier
dominio
Clinical Dementia Rating (CDR) focaliza en declinacioacuten cognitiva en las funciones de la vida diaria mas que en el deacuteficit cognitivo objetivo
Hipoacutetesis la prevalencia de DCL varia considerablemente seguacuten la definicioacuten
Estudios de
cohorte
indican al igual
que estudios
previos que el
DCL es una
entidad
heterogeacutenea a
nivel de
poblacioacuten
Arch Neurol 2011 June 68(6) 761ndash767
Outcomes of mild cognitive impairment depend on definition a
population study
Olvidos leves constantes
Orientado pero con leve dificultad
para las relaciones temporales
Leve dificultad para resolver
problemas similitudes y diferencias
Leve dificultad en las actividades
fuera de la casa
Aficiones e intereses intelectuales
algo limitados
Capaz de cuidarse por si mismo
Detection of Dementia Page 4
age-associated cognitive decline (AACD) have been used They are distinct from the concept of mild cognitive
impairment as used in the current article Age-associated memory impairment refers to the concept of increasing memory
impairment with age and references memory function in the elderly cohort to young normal adult subjects As such there
can be an overinclusion of neurologically normal individuals in this concept and it has been critiqued as such13 Age-
associated cognitive decline refers to the concept of mild impairments in multiple cognitive domains but not of sufficient
severity to constitute the diagnosis of dementia This is a useful concept however few longitudinal studies have been
conducted using this nomenclature and this classification scheme also includes many normal elderly persons Each of
these terms either includes a segment of the normal population and represents extremes of normal aging andor is more
inclusive than the current definition of mild cognitive impairment As such they are not directly germane to the current
discussion Individuals with mild cognitive impairment meet criteria similar to those shown in table 1 There are
differences in the literature with respect to the sources of subjects age education and criteria but a general pattern of
clinical progression has emerged These studies are summarized in table 5 The conversion criteria refer to either the
development of dementia or AD
Table 5 Studies demonstrating outcome of persons with mild cognitive impairment (MCI) or similar condition
Study
Subjects
no
Mean age
y Source Criteria
Duration
follow-
up y
Annual
conversion
rate to
dementia or
AD Class
Mayo2 66 81 Community practice MCI 4 12 II
Toronto1415 107 74 Family practice Memory impairment 2 14 II
Columbia16 127 66 Memory disorders clinic Questionable dementia 27 15 II
MGH17 123 72 Community advertising CDR 05 3 6 II
Seattle18 21 74 Health Maintenance
Organization
Isolated memory loss 38 12 III
NYU19 32 71 Dementia clinic GDS 3 22 25 III CDR = Clinical Dementia Rating GDS = Global Deterioration Scale
In a Class II US study from the Mayo Clinicrsquos longitudinal study of aging and dementia subjects were recruited
from a primary care practice which served the residents of Rochester MN2 Subjects were enrolled if they expressed a
concern about their cognitive function a family member appreciated a change in cognitive function or the primary care
physician indicated a concern These were community-dwelling individuals and the mean age at the time of enrollment
was 81 years The subjects were classified as having mild cognitive impairment if they met criteria similar to those shown
in table 1 When the subjects were followed for up to 4 years they converted to AD at a rate of 12 per year2 By 6 years
approximately 80 of the individuals had developed AD10
In another Class II Canadian study from a similar setting in Toronto 107 subjects with a memory impairment without
dementia were followed for 2 years1415 Subjects were referred to the study by family physicians and the mean age of the
subjects was 74 years During the 2-year follow-up 29 (approximately 28) developed AD for an approximate annual
conversion rate of 14
A Class II US study exploring the natural history of subjects from a memory disorders clinic at Columbia University
evaluated 127 consecutive subjects with questionable dementia However these subjects did not meet criteria for
dementia16 This group represented subjects seen in a referral setting with a mean age of 66 years Approximately 40 of
the subjects were not followed for various reasons During the course of 27 years 413 of the subjects who were
followed became demented for an annual conversion rate of approximately 15
In a recent US Class II study from Massachusetts General Hospital persons were recruited from the community
through media advertisements17 A total of 123 persons with a Clinical Dementia Rating (CDR) of 05 (questionable
dementia) were followed for 3 years During this time frame 23 individuals converted to probable AD for an annual rate
of approximately 6
In a US Class III study from a large health maintenance organization in Seattle a group of memory impaired
subjects were followed18 Of 811 subjects with a mean age of 74 years who had been recruited through a registry for
cognitive complaints 21 subjects with a severe isolated memory loss were followed for a mean of 48 months During this
time period 48 developed dementia for an annual conversion rate of approximately 12 per year
Investigators at New York University in a Class III study using the Global Deterioration Scale as a measure to assess
impairment followed individuals with a Global Deterioration Scale rating of 3 which represented mild cognitive
impairment for these investigators19 They found that 16 of 32 of these individuals had progressed to a diagnosis of AD
over 22 years (25 per year)19 and concluded that mild cognitive impairment was a risk factor for subsequent
development of dementia
Conclusions Taken together these studies indicate that individuals characterized as being cognitively impaired but
not meeting clinical criteria for dementia or AD (mild cognitive impairment) have a high risk of progressing to dementia
or AD If the figures for incident AD from the general population are used from table 4 one can see that the rates range
by on August 22 2010 wwwneurologyorgDownloaded from
Factores de riesgo de conversioacuten
ldquoReserva Funcionalrdquo
Baja escolaridad
Menor nivel intelectual
Edad
Inactividad laboral
Bajo nivel cultural
Estudio longitudinal de una poblacioacuten en riesgo de demenciaSeguimiento 50 mesesAllegri
No todo DCL evoluciona a demencia la bibliografiacutea reporta desde un12 a un 2 Los pacientes que presentariacutean mayor riesgo seriacutean losque presentan afeccioacuten de la memoria mas otro dominio
In various studies a substantial percentage (11 to 40) of patients with MCIimprove even to normal over a one to three-year follow-up time
Faltariacutea aun el punto de corte de normalidad y anormalidad
Descartar depresioacuten
La persistencia de los cambios en evaluaciones sucesivas
En el DLC puede existir dependencia parcial en AIVD
El diagnostico de DCL es cliacutenico cognitivo y funcional
Llamadas de atencioacuten en el perfil neuropsicoloacutegico
Fallas en la memoria episoacutedica semaacutentica (estrategia de asociacioacuten semaacutentica en elaprendizaje de palabras) y diferida
Presencia de intrusiones (produccioacuten equivocada del nombre de un objeto) A mayornumero de intrusiones mayor riesgo de AD
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
Ann Neurol 2008 April 63(4) 494ndash506Frequency and Course of Mild
Cognitive Impairment in a Multiethnic Community
10517 personasantildeos
21 de Sano a DLC
(Incidencia anual = 51 95
CI = 46ndash56)
218 de DCL a AD
(Incidencia anual = 54 95
CI = 47ndash63)
47 permanecioacute sin cambios
y 31 revertioacute a normal
Aquellos con MCI tuvieron 28
veces mas probabilidad de
desarrollar AD comparado con
ancianos normales
MCI con alteracioacuten de la
memoria y al menos otro
dominio cognitivo se asocioacute
con mayor riesgo de AD
Queja cognitiva referida por el paciente o conviviente
Deterioro en uno o mas dominios cognitivos comparado por
edadnivel educacional El deacuteficit en memoria episoacutedica (la habilidad
para aprender y retener nueva informacioacuten) es el dominio mas
afectado en DLC de los pacientes que progresan a AD
Independencia en AVD pero puede existir compromiso en
actividades complejas como manejo de dinero cocinar y
comprar las cuales pueden llevar mas tiempo ser menos
eficientes o mas errores al realizarlas
Alzheimers Dement 2011 May 7(3) 270ndash279
The diagnosis of mild cognitive impairment due to Alzheimerrsquos diseaserecommendations from the National
Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for Alzheimerrsquos disease
Arch Gen Psychiatry 2011 June 68(6) 617ndash626
Functional impairment in elderly patients with mild cognitive impairment and mild Alzheimers disease
Deterioro Cognitivo Leve
Actividades Instrumentales
de la vida diaria Nuevos criterios para el deterioro cognitivo leve
Revisioacuten retrospectiva de 17535 pacientes con la cognicioacuten normal DCL o Demencia AD evaluados en los Centros de la Enfermedad de Alzheimer
Casi todos ( 998 ) de los pacientes con diagnoacutestico de Demencia AD muy leve y la gran mayoriacutea ( 927 ) con diagnostico de Demencia leve AD pueden ser reclasificados como DCL con los criterios revisados
Arch Neurol 2012 June 69(6) 700ndash708
Revised Criteria for Mild Cognitive Impairment May Compromise the Diagnosis of Alzheimer Disease Dementia
Deacuteficit AIVD DLC amneacutesico vs no amneacutesico
Dement Geriatr Cogn Disord 2010 November 30(3) 189ndash197
Subtle Deficits in Instrumental Activities of Daily Living in Subtypes of Mild Cognitive Impairment
Trastornos conductuales en DCL
Estudio InDDEX (n=1000) con dg de DLC 59 presentoacute alguacuten
trastorno neuropsiquiaacutetrico
(depresioacuten ansiedad apatiacutea irritabilidad) Estos pacientes
exhibiacutean mayor alteracioacuten cognitiva y funcional que aquellos
que no teniacutean trastornos de conducta asociados
Feldman H Scheltens P Scarpini E Hermann N Mesenbrink P Mancione L et al
Behavioral symptoms in mild cognitive impairment Neurology 2004621199- 201
Estudio grupo UCLA (n=51) seguimiento 23 meses demostroacute
que los siacutentomas neuropsiquiaacutetricos (NPI) como depresioacuten y
apatiacutea se asocian a mayor riesgo de conversioacuten
Teng E Lu PH Cummings JL Neuropsychiatric symptoms are associated with
progression from mild cog- nitive impairment to Alzheimerrsquos disease Dement Geriatr
Cogn Disord 200724253-9
DLC
Mayo Clinic criteria para DLC amneacutesico deacuteficit y queja cognitiva
International Working Group deacuteficit objetivo y subjetivo de cualquier
dominio
Clinical Dementia Rating (CDR) focaliza en declinacioacuten cognitiva en las funciones de la vida diaria mas que en el deacuteficit cognitivo objetivo
Hipoacutetesis la prevalencia de DCL varia considerablemente seguacuten la definicioacuten
Estudios de
cohorte
indican al igual
que estudios
previos que el
DCL es una
entidad
heterogeacutenea a
nivel de
poblacioacuten
Arch Neurol 2011 June 68(6) 761ndash767
Outcomes of mild cognitive impairment depend on definition a
population study
Olvidos leves constantes
Orientado pero con leve dificultad
para las relaciones temporales
Leve dificultad para resolver
problemas similitudes y diferencias
Leve dificultad en las actividades
fuera de la casa
Aficiones e intereses intelectuales
algo limitados
Capaz de cuidarse por si mismo
Detection of Dementia Page 4
age-associated cognitive decline (AACD) have been used They are distinct from the concept of mild cognitive
impairment as used in the current article Age-associated memory impairment refers to the concept of increasing memory
impairment with age and references memory function in the elderly cohort to young normal adult subjects As such there
can be an overinclusion of neurologically normal individuals in this concept and it has been critiqued as such13 Age-
associated cognitive decline refers to the concept of mild impairments in multiple cognitive domains but not of sufficient
severity to constitute the diagnosis of dementia This is a useful concept however few longitudinal studies have been
conducted using this nomenclature and this classification scheme also includes many normal elderly persons Each of
these terms either includes a segment of the normal population and represents extremes of normal aging andor is more
inclusive than the current definition of mild cognitive impairment As such they are not directly germane to the current
discussion Individuals with mild cognitive impairment meet criteria similar to those shown in table 1 There are
differences in the literature with respect to the sources of subjects age education and criteria but a general pattern of
clinical progression has emerged These studies are summarized in table 5 The conversion criteria refer to either the
development of dementia or AD
Table 5 Studies demonstrating outcome of persons with mild cognitive impairment (MCI) or similar condition
Study
Subjects
no
Mean age
y Source Criteria
Duration
follow-
up y
Annual
conversion
rate to
dementia or
AD Class
Mayo2 66 81 Community practice MCI 4 12 II
Toronto1415 107 74 Family practice Memory impairment 2 14 II
Columbia16 127 66 Memory disorders clinic Questionable dementia 27 15 II
MGH17 123 72 Community advertising CDR 05 3 6 II
Seattle18 21 74 Health Maintenance
Organization
Isolated memory loss 38 12 III
NYU19 32 71 Dementia clinic GDS 3 22 25 III CDR = Clinical Dementia Rating GDS = Global Deterioration Scale
In a Class II US study from the Mayo Clinicrsquos longitudinal study of aging and dementia subjects were recruited
from a primary care practice which served the residents of Rochester MN2 Subjects were enrolled if they expressed a
concern about their cognitive function a family member appreciated a change in cognitive function or the primary care
physician indicated a concern These were community-dwelling individuals and the mean age at the time of enrollment
was 81 years The subjects were classified as having mild cognitive impairment if they met criteria similar to those shown
in table 1 When the subjects were followed for up to 4 years they converted to AD at a rate of 12 per year2 By 6 years
approximately 80 of the individuals had developed AD10
In another Class II Canadian study from a similar setting in Toronto 107 subjects with a memory impairment without
dementia were followed for 2 years1415 Subjects were referred to the study by family physicians and the mean age of the
subjects was 74 years During the 2-year follow-up 29 (approximately 28) developed AD for an approximate annual
conversion rate of 14
A Class II US study exploring the natural history of subjects from a memory disorders clinic at Columbia University
evaluated 127 consecutive subjects with questionable dementia However these subjects did not meet criteria for
dementia16 This group represented subjects seen in a referral setting with a mean age of 66 years Approximately 40 of
the subjects were not followed for various reasons During the course of 27 years 413 of the subjects who were
followed became demented for an annual conversion rate of approximately 15
In a recent US Class II study from Massachusetts General Hospital persons were recruited from the community
through media advertisements17 A total of 123 persons with a Clinical Dementia Rating (CDR) of 05 (questionable
dementia) were followed for 3 years During this time frame 23 individuals converted to probable AD for an annual rate
of approximately 6
In a US Class III study from a large health maintenance organization in Seattle a group of memory impaired
subjects were followed18 Of 811 subjects with a mean age of 74 years who had been recruited through a registry for
cognitive complaints 21 subjects with a severe isolated memory loss were followed for a mean of 48 months During this
time period 48 developed dementia for an annual conversion rate of approximately 12 per year
Investigators at New York University in a Class III study using the Global Deterioration Scale as a measure to assess
impairment followed individuals with a Global Deterioration Scale rating of 3 which represented mild cognitive
impairment for these investigators19 They found that 16 of 32 of these individuals had progressed to a diagnosis of AD
over 22 years (25 per year)19 and concluded that mild cognitive impairment was a risk factor for subsequent
development of dementia
Conclusions Taken together these studies indicate that individuals characterized as being cognitively impaired but
not meeting clinical criteria for dementia or AD (mild cognitive impairment) have a high risk of progressing to dementia
or AD If the figures for incident AD from the general population are used from table 4 one can see that the rates range
by on August 22 2010 wwwneurologyorgDownloaded from
Factores de riesgo de conversioacuten
ldquoReserva Funcionalrdquo
Baja escolaridad
Menor nivel intelectual
Edad
Inactividad laboral
Bajo nivel cultural
Estudio longitudinal de una poblacioacuten en riesgo de demenciaSeguimiento 50 mesesAllegri
No todo DCL evoluciona a demencia la bibliografiacutea reporta desde un12 a un 2 Los pacientes que presentariacutean mayor riesgo seriacutean losque presentan afeccioacuten de la memoria mas otro dominio
In various studies a substantial percentage (11 to 40) of patients with MCIimprove even to normal over a one to three-year follow-up time
Faltariacutea aun el punto de corte de normalidad y anormalidad
Descartar depresioacuten
La persistencia de los cambios en evaluaciones sucesivas
En el DLC puede existir dependencia parcial en AIVD
El diagnostico de DCL es cliacutenico cognitivo y funcional
Llamadas de atencioacuten en el perfil neuropsicoloacutegico
Fallas en la memoria episoacutedica semaacutentica (estrategia de asociacioacuten semaacutentica en elaprendizaje de palabras) y diferida
Presencia de intrusiones (produccioacuten equivocada del nombre de un objeto) A mayornumero de intrusiones mayor riesgo de AD
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
Queja cognitiva referida por el paciente o conviviente
Deterioro en uno o mas dominios cognitivos comparado por
edadnivel educacional El deacuteficit en memoria episoacutedica (la habilidad
para aprender y retener nueva informacioacuten) es el dominio mas
afectado en DLC de los pacientes que progresan a AD
Independencia en AVD pero puede existir compromiso en
actividades complejas como manejo de dinero cocinar y
comprar las cuales pueden llevar mas tiempo ser menos
eficientes o mas errores al realizarlas
Alzheimers Dement 2011 May 7(3) 270ndash279
The diagnosis of mild cognitive impairment due to Alzheimerrsquos diseaserecommendations from the National
Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for Alzheimerrsquos disease
Arch Gen Psychiatry 2011 June 68(6) 617ndash626
Functional impairment in elderly patients with mild cognitive impairment and mild Alzheimers disease
Deterioro Cognitivo Leve
Actividades Instrumentales
de la vida diaria Nuevos criterios para el deterioro cognitivo leve
Revisioacuten retrospectiva de 17535 pacientes con la cognicioacuten normal DCL o Demencia AD evaluados en los Centros de la Enfermedad de Alzheimer
Casi todos ( 998 ) de los pacientes con diagnoacutestico de Demencia AD muy leve y la gran mayoriacutea ( 927 ) con diagnostico de Demencia leve AD pueden ser reclasificados como DCL con los criterios revisados
Arch Neurol 2012 June 69(6) 700ndash708
Revised Criteria for Mild Cognitive Impairment May Compromise the Diagnosis of Alzheimer Disease Dementia
Deacuteficit AIVD DLC amneacutesico vs no amneacutesico
Dement Geriatr Cogn Disord 2010 November 30(3) 189ndash197
Subtle Deficits in Instrumental Activities of Daily Living in Subtypes of Mild Cognitive Impairment
Trastornos conductuales en DCL
Estudio InDDEX (n=1000) con dg de DLC 59 presentoacute alguacuten
trastorno neuropsiquiaacutetrico
(depresioacuten ansiedad apatiacutea irritabilidad) Estos pacientes
exhibiacutean mayor alteracioacuten cognitiva y funcional que aquellos
que no teniacutean trastornos de conducta asociados
Feldman H Scheltens P Scarpini E Hermann N Mesenbrink P Mancione L et al
Behavioral symptoms in mild cognitive impairment Neurology 2004621199- 201
Estudio grupo UCLA (n=51) seguimiento 23 meses demostroacute
que los siacutentomas neuropsiquiaacutetricos (NPI) como depresioacuten y
apatiacutea se asocian a mayor riesgo de conversioacuten
Teng E Lu PH Cummings JL Neuropsychiatric symptoms are associated with
progression from mild cog- nitive impairment to Alzheimerrsquos disease Dement Geriatr
Cogn Disord 200724253-9
DLC
Mayo Clinic criteria para DLC amneacutesico deacuteficit y queja cognitiva
International Working Group deacuteficit objetivo y subjetivo de cualquier
dominio
Clinical Dementia Rating (CDR) focaliza en declinacioacuten cognitiva en las funciones de la vida diaria mas que en el deacuteficit cognitivo objetivo
Hipoacutetesis la prevalencia de DCL varia considerablemente seguacuten la definicioacuten
Estudios de
cohorte
indican al igual
que estudios
previos que el
DCL es una
entidad
heterogeacutenea a
nivel de
poblacioacuten
Arch Neurol 2011 June 68(6) 761ndash767
Outcomes of mild cognitive impairment depend on definition a
population study
Olvidos leves constantes
Orientado pero con leve dificultad
para las relaciones temporales
Leve dificultad para resolver
problemas similitudes y diferencias
Leve dificultad en las actividades
fuera de la casa
Aficiones e intereses intelectuales
algo limitados
Capaz de cuidarse por si mismo
Detection of Dementia Page 4
age-associated cognitive decline (AACD) have been used They are distinct from the concept of mild cognitive
impairment as used in the current article Age-associated memory impairment refers to the concept of increasing memory
impairment with age and references memory function in the elderly cohort to young normal adult subjects As such there
can be an overinclusion of neurologically normal individuals in this concept and it has been critiqued as such13 Age-
associated cognitive decline refers to the concept of mild impairments in multiple cognitive domains but not of sufficient
severity to constitute the diagnosis of dementia This is a useful concept however few longitudinal studies have been
conducted using this nomenclature and this classification scheme also includes many normal elderly persons Each of
these terms either includes a segment of the normal population and represents extremes of normal aging andor is more
inclusive than the current definition of mild cognitive impairment As such they are not directly germane to the current
discussion Individuals with mild cognitive impairment meet criteria similar to those shown in table 1 There are
differences in the literature with respect to the sources of subjects age education and criteria but a general pattern of
clinical progression has emerged These studies are summarized in table 5 The conversion criteria refer to either the
development of dementia or AD
Table 5 Studies demonstrating outcome of persons with mild cognitive impairment (MCI) or similar condition
Study
Subjects
no
Mean age
y Source Criteria
Duration
follow-
up y
Annual
conversion
rate to
dementia or
AD Class
Mayo2 66 81 Community practice MCI 4 12 II
Toronto1415 107 74 Family practice Memory impairment 2 14 II
Columbia16 127 66 Memory disorders clinic Questionable dementia 27 15 II
MGH17 123 72 Community advertising CDR 05 3 6 II
Seattle18 21 74 Health Maintenance
Organization
Isolated memory loss 38 12 III
NYU19 32 71 Dementia clinic GDS 3 22 25 III CDR = Clinical Dementia Rating GDS = Global Deterioration Scale
In a Class II US study from the Mayo Clinicrsquos longitudinal study of aging and dementia subjects were recruited
from a primary care practice which served the residents of Rochester MN2 Subjects were enrolled if they expressed a
concern about their cognitive function a family member appreciated a change in cognitive function or the primary care
physician indicated a concern These were community-dwelling individuals and the mean age at the time of enrollment
was 81 years The subjects were classified as having mild cognitive impairment if they met criteria similar to those shown
in table 1 When the subjects were followed for up to 4 years they converted to AD at a rate of 12 per year2 By 6 years
approximately 80 of the individuals had developed AD10
In another Class II Canadian study from a similar setting in Toronto 107 subjects with a memory impairment without
dementia were followed for 2 years1415 Subjects were referred to the study by family physicians and the mean age of the
subjects was 74 years During the 2-year follow-up 29 (approximately 28) developed AD for an approximate annual
conversion rate of 14
A Class II US study exploring the natural history of subjects from a memory disorders clinic at Columbia University
evaluated 127 consecutive subjects with questionable dementia However these subjects did not meet criteria for
dementia16 This group represented subjects seen in a referral setting with a mean age of 66 years Approximately 40 of
the subjects were not followed for various reasons During the course of 27 years 413 of the subjects who were
followed became demented for an annual conversion rate of approximately 15
In a recent US Class II study from Massachusetts General Hospital persons were recruited from the community
through media advertisements17 A total of 123 persons with a Clinical Dementia Rating (CDR) of 05 (questionable
dementia) were followed for 3 years During this time frame 23 individuals converted to probable AD for an annual rate
of approximately 6
In a US Class III study from a large health maintenance organization in Seattle a group of memory impaired
subjects were followed18 Of 811 subjects with a mean age of 74 years who had been recruited through a registry for
cognitive complaints 21 subjects with a severe isolated memory loss were followed for a mean of 48 months During this
time period 48 developed dementia for an annual conversion rate of approximately 12 per year
Investigators at New York University in a Class III study using the Global Deterioration Scale as a measure to assess
impairment followed individuals with a Global Deterioration Scale rating of 3 which represented mild cognitive
impairment for these investigators19 They found that 16 of 32 of these individuals had progressed to a diagnosis of AD
over 22 years (25 per year)19 and concluded that mild cognitive impairment was a risk factor for subsequent
development of dementia
Conclusions Taken together these studies indicate that individuals characterized as being cognitively impaired but
not meeting clinical criteria for dementia or AD (mild cognitive impairment) have a high risk of progressing to dementia
or AD If the figures for incident AD from the general population are used from table 4 one can see that the rates range
by on August 22 2010 wwwneurologyorgDownloaded from
Factores de riesgo de conversioacuten
ldquoReserva Funcionalrdquo
Baja escolaridad
Menor nivel intelectual
Edad
Inactividad laboral
Bajo nivel cultural
Estudio longitudinal de una poblacioacuten en riesgo de demenciaSeguimiento 50 mesesAllegri
No todo DCL evoluciona a demencia la bibliografiacutea reporta desde un12 a un 2 Los pacientes que presentariacutean mayor riesgo seriacutean losque presentan afeccioacuten de la memoria mas otro dominio
In various studies a substantial percentage (11 to 40) of patients with MCIimprove even to normal over a one to three-year follow-up time
Faltariacutea aun el punto de corte de normalidad y anormalidad
Descartar depresioacuten
La persistencia de los cambios en evaluaciones sucesivas
En el DLC puede existir dependencia parcial en AIVD
El diagnostico de DCL es cliacutenico cognitivo y funcional
Llamadas de atencioacuten en el perfil neuropsicoloacutegico
Fallas en la memoria episoacutedica semaacutentica (estrategia de asociacioacuten semaacutentica en elaprendizaje de palabras) y diferida
Presencia de intrusiones (produccioacuten equivocada del nombre de un objeto) A mayornumero de intrusiones mayor riesgo de AD
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
Actividades Instrumentales
de la vida diaria Nuevos criterios para el deterioro cognitivo leve
Revisioacuten retrospectiva de 17535 pacientes con la cognicioacuten normal DCL o Demencia AD evaluados en los Centros de la Enfermedad de Alzheimer
Casi todos ( 998 ) de los pacientes con diagnoacutestico de Demencia AD muy leve y la gran mayoriacutea ( 927 ) con diagnostico de Demencia leve AD pueden ser reclasificados como DCL con los criterios revisados
Arch Neurol 2012 June 69(6) 700ndash708
Revised Criteria for Mild Cognitive Impairment May Compromise the Diagnosis of Alzheimer Disease Dementia
Deacuteficit AIVD DLC amneacutesico vs no amneacutesico
Dement Geriatr Cogn Disord 2010 November 30(3) 189ndash197
Subtle Deficits in Instrumental Activities of Daily Living in Subtypes of Mild Cognitive Impairment
Trastornos conductuales en DCL
Estudio InDDEX (n=1000) con dg de DLC 59 presentoacute alguacuten
trastorno neuropsiquiaacutetrico
(depresioacuten ansiedad apatiacutea irritabilidad) Estos pacientes
exhibiacutean mayor alteracioacuten cognitiva y funcional que aquellos
que no teniacutean trastornos de conducta asociados
Feldman H Scheltens P Scarpini E Hermann N Mesenbrink P Mancione L et al
Behavioral symptoms in mild cognitive impairment Neurology 2004621199- 201
Estudio grupo UCLA (n=51) seguimiento 23 meses demostroacute
que los siacutentomas neuropsiquiaacutetricos (NPI) como depresioacuten y
apatiacutea se asocian a mayor riesgo de conversioacuten
Teng E Lu PH Cummings JL Neuropsychiatric symptoms are associated with
progression from mild cog- nitive impairment to Alzheimerrsquos disease Dement Geriatr
Cogn Disord 200724253-9
DLC
Mayo Clinic criteria para DLC amneacutesico deacuteficit y queja cognitiva
International Working Group deacuteficit objetivo y subjetivo de cualquier
dominio
Clinical Dementia Rating (CDR) focaliza en declinacioacuten cognitiva en las funciones de la vida diaria mas que en el deacuteficit cognitivo objetivo
Hipoacutetesis la prevalencia de DCL varia considerablemente seguacuten la definicioacuten
Estudios de
cohorte
indican al igual
que estudios
previos que el
DCL es una
entidad
heterogeacutenea a
nivel de
poblacioacuten
Arch Neurol 2011 June 68(6) 761ndash767
Outcomes of mild cognitive impairment depend on definition a
population study
Olvidos leves constantes
Orientado pero con leve dificultad
para las relaciones temporales
Leve dificultad para resolver
problemas similitudes y diferencias
Leve dificultad en las actividades
fuera de la casa
Aficiones e intereses intelectuales
algo limitados
Capaz de cuidarse por si mismo
Detection of Dementia Page 4
age-associated cognitive decline (AACD) have been used They are distinct from the concept of mild cognitive
impairment as used in the current article Age-associated memory impairment refers to the concept of increasing memory
impairment with age and references memory function in the elderly cohort to young normal adult subjects As such there
can be an overinclusion of neurologically normal individuals in this concept and it has been critiqued as such13 Age-
associated cognitive decline refers to the concept of mild impairments in multiple cognitive domains but not of sufficient
severity to constitute the diagnosis of dementia This is a useful concept however few longitudinal studies have been
conducted using this nomenclature and this classification scheme also includes many normal elderly persons Each of
these terms either includes a segment of the normal population and represents extremes of normal aging andor is more
inclusive than the current definition of mild cognitive impairment As such they are not directly germane to the current
discussion Individuals with mild cognitive impairment meet criteria similar to those shown in table 1 There are
differences in the literature with respect to the sources of subjects age education and criteria but a general pattern of
clinical progression has emerged These studies are summarized in table 5 The conversion criteria refer to either the
development of dementia or AD
Table 5 Studies demonstrating outcome of persons with mild cognitive impairment (MCI) or similar condition
Study
Subjects
no
Mean age
y Source Criteria
Duration
follow-
up y
Annual
conversion
rate to
dementia or
AD Class
Mayo2 66 81 Community practice MCI 4 12 II
Toronto1415 107 74 Family practice Memory impairment 2 14 II
Columbia16 127 66 Memory disorders clinic Questionable dementia 27 15 II
MGH17 123 72 Community advertising CDR 05 3 6 II
Seattle18 21 74 Health Maintenance
Organization
Isolated memory loss 38 12 III
NYU19 32 71 Dementia clinic GDS 3 22 25 III CDR = Clinical Dementia Rating GDS = Global Deterioration Scale
In a Class II US study from the Mayo Clinicrsquos longitudinal study of aging and dementia subjects were recruited
from a primary care practice which served the residents of Rochester MN2 Subjects were enrolled if they expressed a
concern about their cognitive function a family member appreciated a change in cognitive function or the primary care
physician indicated a concern These were community-dwelling individuals and the mean age at the time of enrollment
was 81 years The subjects were classified as having mild cognitive impairment if they met criteria similar to those shown
in table 1 When the subjects were followed for up to 4 years they converted to AD at a rate of 12 per year2 By 6 years
approximately 80 of the individuals had developed AD10
In another Class II Canadian study from a similar setting in Toronto 107 subjects with a memory impairment without
dementia were followed for 2 years1415 Subjects were referred to the study by family physicians and the mean age of the
subjects was 74 years During the 2-year follow-up 29 (approximately 28) developed AD for an approximate annual
conversion rate of 14
A Class II US study exploring the natural history of subjects from a memory disorders clinic at Columbia University
evaluated 127 consecutive subjects with questionable dementia However these subjects did not meet criteria for
dementia16 This group represented subjects seen in a referral setting with a mean age of 66 years Approximately 40 of
the subjects were not followed for various reasons During the course of 27 years 413 of the subjects who were
followed became demented for an annual conversion rate of approximately 15
In a recent US Class II study from Massachusetts General Hospital persons were recruited from the community
through media advertisements17 A total of 123 persons with a Clinical Dementia Rating (CDR) of 05 (questionable
dementia) were followed for 3 years During this time frame 23 individuals converted to probable AD for an annual rate
of approximately 6
In a US Class III study from a large health maintenance organization in Seattle a group of memory impaired
subjects were followed18 Of 811 subjects with a mean age of 74 years who had been recruited through a registry for
cognitive complaints 21 subjects with a severe isolated memory loss were followed for a mean of 48 months During this
time period 48 developed dementia for an annual conversion rate of approximately 12 per year
Investigators at New York University in a Class III study using the Global Deterioration Scale as a measure to assess
impairment followed individuals with a Global Deterioration Scale rating of 3 which represented mild cognitive
impairment for these investigators19 They found that 16 of 32 of these individuals had progressed to a diagnosis of AD
over 22 years (25 per year)19 and concluded that mild cognitive impairment was a risk factor for subsequent
development of dementia
Conclusions Taken together these studies indicate that individuals characterized as being cognitively impaired but
not meeting clinical criteria for dementia or AD (mild cognitive impairment) have a high risk of progressing to dementia
or AD If the figures for incident AD from the general population are used from table 4 one can see that the rates range
by on August 22 2010 wwwneurologyorgDownloaded from
Factores de riesgo de conversioacuten
ldquoReserva Funcionalrdquo
Baja escolaridad
Menor nivel intelectual
Edad
Inactividad laboral
Bajo nivel cultural
Estudio longitudinal de una poblacioacuten en riesgo de demenciaSeguimiento 50 mesesAllegri
No todo DCL evoluciona a demencia la bibliografiacutea reporta desde un12 a un 2 Los pacientes que presentariacutean mayor riesgo seriacutean losque presentan afeccioacuten de la memoria mas otro dominio
In various studies a substantial percentage (11 to 40) of patients with MCIimprove even to normal over a one to three-year follow-up time
Faltariacutea aun el punto de corte de normalidad y anormalidad
Descartar depresioacuten
La persistencia de los cambios en evaluaciones sucesivas
En el DLC puede existir dependencia parcial en AIVD
El diagnostico de DCL es cliacutenico cognitivo y funcional
Llamadas de atencioacuten en el perfil neuropsicoloacutegico
Fallas en la memoria episoacutedica semaacutentica (estrategia de asociacioacuten semaacutentica en elaprendizaje de palabras) y diferida
Presencia de intrusiones (produccioacuten equivocada del nombre de un objeto) A mayornumero de intrusiones mayor riesgo de AD
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
Deacuteficit AIVD DLC amneacutesico vs no amneacutesico
Dement Geriatr Cogn Disord 2010 November 30(3) 189ndash197
Subtle Deficits in Instrumental Activities of Daily Living in Subtypes of Mild Cognitive Impairment
Trastornos conductuales en DCL
Estudio InDDEX (n=1000) con dg de DLC 59 presentoacute alguacuten
trastorno neuropsiquiaacutetrico
(depresioacuten ansiedad apatiacutea irritabilidad) Estos pacientes
exhibiacutean mayor alteracioacuten cognitiva y funcional que aquellos
que no teniacutean trastornos de conducta asociados
Feldman H Scheltens P Scarpini E Hermann N Mesenbrink P Mancione L et al
Behavioral symptoms in mild cognitive impairment Neurology 2004621199- 201
Estudio grupo UCLA (n=51) seguimiento 23 meses demostroacute
que los siacutentomas neuropsiquiaacutetricos (NPI) como depresioacuten y
apatiacutea se asocian a mayor riesgo de conversioacuten
Teng E Lu PH Cummings JL Neuropsychiatric symptoms are associated with
progression from mild cog- nitive impairment to Alzheimerrsquos disease Dement Geriatr
Cogn Disord 200724253-9
DLC
Mayo Clinic criteria para DLC amneacutesico deacuteficit y queja cognitiva
International Working Group deacuteficit objetivo y subjetivo de cualquier
dominio
Clinical Dementia Rating (CDR) focaliza en declinacioacuten cognitiva en las funciones de la vida diaria mas que en el deacuteficit cognitivo objetivo
Hipoacutetesis la prevalencia de DCL varia considerablemente seguacuten la definicioacuten
Estudios de
cohorte
indican al igual
que estudios
previos que el
DCL es una
entidad
heterogeacutenea a
nivel de
poblacioacuten
Arch Neurol 2011 June 68(6) 761ndash767
Outcomes of mild cognitive impairment depend on definition a
population study
Olvidos leves constantes
Orientado pero con leve dificultad
para las relaciones temporales
Leve dificultad para resolver
problemas similitudes y diferencias
Leve dificultad en las actividades
fuera de la casa
Aficiones e intereses intelectuales
algo limitados
Capaz de cuidarse por si mismo
Detection of Dementia Page 4
age-associated cognitive decline (AACD) have been used They are distinct from the concept of mild cognitive
impairment as used in the current article Age-associated memory impairment refers to the concept of increasing memory
impairment with age and references memory function in the elderly cohort to young normal adult subjects As such there
can be an overinclusion of neurologically normal individuals in this concept and it has been critiqued as such13 Age-
associated cognitive decline refers to the concept of mild impairments in multiple cognitive domains but not of sufficient
severity to constitute the diagnosis of dementia This is a useful concept however few longitudinal studies have been
conducted using this nomenclature and this classification scheme also includes many normal elderly persons Each of
these terms either includes a segment of the normal population and represents extremes of normal aging andor is more
inclusive than the current definition of mild cognitive impairment As such they are not directly germane to the current
discussion Individuals with mild cognitive impairment meet criteria similar to those shown in table 1 There are
differences in the literature with respect to the sources of subjects age education and criteria but a general pattern of
clinical progression has emerged These studies are summarized in table 5 The conversion criteria refer to either the
development of dementia or AD
Table 5 Studies demonstrating outcome of persons with mild cognitive impairment (MCI) or similar condition
Study
Subjects
no
Mean age
y Source Criteria
Duration
follow-
up y
Annual
conversion
rate to
dementia or
AD Class
Mayo2 66 81 Community practice MCI 4 12 II
Toronto1415 107 74 Family practice Memory impairment 2 14 II
Columbia16 127 66 Memory disorders clinic Questionable dementia 27 15 II
MGH17 123 72 Community advertising CDR 05 3 6 II
Seattle18 21 74 Health Maintenance
Organization
Isolated memory loss 38 12 III
NYU19 32 71 Dementia clinic GDS 3 22 25 III CDR = Clinical Dementia Rating GDS = Global Deterioration Scale
In a Class II US study from the Mayo Clinicrsquos longitudinal study of aging and dementia subjects were recruited
from a primary care practice which served the residents of Rochester MN2 Subjects were enrolled if they expressed a
concern about their cognitive function a family member appreciated a change in cognitive function or the primary care
physician indicated a concern These were community-dwelling individuals and the mean age at the time of enrollment
was 81 years The subjects were classified as having mild cognitive impairment if they met criteria similar to those shown
in table 1 When the subjects were followed for up to 4 years they converted to AD at a rate of 12 per year2 By 6 years
approximately 80 of the individuals had developed AD10
In another Class II Canadian study from a similar setting in Toronto 107 subjects with a memory impairment without
dementia were followed for 2 years1415 Subjects were referred to the study by family physicians and the mean age of the
subjects was 74 years During the 2-year follow-up 29 (approximately 28) developed AD for an approximate annual
conversion rate of 14
A Class II US study exploring the natural history of subjects from a memory disorders clinic at Columbia University
evaluated 127 consecutive subjects with questionable dementia However these subjects did not meet criteria for
dementia16 This group represented subjects seen in a referral setting with a mean age of 66 years Approximately 40 of
the subjects were not followed for various reasons During the course of 27 years 413 of the subjects who were
followed became demented for an annual conversion rate of approximately 15
In a recent US Class II study from Massachusetts General Hospital persons were recruited from the community
through media advertisements17 A total of 123 persons with a Clinical Dementia Rating (CDR) of 05 (questionable
dementia) were followed for 3 years During this time frame 23 individuals converted to probable AD for an annual rate
of approximately 6
In a US Class III study from a large health maintenance organization in Seattle a group of memory impaired
subjects were followed18 Of 811 subjects with a mean age of 74 years who had been recruited through a registry for
cognitive complaints 21 subjects with a severe isolated memory loss were followed for a mean of 48 months During this
time period 48 developed dementia for an annual conversion rate of approximately 12 per year
Investigators at New York University in a Class III study using the Global Deterioration Scale as a measure to assess
impairment followed individuals with a Global Deterioration Scale rating of 3 which represented mild cognitive
impairment for these investigators19 They found that 16 of 32 of these individuals had progressed to a diagnosis of AD
over 22 years (25 per year)19 and concluded that mild cognitive impairment was a risk factor for subsequent
development of dementia
Conclusions Taken together these studies indicate that individuals characterized as being cognitively impaired but
not meeting clinical criteria for dementia or AD (mild cognitive impairment) have a high risk of progressing to dementia
or AD If the figures for incident AD from the general population are used from table 4 one can see that the rates range
by on August 22 2010 wwwneurologyorgDownloaded from
Factores de riesgo de conversioacuten
ldquoReserva Funcionalrdquo
Baja escolaridad
Menor nivel intelectual
Edad
Inactividad laboral
Bajo nivel cultural
Estudio longitudinal de una poblacioacuten en riesgo de demenciaSeguimiento 50 mesesAllegri
No todo DCL evoluciona a demencia la bibliografiacutea reporta desde un12 a un 2 Los pacientes que presentariacutean mayor riesgo seriacutean losque presentan afeccioacuten de la memoria mas otro dominio
In various studies a substantial percentage (11 to 40) of patients with MCIimprove even to normal over a one to three-year follow-up time
Faltariacutea aun el punto de corte de normalidad y anormalidad
Descartar depresioacuten
La persistencia de los cambios en evaluaciones sucesivas
En el DLC puede existir dependencia parcial en AIVD
El diagnostico de DCL es cliacutenico cognitivo y funcional
Llamadas de atencioacuten en el perfil neuropsicoloacutegico
Fallas en la memoria episoacutedica semaacutentica (estrategia de asociacioacuten semaacutentica en elaprendizaje de palabras) y diferida
Presencia de intrusiones (produccioacuten equivocada del nombre de un objeto) A mayornumero de intrusiones mayor riesgo de AD
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
Trastornos conductuales en DCL
Estudio InDDEX (n=1000) con dg de DLC 59 presentoacute alguacuten
trastorno neuropsiquiaacutetrico
(depresioacuten ansiedad apatiacutea irritabilidad) Estos pacientes
exhibiacutean mayor alteracioacuten cognitiva y funcional que aquellos
que no teniacutean trastornos de conducta asociados
Feldman H Scheltens P Scarpini E Hermann N Mesenbrink P Mancione L et al
Behavioral symptoms in mild cognitive impairment Neurology 2004621199- 201
Estudio grupo UCLA (n=51) seguimiento 23 meses demostroacute
que los siacutentomas neuropsiquiaacutetricos (NPI) como depresioacuten y
apatiacutea se asocian a mayor riesgo de conversioacuten
Teng E Lu PH Cummings JL Neuropsychiatric symptoms are associated with
progression from mild cog- nitive impairment to Alzheimerrsquos disease Dement Geriatr
Cogn Disord 200724253-9
DLC
Mayo Clinic criteria para DLC amneacutesico deacuteficit y queja cognitiva
International Working Group deacuteficit objetivo y subjetivo de cualquier
dominio
Clinical Dementia Rating (CDR) focaliza en declinacioacuten cognitiva en las funciones de la vida diaria mas que en el deacuteficit cognitivo objetivo
Hipoacutetesis la prevalencia de DCL varia considerablemente seguacuten la definicioacuten
Estudios de
cohorte
indican al igual
que estudios
previos que el
DCL es una
entidad
heterogeacutenea a
nivel de
poblacioacuten
Arch Neurol 2011 June 68(6) 761ndash767
Outcomes of mild cognitive impairment depend on definition a
population study
Olvidos leves constantes
Orientado pero con leve dificultad
para las relaciones temporales
Leve dificultad para resolver
problemas similitudes y diferencias
Leve dificultad en las actividades
fuera de la casa
Aficiones e intereses intelectuales
algo limitados
Capaz de cuidarse por si mismo
Detection of Dementia Page 4
age-associated cognitive decline (AACD) have been used They are distinct from the concept of mild cognitive
impairment as used in the current article Age-associated memory impairment refers to the concept of increasing memory
impairment with age and references memory function in the elderly cohort to young normal adult subjects As such there
can be an overinclusion of neurologically normal individuals in this concept and it has been critiqued as such13 Age-
associated cognitive decline refers to the concept of mild impairments in multiple cognitive domains but not of sufficient
severity to constitute the diagnosis of dementia This is a useful concept however few longitudinal studies have been
conducted using this nomenclature and this classification scheme also includes many normal elderly persons Each of
these terms either includes a segment of the normal population and represents extremes of normal aging andor is more
inclusive than the current definition of mild cognitive impairment As such they are not directly germane to the current
discussion Individuals with mild cognitive impairment meet criteria similar to those shown in table 1 There are
differences in the literature with respect to the sources of subjects age education and criteria but a general pattern of
clinical progression has emerged These studies are summarized in table 5 The conversion criteria refer to either the
development of dementia or AD
Table 5 Studies demonstrating outcome of persons with mild cognitive impairment (MCI) or similar condition
Study
Subjects
no
Mean age
y Source Criteria
Duration
follow-
up y
Annual
conversion
rate to
dementia or
AD Class
Mayo2 66 81 Community practice MCI 4 12 II
Toronto1415 107 74 Family practice Memory impairment 2 14 II
Columbia16 127 66 Memory disorders clinic Questionable dementia 27 15 II
MGH17 123 72 Community advertising CDR 05 3 6 II
Seattle18 21 74 Health Maintenance
Organization
Isolated memory loss 38 12 III
NYU19 32 71 Dementia clinic GDS 3 22 25 III CDR = Clinical Dementia Rating GDS = Global Deterioration Scale
In a Class II US study from the Mayo Clinicrsquos longitudinal study of aging and dementia subjects were recruited
from a primary care practice which served the residents of Rochester MN2 Subjects were enrolled if they expressed a
concern about their cognitive function a family member appreciated a change in cognitive function or the primary care
physician indicated a concern These were community-dwelling individuals and the mean age at the time of enrollment
was 81 years The subjects were classified as having mild cognitive impairment if they met criteria similar to those shown
in table 1 When the subjects were followed for up to 4 years they converted to AD at a rate of 12 per year2 By 6 years
approximately 80 of the individuals had developed AD10
In another Class II Canadian study from a similar setting in Toronto 107 subjects with a memory impairment without
dementia were followed for 2 years1415 Subjects were referred to the study by family physicians and the mean age of the
subjects was 74 years During the 2-year follow-up 29 (approximately 28) developed AD for an approximate annual
conversion rate of 14
A Class II US study exploring the natural history of subjects from a memory disorders clinic at Columbia University
evaluated 127 consecutive subjects with questionable dementia However these subjects did not meet criteria for
dementia16 This group represented subjects seen in a referral setting with a mean age of 66 years Approximately 40 of
the subjects were not followed for various reasons During the course of 27 years 413 of the subjects who were
followed became demented for an annual conversion rate of approximately 15
In a recent US Class II study from Massachusetts General Hospital persons were recruited from the community
through media advertisements17 A total of 123 persons with a Clinical Dementia Rating (CDR) of 05 (questionable
dementia) were followed for 3 years During this time frame 23 individuals converted to probable AD for an annual rate
of approximately 6
In a US Class III study from a large health maintenance organization in Seattle a group of memory impaired
subjects were followed18 Of 811 subjects with a mean age of 74 years who had been recruited through a registry for
cognitive complaints 21 subjects with a severe isolated memory loss were followed for a mean of 48 months During this
time period 48 developed dementia for an annual conversion rate of approximately 12 per year
Investigators at New York University in a Class III study using the Global Deterioration Scale as a measure to assess
impairment followed individuals with a Global Deterioration Scale rating of 3 which represented mild cognitive
impairment for these investigators19 They found that 16 of 32 of these individuals had progressed to a diagnosis of AD
over 22 years (25 per year)19 and concluded that mild cognitive impairment was a risk factor for subsequent
development of dementia
Conclusions Taken together these studies indicate that individuals characterized as being cognitively impaired but
not meeting clinical criteria for dementia or AD (mild cognitive impairment) have a high risk of progressing to dementia
or AD If the figures for incident AD from the general population are used from table 4 one can see that the rates range
by on August 22 2010 wwwneurologyorgDownloaded from
Factores de riesgo de conversioacuten
ldquoReserva Funcionalrdquo
Baja escolaridad
Menor nivel intelectual
Edad
Inactividad laboral
Bajo nivel cultural
Estudio longitudinal de una poblacioacuten en riesgo de demenciaSeguimiento 50 mesesAllegri
No todo DCL evoluciona a demencia la bibliografiacutea reporta desde un12 a un 2 Los pacientes que presentariacutean mayor riesgo seriacutean losque presentan afeccioacuten de la memoria mas otro dominio
In various studies a substantial percentage (11 to 40) of patients with MCIimprove even to normal over a one to three-year follow-up time
Faltariacutea aun el punto de corte de normalidad y anormalidad
Descartar depresioacuten
La persistencia de los cambios en evaluaciones sucesivas
En el DLC puede existir dependencia parcial en AIVD
El diagnostico de DCL es cliacutenico cognitivo y funcional
Llamadas de atencioacuten en el perfil neuropsicoloacutegico
Fallas en la memoria episoacutedica semaacutentica (estrategia de asociacioacuten semaacutentica en elaprendizaje de palabras) y diferida
Presencia de intrusiones (produccioacuten equivocada del nombre de un objeto) A mayornumero de intrusiones mayor riesgo de AD
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
DLC
Mayo Clinic criteria para DLC amneacutesico deacuteficit y queja cognitiva
International Working Group deacuteficit objetivo y subjetivo de cualquier
dominio
Clinical Dementia Rating (CDR) focaliza en declinacioacuten cognitiva en las funciones de la vida diaria mas que en el deacuteficit cognitivo objetivo
Hipoacutetesis la prevalencia de DCL varia considerablemente seguacuten la definicioacuten
Estudios de
cohorte
indican al igual
que estudios
previos que el
DCL es una
entidad
heterogeacutenea a
nivel de
poblacioacuten
Arch Neurol 2011 June 68(6) 761ndash767
Outcomes of mild cognitive impairment depend on definition a
population study
Olvidos leves constantes
Orientado pero con leve dificultad
para las relaciones temporales
Leve dificultad para resolver
problemas similitudes y diferencias
Leve dificultad en las actividades
fuera de la casa
Aficiones e intereses intelectuales
algo limitados
Capaz de cuidarse por si mismo
Detection of Dementia Page 4
age-associated cognitive decline (AACD) have been used They are distinct from the concept of mild cognitive
impairment as used in the current article Age-associated memory impairment refers to the concept of increasing memory
impairment with age and references memory function in the elderly cohort to young normal adult subjects As such there
can be an overinclusion of neurologically normal individuals in this concept and it has been critiqued as such13 Age-
associated cognitive decline refers to the concept of mild impairments in multiple cognitive domains but not of sufficient
severity to constitute the diagnosis of dementia This is a useful concept however few longitudinal studies have been
conducted using this nomenclature and this classification scheme also includes many normal elderly persons Each of
these terms either includes a segment of the normal population and represents extremes of normal aging andor is more
inclusive than the current definition of mild cognitive impairment As such they are not directly germane to the current
discussion Individuals with mild cognitive impairment meet criteria similar to those shown in table 1 There are
differences in the literature with respect to the sources of subjects age education and criteria but a general pattern of
clinical progression has emerged These studies are summarized in table 5 The conversion criteria refer to either the
development of dementia or AD
Table 5 Studies demonstrating outcome of persons with mild cognitive impairment (MCI) or similar condition
Study
Subjects
no
Mean age
y Source Criteria
Duration
follow-
up y
Annual
conversion
rate to
dementia or
AD Class
Mayo2 66 81 Community practice MCI 4 12 II
Toronto1415 107 74 Family practice Memory impairment 2 14 II
Columbia16 127 66 Memory disorders clinic Questionable dementia 27 15 II
MGH17 123 72 Community advertising CDR 05 3 6 II
Seattle18 21 74 Health Maintenance
Organization
Isolated memory loss 38 12 III
NYU19 32 71 Dementia clinic GDS 3 22 25 III CDR = Clinical Dementia Rating GDS = Global Deterioration Scale
In a Class II US study from the Mayo Clinicrsquos longitudinal study of aging and dementia subjects were recruited
from a primary care practice which served the residents of Rochester MN2 Subjects were enrolled if they expressed a
concern about their cognitive function a family member appreciated a change in cognitive function or the primary care
physician indicated a concern These were community-dwelling individuals and the mean age at the time of enrollment
was 81 years The subjects were classified as having mild cognitive impairment if they met criteria similar to those shown
in table 1 When the subjects were followed for up to 4 years they converted to AD at a rate of 12 per year2 By 6 years
approximately 80 of the individuals had developed AD10
In another Class II Canadian study from a similar setting in Toronto 107 subjects with a memory impairment without
dementia were followed for 2 years1415 Subjects were referred to the study by family physicians and the mean age of the
subjects was 74 years During the 2-year follow-up 29 (approximately 28) developed AD for an approximate annual
conversion rate of 14
A Class II US study exploring the natural history of subjects from a memory disorders clinic at Columbia University
evaluated 127 consecutive subjects with questionable dementia However these subjects did not meet criteria for
dementia16 This group represented subjects seen in a referral setting with a mean age of 66 years Approximately 40 of
the subjects were not followed for various reasons During the course of 27 years 413 of the subjects who were
followed became demented for an annual conversion rate of approximately 15
In a recent US Class II study from Massachusetts General Hospital persons were recruited from the community
through media advertisements17 A total of 123 persons with a Clinical Dementia Rating (CDR) of 05 (questionable
dementia) were followed for 3 years During this time frame 23 individuals converted to probable AD for an annual rate
of approximately 6
In a US Class III study from a large health maintenance organization in Seattle a group of memory impaired
subjects were followed18 Of 811 subjects with a mean age of 74 years who had been recruited through a registry for
cognitive complaints 21 subjects with a severe isolated memory loss were followed for a mean of 48 months During this
time period 48 developed dementia for an annual conversion rate of approximately 12 per year
Investigators at New York University in a Class III study using the Global Deterioration Scale as a measure to assess
impairment followed individuals with a Global Deterioration Scale rating of 3 which represented mild cognitive
impairment for these investigators19 They found that 16 of 32 of these individuals had progressed to a diagnosis of AD
over 22 years (25 per year)19 and concluded that mild cognitive impairment was a risk factor for subsequent
development of dementia
Conclusions Taken together these studies indicate that individuals characterized as being cognitively impaired but
not meeting clinical criteria for dementia or AD (mild cognitive impairment) have a high risk of progressing to dementia
or AD If the figures for incident AD from the general population are used from table 4 one can see that the rates range
by on August 22 2010 wwwneurologyorgDownloaded from
Factores de riesgo de conversioacuten
ldquoReserva Funcionalrdquo
Baja escolaridad
Menor nivel intelectual
Edad
Inactividad laboral
Bajo nivel cultural
Estudio longitudinal de una poblacioacuten en riesgo de demenciaSeguimiento 50 mesesAllegri
No todo DCL evoluciona a demencia la bibliografiacutea reporta desde un12 a un 2 Los pacientes que presentariacutean mayor riesgo seriacutean losque presentan afeccioacuten de la memoria mas otro dominio
In various studies a substantial percentage (11 to 40) of patients with MCIimprove even to normal over a one to three-year follow-up time
Faltariacutea aun el punto de corte de normalidad y anormalidad
Descartar depresioacuten
La persistencia de los cambios en evaluaciones sucesivas
En el DLC puede existir dependencia parcial en AIVD
El diagnostico de DCL es cliacutenico cognitivo y funcional
Llamadas de atencioacuten en el perfil neuropsicoloacutegico
Fallas en la memoria episoacutedica semaacutentica (estrategia de asociacioacuten semaacutentica en elaprendizaje de palabras) y diferida
Presencia de intrusiones (produccioacuten equivocada del nombre de un objeto) A mayornumero de intrusiones mayor riesgo de AD
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
Detection of Dementia Page 4
age-associated cognitive decline (AACD) have been used They are distinct from the concept of mild cognitive
impairment as used in the current article Age-associated memory impairment refers to the concept of increasing memory
impairment with age and references memory function in the elderly cohort to young normal adult subjects As such there
can be an overinclusion of neurologically normal individuals in this concept and it has been critiqued as such13 Age-
associated cognitive decline refers to the concept of mild impairments in multiple cognitive domains but not of sufficient
severity to constitute the diagnosis of dementia This is a useful concept however few longitudinal studies have been
conducted using this nomenclature and this classification scheme also includes many normal elderly persons Each of
these terms either includes a segment of the normal population and represents extremes of normal aging andor is more
inclusive than the current definition of mild cognitive impairment As such they are not directly germane to the current
discussion Individuals with mild cognitive impairment meet criteria similar to those shown in table 1 There are
differences in the literature with respect to the sources of subjects age education and criteria but a general pattern of
clinical progression has emerged These studies are summarized in table 5 The conversion criteria refer to either the
development of dementia or AD
Table 5 Studies demonstrating outcome of persons with mild cognitive impairment (MCI) or similar condition
Study
Subjects
no
Mean age
y Source Criteria
Duration
follow-
up y
Annual
conversion
rate to
dementia or
AD Class
Mayo2 66 81 Community practice MCI 4 12 II
Toronto1415 107 74 Family practice Memory impairment 2 14 II
Columbia16 127 66 Memory disorders clinic Questionable dementia 27 15 II
MGH17 123 72 Community advertising CDR 05 3 6 II
Seattle18 21 74 Health Maintenance
Organization
Isolated memory loss 38 12 III
NYU19 32 71 Dementia clinic GDS 3 22 25 III CDR = Clinical Dementia Rating GDS = Global Deterioration Scale
In a Class II US study from the Mayo Clinicrsquos longitudinal study of aging and dementia subjects were recruited
from a primary care practice which served the residents of Rochester MN2 Subjects were enrolled if they expressed a
concern about their cognitive function a family member appreciated a change in cognitive function or the primary care
physician indicated a concern These were community-dwelling individuals and the mean age at the time of enrollment
was 81 years The subjects were classified as having mild cognitive impairment if they met criteria similar to those shown
in table 1 When the subjects were followed for up to 4 years they converted to AD at a rate of 12 per year2 By 6 years
approximately 80 of the individuals had developed AD10
In another Class II Canadian study from a similar setting in Toronto 107 subjects with a memory impairment without
dementia were followed for 2 years1415 Subjects were referred to the study by family physicians and the mean age of the
subjects was 74 years During the 2-year follow-up 29 (approximately 28) developed AD for an approximate annual
conversion rate of 14
A Class II US study exploring the natural history of subjects from a memory disorders clinic at Columbia University
evaluated 127 consecutive subjects with questionable dementia However these subjects did not meet criteria for
dementia16 This group represented subjects seen in a referral setting with a mean age of 66 years Approximately 40 of
the subjects were not followed for various reasons During the course of 27 years 413 of the subjects who were
followed became demented for an annual conversion rate of approximately 15
In a recent US Class II study from Massachusetts General Hospital persons were recruited from the community
through media advertisements17 A total of 123 persons with a Clinical Dementia Rating (CDR) of 05 (questionable
dementia) were followed for 3 years During this time frame 23 individuals converted to probable AD for an annual rate
of approximately 6
In a US Class III study from a large health maintenance organization in Seattle a group of memory impaired
subjects were followed18 Of 811 subjects with a mean age of 74 years who had been recruited through a registry for
cognitive complaints 21 subjects with a severe isolated memory loss were followed for a mean of 48 months During this
time period 48 developed dementia for an annual conversion rate of approximately 12 per year
Investigators at New York University in a Class III study using the Global Deterioration Scale as a measure to assess
impairment followed individuals with a Global Deterioration Scale rating of 3 which represented mild cognitive
impairment for these investigators19 They found that 16 of 32 of these individuals had progressed to a diagnosis of AD
over 22 years (25 per year)19 and concluded that mild cognitive impairment was a risk factor for subsequent
development of dementia
Conclusions Taken together these studies indicate that individuals characterized as being cognitively impaired but
not meeting clinical criteria for dementia or AD (mild cognitive impairment) have a high risk of progressing to dementia
or AD If the figures for incident AD from the general population are used from table 4 one can see that the rates range
by on August 22 2010 wwwneurologyorgDownloaded from
Factores de riesgo de conversioacuten
ldquoReserva Funcionalrdquo
Baja escolaridad
Menor nivel intelectual
Edad
Inactividad laboral
Bajo nivel cultural
Estudio longitudinal de una poblacioacuten en riesgo de demenciaSeguimiento 50 mesesAllegri
No todo DCL evoluciona a demencia la bibliografiacutea reporta desde un12 a un 2 Los pacientes que presentariacutean mayor riesgo seriacutean losque presentan afeccioacuten de la memoria mas otro dominio
In various studies a substantial percentage (11 to 40) of patients with MCIimprove even to normal over a one to three-year follow-up time
Faltariacutea aun el punto de corte de normalidad y anormalidad
Descartar depresioacuten
La persistencia de los cambios en evaluaciones sucesivas
En el DLC puede existir dependencia parcial en AIVD
El diagnostico de DCL es cliacutenico cognitivo y funcional
Llamadas de atencioacuten en el perfil neuropsicoloacutegico
Fallas en la memoria episoacutedica semaacutentica (estrategia de asociacioacuten semaacutentica en elaprendizaje de palabras) y diferida
Presencia de intrusiones (produccioacuten equivocada del nombre de un objeto) A mayornumero de intrusiones mayor riesgo de AD
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
Factores de riesgo de conversioacuten
ldquoReserva Funcionalrdquo
Baja escolaridad
Menor nivel intelectual
Edad
Inactividad laboral
Bajo nivel cultural
Estudio longitudinal de una poblacioacuten en riesgo de demenciaSeguimiento 50 mesesAllegri
No todo DCL evoluciona a demencia la bibliografiacutea reporta desde un12 a un 2 Los pacientes que presentariacutean mayor riesgo seriacutean losque presentan afeccioacuten de la memoria mas otro dominio
In various studies a substantial percentage (11 to 40) of patients with MCIimprove even to normal over a one to three-year follow-up time
Faltariacutea aun el punto de corte de normalidad y anormalidad
Descartar depresioacuten
La persistencia de los cambios en evaluaciones sucesivas
En el DLC puede existir dependencia parcial en AIVD
El diagnostico de DCL es cliacutenico cognitivo y funcional
Llamadas de atencioacuten en el perfil neuropsicoloacutegico
Fallas en la memoria episoacutedica semaacutentica (estrategia de asociacioacuten semaacutentica en elaprendizaje de palabras) y diferida
Presencia de intrusiones (produccioacuten equivocada del nombre de un objeto) A mayornumero de intrusiones mayor riesgo de AD
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
No todo DCL evoluciona a demencia la bibliografiacutea reporta desde un12 a un 2 Los pacientes que presentariacutean mayor riesgo seriacutean losque presentan afeccioacuten de la memoria mas otro dominio
In various studies a substantial percentage (11 to 40) of patients with MCIimprove even to normal over a one to three-year follow-up time
Faltariacutea aun el punto de corte de normalidad y anormalidad
Descartar depresioacuten
La persistencia de los cambios en evaluaciones sucesivas
En el DLC puede existir dependencia parcial en AIVD
El diagnostico de DCL es cliacutenico cognitivo y funcional
Llamadas de atencioacuten en el perfil neuropsicoloacutegico
Fallas en la memoria episoacutedica semaacutentica (estrategia de asociacioacuten semaacutentica en elaprendizaje de palabras) y diferida
Presencia de intrusiones (produccioacuten equivocada del nombre de un objeto) A mayornumero de intrusiones mayor riesgo de AD
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
Estimulacioacuten cognitiva Habitualmente es llevada a cabo por personal adiestrado con un grupo pequentildeo de cuatro
o cinco pacientes con demencia durante alrededor de 45 minutos al menos dos veces por
semana
Revisioacuten (15 ensayos con 718 participantes) la estimulacioacuten cognitiva tiene un efecto
beneficioso sobre las puntuaciones de las pruebas de la memoria y el pensamiento en los
pacientes con demencia
La n con un beneficio claro en la funcioacuten cognitiva
(diferencia de medias estandarizada [DME] 041 IC del 95 025 a 057) al mes y a tres
meses Se observaron beneficios en la calidad de vida y el bienestar informados por el
paciente (DME 038 [IC del 95 011 065]) y en las calificaciones del personal en
cuanto a la comunicacioacuten y la interaccioacuten social (DME 044 IC del 95 017 a 071)
No se encontraron pruebas de mejoriacuteas en el estado de aacutenimo ni en su capacidad de
cuidarse a siacute mismos o de funcionar de forma independiente
Los ensayos incluyeron a pacientes con estadios leves a moderados de demencia y la
intervencioacuten no parece ser apropiada para los pacientes con demencia grave
Aguirre E Spector A Orrell M Estimulacioacuten cognitiva para mejorar el funcionamiento cognitivo en pacientes con
demencia Cochrane Database of Systematic Reviews 2012httpwwwuptodatecomcontentsmild-cognitive-impairment-prognosis-and-treatmentabstract200
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
Tratamiento farmacoloacutegico Inhibidores ACE (donepezil galantaminerivastigmine) en el
tratamiento del DCL no han demostrado prevenir el riesgo de desarrollo de demencia
Cholinesterase inhibitors for mild cognitive impairmentCochraneDatabase Syst Rev 20129CD009132
The risk ratio (RR) for conversion at two years was significantly
There was essentially no effect of cholinesterase inhibitors on cognitivetest scores
There were significantly more adverse events in the cholinesteraseinhibitor groups (RR 109 95 CI 102 to 116)
Gastrointestinal side effects were much more common (diarrhoea RR 210 95 CI 130 to 339 nausea RR 297 95 CI 257 to 342 vomiting RR 442 95 CI 323 to 605)
Muscle spasmsleg cramps (RR 752 95 CI 434 to 1302) headache (RR 134 95 CI 105 to 171) syncope or dizziness (RR 162 95 CI 136 to193) insomnia (RR 166 95 CI 136 to 202) and abnormal dreams (RR 425 95 CI 257 to 704)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
Conclusiones El deterioro cognitivo leve no es una enfermedad ni un
desorden pero si un factor de riesgo para el desarrollo de demencia
y AD(Int J Alzheimers Dis 2010 2010 417615Are Guidelines Needed for the Diagnosis and Management of Incipient
Alzheimers Disease and Mild Cognitive Impairment)
En el campo de la AD todaviacutea no se ha establecido un viacutenculo entre
la aparicioacuten de cualquier biomarcador especiacutefico en individuos
asintomaacuteticos y la posterior aparicioacuten de la sintomatologiacutea cliacutenica(Alzheimers Dement 2011 May 7(3) 280ndash292Toward defining the preclinical stages of Alzheimers disease
Recommendations from the National Institute on Aging-Alzheimers Association workgroups on diagnostic
guidelines for Alzheimers disease)
Hay varias razones para esta limitacioacuten (1) se necesita
investigar maacutes sobre el uso de biomarcadores (2) no existe
estandarizacioacuten de marcadores bioloacutegicos de un lugar a otro
y hay limitada experiencia con puntos de corte para el
diagnoacutestico y (3) el acceso a los biomarcadores puede ser
limitado en diferentes contextos
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
Al paciente iquestQueacute se le dice a los pacientes con deterioro cognitivo leve
No hay tratamiento farmacoloacutegico para el DCL Puede conversar
con el paciente sobre el posible uso no aprobado de los inhibidores
acetylcholinesterasa
En todos los pacientes con DCL el asesoramiento debe ofrecerse
sobre las expectativas de esta afeccioacuten
A 5 antildeos hay un 50 de probabilidades de que una persona se
mantenga estable y hay una probabilidad pequentildea tambieacuten que la
persona vuelva a la normalidad
Sugerencias para la modificacioacuten de estilo de vida incluyendo las
actividades intelectuales actividades fiacutesicas conexioacuten social y
una dieta saludable tambieacuten puede ser beneficioso
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
From a clinical perspective patients with mild cognitive
impairment should not be labeled as having early Alzheimers
disease prodromal Alzheimers disease or mild cognitive
impairment of the Alzheimers disease type since the patient and
family are likely to hear only ldquoAlzheimers diseaserdquo and not
appreciate the uncertainty of the association with Alzheimers
disease Clinicians should make it clear that mild cognitive
impairment is an abnormal condition but that the precise outcome
is not certain
Mild Cognitive ImpairmentRonald C Petersen MD PhDN Engl J Med 2011 3642227-2234
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
Conducta Reevaluar a 6 meses para determinar progresioacuten de deterioro
Valorar continuidad de tratamiento antidemencial
Citar familiar para completar valoracioacuten
Pautas de estimulacioacuten cognitiva
Evidence of progressive decline in cognition provides
additional evidence that the individual has ldquoMCI due to ADrdquo
as noted earlier in the text Thus it is important to obtain
longitudinal assessments of cognition whenever possible
(The diagnosis of mild cognitive impairment due to Alzheimerrsquos disease Recommendations from
the National Institute on Aging-Alzheimerrsquos Association workgroups on diagnostic guidelines for
Alzheimers disease)
