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Introduction
The aim of this paper is to analyze a treatment guideline as it relates to a recent clinical
experience. Mild neurocognitive impairment (MCI) is the selected psychiatric disorder for this
The patient in this interesting case is a married, 60 year-old male Veteran of the U.S. Army
who presented to the Veteran’s Administration Hospital GEM clinic with a ten-year history of
progressive memory loss and word-finding difficulty. He was referred by his primary care physician
(PCP). He had been started on bupropion 50mg, for smoking cessation, about 4 weeks prior to the
visit. Recent laboratory studies revealed low vitamin B12 level of 44ng/L and his MRI of the brain
revealed both parietal and frontotemporal region volume loss. During this GEM clinic visit, a full
mental health evaluation was completed along with three screening tools administered, the Lawton
Instrumental Assessment of Daily Living (IADL), Montreal Cognitive Assessment (MoCA) and
Geriatric Depression Scale (GDS). Results of these screening evaluations were: MoCA 24/30 and
GDS 6/15. He displayed minimal deficits related to the IADL screening. During the interview the
patient demonstrated mild word finding difficulty and memory impairment. After careful review of
past, present and collateral information, the patient was diagnosed with mild cognitive impairment.
intended to optimize patient care. They contain a systematic review of research and assessment of
the benefits and risks of treatment options. The American Academy of Neurology (AAN) practice
guideline for the treatment of Mild Cognitive Impairment (2016) is an update from their 2001 MCI
guideline and was selected for application to this case because it provides the most current
recommendations for screening, diagnosis and treatment. The AAN guidelines are based on Class I
PATIENT MANAGEMENT PAPER 3
thru Class III clinical research and include Level A thru Level C recommendations to clinicians on
assessing and diagnosing MCI. The AAN (2016) clinical practice guidelines are also the foundation
for MCI treatment in UpToDate. Furthermore, they are endorsed by the Alzheimer’s Association.
The guideline was retrieved from the internet on the AAN website.
The AAN practice guideline for MCI is broken down into four sections: prevalence,
They begin by discussing the prevalence of MCI in populations aged 60 and older:
14.8% 75-79
Of great concern for patients, families and clinicians is the prognosis of MCI to dementia.
Identification of reversible causes of MCI as well as prevention to dementia above all else is the
objective in treatment. Class I evidence reports persons 65 and older with MCI have a 14.9% higher
The U.S. Food and Drug Administration (FDA) approved one class of medication for
messenger important for learning and memory. Class II evidence illustrates use of donepezil is
possibly ineffective for reducing the chances of progression to dementia or Alzheimer’s dementia as
well as galantamine and rivastigmine. Patient 123 was not placed on an anticholinesterase inhibitor
at this time based on his symptoms. Should clinicians choose to offer cholinesterase inhibitors,
PATIENT MANAGEMENT PAPER 4
they must first discuss with patients the fact that this is an off-label prescription not currently
lowering B vitamin therapies, piribedil and rofecoxib. There is insufficient evidence to support or
refute the cognitive benefits of any such treatment and rofecoxib could possibly increase the risk of
progression to dementia (AAN, 2016). Flavanoid containing drink mixes have garnered much
attention in the media for their antioxidant protective benefits however as mentioned in the practice
including folate, are not supported as an evidence-based treatment practice. Piribedil, a dopamine
receptor agonist used in Parkinson’s disease, and rofecoxib, an anti-inflammatory, both lack
evidence to support a positive effect on cognitive measures in MCI. Data on Vitamin E and
Vitamin C are insufficient to support an effect on MCI however; one Class II study demonstrates
some possible cognitive improvement with tesamorelin growth hormone injections over a 20 week
period (AAN, 2017). Patient 123 is currently on none of these medications nor any over-the-
evidence likely to improve cognition and also provides overall health benefits (AAN, 2016).
Patient 123 continues to be physically active however his body mass index (BMI) is 27.4 per the
National Institute of Health (NIH) which deems him overweight (NIH, 2018). He does not engage
in any type of formal cognitive training interventions such as memory-recall tests nevertheless,
Class II evidence does not support nor refute the use of any individual cognitive intervention
Recommendations from the AAN stress the importance of assessing individuals with MCI.
Clinicians should not assume concerns about memory or impaired cognition voiced
by the patient or close relatives with whom the patient is in contact are related to
Clinicians should not rely on historical reporting of memory concerns alone when
Clinicians should use validated assessment tools to assess for cognitive impairment
and for patient who test positive for MCI, clinicians should perform a more formal
Patients with MCI should be assessed for the presence of functional impairment
Clinical should perform a medical evaluation for MCI risk factors that are
potentially modifiable.
Clinicians should perform serial assessments over time to monitor for changes in
cognitive status.
effects on MCI as well. There is also little evidence to support the use of cognitive interventions
however; twice-weekly exercise for six months does seem to show improvement in cognitive
PATIENT MANAGEMENT PAPER 6
measures. Patient 123 is currently not being treated per any of the AAN pharmacologic or
nonpharmacological guidelines since he is in the early phase of his diagnosis and the AAN stresses
the importance of assessing and identifying the possible underlying contributing factors for
individuals with MCI as judicious part of the treatment plan. Patient 123 received a thorough
medical evaluation, screening with three validated assessment tools and will be follow up serially at
the GEM clinic as part of his treatment plan in accordance with the AAN (2016) practice guidelines
for MCI.
Application of Guideline
The goal of treatment is to identify any modifiable risk factors as well as to limit and
potentially reverse progression to dementia. The patient’s treatment plan will also include a
associated with an increased risk for dementia. Patient 123 was placed on buproprion for smoking
cessation. This medication has dual benefits of treatment for both smoking cessation and
depressive symptoms. Bupropion 50mg daily will be continued. This medication is also continued
due to its favorable side effect profile of decreased sexual dysfunction compared to SSRIs (Rigotti,
2018).
Hearing loss—The patient has a history of hearing loss. A growing number of studies suggest that
peripheral hearing loss may be a risk factor for the development of dementia, independent of age
and other potential confounding factors and greater annual rates of cognitive decline than those
without baseline hearing loss (Larson, 2017). It is important for the patient to follow up with his
Head trauma—Patient 123 has been diagnosed with multiple concussions throughout his lifetime.
Risk factors for chronic cognitive impairment after head injury are not well recognized although
this remains a possible contributing factor to cognitive impairment for the patient (Larson, 2017). It
is important for him to maintain a safe environment in order to prevent further head trauma by
decreasing potentially dangers such as climbing ladders, working with heavy equipment or
Vitamin B 12 deficiency- Although the AAN practice guidelines demonstrate insufficient evidence
use of homocysteine-lowering therapies they also do not refute the treatment. There is some
evidence that elevated serum homocysteine and/or low serum levels of folate, vitamin B6, and
vitamin B12 may be associated with impaired cognition and risk of dementia (Press and Alexander,
2018). Correction of low vitamin B12 levels can be accomplished over a short period of time using
Hypertension-- Although the relationship between blood pressure and dementia risk is complex,
most evidence suggests that hypertension is associated with an approximate 1.5-fold increase in the
relative risk of dementia, especially when present in midlife (Larson, 2017). Vital signs will be
monitored as part of the routine office visit with his mental health provider and recommendations to
Smoking—First-line pharmacologic therapy for smoking cessation, approved by the Food and Drug
atherosclerosis risk factors. There are long documented risks to cardiovascular health associated
vascular dementia however, there remains inconclusive data as to whether it plays a significant part
cerebrovascular disease. The patient will be referred to his PCP for evaluation of
hypercholesterolemia.
homeostasis. APOE 4 is a susceptibility gene not a determinative gene in that individuals with two
copies of the APOE 4 allele are at the highest risk of acquiring Alzheimer’s dementia (Sherva and
Kowall, 2017). Patient 123 will be referred to the VA laboratory for serum blood work to include
Remission of Depression--Rescreening with the GDS and during the interview assessing mood and
treatment plan.
Follow-Up Care—Continue to follow up at the GEM clinic and annually screen the patient using
the MoCA, IADL, EXIT-16, CLOX1, CLOX2 to evaluate improvement or decline in MCI.
Exercise Plan—Have the patient develop and engage in an exercise program to lower his BMI to
NIH healthy standards (BMI 18.5-24.9) for cardiovascular health and as an adjunct to treatment of
depressive symptoms.
Cognitive Interventions—Discuss with the patient use of cognitive rehabilitation exercises as part
of treatment such as memory training. Multiple small studies have demonstrated short-term
improvements in various cognitive domains after cognitive training programs compared with a
control condition, the benefits tend to be small, and studies that have measured long-term outcomes
generally demonstrate waning effects over time (McDade & Peterson, 2018).
improvement in cognitive test performance in patients with MCI (Larson, 2017). It would be
beneficial to include this in the treatment plan for patient 123 should bupropion be ineffective.
Anticipatory Guidance
Anticipating needs for patients and caregivers with MCI can be challenging. The most
important need would include ongoing discussions to help the patient and family understand the
potential causes and contributing factors of MCI and to discuss the possibilities of converting from
mild to major cognitive impairment in the future. Failure to discuss this possibility and balancing
PATIENT MANAGEMENT PAPER 10
the anxiety of such a reality will take time. This type of information is not given to the patient in a
single visit but as the therapeutic relationship builds these conversations will be necessary.
Referrals/Consultations
sources of information about the patient, including data collected from an interview, collateral
complement the clinician’s assessment and assist with MCI diagnosis (Larson, 2018).
Continuity of Care
Collaborating with his PCP regarding the diagnosis of MCI and the treatment plan is
imperative. Requesting data from previous health records, laboratory findings, and physical
Critical Analysis
Patients and caregivers of individuals with MCI and dementias face a multitude of obstacles.
In 2016, the economic impact of MCI and dementia was astronomical with regard to unpaid
caregivers at 18.2 billion unbilled hours at an average of $12.65/hour equating to $230.1 billion
dollars in the U.S. alone (Alzheimer’s Association, 2017). These estimates are expected to rise
dramatically as the number of adults aged 65 and older in 2025 reaches about 60% (U.S.
Department of Commerce, 2014). This financial burden is not lost within the workplace either,
with caregivers contributing less working hours per week due to coming in late or leaving early,
leave of absence, switching from full to part-time or leaving the workforce all together accounting
for almost $470 billion dollars in 2013 (Family Caregiving Alliance, 2016).
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The social impact of individuals with MCI or dementias has an impact on the use of health
care services. People with cognitive impairment have twice as many hospital stays per year than
older adults without MCI or dementia. Furthermore, the use of health care services by people with
other serious medical conditions is strongly affected by the presence or absence of cognitive
impairment or dementia resulting in longer hospital stays with a potential lack of resources to
There is also a shortage of professionals who are specialized in treating older adults.
The American Geriatrics Society states “due to the increase in older Americans and the stagnation
in the number of new geriatric professionals trained in the past decade, the differential will increase
to one geriatrician and one geriatric psychiatrist for every 4,484 and 20,448 older Americans, by the
year 2030” (Alzheimer’s Association, 2017). In addition, less than 1 percent of registered nurses,
Association, 2017). This could create a potential moral burden on society if mental health
Educating patients and families to anticipate problems with accomplishing daily tasks,
short-term memory, concentration, or language are expected (McDade and Peterson, 2018).
Educating patients and families that trials of anticholinesterase inhibitors have been found to
not prevent the progression of MCI to dementia and are not routinely recommended
Education regarding support groups (i.e. Alz. Connected) for caregiver needs would be
provided during treatment should symptoms progress to help prevent caregiver burnout (Alz.
Org, 2018).
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Summary
psychiatric nurse practitioners it is imperative to understand that evidenced based guidelines are
established and are meant to assist with developing a comprehensive and sound treatment plan.
Nurse practitioners are best suited in patient-family centered care when educating about MCI by
incorporating a comprehensive treatment plan that includes safety needs, activities of daily living,
pharmacologic interventions and collaborating with members of the patient’s health care team.
PATIENT MANAGEMENT PAPER 13
References
Alzheimer’s Association. (2017). 2018 Alzheimer’s disease facts and figures. Alz.Org. Retrieved
from: https://www.alz.org/facts/overview.asp
American Academy of Neurology. (2016). Mild cognitive impairment: report of the guideline
https://www.aan.com/Guidelines/home/GetGuidelineContent/887
Family Caregiver Alliance. (2016). Caregiver statistics. Family Caregiver Alliance. Retrieved from:
https://www.caregiver.org/caregiver-statistics-demographics
Larson, E. B. (2017). Risk factors for cognitive decline and dementia. UpToDate. Retrieved from:
https://www.uptodate.com/contents/risk-factors-for-cognitive-decline-and-dementia
Larson, E.B. (2018). Evaluation of cognitive impairment and dementia. UpToDate. Retrieved from:
https://www.uptodate.com/contents/evaluation-of-cognitive-impairment-and-dementia
McDade, E.M. & Peterson, R.C. (2018). Mild cognitive impairment: prognosis and treatment.
impairment-prognosis-and-treatment
National Institute of Health [NIH]. 2018. Calculate your body mass index. National Institute of
https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
Peterson, R.C., Lopez, O., Armstrong, M.J., Getchius, T.S.D., Ganguli, M., Gloss, D., …Rae-Grant,
90(3), 126-135
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https://www.uptodate.com/contents/prevention-of-dementia
from: https://www.uptodate.com/contents/overview-of-smoking-cessation-management-in-
adults
Sherva, R. & Kowall, N. W. (2017). Genetics of Alzheimer disease. UpToDate. Retrieved from:
https://www.uptodate.com/contents/genetics-of-alzheimer-disease