An Update for Nurses

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An Update for Nurses HOW TO OBTAIN CONTACT HOURS BY READING THIS ARTICLE

ABSTRACT Mild cognitive impairment (MCI) is a mild decline in single or

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multiple cognitive domains, while global cognition and basic

2.1 contact hours will be awarded for this activity. A contact hour is 60 minutes of instruction. This is a Learner-Paced Program. Vindico Medical Education does not require submission of quiz answers. A contact hour certificate will be awarded 4 to 6 weeks upon receipt of your completed Registration Form, including the Evaluation portion. To obtain contact hours: 1. Read the article “TITLE” on pages xx-xx, carefullyImpairment: noting the “Caringby forAUTHORS Older Adults with Mild Cognitive tables and other illustrative materials that areDavid provided to enhance your An Update for Nurses” by Feng Lin, PhD, RN; E. Vance, PhD, MGS; knowledge and understanding of the M. content. Carey E. Gleason, PhD, MS; and Susan Heidrich, PhD, RN, on pages 22-35,each carefully noting tables andanswers. other illustrative materialsallthat are 2. Read question andthe record your After completing quesprovided to enhance your knowledge and understanding tions, compare your answers to those provided at the end of of the the content. quiz. 2. Type Read or each question record your answers. completing all ques3. print your fulland name, address, and dateAfter of birth in the spaces tions, compare answersform. to those provided at the end of the quiz. provided on theyour registration 3. Indicate Type or print yourtime full name, address, and date of birth in the spaces 4. the total spent on the activity (reading article and completprovided on the and registration form. be processed if this section is incoming quiz). Forms quizzes cannot Allthe participants required the accreditation agency attest to 4. plete. Indicate total timeare spent on thebyactivity (reading article andtocompletthe activity. ing time quiz).spent Formscompleting and quizzesthe cannot be processed if this section is incomplete. Allthe participants areform required by the accreditation to $20 attest to 5. Forward completed with your check or moneyagency order for the time spentto completing thepayments activity. must be made in U.S. dollars and made payable JGN-CNE. All be drawn on U.S.with banks. CNE Registration be 5. checks Forwardmust the completed form your check or moneyForms ordermust for $20 received no later Month 20XX. must be made in U.S. dollars and made payable to than JGN-CNE. AllDay, payments checks must be drawn on U.S. banks. CNE Registration Forms must be Thisreceived activity isno co-provided by Vindico31, Medical later than December 2014. Education and the Journal of Gerontological Nursing. This activity is co-provided by Vindico Medical Education and the Journal of Vindico Medical Education, Gerontological Nursing. LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Vindico Medical Education, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Activity Objectives Accreditation. 1. Objective 1

activities of daily living remain intact. Nurses play an impor-

Activity Objectives

2. Objective 2 1. Identify the prevalence and progression data related to mild cognitive 3. Objective 3 (MCI). impairment 4. 4 diagnostic criteria and clinical diagnosis for MCI. 2. Objective Discuss the 5. 5 factors associated with MCI. 3. Objective Describe risk 4. Describe the updated information on prevention and treatment of MCI.

Author Disclosure Statement

5. Discuss the challenges individuals with MCI and their families face. Statement

Author Disclosure Statement Commercial Support Statement

Theauthors authors disclose that they havethat no significant interests in any All and planners have agreed this activityfinancial will be free of commercial product orisclass of products discussed directly or There indirectly this activity, bias. There no commercial support for this activity. is no in non-commercial including support. support forresearch this activity.

Commercial Support Statement

All authors and planners have agreed that this activity will be free of commercial bias. There is no commercial support for this activity. There is no non-commercial support for this activity.

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tant role in early detection of MCI and providing care to maintain maximum independence for individuals with MCI. This article seeks to provide nurses with a review of the most recent research regarding the etiology and diagnosis of MCI, related risk and protective factors, patient and family experiences, and current interventions. This update provides research evidence to inform nursing practice of MCI care.

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ild cognitive impairment (MCI) is diagnosed when there is a mild decline in either single or multiple cognitive domains—such as memory, executive functioning, attention, or visuospatial abilities—while global cognition and basic activities of daily living (ADLs) remain intact (Albert et al., 2011; Gauthier et al., 2006). According to the most recently developed diagnostic criteria, MCI is considered to be a “symptomatic predementia phase of AD [Alzheimer’s disease]” (Albert et al., 2011, p. 271). Individuals with MCI often have more difficulty or may take longer than their counterparts without MCI in performing more cognitively demanding instrumental ADLs (IADLs) such as driving, telephone use, finding belongings, grocery shopping, medication management, food preparation, traveling alone, and handling finances (Aretouli & Brandt, 2010; Wadley, Okonkwo, Crowe, & Ross-Meadows, 2008). In older adults with MCI, even subtle declines in cognitive abilities or everyday functioning are associated with decreased independence and safety, caregiver burden (Gauthier et al.,

Feng Lin, PhD, RN; David E. Vance, PhD, MGS; Carey E. Gleason, PhD, MS; and Susan M. Heidrich, PhD, RN Copyright © SLACK Incorporated

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2006), a reduced chance of reverting to normal cognitive status (Peres et al., 2006), and an increased likelihood of developing dementia (Farias, Mungas, Reed, Harvey, & DeCarli, 2009). Despite these impairments, older adults with MCI generally live independently in the community. The impairments they report do not interfere with their ability to adequately carry out important social, family, and occupational roles (Aretouli & Brandt, 2010; Wadley et al., 2008). It is important to understand both the challenges these individuals face as well as how to assist them in meeting these challenges in order to assist older adults with MCI maintain their independence. The most recent National Institutes of Health statement emphasized the importance of under-

standing and providing better care to individuals diagnosed with MCI (Daviglus et al., 2010). A recent review found that primary care providers have difficulty identifying MCI in their patients and recording the diagnosis in the medical record (A.J. Mitchell, Meader, & Pentzek, 2011). Most individuals with MCI are community dwelling; thus, primary care providers, including nurses, play an important role in early detection and in providing evidence-based care to those with MCI. Since January 2011, Medicare has started reimbursing primary care providers to perform a more complete “Welcome to Medicare” visit with newly eligible members and a complete wellness visit on an annual basis. Both types of visit include detection of cognitive impairment, which further supports the

Journal of Gerontological Nursing • Vol. 38, No. 12, 2012

importance of developing expertise in detecting MCI for primary care providers (Alzheimer’s Association, 2012). The purpose of this article is to provide an update of current research on the diagnosis, prevention, and treatment of MCI. The goals are to assist nurses in primary care settings to understand the challenges those with MCI face, examine ways to help older adults overcome these challenges, and discuss the relevance for future nursing research. This update was based on published studies using the most recent standardized diagnostic criteria for MCI (Albert et al., 2011; Winblad et al., 2004). Published studies using other diagnostic criteria (e.g., Stage 3 of Reisberg’s Global Deterioration Scale, Clinical Dementia Rating score of 0.5) were not used in this review.

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CLINICAL DIAGNOSIS OF MCI

Historically, confusion and lack of precision surrounded the diagnosis of MCI. Terms and concepts such as amnestic MCI, aging-associated cognitive decline, cognitive impairment no dementia, and other such designations were used interchangeably (Ganguli, 2006). At the 2004 Stockholm International Workshop on Mild Cognitive Impairment, standard diagnostic criteria for MCI were established (Winblad et al., 2004). In October 2008, a billing code for MCI was established in the International Classification of Diseases, 9th Revision, Clinical Modification (Centers for Disease Control and Prevention, 2011). In April 2011, the diagnostic criteria of MCI due to Alzheimer’s disease (AD) were first added into the diagnostic guidelines for AD dementia as one of the phases of AD, although mainly for research purposes (Albert et al., 2011). The prevalence of MCI varies depending on the population in which it has been studied. Using Windblad’s 2004 diagnostic criteria, the prevalence of MCI was 42% in France (Artero et al., 2008), 28.3% in the United States (Manly et al., 2005), 24.3% in Austria (Fischer et al., 2007), 17.2% in Germany (Busse, Hensel, Gühne, Angermeyer, & Riedel-Heller, 2006), and 12.7% in China (Nie et al., 2011). According to a recent review of population- and community-based studies, the annual incidence rate of MCI ranged from 51 to 77 per 1,000 individuals 60 and older (Luck, Luppa, Briel, & Riedel-Heller, 2010). A review of 41 cohort studies with a maximum follow up of 10 years suggested that, on average, only 32% of people with MCI progress to dementia (A.J. Mitchell & Shiri-Feshki, 2009). In a multiethnic community-based study of 2,364 participants, the investigators specifically examined the reversion rate of MCI and found that 47% remained unchanged and 31% reverted to normal within an average of 4.7 years follow up (Manly et al.,

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2008). The reasons for these different outcomes remain unknown. The risk of mortality increased by 50% to 150% in individuals with MCI compared to those without MCI (Guehne, Luck, Busse, Angermeyer, & Riedel-Heller, 2007; Hunderfund et al., 2006; Wilson et al., 2009). A key recommendation arising from the National Institute on Aging and the Alzheimer’s Association Workgroup (Albert et al., 2011) was that MCI should be diagnosed based on the following measures: patient/ family interview, physical examination (including laboratory tests), and neuropsychological testing. However, in many primary care settings, a diagnosis of MCI is made on fewer criteria because the full range of diagnostic services is not available (Kaduszkiewicz et al., 2010). In general, a diagnosis of MCI is made if there is an objectively measured decline (1 to 1.5 standard deviation below the population norms) in one or more cognitive domains over time or a subjective report of decline by self-report or by an informant (e.g., family member) in conjunction with observed cognitive deficits. Basic ADLs are preserved, and IADLs are either intact or minimally impaired. There are four subtypes of MCI: amnestic singledomain, amnestic multiple-domain, non-amnestic single-domain, and non-amnestic multiple-domain. The subtypes are based on the number of cognitive domains affected and whether memory is one of them (i.e., amnestic) (Winblad et al., 2004). Patient/Family Interview It is essential to obtain the person’s health history to elicit information regarding the person’s impairment in relation to his or her functional and cognitive status. Open-ended questions should address the person’s cognition, social life, hobbies and interests, ADLs, IADLs, and family history of cognitive impairment. Some semi-structured interview checklists, such as the Total

Box Score (Daly et al., 2000) can also assist in obtaining a comprehensive background of the patient. Structured assessments of daily functioning are useful in determining the status of ADLs and IADLs. Individuals with MCI may or may not have the insight to provide information on their own health history, including cognitive decline and the status of ADLs and IADLs (Roberts, Clare, & Woods, 2009). On the other hand, caregivers’ or other family members’ emotional state and stress encountered during caregiving may interfere with their judgment of the person’s actual function or ability (Bruce, McQuiggan, Williams, Westervelt, & Tremont, 2008). Thus, it is important to obtain the person’s health history through interviewing both the person and the caregiver or other family members. The Table describes some of the instruments that have been used to assess ADLs and IADLs in those with MCI. Physical Examination and Laboratory Tests A thorough physical examination assists in identifying the etiology of symptoms of cognitive impairment to rule out other illnesses or conditions that can mimic MCI. For example, a thiamine deficiency can mimic symptoms of MCI (Sechi & Serra, 2007), as can physical trauma, dehydration, and malnutrition. In addition to a general physical examination and routine laboratory tests (e.g., vitamin B12, folic acid, thyroid-stimulating hormone, electrolytes, blood pressure, rapid plasma reagin), clinicians should particularly assess for neurological changes in gait, balance, sensory function, and motor ability (Scherder et al., 2007), as well as signs of parkinsonism, among other neurological abnormalities. In addition, self-care capacity and adherence with treatment should be assessed. Neuropsychological Tests Neuropsychological tests used in the diagnosis of MCI include numerous tests of cognitive function and

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Journal of Gerontological Nursing • Vol. 38, No. 12, 2012

BSRS (Rabins, 1994) CBRSD (Tariot, Mack, Patterson, & Edland, 1995)

5 5 to 10 n/a 10 to 15

Behavioral and neuropsychiatric symptomsd Depression CES-D (Radloff, 1977) GDS (Yesavage, 1988) Apathy Apathy Inventory (Robert et al., 2002) Multiple domains NPI (Cummings et al., 1994)

10 to 15 20 to 30

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Possible total score = 60 of 12 items, with scores > 16 indicating depression. Possible total score = 15 of 15 items, with scores >5 indicating depression. Possible total score = 36 of 3 dimensions, with scores >2 indicating potential cognitive impairment. Possible total score = 12, measuring the frequency of the symptoms, with scores >0 indicating neuropsychiatric symptoms and increased risk of dementia. Possible total score = 12, with higher scores indicating more symptoms. Five items are rated as present, absent, or having occurred since the illness began but not in the past month. The other 46 items are rated by frequency of occurrence from 0 (has not occurred since illness began) to 9 (unable to rate). Higher total scores indicate more symptoms.

Possible total score = 30. In those with less than a high school education, scores of 19.5 to 23.5 indicate mild neurocognitive disorder. Sensitivity = 0.92; specificity = 1. In those with a high school education or higher, scores of 21.5 to 25.5 indicate mild neurocognitive disorder. Sensitivity = 0.95; specificity = 0.98.

4 to 10

MMSE (Folstein, Folstein, & McHugh, 1975) Mini-Cog (includes the Clock Drawing Test) (Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000) SLUMS (Tariq et al., 2006)

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Possible total score = 30, with scores 24 indicating possible MCI. Sensitivity = 0.45; specificity = 0.69. Possible total score = 3, with scores 3 indicating impaired performance. Items named within 1 minute are counted. Higher scores indicate better performance.

t scores are used, with higher scores indicating better performance.b

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3 to 5

3 to 5 5

5

Scoring or Psychometric Properties Related to MCI

Possible total score = 100, with scores 1.5 exhibited amyloid-beta levels similar to controls; MCI group with a Total Box Score