Q&A: How to Diagnose & Treat Mild Cognitive Impairment?

Q: I realize that I sometimes have difficulty connecting a name and a face.  I presume that this is mild cognitive impairment.

On researching the topic online, I find a variety of suggestions for alleviating it.  These include supplements (lipoic acid, vitamin E, omega 3s, curcumin), food choices (fish, vegetables, black and green teas), aerobic exercise, yoga, and meditation. 

Do these actually help with mild cognitive impairment? What’s been proven to work?

A: It’s common for older adults to feel they’re having trouble with certain memory or thinking tasks as they get older.

I can’t say whether it’s mild cognitive impairment (MCI) in your particular case. But we can review what is known about stopping or slowing cognitive changes in people diagnosed with MCI.

First, let’s start by reviewing what MCI is, and how it’s diagnosed. Then I’ll share some information on the approaches you are asking about, as well as other approaches for treating MCI.

What is Mild Cognitive Impairment?

Mild cognitive impairment (MCI) means having cognitive abilities (memory and thinking skills) that have become worse than “normal” for your age. However, the memory or other problems shouldn’t be so bad that you no longer can complete daily life tasks you used to do, such as finances or meal preparation, without assistance.

In other words, the impairments can’t be bad enough to meet the criteria for dementia, which requires cognitive skills to have declined to the point that independence in common daily life tasks is compromised.

If you’re concerned about your memory, it’s important that you not assume it’s MCI. Instead, you’ll want to have your thinking skills assessed by a clinician. This is how you can find out if your difficulties fall within the range of “normal age-related changes” versus being worse than normal, which is a criterion for having MCI.

Studies find that many older people feel that their memory or thinking is getting worse. However, this doesn’t necessarily mean they have MCI.

This is because declines in certain types of memory and thinking skills are now known to be part of normal “cognitive aging.” For more on what is often normal with aging, see 6 Ways that Memory & Thinking Change with Normal Aging (& What to Do About This).

In fact, difficulty connecting “names and faces” is common among normal older adults. It’s probably due to the known slowing in brain processing speed that occurs as people age.

As of 2013, MCI is also called “mild neurocognitive disorder” whereas dementia has been renamed “major neurocognitive disorder.” While you might not need to know these more technical terms, it may save some confusion if you are reading about newer research. (Most practicing doctors still use the older terms.)

Experts agree that some people with MCI are essentially in the very earliest symptomatic stages of a brain-changing condition such as Alzheimer’s or another type of dementia. It is also possible for cerebral small vessel disease to cause vascular cognitive impairment, which can eventually become vascular dementia. Studies suggest that over 5 years, 30-40% of people with MCI will progress to dementia.

However, that’s only 30-40% of people. So not all MCI is early dementia. Some people with MCI never seem to get much worse, and some even seem to get better.

How is mild cognitive impairment diagnosed?

MCI is diagnosed through a clinical assessment done by a qualified doctor or other healthcare professional.

A clinical assessment should usually include:

• Interviewing the patient regarding his concerns, and inquiring about difficulties managing life tasks, such as Activities of Daily Living and Instrumental Activities of Daily Living (ADLs and IADLs)
• Assessing whether family members and other observers have noticed anything concerning
• Evaluating cognitive abilities using a short office-based test, such as the Montreal Cognitive Assessment
• Checking prescribed and over-the-counter medications, to see if any are known to make thinking worse (see 4 Types of Brain-Slowing Medication to Avoid if You’re Worried About Memory)
• Evaluating for medical conditions, including mental health conditions and sleep disorders, that can worsen thinking or can mimic early dementia

Laboratory work is often necessary, to check for problems such as thyroid disorders, vitamin B12 deficiency, and electrolyte imbalances.

After this initial assessment, a person might be referred for additional neuropsychological testing. These tests provide a more in-depth assessment of specific memory and thinking skills. They can help further categorize MCI as “amnestic” (meaning the problems are mainly with memory) versus non-amnestic.

Ultimately, the process of diagnosing MCI is similar to diagnosing dementia: it requires documenting concerns and difficulties, objectively assessing cognitive abilities, and ruling out other medical problems (including medication side-effects and delirium) that might be interfering with brain function.

But in MCI, the cognitive impairments should not be severe enough to interfere with independence in daily life tasks.

For more on evaluating the complaint of cognitive impairment in older adults, see here: Cognitive Impairment in Aging: 10 Common Causes & 10 Things the Doctor Should Check.

What are proven ways to treat mild cognitive impairment?

In many clinical trials, the goal in “treating” mild cognitive impairment has been to reduce the risk of progression to Alzheimer’s or another dementia.

Unfortunately, almost nothing has been proven to work, although some approaches are promising.

In particular, no medications are FDA-approved for the treatment of MCI, as none have been shown to prevent progression to dementia.

(Note: the controversial new Alzheimer’s drug Aduhelm did get FDA-approved in 2021 and can be used in certain MCI patients, but it’s a special case. See the Medications in MCI section below.)

In January of 2018, the American Academy of Neurology issued their “Practice guideline update summary: Mild cognitive impairment. They suggest that clinicians recommend regular exercise and say they “may recommend cognitive training.” They make a stronger recommendation for stopping medications that interfere with cognition, and they reiterate that “no high-quality evidence exists to support pharmacologic treatments for MCI.”

Much of the research on treating mild cognitive impairment is summarized in the Agency for Healthcare Research & Quality’s (AHRQ) detailed 2017 review: Interventions to Prevent Age-Related Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer’s-Type Dementia. This review’s conclusion notes that exercise is promising but most treatments have failed to show conclusive benefits so far.

Exercise for MCI

The approach that seems most consistently promising is exercise, although it’s unclear which exercise is best. One randomized study showed an improvement in patients doing different exercises, whereas another indicated that resistance training helped.

A sensible approach is to include all important types of exercise. That is: aerobic, resistance, balance, and flexibility exercises.

Although it may not be clear which one is best for MCI, all four are necessary to maintain overall health and mobility in older adults.

You can learn more about the four types of exercise at the National Institute on Aging’s site: Four Types of Exercise Can Improve Your Health and Physical Ability.

There is also promising research showing that a group movement program called PLIE can improve outcomes in MCI: Preventing Loss of Independence through Exercise (PLIÉ): A Pilot Trial in Older Adults with Subjective Memory Decline and Mild Cognitive Impairment.

Dietary approaches for MCI

There is research to suggest that diet plays a role in dementia. However, it’s not yet clear what particular diet will prevent MCI from progressing in most people.

In general, a diet that is good for overall health will also be good for brain health. The MIND diet (a variant of the Mediterranean diet) is probably a good place to start. The general principles include:

• Eat lots of vegetables, of all types and colors
• Eat berries, and other fruits
• Eat nuts, avocados, and other forms of “healthy” fats
• Eat fish at least once a week (preferably fish low in mercury)
• Eat beans and legumes
• Limit meat and animal-based saturated fats
• Minimize transfats, packaged food, fast food, added sugar, and cured meat products

A 2021 scholarly review can be read here: Effects of Nutrition on Cognitive Function in Adults with or without Cognitive Impairment: A Systematic Review of Randomized Controlled Clinical Trials.

Some experts recommend vegan diets for better brain health, but most experts feel that the scientific evidence doesn’t justify this.

What IS becoming clear is one’s response to a certain diet is highly individual, and appears to be especially driven by the microbiome (the community of gut microbes) we each have in our intestines. So newer research is developing dietary approaches that help people do the trial and error necessary to find out which diet reduces inflammatory markers, blood fat levels, and stabilizes blood glucose levels in their own body.

Although it will be a while before we know whether these personalized diet approaches can treat MCI in particular, I expect that a better diet will improve brain outcomes in at least some people.

Otherwise: one of my favorite clinical nutrition trials is titled the “Cocoa, Cognition, and Aging (CoCoA) Study.” In 2012 the researchers published the results of a study in which they found that giving people with MCI a daily cocoa drink led to improved cognitive function and insulin metabolism eight weeks later.

Now, we still don’t know if daily cocoa would change the likelihood of having dementia a few years later. But it’s encouraging news for those who like dark chocolate.

Supplements for MCI

Some researchers have found that a vitamin B supplement (a combination of folic acid, vitamin B6, and vitamin B12) reduces cognitive decline in MCI. But this may only be in people who have high homocysteine levels.

(Homocysteine is a common amino acid – one of the building blocks that make up proteins – found in the blood. High levels have been associated with low intake of folate and vitamin B12.)

A large trial published in 2005 found that vitamin E had no effect on the progression of MCI.

A variety of other anti-oxidants have been studied, but so far nothing seems to be definitely beneficial. A review of anti-oxidants can be found here.

A 2018 Cochrane Review concluded that “the evidence on vitamin and mineral supplements as treatments for MCI is very limited.”

Vitamin D has also been studied, with mixed results when it comes to meaningfully influencing cognitive outcomes. You can find a good summary of research studying the association between Vitamin D, cognitive decline, and Alzheimer’s here. It’s probably reasonable to try to avoid frank vitamin D deficiency by taking a daily supplement of 800-1000 IU. But there is no evidence that treating MCI with higher doses of vitamin D will delay progression to dementia.

One type of supplement not covered in the Cochrane review was omega-3 fatty acids, which are found in fatty fish (as well as in some other foods such as nuts and seeds). Supplementation of omega-3 fatty acids via fish oil has shown some beneficial effects for cardiovascular health, which means it might help with brain health as well. To date, I would describe the evidence for omega-3 fatty acid supplements helping in MCI as promising but not yet proven (when it comes to preventing progression to dementia).  A good recent review on this topic is here: Omega-3 fatty acids and cognitive decline: a systematic review.

In general, when people ask me about supplements and MCI, I tell them that I think it’s reasonable to consider vitamin B12 and omega 3 fatty acids, and that I think all older adults should take 800-1000 IU/day of vitamin D. These supplements are unlikely to harm and may help treat common deficiencies that can worsen cognitive decline. That said, there’s no proof that these supplements can treat or delay MCI in most people, so it’s important to be realistic about the likely small effect.

Medications for MCI

There are currently no medications that have FDA approval for the treatment of MCI.

Some medications have been trialed but have not been shown to prevent the progression of MCI. These include medications FDA-approved for the treatment of dementia, such as donepezil, galantamine, rivastigmine, and memantine (brand names Aricept, Razadyne, Exelon, and Namenda, respectively).

One 2012 review published by the respected Cochrane Library concluded that these types of medicines ” should not be recommended for mild cognitive impairment.”

However, many doctors prescribe these medications to people with MCI, especially if they have amnestic MCI. In theory, this might help mitigate some of the memory symptoms.

But if a person with MCI doesn’t notice some improvement after starting the medication, they should not be surprised. And they should not feel obligated to continue the medication.

Note: Aduhelm, a new infusion for the treatment of Alzheimer’s disease, was approved by the FDA in 2021. The approval was controversial, due to weak evidence of clinical benefit, and Medicare has opted to not cover this medication for the time being, unless the person is enrolled in a trial.  Aduhelm can potentially be used to treat those forms of mild cognitive impairment that have been shown to be due to very early Alzheimer’s disease. This type of proof requires special scans and biomarkers that are usually only done as part of research studies and are not routinely covered by insurance.

Yoga and meditation for MCI

Stress tends to worsen brain function. So it’s possible that stress-reducing activities like yoga or meditation might help in MCI.

Yoga has mainly been studied in older adults with “normal” cognition. Results suggest yoga can benefit cognition but further research is recommended.

A 2019 review of yoga specifically for mild cognitive impairment or dementia reached similar conclusions: The effects of yoga on patients with mild cognitive impairment and dementia: A scoping review.

Meditation and related mindfulness practices may improve MCI. Smaller studies, such as this one, have found that a mindfulness program was associated with encouraging brain changes on functional MRI scans.

However, other studies of mindfulness in MCI, such as this one,  have not shown an improvement in outcomes. Most systematic reviews, such as this one, conclude that mindfulness is promising but not proven, as a treatment for MCI.

That said, even though the evidence isn’t very strong, I highly recommend that anyone with MCI try a mindfulness-based intervention. For those who are able to find a practice that works for them, I believe this can play a valuable role in coping with the worry and uncertainty that often comes with MCI.

A good way to get started is to sign up for an 8-week mindfulness-based stress reduction (MBSR) course. Paying for a live course or online course often helps one complete the course. There is also a free self-paced course available here.

Brain training for MCI

People sometimes wonder if “brain training” can keep MCI from progressing to dementia. So far this is unknown.

Much of the brain training research has studied whether the intervention improves memory and cognitive function in the short-term. A 2016 review found that brain training does indeed seem to improve certain cognitive abilities in the short-term.

But, it’s still unclear whether this results in long-term benefits, or delays overall progression to dementia. A good summary of the research on this topic can be found in this chapter of the AHRQ review: Cognitive Training.

Hearing aids for MCI

Last but not least, if you’ve been concerned about MCI, it is probably worthwhile to have your hearing checked, and any hearing loss corrected if possible.

Quite a lot of research has confirmed that there is an association between hearing loss and cognitive impairment.

Now, does treating hearing loss actually prevent or delay the progression of MCI? This is a hot topic that is being actively researched. So far, a large retrospective study has found that using hearing aids did reduce progression to dementia. Randomized trials are now underway to see if they can confirm this finding.

Personally, I think treating hearing loss sounds more likely to improve MCI outcomes than brain training does, so I would highly recommend this approach.

Although hearing aids have historically been expensive and challenging to obtain, over-the-counter hearing aids are expected to be available soon.

For more on hearing loss in aging, see 4 Key Things to Know About Age-Related Hearing Loss.

My main recommendations for managing MCI

The bottom line is that no treatment has been convincingly proven to improve long-term outcomes in MCI. So I think it’s best to focus on general things that promote brain health.

That is:

• Stay physically active and exercise regularly
• Address risk factors for cardiovascular disease
• Consider the MIND diet (or better yet, a personalized nutrition approach that helps you stabilize inflammation, glucose levels, and fat levels in your blood)
• Identify and treat any hearing loss
• Avoid brain-slowing medications
• Treat sleep disorders when possible and avoid chronic sleep-deprivation
• Avoid delirium
• Find constructive ways to manage chronic stress (consider a mindfulness-based stress reduction class, meditation, or yoga)
• Seek treatment if you have signs of depression or chronic anxiety
• Pursue positive social activities, purposeful activities, and activities that “nourish the soul”

For more information on these common-sense brain health approaches (which are generally good for physical health and healthy aging), see “How to Promote Brain Health: The Healthy Aging Checklist, Part 1.”

If you’re worried you might have MCI

You can see that this is a complex area. Mild cognitive impairment is not as simple to diagnose as diabetes, nor is it as easy to treat.

However, it’s just as important to see a doctor. So don’t make assumptions if you notice changes in memory or thinking. That’s a huge risk.

Instead, if you have signs of MCI, make sure you get evaluated by a professional. See your doctor.

They can check what other factors may be affecting your memory and thinking. They can support you and help you find answers to your questions. They can help you manage your symptoms and provide peace of mind.

So don’t sit, and wait, and worry.

Pick up the phone and make an appointment. Make sure they check for medication side-effects and other medical problems that can worsen thinking. And make sure they know if you’ve been having trouble with finances, driving, or other life tasks.

And then if you are diagnosed with MCI, you can come back to this article for a refresher on what approaches are most promising, when it comes to treatment.