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Impaired Risk Review...
Mild Cognitive Impairment

Robert Goldstone
May 2013 Issue

There’s not one of us who hasn’t feared that we are accelerating in the process of mental aging when we forget where we put our keys, that our eyeglasses are right in our pockets where we left them, or what we were trying to say after having been interrupted in mid-sentence. These are normal phenomena involved with the aging process.

Cognitive changes occur normally with aging. However, impairment that causes a noticeable and measurable decline in cognitive abilities is defined as mild cognitive impairment (MCI).

MCI is the physiologic syndrome that bridges the gap between normal aging and early dementia.

People naturally process information about their world and environment with skills such as memory, language, attention, spatial relations and mental processing speed. Generally we are sharpest in our thirties and forties, level out in our fifties and sixties, and begin to slow and/or decline in our seventies and beyond.

Normal aging affects new information processing, visual acuity, memory and performance speed, all of which become slower and not as efficient—plus distractibility increases. The line, though, becomes less distinct between normal aging and MCI when the changes become more profound and are noticeable to others who may mention or point them out as being a noticeable change from their previous experience with an individual.

In normal aging, most detail is remembered without prompting, cognitive evaluation is normal, short term memory is intact, and activities and instrumental activities of daily living are preserved. With MCI, the ability to recall issues is noticeably delayed, and the affected individual is usually aware of it. Short term memory may be impaired, as may cognitive ability, and while activities of daily living are preserved, the instrumental activities (such as managing finances) may be impaired. MCI may also involve forgetting conversations, repeating oneself and forgetting appointments and events that were formerly easily remembered.

A workup for MCI involves a thorough medical history by a physician, assessment of independent function and daily living, input from closely involved family and friends who know the person well, a neurological examination to rule out other treatable causes, and basic laboratory tests. Depression must be ruled out, because it often mimics MCI with a lack of attention to detail or to situation.

Cognitive tests such as the Mini Mental State Examination (MMSE) or the Saint Louis University Mental Status examination (SLUMS) are often used in assessment. Neuropsychological tests and even brain CT scanning also help to make the diagnosis.

If aging, and MCI to some degree, are a normal function of aging, when does it become problematic in insurance evaluation? First, a person with MCI is at an increased risk of developing Alzheimer’s or other dementia. MCI is thought to have a 5 to 10 percent risk of yearly progression to dementia, according to studies such as the ones done by the Alzheimer’s Disease Cooperative Group. When reasoning and intellectual function are impaired, an individual becomes at risk for problems associated with impaired judgment. The inability to make sound decisions, poor motor and spatial skills, or the inability to carry out functions of independent living put people at significant health and accident risks.

Also remember that for individuals whose bodies show signs of vitality despite mental decline, the ability to enter into contract is always an issue to address. A person must have the faculties and reasoning to understand the goals of a purchase and to make sure it is in their best interest. At times, a medical as well as a legal professional may have to be consulted.

Dementia isn’t always a linear or gradual process either. Some forms progress from MCI to profound dementia and impairment relatively quickly.

Since the major source of evaluation of MCI is going to come from attending physician statements, a physician must be clear on whether his patient’s status reflects the process of normal aging or a faster, more pathologic process. More involved testing may be required in order to show that the changes involved are subtle and gradual; that physical activities of daily living are not expected to be compromised in the near future; and that instrumental activities such as medication management, handling finances, etc., are intact. Although no medication has been approved by the FDA for MCI, some patients actually improve with staying healthy, active and involved—thus it is important to demonstrate that when submitting an insurance application.

References:

 Alzheimer’s Disease Cooperative Study, www.adcs.org.

 “Mild Cognitive Impairment,” Ronald C. Petersen, MD, PhD, New England Journal of Medicine, June 2011.

Author's Bio
Robert Goldstone, MD, FACE, FLMI
Goldstone, board certified internist and endocrinologist, is vice president and chief medical officer for Pacific Life and Pacific Life and Annuity. He has extensive brokerage and life insurance experience, having been medical director at both MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World since 1990. Goldstone can be reached by telephone at 949-420-8390. Email: bgoldstone@pacificlife.com.