AgingNeurologyPreventive Medicine


“35 million people worldwide were estimated to be living with dementia.” That’s a huge number, but it doesn’t include the millions of folks who are occasionally starting to show memory problems. Observers think these people have dementia, but they have yet to be fully diagnosed. These are the patients categorized as having Mild Cognitive Impairment (MCI). 

Mild Cognitive Impairment is the term we use for everyone who occasionally has difficulty learning, forgets to take his medications, or has trouble with daily work tasks like housekeeping or shopping. You know something about them just isn’t right, but they seem fine much of the time. You hate to judge them or call them demented because they aren’t that bad. People with MCI usually have three outcomes: they stay the same, they get better, or they progress to Alzheimer’s Disease. 

About 60% to 80% of folks with MCI really do have Alzheimer’s disease and over time progress into full-blown dementia. Determining who in the MCI group will progress to Alzheimer’s is important because early detection leads to better outcomes and improved quality of life. 

But how do you know whether grandma is “just getting old” or is headed for the dementia wing at Sleepy Hollow Senior Nursing Center? Is there a way to diagnose Alzheimer’s when MCI first appears?

A broad analysis of the effectiveness of the Mini-Mental Status Exam (MMSE) for that purpose was conducted by researchers and reported last month. The MMSE is the most commonly used and accepted screening test administered to patients suspected of dementia to determine if they do indeed have Alzheimer’s and need further investigation. The MMSE has been used for decades, is very easy to perform, and is relied upon by most physicians. It is a fairly objective test of cognitive function, but the diagnosis of Alzheimer’s is only suggested by this test. Other factors are also considered.

After reviewing 11 studies involving 1569 patients, researchers reached the conclusion that a baseline MMSE, done at the first sign of problems, could not reliably “identify the MCI patients who could develop dementia” later. As a stand-alone test, the MMSE was informative but was an accurate predictor between 23% to 94% of the time. That’s a wide range; too wide. The researchers were uncertain that the MMSE score by itself could indicate if a person will progress to Alzheimer’s. 

So, the MMSE should be administered but not be the sole determinant. A set of tests to assess cognition “may be more successful in predicting conversion from MCI to dementia of the Alzheimer’s type.” How do we know if Grandma’s forgetfulness will get worse? We don’t, but performing the MMSE, doing other cognitive tests, and combining them with the results of more invasive tests (a PET scan, Cerebrospinal fluid analysis for amyloid beta), will give us the  answer we seek. 

Spinal fluid analysis for “amyloid beta” is a new procedure. Before I retired, I don’t recall it being done. It requires the patient to undergo a lumbar puncture, the dreaded procedure I blogged about in “Spinal Tap—The Godfather of all Tests.” If the test for amyloid beta is positive, the patient has early-stage Alzheimer’s disease, and can no longer be classed as Mild Cognitive Impairment. The patient and their family must be informed that Alzheimer’s dementia will develop in 2-6 years, and that early management of their disease is imperative. 

An amazing number of people are concerned they have Alzheimer’s. At the first realization they’re slipping mentally, they run to the doctor to be tested to relieve their anxiety. However, when a person is aware they are becoming forgetful, it’s highly probable they are just having “senior moments” rather than dementia. It’s the folks who have no awareness of their forgetfulness who are the ones we need to worry about. They are candidates for the MMSE and amyloid beta tests. 

So, yes, we now have a way to tell if Grandma is getting Alzheimer’s. We hope, however, she tests negative for amyloid beta, but if she is positive, we hope she is only mildly affected. Only time will tell that. We can only hope for the best. 


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