NUR 7643 Module 5 Mild Cognitive Impairment Case: MoCA Screening, Reversible Causes and Lecanemab Counseling Example

Forgetting Names at the Book Club: Screening, Working Up and Counseling a 71-Year-Old With Mild Cognitive Impairment

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7643: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Geriatric Populations Part B

Mentor Name

Month Day, Year

Forgetting Names at the Book Club: Screening, Working Up and Counseling a 71-Year-Old With Mild Cognitive Impairment

Her Worry

Joan, an invented patient, is 71 and was a reference librarian at a public library in Montclair for thirty-five years. Over the past year she has noticed that she forgets the names of people she knows, repeats a story to her sister, and once missed a dentist appointment she had written down. She still manages her finances, drives without getting lost, cooks for friends and leads a monthly book club. Her mother developed Alzheimer disease in her late seventies, and Joan is frightened that the same thing is starting.

She takes amlodipine for blood pressure, a statin, and oxybutynin for an overactive bladder, started two years ago. She sleeps poorly and snores loudly, according to her sister, who stays with her on weekends. Since her husband died eighteen months ago she has felt low and has withdrawn from some friends. Most evenings end with a glass of red.

Her worry has a shape the paper records in her words. She is afraid of becoming a burden to her sister, of losing her independence and of not recognizing the people she loves, as happened with her mother. She has been reading about memory loss online every night, which has made her more anxious. She asks directly whether she has Alzheimer disease, and the paper shows how that question is answered honestly at each stage of the workup.

Screening

Nasreddine et al. (2005) developed the Montreal Cognitive Assessment and compared it with the Mini-Mental State Examination in 94 people with mild cognitive impairment, 93 with mild Alzheimer disease and 90 healthy older adults. At a cutoff of 26, the MMSE picked up only 18 percent of the MCI group and the MoCA 90 percent, and it detected all of those with mild Alzheimer disease. Specificity was 87 percent, lower than the older test's 100 percent, meaning some healthy people scored below the cutoff. The test takes about ten minutes and covers memory, attention, language, visuospatial skills and executive function.

Joan scores 24 out of 30, losing points on delayed recall and on one executive task. With her advanced education the score is not adjusted upward, and the paper notes that the test can misclassify some healthy, highly educated people as well as those with less schooling. Her daily function is intact by her own and her sister's report, which points to mild cognitive impairment rather than dementia, if no reversible cause explains the findings.

Looking for Reversible Causes

Langa and Levine (2014) reviewed the diagnosis and management of mild cognitive impairment. They estimated that 10 to 20 percent of adults 65 and older have it, that no medicine has proven effective for it, and that clinicians should look for depression, too many medicines and uncontrolled cardiovascular risks, all of which can worsen thinking. They noted that the yearly rate of progression to dementia varies widely between studies, from under 5 to about 20 percent, and that aerobic exercise, mental activity and social engagement may help.

Joan's workup follows that advice. Her oxybutynin is a strongly anticholinergic drug that can impair memory in older adults, and it is stopped and replaced with a bladder medicine without that effect. Her depression screen is moderately raised, and grief after her husband's death is part of the picture, so she is referred for therapy. Her snoring and poor sleep lead to a sleep study, which shows moderate sleep apnea, and she starts a breathing device at night. Her vitamin B12, thyroid tests and blood count are normal. Her blood pressure is well controlled. An MRI of the brain shows mild changes in small blood vessels and mild shrinkage in the memory regions.

Sharing the Diagnosis

After three months with these changes, her score is repeated and is 25, with improvement in attention but persistent difficulty with delayed recall. The diagnosis of mild cognitive impairment is shared with Joan and her sister in a quiet visit. The paper explains what it means: her memory has changed more than expected for her age, she remains independent, and while her risk of dementia is higher than average, many people with mild cognitive impairment stay stable for years, and some improve. Her fear about her mother is acknowledged directly.

New Treatments

Joan has read about lecanemab and asks if she should take it. Van Dyck et al. (2023) randomly assigned 1,795 people with mild cognitive impairment or mild dementia due to Alzheimer disease, with amyloid confirmed, to lecanemab infusions every two weeks or placebo for 18 months. On a dementia rating scale that ranges from 0 to 18, scores worsened by 1.21 points with lecanemab and 1.66 with placebo, a difference of 0.45 points, and amyloid in the brain fell substantially. Brain swelling or bleeding seen on scans, known as amyloid-related imaging abnormalities, occurred more often with lecanemab, and were sometimes serious.

The paper explains to Joan that lecanemab is only for people with confirmed amyloid, that it slows decline modestly rather than stopping or reversing it, that it requires infusions every two weeks and repeated MRI scans, and that the risk of brain swelling or bleeding is higher in people who carry two copies of a gene variant called APOE e4, which is tested before treatment. She is referred to a memory center to discuss amyloid testing, with the decision left to her.

Living Well Now

She begins brisk walking five days a week with a friend, joins a library volunteer program and keeps her book club. A neuropsychological evaluation is arranged to set a detailed baseline. She completes advance directives and a health care proxy now, while her decisions are clearly her own. Her score will be repeated in twelve months.

Conclusion

Joan has mild cognitive impairment, found with the Montreal Cognitive Assessment, whose sensitivity and lower specificity are both stated. A search for reversible causes found an anticholinergic drug, depression and grief, and sleep apnea, each treated. The diagnosis is shared honestly, with her fear about her mother acknowledged. Lecanemab is explained with its modest benefit and its risks, and she is referred for amyloid testing on her own terms. Exercise, social engagement, advance planning and yearly testing complete the plan.

References

Langa, K. M., & Levine, D. A. (2014). The diagnosis and management of mild cognitive impairment: A clinical review. JAMA, 312(23), 2551-2561. https://doi.org/10.1001/jama.2014.13806

Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., Cummings, J. L., & Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53(4), 695-699. https://doi.org/10.1111/j.1532-5415.2005.53221.x

van Dyck, C. H., Swanson, C. J., Aisen, P., Bateman, R. J., Chen, C., Gee, M., Kanekiyo, M., Li, D., Reyderman, L., Cohen, S., Froelich, L., Katayama, S., Sabbagh, M., Vellas, B., Watson, D., Dhadda, S., Irizarry, M., Kramer, L. D., & Iwatsubo, T. (2023). Lecanemab in early Alzheimer's disease. New England Journal of Medicine, 388(1), 9-21. https://doi.org/10.1056/NEJMoa2212948