AAN favours exercise over medication for mild cognitive impairment

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A new American Academy of Neurology (AAN) guideline recommends exercise and possibly cognitive training to improve memory and thinking in people with mild cognitive impairment.

The recommendation is part of an updated guideline for mild cognitive impairment.

“Regular physical exercise has long been shown to have heart health benefits, and now we can say exercise also may help improve memory for people with mild cognitive impairment,” says Dr Ronald Petersen, lead author, director of the Alzheimer’s Disease Research Centre, Mayo Clinic, and the Mayo Clinic Study of Ageing. “What’s good for your heart can be good for your brain.” Petersen is the Cora Kanow professor of Alzheimer’s disease research.

Mild cognitive impairment is an intermediate stage between the expected cognitive decline of normal ageing and the more serious decline of dementia. Symptoms can involve problems with memory, language, thinking and judgement that are greater than normal age-related changes.

Generally, these changes aren’t severe enough to significantly interfere with day-to-day life and usual activities. However, mild cognitive impairment may increase the risk of later progressing to dementia caused by Alzheimer’s disease or other neurological conditions. But some people with mild cognitive impairment never get worse, and a few eventually get better.

The academy’s guideline authors developed the updated recommendations on mild cognitive impairment after reviewing all available studies. Six-month studies showed twice-weekly workouts may help people with mild cognitive impairment as part of an overall approach to managing their symptoms.

Petersen encourages people to do aerobic exercise: Walk briskly, jog, whatever you like to do, for 150 minutes a week – 30 minutes, five times or 50 minutes, three times. The level of exertion should be enough to work up a bit of a sweat but doesn’t need to be so rigorous that you can’t hold a conversation. “Exercising might slow down the rate at which you would progress from mild cognitive impairment to dementia,” he says.

Another guideline update says clinicians may recommend cognitive training for people with mild cognitive impairment. Cognitive training uses repetitive memory and reasoning exercises that may be computer-assisted or done in person individually or in small groups. There is weak evidence that cognitive training may improve measures of cognitive function, the guideline notes.

The guideline did not recommend dietary changes or medications. There are no drugs for mild cognitive impairment approved by the US Food and Drug Administration.

More than 6% of people in their 60s have mild cognitive impairment across the globe, and the condition becomes more common with age, according to the American Academy of Neurology. More than 37% of people 85 and older have it.

With such prevalence, finding lifestyle factors that may slow down the rate of cognitive impairment can make a big difference to individuals and society, Petersen notes. “We need not look at aging as a passive process; we can do something about the course of our ageing,” he says. “So, if I’m destined to become cognitively impaired at age 72, I can exercise and push that back to 75 or 78. That’s a big deal.”

The guideline, endorsed by the Alzheimer’s Association, updates a 2001 academy recommendation on mild cognitive impairment. Petersen was involved in the development of the first clinical trial for mild cognitive impairment and continues as a worldwide leader researching this stage of disease when symptoms possibly could be stopped or reversed.

Abstract
Objective: To update the 2001 American Academy of Neurology (AAN) guideline on mild cognitive impairment (MCI).
Methods: The guideline panel systematically reviewed MCI prevalence, prognosis, and treatment articles according to AAN evidence classification criteria, and based recommendations on evidence and modified Delphi consensus.
Results: MCI prevalence was 6.7% for ages 60–64, 8.4% for 65–69, 10.1% for 70–74, 14.8% for 75–79, and 25.2% for 80–84. Cumulative dementia incidence was 14.9% in individuals with MCI older than age 65 years followed for 2 years. No high-quality evidence exists to support pharmacologic treatments for MCI. In patients with MCI, exercise training (6 months) is likely to improve cognitive measures and cognitive training may improve cognitive measures.
Major recommendations: Clinicians should assess for MCI with validated tools in appropriate scenarios (Level B). Clinicians should evaluate patients with MCI for modifiable risk factors, assess for functional impairment, and assess for and treat behavioral/neuropsychiatric symptoms (Level B). Clinicians should monitor cognitive status of patients with MCI over time (Level B). Cognitively impairing medications should be discontinued where possible and behavioral symptoms treated (Level B). Clinicians may choose not to offer cholinesterase inhibitors (Level B); if offering, they must first discuss lack of evidence (Level A). Clinicians should recommend regular exercise (Level B). Clinicians may recommend cognitive training (Level C). Clinicians should discuss diagnosis, prognosis, long-term planning, and the lack of effective medicine options (Level B), and may discuss biomarker research with patients with MCI and families (Level C).

Authors
Ronald C Petersen, Oscar Lopez, Melissa J Armstrong, Thomas SD Getchius, Mary Ganguli, David Gloss, Gary S Gronseth, Daniel Marson, Tamara Pringsheim, Gregory S Day, Mark Sager, James Stevens, Alexander Rae-Grant

Mayo Clinic material
Neurology abstract


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