What medications are recommended for starting treatment in patients with Mild Cognitive Impairment (MCI)?

Medication Management for Mild Cognitive Impairment (MCI)

Currently, no specific medications are recommended as first-line treatment for mild cognitive impairment (MCI), as there is insufficient evidence supporting pharmacological interventions for this condition. 1, 2

Pharmacological Options

• Cholinesterase inhibitors (donepezil, galantamine, rivastigmine) should not be routinely offered to patients with MCI as they have not been shown to reduce progression to dementia 2, 1
• If considering cholinesterase inhibitors, clinicians must first discuss the lack of evidence for their efficacy with patients (Level A recommendation) 1
• Memantine is not recommended for MCI treatment, as evidence supports its use only in moderate to severe dementia 3
• For patients with vascular cognitive impairment, cholinesterase inhibitors and memantine may be considered in selected patients (2B recommendation, 89% consensus) 4

Management of Vascular Risk Factors

• Treatment of hypertension is strongly recommended for patients with cognitive disorders with vascular contributions (1B recommendation, 98% consensus) 4
• For patients with MCI and vascular risk factors, antihypertensive therapy should be considered for diastolic BP ≥90 mmHg and systolic BP ≥140 mmHg (1B recommendation, 96% consensus) 4
• A systolic BP target of <120 mmHg may be associated with decreased risk of developing MCI in middle-aged and older persons with vascular risk factors (2C recommendation, 83% consensus) 4
• Aspirin is not recommended for patients with MCI who have white matter lesions without history of stroke or brain infarcts (2C recommendation, 96% consensus) 4

Non-Pharmacological Interventions

• Regular exercise training (minimum 6 months) should be recommended as it is likely to improve cognitive measures (Level B recommendation) 1, 5
• Cognitive training may be recommended as it may improve cognitive measures (Level C recommendation) 1, 2
• Social engagement and mentally stimulating activities should be encouraged as part of a healthy lifestyle approach 3, 6

Medications to Avoid in MCI

• Anticholinergic medications should be discontinued or avoided as they were found to be the most common potentially inappropriate medications (35.7%) in MCI patients 7
• Benzodiazepines should be avoided or minimized as they were the second most common potentially inappropriate medications (31.5%) in MCI patients 7
• All cognitively impairing medications should be discontinued where possible (Level B recommendation) 1

Monitoring and Follow-up

• Cognitive status of patients with MCI should be monitored over time (Level B recommendation) 1
• Clinicians should evaluate patients with MCI for modifiable risk factors and assess for functional impairment (Level B recommendation) 1
• Behavioral and neuropsychiatric symptoms should be assessed and treated when present (Level B recommendation) 1

Special Considerations

• Patients with MCI are at increased risk for developing dementia compared to the general population, with annual conversion rates varying from <5% to 20% 5
• Cumulative dementia incidence was found to be 14.9% in individuals with MCI older than 65 years followed for 2 years 1
• Treatment decisions should always be based on individualized assessment of benefits versus risks, considering the patient's overall health status and goals of care 3