How to Diagnose MCI

8/3/2019 How to Diagnose MCI

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Mild Cognitive ImpairmentMild Cognitive Impairment

How to diagnoseHow to diagnose

Paulus Anam OngMemory Clinic - Hasan Sadikin Hospital Bandung

Padjadjaran University - Indonesia


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Ou tline of PresentationOu tline of Presentation

IntroductionIntroduction Aging in Indonesia Aging in Indonesia Progression of normal aging to MCIProgression of normal aging to MCI

Early detection is the main roleEarly detection is the main roleClinical Diagnostic of MCIClinical Diagnostic of MCI Definition of MCIDefinition of MCI Clinical diagnostic of MCIClinical diagnostic of MCI

MMSEMMSE CDRCDR GDSGDSConclusionConclusion


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Aging in Indonesia Aging in Indonesia Aging in Indonesia Aging in Indonesia

0

10000

20000

30000

40000

50000

60000

1997 2025 2050

80+

75 - 79

65 - 74

N N (1000 s)(1000 s)

N N (1000 s)(1000 s)

(WHO, 1998)(WHO, 1998)


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T he 4th populous elderly after China, IndiaT he 4th populous elderly after China, Indiaand South Americaand South America

We will encounter large numbers of dementia cases in the futurein the future

Massive medical, social, and economicMassive medical, social, and economic

problems in the futureproblems in the future

..

IndonesiaIndonesia


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Progression of normal aging to dementiaProgression of normal aging to dementia

Brain AgingN ormalCognition

ProdromalDementia

Dementia

Mild Cognitive

Impairment

Other Dementias

AlzheimersDisease

Vascular Dementia

Stable or ReversibleImpairment

Reversible


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Progression of normal aging toProgression of normal aging todementiadementia

A minority of persons diagnosed with A minority of persons diagnosed withMCI remain stable or improve overMCI remain stable or improve overtimetimeT he majority of declining MCI patientsT he majority of declining MCI patientsconvert to AD, besides mixed withconvert to AD, besides mixed with

vascular and other dementiavascular and other dementia

Golumb J, Kluger A, Ferrsis SH. Mild Cognitive Impairment:

Identifying and treating the earliest stage of Alzheimer s disease


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Correct diagnosis in its early stages can be:Correct diagnosis in its early stages can be:

Beneficial of treatment Beneficial of treatment

Prevent costly and inappropriate treatment Prevent costly and inappropriate treatment resulting from misdiagnosisresulting from misdiagnosis

Give patients and families time to prepareGive patients and families time to preparefor the challenging financial, legal, andfor the challenging financial, legal, andmedical decisions that may lie ahead.medical decisions that may lie ahead.

Early detection of MCI cases is theEarly detection of MCI cases is themain rolemain role


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Definition of MCIDefinition of MCI

Memory Complaints confirmed by an informant Memory Complaints confirmed by an informant

Normal activities of daily livingNormal activities of daily living

General cognitive preservedGeneral cognitive preserved Abnormal memory for age and education Abnormal memory for age and educationnorms (1,5 SD below normative values )norms (1,5 SD below normative values )

Not dementedNot demented

Petersen et al (1999) Arch Neurol 56,303-308


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MCI Tenets :MCI Tenets :

Not all MCI represent ADNot all MCI represent AD

All AD patients go through an MCI stage All AD patients go through an MCI stage

AD symptoms progress from MCI to greater severity of AD symptoms progress from MCI to greater severity of

dementiadementia

Conversions Conversions ( MCI to AD ) is a clinical construct ( MCI to AD ) is a clinical construct

inconsistent with pathologyinconsistent with pathology

Clinical methods accurately identify MCIClinical methods accurately identify MCI AD AD

Quality of clinical information ( informants ) andQuality of clinical information ( informants ) and

labeling threshold of clinician determines diagnosislabeling threshold of clinician determines diagnosis


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Clinical Diagnosis of MCIClinical Diagnosis of MCI

Diagnosis of MCI requires anDiagnosis of MCI requires aninformant based history documentinginformant based history documentinga meaningful deterioration in cognitivea meaningful deterioration in cognitivestatus in daily functioningstatus in daily functioningT wo commonly used rating scalesT wo commonly used rating scales

Clinical Dementia Rating (CDR)Clinical Dementia Rating (CDR) Global Deterioration Scale (GDS)Global Deterioration Scale (GDS)


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MCI Clinical AssessmentMCI Clinical Assessment

As a part of dementia assessment: As a part of dementia assessment:Careful history from familyCareful history from familymember / collateral source (keymember / collateral source (keyelement) and from patient element) and from patient Physical / neurological examinationPhysical / neurological examinationEvaluation of behavior and moodEvaluation of behavior and mood


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Clinical approach :Clinical approach :

General medical historyGeneral medical history

CCVD and risk factorCCVD and risk factor

Endocrine disordersEndocrine disorders

Chronic infectionsChronic infectionsLife styleLife style

General neurologic historyGeneral neurologic history

Specific conditionsSpecific conditionsWhich could be responsible for dementiaWhich could be responsible for dementia

Head traumaHead trauma

SOL intracranialSOL intracranial


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Psychiatric history :Psychiatric history :Pure psychiatric disordersPure psychiatric disorders

Cognitive impairment Cognitive impairment

associated with psychiatric diseasesassociated with psychiatric diseasesT oxic, nutritions and drug historyT oxic, nutritions and drug historyFamily historyFamily history

DementiaDementiaDown s syndromeDown s syndrome

Degenerative diseasesDegenerative diseases


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General physical examination :General physical examination :

Vital signs Vital signs

Risk factor for vascular eventsRisk factor for vascular events

Metabolic and endocrineMetabolic and endocrine

Neurological examinationNeurological examination

Focal deficit Focal deficit Abnormalities of muscle tone, movement or Abnormalities of muscle tone, movement orprimitive reflexesprimitive reflexes


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Ne u ropsychological examinationsNe u ropsychological examinations

Minimental State Examination ( MMSE ) :Minimental State Examination ( MMSE ) : uu 2424Clinical Dementia Rating Scale ( CDR )Clinical Dementia Rating Scale ( CDR ) 0,50,5

MemoryMemoryOrientationsOrientationsJudgment and problem solvingJudgment and problem solvingCommunity affairsCommunity affairsHome and hobbiesHome and hobbies

Personal carePersonal careGlobal Deterioration Scale ( GDS ):stage 2Global Deterioration Scale ( GDS ):stage 2- -33


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Mini Mental Stat u sMini Mental Stat u s

Examination (MMS E)Examination (MMS E)


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Mini Mental Stat u sMini Mental Stat u s

Examination (MMS E) Examination (MMS E) Screening test to provide brief,Screening test to provide brief,objective measure of cognitiveobjective measure of cognitivefunction.function.

Administered in 10 Administered in 10- -15 minutes, scores15 minutes, scoresrange from 0 to 30range from 0 to 30


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MMS E: Different cognitiveMMS E: Different cognitivedomains testeddomains tested

Questions grouped into seven categories:Questions grouped into seven categories:Orientation to timeOrientation to time 5 points5 pointsOrientation to placeOrientation to place 5 points5 pointsRegistration of three wordsRegistration of three words 3 points3 points

Attention and calculation Attention and calculation 5 points5 pointsRecall of three wordsRecall of three words 3 points3 pointsLanguageLanguage 8 points8 points

Visual construction Visual construction 1 point 1 point


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N oN o TesTes N ilaiN ilaimakmak

N ilaiN ilai

ORIE N TASIORIE N TASI11 Sekarang (tahun), (musim), (bulan), (tanggal), hariSekarang (tahun), (musim), (bulan), (tanggal), hari

apa?apa?

55 ------

22 Kita berada dimana? (negara), (propinsi), (kota),Kita berada dimana? (negara), (propinsi), (kota),(rumah sakit), (lantai/kamar)(rumah sakit), (lantai/kamar)

55 ------

REGISTRASIREGISTRASI33 Sebutkan 3 buah nama benda ( Apel, Meja, Koin),Sebutkan 3 buah nama benda ( Apel, Meja, Koin),

tiap benda 1 detik, pasien disuruh mengulangitiap benda 1 detik, pasien disuruh mengulangiketiga nama benda tadi.ketiga nama benda tadi.

33 ------

ATE N SI DA N KALKULASIATE N SI DA N KALKULASI44 Kurangi 100 dengan 7. Nilai 1 untuk tiap jawabanKurangi 100 dengan 7. Nilai 1 untuk tiap jawaban

yang benar. Hentikan setelah 5 jawaban. Atauyang benar. Hentikan setelah 5 jawaban. Ataudisuruh mengeja terbalik kata WAHYUdisuruh mengeja terbalik kata WAHYU

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PEMERIKSAA N STATUS ME N TAL MI N I (MMSE)P OK DI FU NG SI LUHUR PUS AT (modifikasi F O LSTEI N)


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ME N GIN GAT KEMBALI ( RECALL )5 Pasien disuruh menyebut kembali 3 nama benda di

atas3 ---

BAHASA6 Pasien disuruh menyebutkan nama benda yang

ditunjukkan ( pensil, buku)2 ---

7 Pasien disuruh mengulang kata-kata: namun , tanpa, bila 1 ---

8 Pasien disuruh melakukan perintah: Ambil kertas inidengan tangan anda, lipatlah menjadi dua danletakkan di lantai.

3 ---

9 Pasien disuruh membaca dan melakukan perintah

Pejamkanlah mata anda

1 ---

10 Pasien disuruh menulis dengan spontan 1 ---11 Pasien disuruh menggambar bentuk di bawah ini 1 ---

Total 3 0 ---

PEMERIKSAA N STATUS ME N TAL MI N I (MMSE)


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Penilaian MMS E

Nilai:

24 -30: T idak ada gangguan kognitif 17 -23: Probable gangguan kognisi0 - 16: Definite gangguan kognisi


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Good points of the MMS EGood points of the MMS E

Most widely accepted screening test Most widely accepted screening test Good internal consistencyGood internal consistency

Good test Good test- -retest reliabilityretest reliabilityHigh validity: good sensitivity and specificityHigh validity: good sensitivity and specificityCorrelates well with other screening tests e.g.Correlates well with other screening tests e.g.

clock drawing test and Short Blessed test clock drawing test and Short Blessed test Can be used for diagnostic, follow up,Can be used for diagnostic, follow up,measurement of therapeutic outcomemeasurement of therapeutic outcome


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Correlation between ADL and MMSE

An integrated approach to the management of AD. Eur J Neurol.5 (suppl 4). S9-17


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LimitationLimitation

Confounded by age, education and culture.Confounded by age, education and culture.

Highly educated people with obvious dementiaHighly educated people with obvious dementia

may score 27 or above (ceiling effect)may score 27 or above (ceiling effect)

Non demented subjects with modest educationalNon demented subjects with modest educationalattainment may score as low as 24 (floor effect)attainment may score as low as 24 (floor effect)

Can not be used as a single tool for diagnosisCan not be used as a single tool for diagnosisand it has to be interpreted within context of and it has to be interpreted within context of clinical history and examinationclinical history and examination


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Concl u sions from the MMS EConcl u sions from the MMS E

U seful in quantitatively estimating the U seful in quantitatively estimating the

severity of cognitive impairmentseverity of cognitive impairment

...in serially documenting cognitive ...in serially documenting cognitivechangechange


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Clinical Dementia RatingClinical Dementia Rating(CDR)(CDR)


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SemiSemi--structured interview with thestructured interview with thepatient/subject and a wellpatient/subject and a well- -informedinformedcollateral source (informant).collateral source (informant).

For diagnosis, staging, and changes (forFor diagnosis, staging, and changes (forclinical trial)clinical trial)More than 90% sensitivity and specificity.More than 90% sensitivity and specificity.

Validated against neuropathology Validated against neuropathologyinformation (Morris et al, 1988)information (Morris et al, 1988)One of the Gold Standard of Global rating of One of the Gold Standard of Global rating of dementia in trial of patients with ADdementia in trial of patients with AD

Clinical Dementia Rating (C DR)Clinical Dementia Rating (C DR)


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FaceFace validityvalidity:: measuresmeasures declinedecline relativerelative toto thetheindividualindividual that that interferesinterferes withwith usualusual functionsfunctionsMultidimensionalMultidimensionalClinically meaningful, even whenClinically meaningful, even whenneuropsychological test is normalneuropsychological test is normal

Avoids Avoids confoundsconfounds factorsfactors ee..gg.. education,education, ageage;;practicepractice effectseffects that that affect affect cognitivecognitive teststests

LessLess affectedaffected byby ceiling ceiling andand floor floor effectseffectsReliableReliable

Morris JC, Clinical Dementia Rating, 3 rd Asia-Pacific Regional Meeting of

!WGH, Bangkok 24 th -26 th March 2004

Advantages of Advantages of CDRCDR


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RelyRely onon availabilityavailability of of aa goodgood collateralcollateral

sourcesource (eg(eg.. caregiver)caregiver)Interviews are timeInterviews are time- -consumingconsumingcompared to brief cognitive testscompared to brief cognitive tests

RequireRequire clinicalclinical judgment judgment

Morris JC, Clinical Dementia Rating, 3 rd Asia-Pacific Regional Meeting of !WGH, Bangkok 24 th -26 th March 2004

Disadvantages of C DRDisadvantages of C DR


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Clinical Dementia RatingClinical Dementia Rating

(C DR)(C DR)Provides assessment of 6 domains / categories:Provides assessment of 6 domains / categories:3 cognitive + 3 functional domains.3 cognitive + 3 functional domains.

Cognitive domains:Cognitive domains:1. Memory1. Memory2. Orientation2. Orientation3. Judgment and problem solving ability3. Judgment and problem solving abilityFunctional domains:Functional domains:4. Community affairs4. Community affairs5. Home and hobbies5. Home and hobbies6. Personal care.6. Personal care.


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Impairment Impairment

00NoneNone

0.50.5QuestionableQuestionable

11MildMild

22ModerateModerate

33SevereSevere

MemoryMemory

OrientationOrientation

Judgment and problem solvingJudgment and problem solving

Community AffairsCommunity Affairs

Home & HobbiesHome & Hobbies

Personal CarePersonal Care


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None0

Questionable0.5

Mild 1 Moderate 2 Severe 3

Memory Nomemoryloss, or

slight inconsistent forgetful-ness

Consistent slight forgetfulnes;

partialrecollectionof events; benignforgetfulness

Moderate memorylose; more markedfor recent events;

defect interferes witheveryday activities

Severememoryloss; only

highlylearnedmaterialretained,newmaterialrapidly lost

Severememoryloss; only

fragmentsremain

Orientation Fullyoriented

Fullyorientedexcept forslight difficultywith timerelationship

Some difficulty withtime relationship;oriented for place&person at examination, but mayhave geographicdisorientation

Usuallydisorientedto time,often toplace

Orientedto persononly


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None0

Questionable0.5


Judgement andproblemsolving

Solveseverydayproblems andhandles

business andfinancial affairswell;

judgement good in relationto past performance

Slight impairment in solvingproblems,

similaritiesanddifferences

Moderatedifficulty inhandlingproblem,

similarities anddifferences;social judgement usuallymaintained

Severely impairedin handlingproblems,similarities and

differences; social judgement usuallyimpaired

Unable tomake

judgements orsolve

problems

Communityaffair

Independent function at usual level in

job, shopping,and volunteerand socialgroups

Slight impairment in theseactivities

Unable tofunctionindependently at these activitiesalthough may stillbe engaged insome; appearsnormal to causal

inspection

No pretense of independent function outsidehome. Appearswell enough to betaken to functionsoutside a familyhome

No pretense of independent functionoutside home.

Appears too illto be taken tofunctionsoutside a

family home


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None0

Questionable0.5


Homeandhobbies

Life at home,hobbies andintellectualinterest well

maintained

Life at home,hobbies andintellectualinterests

slightlyimpaired

Mild but definiteimpairment of function at home; more

difficult choresabandoned;morecomplicatedhobbies andinterest abandoned

Only single chorespreserved; veryrestricted interest,poorly maintained

No significant function inhome

Personalcare

Fully capable of self-care Needs prompting Requiresassistance indressing, hygiene,keeping of personal effects

Requiresmuch helpwith personalcare; frequent incontinence

Morris JC,. Neurologly 1993; 43:2412-14(20)


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CDRCDR DiagnosisDiagnosis

T hree classificationT hree classification No dementiaNo dementia = CDR 0= CDR 0 Uncertain dementia = CDR 0.5Uncertain dementia = CDR 0.5

(questionable dementia / MCI)(questionable dementia / MCI) DementiaDementia

CDR 0.5 = very mild dementiaCDR 0.5 = very mild dementiaCDR 1 = mild dementiaCDR 1 = mild dementiaCDR 2 = moderate dementiaCDR 2 = moderate dementiaCDR 3 = severe dementiaCDR 3 = severe dementia


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Definition of C DR 0.5Definition of C DR 0.5

..for subjects who are neither clearlydemented nor healthy. Many in this group havesyndromes compatible with the benign senescent forgetfulness of Kral while others probably havenormal cognitive function but may be mildlydepressed or concerned over minor forgetfulness.Still others are probably in an early stage of SDA T

Hughes et al. Brit J Psychiat 1982;140;566-572

Morris JC, Clinical Dementia Rating, 3 rd Asia-Pacific Regional Meeting of

!WGH, Bangkok24 th

-26 th

March2004


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Global Deterioration ScaleGlobal Deterioration ScaleGDSGDS


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Global Deterioration ScaleGlobal Deterioration Scale

A seven A seven--point rating scalepoint rating scaleStage 1: normal cognitive capacityStage 1: normal cognitive capacityStage 2: normal agingStage 2: normal agingStage 3: mild memory impairment Stage 3: mild memory impairment (MCI)(MCI)Stage 4: Mild ADStage 4: Mild ADStage 5: Moderate ADStage 5: Moderate AD

Stage 6:Moderately severe ADStage 6:Moderately severe ADStage 7: Severe ADStage 7: Severe AD


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Global deterioration scaleGlobal deterioration scaleClinical CharacteristicsClinical Characteristics

GDSStage

Clinical Characteristics

1Normal

No Subjective c omplaints of memory def icitNo memory deficit evident on clinical interview

2Normalaging

Subjective c omplaints of memory def icit,Most frequently in the following areas:

forgetting where one has placed familiar objectsforgetting names one formerly knew well

No objective evidence of memory deficits on clinical interviewNo objective deficit in employment or social situations Appropriate concern with respect to symptomatology


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GDSStage

Clinical Characteristics

4

Mild AD

Clear-cut de f icit on care f ul clinical interviewDeficit manifest in following areas:

Decrease knowledge of current and recent events

May exhibit some deficit in memory of ones personal historyConcentration deficit elicited on serial subtractionsDecreased ability to travel, handle finances, etcFrequently no deficit in the following areas:Orientation of familiar persons and faces

Ability to travel to familiar locationsnability to per for m complex task

Denial is dominant defence mechanismFlattering of affect and withdrawal from challenging situation occur


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GDSStage Clinical Characteristics

5

Moderate AD

P atient can n o longer survive with out some assistancePatient is unable during interview to recall a major relevant aspect of their

current life. For example:Their address or telephone number for many yearsThe names of closes members of their family (e.g grandchildren)The name of the high school or college from which they graduated

Frequently some disorientation to time (date, day of the week, season, etc) or to place

An educated person may have difficulty counting back from 40 by for fours or from 20 by twos

Person at this stage retain knowledge of many major facts regardingthemselves and others

They invariably know their own names and generally know their spouses andchildrens names

They require no assistance with toileting or eating, but may have difficultychoosing the proper clothing to wear


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GDS Stage Clinical Characteristics

6

Moderatelysevere

AD

May occasionally forget the name of the spouse upon whom they areentirely dependent for survival

Will belargely unaware of all recent events and ex periences in their lives

Retain some knowledge of their surroundings; the yea, the season etcMay have difficulty counting by ones from 10, both backward and sometimesforward

Will require some assistance with activities of daily livingMay become incontinentWill require travel assistance but occasionally will be able to travel to

familiar locationDiurnal rhythm frequently disturbed Almost always recall their own nameFrequently continue to be able to distinguish familiar from unfamiliar persons

in their environment


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6

Moderately

severe AD

Personality and emotional changes occur, these are quite variable andinclude:Delusional behaviour (eq, patients may accuse their spouse of beingan imposter; may talk to imaginary fiqures in the environment, or totheir own reflection in the mirror)Obsessive symptoims (eg. Person may continually repeat simplecleaning activities) Anxiety symptoms, agitation, and even previously non-existent violentbehaviour may occur Cognitive abulia (eg. Loss of willpower because an individual can notcarry a thought long enough to determine a purposeful course of action)


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7

Moderately

severe AD

(sambungan)

All verbal abilities are lost over the course of this stageEarly in this stage words and phrases are spoken but speech is very

circumscribed

Later there is no speech at all- only babblingIncontinent of urine, requires assistance toileting and feedingBasic psychomotor skill (eq, abililty to walk), are lost with the progression o

this stageThe brain appears to no longer be able to tell the body what to do

Generalized and cortical neurological signs and symptoms are frequentlypresent

Reisberg B, Ferris FH, de Lean MJ et al. The global deterioration scale forassessment of primary degenerative dementia


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T he best diagnostic test is a careful T he best diagnostic test is a carefulhistory and physical and mental statushistory and physical and mental statusexamination by a physician with aexamination by a physician with aknowledge of and interest in dementiaknowledge of and interest in dementiaand the dementing disease. Such anand the dementing disease. Such anevaluation is time consuming, but evaluation is time consuming, but nothing can replace itnothing can replace it

Differential diagnosis of dementing diseases.NIH Consensus Statement.Differential diagnosis of dementing diseases.NIH Consensus Statement.J AM A 1987, 258:3411J AM A 1987, 258:3411- -34163416


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Concl u sionConcl u sion

1. Early detection and correct diagnosis1. Early detection and correct diagnosisin early stages can be beneficial of:in early stages can be beneficial of:

T reatment efficacyT reatment efficacyPreventing costly and inappropriatePreventing costly and inappropriatetreatment resulting from misdiagnosistreatment resulting from misdiagnosis

Giving patients and families time toGiving patients and families time toprepare for the challenging financial, legal,prepare for the challenging financial, legal,and medical decisions that may lie aheadand medical decisions that may lie ahead


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Concl u sionConcl u sion

2. T he best diagnostic test is a careful2. T he best diagnostic test is a carefulhistory, physical and mental statushistory, physical and mental statusexamination by a physician with aexamination by a physician with aknowledge of and interest in dementiaknowledge of and interest in dementia

and the dementing disease. Such anand the dementing disease. Such anevaluation is time consuming, but evaluation is time consuming, but nothing can replace it nothing can replace it


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Dementia, operationDementia, operation

definitiondefinitionSyndrome of multiple acquired cognitiveSyndrome of multiple acquired cognitive

deficits that sufficient to interfere withdeficits that sufficient to interfere witheveryday activitieseveryday activities


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Dementia, diagnostic criteriaDementia, diagnostic criteria

NINCDSNINCDS--ADRDA ADRDA andand DSMDSM--IV criteriaIV criteria(any two of the five below) (memory +any one below)(any two of the five below) (memory +any one below)

1. Memory impairment *1. Memory impairment *2. Aphasia (language disturbance)2. Aphasia (language disturbance)3. Agnosia (impaired recognition/knowledge)3. Agnosia (impaired recognition/knowledge)4. Apraxia (disability in performance of previously4. Apraxia (disability in performance of previously

learned skills or tasks)learned skills or tasks)5. Executive dysfunction5. Executive dysfunction


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Laboratory testingLaboratory testing

UrinalysisUrinalysisComplete blood count, ESRComplete blood count, ESR

Liver enzymesLiver enzymesBUN, creatininBUN, creatininElectrolytes, blood glucoseElectrolytes, blood glucose

Vitamin B12, folic acid Vitamin B12, folic acidT SH, free thyroid indexT SH, free thyroid indexSyphilis serology, HIV testing, ApoE?Syphilis serology, HIV testing, ApoE?


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Pilihlah jawaban yang paling tepat, yang sesuai dengan perasaaanPilihlah jawaban yang paling tepat, yang sesuai dengan perasaaan

anda dalam satu minggu terakhir.anda dalam satu minggu terakhir.

11 .. Apakah Apakah andaanda sebenarnyasebenarnya puaspuas dengandengan kehidupankehidupan anda?anda? YaYa TIDAKTIDAK

22.. Apakah Apakah andaanda telahtelah meninggalkanmeninggalkan banyakbanyak kegiatankegiatan

dandan minatminat atauatau kesenangankesenangan anda?anda? YA YA TidakTidak

33.. Apakah Apakah andaanda merasamerasa kehidupankehidupan andaanda kosong?kosong? YA YA TidakTidak

44.. Apakah Apakah andaanda seringsering merasamerasa bosan?bosan? YA YA TidakTidak

55.. Apakah Apakah andaanda mempunyaimempunyai semangatsemangat yangyang baikbaik setiapsetiap saat?saat? YaYa TIDAKTIDAK66.. Apakah Apakah andaanda takuttakut bahwabahwa sesuatusesuatu yangyang burukburuk akanakan

terjaditerjadi padapada anda?anda? YA YA TidakTidak

77.. Apakah Apakah andaanda merasamerasa bahagiabahagia untukuntuk sebagiansebagian besar besar hiduphidup anda?Yaanda?Ya TIDAKTIDAK

SK AL A DEPR ESI GERI ATRI K 15SK AL A DEPR ESI GERI ATRI K 15


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Cognitive ProgressionCognitive ProgressionClinical Dementia RatingPresymptomatic

CDR 0.5 CDR 1 CDR 2 CDR 3Neuropsychological

Functional

Time (years )

P r o g r e s s i o n

d d f ff

MCI

How to Diagnose MCI

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