Research Article: Operationalisation of Mild Cognitive Impairment: A Graphical Approach

Date Published: October 30, 2007

Publisher: Public Library of Science

Author(s): Fiona E Matthews, Blossom C. M Stephan, John Bond, Ian McKeith

Abstract: A new online tool allows mapping of the different classifications of mild cognitive impairment.

Partial Text: Despite intensive use of the term mild cognitive impairment (MCI) to describe an intermediate stage of cognitive decline between normal and pathological brain ageing, no formally agreed process of characterising this condition exists [1–3]. Various definitions have been proposed in the literature, each with differences in focus (e.g., age-associated change versus pathological decline) and non-uniform diagnostic criteria [4–18]. The degree of inconsistency is not trivial: current classifications define heterogeneous populations with different patterns of aetiology, cognitive decline, and clinical outcome [19].

The first step to coding MCI is to determine the necessary criteria and thresholds for operationalisation of each definition. We compiled a comprehensive list of those classifications which represent different aspects and definitions of MCI. The necessary components for each were abstracted and formulated into a diagnostic algorithm.

For example, following the flow diagram to arrive at a classification of benign senescent forgetfulness (BSF) takes just three steps: from the “START” box you move to the “Demented” box. If the individual does not have dementia (as indicated by the red arrow), you next move to the “Long-Term Memory Problem” box, and if the individual shows a long-term memory problem with intact recent memory (as indicated by the green arrow), you then arrive at a classification of BSF. (See Figure 2 for the BSF-specific path.)

The flow diagram details this process for each of the 18 different classification systems, allowing for reproduction across studies. Each concept has been detailed in turn with a criteria-specific graph and the appropriate references on the CFAS Web site ( The clinical utility of the concept of mild cognitive impairment depends on the validity of the diagnosis and the ability to predict higher rates of progression to dementia. The advantage of retrospective definition of these concepts is that they are not adjusted by current knowledge or changing criteria, an unfortunate downside of consensus criteria being that they can be influenced by changing knowledge over time. The disadvantage of mapping with retrospective information is that it removes clinical experience from the definition, and the information measured from all individuals must have enough scope to encompass the entire original definition.

It is time to re-examine the concept of MCI. The diagnostic disparity and the lack of consistency in case definition calls into question what exactly is being captured in each classification. This is a fundamental weakness of research on MCI, as highlighted by the complicated nature of Figure 1. Using this flow diagram, MCI systems can be mapped in other population datasets to investigate: (1) what are the best boundaries for impairment; (2) which tests are most sensitive for measuring each criteria; (3) which criteria, if any, can adequately predict individuals at risk of developing dementia; and (4) would adopting multiple systems across different populations (specialist clinic versus population based) and age groups be more appropriate? It is hoped that graphical operationalisation of the criteria will aid in diagnostic consistency and assist in the visualisation of the current problem, with the aim of formulating a gold standard definition for both research and clinical practice.



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