Mild. It’s a gentle word. A diagnosis of Mild Cognitive Impairment sounds like something to keep an eye on. It sounds like there’s time. Patients are often reassuringly told that it may not result in dementia. So you go home, keep living your life, and you wait. Hoping it doesn’t get worse.
Things are beginning to change, and the diagnosis is now sometimes preceded by Alzheimer’s blood biomarker tests and/or imaging that help clarify whether Alzheimer’s is on the horizon. That’s a good thing, except that it typically ends with a prescription that won’t stop or improve the disease, and no investigation into the actual causes for each individual.
The word “mild” is a comparison. It puts MCI on the scale below dementia and tells you nothing about how long it’s been building or why.
To see what that word leaves out, it helps to know how late-onset Alzheimer’s disease unfolds.
Alzheimer’s takes more than one form, and the one most people mean when they say the word is late-onset Alzheimer’s, diagnosed after age 65. There are other forms that begin earlier and progress more rapidly, and I’ll write about those another time.
Late-onset is associated with age, but it is not a disease of old age. It moves slowly through three stages that can take 20-30 years before a diagnosis.
Stage 1: Presymptomatic. You have no symptoms and cognitive tests would be normal, but other types of tests like p-tau217 would already be abnormal, showing that the processes related to an Alzheimer’s diagnosis have started. This stage can last 10-20 years, which gives you a long runway to take action to reverse it.
Stage 2: Subjective Cognitive Impairment. You notice changes, but they look like normal aging. A word won’t come. You lose the thread of what you were saying. You’re writing down appointments you used to remember without prompts. You have to think about where you parked your car. You may wonder if it’s something more than “normal,” and you may also be inclined to assume it isn’t until it gets worse.
Stage 3: Mild Cognitive Impairment. By the time it bothers you enough to schedule a doctor’s appointment and you hear the words Mild Cognitive Impairment, things have been going wrong for a long time. MCI is the stage before dementia. There is still a meaningful window to act, and MCI has been improved.
The most recent evidence is a randomized controlled trial of the ReCODE protocol, led by Dr. Bredesen and colleagues, and now in preprint while it goes through peer review. A very brief summary: Seventy-three people with MCI or early dementia, with MoCA scores of 18 or higher, were randomly assigned to a personalized protocol or to standard of care and followed for nine months at six clinics.
Of the 70 people who had blood biomarker testing, 68 showed brain changes associated with Alzheimer's. The personalized group improved on every cognitive and symptom measure, while the standard of care group declined in overall cognitive function and memory.
The treatment effect size for overall cognitive function was calculated to be greater than previously published clinical trials, seven times the effect size of the lecanemab trial and four times the effect size of the donanemab trial.
You can read the full study with all the details here.
Stage 4: Alzheimer’s dementia diagnosis. The symptoms now interfere with daily life. Bills go unpaid, medications get missed, familiar routes become confusing, and tasks like cooking, driving, or keeping track of the day need help from someone else. While people have improved and even reversed their symptoms at this point, there are a lot of variables.
The First Survivors of Alzheimer’s: How Patients Recovered Life and Hope in Their Words is an encouraging book. There’s a complete Q/A section written by Dr. Bredesen in the second half.
Review those stages and think about how we handle cancer. Nobody suggests waiting for stage 4 to find out. We have mammograms and colonoscopies so it can be caught at stage 1, when there are the most options and the best outcomes. Alzheimer’s has a stage 1 too, and finding it there, before any symptoms, is a completely different situation from finding it at stage 4 with a dementia diagnosis.
Right now, most people find out at stage 3 or 4.
Waiting for an Alzheimer’s diagnosis is clearly not a good idea. Unfortunately, most people don’t have this information, so they never learn that there were opportunities to act long before it got to that point.
Recently, I was at a social event, and a woman asked what kind of work I do. I told her, and she looked at me, confused. Then she told me her sister had been diagnosed with Alzheimer’s. She had never heard any of what you just read. She had never heard of Dr. Bredesen or the ReCODE protocol. I didn’t go into details in that situation. She didn’t ask questions.
We only talked for a few minutes, but it reminded me again that what I’ve spent the last decade doing, which feels so normal to me now, is still not widely known.
Sharing this post or forwarding it to friends could help more people learn that there’s a whole new body of research related to Alzheimer’s that lights up a very different path forward than what has always been thought of as a one-way street.
A few common symptoms in the Subjective Cognitive Impairment stage that are easy to dismiss as “normal aging”:
Words that won’t come, replaced with “the thing” or “you know”
Losing the thread mid-conversation
Repeating stories and not realizing you had told them before, over and over again. People listen politely, not wanting to point it out. So you may not know if you’re doing this.
Things put in places they don’t belong
Missed appointments, or needing reminders for what used to be automatic
Mild Cognitive Impairment
Each year, about 15 percent of people with MCI progress to an Alzheimer’s diagnosis. Over several years, that adds up to a large share of the people who receive this label. I have more than a decade of experience working with people at every stage, and I have seen far more improvement at SCI and MCI than after an Alzheimer’s diagnosis.
Here’s a real-life example: He had an MCI diagnosis and elevated p-tau217. He had “cognoscopy” lab testing, a term coined by Dr. Bredesen reflecting a wide array of tests for underlying contributors, and a year of implementing his personalized plan. His wife explains his progress after a year of using the ReCODE protocol:
“I’d been noticing lots of confusion, he didn’t remember recent conversations, and quite often would give me a ‘blank stare’ — like nobody’s home. Our GP listened carefully to our issues and ordered a cognitive test for him. Thus, the result — somehow it’s quite daunting to see it written in black and white from a ‘clinical’ perspective. As of now, he is sharper mentally. He is a retired pastor, now in an interim position. His memory is better, his delivery is on point — with clarity — no stumbling or losing his place. Also, I — and other family members — have noticed that he doesn’t have the ‘blank look’ that he had a year ago.”
That’s real progress.
Aside from MCI, declining cognition as you age is common. That doesn’t mean it’s normal. It’s common because we accept it as part of aging, most people don’t know how to prevent it, and because our modern diet, lifestyles, infections, and an increasingly toxic world sit at the root of cognitive decline and of the escalating number of people being diagnosed with MCI and Alzheimer’s. For most people, it doesn’t have to happen or keep getting worse when you intentionally give the brain what it needs to drive brain plasticity in a positive direction. There are quite a few things that it requires.
An aging brain responds to how you treat it, what you feed it, novelty, stress, movement, heart and gut health, sleep, infections, and exposures. Whether or how much it declines with age depends on those inputs.
If you’re on a prevention path, noticing symptoms, or have a diagnosis, here are three things you can do right now, one each for diet, sleep, and your home, and what to do after that.