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10 The Open Geriatric Medicine Journal, 2008, 1, 10-13
1874-8279/08 2008 Bentham Open
Open Access
Psychiatric Diagnoses in a Sample of Outpatient Psycho-Geriatric New
Referrals with Suspected Mild Cognitive Impairment
Jeremia Heinik*,1,2, Perla Werner3 and Gitit Kavé4,5
1Margoletz Psychogeriatric Center, Ichilov Hospital, Tel Aviv, Israel
2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
3Department of Gerontology, University of Haifa, Haifa, Israel
4Margoletz Psychogeriatric Center, Ichilov Hospital, Tel Aviv, Israel
5Herczeg Institu te on Aging, Tel Aviv University, Tel Aviv, Israel
Abstract: Psychiatric symptoms/syndromes are frequent in Mild Cognitive Impairment (MCI). However, only a few stud-
ies reported full psychiatric diagnoses in MCI. We describe the nosology and prevalence of psychiatric diagnoses in a
group of 102 consecutive patients evaluated for suspected MCI and finally re-classified into dementia, MCI and No Cog-
nitive Imp airment. Psychiatric diagnoses were frequent in MCI and the other groups as well, however they were qualita-
tively different in each group.
Keywords: DSM-IV, psychiatric diagnoses, mild cognitive impairment (MCI), dementia, outpatient psycho-geriatric setting.
INTRODUCTION
The term mild cognitive impairment (MCI) is used to
describe a group of elderly subjects who have cognitive im-
pairments, often involving memory, not of sufficient severity
to warrant the diagnosis of dementia [1]. Psychiatric distur-
bances are common in MCI [2, 3] even though they do not
constitute part of its formal definition that emphasizes self
and/or informant cognitive complaints, impairment in per-
formance of objective cognitive tasks and essentially pre-
served activities of daily living [4, 5]. They might affect etio-
logic considerations, clinical presentation, outcome, and
treatment. With the aid of psychiatric and neuropsychiatric
rating scales the prevalence of symptoms, symptom-groups
and syndromes could be established in community and clini-
cal samples. Psychiatric symptoms in MCI are estimated to
range between 36.2 and 86.8 percent [6-9], depending on the
various definitions and methodologies for assessment. How-
ever, only a few studies [3, 10, 11] attempted to apply, even
in part, official psychiatric diagnoses to their study samples
of MCI and other subjects. In a population-based study,
Forsell et al. [10] used DSM-III-R [12] criteria for the diag-
nosis of depression (with no further specification regarding
this diagnosis), as well as a list of psychotic and anxiety
symptoms derived from the above manual. In a clinical set-
ting, Gabryelewicz et al. [11] defined major and minor de-
pressive episodes according to DSM-IV criteria [13]. They
excluded some individuals with severe major depression
because these may have contributed to observed cognitive
difficulties. In addition, they provided no specific definition
and classification of depressive episodes, and reported only
depression but no other types of psychopathology. Similarly,
*Address correspondence to this author at the Margoletz Psychogeriatric
Center, Ichilov Hospital, 6 Weizman Street, Tel Aviv, Israel 64239; Tel:
972-3-6973325; Fax: 972-3-6974658; E-mail: heinik@post.tau.ac.il
in a sample of dementia clinic referrals Lopez et al. [3] used
DSM-IV criteria for major depression but provided no fur-
ther specification of their diagnoses. Thus far, only Kumar et
al. [14] used specifically evaluated DSM-IV criteria for ma-
jor and minor depressive syndromes in a small sample of
community-dwelling, relatively young (60-64) subjects. Im-
portantly, however, current nomenclature deals with disor-
ders rather than syndromes.
The present study aims to describe the nosology and
prevalence of DSM-IV axis I non-cognitive diagnoses in
individuals referred for further evaluation for suspected MCI
in the context of an outpatient psycho-geriatric setting, with
special reference to the psychiatric diagnoses in those indi-
viduals finally diagnosed with MCI.
MATERIALS AND METHODS
The patient population referred to our outpatient psycho-
geriatric service includes mainly patients with cognitive im-
pairment and individuals with depressive and anxiety disor-
ders, treatable on an ambulatory basis. Each new referral
undergoes a comprehensive multidisciplinary assessment
process (geriatric psychiatrist, geriatrician, social worker,
nurse). Laboratory investigations, including imaging studies,
are suggested in each case to exclude potentially treatable
causes for cognitive impairment and physical causes for
emotional disorders. For those subjects with very early or
early stages of cognitive impairment an MCI clinic was es-
tablished, where subjects with a working diagnosis of sus-
pected MCI undergo further evaluation. Subjects for the pre-
sent study were recruited from these clinic referrals. The
cognitive states of subjects with suspected MCI were further
evaluated with the Hebrew version of the Cambridge Cogni-
tive Examination – Revised (CAMCOG-R) [15, 16] (range
0-105; 80/81 published cut-off point for cognitive impair-
ment [15]), out of which an MMSE score can be generated
Outpatient Psycho-Geriatric New Referrals The Open Geriatric Medicine Journal, 2008, Volume 1 11
(range 0-30; 23/24 published cut-off point for cognitive im-
pairment [17]). Psychiatric data were obtained with a modi-
fied Hebrew version of CAMDEX-R. The Cambridge ex-
amination for mental disorders of the elderly-revised (Heinik
et al., in preparation), sections A (interview with patient), C
(interviewer observations) and H (interview with informant).
CAMDEX-R items makes it possible to derive various
DSM-IV diagnoses [15]. This entire workup is usually com-
pleted within 1-2 months. The study protocol was approved
by the local Helsinki committee.
For the purposes of the present study, DSM-IV [13] axis
I operational criteria were used for cognitive and psychiatric
diagnoses. When inapplicable, the criteria included in the
DSM-IV “criteria sets and axes provided for further study”
were used (e.g., minor depressive disorder, mixed anxiety-
depressive disorder). MCI diagnosis was established accord-
ing to the Winblad et al. [5] criteria operationalized in the
following order: 1. Not demented according to DSM-IV cri-
teria, 2. Self and/or informant report of cognitive decline. 3.
Impairment on objective cognitive task (defined as CAM-
COG-R total score below the 25th percentile compared to
normative values by age-group, sex and educational level
[18]. 3. Preserved basic activities of daily living/ minimal
impairment in complex instrumental functions. 4. Not nor-
mal. Consensus regarding diagnosis was reached by two
geriatric psychiatrists.
A total of 102 consecutive persons with suspected MCI
were assessed. The overall mean age of the sample was 76
years (SD = 6.3), and the mean years of education was 12
(SD = 3.3). Females constituted 50%. Final cognitive diag-
noses were: dementia - 49 individuals (48%;of which 63%
with Alzheimer`s type, 8% with vascular dementia, 10%
with mixed type, 19% with other type dementia), mild cogni-
tive impairment (MCI) - 36 individuals (35%) and no cogni-
tive impairment (NCI) - 17 individuals (17%). Mean MMSE
score in the total group was 26.37 (SD = 2.27), and 24.81
(SD = 1.79) in the dementia group, 27.6 (SD = 1.76) in the
MCI group, 28.12 (SD = 1.36) in the NCI group. The mean
total CAMCOG-R scores in the total sample were 82.73 (SD
= 9.36), with 76.31 (SD = 7.96) in the dementia group, 86.25
(SD = 5.38) in the MCI group, and 93.41 (SD = 5.04) in the
NCI group. The one-way Analyses of Variance (ANOVA)
revealed significant group effects on the MMSE score (F
(2)=37.8, p<0.001) and the CAMCOG-R total score (F
(2)=48.6, p<0.001).
RESULTS
Table 1 shows that the total sample was almost equally
divided in to persons who received a psychiatric diagnosis or
demonstrated DSM-IV predominant psychiatric features in
dementia, and persons who had no psychiatric diagnosis.
Most individuals within the dementia group did not receive
any additional psychiatric functional diagnosis, and pre-
dominant psychiatric features (mostly depressive with or
without anxiety) were found in under half (43%) of this
group. In the MCI and NCI groups, DSM-IV psychiatric
diagnoses were found in 61% and 59% of the sample, re-
spectively. Within the MCI group, categories suggested for
possible inclusion in DSM-IV, such as minor depressive
Table 1. Psychiatric Diagnoses and Predominant Features
Dementia (n=49) MCI (n=36) NCI (n=17) Total (n=102)
No psychiatric diagnosis 28 (57%)a 14(39%) 7(41%) 49(48%)
Total psychiatric diagnoses 21(43%) 22(61%) 10(59%)b 53(52%)
Major depressive disorder (MDD) - 5(22.7%)* 3(30%)* 8(15%)*
Dysthymic disorder - 2(9%)* - 2(3.7%)*
Bipolar disorder - 1(4.5%)* - 1(1.9%)*
Post traumatic stress disorder (PTSD) - 1(4.5%)* 1(10%)* 2(3.7%)*
Generalized anxiety disorder - - 1(10%)* 1(1.9%)*
Anxiety disorder NOS - 1(4.5%)* 1(10%)* 2(3.7%)*
Adjustment disordersc - 1(4.5%)* 5(50%)* 6(11.3%)*
Minor depressive disorder - 5(22.7)* - 5(9.4%)*
Mixed anxiety-depressive disorder - 6(27.2%)* - 6(11.3%)*
Dementia predominant psychiatric features:
With delusions 2(9.5%)* - - 2(3.7%)*
With depressed mood 15(71.4%)*d - - 15(28%)*
With behavioral disturbance 4(19%)* - - 4(7.5%)*
Abbreviations
MCI-Mild cognitive im pairment; NCI-No cognitive impairment; NOS-Not oth erwise specified. Dash ind icates the absence of a specific psychiatric diagnosis/feature.
*Out of total psychiatric diagnoses in each diagnostic group.
Notes
aDenotes uncomplicated dementia.
bOne person had two psychiatric diagnoses (adjustment disorder and PTSD).
cWith the following subtypes: MCI – 1 with both depression and anxiety; NCI – 3 with depression, 1 with anxiety, 1 with both.
dIncludes 4 persons with predominant depression and anxiety and 2 with predominant anxiety. DSM-IV offers no separate classification for dementia and anxiety, hence included
under depression.
12 The Open Geriatric Medicine Journal, 2008, Volume 1 Heinik et al.
disorder and mixed anxiety-depressive disorder accounted
for 50% of psychiatric diagnoses. This group included 1 per-
son with Major Depressive Disorder (MDD) with psychosis
in partial remission and 1 person with bipolar disorder in
remission. Within the NCI group, adjustment disorders pre-
vailed. MDD was almost equal in frequency in the MCI and
NCI groups. Thus, diagnoses suggesting psychosis and be-
havioral disturbance were noted in a minority of individuals
in our MCI sample compared with the dementia group (4.5%
vs 28.6%). In the MCI group minor mood disorders
(dysthymic, adjustment, minor depressive and mixed-anxiety
depressive disorders) were more common than major depres-
sion (63.4% vs 22.7%).
DISCUSSION
We investigated the nosology and prevalence of psychiat-
ric diagnoses in a sample of subjects with suspected MCI
seen at a specialized outpatient psycho-geriatric setting. The
sample in total demonstrated reasonable performance on the
cognitive tasks (mean scores for both tests above the pub-
lished cut-off points for dementia), hence a suspected MCI
diagnosis. However, a second in-depth evaluation led to re-
classification of the original working diagnosis into demen-
tia, MCI and NCI groups.
Psychiatric diagnoses were frequent in all three groups
and highest in the MCI group (61%). This finding is congru-
ent with the significant amount of psychiatric symp-
toms/syndromes reported in this disorder [2, 3, 6-11,14].
However, the nature of the psychiatric diagnoses was quali-
tatively different in the three groups. In the NCI group the
psychiatric diagnoses were minor traditional diagnoses (e.g.,
mostly adjustment disorders which might explain some di-
agnostic shifts during the diagnostic work-up from suspected
MCI to NCI). In the MCI group suggested new minor diag-
noses were significant, whereas in the dementia group pre-
dominant psychiatric features were found, though they did
not amount to a full functional psychiatric diagnosis. It has
been suggested [8, 19] that neuropsychiatric symptoms in
MCI are quantitatively and qualitatively intermediate to that
of healthy participants and those with dementia, and are
therefore reminiscent of the clinical, neuroimaging and neu-
ropsychological profile of MCI [19]. However this statement
is true with regard to dementia of the Alzheimer type, am-
nestic MCI, and controls who are essentially free of any dis-
turbances whatsoever. This is not the situation concerning
our sample in which dementia etiology was heterogeneous
and the NCI group was defined on the basis of cognitive
functioning rather than on the exclusion of other disorders.
Thus, we cannot commit as for the "intermediacy" of the
MCI group concerning the psychiatric diagnoses.
Our findings concerning the low prevalence of diagnoses
suggesting psychosis in MCI are in accordance with Chan et
al. [2] and with Lopez et al. [3], both studies having demon-
strated lower prevalence of psychosis and disruptive behav-
ior in MCI compared with dementia patients, as well as with
Lyketsos et al. [8] and Geda et al. [19] who reported symp-
toms of psychosis (delusions, hallucinations) and of disrup-
tive behavior to be significantly lower in MCI compared
with mild Alzheimer disease patients, albeit higher than in
normal controls [19] and in MCI compared with dementia
[8]. Similarly, minor depression was reported to be more
prevalent in MCI than major depression, both in a clinical
sample (26.5% vs 19.6% [11]) and in a community sample
(17.2% vs 3.4% [14]), and this was the case in the present
study as well (63.4% vs 22.7%). The above stands for the
minor nature of the psychiatric diagnoses we found among
MCI subjects.
As for limitations of this study: First, the number of sub-
jects in the total sample and in each diagnostic group was
relatively small; Second, the study population was biased
toward those subjects and caregivers cooperative enough to
undertake prolonged cognitive assessment, as well as to
those subjects in which demographics (schooling, fluency in
language), sensory (appropriate sight and hearing capacity),
physical (motor ability), and psychiatric conditions, are fa-
vorable for inclusion in such an assessment; Third, th e defi-
nition of cognitive impairment we used differs from other
psychometric definitions of MCI in which more stringent
cut-points were used (e.g., -1.5 SD [3], -1 SD, beneath the
16th percentile [20]). Fourth, the use of the entire DSM-IV
multi-axial assessment would have probably provided us
with a more comprehensive view of subjects and their ail-
ments.
Even-though these limitations preclude generalization of
our findings, the current work nonetheless demonstrates that
psychopathology, expressed in clinical diagnoses, is com-
mon, heterogeneous and mostly mild in MCI. This might
have repercussions regarding the psychiatric treatment of
MCI. In fact, psychiatric diagnoses more than mere symp-
toms/syndromes should be evaluated in order to provide
proper management of the MCI patient. The relationship
between psychiatric symptoms, syndromes and full diagno-
ses in MCI warrants further investigation.
ACKNOWLEDGEMENT
We are grateful to Mrs. Rena Kurs for her editorial assis-
tance in preparation of the manuscript.
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Received: March 25, 2008 Revised: April 4, 2008 Accepted: April 15, 2008
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