Mild Cognitive Impairment (MCI): Assessment and Treatment

Editor's note: This text-based course is a transcript of the webinar, Mild Cognitive Impairment (MCI): Assessment and Treatment, presented by Kim McCullough, PhD, CCC-SLP.

Please also use the handout with this text course to supplement the material.

Learning Outcomes

After this course, participants will be able to:

• Explain the rationale for early intervention with adults with MCI
• Describe the recommended procedures for conducting an assessment of MCI
• Describe the best practices associated with intervention

Introduction

Welcome, everyone. Today, we are talking about mild cognitive impairment, and I am thrilled to share what the research and my two decades of clinical and community work have shown about how we can best assess and support individuals who are concerned about changes in their memory and thinking. Before we dive in, I want to establish some context for why this work matters so deeply.

Early intervention for those with cognitive impairment is a global priority. Worldwide, approximately 50 million people have dementia, and cognitive impairment creates a significant social and economic impact. Because there is really no curative treatment, it is critically important for countries around the world to focus on reducing modifiable risk factors. We will be discussing throughout this presentation the proactive management of modifiable risk factors and how they can delay or slow the onset or progression of cognitive impairment. Prevention through risk reduction is the priority.

Let me share some statistics that frame why this work is so urgent. An estimated 7.2 million Americans are living with Alzheimer's disease, and this number is projected to double by 2060. One in three older adults dies with Alzheimer's or another type of dementia. In fact, Alzheimer's disease kills more people than breast cancer and prostate cancer combined. Dementia costs the United States over $232 billion annually in direct medical and long-term care, and if you include unpaid caregiver costs, lost earnings, and lost quality of life, the estimate rises to upwards of $780 billion annually. Gender is also a risk factor. The lifetime risk for Alzheimer's disease at age 45 is one in five for women, contrasted with one in ten for men.

Here is another set of statistics that I find particularly motivating as a clinician. More than 80% of Americans know little about or are not familiar with the term mild cognitive impairment. However, approximately 85% of Americans say they would want to know if they had Alzheimer's disease early, including during the MCI stage. The reasons they cite most often include planning for the future, allowing for earlier treatment of symptoms, taking steps to preserve existing cognitive function, and simply understanding what is happening. Almost all primary care providers (96%) say it is important to assess patients aged 60 and older and screen them for cognitive impairment. However, only 48% report actually conducting those assessments, and they cite challenges in distinguishing mild cognitive impairment from normal aging. Nine out of ten say it is just hard to know where MCI ends, and dementia begins.

This tells us that increasing knowledge and education, particularly for and from clinicians, is an essential part of our professional responsibility. That is exactly what today's presentation aims to address. We are going to focus on recommended best practices for defining, assessing, and managing mild cognitive impairment and subjective cognitive decline. And I want to say from the start that this work is not just clinically important. It is enormously impactful for the individuals and families we serve. The earlier we identify people who are concerned about their cognition and support them with evidence-based strategies, the better their outcomes will be.

Defining MCI and the Cognitive Impairment Continuum

The Cognitive Impairment Continuum

I like to use a continuum graphic to help visualize where different conditions fall in relationship to one another. On this continuum, you have subjective cognitive decline, then early MCI, middle MCI, and late MCI, followed by dementia. Importantly, this continuum does not always result in dementia. The majority of individuals who have subjective cognitive decline and mild cognitive impairment do not convert to dementia. The area on the continuum spanning from SCD through the MCI stages is really a sweet spot for intervention. Clinicians have a real opportunity to provide interventions at this stage that can slow or delay the onset to dementia, and I want you to see that clearly.

Subjective Cognitive Decline

The first term I want to define is subjective cognitive decline, or SCD. This term was coined in 2014 and describes an extremely common complaint among healthy aging adults. Subjective cognitive decline is defined as an individual's self-reported, persistent concern about a decline in cognitive capacity, in the context of normal performance on objective cognitive measures (Jessen et al., 2020). So, although SCD was initially thought to represent the "worried well," these concerns can actually be linked to subtle brain changes that occur prior to changes in objective cognitive performance. In some individuals, subjective cognitive decline may represent the earliest stages of an underlying neurodegenerative disease process. We consider it one of the earliest warning signs of dementia, and it may be a way to identify people who are at higher risk.

That said, I want to keep repeating this: the majority of individuals with subjective cognitive decline will not show progressive cognitive decline. Since it is hard to distinguish SCD from normal aging, researchers have identified clinical features that increase the likelihood of progression to dementia. These features define what is referred to as SCD-plus, and they include subjective decline specifically in memory, irrespective of other cognitive domains. If someone is really complaining about changes in their memory, that is a higher risk indicator. A relatively recent onset of decline within the past five years also raises concern, as does being over 60 and having a high level of concern about the changes. If it does not bother the person, that is a different picture. But when someone has a high level of sustained concern, that can be a red flag. The presence of minor neurological signs is also a risk factor, as is observation of cognitive change by a care partner or family member.

Mild Cognitive Impairment

The distinction between subjective cognitive decline and mild cognitive impairment is the presence of objective impairment. With SCD, we are dealing with reported feelings of decline. With MCI, there is measurable, objective impairment on assessment. I want to note that throughout this presentation, I am using the terms mild cognitive impairment and mild neurocognitive disorder interchangeably. The term mild neurocognitive disorder is independent of etiology and age, whereas MCI initially referred specifically to Alzheimer's disease. But those two terms are frequently used together, and I will use MCI throughout.

The established diagnostic criteria for mild cognitive impairment include three core elements. First, these individuals have to have subjective cognitive decline, meaning they have to be concerned about their cognitive functioning. Second, they must have test performance on a standardized neuropsychological battery that is lower than expected for their age and education, indicating some type of objective cognitive impairment. Third, they retain the ability to perform basic activities of daily living. They may have some difficulty with instrumental activities of daily living, but their cognitive and behavioral changes are insufficient to significantly interfere with social or occupational functioning. A fourth criterion, not always listed but equally important, is that these individuals do not have dementia.

MCI Versus Dementia

The distinction between MCI and dementia is fundamentally about the impact on daily functioning. Mild cognitive impairment is considered a mild neurocognitive disorder because the impairment does not interfere with activities of daily living. Dementia, including Alzheimer's disease and other types, is designated as a major neurocognitive disorder because the cognitive dysfunction does interfere with activities of daily living. That interference with daily function is the critical distinguishing feature between the two.

Frequency of MCI Conversion to Dementia

The research literature indicates that about 15 to 20% of individuals aged 65 and older may have mild cognitive impairment. Of those, about 14.9% of those older than 65 followed for two years developed dementia. Age matters significantly here. About 6.7% of individuals aged 60 to 64 with MCI progress to dementia, rising to 8.4% for ages 65 to 69, then 10.1% for ages 70 to 74, 14.8% for ages 75 to 79, and 25.2% for those aged 80 to 84 (Petersen et al., 2018). So not everyone with mild cognitive impairment will go on to develop dementia, but age is a meaningful risk factor in that progression. Clinically, it is also important to know which features are associated with higher conversion risk. Those whose test performance is 1.5 standard deviations below the mean on cognitive assessments are at higher risk, as are older individuals, those with amnestic MCI (impairment particularly in memory), and those with multi-domain MCI (impairments across memory, language comprehension, attention, and language expression). Multi-domain involvement is associated with the highest risk of conversion to dementia.

Assessment

Where to Start: Setting and Purpose

When an older adult comes to you and expresses concern about changes in their memory or thinking, the first question to ask yourself is: where are you, and what is the purpose of this visit? Are they looking for a consultation, a screening, or a comprehensive assessment? The setting shapes your approach, and the purpose of the visit shapes what you prioritize. I work at Appalachian State University, where we have the Aging Well Program, a collaboration between our Appalachian Institute for Health and Wellness and numerous community partners focused on healthy aging for older adults. Within this program, we provide cognitive wellness consultations and exercise prescriptions, group and individual intervention, support groups, an aging well academy with monthly educational opportunities for older adults, and annual screening and assessment for community members. Our interprofessional team includes nursing, social work, occupational therapy, speech-language pathology, nutrition, and exercise science, all of whom are actively involved in this programming.

Before you can choose your assessment approach, it helps to understand what motivates the individual in front of you. The literature identifies several reasons that individuals would seek an early diagnosis. These include wanting to plan for the future with family, seeking earlier treatment of symptoms, beginning health measures to preserve existing function, understanding what is happening, accessing new or approved medications, addressing safety issues ahead of time, seeking education and support resources, assembling medical and caregiving teams, and ruling out reversible causes. But there are also reasons some individuals would not seek an early diagnosis, including finding it too difficult to accept a dementia diagnosis, believing treatment options are so limited that there is no point, worrying that others will treat them differently if diagnosed, or feeling they can manage their problems through lifestyle changes on their own. Understanding where your client sits in that spectrum is essential, because it shapes how you frame the assessment conversation and how you build rapport and trust.

The 5M Framework

Another concept I want to briefly introduce is the 5M framework, which challenges us to reframe aging as a dynamic, complex process. Anyone working with older adults needs to focus on the five Ms: mind, mobility, medications, with polypharmacy recognized as a significant and growing problem, what matters most, and the multi-complexity of working with older adults. Of these, I want to particularly emphasize what matters most and multi-complexity, as these two constructs are central to today's recommendations.

How do we determine what matters most? One of the most important things we can do is conduct an interview or have a genuine conversation. People and the systems in which they live are complex and layered. We want to identify and document the types of cognitive communication impairments the individual has. We want to determine in what situations they are having difficulty or what they are most concerned about. We want to know what strategies and practices they are currently using to help them compensate, if any. We want to assess their level of concern and how they feel about the situation. And we want to ask ourselves: are they motivated to change? Is depression a factor we need to screen for?

These are all questions you are asking yourself and exploring with your client. There is no gold standard tool for this, and clinicians need to find what works best in the setting in which they practice. The goal is to build a clear picture of the individual's experience before moving on to a more formal assessment.

Subjective Cognitive Decline Interview

One of the tools I recommend for assessing what matters most is the Subjective Cognitive Decline Interview, or SCD-I. This tool can be used with the person who has a concern, or with a family member or friend. It begins with an open question: "During the past few years, have you noticed any changes in your mental abilities? Could you give an example from everyday life?" You start with that open prompt, then follow up in a more structured format. The structured portion specifically asks about memory, word-finding difficulties, planning and organization, increased errors when not paying full attention, and any other cognitive changes (Miebach et al., 2019). Then you follow up with questions like, does this worry you? When did the decline start? Do you think your performance is worse compared to others your age? Have you talked to a physician?

What I like about this tool, and the other tools I will share, is that it provides a script or standardized format I can rely on clinically. Having that standardized structure is very helpful, both for consistency and for ensuring I do not miss important areas.

AD8 Dementia Screening Interview

Another tool I have used frequently is the AD8, available at alz.org. It is a screening tool and a conversation starter that helps identify where the individual has the most concern. I typically print it out and have individuals complete it either before their appointment or during check-in, so they can bring it into the assessment as a starting point for a shared conversation. However, I will usually remove the title because it says AD8 Dementia Screening Interview, which understandably makes people very concerned, so I tend to strip that out to reduce anxiety. The AD8 covers eight areas of potential change, asking whether there have been problems with judgment, reduced interest in hobbies, forgetting the correct month or year, and others. For each area, the individual indicates whether there has been a change, no change, or if they do not know. If an individual indicates two or more changes, a cognitive impairment is likely present. This is a simple and efficient way to understand what kinds of problems the individual is experiencing and whether a more in-depth assessment is warranted.

Memory Impact Questionnaire

Another tool that is readily available on the internet is the Memory Impact Questionnaire, or MIQ, from the University Health Network at Baycrest. Its premise is that many people notice changes in their memory over time, and these changes are small for some and larger for others. This questionnaire asks individuals to respond to impact statements about how memory changes have affected their lives. Examples include "Because of my memory changes, I sometimes feel left out of relationships," "My memory changes make me feel scared," and "Because of my memory changes, I don't get out for social occasions as often as in the past." Individuals respond on a four-point scale from disagree to agree to each statement. The MIQ provides three subscale scores: one for lifestyle restriction, one identifying positive coping strategies, and one for negative emotions or worry related to the memory change. This is very helpful for determining the impact of memory changes on day-to-day life, and it informs both the assessment conversation and the intervention planning that follows.

Multifactorial Memory Questionnaire

The Multifactorial Memory Questionnaire, or MMQ, also available from Baycrest, is a self-report questionnaire for assessing metamemory in middle-aged and older adults. It has three scales: satisfaction with memory functioning, a self-appraisal of actual memory ability, and self-reported use of memory strategies. One particularly practical feature of the MMQ is that it is available in many languages, including Arabic, Chinese, Czech, English, French, German, Greek, Hebrew, Hungarian, Portuguese, Serbian, Spanish, and Swedish, making it a genuinely accessible tool across diverse populations. These screening tools collectively provide a rich picture of the issues individuals face in their daily lives and what they are most concerned about.

Recommendations for Comprehensive Test Batteries

The screening tools I have described help you determine what matters most and begin to understand the individual's experience. But I want to be clear: these are not full standardized objective cognitive assessments. If you are looking to formally classify someone as having MCI, you need to use a comprehensive test battery. The literature offers some key recommendations to guide that choice (McCullough, Bayles, & Bouldin, 2019).

First, use an assessment with normative data. This is non-negotiable because normative data increases your ability to make valid judgments about whether a person's performance is atypical for their age and education. Without normative comparison data, it is genuinely difficult to identify what is atypical. With MCI, the performance decrements are often subtle.

Second, use a comprehensive battery that assesses multiple cognitive domains. Because multi-domain impairment is associated with higher conversion risk, seeing patterns across multiple domains is clinically meaningful. When you see lower levels of performance across several measures and in more than one cognitive domain, you can feel more confident in an MCI diagnosis.

Third, use measures with a gradient of difficulty. This is what enables you to detect subtle impairments. If all items on a test are the same difficulty level, you will miss the nuanced performance differences that distinguish MCI from normal aging.

Fourth, assess episodic memory. Alzheimer's disease is the most common cause of MCI and dementia, and its signature characteristic is episodic memory loss, specifically, rapid forgetting. Clinicians should therefore include an objective assessment of memory in both immediate and delayed recall conditions. Seeing how much a person retains after a delay is one of the most clinically informative data points you can have.

The ABCD-2 as an Example Assessment

The assessment I use most frequently is the Arizona Battery for Cognitive-Communication Disorders, Second Edition, or ABCD-2. I like it because it provides normative scores for both mild cognitive impairment and dementia, and because it assesses multiple cognitive domains, allowing me to look for patterns in scores across subtests. I can see declining scores from normal controls to mild cognitive impairment to mild dementia, which gives me a meaningful clinical picture.

One example subtest I want to highlight is the Following Commands Test, which illustrates the value of a gradient level of difficulty. This subtest includes one-step, two-step, and three-step commands. For a one-step command, such as "clap, then point," there is little difference between normal controls and those with mild cognitive impairment. But once you get to three-step commands such as "cough, smile, then whistle," you begin to see a real difference between individuals with MCI and normal controls. That difference would not be apparent without the task's built-in difficulty gradient.

The ABCD-2 also includes story retelling in both immediate and delayed conditions. The instructions are straightforward: "I am going to tell you a short story. When I am done, I want you to tell it back to me." Out of a best possible score of 17, normal controls typically give back about 14.6 points immediately and 14.1 points after a 15-minute delay. Those with mild cognitive impairment show a drop-off, averaging about 12.5 on immediate recall and 10.7 on delayed recall. And with mild Alzheimer's disease, individuals sometimes have difficulty after 15 minutes even remembering that a story was read. This kind of story retelling task, using both immediate and delayed conditions, is a powerful tool for assessing episodic memory and identifying the rapid forgetting that is characteristic of Alzheimer's disease.

Management

The Evidence Base for Cognitive Intervention

The literature on management is really exciting, and I want you to hear this clearly: the evidence indicates that everyone can benefit, including typical aging adults, those with subjective cognitive decline, those with mild cognitive impairment, and even those with dementia. from the management concepts I am about to share. Collectively, the studies in this area provide strong evidence that cognitive training, particularly multi-domain, strategy-based programs, leads to meaningful and durable improvements in cognitive functioning among older adults with SCD or MCI. And importantly, long-term follow-up data, including five-year follow-up, demonstrate that such interventions may even delay the progression to dementia. This really emphasizes the importance of early and sustained cognitive engagement.

One program with particularly compelling evidence is the MEMO+ intervention developed by Sylvie Belleville and colleagues. This is a structured cognitive intervention for older adults, delivered in 8 weekly sessions of approximately 2 hours each (Belleville et al., 2021). The program covers memory and healthy aging, attention training, visual imagery skill-building, the Method of Loci, learning the names of new acquaintances, PQRST (Preview, Question, Read, State, Test), external memory aids, and a final review session. The program emphasizes memory strategies and organizational techniques, alongside metacognitive components that encourage participants to reflect on when and how to apply those strategies in daily life. What Belleville and colleagues have shown is that individuals who completed this eight-week training maintained benefits that were evident five years after the intervention. Participants who completed MEMO+ not only maintained better cognitive performance than the control group but also showed a slower rate of decline and a reduced risk of conversion to dementia. This really highlights the program's potential as an effective long-term cognitive intervention.

Another significant piece of evidence is the US POINTER trial, published in JAMA in July 2025, which examined whether a structured healthy lifestyle program could help protect brain function in older adults at risk of memory decline. This randomized clinical trial enrolled over 2,000 adults aged 60 to 79. Everyone participated in lifestyle changes across five areas: physical activity, diet, mental and social engagement, and heart health. But one group received a structured, coach-supported program that included aerobic training four days per week, resistance and flexibility training two days per week, guidelines for following the MIND diet, weekly web-based cognitive training using BrainHQ three times per week, and biannual review of laboratory results with reinforcement of intervention goals. The other group followed a self-guided version with publicly available education materials. After two years, both groups showed improvement in overall cognitive function, but those in the structured group did a little bit better. And the benefits were similar across all participants, regardless of background or genetic risk. The takeaway is that making lifestyle changes, including those modifiable risk factors we discuss throughout this course, can genuinely boost brain health, and having structure, support, and accountability makes those changes more effective over time.

The Aging Well Program and the Strong Mind Intervention

In the context of management, I want to share a program I have implemented here at Appalachian State University. It is a group intervention called the Strong Mind program, part of our broader Aging Well Program. In the past, we have partnered with Kinesiology in what we called Strong Body, Strong Mind, which combined one hour of physical movement with one hour of cognitive activities. Here, I will focus on the cognitive intervention component.

When using a group intervention, I have found it very helpful to include three components: brain health education, cognitive stimulation, and strategy instruction. Those three components work together to optimize cognitive performance for the individuals we serve, and the literature supports their inclusion. The Strong Mind program is 10 weeks long. Week 1 is dedicated to self-assessment and goal setting. Weeks 2 through 5 focus on attention and memory strategies and exercises. Weeks 6 and 7 address communication strategies and exercises. Weeks 8 and 9 cover planning and organization. And Week 10 is a post-assessment week.

These sessions can range from 60 minutes to two hours, depending on the group. I have run groups as large as 20 people and as small as four or five. Four to five is a good number for this type of group intervention. I have also found it helpful, when setting up groups, to pay attention to the level of cognitive impairment or concern. Pairing those with less cognitive impairment and less concern together, and grouping those with more impairment together. That way, the content and pace can be calibrated appropriately.

Session Structure

Each session in the Strong Mind program has a consistent structure. The first five minutes consist of introductions and a warm welcome, which create a non-threatening learning environment and give participants a sense of security. You want to forecast what the session is going to cover so people know what to expect.

The next segment focuses on goals and strategies. In the first session, I provide participants with a pre-selected list of strategies covering attention, memory, word finding, planning, and organization, and they identify which strategies they are already using and which they want to work on. From that point forward, every session returns to those goals and strategies. We introduce and explain how to use them, encourage discussion of how participants use their strategies in daily life, and practice applying them throughout the other portions of the session as well.

Wellness Education

The wellness education component is one I particularly value. We create wellness education handouts for participants, but you can also draw on articles from reliable media sources available online. The key is that we know there are profound effects of exercise, diet, socialization, and sleep on our ability to learn and on our physical and mental health. Each session covers a new topic. The very first topic we address is neuroplasticity, and I do this intentionally. We want to increase participants' self-efficacy. When individuals begin to realize that their brain can change, that it is responsive and not fixed, that understanding itself becomes a powerful driver of engagement. If people do not believe they can improve their cognitive and language skills, they will not try. But when they understand neuroplasticity, they are empowered to do so. As we progress through the program, we also include sessions on stress, then on nutrition, and finally on sleep.

One thing I want to point out is that, within our wellness education component, we also use that content as a context for cognitive linguistic stimulation activities and opportunities to practice goals and strategies. For example, we might have participants read the wellness education handout and then set it aside. Then they turn to a partner and try to recall four important or interesting points from what they just read. They identify any information they did not remember, share it with a partner, and discuss the strategies they might have used to better remember that content. So there are all sorts of activities you can incorporate into wellness education. It does not have to stand alone as a means of information delivery. It can simultaneously serve as a context for memory practice, strategy use, and meaningful discussion.

There does get to be some overlap between the goals and strategies segment and the wellness education component, and that is fine. It gets a little muddy between those segments and the cognitive linguistic stimulation that follows. But we really try to focus on a particular area for the week, either attention and memory, or communication, or planning and organizing, while allowing the wellness education to serve as both substantive content and a platform for strategy practice.

Modifiable Risk Factors

Speaking of wellness education, I want to direct your attention to the Livingston and colleagues 2024 article, which discusses the fact that nearly 45% of dementias could theoretically be prevented by eliminating 14 modifiable risk factors. These risk factors include controlling diabetes and LDL cholesterol, treating blood pressure, preventing head injury, reducing air pollution, addressing and treating depression, stopping smoking, maintaining a healthy weight, avoiding excessive alcohol, addressing vision loss, addressing hearing loss, promoting social connections and avoiding isolation, encouraging cognitively stimulating activities, and encouraging exercise. These 14 factors work through several mechanisms: reducing neuropathology, decreasing vascular damage, reducing inflammation and stress, and improving and maintaining cognitive reserve.

I want to make clear why these belong in a group intervention program. By conducting group sessions, we are simultaneously addressing several of these factors. We are promoting social connections and helping individuals avoid isolation. We are encouraging cognitively stimulating activities. We are providing the knowledge and motivation to address others. These wellness education topics fit naturally into the group format and are substantive. When we talk about this research with our participants, we are not just delivering information. We are giving people a sense of agency over their own futures.

I also want to reinforce a message I carry through all of our programming: you need to empower and educate older adults with subjective cognitive decline and mild cognitive impairment that they indeed have some control over what happens next. That empowerment is itself a clinical tool. Evidence is building that almost half of dementias could be prevented by addressing these 14 risk factors, and communicating that to our participants with clarity and conviction changes how they engage with the program and with their own health behaviors.

I have also used the Brain Care Score tool from the Singh and colleagues 2024 article, and my participants really respond to it. It is a 211-point scale covering physical factors such as blood pressure, blood sugar, cholesterol, and BMI; lifestyle factors such as nutrition, alcohol, smoking, aerobic activities, and sleep; and social-emotional factors such as stress, social relationships, and meaning in life. Lower scores indicate increased risk for stroke and dementia. I ask participants to calculate their Brain Care Score at the beginning of the 10-week program and then again at the end, so they can track their own progress. And they can continue using it after the program concludes to monitor their modifiable risk factors over time. This is one of those tools that participants find genuinely engaging because it makes abstract risk factors personal and concrete. It takes only about five minutes to complete and gives people something actionable to focus on.

Cognitive Linguistic Stimulation

The cognitive linguistic stimulation portion of our sessions is where we do more traditional activities, and I want to be honest: although I sometimes hesitate to use worksheet-style activities, my participants actually love them. They provide a concrete way to practice strategies, they enjoy the challenge, and many like the element of friendly competition. People like to win, and that is fine. That motivation is a feature, not a problem. These activities can include face-name associations, paying attention to your environment, reading for details, word-creation tasks, and thinking of alternative words in the context of word-finding. All of these give participants an opportunity to practice the strategies we have discussed and apply them to new tasks.

Here is the principle behind it: to stimulate cognitive abilities, you have to try new activities. Familiar activities do not challenge the brain in the same way. So the worksheet activities, word-creation tasks, and face-name association exercises are not busywork. They provide a novel stimulus for the brain to engage with, and they embed strategy practice in that context.

Our cognitive-linguistic stimulation segments follow the program's structure. We have four weeks focused on attention and memory, two weeks on communication, including word-finding and following instructions, and two weeks on planning and organization. That structure gives participants enough time in each area to genuinely practice and internalize strategies rather than just being introduced to them once and moving on.

Homework and Home Challenges

We always close our sessions with homework assignments or home challenges. These do not need to be complicated or elaborate. One common assignment is simply to try one new thing during the week and then come back to the group and report how it went. Another is to commit to using one of their strategies, whether a memory strategy, a word-finding strategy, or a planning strategy, at every appropriate opportunity during the week, and then report back.

I want to share an example that captures why this matters. A gentleman in one of my groups came back one week and reported that he had tried something new: he had gone out a different door of his house every single day. He loved it. He discovered that he needed to tidy up that area of his house, found a letter he had never seen because he always went through the garage, and noticed some dead plants that needed attention. But he concluded with a laugh that he would not be doing it anymore. When I asked why, he explained that his little dog lived with him, and although he liked going out the new door, his dog did not find it at all acceptable. So they went back to the side door. The point is that trying something new can be as simple as brushing your teeth with the opposite hand, driving to the grocery store a different way, or starting at the opposite end of the grocery store. Obviously, learning a new language, a new instrument, or a new skill like quilting would provide a more substantial cognitive challenge. But anything new, approached with intention and awareness, is valuable.

We also close every session with a relaxation and mindfulness exercise. By the time the 10 weeks are over, participants have practiced enough types of mindfulness and relaxation that they have a toolkit they can take home and continue to use independently.

Participant Feedback

Some of the feedback we have received from participants in this 10-week program over the years is genuinely compelling. One participant said simply, "I worry less." And that matters clinically. If someone is worrying less about their word-finding difficulties, that stress reduction itself helps with word-finding abilities and memory. Worry and rumination consume cognitive resources. So reducing the level of concern is not just an emotional win. It is a functional one.

Another participant is one I will always remember. She came in at the beginning of the first session and, after I gave her the pre-selected list of strategies, informed me that she already used all of them. I thought, this is going to be a challenging 10 weeks. She participated every week, often with a somewhat skeptical posture. Her attitude at many points was that these were things she already knew. But at the end, she handed me a letter with her reflections, and I will be honest: I was a little nervous to read it. She shared that participation in the program had changed her thinking. She had believed that using memory strategies and word-finding strategies, things like writing things down, staying organized, and using a timer or alarm, was cheating. But after 10 weeks of intentionally practicing those strategies and seeing how they helped, she realized it was not cheating at all. It was strategizing. As she put it: "Using techniques is not cheating, it's strategizing." And so it really changed the way she used those strategies in her daily life going forward.

Other participants said they had used most of the strategies before, but that it was valuable to have them reinforced, and also to hear from others in the group. Hearing peers' stories about their experiences with word-finding, memory challenges, and how they applied strategies was a meaningful part of what made the group valuable. Shared experience is a powerful element of group intervention that you simply cannot replicate in individual therapy.

Still others said they came looking for a magic pill, but there was none. But, as one participant put it, "This program worked because I did the work." The accountability, the peer community, and the intentional practice across 10 weeks made the difference. And others reported that they had not realized they could strengthen their memory, just as they strengthen their bodies. That analogy, comparing cognitive fitness to physical fitness, is one I use deliberately. When people understand that the brain is responsive to training and to modifiable lifestyle factors, the entire intervention becomes more meaningful to them. They are not just filling time in a group. They are doing something that the research says can actually change their trajectory.

These cognitive intervention programs are low-cost, not inventory-based, and benefit everyone, whether they are experiencing normal aging, subjective cognitive decline, or mild cognitive impairment. There really are no downsides. And I believe we are going to see more and more of these programs in the future, because science is increasingly clear that people do have control. You can change the trajectory of cognitive impairment. You can empower older adults to take meaningful action. And that is exactly what our job as clinicians is all about.

Conclusion

Mild cognitive impairment is a condition that sits at a critical juncture between normal aging and dementia. The opportunity to intervene meaningfully at this stage is real, and the evidence shows that it works. We have research showing that cognitive training programs lead to durable improvements that can be measured five years later. We have evidence from the US POINTER trial that structured lifestyle intervention makes a meaningful difference. And we have clinical experience showing that individuals who engage with these programs worry less, use their strategies with greater intention, and leave feeling empowered rather than defeated.

Returning to our learning outcomes: we have explained the rationale for early intervention with adults with MCI, grounded in the global priority of prevention, the epidemiology of Alzheimer's and dementia, and the compelling evidence that intervention during the SCD and MCI stages can slow or delay progression to dementia. We have described the recommended procedures for conducting an assessment of MCI, including the use of screening tools like the SCD-I, AD8, MIQ, and MMQ for determining what matters most, and the principles guiding selection of a comprehensive test battery: normative data, multiple cognitive domains, gradient difficulty, and episodic memory assessment. And we have described best practices for intervention, centered on multi-component programs that include brain health education, cognitive linguistic stimulation, and strategy instruction, delivered in a group format with homework challenges, wellness education on modifiable risk factors, and a mindfulness component.

Every older adult who walks through our doors with a concern about their memory or thinking deserves a clinician who understands this continuum, knows how to assess it accurately, and can offer evidence-based support. That is what best practice looks like in this space.

References

See additional handout.