Management of Patients With Mild Cognitive Impairment in the Era of Anti-Amyloid Therapy: A Worldwide Neurology Survey.

Background and objectives: The aim of this study was to explore practice patterns in managing mild cognitive impairment (MCI). The investigation and management of MCI is considered important because it offers the opportunity to potentially stave off conversion to dementia. However, there are few data on current practices/approaches in this area, especially worldwide; such data can help identify potential disparities and anticipate adoption of new therapies.

Methods: We performed a worldwide electronic survey of neurology practitioners through the Practice Current section of Neurology® Clinical Practice with clinical and practice-related questions in November 2019-August 2021 and repeated it in May-October 2023 after the FDA's approval of aducanumab and lecanemab but before the approval of donanemab. Clinical questions addressed access to and utilization of diagnostic investigations, pharmacologic and nonpharmacologic management of MCI, and (in 2023) attitudes toward novel anti-amyloid agents. Responses were compared using the Fisher exact test and multivariable logistic regression adjusted for region, regional income, year of survey response, years in practice, and number of cognitive patients seen annually.

Results: We received 1,257 responses from 95 countries, including 237 cognitive subspecialists and 464 respondents from low-/middle-income countries. On multivariable analysis, cognitive subspecialists were more likely than other practitioners to investigate MCI with a lumbar puncture (aOR 1.90, 95% CI 1.32-2.73), luorodeoxyglucose-PET (FDG-PET) (aOR 1.45, 95% CI 1.00-2.10) and to offer pharmacotherapy if investigations suggested neurodegeneration (aOR 1.92, 95% CI 1.29-2.85). Regionally, respondents from Europe, Latin America, and Asia were more likely than those from the United States/Canada to order FDG-PET (e.g., Europe: aOR 2.38, 95% CI 1.29-4.39) and amyloid PET (Europe: aOR 3.30, 95% CI 1.85-5.87), controlling for reported access to these tests. Pharmacologic and nonpharmacologic approaches were comparable between cognitive subspecialists and other respondents. Despite concerns about safety (77.1% expressed being somewhat or very concerned), attitudes toward prescribing new anti-amyloid agents were similar among all respondents, reflecting a generally favorable attitude (e.g., 62% would prescribe anti-amyloid therapy if it was available).

Discussion: Our results highlight practice differences among cognitive subspecialists and other practitioners worldwide in the management of MCI. Attitudes toward anti-amyloid therapy indicate cautious optimism, with concerns about side effects but a general interest to prescribe.