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Am J Geriatr Psychiatry. 2019 Aug;27(8):823-834. doi: 10.1016/j.jagp.2019.01.215. Epub 2019 Feb 2.

Mild Behavioral Impairment as a Marker of Cognitive Decline in Cognitively Normal Older Adults.

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University of Exeter Medical School (BC, HB, KAW, AC, CB), University of Exeter, Exeter, UK. Electronic address:
University of Exeter Medical School (BC, HB, KAW, AC, CB), University of Exeter, Exeter, UK.
Departments of Psychiatry, Clinical Neurosciences, and Community Health Sciences (ZI), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.
University of Exeter Medical School (BC, HB, KAW, AC, CB), University of Exeter, Exeter, UK; Wesnes Cognition Ltd. (KAW), Streatley on Thames, UK; Northumbria University (KAW), Newcastle, UK; Swinburne University (KAW), Melbourne; Newcastle University (KAW), Newcastle, UK.
Imperial College London (AH), London.
King's College London (ZK, MM, DA), London.
King's College London (ZK, MM, DA), London; Stavanger University Hospital (DA), Stavanger, Norway.



Mild behavioral impairment (MBI) is a neurobehavioral syndrome characterized by later life emergent neuropsychiatric symptoms (NPS) that represent an at-risk state for incident cognitive decline and dementia in people with mild cognitive impairment (MCI). We undertook a study to determine whether MBI was associated with progressive changes in neuropsychological performance in people without significant cognitive impairment.


A total of 9,931 older adults enrolled in the PROTECT study who did not have MCI or dementia undertook a comprehensive neuropsychological battery measuring attention, reasoning, executive function, and working memory at baseline and 1 year. MBI was ascertained using self-administration of the Mild Behavioral Impairment Checklist at 1 year, and participants were grouped according to MBI status: No Symptoms, Intermediate NPS and MBI. All assessments were completed online, and data analyzed using mixed-effects model repeated measures analysis of covariance.


A total of 949 (10%) people had MBI. These individuals had significantly worse cognitive performance at baseline and significantly greater decline over 1 year in the four composite cognitive scores measuring attentional intensity (F [2,8578] = 3.97; p = 0.019), sustained attention (F [2,8578] = 18.63; p <0.0001), attentional fluctuation (F [2,8578] = 10.13; p <0.0001) and working memory (F [2,9895] = 13.1; p <0.0001).


Our novel findings show that MBI is associated with faster decline in attention and working memory in this cognitively normal sample. MBI may be an earlier marker of neurodegenerative disease than MCI, captured at the stage of subjective cognitive decline or before, raising the possibility that MBI represents a novel target for dementia clinical trials or prevention strategies.


CogTrack; MBI; MBI-C; PROTECT; preclinical dementia; subjective cognitive decline (SCD)


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