Noninvasive Brain Stimulation for Mild Cognitive Impairment

This study aims to test the efficacy of a non-pharmacological treatment for MCI that involves
noninvasive brain stimulation (NIBS). Early studies in Alzheimer's disease (AD) dementia
patients have found that repetitive transcranial magnetic stimulation (rTMS, a form of NIBS)
improved global cognitive function and activities of daily living. Given that in AD, neuronal
loss and synaptic dysfunction progress along brain networks, the results of these early
studies of brain stimulation suggest there is sufficient neuroplasticity in AD for
efficacious effects of brain stimulation. Of the very few rTMS studies in MCI that have been
published, the effect size appears to be moderately large. However, it is not clear whether
the dorsolateral prefrontal cortex (DLPFC), the stimulation site used in the most of the
prior MCI/AD rTMS trials, is the optimal site for achieving the most efficacious effects
including effects on episodic memory. Importantly, when other investigators used rTMS to
stimulate a lateral parietal cortical (LPC) site in healthy young adults, significant effects
of rTMS on memory were measureable weeks later. Moreover, functional connectivity of brain
regions was selectively increased, including the posterior cingulate cortex (PCC), a "hub" of
brain networks that is affected in amnestic MCI.

Because stimulation of the DLPFC and the LPC may each have distinct effects, we designed this
pilot trial to have two active rTMS treatment groups: DLPFC and LPC. A third group will
receive inactive (placebo) rTMS to achieve a controlled, randomized, double-blind trial. For
each of the three groups, stimulation will be bilateral, based on effects achieved in the AD
studies. The primary hypothesis is that active rTMS (to either site of stimulation) will be
superior to inactive (placebo) rTMS in improving memory. Measures of change in functional
connectivity will be computed to examine whether there is evidence that rTMS changes
connectivity of the PCC with other regions of the brain. In addition to looking at effects of
rTMS on functional connectivity and cognition in relation to the cortical site stimulated,
genetic markers will be collected toward addressing heterogeneity of response. To track the
durability of rTMS effects on memory, participants will be followed longer than in any prior
study (up to 6 months after the intervention). If this study finds rTMS improves memory in
older adults with MCI, further clinical development of this non-pharmacological treatment
could ultimately improve the lives of millions of older adults who have MCI and are at an
increased risk of developing dementia.

- Both Veterans and Non-Veterans may enroll if they meet the following criteria **

Inclusion Criteria:

- Diagnosed with amnestic Mild Cognitive Impairment (aMCI);

- Stable medications (including any dementia-related meds) for at least 4 weeks prior to
Baseline;

- Geriatric Depression Scale score less than 6;

- Ability to obtain a motor threshold, determined during the screening process;

- Study partner available; living situation enables attendance at clinic visits;

- Visual and auditory acuity adequate for neuropsychological testing;

- Good general health with no diseases expected to interfere with the study;

- Participant is not pregnant or of childbearing potential (i.e. women must be 2 years
post-menopausal or surgically sterile);

- Modified Hachinski Ischemic score less than or equal to 4;

- Agree to DNA extraction for single nucleotide polymorphism (SNP) genotyping;

- Able to understand study procedures and comply with them for the entire length of the
study.

Exclusion Criteria:

- Prior exposure to rTMS within the past 12 months;

- Magnetic field safety concern such as a cardiac pacemaker, cochlear implant, implanted
device in the brain (deep brain stimulation), or metal fragments or foreign objects in
the eyes, skin or body;

- Any significant neurological disease other than suspected incipient Alzheimer's
disease;

- Unstable cardiac disease or recent (< 3 months previous) myocardial infarction. Any
significant systemic illness or unstable medical condition that could lead to
difficulty with protocol adherence;

- History of epilepsy or repetitive seizures, as determined by patient report or chart
review;

- History of a medical condition or current use/abuse of medications and substances that
increase the risk of a seizure, specifically:

- Traumatic brain injury within 2 months that would increase the risk for seizure;

- Unable to safely withdraw, at least 4 weeks prior to Baseline, from medications
that substantially increase the risk of having seizures (for example:
theophylline, clozapine, and methylphenidate).

- Current or past history of a mass lesion, cerebral infarct, or other noncognitive
active neurological disease that would increase the risk for seizure.

- Stimulant abuse within the previous 90 days. Cocaine and abuse of amphetamine and
methylphenidate are associated with an increased risk of seizures;

- Major depression or bipolar disorder (DSM-IV) within the past 1 year, or psychotic
features within the last 3 months that could lead to difficulty with protocol
adherence;

- Taking sedative hypnotics or medications with anti-cholinergic properties and unable
to withdraw at least 4 weeks prior to Baseline;

- Current alcohol or substance abuse (not including caffeine or nicotine) within the
past 1 year, as determined by chart review, participant or study partner report, or
greater than "moderate" alcohol use defined by the Quantity-Frequency-Variability
Index (Cahalan, Cisin, & Crossley, 1969);

- Any contraindications for magnetic resonance imaging (MRI) studies, e.g. severe
claustrophobia, weight above 350 lb maximum allowed by MRI scanner, pregnancy;

- Participation in another concurrent clinical trial;

- Inability or unwillingness of individual or legal representative to give written
informed consent.