Alzheimer’s & Dementia - (2013) 1–9

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The prevalence of mild cognitive impairment and its etiological

subtypes in elderly Chinese
Jianping Jiaa,*, Aihong Zhoua, Cuibai Weia, Xiangfei Jiab, Fen Wanga, Fang Lic, Xiaoguang Wud,
Vincent Moke, Serge Gauthierf, Muni Tangg, Lan Chuh, Youlong Zhoui, Chunkui Zhouj,
Yong Cuik, Qi Wanga, Weishan Wangl, Peng Yinm, Nan Hum, Xiumei Zuoa, Haiqing Songa,
Wei Qina, Liyong Wua, Dan Lia, Longfei Jian, Juexian Songa, Ying Hana, Yi Xinga, Peijie Yanga,
Yuemei Lia, Yuchen Qiaoa, Yi Tanga, Jihui Lvl, Xiumin Donga
a
Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, People’s Republic of China
b
Department of Computer Science, University of Otago, Dunedin, New Zealand
c
Department of Neurology, Fu Xing Hospital, Capital Medical University, Beijing, People’s Republic of China
d
Evidence-Based Medicine Center, Xuan Wu Hospital, Capital Medical University, Beijing, People’s Republic of China
e
Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, People’s Republic of China
f
McGill Center for Studies in Aging, McGill University, Montreal, Quebec, Canada
g
Department of Geriatrics, Guangzhou Brain Hospital, Affiliated Hospital of Guangzhou Medical College, Guangzhou, Guangdong Province,
People’s Republic of China
h
Department of Neurology, Affiliated Hospital of Guiyang Medical College, Guiyang, Guizhou Province, People’s Republic of China
i
Department of Neurology, Third Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou, Henan Province,
People’s Republic of China
j
Department of Neurology, First Hospital of Jilin University, Changchun, Jinlin Province, People’s Republic of China
k
Department of Neurology, Fourth Hospital of Jilin University, Changchun, Jinlin Province, People’s Republic of China
l
Department of Neurology, Beijing Geriatric Hospital, Beijing, People’s Republic of China
m
National Center for Chronic and Noncommunicable Disease Control and Prevention, Beijing, People’s Republic of China
n
Department of Neurology, Tongren Hospital, Capital Medical University, Beijing, People’s Republic of China

Abstract Background: Epidemiologic studies on mild cognitive impairment (MCI) are limited in China.
Methods: Using a multistage cluster sampling design, a total of 10,276 community residents
(6096 urban, 4180 rural) aged 65 years or older were evaluated and diagnosed with normal cognition,
MCI, or dementia. MCI was further categorized by imaging into MCI caused by prodromal
Alzheimer’s disease (MCI-A), MCI resulting from cerebrovascular disease (MCI-CVD), MCI with
vascular risk factors (MCI-VRF), and MCI caused by other diseases (MCI-O).
Results: The prevalences of overall MCI, MCI-A, MCI-CVD, MCI-VRF, and MCI-O were
20.8% (95% confidence interval [CI] 5 20.0–21.6%), 6.1% (95% CI 5 5.7–6.6%), 3.8%
(95% CI 5 3.4–4.2%), 4.9% (95% CI 5 4.5–5.4%), and 5.9% (95% CI 5 5.5–6.4%) respectively.
The rural population had a higher prevalence of overall MCI (23.4% vs 16.8%, P , .001).
Conclusions: The prevalence of MCI in elderly Chinese is higher in rural than in urban areas.
Vascular-related MCI (MCI-CVD and MCI-VRF) was most common.
Ó 2013 The Alzheimer’s Association. All rights reserved.
Keywords: Mild cognitive impairment; Etiological subtypes; Prevalence; Risk factors

1. Introduction
Mild cognitive impairment (MCI) constitutes an intermedi-
*Corresponding author. Tel.: 0086-10-83198730; Fax: 0086-10-83171070. ate stage between normal aging and dementia [1,2]. As a key
E-mail address: jjp@ccmu.edu.cn interventional target for dementia, MCI has been an important
1552-5260/$ - see front matter Ó 2013 The Alzheimer’s Association. All rights reserved.
http://dx.doi.org/10.1016/j.jalz.2013.09.008
2 J. Jia et al. / Alzheimer’s & Dementia - (2013) 1–9
research topic during the past several decades. Initially,
Petersen and colleagues characterized MCI as memory
impairment, referred to as amnestic MCI in subsequent
years [3]. Thereafter, the concept of MCI has been broadened
to include patients with cognitive impairments in the nonme-
mory domain or multiple domains [1,2]. Currently,
epidemiological studies usually subcategorize MCI
according to the impaired cognitive domains [4–8], which is
less helpful for etiological intervention.
MCI demonstrates considerable heterogeneity regarding
its etiology [1,2]. MCI has been attributed to numerous
etiologies, such as Alzheimer’s pathology, ischemia,
trauma, psychiatric disorders, and others [1,2].
Understanding the etiologies of MCI is imperative in terms
of establishing precise prevention and treatment strategies.
Some longitudinal studies have already addressed various
MCI etiologies [9]. However, only two epidemiological
studies investigated the etiology of “cognitive impairment,
no dementia” (CIND), a concept similar to the broadened
concept of MCI [10,11]. A U.S. survey used 12
subcategories, including prodromal Alzheimer’s disease
(AD), amnestic MCI, vascular cognitive impairment
without dementia, stroke, medical conditions or sensory
impairment, and other origins. These classifications are
based not only on etiologies but also on cognitive
domains, and they overlap one another to some degree
[10]. Another study conducted in Portugal subcategorized
MCI as general vascular disorders, depression, cerebrovas-
cular disorders, alcohol or drug abuse, traumatic brain
injury, and other neurological conditions, but it provided
no definitive criteria [11]. MCI due to Alzheimer’s pathol-
ogy, the first identified cause of dementia, was also neglected
in that study [11]. Furthermore, the diagnostic subtypes in
these two studies were loosely defined, relied substantially
on clinical judgment, and lacked the support of brain
imaging findings, which are necessary for an etiological
diagnosis [10,11].
Few surveys on MCI have been conducted in China
[12–17]. Furthermore, most of these studies were regional
and recruited only individuals from urban populations. The
nationwide prevalence of MCI in rural and urban
populations of China is currently unavailable. In the
present study, using a more precise etiological
classification based on brain scans, we estimated the
prevalence of MCI and its etiological subtypes in rural and
urban populations of community-dwelling elderly Chinese
individuals.
2. Methods
2.1. Study design and samples
A multistage, cluster sampling design was used. First,
we chose five representative regional centers across China
(Changchun for Northeast China, Beijing for North China,
Zhengzhou for Central China, Guangzhou for South China,
and Guiyang for Southwest China). Using random-number
tables, 10 urban districts and 12 rural counties were
randomly selected from these centers. Finally, within the
selected districts and counties, 30 urban communities
and 45 rural villages were randomly sampled. The investi-
gation was conducted from October 2008 through
October 2009.
The inclusion criteria were being aged 65 years and older,
Han Chinese, and listed in the census of the community
registry office as well as living in the target community for
at least 1 year preceding the survey date. Institutionalized
people were not included. Two eligible populations were
drawn from urban (n 5 8414) and rural (n 5 5392) areas.
Subjects who were untraceable or deceased, who refused
to participate, or who had incomplete data for diagnostic
purposes were excluded. Finally, a total of 10,276 residents
(6096 urban and 4180 rural) participated in the survey
(Figure 1). The participation rate among rural residents
was higher than that among urban residents (77.5% vs
72.5%, P , .001). Participation rates did not differ
significantly among centers. No significant differences in
age, sex, or education distribution were found between
participants and nonparticipants in the urban or the rural
population. The medical ethics committee at each center
approved the study. Informed consent was directly obtained
from each subject or was indirectly obtained from his or her
guardian.
2.2. Assessment and diagnosis procedure
Eight to 10 pairs of interviewers were recruited in each
region. Most were junior neurologists or senior graduate
students specializing in neurology. Furthermore, we set
up a regional expert panel that included two neurologists
and two neuropsychologists with special expertise in
cognitive impairment disorders. All interviewers and ex-
perts received uniform training on neuropsychological
assessment and diagnosis for 1 week and participated in
a retraining course every 3 months thereafter. The inter-
rater reliability for cognitive tests and diagnoses, which
relied on videotaped interviews, was required to exceed
0.90.
A two-step door-to-door diagnostic procedure was used.
First, each specially trained interviewer pair conducted a
semistructured interview with participants and their close
informants at their residence. The interview lasted
approximately 2 hours. Sociodemographic characteristics
were collected. A questionnaire on cigarette smoking
and alcohol consumption was administered. A self-report
medical history questionnaire was also administered.
Participants responded “yes” or “no” to ever being diag-
nosed with hypertension, diabetes, hypercholesterolemia,
coronary artery disease, stroke, or other neurologic or sys-
temic diseases. Medical records were examined as far back
as possible. Thereafter, extended neuropsychological tests
examining four cognitive domains were administered to
 J. Jia et al. / Alzheimer’s & Dementia - (2013) 1–9 3

Eligible urban population: 8414 Eligible rural population: 5392

Non-respondents: 1676 Non-respondents: 772

1. Refused: 1378 1. Refused: 625
2. Untraceable: 185 2. Untraceable: 82
3. Life-threatening illness: 92 3. Life-threatening illness: 52
4. Deceased: 21 4. Deceased: 13

Respondents: 6738 Respondents: 4620

Excluded: 642 Excluded: 440

1. Incomplete data: 497 1. Incomplete data: 334
2. Repeated or doubtful data: 62 2. Repeated or doubtful data: 36
3. Hearing or vision deficit: 53 3. Hearing or vision deficit: 48
4. Other reasons: 30 4. Other reasons: 22

Participants: 6096 Participants: 4180

Normal: 4740 MCI: 1089 Dementia: 267 Normal: 2871 MCI: 1048 Dementia: 261

MCI-A: MCI-CVD: MCI-VRF: MCI-O: MCI-A: MCI-CVD: MCI-VRF: MCI-O:

261 243 302 283 369 149 205 325

Fig. 1. Study flow chart. Abbreviations: MCI, mild cognitive impairment; MCI-A, MCI prodromal Alzheimer disease; MCI-CVD, MCI resulting from
cerebrovascular disease; MCI-VRF, MCI with vascular risk factors; MCI-O, MCI caused by other factors.

participants: (1) memory—the World Health Organization-
University of California–Los Angeles Auditory Verbal
Learning Test (WHO-UCLA AVLT), including immediate
recall, short-delay free recall (3 minutes), long-delay free
recall (30 minutes), and long-delay recognition [18]; (2) ex-
ecutive function—Trail Making Test B [19]; (3) language—
semantic verbal fluency test (category, animals) [20]; and (4)
visuoconstructive skill—clock-drawing test (CDT) [21]. In
addition, the Mini-Mental State Examination (MMSE)
[22] and Montreal Cognitive Assessment (MoCA) [23]
were performed to assess global cognition. The Functional
Activities Questionnaire (FAQ) [24] was administered for
social functioning, the Center for Epidemiologic Studies
Depression Scale (CESD) [25] was adopted for mood, and
the Hachinski Ischemic Index (HIS) [26] was used to
differentiate between degenerative and vascular etiologies.
The Clinical Dementia Rating Scale (CDR) [27] was
administered to assess cognitive level. Finally, standardized
general and neurological examinations were performed. At
the end of each workday, the expert panel and interviewers
reviewed all data and assigned final cognitive diagnoses.
When a consensus could not be reached, an expert returned
to the residence the following day for further evaluation.
Participants were divided into the following categories
according to cognitive level: cognitively normal (CN),
MCI, or dementia. CN was assigned when participants
achieved a normal score in all four cognitive domains
and scored 0 on the CDR. Dementia was diagnosed accord-
ing to the Diagnostic and Statistical Manual of Mental
Disorders, fourth edition (DSM-IV) criteria for dementia
[28]. Participants who were neither normal nor demented
were classified as having MCI [1,2]. The criteria
included the following elements: cognitive impairment in
one or more domains (scored at least 1.5 standard
deviations below the norm in memory, executive
function, language, or visuoconstructive skill), global
CDR score of 0.5 or less, preserved ability to perform daily
activities and social functions, and absence of dementia.
Once the MCI diagnosis was made, brain scans were
evaluated for etiological diagnosis. For economic reasons,
computed tomography (CT) scans were performed first,
followed by magnetic resonance imaging (MRI) if the
etiology could not be determined based on the CT images.
Brain scans were not necessary when the diagnosis could
be made based on clinical data (e.g., patients with an
identified stroke history and temporal relationship be-
tween the stroke and cognitive impairment, which
strongly supports a diagnosis of MCI resulting from cere-
brovascular disease [CVD]) or when patients had under-
gone a brain scan within 3 months before the cognitive
assessments. Ultimately, 1676 (78.43%) patients with
MCI underwent brain imaging, including 475 who under-
went MRI scans.
We divided MCI into four etiological subtypes: MCI
prodromal AD (MCI-A), MCI resulting from CVD
(MCI-CVD), MCI with vascular risk factors (MCI-VRF),
and MCI caused by other diseases (MCI-O). The diagnoses
of etiological subtypes were made by consensus, taking
into account all collected data (clinical characteristics,
neuropsychological profile, brain images, medical history,
and lifestyle). Patients with all of the following elements
were diagnosed with MCI-A [3]: (1) memory impairment
4 J. Jia et al. / Alzheimer’s & Dementia - (2013) 1–9

with an insidious onset and gradual progression, (2) neuro- tion, smoking, alcohol consumption, and comorbidities as
psychological profile supporting prodromal AD (scores at the independent variables and diagnosis as the dependent
least 1.5 standard deviations below the age- and education- variable, binary logistic regression analyses with the for-
adjusted norms on the WHO-UCLA AVLT long-delay free ward conditional method were performed to examine the
recall), (3) neuroimaging features consistent with incipient potential risk factors for each subtype. The normal cogni-
AD (i.e., hippocampal and entorhinal cortex atrophy) and tive population (those with neither MCI nor dementia)
no other diseases, and (4) no other medical or neuropsychi- was used as the reference group for all regression models.
atric conditions that could account for the cognitive Odds ratios (ORs) were calculated for each variable, and
impairment. MCI-CVD was diagnosed according to one of a significance level of P , .05 was required for variable
the following criteria [29,30]: (1) cognitive impairment retention in the model.
caused by strategic infarcts or multiple infarcts, as
indicated by a sudden onset or stepwise progression, and
temporal relationship between cognitive decline and 4. Results
infarcts confirmed by MRI or CT scan; (2) cognitive Table 1 details the major characteristics of the study
impairment due to subcortical small-vessel disease, as populations. Notably, very large differences in education
suggested by minor neurological signs, moderate white and occupation were found between the urban and rural
matter changes (at least one region score of
2 according participants (P , .001 for both). Most participants (86.4%)
to the Wahlund rating scale) [31], and/or multiple lacunar living in rural areas were farm laborers, and nearly half
infarcts (
2) on brain imaging; and (3) cognitive impair- (48.2%) were illiterate. Urban participants were better
ment resulting from hemorrhagic stroke as supported by educated and held more diverse occupations.
the temporal relationship between cognitive deficits and Table 2 shows the crude and standardized prevalences
cerebral hemorrhage confirmed by CT scans. The detailed of MCI and its etiological subtypes in the total, urban,
criteria for MCI-VRF were (1) patients with long-term and rural populations. MCI was high in rural (25.1%,
(
5 years) vascular risk factors (such as hypertension,
diabetes, high cholesterol, cardiac disease, etc.), (2) neuro-
Table 1
imaging scans showing neither evidence for AD nor features Characteristics of the urban and rural sample populations
of cerebral vascular lesions, and (3) no other medical or
Characteristics Urban, n (%*) Rural, n (%*) Px
neuropsychiatric conditions that could explain the cognitive
impairment. Patients with cognitive impairment attributed to Overall 6096 (100) 4180 (100)
conditions other than MCI-A, MCI-CVD, and MCI-VRF Male 2633 (43.2) 1746 (41.8) .152
Age, years
were classified as MCI-O. In such cases, several potential 65–69 1767 (29.0) 1450 (34.7) ,.001
etiologies, such as Parkinson’s disease, alcohol and drug 70–74 2088 (34.3) 1141 (27.3)
abuse, depression, and psychiatric illness may be involved. 75–79 1399 (22.9) 950 (22.7)
Patients with no identified diseases contributing to the
80 842 (13.8) 639 (15.3)
cognitive impairment were also classified as MCI-O. Education, years
,1 1076 (17.7) 2015 (48.2) ,.001
1–6 1993 (32.7) 1621 (38.8)
3. Statistical analysis 7–9 1161 (19.0) 409 (9.8)

10 1822 (29.9) 129 (3.1)
We conducted all analyses using the Statistical Package Occupation
for the Social Sciences version 16.5 (SPSS Inc., Chicago, Farm laborer 400 (6.6) 3613 (86.4) ,.001
Nonfarm laborer 3195 (52.4) 280 (6.7)
IL). Descriptive statistics (sociodemographic characteristics Civil servants and professional 2103 (34.5) 218 (5.2)
and comorbidities) of the study populations were calculated Others 67 (1.1) 0 (0.0)
by percentages. The c2 test was used to assess group Cigarette smokingy 1617 (26.5) 1524 (36.5) ,.001
differences between urban and rural populations. The Alcohol consumptionz 524 (8.6) 717 (17.2) ,.001
prevalence of overall MCI and that of its subtypes were Comorbidity
Hypertension 2870 (47.1) 1431 (34.2) ,.001
then calculated with 95% confidence intervals (CIs) in the Hyperlipidemia 1454 (23.9) 464 (11.1) ,.001
total, rural, and urban populations. The crude prevalence Diabetes mellitus 964 (15.8) 829 (19.8) ,.001
was directly calculated by dividing the number of patients Heart disease 1599 (26.2) 437 (10.5) ,.001
with MCI by the corresponding population. Standardized Stroke 979 (16.1) 434 (10.4) ,.001
prevalence rates were estimated using the direct standardi- *The characteristics were calculated by percentages (in parentheses).
zation method adjusted by age and sex to the total Chinese Totals do not all add up to 100% because of missing data.
y
population (according to the census conducted in 2005). Cigarette smoking was defined as having smoked at least 100 cigarettes
in one’s lifetime.
The prevalence ratios (PRs) between urban and rural z
Alcohol drinking was defined as consumption of at least 0.1 drink/day
populations were calculated, and differences were analyzed for
1 year and 1 drink is equal to 10 g of pure alcohol.
using c2 tests. The age- and sex-specific prevalences were x 2
c tests were used to assess group differences between urban and rural
then calculated. Finally, using sex, age, education, occupa- populations.
 J. Jia et al. / Alzheimer’s & Dementia - (2013) 1–9 5

Table 2
Prevalence (95% CI) of MCI and MCI subtypes in the total, urban, and rural populations
Crude* Standardized* PR (rural/urban)
Diagnosis Total Urban Rural Total Urban Rural Py
MCI 20.8 (20.0–21.6) 17.9 (16.9–18.8) 25.1 (23.8–26.4) 19.5 (18.8–20.3) 16.8 (15.9–17.8) 23.4 (22.1–24.7) 1.5 (1.4–1.7) ,.001
MCI-A 6.1 (5.7–6.6) 4.3 (3.8–4.8) 8.8 (8.0–9.7) 5.6 (5.2–6.0) 3.9 (3.4–4.4) 8.1 (7.3–8.9) 2.2 (1.8–2.6) ,.001
MCI-CVD 3.8 (3.4–4.2) 4.0 (3.5–4.5) 3.6 (3.0–4.3) 3.4(3.3–4.1) 3.9 (3.4–4.4) 3.5 (2.9–4.0) 0.9 (0.7–1.1) .2719
MCI-VRF 4.9 (4.5–5.4) 5.0 (4.4–5.5) 4.0 (4.3–5.6) 4.6 (4.2–5.0) 4.7 (4.1–5.2) 4.5 (3.9–5.2) 1.0 (0.8–1.2) .7756
MCI-O 5.9 (5.5–6.4) 4.6 (4.1–5.2) 7.8 (7.0–8.6) 5.6(5.2–6.1) 4.4(3.9–4.9) 7.3 (6.5–8.1) 1.7 (1.4–2.0) ,.001
Abbreviations: CI, confidence intervals; MCI, mild cognitive impairment; MCI-A, MCI prodromal Alzheimer disease; MCI-CVD, MCI resulting from
cerebrovascular disease; MCI-VRF, MCI with vascular risk factors; MCI-O, MCI caused by other factors; PR, prevalence ratio.
*Prevalence (%) and 95% CIs (in parentheses) provided.
y
Comparison between urban and rural populations after age and sex standardization using c2 tests.

95% CI 5 23.8–26.4%) and urban (17.9%, 95% than did the urban population (P , .001). No significant
CI 5 16.9–18.8%) populations for an overall prevalence differences in MCI-CVD (P 5 .2719) or MCI-VRF
of 20.8% (95% CI 5 20.0–21.6%). The rural population (P 5 .7756) were found between the rural and urban pop-
had higher prevalences of MCI, MCI-A, and MCI-O ulations. The frequencies of the four etiological subtypes

Fig. 2. Age- and sex- specific prevalence of MCI and its etiological subtypes in the total population. The overall MCI and the MCI-A increased sharply by 5-year
age intervals in both sexes. MCI-O and MCI-VRF also showed a relatively modest age trend in both sexes. MCI-CVD decreased after the age of 80 years in both
sexes (A, B, C). Abbreviations: MCI, mild cognitive impairment; MCI-A, MCI prodromal Alzheimer disease; MCI-CVD, MCI resulting from cerebrovascular
disease; MCI-VRF, MCI with vascular risk factors; MCI-O, MCI caused by other factors.
6 J. Jia et al. / Alzheimer’s & Dementia - (2013) 1–9

of MCI were estimated further. The percentages of MCI-
A, MCI-CVD, MCI-VRF, and MCI-O were 29.5%,
18.3%, 23.7%, and 28.5%, respectively, among all of the
patients. The vascular-related MCI (including MCI-CVD
and MCI-VRF) constituted the most frequent subcategory
(42.0%).
The age- and gender-specific prevalences of MCI and
its subtypes in the total population are shown in Figure 2.
The prevalences of overall MCI, MCI-A, MCI-VRF, and
MCI-O increased with age in both sexes. Notably, the
prevalence of the overall MCI and MCI-A increased sharply
by 5-year age intervals. The increase in the other subtypes
was relatively modest. MCI-CVD differed in that it
decreased after 80 years of age in both sexes. A similar
age pattern was identified in the rural and urban popula-
tions.
Binary logistic regression analysis found that older age
was significantly associated with greater odds of devel-
oping MCI and all MCI subtypes, whereas higher educa-
tion was identified as a protective factor for all MCI
groups. Compared with farm laborers, other occupations
provided a protective effect for total MCI, MCI-AD, and
MCI-O (Table 3). Compared with women, men had a
greater risk of developing MCI-CVD. Stroke increased
the risk of overall MCI and MCI-CVD. Hypertension, dia-
betes mellitus, and heart disease were associated with an
increased risk of developing MCI-VRF. Hypertension
and diabetes mellitus also tended to increase the risk of
MCI-CVD. Hyperlipidemia, smoking, and alcohol intake
were not associated with overall MCI or any of its sub-
types.
5. Discussion
The current study is the first to report the prevalence of
MCI and its etiological subtypes in multiregional centers
of rural and urban populations in China. We found an over-
all MCI prevalence of 20.8% (95% CI 5 20.0–21.6%),
indicating that approximately 23.86 million individuals
aged 65 years or older suffer from MCI in China. Further
study of the etiological subtypes identified that vascular-
related MCI subtypes (MCI-CVD and MCI-VRF) are
most frequent (42.0% vs 29.5% for MCI-A and 28.5%
for MCI-O), indicating that interventions for stroke and
its risk factors are highly important for MCI prevention.
The findings that poor education is the major factor asso-
ciated with the higher prevalence of MCI in rural
compared with urban populations reveals the importance
of establishing appropriate educational programs for rural
populations.

Table 3
Logistic regression models for MCI and the main subtypes
Total MCI MCI-A MCI-CVD MCI-VRF MCI-O
Characteristics OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Sex
Female Ref. Ref. Ref. Ref. Ref.
Male 1.36 (1.035–1.780)
Age, years
65–69 Ref. Ref. Ref. Ref. Ref.
70–74 1.79 (1.52–2.09) 1.61 (1.18–2.18) 1.52 (1.07–2.16) 1.79 (1.34–2.38) 1.88 (1.43–2.48)
75–79 2.39 (2.03–2.83) 2.73 (2.02–3.69) 1.84 (1.28–2.67) 2.06 (1.52–2.80) 2.24 (1.67–3.01)

80 3.56 (2.96–4.27) 4.37 (3.19–5.99) 2.06 (1.34–3.15) 3.10 (2.23–4.30) 3.68 (2.68–5.05)
Education, years
,1 Ref. Ref. Ref. Ref. Ref.
1-6 0.53 (0.46–0.60) 0.39 (0.31–0.50) 0.56 (0.41–0.78) 0.53 (0.42–0.68) 0.57 (0.45–0.72)
7-9 0.36 (0.29–0.44) 0.17 (0.11–0.28) 0.31 (0.20–0.48) 0.429 (0.30–0.59) 0.40 (0.27–0.60)

10 0.31 (0.24–0.39) 0.12 (0.07–0.23) 0.22 (0.15–0.33) 0.35 (0.25–0.47) 0.42 (0.26–0.68)
Occupation
Farm laborer Ref. Ref. Ref. Ref. Ref.
Nonfarm laborer 0.75 (0.65–0.85) 0.59 (0.46–0.75) 0.74 (0.59–0.93)
Official and professional 0.63 (0.50–0.79) 0.68 (0.43–1.09) 0.50 (0.32–0.78)
Comorbidity
Hypertension 1.32 (1.00–1.75) 3.05 (2.44–3.82)
Diabetes mellitus 1.38 (1.02–1.86) 1.48 (1.16–1.87)
Heart disease 1.96 (1.57–2.43)
Stroke 2.21 (1.90–2.56) 47.53 (33.9–66.59)
Abbreviations: MCI, mild cognitive impairment; MCI-A, MCI prodromal Alzheimer disease; MCI-CVD, MCI resulting from cerebrovascular disease;
MCI-VRF, MCI with vascular risk factors; MCI-O, MCI caused by other factors; OR, odds ratio; CI, confidence interval; Ref., reference.
NOTE. Where numbers are missing are variables that were not significant and therefore not included in the models. Binary logistic regression analyses with
the forward conditional method were used with sex, age, education, occupation, smoking, alcohol consumption, and comorbidities (hypertension, high
cholesterol, diabetes mellitus, heart disease, and stroke) as the independent variables and diagnosis as the dependent variable. OR and 95% CIs (in parentheses)
provided.
 J. Jia et al. / Alzheimer’s & Dementia - (2013) 1–9
5.1. High MCI prevalence in China
To date, only a few surveys on MCI have been conducted
in China [12–17]. However, most of these studies were
regional, small, and restricted to urban residents. The
nationwide prevalence of MCI in urban and rural
populations remains unknown. The prevalence reported
by these previous surveys ranges from 0.4% to 12.7%
[12–17], which is significantly lower than our estimate.
The disparity may be explained by the use of different
diagnostic criteria. Different regions such as rural or urban
areas and age intervals of the participants may also affect
the final data. Most previous studies in China were
conducted among urban residents, used the amnestic MCI
criteria, and recruited subjects aged 55 or 60 years
(and few older subjects). As a result, a relatively low
prevalence has been reported (6.1–12.3% even after
adjustment for individuals older than 65 years) [15–17]. In
contrast, our survey used broader criteria (various
presentations with different causes) [1,2], which are more
suitable for the early detection of MCI resulting from
different causes. Moreover, our study recruited individuals
aged 65 years and older, a standard that is adopted
worldwide. Furthermore, we included more elderly people
from rural areas (4180) than did previous studies. These
factors may account for the higher estimated prevalences
found in the present study. A high prevalence of MCI has
also been reported in other countries. Surveys in the
United States reported that 16.0–22.2% of elderly subjects
met the broadened MCI criteria [4,10,32]. A nationwide
survey in South Korea found an MCI prevalence of 24.1%
[33]. In Japan, 18.9% of participants were diagnosed with
MCI [6]. The present study shows that the prevalence of
MCI in community elders in China is higher than expected,
but it is similar to that in some Western and other Asian
countries.
5.2. Higher MCI prevalence in rural than in urban
populations
We found a higher prevalence of MCI in the rural than
in the urban population. An epidemiological survey
conducted in Portugal supported this finding [11]. The
less-advanced conditions (illiteracy and low-skill occupa-
tions) in rural areas may explain the high prevalence of
MCI. Nearly 70% of participants in our study were more
than 70 years of age. These people were born during World
War II and were deprived of educational opportunities.
This situation was more pronounced in rural areas because
of poverty at that time. As a result, 48.2% of the rural
participants were illiterate, which is 2.7 times the rate for
the urban elders. A low educational level has been
consistently found to be an independent risk factor for
cognitive impairment [10,11], and the present study
revealed a steep increase in the MCI prevalence as the
educational level declined. Exceedingly poor literacy
7
levels may be the primary reason for the high prevalence
of MCI in rural areas. Occupation may be another
important contributing factor. China is traditionally an
agricultural country, and most elderly people in rural
areas are farmers. Working in low-skill occupations has
been repeatedly identified as a risk factor for dementia
[34]. In our study, the regression analysis also revealed
that working as a farm laborer was associated with a
greater risk of developing MCI. The focus on appropriate
programs should be shifted to rural populations to enhance
the educational level, which may reduce the incidence of
MCI in the future.
5.3. Rationale for subclassification of MCI with vascular
risk factors
On the basis of clinical experience and an extensive
literature review, the current study proposed a concise
etiological subcategory of MCI including a vascular
risk factor-related subtype with no clear CVD or visible
radiologic evidence on conventional imaging (MCI-
VRF). It is necessary to elaborate the application of the
MCI-VRF subtype, a subtype with preventive potential
that is frequently seen in clinical practice. A long dura-
tion of vascular risk factors is known to increase the
risk of MCI through different pathways. Diabetes melli-
tus may increase the risk of cognitive impairment medi-
ated by hyperglycemia toxicity, insulin resistance, and
oxidative stress [35–37]. Hypertension may result in
loss of brain volume [38], leading to a decline in global
cognition [39]. Moreover, diabetes and hypertension
might evoke microinfarcts and microbleeds [40,41],
which typically go undetected on conventional
structural MRI [42]. Increasing evidence has suggested
that microinfarcts and microbleeds are associated with a
greater risk of developing cognitive impairment, even af-
ter controlling for macroscopic infarcts and other patho-
logical covariates [43]. Thus, studies conducted from
various viewpoints have verified that vascular risk factors
may act on cognitive decline in the absence of visible ce-
rebral vascular lesions on conventional imaging. There-
fore, MCI-VRF was introduced in the current study as
a specific MCI subtype. MCI-VRF may be an earlier
stage before MCI-CVD and of greater importance for
early intervention.
5.4. Higher prevalence of vascular-related MCI subtypes
The present study estimated the prevalence of four
etiological subtypes of MCI. The results showed that
vascular-related MCI subtypes, including MCI-CVD and
MCI-VRF, were the most common subtypes (42.0%).
This may reflect an unexpected constituent ratio for the
MCI pattern. In fact, China has a high incidence of cere-
bral vascular disease because of increased rates of hyper-
tension, diabetes, and high cholesterol in recent years
[44]. Stroke directly injures the brain and affects
8 J. Jia et al. / Alzheimer’s & Dementia - (2013) 1–9
cognition. The frequency of cognitive impairment after
stroke reached 37.1% in one Chinese survey [45]. More-
over, several studies have shown that hypertension and
diabetes are associated with cognitive decline indepen-
dent of identified strokes [46,47]. The high prevalence
of cerebral vascular disease and its risk factors in China
may underlie the high prevalence of MCI with vascular
components. This result is not unique to China. A study
in Portugal, a country in which stroke is prevalent [48],
revealed that CIND associated either with CVD or
vascular risk factors was more frequent (39.7%) than
CIND of any other etiology [11]. In the United States,
CIND with a vascular origin accounted for 25.6% of the
total cases, second only to the prodromal AD subtype
(34.2%) [10]. These results emphasize the importance
of vascular-related MCI and call for more resources and
greater effort toward addressing these relatively neglected
MCI subtypes.
Several limitations need to be discussed. We subcate-
gorized MCI into four subtypes according to potential eti-
ologies in the current survey. Although the MCI-VRF
subtype is of great importance in terms of identifying in-
dividuals in whom prevention will be effective and thus
reduce the prevalence of MCI, this concept was proposed
for the first time here and requires validation in longitudi-
nal follow-up. The current study assessed four cognitive
domains (memory, executive function, language, and vi-
suoconstructive skill) in all participants. However, only
one test was adopted for each cognitive domain, which
may have increased the occurrence of false-positive or
false-negative results and thus have led to misdiagnosis
in some cases. Epidemiological studies usually adopt a
screening procedure and may miss some real patients.
However, in the current study, the results of a detailed
clinical history, standardized neuropsychological tests,
and systematic general and neurologic examinations
were collected for all participants. Misdiagnosis was ex-
pected to be relatively low by this single-stage assess-
ment.
The high prevalence of MCI in Chinese elders imposes
a heavy burden that must be met with appropriate public
policies. The higher MCI prevalence in rural than in ur-
ban areas indicates that special attention must be given
to implementing new strategies for these areas. The con-
stituent ratio of MCI indicates that vascular-related sub-
types were more common than any other, suggesting
that more work should be done on the prevention of
stroke and intervention in its risk factors. Follow-up
studies are necessary to refine our MCI subtype classifica-
tions in future.
Acknowledgements
All authors report no conflicts of interest. This work was
supported by the National Key Technology R&D Program
in the Eleventh Five-Year Plan Period (2006BAI02B01),
the Major Program of Science and Technology Plan of
Beijing (D111107003111009), and the Medical Elite
Foundation from the Peking Public Health Bureau
(2011-3-089).
RESEARCH IN CONTEXT
1. Systematic review: We searched the MEDLINE and
China National Knowledge Infrastructure (CNKI)
databases for the past 10 years, focusing on
population-based studies on the prevalence of MCI.
There have been no nationwide epidemiologic
studies on MCI so far, in particularly on its etiolog-
ical classification by imaging, in rural and urban
populations in China.
2. Interpretation: In the present study, we found a high
MCI prevalence (20.8%) in community Chinese el-
ders and a higher prevalence in rural (25.1%) than ur-
ban populations. By etiological classification,
vascular-related MCI is identified as the most com-
mon subtype (42.0%). The results call for a special
policy to improve conditions in rural areas of China
and a useful strategy for early intervention in patients
with vascular-related MCI.
3. Future directions: Larger samples are necessary to
refine our MCI subtype classifications, and an inter-
ventional clinical trial might be needed to further
validate their clinical relevance.
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