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Objective:  Mild cognitive impairment (MCI) is an at-risk state for dementia, however not all individuals with MCI transition to dementia, and some revert to normal cognition. Here, we investigate whether mild behavioral impairment (MBI), the late-life onset of persistent neuropsychiatric symptoms (NPS), improves the prognostic specificity of MCI.    Methods:  Participants with MCI from the National Alzheimer's Coordinating Center Uniform Data Set were included. Neuropsychiatric symptoms were operationalized with the neuropsychiatric inventory questionnaire (NPI-Q) to identify participants without NPS and those with MBI (persistent, late-onset NPS). Individuals with late-onset NPS not meeting the MBI persistence criterion (NPS_NOT_MBI) were retained for secondary analyses. Progression to dementia, stable MCI, and reversion to NC after 3 years of follow-up were defined as per NIA-AA and Petersen criteria.    Results:  The primary sample consisted of 739 participants (NPS-  n =409 and MBI+  n =330; 75.16±8.6 years old, 40.5% female). After 3 years, 238 participants (33.6%) progressed to dementia and 90 (12.2%) reverted to NC. Compared to participants without NPS, participants with MBI were significantly more likely to progress to dementia (Adjusted Odds Ratio [AOR]=2.13, 95%CI 1.52-2.99), with an annual progression rate of 14.7% (vs 8.3% for MCI participants without NPS). Compared to participants without NPS, MBI participants were less likely to revert to NC (AOR=0.48, 95%CI 0.28-0.83, 2.5% vs 5.3% annual reversion rate). The NPS_NOT_MBI group (n=331, 76.5±8.6 years old 45.9% female), were more likely to progress to dementia (AOR=2.18, 95%CI 1.56-3.03, 14.3% annual progression rate) but not less likely to revert to NC than those without NPS. Accordingly, both NPS_NOT_MBI and MBI+ participants had lower MMSE scores than NPS- participants after 3 years.    Discussion:  Late-onset NPS improve the specificity of MCI as an at-risk state for progression to dementia. However, only persistent late-onset NPS are associated with a lower likelihood of reversion to NC, with transient NPS (i.e., NPS_NOT_MBI) not differing from the NPS- group. Clinical prognostication can be improved by incorporating late-onset NPS, especially those that persist (i.e., MBI), into risk assessments. Clinical trials may benefit from enrichment with these higher-risk MCI participants.

Progression to Dementia or Reversion to Normal Cognition in Mild Cognitive Impairment as a Function of Late-Onset Neuropsychiatric Symptoms