Published on: September 10, 2012
by Judith Graham for The New Old Age:
About 10 to 15 percent of adults age 65 and older are believed to have mild cognitive impairment — a condition commonly characterized by memory problems, well beyond those associated with normal aging.
Alarmingly, mild cognitive impairment, or M.C.I., can signal serious problems ahead: About half of people with this condition go on to a diagnosis of Alzheimer’s disease or another dementia within five years.
Yet when researchers from the University of Toronto searched worldwide for programs that educate people about M.C.I. and how to adapt to it, they found only five — three in Canada, one in Germany and one in Rochester, Minn., home to the Mayo Clinic, which first defined M.C.I. in 1999. Similarly, a North American search for support groups for people with M.C.I. turned up just a handful.
The University of Toronto researchers set out to rectify this lack of attention by writing “Living With Mild Cognitive Impairment,” published recently by Oxford University Press. One of its authors, Nicole Anderson, an associate professor of psychiatry at the University of Toronto, spoke with me at length, and our conversation has been edited for clarity and length.
Q. There’s some confusion about mild cognitive impairment. Is it the earliest stage of dementia or something else?
A. Most often, it is the earliest, preclinical stage of dementia. That means symptoms are not severe enough to meet the criteria for dementia. But pathology is developing in the brain that will likely lead to dementia.
Sometimes, however, people have other health problems that lead to an M.C.I. diagnosis, and once these are treated their cognition improves.
Q. What cognitive functions are affected by M.C.I.?
A. The most typical one is memory. Also common are subtle language difficulties and executive functioning deficits. This refers to an ability to multitask, switch back and forth between two tasks, or inhibit irrelevant information and stay focused on what’s important.
Q. What isn’t affected?
A. People’s general knowledge. Their vocabulary. Their intellectual ability. And by definition, people with M.C.I. do not have deficits in their ability to engage in activities of daily living, such as bathing, eating or cooking.
Q. What about work?
A. People will still be able to work. But they might find they need to put some more supports in place. They may become more reliant on Day-Timers or need more reminders from a secretary keeping track of their schedule. And they might find it takes them longer to do complicated activities.
Q. What changes in the brain are observed with M.C.I.?
A. A vast majority of research has been done on people with “amnestic” M.C.I. – the kind involving memory loss. There we see shrinkage of key brain areas important for memory: the hippocampus and other areas around it in the medial temporal lobes. We can now also scan for amyloid protein in the brain, and often we will see elevated levels.
Q. Yet high concentrations of amyloid don’t always signify dementia.
A. That brings up the whole notion of cognitive reserve. This refers to the idea that people can engage in certain activities in their lives — getting higher levels of education, exercise, eating a healthy diet, being bilingual — that help protect them against the clinical impact of various brain diseases, especially dementia.
Q. How does that work?
A. We don’t know for sure, but people with larger reserves often have greater connectivity between different brain regions and use different areas of the brain to do different tasks.
Q. Why is this important?
A. We don’t have any medications at this point to prevent or treat M.C.I. or dementia. Yet we can engage in activities that will help reduce the impact of the disease and maintain our level of functioning.
Q. What contributes to cognitive reserve?
A. The most studied and validated factors are education, exercise and Mediterranean-style diets. There is also some evidence that the more complex your occupation is, the less likely you are to develop dementia. And people who have larger social networks are less likely to develop dementia, especially if the social connections they have are meaningful or rewarding.
Q. What diminishes reserve?
A. Having a prior head injury. Having high blood pressure, diabetes, high cholesterol.
Q. What are M.C.I. symptoms to watch out for?
A. A. Repeatedly asking questions or making the same comments. Getting lost in a place that you’re familiar with. Forgetting an important event — say, a big meeting coming up — when that’s not something you would have done before.
Q. Do people who come in for testing often have negative results?
A. That is common. We see a lot of the worried well. Usually, what we detect with them is normal aging.
Q. What is normal, when it comes to the aging brain?
A. As we get older, our memory starts to decline, starting in our 20s. Primarily affected is the ability to get new information stored in long-term memory. How fast we think and do simple mental activities slows down. And word problems become more prevalent as we become older.
Q. Are there other reasons older adults might have cognitive problems?
A. Absolutely. Thyroid problems, a vitamin B12 deficiency and depression can all be involved, and it’s important that all these be ruled out.
It’s notable that research also shows about 25 percent of people initially diagnosed with M.C.I. turn out to be normal. That tells us we don’t have a perfectly accurate way of testing for this yet.
Q. You’ve said there are no medical treatments for M.C.I.
A. True, but there are ways of elevating the levels at which a person functions so that the impact of M.C.I. will be smaller. I’ve mentioned several already. I’d add to those developing a good set of memory strategy habits.
Q. Can you give some examples?
A. There are a number of them. One, for remembering things in the future, involves regularly using a Day-Timer or a personal digital assistant. A lot of older adults just have the fridge calendar at home. It’s a problem because it’s at home — it’s not with them when their friend says, “Let’s have lunch next week,” or the doctor says, “Let’s schedule a new appointment.”
We really encourage people to carry a memory book with them at all times, including a section for making notes and lists, a calendar, a phone book, a to-do list and essentials like a record of their medications. It absolutely helps. There’s research going on here that when you train people with profound amnesia to use devices like an iPhone they can live independently.
Another memory strategy is spaced retrieval. That involves repeating a word or phrase, then waiting a few seconds, then waiting a few more, and then waiting a few more before each repetition.
That way, you’re putting what you want to remember into long-term memory and pulling it out again.
A big problem with memory is that we don’t pay attention. So, what most of these strategies are doing is forcing us to pay attention. Another way to do that is to say out loud, “I’m going to go into the other room and get my book,” when that’s what you plan to do. Then, imagine yourself walking into the room and picking up the book. That forces you to pay attention to your intention and solidifies it in memory.
Q. You and your co-authors are involved in a program for people with M.C.I. and their families in Toronto. What have you learned?
A. It’s hugely beneficial for people. We have eight sessions, each two hours long. In the first hour, everyone is all together and there’s an educational session. The second hour, the family members go to another room where they meet with health care professionals who talk to them about diet or community resources or estate planning.
Meanwhile, the people with M.C.I. stay in the room and learn practical memory strategies. They practice them over and over again. Then they get homework during the week to implement those strategies. What we hear from people is that this helps them regain their confidence because now they’re armed with ways of combating the effects of cognitive symptoms.
Q. Why aren’t there more programs of this kind?
A. I think the world is just catching up with M.C.I. Knowledge about M.C.I. and interventions for M.C.I. has unfortunately lagged behind.
Although it’s great to celebrate the big achievements, it’s also important to celebrate the small wins.
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