MCI

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[0:16] Hi, everyone. I'm Emily. And this is Eva. And you're listening to Speech Talk. We're your research-based book club so you can do evidence-based practice in practice. So let's start talking. Today, we're going to start talking about mild cognitive impairment. I wanted to do this episode on cognition since cognition is such a huge topic. And to me, at least, it's one of the most overwhelming. Yes, overwhelming. 100% is the adjective I would use. It gives me the most imposter syndrome. Also for our mild cognitive impairment folks, which I love that that's who this article focuses on. I just feel like I don't know what I'm doing because they're so functional in so many other capacities that you're like, what am I even doing here? But you know that something is just off enough that you're like, we should really be addressing this. But it can be so hard to pinpoint and not to mention choose treatment activities for. I don't know about you, but a lot of my CMI patients are like, I'm fine. Why are we doing this? And so the activities I bring, I feel like sometimes just cause them frustration or they're just like, I've actually had people be like, I need to talk to your supervisor. Like, I don't understand why I'm getting this treatment. And I'm like.

[1:30] Okay, yeah, I get why you think this is dumb, because otherwise you're super functional, except for like you couldn't do executive function tasks on your assessments. Right, and that's the thing. It's like, I find that specifically for this crowd, I'm really trying to convince them like, this is not typical. Like, we can address this. I can teach you things. We can get ahead of this. like let's try and then I bring my tablet with my games and they're like you're kidding right this is a joke like you're actually joking and I'm like no like here are my strategies to like couple with these games like let's download it on your tablet they're like, What? Yeah. They're like, and you're billing for this? Excuse me?

[2:20] Yeah. So I'm really glad that we're doing this topic today because I really think this is something that causes a lot of anxiety for me at work. So we wanted to talk about CMI treatment strategies to understand what, according to current research, is helpful and what isn't. So this week's article is titled, Comparative Efficacy of Seven Non-Pharmalogical Interventions on Global Cognition of Older Adults with and Without Mild Cognitive Impairments, a Network Meta-Analysis of Randomized Controlled Trials. Oh, I thought I was going to do it in one breath. I couldn't. No, that's how you know. Like, it's a long title. It's like, it's a big gasp. For context, on our notes, this takes up a whole paragraph. Just the title.

[3:06] And it was by C.O.K. J.W. Kim et al. The researchers were looking at, and in general, there's this growing evidence showing that non-pharmaceutical interventions are as effective as pharmaceutical ones, which they assess through neuroimaging. So I just thought that is so interesting, right? And it's impressive that you can actually look at it now. Not only can we be instituting these various trials, but we are increasingly getting the imaging to back it up. That's pretty amazing. Yeah, I mean, talk about like pharmaceutical interventions in general, like that is one, pharmaceutical companies are like such big business. So any, any workaround to not have our patients paying for all of these medications, uh.

[3:57] It's awesome. And then to say that they're as effective, like these things that you can do that you can actively incorporate without having to have to go to your doctor for extra things like that's amazing. Yeah. And another quick comment is that if you've ever worked in a dementia ward, you see a lot of people who have like the zombie walk, they're kind of glazed over. And so in as much as we can be implementing non-pharmaceutical interventions and helping our patients avoid potentially heavier pharmaceuticals, the kind that really dull other aspects of yourself, you know, that's great. Particularly for mild cognitive impairments, you don't want to have to over-medicate when most of things are fine.

[4:45] Unfortunately, a lot of medications for cognitive stuff are not tiny targeted. They're kind of more broad sweeping. We should really talk to somebody who does pharmacology and learn more. Yeah. Yeah. Next, more about this. So this article, they're specifically looking at how comparing the efficacy of these different approaches. They looked at increasing growth factor. You can't see my little air quotes, but we looked up what this meant. And it appears to be either like a neuron growth or a protein growth, something or hormonal. We weren't able to really nail down what is growth. They also didn't say in the article, they just said growth factor, super unhelpful, but it's there. Something is growing, and it's a factor, you guys. They are looking at increasing the brain's processes that help remove damaged cells, regulating oxygen stress levels, and decreasing the brain's creation of a protein that produces inflammation. Additionally, something called amyloid beta pathology, which is a hallmark feature of Alzheimer's disease, is shown to decrease in these studies. Yeah, you can tell by how we stumble over a lot of these phrases that we know a lot about the brain or like that there's some.

[6:02] Pathology beta processes protein. So the main purpose of this article was to look at non-pharmacological approaches to cognitive intervention for people 55 and older who were A, healthy, i.e. Not having cognitive impairments, or for those who have mild cognitive impairments, MCI. And the researchers were looking at articles to see if people improved using non-pharmacological approaches and what the similarities or differences were between the groups. And what are those non-pharmacological approaches they included, you may ask? What were they most for? They let's see. They did a CTI, cognitive training intervention. One of the articles they cited used memory training, use of visual imagery training, and mnemonics. They did some non-invasive brain stimulation like TMS, music therapy, ACU, which is like acupuncture, acupressure. I was telling Emily I'm going to have to start taking acupuncture seriously. I mean, probably tell my sister-in-law that it's valid after all, even though I've teased her about it. Mind-body exercises. It just seems so weird. You're getting poked. I know. I just, yeah. I always think of that scene from, what's the panda movie?

[7:25] Kung Fu Panda. Kung Fu Panda. Kung Fu Panda. Oh no. Where he's like, it's the acupuncture needle and it makes his face go all weird. Anyways. Acupuncture is valid now, people.

[7:41] And then there was some mind body exercises. If you are wondering what just broadly mind-body means, some of the studies they looked at, people are doing Qigong, which is kind of a Tai Chi situation. In others, it looked at training patients' attention, visuospatial, perceptual, multitasking, planning skills, all while focusing on postural stability. So I don't know about you guys, but I have this like crazy visual of an old Biddy just standing on one leg, balancing her checkbook or balancing your body and your checkbook at the same time. I look fully centered now. I have both balanced my checkbook and myself. Emily and I are always plugging for co-treats and getting in with our rehab team more broadly. And this is a great opportunity doing postural stuff and cognitive stuff because, you know, PT and OT people are always looking for, like, dynamic standing balance opportunities. So, you know, check in with them on, like, what activities you could be doing with your patient standing or doing, like.

[8:43] Sitting balance if they, you know, if they can't stand, and then incorporating something cognitive into it. Wonderful coat treat. Oh, yeah. And there was meditation. They also did meditation. Oh, don't forget. So there was two control groups they used to compare. One was passive treatment, so they really didn't receive any intervention. And one they labeled a sham, which was essentially a fake or placebo intervention, which they did physical exercise, which is funny because like, Yeah. Physical exercise is great and helps everything. So why are we calling it a sham? It's not a sham. It's great.

[9:20] So let's talk about what they found. Turns out all therapy techniques showed a significant positive outcome for participants, even the sham intervention, which now when people are like, this doesn't make any sense, this is like a fake activity. I'll be like, it is. And that still counts. It's still helpful.

[9:39] I had a supervisor one time who I was like, I honestly feel like I'm faking it. I'm trying, but these activities don't feel like they're making a difference. And she was like, look, you're getting in there. You're getting some FaceTime in there. You're making them think. And even if it feels silly, this is still helpful. And I don't know, I think I kind of blew that off. I was like, things need to be more rigorous than that. But apparently, they don't. So if you're struggling for a couple treatment sessions while you're trying to find your footing, hey, getting in there and just trying stuff, whether it's, you know, just even just physical exercises, apparently helps. I'm glad to know that I feel so validated. And he's validating because every, I mean, we all have those bad days where it's like, poof, like I, we're reading the newspaper today. We're discussing it because I, I can't, I can't think. We're just, but it's, it's good to have those days where it's like, you know, even though it wasn't my best therapy day, I'm still helping. Still making a difference. Yeah, man. I, I read an article and the, like in the opening paragraph, it was like.

[10:54] As a speech therapist, we often have these days where we ask ourselves, am I even helping? And I was like, oh, God, I feel so seen. But very quickly, the one activity that didn't show improvement was the passive control group or the true placebo groups. So small caveat there. They said that the research showed no significant superiority of any of the techniques necessarily, but they did show a pattern of sorts. So people without MCI showed the highest improvement through mind-body, ACU or the acupuncture, cognitive training intervention, and meditation techniques, whereas the MCI group showed the highest improvement also with mind-body, ACU, and CTI, but additionally benefited from non-invasive brain stimulation. So that's the TMS or the transcranial magnetic stimulation. God, I appreciate abbreviations because some of those phrases are so freaking long.

[11:54] You say transcranial magnetic stimulation 10 times. I don't think I could. Yeah, I can't. And I've never seen this. Have you ever seen this happening in practice? TMS? Yeah. No, I don't know. Well, and, you know, in terms of things that we can actually apply in practice, uh not really one yeah one can't really do that we did have like an e-stem on site uh for pt at um a location i was at which was cool i like seeing people do it and it seems to really help people come in be like give me give me the electrode thing but we will not be frankenstein anytime soon. Like no monsters running around. But that was like more on like targeted body parts for like chronic pain and stuff. That was how it was used on our site. So not exactly a non-invasive brain stimulation.

[12:51] You gotta, I don't know, send people out for that. Limitations of the study. Their primary concern listed was validity of the findings was small, was a small sample size. So the number of research articles they had, only MCI were limited, which can skew the implications and results.

[13:10] Yeah. So if you're doing this meta review and you're like, okay, I'm looking for mild cognitive impairment, acupuncture, or music therapy research, turns out not a lot of people are doing that. So whatever the findings are going to be from those limited research articles are going to look really big because they're not being compared against a lot of other stuff. They also excluded people with neurological and psychological disorders like schizophrenia, MS, and people with dementia, which is, you know, a big subset of our aging population. Yeah. And they were missing that long-term follow-up. So wanting to know how effective these techniques are over time was not visible from this meta-analysis. Again, great research opportunity, man. Do go to the park, do some Qigong with some people who have mild cognitive impairments. Go back, do it a month later, go a month later, do it again, and see if it helps long-term. Let's check it out. So I don't know about you, but I feel like this article just gave me more peace of mind and an ability to explain more clearly why my brain games are beneficial. I love that your patients call it like your brain games. They're like, why are you doing these brain games?

[14:23] I know. And I like, well, cognitive therapy is, you know, one of those mouthfuls, but it really is. Like I, I have, I live my therapy life through my tablet. Like I have a bunch of different games they have. I use Elevate. A lot they have more high levels. There's also apps called Senior Games that I play a lot, which are, you know, those brain games. But it helps to have, you know, me giving them the strategies, like remember our memory strategies and what we're specifically working on to help get them through some of those activities with more success. Yeah, man, you are the iPad queen. Like I probably something I should work on is like downloading everything Emily has ever downloaded. Oh, it's so awesome. Well, I'm so happy.

[15:11] I don't use the apps i try to find other things that are available within my department already and they're pretty limited and apps are very accessible so i should really just bite the bullet and steal your ipad for a weekend and download everything you have and most of these like they're free elevate is a new one that i found and it is more uh high level so it's they have a lot of attention and stuff and the which is really great for this population because we talking about mild cognitive impairments. And what I think is great about doing things that are kind of more game-oriented is that it gives people, in my humble opinion, the confidence to feel that they can continue to do cognitive therapy at home.

[15:53] When you think that it's only something you can do by being supported by a therapist versus something you can do through your, say, leisure activities.

[16:01] Then you're like, well, what am I? I can't carry this over. Like, kind of, what's the point? Whereas physical therapy is much more obvious. You can take exercises home. But having things you can bring, they're either games or something you can do with friends or family that I think builds better discharge carryover. What else can we do? Oh, your activities department. So like, I don't know about you, but I don't have a lot of space to do Tai Chi in people's rooms.

[16:31] And I'm not trained in Tai Chi. it's outside of my scope of practice it's outside my scope of practice but our activities departments you know hold activity blocks so maybe they can do a meditation block a music therapy block um i worked at a bougie facility that had a real music therapy um session and, They had a songbook, and people would sing the songs. And guess what? They were the same songs every time. But people loved it. It was from the era that most of our patients were born in, and they just got really into it. It was very sweet. And even our more advanced folks, who I know this research didn't target, but people who you hadn't heard speak ever would come in and hum. And it was like, whoa, you can do that. That's so sweet. We need to get a music. If you are listening and you are a music therapist, we want to talk to you on our podcast because we want to learn more about this. Oh, we do. Message us. Music therapy. We want to know more. And then, oh, one thing about Tai Chi.

[17:42] At one of my facilities that I work at, we have a lot of long-term folks who have pretty significant physical and cognitive disabilities. And one of them who was sitting in the hall who I was checking in and goes I did tai chi today and I was like you are not supposed to be standing by yourself what does that mean and um it turns out they brought somebody in to do tai chi but it was seated tai chi thank god oh cute but it was a lot of like the arm movements and um which is was a great kind of mind body exercise and my patient who ended up following into the next tai chi session had a lot of difficulty coordinating what he heard as the directions with the physical movement and i was like oh this is really interesting like you do have some coordination difficulties even though he presented as really be functional for conversational-level tasks. So I was a big fan of that. Yeah, so we could also be providing these recommendations for families. I'm not poking anybody with needles, but there are people who do that.

[18:53] If you're interested in that kind of thing, like families can help get their loved ones to those areas, or you can seek someone out. You can seek someone out who does music therapy. I mean, a lot of these MCI or even healthy individuals, especially people without MCI, I hope you're not in my long-term facility, they're probably going home. So these are things that you would be seeking out to do outside of...

[19:22] Therapy so getting involved in a tai chi class at home or like having the families reach out on their behalf say hey my loved one does have physical limitations but they want to be i want to get them involved in this like are do you offer situations for people in wheelchairs like can we come to classes modified yeah that and i am a huge advocate for people getting involved in social things. So going to like Tai Chi or Qigong in the park or any kind of really exercise in the park, because as we found out, sham physical exercises were also effective, is great. You know, going to the gym or whatever it is and interacting with other people is a huge benefit. And if somebody experiences decline, already having those like habits and motor patterns down will enable them to continue to do those activities in cases of decline. So a big fan, big fan of getting people out, having a social circle, getting a lot of naturalistic socialization through these tasks is an added benefit. Right. And our MCI population, I feel like they end up being so underserved. Like a lot of times there's so much masking going on in this population that.

[20:46] When we can start implementing these things or start treating people, they either like don't want to admit it or they're having trouble with the acceptance or the families really don't even see it like because they're having conversations so well. So even providing these opportunities for education to be involved in more social things, to be involved in more activities, just to kind of nip these things in the bud without having that. What's it like? Like a social connotation. like a mild cognitive impairment, you know, it's helpful. Yeah. And I think to two of the things you said.

[21:25] Adding to the list of interviews we should do is we should probably talk to a therapist or something because, yeah, even though, like, after a mocha and people don't do very well, they'll be like, oh, okay, yeah, I'd be willing to do therapy. And then you start to do therapy and they're like, this is stupid. I don't want to do this. I don't need this. And to your part, that acceptance factor is really hard. Because it's very hard to do therapy where people don't suddenly are like, this is not for me. So understanding potentially better ways of making this more emotionally accessible to people. Another fun thing about these as being sort of like social activities is that could be more engaging. I have yet to see if Tai Chi is something that my patients will hop in more readily with uh with me but um oh gosh there was a second thing you said oh for families not noticing it um when they're visiting their parents or their grandparents at home they're in their setting right they know where the cups are they know where the knives are they know how to sequence everything because it's very rote memorization.

[22:29] And, but when you start putting them in the facilities, you're like, this is where things start to show that those unfamiliar situations is where those cognitive impairments are going to start to present themselves. And so it can be hard to convince family members. They're like, look, I know what you see at home is probably different than what we're seeing. And that's, I think, important to maintain in terms of getting everyone to be on board with what's happening. To wrap this up cognitive simulation is a valid treatment for mci and for healthy individuals too which is surprising you know yeah if you do the mocha and they're within functioning levels still tell them to go to the park and exercise no shame no shame in that game because it's we're going to increase and maintain these functions these cognitive functions and don't be afraid to stand And stand up for your brain games. Yeah. Promote those with confidence. They are beneficial. Don't let them bully you and think they're dumb. Oh, my God. I'm so bullyable by my patients. They're so crazy. I know. I laugh like a deck of cards.

[23:38] They do. They say, this is dumb. I say, oh, no. No. I'm sorry. This is what I have to do. Oh, right. I'm always, like, leaving the room apologizing. For my behavior. I'm like, you're right, I shouldn't have come in here. Anyways, all that is to say is that mild cognitive impairments do have impacts on people's lives. And in as far as we can support our patients to ameliorate that impact, we should be trying. And there are a lot of valid intervention strategies. Don't be afraid to try. You got this. And let us know. Let us know how it works. Let us know how it's going. Tell us about how your MCI patients bully. Share your successes, but also share the sad stories. We love those too. But thanks for listening, guys. Thanks for listening. Bye.

[24:31] You've been listening to speech talk thank you everyone for coming to listen to our research book club until next time keep learning and leading with research if you like this episode and you want to give us some love please rate us on your favorite podcasting app leave a review and tell the world because as podcasters our love language is in positive affirmations if you have a research topic you want us to cover or you have episode comments clinical experience you want to or just want to send us some love letters, send us an email at hello at speechtalkpod.com. If you want even more speech talk content, check out our website at speechtalkpod.com where you can find all of our resources we made for you, copies of articles covered, and Eva's blog following these topics and more. We're your hosts, Eva Johnson and Emily Brady. Our editor and engineer is Andrew Sims. Our music is by Omar Ben-Zvi. Our executive producers are Erin Corney, Rob Goldman, and Shanti Brooke. To learn about Speech Talk's program disclaimer and ethics policy, verification and licensing terms, and HIPAA release terms, you can go to speechtalkpod.com slash disclaimers. Speech Talk is a proud member of the Human Content Podcast Network.

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