MCI...Now What?

Speaker1:
[0:16] Happy Tuesday, everyone, and welcome to Speech Talk. I'm Emily.

Speaker0:
[0:19] And this is Eva.

Speaker1:
[0:21] And we're your research book club, so you can do evidence-based practice in practice.

Speaker0:
[0:26] Now that we're talking, tell me, what was something fun this week?

Speaker1:
[0:29] I am in a never-ending battle with my facilities about dietary textures. And...

Speaker0:
[0:38] For real.

Speaker1:
[0:39] Today I got the frantic text like, oh no, what was so-and-so's diet? It and i was like i have no idea but i'm not at work i i am off the clock i don't know i was like what's the problem they said i don't know i think it was in a different building but something about a hot dog you know isn't it always just about a hot dog everyone's all concerned about the lantern one

Speaker0:
[1:04] Of the sites i was at was all about a meatball i just just shaped shaped meat

Speaker0:
[1:10] people have problems with it.

Speaker1:
[1:11] I thought one of the facilities i was at before it was a sausage i was like can we just put a band on cylindrical meat and chicken bones please like can that be our lesson of the day so we don't need it our old folks don't need a danger

Speaker0:
[1:30] I just imagine people being like code hot dog, uh let's see also about textures this week um we are finally at our sniffs trying to convert to idsy and no one is ready, They're like, what does this mean? What are these textures? And for some reason, all of the recipes, if you're not on regular texture, all bread products are now puree. So I have to go in and label every single one with additional directions for how to prepare bread. I'm like, this is not how this should go. It's terrible. So we're like knee deep in it. We are knee deep in the IDDSI conversion right now.

Speaker1:
[2:25] Oh, I love that. I mean, I love that, not that you're knee deep in struggles, but I love that your facility is, you know, taking that initiative to switch over to something that will be easier. After you get through the muck, you're in the weeds. After you get out of the weeds, it'll be so much better.

Speaker0:
[2:46] Yeah, I'm really hoping that this like cuts down on admissions complications where there's a whole variety of textures from the hospital people come in on and they don't know what to do with it when they get to my facility. So hopefully now it'll just be like the hospital had them on six. They're on six here. And it won't be about how Eva has a problem with the textures. It'll just be the hospital's recommendations. Like I'm the one making these calls on like what defines mechanical soft.

Speaker1:
[3:19] And it's not us. We're not the diet police. We are not the scientists behind it. But ITZY does have a lot of, I don't know if you have perused that side of ITZY, Eva, but they do have a lot of resources on how to help your facility switch over to ITZY.

Speaker0:
[3:34] I did not know that. Thank you, Emily and everyone else listening. I hope you think Emily too, if you like me did not know.

Speaker1:
[3:42] You always got to ask me first.

Speaker0:
[3:45] Seriously, I got to get in the habit. Anywho, today we're not talking about this at all.

Speaker1:
[3:53] Not even close.

Speaker0:
[3:56] Why don't you introduce our topic?

Speaker1:
[3:57] We're actually talking about mild cognitive impairment.

Speaker0:
[4:02] Still one of my favorite topics.

Speaker1:
[4:05] Hate it. But we wanted to kind of look at what exactly is a mild cognitive impairment and why is it significant in our patients? What does that mean when we say you have a mild cognitive impairment?

Speaker0:
[4:25] Yeah. What is an MCI? Well, according to the National Institute of Health, it is a neurocognitive disorder that denotes memory changes that are greater than the normal aging signs, but less so than someone with dementia. So that real sweet spot between more than your age group and the less than dementia, real narrow there.

Speaker1:
[4:48] Yeah, so we're trying to see how likely it is for someone who scores low on our cognitive test to have dementia down the line. So, what separates the people who have MCI and those who develop dementia, and what do we say to our patients when they ask us? Are you saying I'm going to have dementia?

Speaker0:
[5:09] Yeah, I get that one a lot. And for some folks, they definitely already have it. It's not mild. It's not mild.

Speaker1:
[5:18] Oh, no, I've had to have that conversation before. So I'm doing this dementia staging group, and one of my first lovely participants was not aware of her dementia diagnoses. And I had to be the one to say, yes, you have dementia. She was like, what? Who? Who told you? How did they know? And I was like, oh, my God, which nurse did not divulge this information? Let me go find them. So let them explain this to you.

Speaker0:
[5:53] Yeah, it's kind of like the playing hot potato on who wants to tell somebody they have dementia.

Speaker0:
[5:59] Like oh you know what i think that's your doctor oh your doctor's not in today they're saying it's gonna be me uh i.

Speaker1:
[6:05] Think that there's a janitor out like literally anybody

Speaker0:
[6:10] Else there's somebody sweeping could you just read this paper to them it's good i'll.

Speaker1:
[6:16] Be outside let me know when they're done

Speaker0:
[6:17] All right so what do we look at uh the article today is titled a mild cognitive impairment Risk of Dementia According to Subtypes, and it is by Cecilia M. Serrano et al., published in 2013.

Speaker1:
[6:35] Yeah, so before we get into the research, we've got to separate out these subtypes. So first, AMCI, Amnesic Mild Cognitive Impairment. So this person is scoring low, 1.5 standard deviations below the mean, on memory portion only. Okay. N-A-M-C-I, non-amnesic mild cognitive impairment. So they have a low performance in any one singular area for the testing, but not the memory. M-D-M-C-I, multiple domain mild cognitive impairment with low scores in several areas. So we're talking memory, executive function, attention, language, visuospatial skills, all of them.

Speaker0:
[7:25] Sorry, just hearing you list those, I was like, those sound suspiciously like the mocha category.

Speaker1:
[7:31] That's how I thought about it, too. I was like, why does this sound exactly like the mocha?

Speaker0:
[7:37] Why does this sound like something I explain three to four times a day? So the tests I used to look at these were trail-making tests. Again, I don't know if that sounds familiar to you. One sequential and one alternating attention task, clock drawing, and MMSE.

Speaker1:
[7:55] Yeah. So they were given cognitive evaluations at six months and 12 months. And they found that 35% of the amnesic MCI went on to develop dementia. Multiple domain had 31% developed dementia. And the non-amnesic had 11% developed dementia. So this article is specific in describing the dementia being Alzheimer's dementia, as told by Ginger. Just kidding, the DMS5.

Speaker0:
[8:25] All right, so I had to look it up. What is the difference between dementia and Alzheimer's? I went to the Alzheimer's Association website, and it says that dementia is a general term denoting symptoms of a disease, including changes to reasoning, behavior, and functional changes. And Alzheimer's is the most common disease that causes dementia, with about 60 to 80 percent of dementia stemming from Alzheimer's. Other progressive dementias, in case you have forgotten, like I have, are Lewy body, frontotemporal, and vascular. But the key is that these are progressive diseases that are diagnosed and give us the symptoms for dementia.

Speaker1:
[9:09] Yeah, I think, Eva, you made this connection before that, like, that's like dysphagia. Dysphagia is the symptom. Like, there is a whole bunch of other causes. You don't have teeth, but dysphagia is the general symptom. So that's kind of what it's going for here. And they made this clarification because some participants had risk of dementia, such as vascular or a primary progressive, but they stayed within that Alzheimer's realm. So this is kind of tapping on, you know, our mild cognitive impairments, number one, self-perceived problem, right? Or maybe they're Most masked problem, their memory, right? 35% of those amnesic, mild cognitive impairment people went on to develop dementia. That memory portion is so key in kind of moving up.

Speaker0:
[10:03] Yeah, and we've talked about this before where people have that kind of, oh, well, I don't work anymore, So I don't really have to know the date or, you know, if I had my phone with me, I'd know. And they're finding ways to compensate. But when folks are really starting to have no context for the date or things they have recently been told, these are the indicators that we as clinicians know. I mean, hey, bud, you need to start making plans because it's not going to get better from here. And because their symptoms are still fairly mild relative to what they think of as dementia, they're like, hey, I'm like, I'm fine. It's fine. Meanwhile, like, sink is overflowing.

Speaker1:
[10:56] Yeah. I think this is so important. I mean, we're having these conversations with people. And while we hate to be the person that says like, oh, no, trouble's ahead, like danger's afoot, we are kind of we kind of are those people. We might be the first ones who are checking out how they do their medications. How are they doing? How are they talking about their safety? How are they doing those simple problems?

Speaker0:
[11:24] Definitely. And I know you and I have done a different episode about medication management, but man, do I feel like that unmasks a lot of people. And you get a lot of doubling down on, well, you're having me practice with medications I've never taken before. So this doesn't matter. It's not relevant. And I'm like, well, what if you got a new medication?

Speaker1:
[11:44] Yeah, it's so hard. This small section of population, I feel like almost always dominates my caseload. And it's always been so hard for me because it is always that almost sneaky therapy when you're passively problem solving how you would do this situation. We're like, what if you were making spaghetti and you drop the whole jar of pasta sauce on the ground? Now what are you going to do? They're like, what a ridiculous question. Who's ever done that? But it's this. We're finding all of these problems really doing these mochas or we're doing them in the slums or whatever, you know, your favorite short version test is. But we're the first ones to kind of see it and talk to them about it.

Speaker1:
[12:32] And that's always just a hard thing. and the unmasking. I love that. I always think about masking as like a problem, but now you've got me feeling like Scooby-Doo, like unmasking the problem.

Speaker0:
[12:44] Who is that pesky speech therapist with her sneaky mocha? While I think we laugh a lot about trying to treat mild cognitive impairment because you're working with people who are super functional in so many capacities, and so it can feel so hard to choose appropriate treatment methodologies for them. At the same time, you're like, hey, this is this is going to be hard to process because potentially you you are on the dementia track and where you're at right now is not a normal level of of memory loss. And so you kind of got to thread that uncomfortability with them. So never easy. Never easy to have those talks.

Speaker1:
[13:31] I like that, too, that this one talked about that non-amnesic part of it. Like, 11% doesn't feel like a lot, but when our main thing of diagnosing an MCI is that memory and we're so focused on that, I feel like those people can very easily slip through the cracks.

Speaker0:
[13:49] That's a really good point, Emily, because I think a lot of people in conversational interactions with their patients will flag to me, oh, hey, I think so-and-so has a cognitive impairment. I was talking to them and they forgot who I was or they forgot what I just told them. And so I think you're really right that the memory is often a more salient factor, but we do need to be incorporating things like attention, executive function, language, visuospatial skills. I think another one is vague language. I see that a lot that I'm asking folks to describe stuff and they're like, well, you know, it's coming up. I'm like yes I did say what would you do if you had an appointment yes it is coming up but what are you going to do to get there and they're like well you know the usual things I'm like ah yeah, Give me specific steps.

Speaker1:
[14:43] Moving on to a slightly more contemporary article written in 2019 titled Visual Memory Test Enhance the Identification of Amnesic MCI Cases at Greater Risk of Alzheimer's Disease by Mary Kosmitis.

Speaker0:
[15:00] So this study examined 4,771 participants with part of something called the Cosmic Project from the University of South Wales. I can't do a Welsh accent. I will try. And this is a collection of data from five previous studies. The people were grouped into no cognitive deficit, amnesic, mild cognitive impairment, when that kind of subdivided into verbal, visual, and both.

Speaker1:
[15:29] Yeah, what they basically found was that when there was no deficits, and that was actually most of their sample, with that being about 4,000 people, people weren't likely to develop Alzheimer's disease. They had like 1% of all those people who had Alzheimer's.

Speaker0:
[15:45] Which is great. You can tell folks, if you don't have symptoms of Alzheimer's, you probably not going to get it.

Speaker1:
[15:51] Round of applause. Always like go for the pass. Do the test and wish for the pass. The MCI group was about 700 of the participants with 59% having a verbal memory impairment, 27% having a visual memory impairment, and then the combined visual and memory impairment made up the last 13% of that.

Speaker0:
[16:15] Yeah, those are some pretty wild stats.

Speaker1:
[16:17] So of those groups, 6.5% of those with a visual memory impairment that amnesic MCI went on to develop dementia. 8.2% of the verbal MCI went on to develop dementia. And 11.7% of the combined visual-verbal progressed to dementia. This is a lot of numbers. Yeah.

Speaker0:
[16:46] Okay. So we're seeing some pretty interesting carryover from MCI to a dementia diagnosis down the road.

Speaker1:
[16:54] Some other things to note, the progression to Alzheimer's was more likely when the participants' age was higher and the participants had lower MMSE scores overall.

Speaker0:
[17:07] So in case you're like me and you forgot what MMSE was, is the mini mental. And yeah, I did forget what that was. I had to look it up while Emily was saying it. I was like, the what? Now, is that again? Right. So basically, if you're older, you're more likely to have it. And if you test worse on the MMSE, you're more likely to have it. Anyways, overall, visual versus verbal was not significantly different in the progression towards Alzheimer's.

Speaker1:
[17:39] My biggest takeaway from this article was visual memory is and can be separate than verbal memory and identifying MCI. And I hear this a lot, too, man. Like people are like, yeah, I can't list out these random letters and numbers or pull them backwards. But if I see your face, I'll never forget it. But then I had seen that same person last week.

Speaker0:
[18:06] And they forgot you. And they surely don't remember me. Yeah, man, I see that all the time at work. Where if you're doing not even like a number or letter spanning task, I try to keep it more functional sometimes if they're like, well, this is not representative of what I do. I'm like, OK, well, here are some directions. and they can't do that. And I'm like, okay, so maybe we can just accept that you're having some verbal memory problems. Maybe that's something that I can just come to convince you of.

Speaker1:
[18:42] No, Eva, they don't eat that. They don't eat it. They don't use that. So it doesn't apply to them. They've never seen those three-step directions before.

Speaker0:
[18:54] Well, I will say though that in terms of the counseling component and why people are in denial, And I've, through being a little more open as a clinician and trying to just go for the conversational deep dive, like, as you say, if they're not eating it, if they're not having that snack, and they're like, I do not believe what you are telling me, kind of going, okay, well, let's talk about something else and trying to get them to open up more about their home life and stuff. I had a patient one time who had severe dementia, just fully trying to refute it. And eventually she was like, well, I can't have dementia because where I live is an independent living facility. If you have an impairment, you can't live there. And I was like, oh, there it is. There it is. You're straight up in denial because you have to be in denial if you want to live where you live.

Speaker0:
[19:47] And so just, you know, keeping it out there that part of, aside from the fact that this is a very difficult pill to swallow, part of why somebody might be kind of butting heads over discussing mild cognitive impairment is there's something else going on.

Speaker1:
[20:03] Yeah. And I get that. When we're talking about moving on to different living lifestyles, you are losing so much independence. And I get that.

Speaker0:
[20:16] It sucks.

Speaker1:
[20:17] But like, because we're talking about this right now does not mean that is going to be you. I mean, some of these percentages we looked at, they're not great. You know, they're not. It's not like, you know, we have all the hope. But, you know, we're still trying to we're picking these people up, not just so we can quiz them to see how well they're doing on loading their pill bottles. Yeah, I'm not just trying to make you look the fool. But I want to teach you how to like maintain like that's always what we talk about at these with our dementia people is like the goal is to maintain where you're at. So if right now, currently you're maintaining, but like struggling, like let's talk about things that you can do to keep your level exactly where you're at. So you know, okay, I'm in danger of losing my memory more severely. What can I do? What, what are the games I can play? What are the the things I can put in place, who can I start delegating my family to do these check-ins just in case? What social groups can I join? There's no time to start exercising like your 80s.

Speaker0:
[21:35] That's so real. And, you know, just spitballing here, I think that's a great conversational approach to say, hey, you know, rather than talking about this from an impairment-based perspective, let's just talk about this from a healthy aging perspective. You know, let's go through the checklist of things that are good for you. Exercise, eating well, socializing, you know, making sure that if you're having trouble understanding people, maybe you just need to get your hearing checked. Let's start there. You know, getting hearing aids will also help you. And then transitioning that from away from there's something wrong, there's a big problem here. If they're not ready for that conversation to let's just make sure that you are maintaining what you're doing as well as you can. I think more people are open to that discussion.

Speaker1:
[22:29] Especially if we're not get like slapping on these big labels or telling them no you can't do xyz people always get scared of me too they're like i don't know if i can do speech therapy what if they say i can't go home and it's always in my spiel that like for starters insurance does not care what i say i don't know how many notes i've submitted to insurance and they do not read that i i've been very detailed sometimes they do not read it you're like betty

Speaker0:
[22:55] Ann literally should never be alone in her life and they're like send her home tuesday no support.

Speaker1:
[23:01] I was like okay for the love anyways Besides insurance, not caring at all what I say, anybody can live at home with the amount of, like, with the necessary support. So if all we're doing is figuring out exactly what supports you need, then great. If you just need these lessons and go home with a folder to remind you of these lessons when you're not angry at me for talking to you about them, then that's great, too.

Speaker1:
[23:34] But the the goal is to is to help is to help

Speaker0:
[23:39] Always yeah as i try to tell people i am here to help they.

Speaker1:
[23:45] Don't believe us

Speaker0:
[23:46] Yeah seriously and if you are genuinely having a hard time reaching your patient with this if they have involved family members i have often found that they are more receptive to the conversation because they have often begun to see some of the signs. Not always. Sometimes family's like, what are you talking about? My dad, never. And I'm like, well, he's 80, so you're dead sometimes. But a lot of times the family members are like, yes, we keep having an issue where they're getting locked out of their house and I have to like, come bring them the extra set of keys. And so the family's already starting to see some concerns and just doing that education prevention conversation with family can help them as well. Oh, but before I forget, on the whole, oh, they're going to take something away from me, my grandparents, complete opposite. My grandmother started to feel like she was having some cognitive difficulties and she just handed over her car keys. My grandfather was like, I will drive this car until it kills me.

Speaker1:
[24:52] Not too long ago, I had a client very, very much older. They came in and um tested at like a nine on the bcat and he was living in an independent living situation and driving and i was like very in denial about everything that was going on i was like let me just give him this driver safety test to try and see and we do this we're going through like just general safety things on the road what to expect what you do in a case of emergency and at the end he goes so do you give me my license i was like what and he goes aren't you aren't you from triple a no no i'm your speech therapist this is like the fourth time we've met uh i'll see you tomorrow i

Speaker0:
[25:43] Can only imagine being like just knowing that person is out there driving.

Speaker1:
[25:50] That's oh

Speaker0:
[25:51] As hard to contemplate.

Speaker1:
[25:53] So who who knows they haven't been back so that's i always view that as a positive thing i'm not checking the obituaries but it's always a positive thing if they're not a quick readmit yeah

Speaker0:
[26:06] You're like well it's out of my hands now all right does that mean it's time for us to wrap up emily.

Speaker1:
[26:12] Let's wrap it up with a bow so

Speaker0:
[26:14] To summarize mild cognitive of impairment is an impairment with issues in more than one cognitive domain. It has subtypes that show deficits in either one domain or multiple. We have divisions like amnesia, memory loss, non-amnesic, or non-memory loss, people with amnesic versions of mild cognitive impairments are more likely to have a higher risk of Alzheimer's disease than people without.

Speaker1:
[26:42] If you have any of our lovely MCI patients on your caseload, don't be like me. Be empathetic. Don't curse a world when you know that you're, when you know that there's going to be a fight for the next two to four weeks while we're passively explaining our impairments and sneakily calling family members.

Speaker0:
[27:06] I just imagine you printing the diagnosis list and being like, read it out loud. You tell me when you've heard the news.

Speaker1:
[27:13] I'll take the mop. You take the paper.

Speaker0:
[27:17] And as always, we would love it if people did more research. If you're out there listening and you do research or are affiliated with an institution, we'd be happy to talk to you.

Speaker1:
[27:27] Oh, my gosh. Yeah, please comment on our podcast. Send us an email via our website, speechtalkpod.com. We're here. We're listening.

Speaker0:
[27:38] And if you have any fun stories about being fooled by people with mild cognitive impairments, we want to hear them.

Speaker1:
[27:44] We'll pick this up next time. Until then, keep your research close and the sticky notes closer.

Speaker0:
[27:50] I write a hundred sticky notes a day.

Speaker1:
[27:53] Thanks, guys. You've been listening to Speech Talk.

Speaker0:
[27:58] Thank you, everyone, for coming to listen to our research book club. Until next time, keep learning and leading with research.

Speaker1:
[28:04] 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.

Speaker0:
[28:15] If you have a research topic you want us to cover, or you have episode comments, clinical experience you want to share, or just want to send us some love letters, send us an email at hello at speech talk pod.com.

Speaker1:
[28:29] If you want even more speech talk content, check out our website at speech talk pod.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.

Speaker0:
[28:42] We're your hosts, Eva Johnson and Emily Brady.

Speaker1:
[28:44] Our editor and engineer is Andrew Sims.

Speaker0:
[28:47] Our music is by Omar Benzvi.

Speaker1:
[28:49] Our executive producers are Aaron Corney, Rob Goldman, and Shanti Brooke.

Speaker0:
[28:54] 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.

Speaker1:
[29:06] Speech Talk is a proud member of the Human Content Podcast Network.