Older Patients, Wiser Care
The Diagnosis Was Mild Cognitive Impairment. Could "Brain Training" Help?
Last updated: Mar 05, 2010
The case: A son concerned about small changes
For 70-year-old Mrs. B, as for many people, the first hints of trouble were little things. She'd forget that she and her husband had dinner plans with friends later that night. Or she'd find herself struggling to remember a name. Or in the middle of cooking dinner, she'd suddenly think, "Wait"¦what was I going to do next?"
She herself hadn't paid too much attention; she wasn't the worrying type. But her son, who liked to bring the grandkids to visit every other month, noticed that his mother didn't seem quite as "with it" as she used to be.
"Nothing's wrong. I have little mental slips too!" scoffed his father. "Your mother's so healthy that she hasn't seen her doctor in two years."
The son, an old college friend of mine, didn't give up. He asked my advice, which was to persuade his mother to let him accompany her to a check-up, including an evaluation for possible "cognitive impairment." (This is the catchall medical term for problems involving mental function.)
Everything in her thorough work-up came back normal except for a small part of the thinking testing: Although Mrs. B had been able to do almost everything on the test correctly -- including a test of attention and organization -- after three minutes, she'd only been able to remember one out of five objects on a list. Also, her copy of a three-dimensional cube drawing had been ever-so-slightly wrong.
Diagnosis: mild cognitive impairment. "I heard something on the news about brain training," my friend said. "Can that help prevent my mom from getting dementia?"
The challenge: A common change with a higher chance of turning into dementia
When problems with learning, memory, or other major brain functions become permanently bad enough to interfere with daily life, doctors call this dementia. (The most common cause of dementia is Alzheimer's disease; vascular dementia is also common.)
But some people, like Mrs. B, have memory or other problems, but overall are still able to manage the tasks of daily life. This is often called mild cognitive impairment (MCI). Research studies suggest that MCI probably affects 14-18 percent of Americans ages 70 and older.
So far, studies show that some people with MCI stay the same or eventually even get better, whereas in others, MCI is really "pre-dementia." Depending on the group of people studied, researchers have found that over a year, 11-40 percent of those with MCI stayed the same or got better, whereas 5-16 percent declined to the point that dementia could be diagnosed. (The average older person only has a 1-2 percent chance of developing dementia within a year.)
Scientists haven't found a drug that reliably reduces the chance that MCI will turn into dementia. Because of this, expert guidelines don't recommend that people diagnosed with MCI routinely be given dementia drugs such as donepezil (Aricept).
A possible solution: Specialized brain workouts might help a person function better
A special type of therapy, however, has been showing more promise. It's called cognitive training (also known as cognitive rehabilitation, brain training, or brain fitness). It's based on exciting recent research showing that the older brain is much more adaptable than scientists had previously believed.
Brain training is similar to physical therapy. Usually, a trained provider assesses a person's mental weak spots, then recommends a specialized mental training program meant to improve thinking and function. So far, several published research studies of healthy older people have found that brain training can improve mental skills.
The thing is, researchers are just starting to study its value in people with MCI. Early results are encouraging, at least in that function seems to improve on memory tasks. But nobody really knows if cognitive training will actually help prevent dementia or delay its onset in a meaningful way. Some experts have speculated that cognitive training is basically teaching people to "work around" their weak spots. That's a strategy that might help early on, when the brain may have just a few weaker areas -- but if the underlying disease affecting the brain keeps slowly spreading (as it does in most dementia processes), eventually there's not enough strong brain left to do the work-arounds.
Also, like physical therapy, cognitive training done right tends to be hard work, requiring the discipline to keep doing an activity that often feels difficult. For those on the verge of dementia, that kind of focus and persistence can be hard to maintain.
Mrs. B decided to give brain training a try. "My mother had Alzheimer's disease," she said, with a touch of sadness in her voice. "I want to do everything I can to avoid developing dementia and burdening my family."
The science is so new that reputable cognitive training programs aren't yet widely available. Although her family found lots of brain training sites on the Internet promising fast results, Mrs. B chose instead to sign up for a special research study at a nearby academic medical center. An added benefit was that the research center helped provide other non-drug care that may reduce the chance of developing dementia, such as good control of blood pressure and a regular exercise program.
I last saw Mrs. B a few weeks ago; her son was in town and the family had invited me over for dinner. She proudly showed me her latest memory strategy: a little notebook in which she's now diligently writing down appointments. "I can't keep it all in my head the way I used to," she remarked. "But this notebook is helping me a lot."
My prescription for caregivers:
If you have concerns regarding memory or ability to function in daily life, get your loved one evaluated by a doctor. It's helpful for a knowledgeable caregiver to come along to the doctor's visit. Specify that you'd like your loved one evaluated for "cognitive impairment."
A first evaluation for concern about memory and/or thinking should include a physical exam, detailed questioning about the concerning symptoms, a review of medications being taken, and blood work. These steps also help doctors check for delirium and other reversible causes of thinking problems.
Know that "mild cognitive impairment" (MCI) is usually diagnosed in people who show some objective sign of memory or other thinking problem, while maintaining overall ability to function at home and in society. It doesn't mean your loved one is definitely on the way to developing Alzheimer's or another dementia.
Understand that in many people MCI seems to be a "pre-dementia" stage: About 10 percent of people with MCI convert to dementia every year.
Know that cognitive training (or brain training) hasn't yet been proven to reduce the chance of dementia but can probably help a person with MCI in the short-term.
Realize that reputable brain training programs are not yet widely available. While software programs and other tools may not hurt, signing up to be part of research at an academic medical center may be a better bet.
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