This text-based course is a transcript of the live seminar, “Mild Cognitive Impairment: From Diagnosis to Management,” presented by Michelle Bourgeois, Ph.D., CCC-SLP.
>> Michelle Bourgeois: I will start by mentioning that in today's universe, because of the number of people who are now attaining the ripe old age of 65, all of us baby boomers who are getting to that stage in our lives, this particular discussion about mild cognitive impairment is particularly germane. Many of us are worried about the normal aging process and whether or not the types of memory lapses that we are experiencing, on a daily basis undoubtedly, might be a predictor of future serious memory problems. It is really important to figure out if that is the case or not, so we do not have to live in fear of Alzheimer disease. I would like to talk about when things are beginning to be a problem, when to know whether we should be doing something about it, and what we can do about it.
I will talk a little about mild cognitive impairment (MCI), how we diagnose it, the different types, the history and evolution of this diagnostic category, and then share with you an intervention approach I have been happy to be trying out here at the Ohio State University with my student clinicians. Hopefully this will encourage some of you to do this type of a service with our older adults.
When Do We Need to be Worried There is a Problem?
We need to start with talking about what it is that we do know about MCI at this point. This whole diagnostic category of mild cognitive impairment is relatively young. It does span my personal career, but it is not as well known in the literature of Alzheimer disease and other types of dementia. What we do know about mild cognitive impairment, or symptoms of it, suggests we need to pay better attention to it. When there is a gradual progressive cognitive decline, it could portend eventual diagnosis of Alzheimer disease. When cognitive impairment becomes a problem sufficient that it interferes with everyday functioning, our usual typical activities, work or our daily lives, then we need to pay attention. We need to get it checked out.
One thing that is not so clear in the literature, even today, is knowing specifically when asymptomatic cognitive issues and simple, everyday memory lapses are going to transition to symptomatic pre-dementia phase, an actual MCI phase, and then, eventually, an Alzheimer’s or dementia diagnosis. We are still working on that. At this point, there still is significant uncertainty about the diagnostic process in these early stages.
History of MCI
To give you some history about how the diagnosis of mild cognitive impairment has evolved, back in the late '80s, Barry Reisberg and his colleagues (1988) were beginning to notice that there were people in their stage 3 on the Global Deterioration Scale that were evidencing some mild memory issues, but not ones that were sufficient enough to be concerned about dementia. Morrison and colleagues, in 1993, began to use their clinical dementia rating scale and sorted out people who were either a 0 or a 0.5 on the CDR as deserving of a look at what types of problems they were experiencing. Both of these categories of people were complaining about memory problems, and their families were concerned about it. We were beginning, at that point, to think that we needed to pay better attention to what people in these earlier stages were experiencing, which led to Petersen, Smith, Waring, Tangalos, and Kokmen (1999) being more systematic about coming up with some criteria. The criteria they developed included memory complaints on the part of the individual. These individuals, just like most older adults who are beginning to memory lapses, especially word-finding problems and other aggravating memory lapses, were coming to the physicians and complaining about some things.
In order for the diagnostic category of mild cognitive impairment to be considered, a neurologist decided that these memory complaints needed to be corroborated by a family member, another informant, just to ascertain that these were reliable complaints, things that happened on a reliable basis and were observable. In addition, these memory complaints then would trigger a memory evaluation, and there needed to be a documented memory impairment in order to be considered within this diagnostic category. In addition, the big concern about coming up with this criteria is that we are not inadvertently diagnosing or prematurely diagnosing a problem when it is not actually there. What is important is when there are other cognitive tasks that are evaluated, the ones that were not memory related such as executive functioning task, language tasks, and other cognitive tasks, needed to be within the range of normal performance. That was also reflected in the fact that activities of daily living would be unaffected or preserved. People were able to complete their activities of daily living without assistance. These last two criteria are largely the factors that lead to a diagnosis of non-dementia, not demented. When people cannot perform daily living activities, and they do have a variety of cognitive deficits that span memory and non-memory activities, the person is more likely to have a diagnosis of dementia.
