Normal Aging? Or Mild Cognitive Impairment? During a recent ASHA online conference chat, Valarie B. Fleming explained how fellow SLPs can recognize the often-subtle characteristics of mild cognitive impairment—different from and often confused with normal aging. The Leader listened in. Overheard
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Overheard  |   August 01, 2016
Normal Aging? Or Mild Cognitive Impairment?
Author Notes
  • Valarie B. Fleming, PhD, CCC-SLP, is chair and an associate professor in the Department of Communication Disorders at Texas State University, where she teaches graduate courses in adult neurogenic disorders and swallowing disorders. She is also director and principal investigator of the Cognitive-Communication Laboratory. She is an affiliate of ASHA Special Interest Group 2, Neurophysiology and Neurogenic Speech and Language Disorders. vf13@txstate.edu
    Valarie B. Fleming, PhD, CCC-SLP, is chair and an associate professor in the Department of Communication Disorders at Texas State University, where she teaches graduate courses in adult neurogenic disorders and swallowing disorders. She is also director and principal investigator of the Cognitive-Communication Laboratory. She is an affiliate of ASHA Special Interest Group 2, Neurophysiology and Neurogenic Speech and Language Disorders. vf13@txstate.edu×
Article Information
Special Populations / Older Adults & Aging / ASHA News & Member Stories / Attention, Memory & Executive Functions / Overheard
Overheard   |   August 01, 2016
Normal Aging? Or Mild Cognitive Impairment?
The ASHA Leader, August 2016, Vol. 21, online only. doi:10.1044/leader.OV.21082016.np
The ASHA Leader, August 2016, Vol. 21, online only. doi:10.1044/leader.OV.21082016.np
Krista Marlette: How do you go about assessing the stage of memory? Are there certain tasks/activities where you can differentiate between an encoding problem, storage problem or retrieval?
Valarie Fleming: There are some tasks available in some of the commercially available materials that determine what type of memory problem [the patient has]. However, that information will come to you from their neuropsychological evaluation. They are the ones primarily responsible for assessing memory in-depth.
Julie Brown: Sometimes it’s hard to get families to realize the difference between “old age” and dementia-based memory loss. Any suggestions on how to explain that to them, or how to explain what level of memory loss is considered normal?
Fleming: I give examples to families. It is one thing to forget you are baking a cake. It is another to not recall putting the cake in the oven at all. If they are worried, I tell them to talk to their physician and let them decide or make additional referrals.
Lynn Keener: How do you tell normal decline versus dementia in traumatic brain injuries (TBIs)?
Fleming: When the person has sustained a TBI, we are talking about another diagnosis all together. The label “mild cognitive impairment” (MCI) assumes that all has been well up until that point. Their declines cannot be explained due to injury. If you are concerned about the onset of dementia after a TBI, you would want to determine if there is a change from their plateau status post-injury.
Laura Winters: Do you have any recommendations when you notice your own family members, or anyone for that matter, presenting with MCI but adamant that they are just “getting old”?
Fleming: I get that question a lot! The key is to get them to do something new or novel so that they can see that they are not able to do those new tasks as easily as they once would have approached a new task. That will sometimes get them interested in finding out what is going on. It is very hard to face the potential of having a decline in our cognitive abilities. Some individuals said they faced it more easily when they were able to do it on their own because they simply did not want their children to know. Most went to their primary physicians on their own.
Sarah Snow: Do you determine if MCI is [present] based on reported and observed symptoms or do doctors use brain scans to tell or differentiate between the two? (For instance, if they see plaques, tangles, Lewy bodies, etc.) How often do professionals rely on just observed or reported symptoms versus further investigation?
Fleming: Most physicians base their diagnosis on their clinical judgement. The level of neurological testing would be so in-depth to see those minute changes that they are better served to see if their patients meet the criteria based on the formal assessments they give in their office in the case of a neurologist. Or they refer them to a neuropsychologist for extensive testing of memory, executive function and attention.
Julie Brown: I feel like most adults in their late 80s to early 90s are no longer able to handle complex instrumental activities of daily living (IADLs), such as balancing a checkbook, paying bills, handling medications, etc., which would mean that their cognition is affecting their daily functioning. Does that mean that most adults in their late 80s to early 90s would fall under a dementia umbrella?
Fleming: Some research is starting to indicate that IADLs may be what helps determine who has MCI versus dementia. MCI should not have impact on activities of daily living such as toileting, grooming, etc. The incidence of MCI in individuals over the age of 65 is about 10 to 20 percent. In adults over the ages of 80–85 it is even higher. It is likely that you get a high percentage of older adults. Old age is a primary risk factor for MCI, so you may be seeing a lot of MCI (not dementia).
Carmen Sidlaruk: I suspect I often see people with MCI that have not had a medical diagnosis. Who is best to refer them to for a diagnosis? Primary care? Neurologist? Neuropsychologist?
Fleming: It is going to depend on your work setting as well as their insurance/third-party payer. If you are in a setting where you are seeing them as part of a team, you may already have access to a neurologist or neuropsychologist. Most insurance requires that they see their primary care physician first before they are referred to a specialist. There is a push right now for primary care physicians to become more knowledgeable regarding the signs and symptoms, as well as making appropriate referrals when they have a patient who is at risk for MCI.
Lucy Balch: What typically accounts for the stability (lack of decline) seen in some MCI people? Is it genetics or more environmental factors? A combination?
Fleming: The stability has been attributed to many things. One that interests me the most is this idea that some individuals are more successful at recruiting other areas of the brain to support them when they are engaged in a high-level cognitive task. Roberto Cabeza referred to it as “bilateral activation”—that is, both prefrontal cortices (left and right) were activated when individuals were engaged in cognitive tasks. Not everyone showed the same patterns of activation, but those who did seemed to perform better on cognitive tasks. The question is, why? Is it genetics, education, experience, diet, exercise? Some research has even shown a “bilingual advantage.”
Starr Lieber: You’ve said that individuals with MCI produce a greater percentage of “mazes” and percent of utterances with “mazes” at each time point. Could you elaborate on what mazes are?
Fleming: “Mazes” is a term used in language-sample analysis that means pauses, interjections or reformulations of utterances. When I code my transcripts using SALT (Systematic Analysis of Language Transcripts), I identify each time a participant has a significant pause in speech or adds in phrases like “uh” or other filler words, as well as if they restart a sentence to say it a different way. My hypothesis is that this is a marker for difficulty with higher-order cognitive skills (i.e., executive function) such as planning, organizing or cognitive flexibility.
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August 2016
Volume 21, Issue 8