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Sat, Jun 8 9:40am · Revisiting Brain Exercises in Living with Mild Cognitive Impairment (MCI)

Hi @bonniep! I like your alternative plan. Sounds like you've found something that will give Denny a challenge that will adjust over time. And I like that you guys are planning to do this together. We've started playing around with some board games like Boggle, Scattegories, and Telestrastions in our HABIT class. I'm not convinced that these have the same brain exercise impact as the processing speed based adaptive computer games, but these games do have some time pressure involved and can be a challenge. So, if brain games just aren't feasible these may also be some other options, but I don't have official data on that. But something is likely better than nothing!

Thu, Jun 6 3:35pm · Revisiting Brain Exercises in Living with Mild Cognitive Impairment (MCI)

At present, HABIT is only available at one of the Mayo campuses (Arizona, Florida, or Midwest) and the University of Florida. It is our goal to help support providers at other institutions also launch HABIT programs, but that has not happened yet.

Fri, May 31 1:58pm · Revisiting Brain Exercises in Living with Mild Cognitive Impairment (MCI)

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Last week, I highlighted some research by the HABIT team evaluating the comparative impact of the 5 components of the HABIT program: Cognitive rehabilitation, cognitive training, yoga, support group, and wellness. We concluded that the topic is complicated and that no one intervention is “best.” Multi-component interventions are likely to continue to be most helpful for patients with MCI. I did, however, mention that in evaluating the outcomes of quality of life, mood, anxiety, and self-efficacy, eliminating cognitive training did not negatively impact those outcomes.

Does this mean we think you can stop doing those brain games? Not so fast. I noted that we have not yet evaluated our cognitive outcome data to see if cognitive training may make a difference there.  Because of this, I thought it an opportune time to highlight another recent study, this time from researchers in China, specifically evaluating the cognitive impact of cognitive training. Here are some details and summary, but you can read the study here if you like.

THE STUDY POPULATION:

This study was conducted in patients diagnosed with “vascular cognitive impairment no dementia”. This is essentially another way of saying Mild Cognitive Impairment (MCI) but with a known underlying etiology (cause) of vascular disease. As we discuss in HABIT, MCI is a syndrome that describes the loss of cognitive ability (memory, word finding, or executive functioning for example) but with relatively good day-to-day functioning. There are many diseases that may cause MCI. Alzheimer’s disease is one, but vascular disease (i.e., small strokes or impaired blood flow in blood vessels of the brain) is another. In HABIT, we see patients with MCI with all etiologies and we may not even be sure of the disease. However, in this specific study, researchers limited the sample to patients with evidence of cognitive impairment (but not dementia) with evidence significant small vessel ischemic disease (i.e., vascular disease, primarily based on MRI scan–taking a picture of the brain and seeing evidence of small strokes).

THE INTERVENTION:

Patients were randomly assigned to one of two possible interventions. The training group received a computerized, multidomain, adaptive training program for 7 weeks. They completed 30 minutes of training per day 5 days per week. When patients completed tasks with high accuracy, they upgraded to a higher difficulty level. The active control group received speed and attention tasks, also 30 minutes per day, 5 days per week for 7 weeks. In this group, they completed tasks at the same difficulty level throughout the study. This is a key difference between the interventions--the exercises got progressively more difficult as the participants got better at them in the training group.

OUTCOME MEASURES:

The researchers collected data on measures of cognitive functioning (pencil and paper cognitive measurements) as well as measurements of brain functioning on brain scans (MRI and functional MRI). These measures are mean to evaluate changes in size of memory-important areas of the brain and evaluate the integrity and efficiency of the connections in the brain. They conducted these measurements prior to the intervention, at the end of the interventions, and 6 months later.

RESULTS AND CONCLUSIONS:

The found a significant improvement on pencil and paper cognitive measurements in the training group compared to the active control group. Unfortunately, this effect went away by 6 months after stopping the intervention. They did not find any change in the size of various brain structures with training compared to the active control, but the did see an increase in brain connections. Again, this improvement went away by 6 months after stopping the intervention.

What are the take home message?

  1. This study shows improvements in cognitive functioning and brain efficiency with a specific type of cognitive exercise: adaptive computerized cognitive training.  It is important that the control group–also doing cognitive exercise but without consistent adjustment of the challenge level–did not show the same benefit. So, this suggests that not all cognitive exercises are equal, and that the most benefit on cognitive measures and brain connection efficiency is likely to come from exercises that continue to adapt and provide challenge, even as you get better at the exercises.
  2. However, there is another outcome I would like to see evaluated in these studies, which is lacking here–do the benefits on cognitive outcomes and brain connections from training exercises result in improvements in other outcomes, such as how a person with MCI is functioning and coping day to day?  Or, do these improvements help slow any progression of MCI over the long term? I certainly think these cognitive and brain outcomes are exciting, but our patients want to know more–reasonably so. If I do these brain games, will it slow any decline I might have down the road or will it actually improve how I am able to function and living independently in day-to-day activities? So, I think these results are an exciting start, but I hope we can eventually see longer term funding of these studies to really support evaluating long term outcomes.
  3. This study was done with patients with a specific type of MCI related to vascular disease. The results may not be equally applicable to all other types of MCI (such as MCI thought to be related to Alzheimer’s disease or Parkinson’s disease). However, this study is still of interest in my mind as it is a study with individuals with an abnormal process rather than a study of normal cognitive aging (which many other studies in the area are and are less relevant to our patients with MCI).
  4. It is also very relevant that the benefits of the adaptive cognitive exercises dissipated over time when the participants stopped doing them. By 6 months, they had lost all the benefits they’d gain. This is why we emphasizing creating HABITS in our program–keep doing the exercises to maintain the benefits.

Overall, I usually emphasize to my patients that we need to understand the benefits of cognitive exercise more. Ongoing research seems to suggest that cognitive exercises are not all created equal, and any potential benefits are only sustained with ongoing exercise.  I’m optimistic enough about the benefits given studies like these, that we do routinely recommend brain exercise and help our patients create a habit during our treatment program. If you’ve been successful in creating a cognitive exercise habit, I’d love to hear more about what you are doing and how you maintain the habit!

 

Tue, May 28 10:30pm · HABIT Research Highlight in Living with Mild Cognitive Impairment (MCI)

@debbydew Thank you so much for sharing your story! @drmelaniechandler is one of my hero’s too! I’m glad to hear what a difference the calendar has made! I hope some other habit alums will chime in too.

Tue, May 28 5:00pm · HABIT Research Highlight in Living with Mild Cognitive Impairment (MCI)

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Understanding multi-component interventions

This week, I want to highlight a recent research publication from our team, led by Dr. Melanie Chandler, director of the HABIT program in Florida. For those of you who have followed our newsfeed for a while, you’ve seen our references to the HABIT program already. However, I want to include some description here for any newcomers to our newsfeed. HABIT Healthy Action to Benefit Independence and Thinking ® is Mayo Clinic’s cognitive rehabilitation and wellness program for patients diagnosed with Mild Cognitive Impairment. You can find more detail on our information tab, but briefly, our program has 5 components: cognitive rehabilitation (memory compensation training), cognitive training (brain fitness), yoga, wellness, and support group. There is supportive research literature showing the benefit of each these five components individually, which is why HABIT evolved to include all 5 components in the first place. What we didn’t know, was whether our patients needed all 5 components. That is, could you get just as much benefit from just 4 parts of HABIT because some of the benefits of some pieces of the program overlap? And related to this question is understanding how each of the 5 components is helpful. Which outcomes are helped by which intervention?

For example, perhaps the cognitive rehabilitation piece helps people function better day to day with memory tasks, perhaps cognitive training improves measurements of cognitive function, support group helps improve mood or lessen anxiety, perhaps yoga improves relaxation and physical functioning, and perhaps wellness classes help people change lifestyle habits (e.g. diet and exercise) and also helps with functioning and mood. In our research trial, we attempted to answer these questions.

What is the most important outcome?

We first asked our HABIT alumni to tell us which outcomes were most important, out of 13 possible outcomes that included both patient outcomes (e.g., performance on memory testing, daily functioning in memory related activities, mood, confidence, physical functioning, quality of life, etc.) and partner outcomes (e.g., partner quality of life, burden, mood, anxiety, etc.). That survey showed that the highest priority should be patient quality of life and that all patient outcomes were valued by both patients and partners higher than partner outcomes. Dr. Chandler’s recent publication therefore, focused on this primary outcome as well as mood, self-efficacy (i.e., confidence), and memory-based daily functioning as these were the next most highly rated outcomes.

How do the HABIT pieces contribute to outcomes (so far)?

In this trial, supported by funding from the Patient Centered Outcomes Research Institute, nearly 300 couples agreed to be part of this research study in which they went through the HABIT program, but received just 4 of the components. The 5th component was randomly selected to be left out. The patients did not get to choose or know ahead of time which treatment would be left out. With this type of study, we compared which people had better or worse outcomes by evaluating the cost of not getting the one withheld intervention even if receiving another 4.

In reviewing the primary patient outcomes, Dr. Chandler and our team found that all combinations of four treatments improved quality of life at the end of treatment in our patients. At one year, wellness class had a greater impact on patient mood than cognitive training, and yoga had a greater impact on memory related daily functioning than support groups one year after treatment. Overall, the loss of computerized brain exercise did not negatively impact these primary outcomes. However, the literature on cognitive training suggests that it is most likely to impact cognitive measures, not the measures we’ve evaluated in this study—quality of life, mood, anxiety, or self-efficacy. We collected cognitive measurements in this trial and analyses of those data are ongoing. We also continue to evaluate partner outcomes.

Overall, these results are the first of several making an effort to compare various behavioral interventions (non-medication approaches) for patients with MCI.  The topic is complicated, and there is still more to understand, but we can already say that it is likely that no one behavioral intervention is “best”. Different interventions impact different outcomes for patients (and likely partners), such that patients are likely to continue to be best served overall by multi-component interventions like HABIT.

We wish to express our gratitude to the patients and partners who agreed to be a part of this study and follow with us over time!! We could not do this without you, and we are forever thankful and humbled that we get to work with such special and courageous people. We also wish to acknowledge all the sites who participated in the trial, including Mayo Clinic Arizona, Florida, and Minnesota as well as the University of Washington. If you wish to read Dr. Chandler’s full academic paper, you can find that here!

Wed, May 1 3:12pm · Calling our Arizona members living alone with Mild Cognitive Impairment! in Living with Mild Cognitive Impairment (MCI)

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Back in May of 2018, I posted an article about living alone with MCI. I wanted to revisit this issue again as I’m a provider at Mayo Clinic in Arizona and collaborating with a colleague at Arizona Status University, Dr. David Coon, on the topic. Dr. Coon is leading focus groups to better understand the needs of our patients living alone with MCI, and I wanted to give all our Arizona followers an opportunity to be involved if interested. Our ultimate goal is to revise our existing interventions or develop new ones to better meet your needs. So, if you are in the Phoenix area (or surrounding communities like Scottsdale, Cave Creek, Glendale, Peoria, Chandler, Tempe, etc.) and living alone with MCI (even if you have outside support), we hope we can get your point of view. Dr. Coon will be conducting focus groups sometime in the next couple of months. If you are interested, please call the ASU coordinator at 602-496-1239! You can also review this flyer for more information.

Tue, Mar 26 8:00am · NPR story: Alzheimer's Screening Often Left Out of Seniors Wellness Exams in Living with Mild Cognitive Impairment (MCI)

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This week, I want to highlight a news story on NPR a couple of weeks ago on the role of cognitive screening in primary care. Medicare covers an Annual Wellness Visit and one of the components of this type of visit is “Screen for cognitive impairment, including diseases such as Alzheimer’s and other forms of dementia”. The NPR story highlights that this often is not being done in the wellness visit and discusses some of the reasons why. I hope by helping bring awareness to this issue, you can help your physician by speaking up and asking for this aspect of your wellness exam.

 

 

 

 

Wed, Feb 27 6:05am · Getting Tough on False Claims About Supplements in Living with Mild Cognitive Impairment (MCI)

@drmelaniechandler Thank you for this! I really like the link to the review of alternative treatments on the Alzheimer's Association website. It was helpful to read their analysis of specific supplements.