How to Treat Mild Cognitive Impairment

00:00:00,"Well, hello there everyone. I'm Dr. Leslie Kernisan, board certified geriatrician and the founder of the website, Better Health While Aging dot net. And this is the Better Health While Aging video podcast where we discuss common health problems that affect people over age 60 and the best ways to prevent and manage those problems. We also often address common concerns and dilemmas that come up with aging parents and other older loved ones like what to do if you're worried about falls or

safety or memory," 00:00:26,"or even the quality of an older person's healthcare. So in this episode, I am going to talk more about Brain House. Specifically I am going to talk about mild cognitive impairment, also commonly abbreviated as NCI. Now, in a recent episode, I covered what I believe are the most important and effective ways to maintain brain health and aging. And I mentioned that those approaches tend to work best in people who have not yet started to experience memory loss or other

signs of abnormal decline." 00:00:58,"So that other video was really about how to promote brain health and how to maintain brain health so as to prevent or delay cognitive decline. But what if you or someone you know, actually are starting to experience some memory loss or some other signs that are concerning you about your brain health? In that case, it's possible that you've been diagnosed with a condition called mild cognitive impairment." 00:01:22,"And so you might be wondering what can be d

one to treat it or what can otherwise be done to maintain your brain health. In fact, I find that people often ask me these types of questions about mild cognitive impairment. I get asked, what can be done if an older person has been diagnosed with this condition? And just as a note, this condition is also technically known as minor neurocognitive disorder." 00:01:48,"Can MCI be reversed? How can it be treated to preserve memory and brain health? And although I don't get asked this question a lo

t, I think it's a really important one to consider and talk about, which is, what are the scientifically tested and proven approaches to optimizing brain health when there is a diagnosis of MCI? So that's what I'm planning to cover in this episode of the video podcast." 00:02:14,"And so before I get into answering those frequently asked questions, let's start with what exactly is mild cognitive impairment just to make sure we're all on the same page. Now, I recorded a while back a video that is

about MCI versus dementia versus Alzheimer's that kind of goes into depth about the relationship between those conditions and how we define them, how we distinguish them." 00:02:37,"So if you wanna know about this in depth, I highly recommend you check out that video as well. But briefly, MCI means having these things be true. So first of all, that the person has an objective, abnormal decline in memory or in some other aspect of thinking, but it's most common for it to be memory. So it's also c

alled amnestic," 00:02:57,"MCI. And by an objective decline, I mean that, you know, on cognitive testing, we would see results that are worse than expected for the person's age and level of education. However, that decline should not be bad enough to interfere with independence in daily life activities. So daily life activities like doing the finances or grocery shopping or planning and preparing," 00:03:24,"you know, a meal, it might be harder for the person to do that than usual, but it should

still be possible even if it takes them a little bit more effort or a little bit more time. And then the third condition that needs to be true is that the cognitive issues should not be due to delirium or a major mental illness. So delirium is the condition of becoming confused or developing worse than usual mental function when you're very sick or under a lot of physical stress." 00:03:56,"And so that happens especially to older people when they're hospitalized or after surgery. But it can hap

pen to younger people actually, if they're sick enough. And it can happen to some older people, even if they're not in the hospital. And in particular, people with Alzheimer's or other forms of dementia are especially prone to develop delirium pretty easily. So to have MCI," 00:04:18,"those three conditions that I listed there must be true. And so it's important to know that MCI is, it's a syndrome. I mean it's a diagnosis, but it's a syndrome, meaning that it's a collection of symptoms. We see

those three things be true and it can be caused by several underlying issues that create that kind of syndrome that we see externally." 00:04:44,"So you may be wondering, now is MCI common? And one very good study that gave us some statistics on that fairly recently was the 2016 Health and Retirement study. They had a subsection called the Harmonized Cognitive Assessment Protocol Project. So what they did is they took a random sample of about 3,500 older adults who were 65 and older and put them

through some pretty extensive cognitive testing." 00:05:13,"And so what they found was the prevalence of mild cognitive impairment and they broke it down by age was for age 65 to 69, 20 2% in the seventies, early seventies, 20%, 75 to 79, 20 1%, 80 to 84, 20 5%, and then 85 to 89 was 22%. So what's interesting about this is that first of all, it's about, you know, one person in five," 00:05:37,"and that is supposed to be, you know, nationally representative sample of the United States. And what

's also interesting is that it's about the same at these different levels as people get older until you get to 90 plus where it goes up a bit to 27%. And I consider this a really good data set. The health and retirement study is a very well established," 00:05:59,"longtime longitudinal nationally representative study. They enroll people and then keep checking in with them every few years, and then they do occasional additional projects. And in 2016, this was the project that they did, and this d

ata was published just a few years ago. Now, in case you're wondering, they also tested for dementia. So basically they cognitively assess people and then determined whether they were normal," 00:06:24,"whether they had mild cognitive impairment or whether they had dementia. And one of the big differentiators between mod cognitive impairment and dementia is whether the memory problems or other problems are bad enough to interfere with activities in daily life or with, you know, independence. So

what they found in terms of the prevalence of dementia, I'll list right here. And so that one really for people in their late sixties is 3%." 00:06:48,"And then once people get into their nineties, goes up to 35%. So there they, you know, we really see it going up as people get older, which I think is actually what we would expect. So in short, mild cognitive impairment is pretty common. And so if you've had this diagnosis, you're not alone. Lots of people are in this situation as well." 00:07:0

8,"Now another question that people sometimes ask me is, is MCI related to Alzheimer's and other forms of dementia? So this really depends, first of all, on the underlying cause of the MCI symptoms. But it's true that MCI can be an intermediate stage between normal cognition and dementia because the nature of developing dementia, whether it's due to underlying Alzheimer's disease or actually as people get into their eighties," 00:07:37,"what's most common is that people have mixed dementia where

they have Alzheimer's changes in the brain, but also other forms of door degeneration as well, such as small vessel vascular disease or Lewy body disease. But in most cases, when people are developing dementia, their brains change very slowly. So in short, mild cognitive impairment is pretty common. And so if you've had this diagnosis," 00:08:02,"you're not alone. And it's also true that Alzheimer's is the most common underlying cause of abnormal memory and thinking issues, and it is the most c

ommon cause of dementia. But that said, not all mild cognitive impairment is due to neurodegeneration or other forms of permanent brain changes. So when somebody has mild cognitive impairment in a normal clinical setting, we don't necessarily know whether that's the very beginning of Alzheimer's disease or another form of dementia versus something else that might get better." 00:08:36,"And I'm going to talk more about how many people get better in a moment. But I also wanna speak to the fact tha

t some of you may be watching and you haven't actually gotten a diagnosis or you're not sure. So what should you do if you suspect that you or somebody you care about might have MCI? The most important thing to know is that I would say any older adult who is concerned about memory or thinking should get an evaluation for cognitive impairment," 00:09:04,"you really need a medical evaluation. And that's for a couple reasons. First of all, it's important to get objective confirmation of the memory

or thinking problems. And in the doctor's office, even the primary care doctor's office, it's usually possible to do a shorter cognitive assessment. Something that takes, you know, 10 to 15 minutes like the Montreal Cognitive Assessment or the slums test that can do," 00:09:27,"you know, an initial check to, to see if the thinking seems to be off. And then if that seems normal, it can be possible to get some more detailed testing such as neuropsychological testing. But you wanna get objective co

nfirmation because there are quite a number of people who feel like their memory has gotten worse. And in all honesty, it's almost certainly worse than when you were 30." 00:09:49,"That's just the nature of aging. But it may not be as bad as you're concerned that it is, and you partly find that out through getting a little bit of objective testing. The other reason why it's really important to go get that medical evaluation is that it's really essential to be checked for common causes of cogniti

ve impairment because many of those causes can be treated or potentially modified." 00:10:14,"And so if you wanna know more about what are some really common causes of of cognitive impairment, so of memory or thinking, getting worse in an older person, I have a video that's about that, the top 10 causes of cognitive impairment and what the doctors need to check. And I go through many of the things that, you know, we would check for in geriatrics," 00:10:32,"you know, including medications, delir

ium, you know, thyroid. There's a, a whole list of things that we would consider and and be trying to check for and see if we could manage. So these are the things that are really important to do if you suspect mild cognitive impairment. And I also wanna acknowledge that just in the past few years, there have been some important new developments in mild cognitive impairment evaluation." 00:10:59,"And that is related to the known fact that a certain number of people with MCI are having the very e

arliest clinical signs of underlying Alzheimer's disease. So since that is true, it has raised the question of should we be checking for biomarker signs of Alzheimer's disease? Because we do have ways to do this. So what we've known for quite a while is that when people are developing Alzheimer's," 00:11:23,"they start to develop brain changes, namely amyloid deposition and certain kinds of plaques and tangles in the brain and some other changes that starts to happen at least 10 years before the

re are obvious symptoms. It's probably more like 15 to 20 years in most people. And so we can't tell in the doctor's office very easily if that's happening with someone. But we do now have special methods that can identify amyloid and also the tau protein." 00:11:51,"There are special PET scans, there are FDG scans, which are about, you know, how your brain uptakes glucose throughout the brain. There are spinal taps that can check the cerebral spinal fluid. There's even now, fairly recently, a b

lood-based test that some people think, you know, is, is valid enough. So researchers have been using that for quite a while again," 00:12:15,"and it's through that, that we know that the signs of Alzheimer's appear in the brain at least 10 to 15 years prior to developing. And there is recently this, you know, blood biomarker that's being considered. So that being said, doctors in routine practice have not usually checked for Alzheimer's biomarkers until very recently. This has just been availab

le in the research setting." 00:12:37,"Now, one of the things I'm going to talk about later in this episode is the fact that there are these newer anti-amyloid drugs for Alzheimer's that first, you know, got approved in, the first one was approved in 2021. So because of that, this is potentially going to change the way we routinely evaluate mild cognitive impairment. But I think it has not yet come to the average doctor's office." 00:13:02,"I'm not sure how long it will take, and we can talk mor

e about that a little later in, in the episode. So for now, I'm guessing that many of you'll be experiencing what I consider, you know, the usual MCI situation, which is that most older adults are diagnosed with mild cognitive impairment, either by their primary care provider or by neurology occasionally in a special memory clinic." 00:13:24,"And you know, in general, the norm is that the basic evaluation should check for common causes of cognitive impairment, especially looking for those revers

ible causes or you know, dementia mimics and any potentially reversible causes that are not neurodegenerative should be treated. So things like medication side effects, hypothyroidism, low vitamin B12 and so forth. So now if a person is diagnosed with mod cognitive impairment," 00:13:52,"what are the goals of treating it? And this is relevant because when we look at the research and what has been scientifically tested, we should know what kinds of outcomes and goals they were helping for. So gen

erally the hopes have been, you know, one, can we reverse this, right? Can we get it to go away so that the person resumes having normal cognitive function for their age and education level?" 00:14:14,"Next best would be, you know, can we stabilize the person and keep them that way for as long as possible, keep their cognition from declining. And then, you know, third would be can we delay the progression to dementia? Are there treatments where instead of potentially getting worse and having som

ething become dementia in, you know, say two to five years," 00:14:35,"it takes more like 10 to 15 years. Those have been some of the questions that researchers have asked when they have studied treatments for mild cognitive impairment. Because what happens if you don't treat mild cognitive impairment? So it's important to know that it is not a sentence of you're going to get Alzheimer's and and dementia. Now it's true that a certain number of those people do progress to dementia." 00:15:01,"And

so the American Academy of Neurology did a meta-analysis that they published in 2018. They did it as part of publishing a practice parameter with best practices for the evaluation and management of my cogniti of impairment. And per their meta-analysis, they found that 14.9% of people progressed to dementia within two years. So, you know, that's 85% of people not developing dementia within two years." 00:15:32,"And then also, you know, within the related studies that they surveyed, depending on

the study, they found that about, you know, 14% to 38% of people reverted to normal cognition on follow up. But some of those people who went back to normal later on in their life did develop dementia. And so it seems that it does increase the risk at least," 00:15:51,"you know, lifetime of developing dementia. Although I would also say people who are lucky enough to live a very long time, it can be hard to avoid, you know, not having your brain changing at least a little bit. And what were the

risk factors for progression? So, you know, a pretty strong one is age. People who are older are more likely to progress." 00:16:10,"Also in some studies they check for amyloid on the brain PET scans. So people who had amyloid deposition, which again is quite suggestive of underlying Alzheimer's disease, were more likely to progress eventually. And also people who had significant cerebral small vessel disease. So that's also called white matter lesions. You get little spots on the brain scan. Th

ey're basically little bitty scars throughout the brain," 00:16:36,"often related to the health of the very small vessels in the brain, sometimes related to other things. And when people have a lot of those changes that can potentially lead to vascular dementia. So that was also seen as a, a risk fastener for progression if people had lots of signs of cerebral small vessel disease on MRI. So that is what we know of the prognosis of untreated MCI." 00:16:59,"So most people who are given this diag

nosis, you know, are going to be interested in treatment or what can be done to help improve their odds of recovering, of getting better or of stabilizing. And so let me know, talk about the types of treatments that are available and based on the way the research has been done, I sort of think of them in three main buckets right now." 00:17:22,"First of all, there are single interventions. This is when the researchers studied like one particular thing, like giving people a supplement or having t

hem exercise or, you know, changing their diet. Then there are what we call multi-domain interventions. That's when people are given a package of things to do to support their brain health and help their brain recover. And then there are Alzheimer's specific interventions which are designed to interrupt the," 00:17:55,"the process that's specifically associated with Alzheimer's, especially related to amyloid or to other processes related to Alzheimer's. So I'm gonna talk a little bit more now ab

out what the research shows in terms of these effectiveness, but I will say that generally treatment seems to work less well as people get older or frailer. And I think that is because, you know, ultimately when MCI resolves to normal cognition," 00:18:20,"it's basically about the brain, you know, healing itself and that underlying ability of the body cells and organs to heal gets worse as people get, you know, much older and much frail. Even though every now and then we see somebody who's quite

old and frail make an amazing recovery. Some people have, you know, that ability and it's always wonderful when we see it." 00:18:40,"But in general, part of aging is that it's harder to recover from things. So what MCI treatments have the best evidence? There's lots of stuff out there, you know, I see the ads, you know, that promise to, you know, fix memory and and, and change mild cognitive impairment or sometimes they're even promising to change Alzheimer's. But you know what's actually been

studied and shown to make a difference and probably the thing that has," 00:19:08,"you know, the, is most likely to be effective is exercise. That was the conclusion of the American Academy of Neurology after they reviewed a lot of research a few years ago. And specifically they said that six month studies suggest a possible benefit of twice weekly exercise for cognition in mild cognitive impairment. Now it's still being debated, you know, what kind of exercise specifically?" 00:19:32,"Is it mo

re resistance? Is it more endurance? You know, my advice would be to make sure you do, you know, all the types of exercise that are recommended for older adults, strength training, endurance, also known as cardio and also balance and flexibility are are helpful too. And then there's another potential treatment of sorts, which I think is very promising." 00:19:53,"It wasn't, I think particularly mentioned in the American Academy of Neurology report, but there's been like more interest in it recen

tly, which is treating hearing loss. So for quite a while we've been aware of an association between untreated hearing loss and people's memory and thinking getting worse. So what's now being researched is whether, you know, giving people the hearing aids or otherwise correcting the hearing loss," 00:20:17,"whether that changes the trajectory. And so we're still waiting on the results of those randomized trials, but generally it's quite promising. And there certainly have been observational stud

ies where people with MCI, you know, the ones who get hearing aids or get their hearing corrected seem to do better. So you know, more to be confirmed as the research comes in. But I think this is a very promising approach and it's definitely something that I would recommend for anybody who is dealing with mild cognitive impairment is that they consider treating," 00:20:49,"checking for hearing loss and treating it. And then the thing you should know is that many other MCI treatments have inconc

lusive evidence. So a number of things have been studied in randomized trials and often the evidence is either mixed. So that means that some studies find an effect and similar studies don't, or it's weak meaning, you know, no effect or very small," 00:21:10,"you know, effect or the studies that were done weren't very good. And some of the other single interventions that have been studied include dietary changes, vitamin D and other supplements, anti-inflammatory drugs, intranasal insulin and mo

re. Now you may be wondering, well what about medications? Isn't there a medication that can treat mild cognitive impairments or, you know, help preserve memory?" 00:21:34,"Well this has also been studied extensively and in particular the medications that were FDA approved years ago for Alzheimer's and dementia have also been studied for mild cognitive impairment. Now there are essentially two main types of medication that we've had available to treat Alzheimer's and other forms of dementia for

the past several years. So one type of medication is called a colon tase inhibitor. So these help boost the effect of acetylcholine," 00:22:01,"that neurotransmitter in the brain and body. And so the cholinesterase inhibitors, because cholinesterase breaks down acetylcholine, so a cholinesterase inhibitor prevents the cholinesterase from breaking down the acetylcholine. But the, the medications that you may have heard of are medications like donepezil, rivastigmine, and galantamine. The brand na

mes are Aricept, Exelon and Rasine. And then there's another type of medication for dementia," 00:22:30,"which is memantine. The brand name is Nanda, which has a different mechanism of action. So these medications were studied quite extensively by the pharma companies who wanted to find an effect so that they could also get FDA approval from mild cognitive impairment. But they were not able to show in their randomized trials that these medications prevented MCI from progressing to dementia. The

the best they were able to show is," 00:22:57,"you know, that maybe for some people the cholinesterase inhibitors, you know, reduced certain symptoms temporarily. So based on that, here is what the expert guidance says in that American Academy of Neurology practice parameter from 2018, they wrote, for patients diagnosed with MCI clinicians should counsel the patients and families that there are no pharmacologic or dietary agents currently shown to have symptomatic cognitive benefit in MCI and th

at no medications are FDA approved for this purpose." 00:23:30,"They also say that for patients diagnosed with MCI, clinicians may choose to not offer cholinesterase inhibitors. And then they say that if clinicians choose to offer cholinesterase inhibitors, they must first discuss with patients the fact that this is an off-label prescription, not currently backed by empirical evidence. So that is supposedly the best practice. Now in real life, you know, people who have mild cognitive impairment

are often prescribed either something like donepezil or even I see them prescribed memantine as well." 00:24:04,"You know, I've seen neurologists doing this, I've seen, you know, primary care providers doing this. I'm not sure if the memory clinics are doing this and I don't know that people are always given all the the information. I think often people wanna take something if there's any possibility it might help. And providers have often felt like they don't have much else to offer and they wa

nna offer something." 00:24:24,"And it's true that these medications are usually well tolerated and not, you know, particularly risky as far as as we can tell. But that is what the expert guidance says. So that's the evidence really on, you know, the single treatments for mod cognitive impairment. Now what about multi-domain treatments? You know, so again, these are kind of packages that address lots of things that affect the brain." 00:24:50,"How well do those work for mod cognitive impairment?

And the answer right now is we're not really sure. Now, these types of multi-domain interventions have seemed, they have especially been studied in older adults who are considered at high risk for dementia, either based on their risk factors or on family history of Alzheimer's or another dementia. And often those older adults do not have MCI," 00:25:13,"although sometimes the way they include people is just to make sure they don't actually have dementia. And some of those trials have been promi

sing. You know, the landmark one, the first big one was called Finger Finish Geriatric Intervention Study to prevent cognitive Impairment and disability. It was published in 2015 and that studied offering people a combination of diet advice, exercise, cognitive training and vascular risk monitoring." 00:25:38,"So helping people with their blood pressure, their cholesterol, and other cardiovascular risks. And they found that within a few years the people who had gotten the package, you know, had

less cognitive decline than the control group. And that was exciting, you know, to to see. So since then, you know, there have been some similar studies, some of which have studied people either at very high risk of mild cognitive impairment or who had mild cognitive impairment." 00:26:05,"And I think it's a little too soon to know whether this will work or not. And also the challenge here is that by definition, you know, multi-domain, a package of interventions can be different from study to st

udy or maybe even from individual to individual. So one study was called mapped multi-domain Alzheimer's prevention trial and it found no effect in older adults with memory complaints." 00:26:30,"There have also been studies of just trying to reduce vascular risk factors in people with MCI or who are at high risk. And those don't seem to be particularly effective either for preserving cognition. When we work on people's vascular risk factors, we generally do see fewer strokes and heart attacks a

nd, and often deaths as well. So it works for that part. And," 00:26:52,"but there was a smaller recent study published in 2023, which found that cognition did improve in older adults who got a combination of exercise and computerized cognitive training. Now, what was interesting about this study is that they also included vitamin D as a factor. So some people got vitamin D and some people didn't get a vitamin D supplement and the vitamin D didn't seem to make a difference at all." 00:27:15,"Now

speaking of cognitive training, which is sometimes included in these packages of treatment, what about cognitive training? So, so cognitive training usually refers to, it's often nowadays done with computers, you know, these computerized tasks or they're sometimes referred to as brain games that force your brain to work a certain skill or to practice a certain skill or, you know," 00:27:38,"hopefully improve a certain skill. So various forms of cognitive training have been studied and they're u

sually small studies and often they do find a small cognitive improvement, especially of the skill that was trained. But it's of unclear long-term effect and sometimes of unclear overall effect. And so far, you know, it is totally possible to find some, some small studies that you know," 00:28:00,"get a positive result. Those are often reported in the media, it's just unclear when you look at all the studies together, how much there is there. And it's tricky too because you know, again, there's

a lot of variability and what kind of training program is used. Some studies also combine it with exercise. So teasing apart those two or maybe it's really that they work when they're done together," 00:28:24,"we're still trying to find that out. And then the other challenge about this, if you're interested in pursuing this, this type of therapy for yourself or someone else, is that if you're not in a research study, it can be pretty hard to access a good quality cognitive training program. So m

y conclusion is that I'm not sure it's worth the time and effort to be doing computerized training unless you actually are in a trial and likely to get," 00:28:52,"you know, a really high quality program. Now let me talk about another thing that people have asked me about when it comes to mild cognitive impairment. And that is something that is sometimes called the bresin protocol. So this is a functional medicine approach to treating mod cognitive impairment and Alzheimer's, which was described

in the book the End of Alzheimer's, which was written by Dr. Dale" 00:29:15,"Bison. He's an md, a neurologist, and after spending many years working in the lab on neurons and sort of studying the way Alzheimer's develops, he became interested in the functional medicine approach and applied it to MCI and Alzheimer's and, and described a protocol. So functional medicine in general is what I think one could call, you know, an integrative type of medicine or you know," 00:29:43,"some might call it

alternative medicine that uses a very holistic approach. And there are, their philosophy is that you wanna sort of find the underlying root causes of people's symptoms and health problems and correct those underlying root causes. And often there are several of them, so often they end up evaluating and then treating things that are related to nutrition and nutrients in the body," 00:30:07,"inflammation, stress, gut health, mental health, metabolic health and toxins. And I think actually there's a

lot to be said for this approach, functional medicine, the functional medicine critique of more traditional, you know, medicine is often that what we traditionally do in medicine is people have a health problem, it's a symptom and we just treat the symptom, you know," 00:30:30,"usually with a medication or with a procedure or hospitalization, we don't treat the underlying causes. And I think there's, I think that's actually an extremely valid critique. And I think there is definitely something

to be said for looking to the underlying causes and, and treating those. The question is whether, how likely is this to work in older adults who have developed memory loss or other thinking issues and qualify for a diagnosis of mild cognitive impairment or either dementia there," 00:31:02,"we don't really know. So the other thing about functional medicine is that since it doesn't really fall within mainstream medicine, at least not yet often, many of the tests they wanna do are not covered by in

surance. And so to pursue something like the Bredesen protocol often requires an extensive and pretty expensive initial evaluation. And then that's followed by an extensive and personalized treatment plan." 00:31:25,"So they very much believe in, you know, studying lots of things about the person and then creating a personalized plan that is crafted to help the patient correct the underlying, you know, deficiencies and problems that they have identified. So Dr. Bredesen has been claiming these p

ast few years to have reversed mod cognitive impairment in Alzheimer's in certain cases through this approach." 00:31:49,"But what you should know is that his approach and the research he has published are not currently accepted as entirely credible by many academic experts in Alzheimer's and in in dementia. Now, the reasons for this, I think are beyond the scope of this video, but what I will do is on the podcast show notes page for this episode, I'm going to post some links to some of the rese

arch articles that I've cited." 00:32:17,"And so I'll also post a few links to some of the critiques that have been written about his, his work and his research. So my own take is that this is, I think this is a very intriguing approach and I think, you know, the, the underlying idea that if people have developed mild cognitive impairment or even Alzheimer's disease, you know," 00:32:39,"there are a lot of underlying contributors and we probably can't meaningfully treat it by treating only one c

ontributor. You probably do need that multi-pronged approach and something that supports the body in healing itself. So I think this is an interesting approach and it needs more research, more good research because we still know very little about, you know, if you took 500 people with my kind of impairment and put them through this process," 00:33:09,"how many would improve? That question has not, you know, been, been addressed in Dr. Breen's research. I think also it's important to know that th

e, the extensive personalized treatment plans are often very labor intensive, potentially also, you know, financially expensive to buy all the supplements and do the therapies. And I think they can be very hard for the average older person to implement unless they're extremely motivated," 00:33:38,"have a lot of support and possibly have enough money as as well. Lastly, I've looked at some of Dr. Bredesen's, you know, so he has especially published case reports, reports of, you know, one person

who got better or of a collection of people who got better. And mostly what I notice is that often the patients aren't particularly old and the ones who are older seem to have results that are not as strong and effective as the younger ones." 00:34:05,"Moving on to other treatments to know about. So nuisance 2021 are anti amyloid treatments for Alzheimer's. So you may have heard about these, these are the antiamyloid antibodies that are designed to slow down Alzheimer's disease. Now the thing ab

out these is that these are not simple medications to take. They require IV infusions, I think it's about once a month, and then they require a lot of monitoring for complications which have included brain swelling and micro hemorrhages." 00:34:39,"So it's, it's not trivial. Also, although they were FDA approved, the approval of the first one was controversial. A lot of research scientists felt like there was not enough evidence that it effectively treats Alzheimer's and the clinical effect on s

lowing cognitive decline appears to be small. So the second one of these medications, you know, people were followed for 18 months and people who got the anti amyloid antibodies still declined just not as much as the people who didn't get it." 00:35:11,"So it's not like these treatments, you know, stop Alzheimer's in its tracks or reverse it. And so, so far two of these anti amyloid antibody medications have been approved. The first was Aducanumab ADU helm, it was approved in 2021. That approval

again was controversial. And actually just recently in 2024 the distributor Biogen announced that they were going to voluntarily withdraw it from the United States." 00:35:39,"So it's expected to, I think people who are currently getting it or in a trial are going to be able to finish, but it's basically being taken off the market. And then there's another one, Lecan Le Cambi, which was approved in 2023. And so with these new medications, the issue has been, you know, is Medicare going to cover

them?" 00:36:00,"They both had pretty substantial sticker prices in the tens of thousands of dollars per year, I think, I think at least 30,000, I'm blanking, you know, right now. And so, you know, there's just been a lot of work with Medicare because also Medicare doesn't usually cover the initial tests to diagnose, you know, and confirm that there's amyloid and Alzheimer's in people who have mild cognitive impairment." 00:36:28,"So this is an area of active evolution as of July, 2023, Medicar

e had said that for kinumab, you know, patients would be eligible if they were participating in a qualifying registry with an appropriate clinical team and if they had, you know, follow-up care. So for the time being not something that you can just walk into your PCPs office and get signed up for and," 00:36:52,"and maybe that's just as well since it's a pretty expensive medicine that you know is pretty involved to take. So if you're interested in this route, what you need to know is that, first

of all, it's only an option if you get it confirmed that the mod cognitive impairment is due to Alzheimer's. So basically the person has amyloid plaques in their brain and," 00:37:15,"and so if you do meet that criteria, you should ask yourself, you know, is this worth doing? So, you know, what are the, the benefits as far as we know, and then the burdens and the risks. So the benefit was that we know that over 18 months, lecan map slowed but did not stop a reverse cognitive decline." 00:37:34,

"And the impact beyond that is still to be determined. The burdens, it's expensive, it requires a lot of testing and monitoring the risks. 26% of the participants in the phase three trial had infusion related reactions and 12% of them, or 12.6% had amyloid related imaging abnormalities. So something that was kind of wonky on their follow-up brain scans, whether that was a little bit of swelling or a little bit of bleeding." 00:38:02,"Now most of those 12% didn't get symptoms and you know, what t

hey experienced was not serious but some small percentage, you know, had more significant complications. And either way, you know, it's a lot of monitoring and potentially a certain amount of worry if you fall into that 12%. So if this is a route you're interested in, I would just encourage you to talk with your providers and try to get as much information as possible to make an informed decision." 00:38:34,"So that is what we kind of know so far in terms of, you know, what the research has show

n us about treating mild cognitive impairment. So let me now talk a little bit about how I, you know, would treat it these days. So for me, I especially focus on, you know, first of all, reducing or stopping medications and substances that slow down brain function." 00:38:56,"I mean that's something that almost all geriatricians do because almost all of our patients, you know, benefit from an effort to help their brains function the best they can. Whether they have a diagnosis of mild cognitive

impairment or dementia or you know, are thought to be a normal, you know, person in their eighties or nineties. So we all do that and again," 00:39:16,"if you wanna learn more about the types of medicines that we look out for and stop, I have a couple videos about that. And then I would especially encourage treatment of hearing loss for somebody who has mod cognitive impairment, I often am checking and treating vitamin B12 deficiency super common in older adults. And then I really lean on promot

ing, you know, exercise," 00:39:37,"social engagement, cognitive engagement and then on assessing and trying to treat any issues that come up related to stress, mood, and sleep. Because again, the brain does better when it's experiencing not too much stress when it's not too emotionally distressed and when people are able to sleep better if possible. And for managing those things, I think it's really good to look into non-drug methods." 00:40:05,"There can be a role for medication, especially wh

en it comes to depression, but there are often non-drug methods that can be very effective and otherwise beneficial to people's health. Physical health and emotional wellbeing when it comes to managing stress or reducing it, managing anxiety and emotional wellbeing and managing sleep. And then also for sleep. You know, if an older person is having sleep difficulties," 00:40:34,"we always wanna evaluate and make sure there's not a medical problem, something like sleep apnea or other medical probl

ems that are contributing to their sleep difficulties. And so especially for depression, it can, you know, it's can certainly be reasonable to try an antidepressant, but I think it's really important to try to incorporate also therapy and other non-drug modalities. And in particular," 00:40:58,"a lot of people who have mild cognitive impairment or anxious, they may be anxious about the state of their brain or it can otherwise be associated with anxiety for other reasons. And so there, you know,

therapy to help manage that anxiety, uncertainty, worry, it can be very stressful to have gotten this kind of diagnosis. I think the therapy can be very helpful." 00:41:20,"Mindfulness practices and relaxation practices can be very helpful as well. And then especially for the ones who, so these are less likely to be my personal patients, the young old. So geriatrics, we often, you know, the young oldest people kind of 65 to 75, you know, the middle old is 75 to 85 and the older old are 85 plus."

00:41:41,"So especially for the young old cardiovascular risk management, you know, trying to get, you know, blood pressure, lower cholesterol, it's really not clear as people get older that that makes as much of a difference when it comes to the brain health. But certainly in the young old, I would be thinking about that as well. And then it goes without saying that," 00:42:00,"you know, initially when people are first diagnosed, I'm, you know, or when we're doing that evaluation or if somebod

y transfers into my practice and has been diagnosed with mod cognitive impairment, I'm double checking to make sure we've looked into those other common causes, medical causes that can worsen brain function in older adults. Lastly, optional for treatment is to see if symptoms improve with diet," 00:42:23,"diet changes, it has not really even shown in bigger trials that changing diet seems to protect cognition that much, at least when they randomize people. There's lots of observational trials sh

owing that eating a certain way is associated with better brain health, but when they've actually randomized people it's been a little harder to prove. But if the older person is willing to try changing their diet to try cutting down on sugar or try reducing carbs or maybe even going," 00:42:50,"you know, no carb for for a bit or some people wanna try the kind of full on anti-inflammatory diets where you really restrict it down to, to very few foods and then slowly start adding foods back. I kno

w some people whose joint pain gets better when they stop eating certain kinds of food. So I think that is a sign of less inflammation and if it's affecting the joints it could be affecting the brain." 00:43:16,"So if people are motivated and wanna try that, then that's an option too. And then, you know, there's also like what I do over a few years or what I would recommend when people have mild cognitive impairment. So I think it's important to keep monitoring the cognitive status to see if it

improves, stays the same or worsens. So not that we have to be doing," 00:43:35,"you know, a brain test every day, but probably about every six months, right? Having a little check-in about whether things seem to be better, same or worse. And then I personally am also often, you know, thinking like, are we seeing any signs of what's called mild behavioral impairment? So these are kind of unusual behaviors or you could even call them mental health signs that are sometimes associated with brain ch

anges." 00:44:01,"So they can include things like apathy, so kind of loss of motivation to do things, depression, anxiety, delusions, believing things that are not, that most other people don't believe are true hallucinations, seeing or hearing things that are not there. Agitation, being restless, revved up or disinhibition when people are doing things or saying things that seem kind of inappropriate and kind of not the way they used to be." 00:44:27,"So keeping an eye out for that, you know, an

d that's partly to be aware of it and also to try to support the older person and their family if those issues, you know, come up. And then there's continuing to encourage healthy lifestyle measures, especially you know, exercising, you know, social engagement, cognitive engagement, doing things that you enjoy," 00:44:51,"you know, enough, relaxing, those kinds of things. And then we wanna be careful about hospitalizations, which can provoke delirium. And if you have to be hospitalized, let's sa

y for a joint surgery or something elective, I think it can be a really good idea to choose a hospital that has a delirium prevention program or something called an acute care for elders unit," 00:45:11,"if possible. Last but not least, I think it's optional, but a good idea to take this as an opportunity to do some advanced planning, right? To look into the future and to start planning for a time when a family member or someone else might, you know, need to be more involved to support the, the

older person or even encouraging somebody to be involved to have a partner in the healthcare journey." 00:45:35,"So this is a good time to revisit powers of attorney. Do you have one for healthcare, for general affairs? You know, I think that's a, that's a good time to do that. So let me know. Talk about a couple common MCI pitfalls that I've seen a lot of older adults and you know, a lot of families have described these to me as happening." 00:45:54,"So one pitfall is to worry too much about th

e future. And I get it, you know, they say, I think there was one study where they kind of interviewed people to find out their experience with being diagnosed with mild cognitive impairment and there were some people who kind of had barely registered and they hardly changed anything they were doing afterwards, but then there were the ones who got very," 00:46:16,"very worried about it. And it's understandable to be worried if you learn more about it and to start thinking, what if it gets worse?

What if it doesn't get better? What if my life changes? So it's understandable, but the truth is that it doesn't help the brain. So worry is hard and can improve, especially if you get the support of therapy and certain structured methods to learn to manage that anxiety and worry more effectively." 00:46:43,"So for anyone who's doing worrying, I, I would really encourage, you know, non-drug anxiety management techniques and getting outside and exercising is, you know, actually part of that can

really help with that as well. Getting the treat the hearing treated if applicable is also a good idea. If nothing else, it makes it easier usually to socialize. And then there's the people who take no action at all." 00:47:07,"And I think that's a little too bad because an MCI diagnosis is a great opportunity to consider improving your brain health lifestyle unless you're quite frail or chronically ill. Or just to think about, you know, life. None of us know what lies ahead in life. Am I sort o

f taking full advantage of my life right now? You know, what else would I," 00:47:27,"how would I like to dream? What would I like to do? You know, there's an opportunity there as well. And then there's also just the issue of incorrect diagnosis. So by definition, MCI impairments should not interfere with independence and daily life activities. And if I had a dollar for every family who described, you know, an older relative who was no longer able to manage their finances or the grocery shopping

or you know," 00:47:50,"clearly had lost independence in some day life activity, but then is still getting the diagnosis of mild cognitive impairment from the providers, I'd be a lot wealthier. Yeah. So I, I do see that coming up quite a lot. So the truth is, if independence has been lost for a while, we might be dealing with dementia rather than than MCI," 00:48:11,"not necessarily but a possibility. And so that is something that I see come up. So that's really the bulk of what I had to share

about MCI today. So just to summarize kind of my final recommendations, if you're concerned about this, make sure you've had an adequate evaluation, get help treating any underlying causes or contributors. Focus on exercise, treating," 00:48:31,"hearing loss, social and cognitive engagement, minimize medications that slow the brain and also other substances that slow the brain like alcohol, cannabis. I would minimize all of those. If you can look into non-drug methods to treat anxiety, stress, s

leep, or low mood, consider medication for depression or any other conditions as needed. And then consider looking for a clinical trial to access some kind of treatment," 00:48:57,"especially one of these like promising multi-domain intervention type of things. And consider advanced planning, including powers of attorney for health and general affairs. So end with that. Thank you so much for watching and good luck if you have been diagnosed with MCI also, if you have found this video podcast hel

pful, if you're here on YouTube, please go ahead and subscribe." 00:49:18,"It really helps more people find the channel. If you have been listening to the audio version on the podcast feed, please come and take a look at the video. If you get a chance, you'll see my key points being displayed on the screen and my smiling face. So thank you once again. I look forward to seeing you all again on a future episode of the Better Health While Aging video podcast."