Mental Health

Alzheimer’s Drug Targets People With Mild Cognitive Impairment. What Does That Mean?

The approval of a controversial new drug for Alzheimer’s disease, Aduhelm, is shining a spotlight on mild cognitive impairment — problems with memory, attention, language or other cognitive tasks that exceed changes expected with normal aging.

After initially indicating that Aduhelm could be prescribed to anyone with dementia, the Food and Drug Administration now specifies that the prescription drug be given to individuals with mild cognitive impairment or early-stage Alzheimer’s, the groups in which the medication was studied.

Yet this narrower recommendation raises questions. What does a diagnosis of mild cognitive impairment mean? Is Aduhelm appropriate for all people with mild cognitive impairment, or only some? And who should decide which patients qualify for treatment: dementia specialists or primary care physicians?

Controversy surrounds Aduhelm because its effectiveness hasn’t been proved, its cost is high (an estimated $56,000 a year, not including expenses for imaging and monthly infusions), and its potential side effects are significant (41% of patients in the drug’s clinical trials experienced brain swelling and bleeding).

Furthermore, an FDA advisory committee strongly recommended against Aduhelm’s approval, and Congress is investigating the process leading to the FDA’s decision. Medicare is studying whether it should cover the medication, and the Department of Veterans Affairs has declined to do so under most circumstances.

Clinical trials for Aduhelm excluded people over age 85; those taking blood thinners; those who had experienced a stroke; and those with cardiovascular disease or impaired kidney or liver function, among other conditions. If those criteria were broadly applied, 85% of people with mild cognitive impairment would not qualify to take the medication, according to a new research letter in the Journal of the American Medical Association.

Given these considerations, carefully selecting patients with mild cognitive impairment who might respond to Aduhelm is “becoming a priority,” said Dr. Kenneth Langa, a professor of medicine, health management and policy at the University of Michigan.

Dr. Ronald Petersen, who directs the Mayo Clinic’s Alzheimer’s Disease Research Center, said, “One of the biggest issues we’re dealing with since Aduhelm’s approval is, ‘Are appropriate patients going to be given this drug?’”

Here’s what people should know about mild cognitive impairment based on a review of research studies and conversations with leading experts.

Basics. Mild cognitive impairment is often referred to as a borderline state between normal cognition and dementia. But this can be misleading. Although a significant number of people with mild cognitive impairment eventually develop dementia — usually Alzheimer’s disease — many do not.

Cognitive symptoms — for instance, difficulties with short-term memory or planning — are often subtle but they persist and represent a decline from previous functioning. Yet a person with the condition may still be working or driving and appear entirely normal. By definition, mild cognitive impairment leaves intact a person’s ability to perform daily activities independently.

According to an American Academy of Neurology review of dozens of studies, published in 2018, mild cognitive impairment affects nearly 7% of people ages 60 to 64, 10% of those 70 to 74 and 25% of 80- to 84-year-olds.

Causes. Mild cognitive impairment can be caused by biological processes (the accumulation of amyloid beta and tau proteins and changes in the brain’s structure) linked to Alzheimer’s disease. Between 40% and 60% of people with mild cognitive impairment have evidence of Alzheimer’s-related brain pathology, according to a 2019 review.

But cognitive symptoms can also be caused by other factors, including small strokes; poorly managed conditions such as diabetes, depression and sleep apnea; responses to medications; thyroid disease; and unrecognized hearing loss. When these issues are treated, normal cognition may be restored or further decline forestalled.

Subtypes. During the past decade, experts have identified four subtypes of mild cognitive impairment. Each subtype appears to carry a different risk of progressing to Alzheimer’s disease, but precise estimates haven’t been established.

People with memory problems and multiple medical issues who are found to have changes in their brain through imaging tests are thought to be at greatest risk. “If biomarker tests converge and show abnormalities in amyloid, tau and neurodegeneration, you can be pretty certain a person with MCI has the beginnings of Alzheimer’s in their brain and that disease will continue to evolve,” said Dr. Howard Chertkow, chairperson for cognitive neurology and innovation at Baycrest, an academic health sciences center in Toronto that specializes in care for older adults.

Diagnosis. Usually, this process begins when older adults tell their doctors that “something isn’t right with my memory or my thinking” — a so-called subjective cognitive complaint. Short cognitive tests can confirm whether objective evidence of impairment exists. Other tests can determine whether a person is still able to perform daily activities successfully.

More sophisticated neuropsychological tests can be helpful if there is uncertainty about findings or a need to better assess the extent of impairment. But “there is a shortage of physicians with expertise in dementia — neurologists, geriatricians, geriatric psychiatrists” — who can undertake comprehensive evaluations, said Kathryn Phillips, director of health services research and health economics at the University of California-San Francisco School of Pharmacy.

The most important step is taking a careful medical history that documents whether a decline in functioning from an individual’s baseline has occurred and investigating possible causes such as sleep patterns, mental health concerns and inadequate management of chronic conditions that need attention.

Mild cognitive impairment “isn’t necessarily straightforward to recognize, because people’s thinking and memory changes over time [with advancing age] and the question becomes ‘Is this something more than that?’” said Dr. Zoe Arvanitakis, a neurologist and director of Rush University’s Rush Memory Clinic in Chicago.

More than one set of tests is needed to rule out the possibility that someone performed poorly because they were nervous or sleep-deprived or had a bad day. “Administering tests to people over time can do a pretty good job of identifying who’s actually declining and who’s not,” Langa said.

Progression. Mild cognitive impairment doesn’t always progress to dementia, nor does it usually do so quickly. But this isn’t well understood. And estimates of progression vary, based on whether patients are seen in specialty dementia clinics or in community medical clinics and how long patients are followed.

A review of 41 studies found that 5% of patients treated in community settings each year went on to develop dementia. For those seen in dementia clinics — typically, patients with more serious symptoms — the rate was 10%. The American Academy of Neurology’s review found that after two years 15% of patients were observed to have dementia.

Progression to dementia isn’t the only path people follow. A sizable portion of patients with mild cognitive impairment — from 14% to 38% — are discovered to have normal cognition upon further testing. Another portion remains stable over time. (In both cases, this may be because underlying risk factors — poor sleep, for instance, or poorly controlled diabetes or thyroid disease — have been addressed.) Still another group of patients fluctuate, sometimes improving and sometimes declining, with periods of stability in between.

“You really need to follow people over time — for up to 10 years — to have an idea of what is going on with them,” said Dr. Oscar Lopez, director of the Alzheimer’s Disease Research Center at the University of Pittsburgh.

Specialists versus generalists. Only people with mild cognitive impairment associated with Alzheimer’s should be considered for treatment with Aduhelm, experts agreed. “The question you want to ask your doctor is, ‘Do I have MCI [mild cognitive impairment] due to Alzheimer’s disease?’” Chertkow said.

Because this medication targets amyloid, a sticky protein that is a hallmark of Alzheimer’s, confirmation of amyloid accumulation through a PET scan or spinal tap should be a prerequisite. But the presence of amyloid isn’t determinative: One-third of older adults with normal cognition have been found to have amyloid deposits in their brains.

Because of these complexities, “I think, for the early rollout of a complex drug like this, treatment should be overseen by specialists, at least initially,” said Petersen of the Mayo Clinic. Arvanitakis of Rush University agreed. “If someone is really and truly interested in trying this medication, at this point I would recommend it be done under the care of a psychiatrist or neurologist or someone who really specializes in cognition,” she said.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

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Restoring a Sense of Belonging: The Unsung Importance of Casual Relationships for Older Adults

In May, Vincent Keenan traveled from Chicago to Charlottesville, Virginia, for a wedding — his first trip out of town since the start of the pandemic.

“Hi there!” he called out to customers at a gas station where he’d stopped on his way to the airport. “How’s your day going?” he said he asked the Transportation Security Administration agent who checked his ID. “Isn’t this wonderful?” he exclaimed to guests at the wedding, most of whom were strangers.

“I was striking up conversations with people I didn’t know everywhere I went,” said Keenan, 65, who retired in December as chief executive officer of the Illinois Academy of Family Physicians. “Even if they just grunted at me, it was a great day.”

It wasn’t only close friends Keenan missed seeing during 15 months of staying home and trying to avoid covid-19. It was also dozens of casual acquaintances and people he ran into at social events, restaurants, church and other venues.

These relationships with people we hardly know or know only superficially are called “weak ties” — a broad and amorphous group that can include anyone from your neighbors or your pharmacist to members of your book group or fellow volunteers at a school.

Like Keenan, who admitted he’s an unabashed extrovert, many older adults are renewing these connections with pleasure after losing touch during the pandemic.

Casual relationships have several benefits, according to researchers who’ve studied them. These ties can cultivate a sense of belonging, provide bursts of positive energy, motivate us to engage in activities, and expose us to new information and opportunities — all without the emotional challenges that often attend close relationships with family and friends.

Multiple studies have found that older adults with a broad array of “weak” as well as “close” ties enjoy better physical and psychological well-being and live longer than people with narrower, less diverse social networks. Also, older adults with broad, diverse social networks have more opportunities to develop new relationships when cherished friends or family members move away or die.

“Feeling connected to other people, not just the people who are closest to you, turns out to be incredibly important,” said Gillian Sandstrom, a senior lecturer in the department of psychology at the University of Essex in England.

Sandstrom’s research has found that people who talk to more acquaintances daily tend to be happier than people who have fewer of these interactions. Even talking to strangers makes people feel less lonely and more trusting, she has discovered.

Claire Lomax, 76, of Oakland, California, who’s unmarried, has made a practice of chatting with strangers all her life. Among her greatest pleasures in recent years was volunteering at the Oakland Police Department, where she would ask patrol officers about their families or what was happening at the station.

“I never wanted a man of my own, but I like to be around them,” she explained. “So, I got to have my guy buzz without any complications, and I felt recognized and appreciated,” Lomax told me. Since becoming fully vaccinated, she’s volunteering in person at the police stations again — a deep source of satisfaction.

Even people who describe themselves as introverts enjoy the positivity that casual interactions can engender.

“In fact, people are more likely to have purely positive experiences with weak ties” because emotional complications are absent, said Katherine Fiori, a prominent researcher and chair of the psychology department at Adelphi University in Garden City, New York.

Lynn Eggers, 75, a retired psychologist in Minneapolis, loved going to coffee shops and the gym before covid hit. “In both places, you can be in a group and alone,” she told me. “You can choose to talk to someone or not. But you feel you’re part of the community.”

At a light-rail station, Eggers would strike up conversations with strangers: two police officers who told her about growing up in Somalia, a working-class Texan whose daughter won a scholarship to Harvard, a young Vietnamese woman whose parents worried she was abandoning her culture.

When Eggers stopped taking public transportation for fear of covid, she missed “getting these glimpses into other ways of seeing the world.” Instead, she started chatting with neighbors in daily walks around her neighborhood — another way to feel connected.

Many people may have found that neighbors, mail carriers and delivery people became more important during the pandemic — simply because they were around when others were not, said Karen Fingerman, a professor of human ecology at the University of Texas-Austin. As pandemic restrictions lift, “the key is to get out in daily life again” and reengage with a variety of people and activities, she recommended.

Helen Bartos, 69, a retired clinical psychologist, lives in a condominium community in Rochester, New York. “With covid, a whole group of us started getting together outside,” she told me. “We’d bring out chairs and drinks, wear masks, and sit around and talk. It was very bonding. All of these people are neighbors; now I would call some of them friends.”

Ellie Mixter-Keller, 66, of Milwaukee, turned to social gatherings sponsored by the activity group Meetup six years ago after a divorce disrupted her life. “It was my salvation. It exposed me to a bunch of new people who I didn’t have to date or have to dinner,” she said. Now that she’s fully vaccinated, she’s busy almost every night of the week attending Meetup events and informal get-togethers arranged by people she’s met.

In some cases, varying views of covid vaccines have made casual interactions more difficult. Patty Beemer, 61, of Hermosa Beach, California, used to go swing-dancing two or three times a week before the pandemic. “It’d be 20 seconds of chitchat and just dance” before all those events were canceled, she said.

In the past several months, however, the swing-dance community in and around Los Angeles has split, with some events requiring proof of vaccination and others open to everyone.

“Before, everyone danced with everyone, without really thinking about it. Now, I don’t know if it’s going to be like that. I’m not sure how much mixing is going to happen,” Beemer said. “And that sense of shared humanity, which is so meaningful to all of us, may be harder to find.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

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Tips for Older Adults to Regain Their Game After Being Cooped Up for More Than a Year

Alice Herb, 88, an intrepid New Yorker, is used to walking miles around Manhattan. But after this year of being shut inside, trying to avoid covid-19, she’s noticed a big difference in how she feels.

“Physically, I’m out of shape,” she told me. “The other day I took the subway for the first time, and I was out of breath climbing two flights of stairs to the street. That’s just not me.”

Emotionally, Herb, a retired lawyer and journalist, is unusually hesitant about resuming activities even though she’s fully vaccinated. “You wonder: What if something happens? Maybe I shouldn’t be doing that. Maybe that’s dangerous,” she said.

Millions of older Americans are similarly struggling with physical, emotional and cognitive challenges following a year of being cooped up inside, stopping usual activities and seeing few, if any, people.

If they don’t address issues that have arisen during the pandemic — muscle weakness, poor nutrition, disrupted sleep, anxiety, social isolation and more — these older adults face the prospect of poorer health and increased frailty, experts warn.

What should people do to address challenges of this kind? Several experts shared advice:

Reconnect with your physician. Large numbers of older adults have delayed medical care for fear of covid. Now that most seniors have been vaccinated, they should schedule visits with primary care physicians and preventive care screenings, such as mammograms, dental cleanings, eye exams and hearing checks, said Dr. Robert MacArthur, chief medical officer of the Commonwealth Care Alliance in Massachusetts.

Have your functioning assessed. Primary care visits should include a basic assessment of how older patients are functioning physically, according to Dr. Jonathan Bean, an expert in geriatric rehabilitation and director of the New England Geriatric Research, Education and Clinical Center at the Veterans Affairs Boston Healthcare System.

At a minimum, doctors should ask, “Are you having difficulty walking a quarter-mile or climbing a flight of stairs? Have you changed the way you perform ordinary tasks such as getting dressed?” Bean suggested.

Get a referral to therapy. If you’re having trouble moving around or doing things you used to do, get a referral to a physical or occupational therapist.

A physical therapist can work with you on strength, balance, range of motion and stamina. An occupational therapist can help you change the way you perform various tasks, evaluate your home for safety and identify needed improvements, such as installing a second railing on a staircase.

Don’t wait for your doctor to take the initiative; too often this doesn’t happen. “Speak up and say: Please, can you write me a referral? I think a skilled evaluation would be helpful,” said James Nussbaum, clinical and research director at ProHealth & Fitness in New York City, a therapy provider.

Start slow and build steadily. Be realistic about your current abilities. “From my experience, older adults are eager to get out of the house and do what they did a year ago. And guess what. After being inactive for more than a year, they can’t,” said Dr. John Batsis, associate professor of geriatrics at the University of North Carolina-Chapel Hill.

“I’m a fan of start low, go slow,” Batsis continued. “Be honest with yourself as to what you feel capable of doing and what you are afraid of doing. Identify your limitations. It’s probably going to take some time and adjustments along the way.”

Nina DePaola, vice president of post-acute services for Northwell Health, the largest health care system in New York, cautioned that getting back in shape may take time. “Pace yourself. Listen to your body. Don’t do anything that causes discomfort or pain. Introduce yourself to new environments in a thoughtful and a measured fashion,” she said.

Be physically active. Engaging regularly in physical activity of some kind — a walk in the park, chair exercises at home, video fitness programs — is the experts’ top recommendation. The Go4Life program, sponsored by the National Institute on Aging, is a valuable resource for those getting started and you can find videos of some sample exercise routines on YouTube. The YMCA has put exercise classes online, as have many senior centers. For veterans, the VA has Gerofit, a virtual group exercise program that’s worth checking out.

Bienvenido Manzano, 70, of Boston, who retired from the Coast Guard after 24 years and has significant lower back pain, attends Gerofit classes three times a week. “This program, it strengthens your muscles and involves every part of your body, and it’s a big help,” he told me.

Have realistic expectations. If you’re afraid of getting started, try a bit of activity and see how you feel. Then try a little bit more and see if that’s OK. “This kind of repeated exposure is a good way to deal with residual fear and hesitation,” said Rachel Botkin, a physical therapist in Columbus, Ohio.

“Understand that this has been a time of psychological trauma for many people and it’s impacted the way we behave,” said Dr. Thomas Cudjoe, a geriatrician and assistant professor at Johns Hopkins Medicine in Baltimore. “We’re not going to go back to pre-pandemic activity and engagement like turning on a light switch. We need to respect what people’s limits are.”

Jane Collins “loves getting outside and that has been wonderful,” says daughter Laura. “Her mood immediately shifts when she gets out of the building.” (Laura Collins)

Eat well. Make sure you’re eating a well-balanced diet that includes a good amount of protein. Adequate protein consumption is even more important for older adults during times of stress or when they’re sedentary and not getting much activity, noted a recent study on health aging during covid-19. For more information, see my column about how much protein older adults should consume.

Reestablish routines. “Having a structure to the day that involves social interactions, whether virtual or in person, and various activities, including some time outside when the weather is good, is important to older adults,” said Dr. Lauren Beth Gerlach, a geriatric psychiatrist and assistant professor of psychiatry at the University of Michigan.

Routines are especially true for older adults with cognitive impairment, who tend to do best when their days have a dependable structure and they know what to expect, she noted.

End-of-day routines are also useful in addressing sleep problems, which have become more common during the pandemic. According to a University of Michigan poll, administered in January, 19% of adults ages 50 to 80 report sleeping worse than they did before the pandemic.

Reconnect socially. Mental health problems have also worsened for a segment of older adults, according to the University of Michigan poll: 19% reported experiencing more sadness or depression while 28% reported being more anxious or worried.

Social isolation and loneliness may be contributing and it’s a good idea to start “shoring up social support” and seeing other people in person if seniors are vaccinated, Gerlach said.

Families have an important role to play in re-engaging loved ones with the world around them, Batsis suggested. “You’ve had 15 months or so of only a few face-to-face interactions: Make it up now by visiting more often. Make the effort.”

Laura Collins, 58, has been spending a lot of time this past month with her mother, Jane Collins, 92, since restrictions on visitation at Jane’s nursing home in Black Mountain, North Carolina, eased and both women were vaccinated. Over the past year, Jane’s dementia progressed rapidly and she became depressed, sobbing often to Laura on the phone.

“She loves getting outside and that has been wonderful,” Laura said. “Her mood immediately shifts when she gets out of the building: She’s just happy, almost childlike, like a kid going out for ice cream. And, in fact, that’s what we do — go out for ice cream.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

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