Neuropsychological Intervention of Minimal Cognitive Impairment Including Language Deficits

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European Review for Medical and Pharmacological Sciences 2017; 21 (4 Suppl): 58-64 Neuropsychological intervention of minimal cognitive impairment including language deficits

Y. ZHAO1,2, H. LI1,3

1Brain and Cognitive Neuroscience Research Center, Liaoning Normal University, Liaoning, China 2School of Chinese Language and Literature, Liaoning Normal University, Dalian, China 3College of Psychology and Sociology, Shenzhen University, Shenzen, Guangdong, China

Abstract. – OBJECTIVE: Mild Cognitive Im- activities including multiple aspects of thinking pairment (MCI) is an early dementia or discrete and acting, such as reading, writing, attention, memory loss. The cognitive deficit in MCI im- reasoning, language and judgment. MCI causes pedes people’s daily activities, which influences memory problems and is characterized by cogni- multiple aspects of thinking and acting including tive damage that is disproportion to the education attention, reading, writing, reasoning, language, 1 and judgment. This review aims to assess the background and age of the patients . MCI is pre- outcome of various neuropsychological inter- valent in older individuals, about 10% of people ventions in treating MCI. between the age of 70-79 years and 10% of peo- MATERIALS AND METHODS: MCI causes ple between the age of 80-89 years are affected memory problems and is characterized by the by different degree of MCI. MCI is a transitional cognitive damage that is disproportionate about state between normal ageing and early demen- individual education background and age. RESULTS: Post-mortem biopsies performed tia. People with MCI generally do not perform on 134 patients diagnosed with MCI showed the well in memory tests due to either forgetfulness presence of Alzheimer’s disease AD in 54.4% of or attention deficit. Cognitive impairment in all the patients, mixed pathologies in 19.4% and MCI is progressive and one half of people with gross microscopic infarcts in 39.1% patients. MCI will be diagnosed with Alzheimer’s disease This review was done to assess the outcome of in the following 3 to 5 years. In this review, we MCI and the various neuropsychological interventions, which are being used in the treatment will first discuss the progression of MCI. Also, of MCI. These techniques were studies individ- various neuropsychological interventions used in ually followed by their roles in treating specific the treatment of MCI will be discussed. We will cognitive deficits. discuss these treatments individually, followed by CONCLUSIONS: The study focused on review- reviewing their roles in treating specific cogniti- ing the literature for mainly three cognitive rehabil- ve deficits. Three cognitive rehabilitation strate- itation strategies: (1) rehearsal-based approaches gies including (1) rehearsal-based approaches, (2) (2) compensatory techniques (3) mnemonic strategies. In the present review, rehabilitation of lan- compensatory techniques (3) mnemonic strate- guage deficits in MCI is also included. gies, are the main focuses of this review.

Key Words: Progression of Mild Cognitive Minimal cognitive deficits, Attention deficits, Memo- Impairment ry deficits, Mnemonic strategies, Compensatory tech- Post-mortem biopsies performed on 134 pa- niques. tients diagnosed with MCI showed the presence of AD in 54.4% of all the patients, mixed patho- Introduction logies in 19.4% and gross microscopic infracts in 39.1%. Hence it can be concluded that not all Mild cognitive impairment (MCI), which is patients with MCI develop AD2. Another study an early dementia or discrete memory loss, can showed that a combination of different pathologi- cause detectable and measurable reduction in co- cal processes, usually AD with macroscopic infar- gnitive abilities, including memory and thinking. cts and neocortical Lewy body disease contribu- The cognitive deficit in MCI affects people’s daily ted to 45.8% of the 179 people with suspected AD.

58 Corresponding Author: Yue Zhao, MD; e-mail: [email protected] Neuropsychological intervention of minimal cognitive impairment including language deficits

MCI is a transitional phase that connects physio- ce, superior vision, superior olfactory potential, logical ageing and dementia; therefore, the under- bigger combined volume of the left hippocampus standing of MCI is crucial for the implementation HC and left amygdala, and a steeper decline in of secondary interference on dementia. Currently diastolic blood pressure between baseline and emphasis is laid on the identification and utiliza- follow-up. Poor prognostic markers for MCI were tion of both pharmacological and non-pharmaco- associated with the existence of multiple-domain logical tools to impede or attenuate the transition MCI, a damaged cognitive domain or an infor- from MCI to AD. Several previous studies have mant-founded memory complaint. These results carried out to investigate the progression of MCI were based on data derived from a prospective, to dementia as well as many other cognitive disor- population-founded Sydney Memory and Ageing ders. Different rates of progression were reported Study. Hence controlling vascular factors like fall in different studies; the average conversion rate in diastolic blood pressure and incorporating co- of MCI to dementia is 10% per year, indicating gnitively enriching experiences are promising in- a linear progression in the transition to dementia terventions for MCI. over time1-4. A random population cohort study conducted over a period of 6 years reported that Neuropsychological Intervention approximately 80% of the MCI patients developed Approaches dementia. A community based study conducted over a period of 1 year5 showed that 0-3% of the Rehearsal-Based Approaches MCI patients developed CDR (Clinical Dementia Rehearsal based approaches are to ask patients Rating), and > 1 but ≤ 20% of the patients expe- repeating information over time. The characte- rienced serious cognitive damage, 6-53% showed ristic of the repetitions varies across techniques. improvement or complete recovery, and 29-92% Two examples of such approach include spaced showed no progression. Studies conducted on sin- retrieval approach and subtracting cues approa- gle and multi-domain executive MCI suggest that ch. In the former one, the patient is required to single-domain executive MCI possesses a pro- remember targeted message over gradually incre- gnosis superior to amnestic MCI. Also, executive ased time lapses. In the latter one, the deletion of pathology in multiple-domain MCI is insufficient parts of the target message (e.g., the spelling of to enhance the likelihood of transition to demen- a noun) was applied. Both techniques have been tia6. It’s reported that hypothyroidism, normal proved to be effective in treating patients having pressure hydrocephalus, vitamin B12 deficiency, AD13,14, thus proving the conclusion that rehear- and subdural hematoma caused by MCI, can be sal may be most suitable for late MCI patients. cured in one-third of the subjects. At the same Those approaches are useful in teaching specific time, neurodegenerative disorders like lewy body message like names of new persons in a known disease developed in subjects with MCI7. Subjects societal circle (e.g. church members)15,16. Howe- having subcortical microvascular disease, mild ver, it is important to keep in mind that these ef- parkinsonian signs, non-amnestic MCI, multi-co- fects are stimulus-specific or information-specific gnitive deficit MCI, vascular comorbidity, signs that cannot be generalized across different cross of vascular disease on brain imaging, mood di- sections of the society (e.g., to other church mem- sorders and behavioral indications, are more bers or new comers of a hospital ), making it im- likely to develop vascular dementia8-10. A meta perative to train the individual every time he/she analysis of 41 robust inception cohorts11 reported gets new piece of learning information. The new that the conversion rate of MCI to dementia was piece of information could be a new church mem- 9.6% in specialist clinical settings, to Alzheimer’s ber’s name, the site of certain household items, dementia was 8.1 % and to vascular dementia or a certain road to a new doctor’s office. Hence, was 1.9%, whereas in community settings it was no matter how efficient they are, the application 4.9%, 6.8%, and 1.6%, respectively. Hence it is of these techniques is not only situation-depen- unlikely that most patients will develop demen- dent and stimulation-specific but also limited by tia during the following ten years12. Improvement the length and complicity of the treatment. Many or complete recovery has been reported in up to of the available computerized training programs 33-55% of all the patients and factors related to are designed with the purpose of improving co- the reversion have also been studied12. The factors gnitive abilities and one study reported increased which can improve the disease include complica- hippocampal activation after training17. However, ted mental activity, more readiness to experien- when it comes to generalization of standardized

59 Y. Zhao, H. Li neuropsychological tests18,19 or daily management sing. Procedures such as semantic organization, across patient populations20,21 evidence on such semantic articulation, and mental imagery are approaches are conflicting. This limitation con- included in mnemonic techniques. ‘Internal’ me- solidates the necessity for training to be geared ans that these cognitive tools can be used by the towards outcomes. patients almost everywhere. Mnemonic strategies are considered as normal treatments of patients Compensatory Methods with insignificant memory deficits after traumatic Techniques employing compensatory aids brain injury22 and hence support the earlier repor- aim to alter or augment memory processes and ts that these methods might be most helpful for hence altering the manner of learning, retention patients with early MCI27,28. Mnemonic strate- and information retrieval of patients. Such even gies are believed to be able to improve studying techniques can even benefit cognitively intact in- and memory in old adults as revealed by meta-a- dividuals to improve their daily life quality. For nalysis studies29 and several large scale studies instance, external compensatory aids like grocery employing these techniques within larger pro- lists or smart-phones are perhaps most efficient grams30-32. These techniques can re-establish the for potential tasks like memorizing assignments. use of ‘‘normal’’ brain parts (or networks) and/ Memory note-books conventionally play an im- or engage other compensatory parts (or networ- portant role in treating patients with rehabilitation ks) to improve patients’behavior, given that the- of traumatic brain injury (TBI) or stroke patien- se methods engage multiple cognitive procedu- ts to re-establish their impaired memories22. The res. Researchers26 have indeed shown enhanced Cognitive Rehabilitation Manual released by the fMRI-based activation and connection between American Congress of Rehabilitation Medicine23 numerous crucial prefrontal and parietal regions. describes well-documented approaches that can The authors also showed incomplete reestablish- achieve that effect. In their attempt to modify the ment of hippocampal activation in patients having traditional notebook approach, Greenaway et al24 MCI28. A compensatory role by the right parietal have demonstrated that a disciplined training pro- temporal junction, when applied strategically in gram can be helpful for improvements in the daily MCI patients, has also been suggested by some activities and memory self-effectiveness in people other researchers33. These findings together with having MCI and reduction of the caregivers’ di- the associated behavioral improvements support stress. These external compensatory approaches the theory that mnemonic methods adaptively also have limitations. Aid-dependency is the main alter the way patients deal with messages. The- limitation, and failure in task will happen without refore, generalizing them to other scenarios and aid. Another limitation is the occasional/frequent daily life could be promising because their uni- inappropriate use of these aids. For instance, the versal ‘‘rules’’ can be applied across settings once aid could prove cumbersome and awkward in si- learned. Limitations of those approaches are not tuations such as recalling an individual’s name, lacking. They are time consuming and effortful in a task with social norms is expected to be recal- nature needed to be considered in outcome within led promptly. Likewise, with the outside help in restricted exposure time (e.g., one word every se- mind, an individual tends to accumulate pages cond as in most word lists) or bulky information (electronic or physical), notes, or bookmarks and beyond the handling capacity of attentional/wor- as a result, the retrieval of specific information king memory. In addition, this approach with its could prove challenging with the passage of time. cognitive demands may be too complicated for Although patients can refer to key events (e.g., more cognitively compromised people28. holidays) to retrieve information, studies indicate that temporal referencing25 and associative refe- Cognitive Rehabilitation Techniques for rencing26 will be particularly difficult for patients Specific Cognitive Impairments with MCI. A thorough scrutiny of the available data from patients diagnosed with cognitive impairment Mnemonic Strategies showed that attention parameter gets affected in Cognitive ‘instruments’ that help organize and the early part of the disease. The selective attention connect new messages through internal compen- deficit has often been associated with impairment satory aids fall under the category of mnemonic of implicit memory34. The ability to concentrate strategies. By facilitating new information pro- on a specific stimulus by eliminating unwanted cessing, they facilitate a more in-depth proces- or harmful stimuli is called selective attention.

60 Neuropsychological intervention of minimal cognitive impairment including language deficits

Selective attention also encompasses detailed at- results showed that the test group performed well tention and response to the stimulus35. From pa- in a spatial span task, but performed poorly in the tients’ data, the pattern of cognitive impairment is rest of the tasks. The work design had lacunae re- shown to have started gradually during the early garding the possibilities of having given less co- adulthood. Age-related changes in the brain have gnitively stimulating tasks to the control group. also been responsible for cognitive impairment. Besides, the study did not evaluate the long term Although brain can develop newer synapses as usefulness of the rehabilitation technique in con- a part of the compensatory mechanism, lack of verting MCI to normalized cognition or preven- specific skills further contributes to cognitive ting its progression to dementia. Another paper weakness. Therefore, reinforcement of specific that was reviewed was a quasi-experimental study skills by cognitive training intervention should be conducted by Oskoei et al42. The subjects in that able to arrest progressive worsening of cognition, research consisted of 40 patients from neurology in which cognitive rehabilitation plays a pivotal clinic in Tehran in 2012. All patients in the test role. It includes a wide array of therapeutic tech- group had mild cognitive impairment assessed by niques, most common being the one in which the a medical psychologist (MMSE score lower than therapist evaluates ratio of right responses and the 25 and Wechsler memory test). All the patients rate of cognitive tasks performed by their patien- were above 55 years old with minimum education ts. The degree of difficulty is heightened by the at degree level and no comorbid neurological or therapist once the patient masters the given task36. psychiatric illnesses was found from their medical The impact of cognitive rehabilitation on various records. The entire group was randomly divided parameters like mood and memory has been ex- into test group and control group, 20 patients in tensively studied by Barekatain et al37. Schmit- each group. The test group was administered with ter-Edgecombe et al38 showed beneficial results in 12 sessions (two hours each section) of cognitive people suffering from moderate cognitive impair- rehabilitation using Neurocognitive Joyful Atten- ment regarding behavior management. Stavros et tive Training Intervention (NEJATI). The control al39 reported that attention disability and memory group was exempted from these trail sessions. related impairment can be rectified with cognitive The parameters like discriminating attention of rehabilitation techniques. However, Huckans et both sets were studied before and after the test al40 have suggested the need for a remedial appro- using a Strop computer program. We analyzed the ach in conjunction with rehabilitation techniques data using the covariance statistical test, MAN- to develop a hypothetical model for developing COVA. The outcome showed a significant impro- and evaluating the therapeutic concerns. Abun- vement in discriminating attention scores of the dant data on the evaluation of cognitive function, test group against the control group. Thus, it can quality of life and severity of neural symptoms be deduced that cognitive rehabilitation helps im- are available. Yet, hardly any studies concentrate proving discriminating attention deficits. on evaluating the effect of rehabilitation on mild cognitive damage40. The present has been carried Concentrate Compensatory Cognitive out to examine the efficacy of cognitive rehabili- Training Intervention - Single Domain, tation in improving the discriminating attention Memory deficit of patients having cognitive damage. Greenaway et al24 concentrated on improving memory with a compensatory cognitive training Concentrated Restorative Cognitive tool. It consisted of maintaining calendars and Training Intervention - Single Domain, notebooks 2 hours/week for 6 weeks, like ar- Attention/Information Processing ranging appointments, including “to do” items, Barnes et al41 has shown a significant impro- and journaling. They showed a significant im- vement in selective attention deficit through au- provement in memory self-efficiency and daily ditory attention and discrimination rehabilitation performance compared to the control group. It technique. In that study, the possibility of a down- also showed that improvement in daily functio- stream effect on memory with auditory attention ning lasted for 6 months post intervention. Some rehabilitation technique was discussed. In that of the parameters such as objective global cogni- study, a focused computerized cognitive training tion, QOL, or neuropsychiatric sign seriousness intervention (100 mins/day, 5 days/week for 6 which are used as therapeutic evaluation tools weeks) against a control group, which was given were not significantly improved because these robust computer activities, was developed. The parameters were not the targets of the rehabili-

61 Y. Zhao, H. Li tation design. The drawback of this study was Chinese Language and Literature, Liaoning Normal Uni- that conversion rate of MCI to normalized co- versity: Arrangement and research of the northeast regional culture and literature and art, Hongshan culture and Chinese gnition or dementia was not calculated. A litera- civilization collaborative innovative construction and Higher ture review showed two exclusive reports which education teaching reform project funding. The 13th Five- studied the impact of cognitive rehabilitation Year Plan Project Subject of Liaoning Education Sciences: on memory alone43-45. The rehabilitation in both the Phased Objectives of the Subject of Language Expressing studies mainly consisted of reinforcing and nei- Abilities Improvement in the Innovation and Entrepreneur- ship of Liaoning University Students (Subject Approval No.: ther of them had contact control cohorts. Rapp et JG17DB285). al43 performed rehabilitation programs included six 2-hour sessions arranged across six weeks of training in compensatory memory skills as Conflict of interest well as psycho education and easing (breathing) The authors declare no conflicts of interest. practice. The subjects showed significant improvement in memory tests during the first 6 months after intervention. They also demonstrated better usage of pneumonic methods at follow-up. References The work of Troyer et al44 consisted of ten 120-minute sessions arranged across 6 months, 1) Petersen RC, Doody R, Kurz A, Mohs RC, Morris JC, Rabins PV, Ritchie K, Rossor M, Thal L, Winblad B. one hour dedicated mainly to compensatory me- Current concepts in mild cognitive impairment. mory practice, and the other hour dedicated to Arch Neurol 2001; 58: 1985-1992. focused lifestyle training along with psychothe- 2) Bennett DA, Schneider JA, Arvanitakis Z,Wilson RS. rapeutic therapeutic methods. Their study design Overview and findings from the religious orders was worthy of appreciation in multiple terms like study. Curr Alzheimer Res 2012; 9: 628-645. recruiting dieticians for lifestyle management, 3) DeCarli C. Mild cognitive impairment: prevalence, providing participants with more resources so prognosis, aetiology and treatment. Lancet Neu- that they could heighten their activeness, arrange rol 2003; 2: 15-21. sessions of intervention over long period so that 4) Panza F, D’Introno A, Colacicco AM, Capurso C, Del Parigi A, Caselli RJ, Pilotto A, Argentieri G, Sca- potential benefits could be achieved for a longer picchio PL, Scafato E, Capurso A, Solfrizzi V. Cur- period. However, their study results in terms of rent epidemiology of mild cognitive impairment objective memory behavior, subjective memory and other predementia syndromes. Am J Geriatr complaints, or everyday performance, were not Psychiatry 2005; 13: 633-644. remarkable. Nevertheless, the experimental group 5) Ganguli M, Snitz BE, Saxton JA, Chang CC, Lee CW, reported a certain element of wellness in their li- Vander Bilt J, Hughes TF, Loewenstein DA, Unverzagt festyle with increased usage of compensatory me- FW, Petersen RC. Outcomes of mild cognitive impairment by definition: a population study. Arch mory strategies and this belief was sustained for Neurol 2011; 68: 761-767. three months post intervention. 6) Huey ED, Manly JJ, Tang MX, Schupf N, Brickman AM, Manoochehri M, Mez J, DeCarli C, Devanand DP, Mayeux R. Course and etiology of dysexecutive Conclusions MCI in a community sample. Alzheimers Dement 2013; 9: 632-639. The possibility of ineffective intervention and 7) Jicha GA, Parisi JE, Dickson DW, Johnson K, Cha R, Ivnik RJ, Tangalos EG, Boeve BF, Knopman DS, Braak inadequate measures cannot be ruled out for the H, Petersen RC. Neuropathologic outcome of mild occurrence of non-significant results. Again both cognitive impairment following progression to cli- the studies failed to examine the conversion rate nical dementia. Arch Neurol 2006; 63: 674-681. to normalization of cognition or dementia. Yet, 8) Meyer JS, Xu G, Thornby J, Chowdhury MH, Quach the experimental set did not present considerable M. Is mild cognitive impairment prodromal for va- enhancement on measurement of the scale. scular dementia like Alzheimer’s disease? Stroke 2002; 33: 1981-1985. 9) Mauri M, Corbetta S, Pianezzola C, Ambrosoni E, Ri- boldazzi G, Bono G. Progression to vascular de- Acknowledgments mentia of patients with mild cognitive impairment: This study was supported by Youth Foundation of Liaoning relevance of mild parkinsonian signs. Neurop- Normal University: Research on the cognitive mechanism of sychiatr Dis Treat 2008; 4: 1267-1271. language understanding and output in language acquisition 10) Zanetti M, Ballabio C, Abbate C, Cutaia C, Verga- (Project Number: LS2014W003); Foundation of School of ni C, Bergamaschini L. Mild cognitive impairment

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