The earlier, the better: Spokane couple shares experience with mild cognitive impairment, why early diagnosis is key

Apr. 14—In early 2017, Mary Mosher told her husband Tom that she had concerns about memory lapses beyond usual forgetfulness. She had witnessed her mother's dementia more than 20 years prior.

Tom Mosher eventually noticed signs — like household items put away where it made no sense — so they went that fall to the Banner Alzheimer's Institute in Phoenix, where they wintered. Her diagnosis: mild cognitive impairment, defined as an early stage of memory loss or a cognitive ability decline while still able to do most daily activities.

A research study covered a positron emission tomography, or PET, scan, which found slightly more amyloid plaque in Mosher's brain at age 73 than normal — a hallmark of Alzheimer's disease. Early diagnosis helped Tom Mosher, 79, and Mary Mosher, 78, in multiple ways, he said.

They joined support groups, settled legal affairs, improved diet and sleep, socialized more and did exercises — including mental ones — while Mary Mosher entered drug trials that also helped. They got information from the local Alzheimer's Association chapter. Her mental decline was less steep compared with others her age, Tom Mosher said.

"Early diagnosis got her into meds, and both of us into support groups, both of which I feel helped," he said. "We both became more aware of the expected progress of the disease. This allowed us both at some level to accept what is happening."

Early MCI diagnosis is a best-case scenario. If hallmark changes in the brain are present, MCI can be an early stage of the Alzheimer's disease continuum, but not everyone with MCI progresses.

About 10% to 15% of people with MCI each year develop dementia, says the Alzheimer's Association, which published a March report on mild cognitive impairment. It found 82% of Americans know little or nothing about MCI and often confuse it with normal aging. About 12%-18% of people ages 60-plus are living with MCI.

The Moshers now remain in Spokane year-round in an independent home at Rockwood Retirement South Hill. Raised across the street from each other in Ohio, they dated in high school. His urban-environmental planning career included about 22 years with Spokane County, and they raised a daughter and son here. Retired in 1997, they traveled often across North America.

Today, staying physically active helps, along with any mental exercises, Tom Mosher said, such as discussing news, movie plots and lectures.

"Mary's probably in middle-stage Alzheimer's now, but earlier, we'd try to do those things. We still deliver Meals on Wheels. I drive and take things to the door. Mary's in charge of the list of addresses."

Reading books, a hobby, is something that his wife is losing the ability to do, he said.

Mary Mosher expressed agreement but said little. "Well, you get very frustrated when you can't remember things," she said.

Signs

Spokane neurologist Dr. David Greeley of Northwest Neurological encourages patients in healthier exercise, sleep and diet, which are bound to help anyone at any age. He also agrees that the earlier a MCI diagnosis, the better.

"To me, mild cognitive impairment is more of a category of a definition, kind of like saying mild hearing loss that's not a diagnosis — it's just a statement that it's not normal hearing, and you're not deaf," Greeley said. MCI means cognitive ability isn't normal, but it isn't quite dementia. "Dementia by definition is when you've lost enough cognition or functional ability that you can't do what you used to do socially or occupationally."

It isn't unusual to forget where you set down keys, but it's abnormal if a spouse finds the keys in the refrigerator, Greeley said. Unlike isolated forgetfulness, it's more frequent, follows patterns or can include difficulties learning — new gadgets or a new car's controls. There can be a lack of retaining what's just been read or getting lost in a familiar environment. There might be balance issues, mood changes or frequent car accidents.

"Problem-solving can be an issue, so before they could always just get a recipe and follow it, or they didn't even need a recipe," Greeley said. "They go to the store and they have to make a list, and even still, they'll forget things.

"They might be making poor decisions. There's recognition and awareness of it, where everybody else seems to notice, but the patient themselves can't recognize they even have a problem. That's very common because basically the warning light is broken."

Tests

Costly PET scans often aren't an option. Today, Greeley said if decline is suspected, commonly a doctor conducts cognitive tests along with a MRI-plus volumetric analysis.

"It measures your brain and compares it to the brain of other people your age," Greeley said. "Specifically, the one area we're looking at is the hippocampus because the hippocampus in Alzheimer's disease shrinks first and faster than the rest of the brain.

"If it's smaller, that's very suggestive this could be Alzheimer's disease that's causing your mild cognitive impairment."

Another option is a lumbar puncture, often covered by insurance or an Alzheimer's drug manufacturer, he said, and they're done here at Inland Imaging. It takes a sample of the cerebrospinal fluid that flows around the spinal cord and brain, then it's sent to the Mayo Clinic.

This test looks for amyloid beta protein, the protein in amyloid plaques. It also measures something called tau, the makeup of neurofibrillary tangles, the other hallmark of Alzheimer's disease, Greeley said.

"If you have signs of plaque, signs of tangles and no other explanation for your memory loss, you're now up to 95% likely — if not more — that what you have is Alzheimer's disease even though it might be only at the stage of MCI."

Trials

Tom Mosher said his wife participated in two clinical drug trials in Dr. Greeley's research, including a recent infusion therapy with aducanumab, a monoclonal antibody.

Aducanumab, brand named Aduhelm, received accelerated approval in June as a treatment for Alzheimer's disease from the U.S. Food and Drug Administration, but not without some controversy. It proved highly effective at reducing the plaques, called beta-amyloid, that build up in the brain among Alzheimer's patients, says the FDA.

However, the FDA is requiring Biogen to conduct a post-approval clinical trial to verify the drug's clinical benefit. If the subsequent study doesn't show clinical improvement in patients, the FDA could move to withdraw the approval.

On April 7, the Centers for Medicare and Medicaid Services announced that Medicare will cover Biogen's Aduhelm "only for people who receive it as participants in a clinical trial." The cost is about $28,200 yearly in the U.S. for a patient at about 163 pounds, said Biogen in a December statement.

Greeley said he thinks Mary Mosher and other patients did improve during the aducanumab drug trial, although she had to stop treatments.

"We had 50 people in the research trial at my clinic — some who started as far back as 2017 — and most of the 22 who remain in the study at our site have progressed much slower than expected; for example, losing 1-3 points on the (Mini Mental State Exam) when it would have been expected that they would have lost 12 points or more."

Greeley said at least three other companies are doing ongoing research on similar drugs, including in local clinical trials that need participants.

Mosher said his wife did IV infusions for about four months. A few months in, brain scans showed a slight swelling in the brain, affecting a small percentage, he said. That didn't decline, and she couldn't continue.

She takes Galatamine, one of three longtime Alzheimer's drugs. Tom Mosher said bottom line, "early diagnosis of MCI has so many advantages."

"If you have any suspicion that you have more of a memory loss than what maybe your friends do, get an assessment," Mosher said. "Medicines and lifestyle changes can help."

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