The Memory Bible: An Innovative Strategy for Keeping Your Brain Young
Author: Gary Small; Gigi Vorgan
Date: 2021-06-15T19:51:03.797488+00:00
Keywords: Self-Help; Personal Growth; Memory Improvement; Health & Fitness; Diseases & Conditions; Alzheimer's & Dementia; Science; Life Sciences; Neuroscience
Description: Clear, concise, prescriptive steps for improving memory loss and keeping the brain young—from one of the world's top memory experts. Everybody forgets things sometimes—from your keys to your lunch date to the name of an acquaintance. According to Dr. Gary Small, the director of the UCLA Center on Aging, much of this forgetfulness can be eliminated easily through his innovative memory exercises and brain fitness program—now available for the first time in a book. Using Small's recent scientific discoveries, The Memory Bible can immediately improve your mental performance. One of the ten command
Publisher: Hachette Books

Copyright © 2021 by Gary Small, MD, and Gigi Vorgan, © 2002 by Gary Small, MD

Cover design by LeeAnn Falciani

Cover illustration © Jolygon / Shutterstock

Cover copyright © 2021 by Hachette Book Group, Inc.

The illustrations in Chapters 3 and 6 were created by Diana Jacobs.

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Previously published by Hyperion: June 2002

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ISBNs: 978-0-306-92535-1 (paperback); 978-0-306-84743-1 (ebook)

Note: The information in this book is true and complete to the best of our knowledge. This book is intended only as an informative guide for those wishing to know more about health issues. In no way is this book intended to replace, countermand, or conflict with the advice given to you by your own physician. The ultimate decision concerning care should be made between you and your doctor. We strongly recommend you follow his or her advice. Information in this book is general and is offered with no guarantees on the part of the authors or Hachette Go. The authors and publisher disclaim all liability in connection with the use of this book.

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Contents

1. Cover
2. Title Page
3. Copyright
4. Introduction to the Updated Edition
5. Preface
6. Chapter One
7. You Have More Control Than You Think
8. Chapter Two
9. Rate Your Current Memory
10. Chapter Three

11. LOOK, SNAP, CONNECT: The Three Basic Memory Training Skills

12. Chapter Four
13. Minimize Stress
14. Chapter Five
15. Get Fit with Mental Aerobics
16. Chapter Six

17. Build Your Memory Skills Beyond the Basics

18. Chapter Seven
19. Start Your Healthy Brain Diet Now
20. Chapter Eight

21. Choose a Lifestyle That Protects Your Brain

22. Chapter Nine
23. Wise Up About Medicines
24. Chapter Ten
25. Don’t Forget the First Nine Chapters

26. Appendixes

1. 1. "The Amyloid/Tau Probe—Keeping Watch on Plaques and Tangles"

2. 2. "What to Do If Alzheimer’s Disease Strikes"

3. 3. "Current and Potential Treatments for Memory Loss and Alzheimer’s Disease"

27. Glossary
28. Additional Resources
29. Bibliography
30. Acknowledgments
31. Discover More
32. Source Credits
33. Also by Gary Small, MD, and Gigi Vorgan

1. Begin Reading

2. Table of Contents

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Introduction to the Updated Edition

When The Memory Bible was first released nearly two decades ago, it surprised many people to learn that brain aging and memory loss begin as early as our twenties and thirties. Normal memory slips, such as forgetting where we put our keys or why we walked into a room, can begin this early and tend to get worse over the years. Eventually, memory issues can affect our daily functioning and productivity. The scientific research we described in the book revealed that initiating certain lifestyle habits, including regular exercise, healthy diet, stress management and mental stimulation, can not only slow or stop memory loss in its tracks, it can also help restore prior losses.

In the years since we wrote The Memory Bible (Gigi did not take credit on the original book), continuing research and development in early detection and treatment of brain aging have proven The Memory Bible’s techniques successful. Our methods for improving and maintaining our cognitive strength still hold true today. Recent studies further substantiate the cognitive benefits of mental and physical exercise, as well as the benefits of stress management and a healthy diet. The latest science is compelling—revealing that these strategies not only boost memory and brain health but also lower the risk for developing Alzheimer’s disease and other forms of dementia.

Our memory-boosting methods were the impetus for the UCLA Longevity Center to develop memory education programs that are now available throughout the US. And our ongoing search for innovative methods has led to this new edition of The Memory Bible, which includes cutting-edge brain research, updated information on drugs and supplements, new techniques to overcome many top memory complaints, and more emphasis on such modern topics as stress management and technology.

Modern life continues to see more complications that endanger our brains. Progress in technology has brought us amazing gadgets, computers, phones, and tablets that can help embellish our memory and retention, but they can be detrimental if not used wisely. Engaging in too much technology can distract us, elevate stress levels, and impede memory abilities. And stress management, a factor in the original book, has become even more crucial in today’s world of worries over pandemics, terrorism, economics, social unrest, and more. In updating this book, we have taken into account these complex changes to give you the tools to manage them.

Now that Gigi and I have become seniors ourselves, we are reaping the benefits of following our lifestyle program. We feel as healthy and sharp as we did when we first wrote The Memory Bible, and the content is more relevant than ever. In the following pages, you will learn to easily adjust your lifestyle to protect your memory and stave off—or possibly avoid—memory loss or dementia during your long, healthy, and productive life.

Gary Small, MD

Gigi Vorgan

Weehawken, NJ, November 2020

Preface

Nearly everyone struggles with some form of memory loss before reaching middle age. Thanks to brain-imaging and genetic technologies, scientists can now observe the earliest physical indicators of brain aging in people as young as age 25. Tiny plaques and tangles that develop and grow ever denser in our brains often begin accumulating decades before any middle-age forgetfulness sets in. A minute spot of plaque on a 30-year-old brain could possibly indicate Alzheimer’s disease forty years from now, just as a tiny little snag of the dentist’s probe can mean a cavity in the making.

But we need not despair. Misplacing your keys a couple of times doesn’t mean you should start labeling your cabinets. Memory loss is not an inevitable consequence of aging. Our brains can fight back, and The Memory Bible will give you the tools. We can improve our memory performance immediately and stave off, possibly even prevent, future memory decline. The sooner all of us begin our memory program, the sooner we will be on the path to keeping our brains young and healthy for the rest of our lives.

Chapter One

You Have More Control Than You Think

I have a photographic memory but once in a while I forget to take off the lens cap.

—MILTON BERLE

Imagine struggling your way out the glass doors of a crowded mall in late December, loaded with shopping bags, packages, and presents. Your head is pounding and your feet hate you and the shoes you walked in on. You’d die of starvation this second if you weren’t already dying of thirst. You manage to pull out your car keys and glance up at the humongous, jam-packed parking structure when it hits you—you’ve forgotten where you parked.

Could never happen to you, you say? Ever forgotten your purse, wallet, or phone at home, only to remember it while caught in rush hour traffic? Maybe you’ve struggled to remember the name of a movie you saw last night or that new neighbor you just met, not five minutes ago. Ring a bell?

Most of us laugh off these so-called middle-aged pauses, considering them just another normal annoyance of aging, not a true memory problem, and certainly not a sign of Alzheimer’s disease—not at “our age.” I hate to pop another “I could party all night and still get to work on time if I wanted to” baby-boomer bubble, but it’s time for us all to wake up—we are all one day closer to Alzheimer’s disease.

It Is Never Too Late or Too Early to Fight Brain Aging

Just as all of us inevitably get older, convincing scientific evidence shows that Alzheimer’s disease is not simply an illness that some old people get. Alzheimer’s disease or a related dementia may well be everybody’s end result of brain aging—and it begins forming in our brains much earlier than anyone previously imagined, even in our twenties.

The subtle, gradual aging of the brain starts as tiny plaques and tangles that begin accumulating there, decades before a doctor can recognize any symptoms of the disease. In fact, these plaques and tangles begin forming so early in our adult lives that subtle memory and language changes go unnoticed and ignored for many years. Nonetheless, these minuscule spots of plaque in our otherwise healthy brains are the first signs of brain aging, and they will increase insidiously if we do nothing about them.

When I speak on this subject, I am often asked: Will my brain already be irreversibly damaged by the time I reach middle age? Is it too late for me to try to head off this inevitable process? Is it too soon for me to start? Is my memory ability destined to decline no matter what I try to do about it?

My answer to these questions is no. It is never too late or too early to start beating the brain-aging game. Even if, one day, research finds a way to restore already lost brain cells, scientists agree that preventing the loss of memory will always be easier than restoring it. The sooner we rise to the challenge, the sooner we can intervene in the battle, like little neuron-gladiators, and, with luck, do so while our forgetfulness is minimal or even imperceptible.

Our Brains Aren’t Getting Any Younger, but They Can Get Better

One of the biggest obstacles to starting a program to improve memory performance and protect our brains from Alzheimer’s disease is denial that one’s brain, as well as one’s body, is aging. Many people struggle to accept the physical changes that come with passing years, yet coming to terms with mental changes is often an even greater challenge.

Sally B. knew her sixty-fifth birthday was coming up, but she wished her husband, Jerry, and best friend, Lisa, would stop harping on it. All they talked about was how great her fiftieth birthday party had been and how they wanted to top it. Sally figured she must have had a couple of drinks because she could hardly remember it, and she didn’t recall agreeing to this new party either.

For several weeks, Jerry and Lisa kept reminding Sally to make her guest list, but Sally kept forgetting to do it. Finally, Jerry said either she was trying to avoid the party or she needed to talk to their internist about her memory problems. In fact, Jerry had been worrying about Sally’s forgetfulness for some time.

Sally scoffed at Jerry’s “accusation” and told him that her mind was perfectly fine. If anyone was getting old and losing their marbles, it was him. Sally truly didn’t understand where the last ten years had gone and the thought of turning 60 seemed so odd. She didn’t feel sixty-five, and thanks to Dr. Mark, she sure didn’t look it. In fact, lots of people at the tennis club said that she and her daughter looked just like sisters.

Sally had been a patient of Dr. Mark, a well-known cosmetic surgeon in town, for almost twelve years. Everybody said he gave the best Botox and Restylane injections in town, but he’d also performed a discreet face-lift and tummy tuck on Sally.

Jerry, still going on about her birthday party, insisted that Sally wouldn’t have to do a thing! She could just buy a dress and show up. Sally thought it over, and finally said okay. But, she added, she was going to call Dr. Mark so she could get a mini face-lift ASAP.

Jerry hit the roof. “No more calling Dr. Mark, Sally.

“Don’t you remember how bad the anesthesia was last time? Took you days to recover. Elective surgery is not a good idea at your age.” Sally glared at him and said that at ‘her age’ she could do what she liked.

After bickering back and forth a bit, they cut a deal. If Sally would accompany him to their family doctor to discuss her memory, Jerry would back off about Dr. Mark.

The internist performed a standard memory test on Sally in the office and was concerned enough to send her to a geriatric psychiatrist to get a more detailed assessment. After several meetings, the psychiatrist sat down with Sally and Jerry together. Sally was indeed suffering from some mild age-related cognitive impairment. As difficult as that was for her to accept, thankfully there were plenty of things she could do to fight it; however, getting another face-lift or eye job surely wasn’t going to help.

The psychiatrist recommended she start taking a cholinergic medication, begin a memory-training program, and try various other strategies to protect her brain. He explained to Sally that success with this treatment required acceptance and a strong commitment. The psychiatrist also expressed concern about unnecessary elective surgeries because repeated general anesthesia can potentially worsen memory ability.

Sally began walking a half hour every day and taking medication to improve her memory. She started a program for keeping her brain young that included antioxidant foods and stimulating mental aerobics. In several weeks, Sally, as well as her family and friends, noticed improvement in her memory and her mood.

Sally had a wonderful time at her sixty-fifth birthday party, as did everybody else. And she and her daughter looked just like sisters.

Beginning a program to improve memory and slow down brain aging requires accepting that we need such a program. A better understanding of what actually happens to our memory abilities and our brains as we age will help us keep our brains at their peak performance.

What Is Memory?

Normal memory performance involves both learning and recall (Figure 1.1) and requires intact functioning of several regions of the brain and the brain cells, or neurons, within them. We generally think of memory as an abstract concept—a thought, image, sensation, or feeling that is stored somewhere in our brain’s filing cabinet, ready to be pulled out at will. However, because our brains comprise nerve cells, chemicals, and electrical impulses, our memories are actually encoded, stored, and retrieved as a result of minuscule chemical and electrical interactions.

Each nerve cell in the brain has a single axon that acts like a telephone line, conducting nerve impulses toward neighboring neurons. The friendly neuron next door receives the countless assortment of electrical impulses sent to it daily, through its dendrites—bunches of thin filaments extending out like little antennae, receiving and sending information. But the new info is not home free yet.

To allow all of our brain’s neurons to communicate with the others, the axons and dendrites form thousands of branches, and each branch ends in a synapse, a specialized contact point or receptor that recognizes only extremely specific information being passed between neurons. Each neuron has approximately 100,000 synapses.

Electrical nerve impulses containing the new information, retrieved memories, or relayed messages shoot down the neuron’s axon and slip through one of its skinny dendrites into a hyperspecific synapse, where a packet of chemicals, known as neurotransmitters, gets released. These neurotransmitters are the “carrier pigeons” that travel the minuscule space from one synapse to the next. Upon arrival, the correct chemical neurotransmitter binds with its corresponding receiver, and voilà! The message is received. In this way, thoughts and ideas are conveyed, information is learned, and memories are retrieved, all of which cause us to do, think, or act in different ways.

In any waking situation, our senses are bombarded by sights, sounds, and other stimuli that pass through our immediate memory and move into a holding area known as short-term memory. We usually lose most of these fleeting sensations in milliseconds, and of the few retained in our short-term memory, only a small percentage ever make it into long-term memory storage. Today, thanks to our computers, smartphones, and other devices, we are constantly bombarded with more and more incoming data. This often results in information overload that likely decreases the percentage of stimuli that enter our short- and long-term memory stores.

An essential key to retaining information longer is to organize and rehearse it, thus actively working it into our long-term memory. Some people require great effort to develop these skills, whereas others are born with a knack for memory techniques and “tricks” to reinforce new information and make it stick. They are often considered to have “photographic memories”—a myth we shall discuss later.

Once information is lodged in our long-term memory, it becomes relatively permanent and can be recalled years later—as long as our brains remain healthy. Whereas short-term memory has only limited capacity, long-term memory has the potential to store tremendous amounts of information. Retrieving this information later, or pulling it out of memory storage, is known as recall. Even patients with advanced Alzheimer’s disease, who may have difficulty remembering their morning meal, have been known to recall long-ago events, such as their first date with a sweetheart, in vivid detail.

Figure 1.1

Scientists have learned how the brain converts short-term memories into permanent ones at the molecular and cellular level. A specific protein must be present in the brain’s cerebral cortex, the outer rim of the brain containing gray matter, for the process to succeed.

The brain’s hippocampus, a seahorse-shaped brain structure located in the temporal lobe of the brain (near the temples), stores information on a temporary basis—much as a computer holds data in its random access memory. When the brain converts the information into permanent memory, similar to writing data to a computer’s hard disk, the hippocampus interacts with the cerebral cortex to complete the task.

Sex, Style, and Emotion

People vary in their learning styles. Long before I became interested in memory research, I instinctively relied upon my visual learning strengths in everyday life. I had always found it easier to remember someone’s last name if I spelled it out in my mind’s eye. Auditory learners retain information best if they hear it, whereas visual learners remember best when they actually see the information.

Memory and other cognitive skills often vary according to gender: women tend to have better verbal and language abilities, whereas men generally have the edge in spatial and mathematical abilities. However, when I mentioned this to Gigi, she nearly managed to talk me out of it.

Various other factors influence our memory abilities. Emotional states have a major impact on the efficiency and the quality of memories. Ask yourself where you were and what you were doing when you learned about the planes crashing into the World Trade Center on 9/11. (If you are too young to remember that, you may not need this book yet!) All of us who were around certainly know the details of where we were, whom we were with, and how we felt, yet I doubt that we can remember similar details of events the week before. Information that is emotionally charged has a distinct quality and is easier to learn and recall. The memory of your first crush in elementary school probably remains distinct. Many of us can recall details of that boy or girl we barely knew decades ago. By contrast, when we are experiencing feelings of depression and prolonged anxiety or stress, we become distracted and our memory abilities diminish.

Memory Changes with Age

Although we all experience some forgetfulness as we age, we each differ in our degree of memory change, our concern about it, and the steps we take to cope. By the time we reach our thirties and forties, so-called normal memory complaints become more common.

Middle-aged and older people most often notice difficulties with:

• People’s names

• Important dates

• Location of household objects

• Recent and past events

• Meetings and appointments

• Recalling information

Age-related memory loss more often involves recent memories rather than distant, past ones. We might forget what movie we saw last weekend yet still recall our ninth grade homeroom teacher’s name. Neuropsychological evidence shows that age tends to slow down our learning and recall skills, perhaps making it more difficult for older adults to learn a foreign language or scientific discourse. (I wouldn’t want to try to pass advanced calculus again at 50.)

Older people have greater difficulty multitasking and our reaction time can slow down as we age, which can affect our daily activities. Many older drivers compensate by driving more slowly, which can be a hazard in itself. Memory training (Chapters 3 and 6) and a program of mental aerobics (Chapter 5) can help lessen the impact of many of these age-related changes.

In the early 1990s, memory experts defined diagnostic criteria for the memory changes that accompany normal aging. When someone over 50 had a memory impairment demonstrated by at least one standard memory test, along with a subjective awareness of memory changes, they called the phenomenon age-associated memory impairment (also referred to as normal aging). These experts estimated that 40 percent of all people are affected by this condition upon reaching their fifties, 50 percent in their sixties, and over 70 percent by age 70 and older.

Although there is debate over whether age-associated memory impairment will or will not progress and at what rate, it is likely that the condition precedes other, more severe memory declines.

Without some form of intervention, whether it’s implementing strategies to keep your brain young and healthy or, if needed, medical evaluation and treatment, people who ignore their age-associated memory impairment may eventually develop mild cognitive impairment. An estimated seventeen million Americans over age 65 suffer from this more severe memory decline, and this condition has a 10 to 15 percent chance of developing into Alzheimer’s disease with each year that passes.

Figure 1.2

These diagnostic categories—age-associated memory impairment, mild cognitive impairment, and Alzheimer’s disease—are basically categories of convenience, allowing doctors and scientists to better understand our aging brains and test treatments to alleviate memory decline (Figure 1.2). In reality, the changes in our brains and the memory difficulties we experience are continuous, fluid processes beginning remarkably early in our lives. Several studies point to just how early.

Language Skills and IQ Tests at 20 Predict Alzheimer’s Disease at 80

In the 1980s, Dr. David Snowdon and his associates at the University of Kentucky performed clinical evaluations and standard memory tests on a group of nuns who were aged 70 or older. Each of these participants in what is known as the Nun Study kept diaries when they entered their convents in their early twenties. The scientists had access to these earlier documents and performed a standardized linguistic analysis of these diaries, objectively rating early language ability. The nuns whose youthful writings demonstrated greater idea density and grammatical complexity were much less likely to develop significant memory loss or Alzheimer’s disease decades later, in their seventies.

The study’s conclusion, that language ability at age 20 may predict whether someone will get Alzheimer’s disease fifty years down the road, stirred debate over whether learning and educational enrichment protected the brain from decline over time, the “use it or lose it” theory. Today, we have more scientific information to support the possibility that both nature and nurture contribute to brain aging and memory decline, and that those declines can be detected decades before people reach old age. For example, Dr. Linda Chang of the University of Hawaii and coworkers performed MRI scans (magnetic resonance imaging), cognitive assessments, and genetic tests on more than 1,100 healthy children and adolescents aged 3 to 20 years and found that those young people with the APOE-4 genetic risk for Alzheimer’s disease had smaller hippocampal memory centers and lower memory scores than did those without the genetic risk. The findings suggest that genetic testing in young children may provide the earliest indicators to identify those who might benefit most from early prevention strategies to avoid and delay the onset of dementia late in life.

Other investigators have focused on assessments of intellect, which tend to be stable throughout life, but may still provide early signs of subtle cognitive challenges. Scottish psychiatrist Dr. L. J. Whalley and his colleagues studied intelligence test records to determine whether a person’s IQ early in life predicted Alzheimer’s disease up to fifty years later. This group found that people with lower intelligence test scores in childhood had a greater risk for the late-onset form of Alzheimer’s disease that begins after age 65.

Dr. Whalley offered several explanations for the observation, including the possibility that people with lower intelligence in childhood might engage in behaviors later in life that put them in greater danger of getting Alzheimer’s disease. They may eat a less healthy diet, avoid exercise, or smoke. Alternatively, the low IQ score may reflect the early signs of the disease itself deteriorating the brain subtly early in life. This could then influence school performance and further educational pursuit. Together, this body of research suggests that having less education may not be the cause but may actually be the result of the early stages of brain aging.

The Incredible Shrinking Brain: Beware of Plaques and Tangles

As our brains age, the synapses, or connections between neurons, begin to function less efficiently. Messages firing from one region of the brain to another may get scrambled, and crucial communication from one part of the brain to the other may break down. One area of your brain may tell you to walk into the kitchen and open the refrigerator, but then you just stand there. Unfortunately, the part of the brain that should have told you to reach in and get a soda because you’re thirsty didn’t receive the message.

Data show that as our neurons age and die, the actual overall sizes of our brains shrink or atrophy. Also, our aging brains accumulate lesions known as amyloid plaques and neurofibrillary tangles. These collections of decayed material result from cell death and degeneration of brain tissue, particularly in areas involved in memory: the temporal (under the temples), parietal (above and behind the temples), and frontal (near the forehead) regions of the cerebral cortex, the outer layer of brain cells. As these lesions accumulate, a healthy, plump brain containing only sparse plaques and tangles gradually shrinks to an atrophied Alzheimer’s brain riddled with plaques and tangles.

Historically, a definitive diagnosis of Alzheimer’s disease could only be made at autopsy after a patient had developed dementia (i.e., a cognitive impairment severe enough to interfere with daily life). The pathologist would count up the number of plaques and tangles that had accumulated in these key brain regions, and if their concentration surpassed the defined threshold, the patient under examination definitely had Alzheimer’s disease. Scientists have studied brain autopsies in people who had only mild cognitive impairment rather than dementia. They see the same plaques and tangles, in the same brain areas, only in lower concentrations.

These autopsy studies have now been extended to people in their twenties and thirties who had normal memory abilities, and still these brain lesions are seen to be present, albeit in lower concentrations. In every age group, the accumulation pattern is consistent: the lesions start in areas near the temporal lobe and spread to the parietal and frontal regions. Most of us, unless of course we have a genetic risk or some other predisposition, don’t live long enough to reach the plaque-and-tangle threshold defined as full-blown Alzheimer’s disease.

Studies of the annual incidence of Alzheimer’s disease, or the percentage of the population that develops it each year, show that the rate of new Alzheimer’s cases doubles every five years between ages 65 and 90. Scientists suspect that if the current trend toward increased life span continues, people may soon be living, on average, well into their eighties and nineties. Unfortunately, the proportion of the population with Alzheimer’s or another dementia will rise correspondingly. In fact, I suspect that, if we did nothing to prevent brain aging, the prevalence of Alzheimer’s disease would approach 100 percent if we all lived to be age 110 (Figure 1.3).

Figure 1.3

The rate at which our brains age varies according to our individual genetic predisposition, lifestyle choices, and our lifelong environmental exposures. Also, the use of new technological advances allows us to recognize the earliest signs of brain aging without having to dig up our old high school diaries or agree to a brain biopsy.

Big Heads Don’t Make Men Smarter

Subtle and not so subtle differences between women and men likely influence memory abilities and brain health as they age. Women have smaller brains than men. (It’s just a fact, don’t shoot the messenger.) The average brain weight for an adult man is just over three pounds, whereas the typical woman’s brain is a bit over two and two-thirds pounds. Neuroscientists have found that generally the bigger the brain, the smarter the animal, but that rule does seem to break down with the human brain—a point my better half will argue adamantly.

Studies of brain structure and function have shown that although women have smaller brains, their brains are more efficient, thus leveling the overall intellectual abilities between women and men.

Dr. Ruben Gur and his colleagues at the University of Pennsylvania looked at the amount of gray matter in the brain—the outer part containing cell bodies that allow us to think—and found that, on average, 55 percent of a woman’s brain contains gray matter, compared with only 50 percent of a man’s brain. This may explain why women score higher in language and verbal ability tests than men. By contrast, men have a higher proportion of white matter, which transfers information from distant regions, perhaps a key to their greater visual-spatial abilities.

Granny’s Not Sick, She’s Just Old and Getting Senile

When I was growing up, Billy J., the kid across the street, had his grandmother living with him. Every once in a while, she would wander out of the house, and Billy’s parents would have to go looking for her with the car. One time, they didn’t find her for an entire day. When my father, a physician, asked Billy’s dad if he could recommend a doctor to help her, Billy’s dad laughed and said, “Granny’s not sick, she’s just old and senile.”

Early in my clinical and research training in geriatric psychiatry and Alzheimer’s disease, Dr. Lissy Jarvik stressed that senility was not a normal part of aging but instead a disease. This was an important message at the time because most experts were ignoring the problems of aging, even the most common ones: memory loss and dementia. By emphasizing the disease factor, investigators began to approach the problem as an abnormality that required accurate diagnosis and specific treatment.

In fact, this has long been the basic approach of Western medicine, to diagnose a disease and look for the best treatment and cure. It is still a challenge to initiate proactive, preventive approaches to diseases. We all want a quick cure, a magic pill to alleviate our problems when they occur. Patients and physicians are reluctant to “fix it if it ain’t broke.” But when it comes to an aging brain, what we don’t know will hurt us.

Understanding senility to be a disease state, whether in its early or late forms of dementia or as full-blown Alzheimer’s disease, was crucial to getting researchers to focus on how our brains change with age and the problems that can and do arise. With today’s knowledge, as well as new tools that allow scientists to see the brain changing at its very earliest stages, the future lies in research and treatment to help slow or halt these changes and someday repair any existing damage.

Of course, we must all first face our own fears about what our memory problems may imply and any stigma we attach to “mild forgetfulness.” With the understanding that brain aging is a human phenomenon that affects us all, hopefully people will begin using The Memory Bible’s strategies to become proactive about preventing memory loss and protecting their brains from Alzheimer’s disease. Those with more pronounced memory loss conditions may become empowered to come forward and begin using new brain-imaging technologies for early detection and treatment of dementias and Alzheimer’s disease.

Memory Training—Brain Fitness

If you’re reading this, you are most likely seeking knowledge on how to maintain a young and healthy mind, maximize your memory performance, and protect your brain from Alzheimer’s disease. The memory program described in the chapters ahead will help you accomplish these goals. What’s more, you will see your memory improve as soon as you get started.

When neuroscientists studied brain scans of volunteers playing the computer game Tetris for the first time, they found high levels of brain activity. A month later, when the volunteers had become proficient at the game, their scans displayed significantly lower levels of brain activity. This lower brain activity, indicating greater mental efficiency, tells us that with time, practice, and familiarity, our brains essentially adapt themselves to achieve the same results with less work. The process is similar to what occurs when people train their muscles by lifting weights—their bodies eventually develop muscular efficiency. Bench-pressing the same barbell will require much less effort after a month of training, and most athletes have to add more weight if they wish to continue strengthening.

Knowing that our brains can become more efficient if we practice or become skilled at memory techniques, we can begin to systematically train our brains. By using games, puzzles, and some new approaches to daily activities, we can improve our short- and long-term memory abilities and possibly prevent future memory loss and Alzheimer’s disease.

Studies have shown that memory training, an integral part of any program to slow brain aging, benefits more than just mild forgetfulness and overall memory. The training also gives the user an awareness of their improvement, allowing them to feel good about their enhanced learning and recall skills, which in turn improves their memory performance even more.

Research points to various forms of mental activities, vocational occupations, and educational achievement as a means to decrease our risk for future memory decline and eventual development of Alzheimer’s disease. People engaged in mentally challenging jobs or pursuits are somehow more protected from future memory losses.

Scientific cause and effect has been proven in the laboratory using mature animals, half of which were allowed to live in a mentally stimulating and exciting environment with mazes, toys, and hidden surprises and snacks. The other half was exposed to dull, standard-issue laboratory living environments. Although brain size in these mature laboratory animals generally shrinks with age, the animals exposed to mentally stimulating environments had higher numbers of neurons in the memory areas of the brain as well as better learning abilities than the experimental animals in the less interesting settings. If these findings hold true for humans, they point to continued mental activity throughout life as a strong preventative for future cognitive decline.

Joe T., an insurance agent, and his wife, Alice, a school administrator, used their savings to buy a small second home overlooking the fifth hole of a beautiful golf course in a desert retirement community. Although it took four hours to get there, they used it almost every weekend and holiday, usually inviting friends or family along to golf and enjoy the views. Joe was ecstatic when he and Alice finally qualified for early retirement—at last they could stop working, move to their desert house, and start living the good life while they were young enough to enjoy it.

Alice cried at her office farewell party—after twenty-six years, her coworkers had become like family and she had enjoyed the daily challenge of coming to work and “putting out fires.” As they finished packing, Joe was more excited than a kid on his first trip to Disneyland. He kissed Alice, the love of his life, as he carefully folded an array of new Hawaiian shirts and swore he’d never wear a suit and tie again.

The first six months in the desert passed quickly as Joe relandscaped, installed an outdoor grill, and perfected his golf swing. Alice got busy redecorating the house and entertaining their frequent houseguests. Before the year was out, Alice, who had already cut back on golf due to the heat, was sidelined altogether by a sprained ankle. They got cable TV so she could watch her favorite old movies.

Their daughters and grandchildren began to visit less frequently, as did their friends. Alice understood that everybody had hectic work and school schedules and that it wasn’t easy to get away to the “good life” every weekend, but she still got lonely. Joe encouraged Alice to get involved with the country club and other local groups.

Alice tried, but she was never fond of playing bridge and soon grew weary of the club’s events and the community’s women’s organizations. She spent hours on the phone with friends and family and checked in with her old office at least once a week. She missed her old life and was just plain bored.

She began having trouble sleeping through the night and needed to nap during the day. Alice became withdrawn and depressed, and Joe couldn’t understand it. He tried to make her see the bright side—they were healthy, they were in love, and they were living their dream. Alice wondered if she had ever actually had this dream. Perhaps it was just that Joe had wanted it so badly that she started wanting it too, because she loved him. Well, it hardly mattered now.

Alice’s memory lapses started slowly—forgetting a barbecue at the clubhouse, mixing up the arrival dates of visitors—but they were soon noticeable to Joe and their daughters. Alice had never before missed a birthday call to the grandkids or forgotten to buy half the items she needed at the market. She was worried and told Joe that either she was going senile or the desert heat was cooking her brain.

They consulted a local doctor to help figure out why these memory problems had come on so quickly. After all, she had gotten rid of the stress and responsibilities of her job and she needed to remember less now than she used to. After examining Alice, the doctor concluded that her memory lapses might be due to boredom and general lack of mental stimulation. It sounded to him like maybe what she needed was to get a job. Joe immediately said that was ridiculous, they were retired now, but Alice was intrigued by the idea.

She was reluctant to make Joe alter his dream in any small way, but in marriage one learns to compromise, and they had always done it well.

There was a job opening for an executive administrator at the local school board, and Alice easily landed it. Her memory improved, her ankle healed, and for her, the good life included the daily mental challenge that came with work and productivity.

For Alice and many like her, mental stimulation is crucial to mental health and memory performance. She had thrived on a certain level of mental stimulation, and once that was removed, she swiftly declined. Memory training is actually a focused form of mental stimulation that allows you to efficiently pack a big memory punch in a short amount of time. Even if memory training doesn’t ultimately prevent Alzheimer’s disease, it will improve current memory ability. It is eminently achievable. One of the greatest benefits of memory training is that it gives us tools to use throughout our lives. If we master the techniques early on, we have a better chance of heading off memory loss that might emerge in the future.

Windows to Your Brain: Technologies That Detect Brain Aging

Despite our best efforts in gyms and beauty salons, the physical results of aging are fairly obvious: wrinkling skin, graying hair, even disappearing hair for many of us. In contrast, brain aging is a much greater challenge to detect. Scientists have searched for decades to find a way to view brain structure and function, so as to pinpoint a problem that might improve with treatment and determine the specific treatment, when to intervene, and whether the patient was benefiting from it.

During the past few decades, there have been research breakthroughs from diverse scientific disciplines—genetics, chemistry, physics, biomathematics, as well as others—that are finally opening windows into the brain, using such new technologies as positron emission tomography (PET) scanning. We can now view brain aging directly and thereby specifically guide our treatments to prevent future memory loss.

During medical school in the mid-1970s, I remember our excitement the first time we viewed computed tomography (CT) scans of the brain. We finally had a way to look at brain tissue beyond what conventional X-ray machines could provide. With the development of MRI scans, we could see even more detailed brain images—enabling us to diagnose strokes, tumors, and hemorrhages. Although these innovative techniques provided information on brain structure or shrinkage, indicating that brain cells had already died, they offered no information about how well the still-living brain cells were functioning. If only we could actually see how effectively the neurons were or were not communicating with one another, then we might be able to pick up, and treat, subtler brain deficiencies before the cells died. Thanks to my UCLA colleague Dr. Michael Phelps and others, we have the stunning breakthrough discovery of PET scanning and can finally see this kind of subtle brain dysfunction in living humans.

Positron emission tomography reveals a consistent pattern in Alzheimer’s disease. The parietal and temporal areas—where Alzheimer’s first strikes—show reduced activity in the early stage of the disease. It looks as if those important brain memory centers are subtly and gradually fading away (Appendix 2). The PET scan is certainly a sensitive technology for making an accurate, early diagnosis for guiding treatment. We have used it in our clinics to diagnose Alzheimer’s disease years before most doctors would be able to confirm the diagnosis with conventional methods.

There are many of us who suffer from much milder memory symptoms, and my research team wondered whether these imaging technologies could help us recognize more subtle brain aging. By combining PET scanning and information on a person’s genetic risk for Alzheimer’s disease, we uncovered a way to observe very mild brain aging—the changes that are occurring today in many middle-aged and older adults. These tools may also help us to gauge the success of our memory fitness program and other interventions at slowing that brain-aging process down.

DNA Before AARP—Genetics of Brain Aging

The science of genetics has ballooned in the last fifteen years. Most of us know that genes are the blueprints of life, and everybody’s DNA differs just enough to make us all individuals—more reliable, even, than fingerprints.

When we think of genetic traits being passed from one generation to the next, we usually think of physical features such as hair and eye color, facial features, height and build, and so on. It is only in recent years that medical conditions, such as heart disease, high cholesterol, and cancer, have been discovered to pass within families genetically.

Traditionally, the common, late-onset form of Alzheimer’s disease, which affects people after age 65, was not thought to have a genetic influence, but to be a normal result of aging. We now believe the cause involves a combination of environmental, lifestyle, and genetic influences.

Many genes have been discovered to be involved with age-related memory loss and Alzheimer’s disease. A defect in some genes causes early-onset familial Alzheimer’s, a rare and devastating form of the disease that hits people early in life, before age 65, and normally strikes half the relatives in those families.

For the common late-onset Alzheimer’s, however, one major genetic risk has been discovered: apolipoprotein E, a.k.a. APOE. This APOE gene makes a protein that transports cholesterol and fats through the body and is known to influence the risk for heart disease and related conditions, so it was a big surprise when geneticists found another link—this time to Alzheimer’s disease and memory loss. APOE comes in three different forms, or alleles: APOE-2, APOE-3, and APOE-4. All of us inherit one APOE form or allele from each parent for a combination of two alleles, known as a genotype.

Drs. Allen Roses, Margaret Pericak-Vance, and their coworkers at Duke University were the first to show that the APOE-4 allele was much more frequent in Alzheimer’s patients than in normal people. Approximately 65 percent of the population has the APOE 3/3 genotype; 20 percent has the 3/4 genotype—a high risk for developing late-onset Alzheimer’s disease; and 2 percent the 4/4 genotype—an even higher risk for Alzheimer’s disease.

Although the APOE-4 gene increases a person’s risk for Alzheimer’s and makes it more likely that they’ll get the disease at a younger age, an APOE blood test result alone is not enough to accurately predict whether an individual will get the disease. The research team I have directed achieved a significant advancement in understanding the brain-imaging window using PET by linking it to the latest research in genetics. Combining these scientific technologies for the first time provided a key for early detection of subtle brain changes related to aging, changes that may precede the onset of Alzheimer’s disease by several decades.

Prevention Is the Best Medicine

By the time a patient develops Alzheimer’s disease, the damage is done and irreversible. In the absence of a “cure,” our best shot at beating Alzheimer’s lies in prevention, and targeting mild forgetfulness is where we at UCLA started. A large challenge has been to determine which of the millions of forgetful people would be most likely to benefit from preventative treatments.

In the mid-1990s, our research group combined information about brain function and genetics in our studies of people with only mild memory complaints. With aid from the National Institutes of Health and in collaboration with the Duke University genetics group, we found that middle-aged people without Alzheimer’s disease still displayed decreased brain function in the parietal region of the brain—an area important to memory—if they possessed the APOE-4 genetic risk. Dr. Eric Reiman and his collaborators at the University of Arizona independently confirmed our discovery. Our research group also discovered that this decreased brain activity worsens over the years. Everyone with the APOE-4 genetic risk for Alzheimer’s disease showed decline in brain function on follow-up PET scans in the parietal and temporal memory areas of the brain.

These discoveries have provided us a standard way to detect decline in brain function long before people get to end-stage brain aging, that is, Alzheimer’s disease. In response to these breakthroughs, moreover, my team has developed innovative clinical and research programs wherein we test new treatments to see whether we can slow down the decline in brain function in adults at any age, from 20 to 100 years.

For a preventative treatment to be considered effective, it must slow down the rate that brain activity declines over the years compared with a placebo or an inactive intervention. In Figure 1.4, the solid line indicates the rapid decline of someone receiving a placebo, while the dotted line shows the slower decline of someone receiving an active drug that prevents brain aging as measured by a PET scan. Using this approach, we have tested several drugs and nutritional supplements in middle-aged and older people, as well as the effects of memory training and mental aerobics on stabilizing brain function and slowing brain aging.

Figure 1.4

College Grads Get Higher (… Brain Activity, That Is)

Following up on the conclusions from the Nun Study—that subtle differences in the language abilities of young people might predict the development of Alzheimer’s disease fifty years later—my research team attempted to use PET scans to detect such brain function deficits in young adults. Dr. Daniel Silverman and I looked at the scans of people with normal memory abilities and compared their brain function in the posterior cingulate memory center, according to whether they had finished college. We found that those who had completed college displayed higher brain function during mental rest; however, this increased brain activity diminished with age. The 50-year-old college grads in our study had much higher activity levels than the 50-year-olds who did not complete college, whereas the 80-year-old college grads had only a very slight, if any, increase above 80-year-olds who did not complete college. Age had worn away their brain function reserve.

Based on these findings, Dr. Silverman and I systematically reviewed the PET scan results of a much larger group of young adults according to their educational achievement. We had results of PET scans showing the brain activity of people in their twenties—the same age as the nuns in David Snowdon’s study when they displayed differences in language ability predicting Alzheimer’s disease fifty years later. Figure 1.5 illustrates how people with higher education have enhanced brain activity and how this effect disappears with age.

Our study not only demonstrated subtle patterns of brain function reserve in young adults, but it supported the idea that subtle brain changes can be observed in people beginning in their twenties, an age when Alzheimer’s disease wouldn’t normally strike for another forty or fifty years. When we looked at the effect of higher education added to the effect of the Alzheimer’s APOE-4 genetic risk, we found, as expected, that the young adults with the greatest brain activity had completed college and did not have the APOE-4 gene. It is interesting to note, however, that the influence of a college education on a person’s brain activity reserve was even more powerful than that of the APOE-4 risk gene. Ideally, someone concerned about their APOE-4 genetic risk could compensate for possible brain activity deficits through further education.

Figure 1.5

These observations are consistent with autopsy studies of young individuals aged 22 to 46 years that have found the earliest stages of collections of plaques and tangles in 36 percent of those with the Alzheimer’s APOE-4 genetic risk, compared with only 11 percent of those without the genetic risk.

As yet, there is no conclusive evidence on the mechanism by which education protects brain cells. A study of brain autopsies showed that people with lower educational attainment had more evidence of vascular disease in their brains compared to those who had attended college. Studies show that educated people may be less inclined to smoke, drink too much, and eat fatty diets, which could keep their brains healthier. Our research group’s discovery is also consistent with the “use it or lose it” theory—it is also possible that having a healthier brain to begin with sets one on the college trajectory.

Other studies suggest that protecting the brain early in life through education and mental stimulation may be even more important than later in life. Such early environmental enrichment in childhood likely contributes to cognitive reserve, which is the brain’s ability to find alternate ways of completing a mental task thus allowing it to optimize performance in the presence of injury or pathology. In support of this concept is the repeated observation that some individuals with no apparent symptoms of dementia are found, at autopsy, to have brain changes consistent with advanced Alzheimer’s disease. These individuals did not show symptoms of the disease while they were alive because they had a large enough cognitive reserve to offset the damage and continue to function as usual.

Investigators at Rush University Medical Center in Chicago, Illinois, looked into whether cognitive enrichment that occurs early in life is associated with cognitive decline late in life. To address this question, they studied early-life socioeconomic status, availability of cognitive resources at 12 years of age, the frequency of participation in cognitively stimulating activities, and early-life foreign language instruction in over eight hundred research participants whose average age was 90 years. They found that these indicators of early-life cognitive enrichment were significantly associated with better late-life cognitive health, thus further supporting the idea that it is never too early in life to start protecting our brains.

The Cognitive Stress Test

My research group also has developed a cognitive stress test, similar to a cardiac stress test that a cardiologist might give a heart patient, whereby the patient exercises on a treadmill to stress the heart, in order to bring out subtle cardiac abnormalities not observed on an electrocardiogram performed during rest. In devising the cognitive stress test, we asked volunteers to perform memory tasks during brain scans to observe subtle brain alterations not observed by the scanner during mental rest. Dr. Susan Bookheimer and I used functional MRI scans, which show brain activity during mental tasks.

About half of our study’s volunteers had the APOE-4 genetic risk for Alzheimer’s disease, while the other half did not. Everyone performed the same memory tasks during their scans, which included learning and then attempting to recall a series of unrelated word pairs (e.g., author–tree, table–elephant). All the participants performed this task relatively well, but those with the Alzheimer’s APOE-4 genetic risk required a significantly greater amount of brain activity to accomplish the same memory task. The areas of the brain that worked the hardest to complete the memory tasks were the very same areas where Alzheimer’s disease initially strikes. In fact, within the hippocampus, one of the brain’s main memory centers, brain activity for the at-risk volunteers was double that of people without the genetic risk. Not surprisingly, our cognitive stress test was fairly accurate in predicting which participants eventually developed further memory loss several years later.

PET Scanning and Genetic Testing: Are They Ready for Prime Time?

In 2004, I was part of a group of PET scan researchers to speak to policy makers at the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers Medicare and Medicaid (in partnership with state governments). We detailed the scientific evidence indicating the value of PET scanning in detecting Alzheimer’s disease early in its course and differentiating it from other forms of dementia. Following lengthy discussions and input from community stakeholders, the agency concluded that the use of a PET scan was reasonable and necessary in patients who had a recent dementia diagnosis and met diagnostic criteria for both Alzheimer’s disease and frontotemporal dementia. This decision was based in part on the fact that PET scan patterns can differentiate between these two forms of dementia. The agency realized that the PET scan images can guide treatment strategies, since medications used to treat Alzheimer’s disease are not indicated for patients with frontotemporal dementia.

Most doctors do not recommend APOE genetic testing for only mild memory complaints. If someone receives a clinical diagnosis of Alzheimer’s disease, then an APOE test might be recommended to increase diagnostic accuracy. In those rare families where nearly half of relatives develop Alzheimer’s disease before age 65, more extensive genetic counseling and testing is generally recommended.

We are continuing our work on combining PET scanning and genetic risk testing to assess new therapies for mild memory complaints that would prevent further brain function decline and memory loss. At the same time, geneticists are getting closer to identifying additional genetic risks for Alzheimer’s disease as we continue to refine and automate our biological brain-imaging technologies.

Chapter Two

Rate Your Current Memory

When I was younger, I could remember anything, whether it happened or not.

—MARK TWAIN

To effectively begin a program to improve memory performance and keep our brains young, we first need to rate our current memory ability level. Knowing where our memory abilities stand now directs us as to where to begin our overall anti–brain-aging program, enabling us to set an initial, easily attainable goal to ease us into the program.

Elliot S. was an accomplished 68-year-old statistician—a member of the National Academy of Sciences and among the short list of mathematicians in line for the Nobel Prize. He spent the first thirty years of his career working in a prestigious think tank before accepting an endowed chair from an Ivy League university. It was hard for family and friends to notice his memory decline since it was so gradual and he was such an introvert. Elliot’s records showed that in 1972, his IQ tested at 160—among the top 1 percent. At the time of his first visit to our memory clinic in March 2001, his IQ had declined to 115. Although much lower than his peak performance, he was still among the top 5 percent of the population. Therefore, someone meeting Elliott for the first time would never guess what his PET scan revealed to us: he had advanced Alzheimer’s disease.

The system by which we assess our current state of brain aging can vary, from simple self-assessment questions to more detailed biological measures. Although a PET scan is a sensitive technique to uncover early brain aging, I am not recommending that every one of us run out and get one tomorrow. For most people, this chapter’s memory rating system will suffice. It will also help individuals to find the correct level at which to begin their personal anti–brain-aging program. If upon completing this assessment, you feel you need additional consultation, see Additional Resources (here) to find organizations that provide local and national resources and referrals.

Subjective Versus Objective Memory Loss

Objective memory is how well we actually perform on a pencil-and-paper memory test. Subjective memory is our own perception of how well we think we do in memory functions. Both types of memory assessment are important in understanding the type of memory changes each individual is experiencing as well as in setting up a personalized memory fitness program.

Audrey M. watched her grandfather and aunt succumb to Alzheimer’s disease before their sixtieth birthdays. Although both her own parents died young in a car accident, she was convinced that she, too, would develop the disease at a young age and in her early forties began seeking a specialist. Audrey insisted on consulting the busiest neurologist in town and hounded him to complete an extensive test battery she had read about on the internet. Even though the doctor saw no indication for such an evaluation, he went along with her demands and ordered an EEG, MRI, APOE screening, and other laboratory tests, and a neuropsychological workup.

The doctor left for Europe after explaining that he’d give Audrey feedback when he returned and had the test results in hand. His first day back at the office, he checked his voice mail and found several messages from Audrey:

Message 1: Hello, doctor, this is Audrey M. You told me you’d be back in the office Thursday at 3 p.m. It’s now Friday, 10 a.m., you are not there, and neither are your nurses, Ilene, Carol, or Wendy. Please call me.

Message 2: It’s Audrey M., and I misplaced my keys again, doctor. I’m getting much worse, my memory is going. You must have all my test results by now. The APOE test was supposed to take longest, and that was due back last Wednesday by 4 p.m. Please, please call me.

Message 3: This is Audrey. I just lost my address book. One minute it was here; then it disappears into thin air. I don’t remember touching it. Thank god I know your phone number by heart. Call me the moment you get in.

The doctor checked Audrey’s test results, which showed no signs of Alzheimer’s disease. When he informed her, she broke down in tears of relief.

Clearly, Audrey’s anxiety and worry had colored her subjective memory awareness. Because of her family history, she was convinced that every minor memory lapse was a drastic onset of her worst fears. The doctor pointed out to her that even without her neuropsychological test results, her voice mail messages demonstrated a remarkable attention to detail and high level of objective memory ability.

Each individual is more or less aware of memory changes over a lifetime. Memory experts have found many factors that influence how seriously we take these changes and whether we will complain about them to others. A person’s mood and sense of well-being influence how much they notice and complain about forgetfulness. Depression and anxiety also increase self-awareness of memory difficulties. College graduates and others with higher education tend to rate their memory abilities better than do those who have never attended college. Of course, people are more likely to complain about forgetfulness as they get older. At a certain age, conversations, jokes, and complaints about middle-aged pauses and senior moments are a socially correct form of bonding, just like young parents’ complaints about their toddlers or teenagers’ complaints about their parents.

Memory scientists have developed standardized questionnaires for determining the degree to which each of us is aware of memory loss. Because so many different factors can influence awareness of memory loss, some question whether these so-called subjective memory measures accurately reflect true memory changes or whether they merely reflect each person’s distortions, prejudices, moods, and concerns rather than their actual memory ability.

My research group has performed extensive studies of these self-awareness measures and found that they indeed reflect an objective, biological change. In one of our studies, we asked a group of middle-aged and older adults with only mild memory complaints to complete one of these questionnaires. We found that people with a greater subjective awareness of memory loss had a much greater likelihood of also possessing the gene associated with Alzheimer’s disease risk—the APOE-4 gene. And both this genetic risk and increased awareness of memory loss predicted future decline in objective memory ability.

Dr. Daniel Silverman and I looked at a group of same-aged people with mild memory complaints who had received a PET scan when we evaluated how they rated their own memories. Two years later, we repeated their PET scans and found that those volunteers who believed their recall abilities were worsening actually exhibited significantly decreased activity in the hippocampus memory center of the brain on the later scan.

These findings emphasize the “go with your gut” approach to detection of brain aging. If you think your memory loss is “all in your head,” it may well be true, and worth looking into.

Rate Your Memory Change Awareness

To discover how aware you are of your own memory changes, you need a measuring system. The following assessment will help you to rate your awareness of different aspects of your memory abilities, especially the kinds of memory challenges that people commonly experience as they age.

Complete the following Subjective Memory Assessment by circling a number from 1 to 3 that best reflects how frequently (often, sometimes, seldom) you notice each memory challenge. Afterward, we will tally your results to use in determining the best training level for you to begin your memory program.

Subjective Memory Assessment

How often do you notice difficulties with the following? | Often | Sometimes | Seldom
remembering someone’s face but not their name | 1 | 2 | 3
misplacing keys or glasses | 1 | 2 | 3
forgetting what you wanted to say | 1 | 2 | 3
remembering a familiar word | 1 | 2 | 3
recalling errands or chores | 1 | 2 | 3
losing track of what you just read | 1 | 2 | 3
repeating yourself during a conversation | 1 | 2 | 3
forgetting plans or appointments | 1 | 2 | 3
losing track of what you want to say | 1 | 2 | 3
other people complaining about your memory | 1 | 2 | 3
getting lost in your neighborhood | 1 | 2 | 3
recalling the name of a movie or book | 1 | 2 | 3
walking into a room and forgetting why you went there | 1 | 2 | 3
remembering the day of the week or date | 1 | 2 | 3
recalling something that happened the day before | 1 | 2 | 3
forgetting something you thought you knew | 1 | 2 | 3

Add up all the numbers you have circled. If your total score is 42 or more, then your subjective memory difficulties are minimal. You may find that you quickly master the Three Basic Memory Training Skills (Chapter 3) and can move right on to more advanced memory skills training (Chapter 6). If your score is between 21 and 42, then you are noticing a moderate degree of memory challenge. You may want to spend more time on developing basic memory skills (Chapter 3) before moving on to advanced memory skills training. A total score below 21 reflects an even greater self-awareness of memory difficulties. A score in this range would suggest that memory training will be a greater challenge, so it is important to take your time with the exercises in the following chapters. You also might consider contacting your physician about these concerns or one of the experts in your area (see Additional Resources).

Objective Memory Ability

An objective memory test assesses our current learning and recall abilities. The traditional, extensive types of objective memory assessments—neuropsychological testing—can take hours to complete and require highly trained professionals to administer, score, and interpret. I developed the following simple, do-it-yourself objective memory-rating method that you can complete right now. This brief version of the more extensive assessment we use in our research and clinical work emphasizes retrieval or recall of words you will learn during the test. And, recall—the ability to pull that information out of your memory storage—is the major area of concern for most people. This objective assessment measure will complement the results of your subjective memory assessment and give you a clear idea of where to begin, as well as focus, your program.

Do not be discouraged if you find this memory assessment method too difficult or perhaps too easy. It is designed to assess memory in people with a wide range of abilities. It is also intended to be difficult at first to enable you to see concrete results from your memory skills training program soon after you start it. I guarantee that your score will improve immediately after reading Chapter 3.

The Objective Memory Test

Because the assessment is timed, you will need a stopwatch or kitchen timer or timepiece with a second hand before beginning. The test involves learning a list of ten words over a one-minute period and recalling them after a twenty-minute break. When ready, set your timer for one minute, then read and learn the words on the list in Assessment No. 1.

ASSESSMENT NO. 1 STUDY THE FOLLOWING WORDS FOR UP TO ONE MINUTE:

Plank

Banker

Sauce

Umbrella

Abdomen

Reptile

Lobster

Orchestra

Forehead

Jury

When your minute is up, put aside The Memory Bible, reset your timer for a twenty-minute break, and do something else—read a newspaper, start a crossword puzzle, whatever you like, just make sure you distract yourself from the word list with something else. After the twenty minutes, write down as many of the words as you can recall.

To interpret your score, add up the number of correct words you can write down after twenty minutes of distraction. If you did well on your objective memory recall score (8 or greater), then the basic memory skills (Chapter 3) will probably be quite easy for you to master and you can quickly move on to advanced memory skill training (Chapter 6). If your score is less than 8, then you need to spend more time on learning basic memory skills before moving on. If your score is lower, below 4, don’t panic. This assessment tool is designed to be difficult for many people. Move on to Chapter 3 and then see how you do on your retest. If your objective memory recall score improves, then continue to build your memory skills program. If not, you might consider contacting your physician or an expert in your area for a professional evaluation (Additional Resources).

Many factors can influence your objective memory score, particularly your age and level of educational achievement. In general, younger people score better than older people, and people who have had more educational experience will have better scores. The results are an indicator, a guide, not the last word on your current brain fitness.

Ironically, a common cause of memory complaints is worry and anxiety about memory performance. People with a family history of Alzheimer’s disease may fret about every memory slip. In fact, worry about memory difficulties may worsen actual objective memory performance. If you scored well on objective word recall after twenty minutes but your subjective memory score indicated frequent memory difficulties, you may be suffering from stress and anxiety. If you fit into this group, then I suggest turning to Chapter 4 (Minimize Stress) before beginning basic memory skills training (Chapter 3). Table 2.1 summarizes the information you need to decide at what level to begin your program.

Table 2.1

INTERPRETING SUBJECTIVE AND OBJECTIVE MEMORY SCORES
MEMORY SCORE |
Subjective | Objective | Program
High | High | Move quickly from basic (Chapter 3) to advanced (Chapter 6) memory training.
Low | Low | Take time and focus on basic training, then reassess score. If no improvement, consult expert.

Low

High

Focus on stress reduction (Chapter 4) before basic memory skills training. Reassess score and consult expert if no improvement.

When you have determined your initial, or baseline, subjective and objective memory performance scores, plot them in the charts in Figure 2.1. After completing the basic memory training (Chapter 3), you will be asked to take the objective test again. To assess your progress, return to this figure, enter your score, and congratulate yourself on your improved score after learning only a few basic skills. Try repeating both the subjective and objective tests again after completing Chapter 10. I believe you will see a clear and steady rise in both your subjective and objective performance as you continue to learn and practice the memory training skills and initiate your program of mental aerobics, stress reduction, and more advanced memory training.

Figure 2.1

Chapter Three

LOOK, SNAP, CONNECT:

THE THREE BASIC MEMORY TRAINING SKILLS

Everything should be made as simple as possible but not simpler.

—ALBERT EINSTEIN

Most of us have seen people with so-called photographic memories—they can rapidly learn and recall the order of cards from a shuffled deck or effortlessly memorize long lists of words or numbers. However, there is no such thing as a truly photographic memory; what we have seen are people with good memory techniques.

A memory technique is merely a coding system, a filing cabinet for the brain. A person’s prior knowledge and interests will influence how well they learn and recall new information. Many teenagers can readily recall scores of their favorite sports teams but cannot remember a single important date they learned in history class last fall. (You know who you are.)

Our memory’s filing and storage systems work most effectively when the new information contains meaning for us. Experiments with champion chess players show that they can readily memorize the chess pieces on the board if they are placed as they would be during a match, but the players’ ability to recall a pattern of pieces placed at random is almost impossible. One arrangement of chess pieces has meaning, whereas the other does not.

Such meaning may actually be hard-wired in our brains. When people focus on meaningful words as opposed to strings of random letters, functional MRI brain scans show increased activity in specific areas of the frontal and temporal lobes. The greater the activity, the greater the likelihood that they would remember the words later. Great memories are not born, they are made.

By mastering my three basic skills—LOOK, SNAP, CONNECT—you will incorporate a foundation for a solid memory-training program. If you read only this chapter and learn only these three skills, your memory will improve. I suggest you keep a notebook or writing pad or use a cell phone app specifically dedicated to your memory-training exercises. This way, you will be able to see your progress and keep track of your exercises. These memory techniques are the basic tools necessary for any memory method, whether it’s the Roman Room Method dating back to ancient Rome or more modern strategies described by Joshua Foer in his popular memory book Moonwalking with Einstein.

1. LOOK—Actively Observe What You Want to Learn

I had a friend in college who was not only a brilliant mathematician but also a gifted writer and violinist. He was at the top of the curve in all our pre-med classes. With his many talents and intellectual abilities, he still had extreme difficulty remembering people’s names and connecting the names to the faces when he met them again. Eventually he realized that his problem was that he never really learned the names in the first place—he wasn’t actively looking and listening.

One of the most common barriers to effective learning is that people do not pay attention to situations in which new information is presented. Think about what your husband or wife wore to work this morning. Can you remember what tie he had on? Which blouse she wore? What color your son’s T-shirt was? By actively looking and making a conscious effort to take in this type of information, trivial as it may seem, you can begin to train your brain to log in details. By engaging in this active observation process, we can absorb details and meaning from a new face, event, or conversation, which helps us to learn and remember it.

When we have little interest in something, it is often difficult to remember because we are not paying full attention. Many of us forget names seconds after being introduced to someone new. It’s as if we’re on automatic pilot, responding to various internal and external cues during the introduction, which distract us from retaining any new information. It is essential to slow down—just enough—to notice what is being said and whether it is important to remember.

Our modern obsession with and constant use of the internet and our handheld devices has raised concerns about the impact these digital technologies have on our ability to focus attention. Typically, people divide their attention across multiple media sources and thus miss important information that might otherwise get stored as memories. Many studies have shown a link between extensive screen time (computers, television, video games, etc.) and symptoms of attention-deficit hyperactivity disorder (ADHD). The connection between technology use and attention problems may result from the repetitive attentional shifts and multitasking associated with using these technologies.

Samuel Johnson put it succinctly: “The true art of memory is the art of attention.” Memory for street directions is an excellent example. If you drive yourself to a new destination by following directions, you’ll probably remember how to get there on your own, days or even weeks later. If you were merely a passenger on your first trip, you are likely to get lost on your first solo trip. The goal in active observation (see Active Observation Exercises box) is to mentally stay in the driver’s seat.

LOOK is the first basic skill because our vision is so often our first exposure to the things we want to remember, although we rely heavily on our other senses as well. By repeating information for later memory retrieval, we are listening. Many report that the sense of smell can bring back the most vivid memories of all. Textures and temperatures are useful details for focusing our observational skills that employ sense of touch for future recall. LOOK, as it is used in the Three Basic Skills, is actually shorthand for all five senses: LOOK, LISTEN, FEEL, TASTE, and SMELL.

Active Observation Exercises

1. The next time someone drives you to an unfamiliar location, mentally put yourself in the driver’s seat. Check the directions ahead of time, note the street signs, major intersections, and landmarks. Mentally drive yourself back there later.

2. Before you see a new movie, make a conscious decision to remember certain details at the outset. Try to commit to memory the hero’s hairstyle, the furniture in a memorable indoor scene, and the full name of a supporting character. When you get home, jot down as many details about the movie as you can recall. The next day, check your list and try to write down even more details about the movie if you can.

3. At work, notice a detail about the clothing or general appearance of several coworkers. Write down the person’s name in one column and the detail in another. At the end of the day, cover the second column, look at each name, and try to remember the specific details.

4. Right now, try to remember one specific article of clothing each member of your family put on this morning before leaving the house. Tomorrow do it again, but make a conscious effort to observe details before leaving the house.

2. SNAP—Create Mental Snapshots of Memories

Go back to that image of what your mate wore to work this morning. Red blouse, black slacks and shoes, leather jacket. As you visualize the image, you are already developing the second basic skill—SNAP. You are creating a mental snapshot of the information you wish to remember. Afterward you just pull out the snapshot and describe what you see. Creating vivid and memorable images fixes them into our long-term memory storage.

Snaps can take two forms, real or imagined. A real snap involves active observation, concentrating on what you actually see and making a conscious effort to fix the observed image into a mental snapshot. Imagined snaps are those that you create from your own memories and fantasies, but they still become fixed in your memory as a mental snapshot. Imagined snaps can be a fantasy distortion of an image you observe.

We all have real snaps in our heads that we use instinctively to help us seek and retrieve lost or hidden objects. Our ability to use search images effectively likely evolved as an adaptive advantage in our hunting ancestors, who visually spotted their skirting prey with such images. Likewise, we use them to quickly retrieve that partially hidden green folder on the desk or the slightly soiled lucky basketball jersey in the hamper. Despite the disorganization and ridiculous overcrowding of my home library shelves, I may have little trouble spotting a particular tome if it has a strong search image fixed in my memory—“it’s a thick blue book with two white lines and some circlelike flower things on it.” In the following bookshelf, the search image of one particular book helps it stand out.

Children are naturals in using their imagination. They have active fantasy lives that tend to diminish with age. As adults, we are taught to suppress this natural ability in exchange for more controlled, logical thinking. A child’s whimsical fantasies and imagery might be considered psychotic thinking in the average adult. To help develop effective learning and recall techniques, we need to rekindle these natural creative instincts.

Bright, colorful, enhanced snapshots stick best in memory, as do those with movement, three dimensions, and detail. The more detailed the image, the easier it will be to recall later. The very act of focusing on detail helps us to pay better attention and learn the information contained in the image. Compare the following two drawings of sandwiches. The more detailed version will be easier to remember.

Distorting or exaggerating one or more aspects of your snaps can also give them personal meaning, making them easier to learn and to recall later. The more vividly and creatively we visualize new information for ourselves, the more effectively it will stick in our minds. Imagination can be as outrageous, vivid, or sensual as we like, as long as it enhances our ability to store and recall information.

You need to buy a pumpkin after work for your daughter’s Halloween party, so try personalizing it in your mind. Your daughter loves to wear her pearl necklace to parties, so you could picture one draped on a pumpkin, like so:

Or you can create a literal image—whereby you write out in your mind the word you wish to remember—but for most people, a symbolic image containing personal or emotional meaning works best. If I park my car on level 3B of a parking structure, I could create a three-dimensional visual image, or mental snap, of 3B as follows:

But for me, a more effective strategy would be to visualize an image of three bumblebees hovering over my car. I have a personal aversion to bees, and it would be unpleasant to approach my car with three giant bees hovering above it. I take a mental snap of that image, and the emotional charge of my mental snap helps to fix it in my memory. For someone else, visualizing three bears sitting in their car may have a greater emotional impact—perhaps that was their favorite children’s story. Three Buffalo Bills might work for you—as long as it helps you find the car. See the Mental Snapshot Exercises box for ways to develop effective visualization techniques.

Mental Snapshot Exercises

1. Sit in a comfortable chair, close your eyes, and think of the first thing that comes to mind, be it an object, situation, person, or animal. Now, try to imagine greater detail about how it looks or feels.

2. For each of the following, create a colorful, vivid, and detailed visual image (e.g., rather than a rose, visualize a bright yellow rose with dew drops, lady bugs, and thorny stems):

• Animal

• Kitchen appliance

• Tool

3. Visualize each of the following but alter them slightly so they become unusual in some way (e.g., an automobile with a wig, a snake wearing suspenders):

• Table

• Stadium

• Stethoscope

• Airplane

4. List three details that you might see in a visual image of each of the following places:

• Shopping mall

• Car wash

• Soccer field

• Church

3. CONNECT—Link Your Mental Snapshots Together

Developing techniques to connect mental snaps is a basic element of nearly all memory techniques. CONNECT is the process of associating two mental snaps so you can remember the connection later. This basic skill will help you to remember birth dates or the names of employees’ spouses, and allow you to never again forget the name connected to the face (Chapter 6).

To connect two snaps, simply create a brand-new snap that contains both mental images. Several techniques can make CONNECT an extremely effective memory tool (see box).

Techniques to Effectively Connect Mental Snapshots

• Place one image on top of the other.

• Make one image rotate or dance around the other.

• Have one image crash or penetrate the other.

• Merge or melt the images together.

• Wrap one image around the other.

In this example, we see two ways to connect two mental snaps, one of trees and one of a helicopter. You want to remember that the helicopter is over the trees. The literal image on the left may help, but I doubt you will ever forget the merged, wacky image on the right.

Before proceeding, try a couple of exercises to help fine-tune your own connecting abilities (see box).

Connecting Exercises

1. For each of the following word pairs, imagine a situation or activity that involves the two together. Try to create a situation that is reasonable or logical in some way.

Telephone—hamper

Paper clip—stuffed animal

Apple—policeman

Stethoscope—football

2. Now, go back to the word pairs above and imagine a bizarre or illogical situation for each.

CONNECT is the basis of the link method, which orders items by associating the things to be remembered with one another—the ideas or images become part of a chain, starting with the first item, which is associated with the second, the second with the third, and so forth. When initiating the first link in the chain, be sure that item number one helps you recall your goal or reason for creating this particular list.

Linking often helps when we need to remember a list of unrelated things to do, particularly if writing out the list is inconvenient or impossible (you may be exercising at the gym, sitting in a conference, or in the middle of a shower).

If we need to remember a long list of items, the link method becomes a more elaborate method of connecting mental snapshots and becomes a story. The story’s flow and visual images provide the cues for retrieving the information. A weakness of the link method is that if we forget one link, we can forget all the information that follows. With the story system, the flow of the story will allow most of the remainder of the list to be retrieved even if one link is broken.

Here is a typical list that can be linked into a story line:

• Buy eggs

• Call your cousin in New York City

• Take out the garbage

• Feed your neighbor’s dog

• Get cash at the ATM

To link the ideas, we first choose a single image to represent each task:

• Egg

• A big apple

• Garbage can

• Dog

• Dollar bills

You know you can only begin the errands after work, so that might be the starting point of the linked associations. To help the information stick, you may want to add vivid or emotional detail to the images. The following might be your sequence of linked images:

• Driving home from work, you see a giant egg in the middle of the road.

• The egg rolls down a driveway and smashes against a big apple.

• You pick up the mess and toss it into a garbage can.

• As you close the garbage can, your neighbor’s dog sniffs at it curiously.

• The dog sits up and faces the can with dollar bills in his mouth.

One of the limitations of linked associations is that the images may not immediately bring to mind the task. For example, you may ask yourself, “What about that big apple? Was I supposed to make a pie? Prove yet again Newton’s Law of Gravity? Perhaps make a call to my cousin in New York City?” A better reminder for phoning your cousin in New York might be an image of a big apple talking on the phone.

The most effective links or associations are ones we create ourselves, particularly those stemming from our first association. Psychoanalysts have used the method of free association to help people uncover emotionally charged experiences. Often our first association to an idea is the most vivid and can have the strongest emotional charge or personal meaning, making it easiest to remember.

Another application of CONNECT is the use of acronyms, or the creation of words from the first letters of items to be remembered. To create an acronym, first think of one word to represent each item to be remembered, and then form a word using the first letter of each word to be remembered. As an example, for the list of unrelated words Envelope, Bulb, Aardvark, and Telephone, we might use the first letter of each word—E, B, A, and T—to form the acronym. The next step is to write down the letters and play with their order to try to come up with one word or several words. If you can’t come up with a word, then try substituting one of the words to be remembered. For example, changing bulb to lightbulb allows us to substitute L for B and come up with the acronym LATE. People who like doing word jumble puzzles will enjoy using the acronym memory method (see the More Connecting Exercises box).

The more you practice LOOK, SNAP, CONNECT to help remember tasks, events, and lists of any type, the more familiar and natural it will become. These three fundamental skills are the building blocks for the advanced memory training outlined in Chapter 6 (Build Your Memory Skills Beyond the Basics). But first, check your progress since reading this chapter.

More Connecting Exercises

1. Think up a story that will connect the following items: helicopter, movie theater, library, houseboat, grandmother, coffee mug. After you complete the next five linking exercises, see if you can recall the items from your story, without looking back at this list.

2. Create a single visual image to link each of the following groups of words:

Wire–teddy bear–rosebush

Lamp–potato–motorcycle

Keyboard–cowboy–blimp

Applesauce–parachute–hitchhiker

3. List five things you need to do tomorrow.

4. Now use the link system to recall the above list.

5. Now use the story system for the same list.

6. Create a one-word acronym by using a first letter from each of the following items:

Elephant

Blanket

House

Apple

Tree

Another Shot at the Objective Memory Test: This Time with Ammo

After reading and practicing LOOK, SNAP, CONNECT, your memory abilities have already improved. I have revised the objective memory test from the end of Chapter 2 to include a different list of words so you can retest your learning and recall skills. Get out your stopwatch or kitchen timer and set it for one minute, then read and learn the words on the new list in Assessment No. 2.

ASSESSMENT NO. 2 STUDY THE FOLLOWING WORDS FOR UP TO ONE MINUTE:

Ink

Kettle

Spray

Musician

Volcano

Monarch

Steamer

Dirt

Lawn

Gallery

When your minute is up, put aside The Memory Bible, reset your timer for a twenty-minute break, and distract yourself by doing something else. After twenty minutes, come back and write down as many of the words as you can recall. Compare the number of words you wrote down to the results of your earlier assessment and marvel at your improved memory performance (Chapter 2).

LOOK, SNAP, CONNECT: A Quick Review

1. LOOK—Actively Observe What You Want to Learn. Slow down, take notice, and focus on what you want to remember. Consciously absorb details and meaning from a new face, event, or conversation.

2. SNAP—Create Mental Snapshots of Memories. Create a mental snapshot of the visual information you wish to remember. Add details to give the snaps personal meaning and make them easier to learn and recall later.

3. CONNECT—Link Your Mental Snapshots Together. Associate the images to be remembered in a chain, starting with the first image, which is associated with the second, the second with the third, and so forth. Be sure the first image helps you recall the reason for remembering the chain.

Chapter Four

Minimize Stress

Pressure and stress are the common cold of the psyche.

—ANDREW DENTON

The other day, I was waiting in line at the bank and noticed that the half dozen people in line with me were all transfixed by their cell phones. It made me think about how odd it is that, these days, people are so obsessed with their gadgets that they couldn’t even wait in line for a few minutes without using a device. Just then I heard a ping coming from my jacket pocket, indicating that I had gotten a text. I excitedly grabbed for my phone only to find that it had been someone else’s ping I’d heard, and I had no new text. The immediate disappointment I felt made me realize that I was as hooked as everyone else.

All of these terrific technologies that were designed to make our lives more efficient and reduce stress not only have failed to limit the stress in our lives, but may actually be increasing it. Because of the added efficiency these technologies provide us, we can now take on more activities and responsibilities, which in turn put greater demands on our personal and professional lives.

Chronically high levels of stress are not only bad for blood pressure, cholesterol, and other physical ailments, but such stress levels wear away at brain fitness and overall memory performance. You’ve had a tough week at work, your kids are driving you up the wall with their bickering, that new contractor botched up the remodeling of your kitchen, and your formerly compulsive memory for all the details seems to be getting worse by the minute. Experiences like these can cause physical changes in your body and crank out stress hormones that have an impact on brain aging.

But don’t send the kids to boarding school or fire the contractor. Not yet, anyway. Stress and anxiety can be reduced and even eliminated from our lives, and there are many approaches to help us achieve this. We can choose from a variety of stress-reduction methods, including yoga, jogging, meditation, prayer, or even anger-management classes.

What Causes Stress?

Both external and internal events can trigger a stress response. In our physical environments, we are constantly being bombarded by such stimuli as email notifications, noise, bright lights, heat, or confined spaces—all of which can bring on stress, if the intensity and timing are right. People and various social situations can create stress, whether it’s a rude waitress, critical boss, or a crowded rock concert or amusement park. Anything from a physical examination to a hospital visit, a public verbal presentation, or just getting into a heated discussion can activate our stress response. Deadlines, on and off the job, are common reasons for getting our adrenaline pumping, as are major life events, whether a negative one—death of a relative, getting fired—or even a positive one—getting promoted or having a new baby. Thanks to our email, text messages, and smartphones, we’re essentially always on the job, so that much needed downtime seems more elusive than ever. And, let’s not forget the daily hassles of commuting, misplacing keys, or a mechanical breakdown of one of the pieces of equipment all of us have accumulated to help us eliminate stress.

External sources of stress often come from events out of our control—earthquakes, tsunamis, hurricanes, wars, riots, terrorism, and pandemics, among other causes. When someone survives an experience such as a disaster or assault, it’s possible to become stronger and more resilient, but often catastrophes cause long-lasting stress and can lead to post-traumatic stress disorder (PTSD). The mood changes, sleep disturbances, and other symptoms of PTSD can worsen memory and other cognitive abilities. During the Covid-19 pandemic, social isolation due to quarantine restrictions increased the risk for depression, anxiety, and cognitive decline.

Perhaps our most exasperating and harmful forms of stress come from within ourselves—our so-called internal sources of stress. Examples include the overloaded schedules we take on, the caffeine we drink, and the sleep we deprive ourselves of.

Justin G., the youngest partner in his high-powered litigation firm, attached his heart monitor and prepared to begin working out in his customized supergym, tucked into the loft of his townhouse. He had over $20,000 of the latest home gym equipment available, and his perfectly toned body “in less than an hour a day” was the proof. Starting with a level 6, random uphill run on his knee-saving treadmill, with the financial network flashing across the wide flat screen hung before him, he watched his heart rate monitor climb to the optimal level. While increasing his level to 7, the TV, treadmill, lights, and music went dead. He screamed in frustration over his “frigging fuse box” but it was worse. Power was out in the whole neighborhood.

Justin grabbed the phone but then slammed it back into the cradle, yelling, “Damn electric phone system!” He used his cell phone to call the power company, but the circuits were busy. He stomped and cursed and flipped the fuses again and again. His heart was racing and he was sweating, but he was feeling frustrated and angry instead of exhilarated by his usual postworkout endorphin high.

He finally got the power company on the phone and ranted and raved about his limited time, his exercise machines, etc. The woman on the phone said they were doing all they could and suggested that he try to relax and not get stressed out about it. Incensed, he yelled that his stress level was none of her business. She apologized and wished him well with it.

Glancing out the window, Justin noticed an electric company truck parking across the street a few houses away. He leaped down the stairs and out the front door, practically mowing down his neighbor Rob, who was stretching out before his morning jog.

Rob asked, “Hey, Justin, you okay?”

Justin, distracted, replied, “Yeah, man. I’ve got to get to the office, my power’s out, and I haven’t worked out…”

“So, want to go for a run?” Rob began running in place.

Justin, already across the street and about to chew out the electric company guys, looked back at Rob incredulously. “What? No. I need these jerks to turn my power back on.”

Rob smiled as he jogged away. “Have a nice day, Justin.”

Although much of the stress we experience on a daily basis is self-generated, most people think only of external stressors when they become upset. If only my boss, kids, or spouse would do things differently, then I wouldn’t be so stressed out. If the stock market would just bounce back, I could relax. Coming to terms with our own personality and how we can begin to eliminate some stress for ourselves is an important step in minimizing our anxiety.

High-achieving individuals, sometimes described as type A personalities, perfectionists, or workaholics, often set unrealistic expectations on themselves and overanalyze or worry about what other people think about them and their work. Others tend toward self-criticism and pessimism. These and other mental states or personality styles may cause people to be prone to anxiety, stress responses, and the accompanying release of stress hormones.

How Stress Affects Us and How We React to It

Stress is the body’s response to a demand made upon it, requiring the body, mind, or both to adapt. This demand can take the form of a threat, challenge, or simply an unexpected change. Stress responses are usually immediate and automatic. Everybody responds to stress differently, and these responses are not always negative. A college student stressed out about exams may study harder and perform better, whereas another student may become overwhelmed by anxiety and freeze up at the exam.

Our bodies respond to stress by releasing hormones into the bloodstream that are intended to put us into a protective mode. Adrenaline, a well-known stress hormone, tends to result in the “fight-or-flight response,” providing strength and energy to either fight impending danger or escape it. This physiological response has been genetically programmed through evolution, perhaps dating back to our caveman ancestors. If another caveman came along to steal your food and you were a bigger guy, perhaps even had a big club, you might have fought him off. Otherwise, you’d probably have run for it.

When the stress hormone adrenaline pumps into the bloodstream, your heart rate quickens, blood pressure rises, and breathing gets faster. More blood and oxygen get to the heart, muscles, and brain. Muscles tense in preparation for action, mental alertness increases, sensory organs become more sensitive, and less blood goes to the skin, digestive tract, kidneys, and liver, since those organs won’t be needed as much during a crisis. Sugar, fats, and cholesterol increase in the blood for additional energy, and platelets and blood-clotting factors increase to prevent bleeding in case of injury. All these physiological changes help us adapt to the acute situation our bodies believe to be at hand.

An adaptation to conditions requiring a rapid reaction, the human stress response evolved as a protection against acute threats and sometimes made the difference between survival and death. Unfortunately, this same physiological response can occur in people who are not exposed to physical threats but instead to constant or repeated mental triggers or stressors that have no rapid resolution. They persist and linger and smolder, leading to a chronic stress syndrome characterized by a variety of physical and mental symptoms, sometimes leading to health problems.

Common Symptoms of Chronic Stress

• Physical: headache, fatigue, insomnia, muscle aches and pains, rapid heart rate, chest pain, upset stomach, appetite loss, trembling, cold hands and feet, sweating.

• Emotional: depression, tension, anxiety, anger, frustration, worry, fear, irritability, impatience.

• Mental: poor concentration, memory loss, indecisiveness, confusion, poor sense of humor.

• Behavioral: fidgeting, pacing, nail-biting, foot-tapping, overeating, smoking, drinking, drug abuse.

The Effects of Stress on Memory Ability

Dr. Robert Sapolsky at Stanford University has studied how stress influences the brain and cognitive processes, showing that prolonged exposure to stress hormones has an adverse, shrinking effect on the hippocampus in laboratory animals. Previous research has shown that the hippocampus is essential for turning short-term memories into long-term ones.

Dr. James McGaugh of the University of California at Irvine has shown that corticosterone, a hormone released by severe stress, anxiety, or even a physical blow to the body, can block the retrieval of information stored in long-term memory. His research group, using laboratory rats, found that a small electric shock elevated corticosterone, crippling the animals’ ability to find their way back to a designated target. Their memory was impaired most while the hormone levels were at their highest, up to an hour after the initial shock. Although the memory loss in this experiment was temporary, it raises questions about the long-term effects of repeated stress on the brain.

Dr. John Newcomer of Washington University School of Medicine in St. Louis observed similar stress effects on memory in humans. His group showed that several days of exposure to high levels of the stress hormone cortisol can impair memory. The scientists observed memory impairment only in people treated with high doses—comparable to what a person would experience after a major illness or surgery. A week later, however, their memory performance returned to normal. Although these results suggest that only people who experience severe medical, physical, or psychological trauma will experience stress-related memory impairment, many researchers are convinced that long-term exposure to lower stress levels is also likely to accelerate brain aging.

Getting Mad, Sad, or Even

When faced with a frustrating, seemingly unsolvable problem, our emotional reactions can vary considerably. Anger, fear, sadness, and denial—sometimes expressed as humor—are common responses, and each of these feelings has positive and negative consequences. How our emotions motivate us to act has a significant impact on keeping our brains young.

Some people tend to become overwhelmed by angry feelings or are unable to express them. As a result, they may not fight for their beliefs, try to get even, or even get satisfaction, but instead give up—a response sometimes leading to sadness or even depression.

Sonia J., a 70-year-old widow, was becoming increasingly frustrated and anxious about her constant forgetfulness. It wasn’t so bad at first, but now she was reminding herself of her exasperating older brother, Marty, who was constantly forgetting things and driving everybody crazy. Sonia’s son was concerned that perhaps she was depressed and that maybe she should see a therapist. Sonia dismissed the idea completely—she didn’t buy into all that “talk it to death” stuff.

At Sunday dinner, Sonia snapped so angrily at Marty for again repeating something he’d just told her that she started shaking and had to go lie down. She realized later that part of why she got so mad at Marty was because she was afraid about her own forgetfulness. The next day she called her doctor for help.

Following an evaluation, Sonia’s physician began her on an anti-Alzheimer’s drug, and after several weeks, her memory showed improvement. Sonia was happy and relaxed for the first time in months. Her son was pleased and relieved.

Sonia tried to get Marty to take the same medicine, or at least talk to his doctor about it, but he vehemently denied any memory problems and refused Sonia’s urgings to see any doctors or take any medicines. Unfortunately, Marty’s memory declined rapidly during the next twelve months when he was eventually diagnosed with Alzheimer’s disease.

Anger can sometimes motivate us to act in a positive, constructive manner. However, anger, expressed or not, can also lead to high levels of anxiety, stress hormones, depression, and even memory loss.

It doesn’t necessarily serve us to express every feeling or emotion, especially if we alienate relatives or colleagues, and because we may feel differently once the angry feelings have diminished. Sometimes it’s better not to zoom down to the post office at midnight in your pajamas with that irate letter to your ungrateful, demanding boss until you have read it over again in the morning. The stress of unemployment may prove more detrimental to your brain fitness, not to mention your pocketbook, than the momentary thrill of yelling “I quit” in the boss’s face. Anger management therapy techniques involve learning to understand our feelings and finding new approaches for expressing them.

Scientific evidence supports the idea that outright expressions of anger may not always be the healthiest solution to stress. Dr. James Blumenthal and his associates at Duke University studied the effects of anger, as well as those of physical exercise, on heart disease. They found that the group of cardiac patients who exercised and learned anger management techniques ended up with the lowest risk for ischemic chest pain, resulting from insufficient blood flow and oxygen to the heart. The group of patients who only exercised without anger management instruction lowered their risk for chest pain slightly, but only half as much as the other group. The physiological process leading to this kind of circulatory problem in the heart has the potential for producing similar circulatory problems in the brain.

Dr. Frank B. was a busy internist on the Upper West Side of Manhattan. Although 61 years old, he was in good shape and looked younger. He prided himself on keeping up with all his journals and latest medical advances while continuing to practice like an old-style family doctor who still made an occasional house call.

During the last four years, he had noticed his memory gradually declining. He used to know all of his regular patients’ main health problems and the names of their close relatives. Lately he had to refer to their charts—sometimes even for basic facts and details. On several recent occasions, if Frank bumped into a patient at a local restaurant or bookstore, he would recognize their face but couldn’t recall their name until hours later. This began to secretly terrify him.

Frank was five years into his second marriage with Patricia, now in her midforties. He was afraid to let her know the extent of his memory concerns—after all, he didn’t want to worry her. However, she had already noticed on her own, as did some of his staff, closest friends, and patients. When Patricia brought it up, Frank insisted he was fine—and he should know, he’s a doctor, a healer. He doesn’t need to be healed by anybody else, thank you.

His practice began to suffer. Frank was seeing up to five patients an hour and was still expected to dictate notes between appointments. He started having stomach pain and headaches and couldn’t keep up.

Patricia finally dragged him to a neuropsychiatrist specializing in memory problems. When his physical exam and lab tests turned out normal, Frank grinned at Patricia, vindicated at last. However, the doctor went on to explain that Frank did have subtle memory losses and a strikingly high level of anxiety and stress, which was most likely aggravating his head and stomach pain, as well as his concentration and memory.

Over the next few months, Frank made some changes in his lifestyle. He brought a young partner into his practice, which greatly reduced his patient load and stress at work. He began playing tennis again with friends and accompanied Patricia to her yoga class twice a week.

People at the office began remarking on how alert and focused he seemed, and Frank himself noticed that his memory for names and details had improved. Also, he had fewer aches and pains, and he felt a general sense of well-being. He and Patricia felt closer than ever. Frank wasn’t sure which stress-reducing change had done the trick, and he didn’t care—he just stuck with the program.

Stressing Down, Not Stressing Out

We are often powerless to affect or reduce the external stressors in our lives. However, because much of our daily stress is internal or self-generated, we have the ability to do something about it, if we choose.

People who are able to maintain positive outlooks on life may actually live longer. Findings from the Nun Study indicated that the nuns who expressed feelings of joy, happiness, love, and hope in their early diaries lived as much as ten years longer than those who were less positive.

If time allowed, I would love to write a book called The Relaxation Bible: An Innovative Strategy for Stress Reduction, but I don’t think I could tackle the added stress right now. In the meantime, the strategies contained in the following pages should prove useful in reducing your stress and thereby improving your memory ability.

SET REALISTIC EXPECTATIONS

Many of us set unrealistic expectations upon ourselves as well as others, and although this is a frequent source of self-inflicted stress, it is one of the easiest to change. You can’t become a concert violinist or marathon runner overnight—it takes years of practice and hard work. If you buy a violin with the goal of playing Stravinsky in two weeks, you will put yourself under tremendous stress and most likely fail. When expectations become more reasonable, we gain a sense of control in our lives and are able to plan and prepare ourselves both physically and psychologically.

LET’S GET PHYSICAL

Compelling research indicates that physical exercise improves memory function (Chapter 8). It may also reduce stress through its release of endorphins, the body’s natural antidepressant hormone. In a sense, exercise works off much of our “stress energy.” With the fight-or-flight reaction that adrenaline and other stress hormones bring about, many of us are inclined to either act somewhat impulsively or keep these hormones and impulses bottled up inside. In today’s modern world, fight or flight—though it worked for cavemen under attack—may not be an option. Our bodies thus remain in a state of heightened energy with no release.

Exercise helps us dissipate such excess energy. Channeling the energy into a brisk walk will be more effective in reducing stress than gulping down a couple of beers. Any aerobic activity can have the same effect, whether it’s jogging, walking, bicycling, swimming, racquet sports, or aerobics classes. Be sure to choose activities you like and vary your exercises to maintain your interest.

Approximately twenty million Americans include some form of yoga in their fitness program. Yoga not only offers a way to build strength, balance, and stamina, but it can also reduce stress. Dr. Dean Ornish and his coworkers found that 80 percent of the cardiac patients in their experimental group practicing yoga along with other lifestyle interventions were able to avoid coronary bypass surgery.

PREPARE AHEAD

Much of our stress and anxiety depends on the situation we are in. Many people fear public speaking, whether it’s a sales pitch, a marriage proposal, or a State of the Union address. I am struck by how many people fear that they will get up there and forget everything they are supposed to say and do.

Any new or unfamiliar situation can create stress and anxiety, particularly if we face it unprepared. Therefore, an effective approach is to prepare in advance. When I studied piano as a teenager, my father always advised me to practice “110 percent” so I had 10 percent “cushion” room left for anxiety, fear, and forgetfulness. I still flubbed a few notes at recitals, but I understood his point and it served me well.

When preparing for an oral report, speech, or exam, you might visit the location in advance, if possible, and familiarize yourself with it. Taking slow, deep breaths, as well as closing your eyes and envisioning a calm place just before a performance, can help you to relax when feeling anticipatory anxiety or stress. Another useful technique when speaking in public is to focus on one person in the crowd. Some people find it helpful to take their feelings of anxiety and rename and transform them into feelings of excitement and energy. Others like that old trick of imagining their audience in their underwear. I guess it all depends on your audience.

RECESS ISN’T JUST FOR KIDS

Most of us lead fast-paced lives and pay little attention to warning signs that it is time to rest. For some, a certain mild, optimum degree of stress can lead to a healthy tension that helps them function at their best. However, excessive stress, or distress, can cause fatigue and eventually exhaustion—glaring red flags telling us to slow down and rest. Pacing ourselves while we work and play involves monitoring our levels of stress and energy, and taking breaks when we need them, much like small children need their naps to behave nicely.

A helpful approach to avoiding the workaholic syndrome is to take periodic time-outs. For many of us, breaks are built into our daily schedules, as we tend to divide our days into four two-hour segments: midmorning break, lunch, midafternoon break, and dinner. We can use these times for power naps, meditation, yoga breaks, walks, refreshments, and other activities that recharge our emotional and physical batteries, increase productivity, and reduce stress levels.

RELAX, THIS WON’T HURT

Whether you practice yoga every day, meditate, or sing in the shower, any conscious effort you make to relax, both mentally and physically, will reduce stress. Dr. Herbert Benson of Harvard University has described this process as the relaxation response. Just as our bodies evolved and developed an automatic stress response, we can teach ourselves, through conscious effort and repetition, to switch on a relaxation response—a state of deep mental and physical relaxation. Physiological activities slow down—heart and breathing rates decrease, blood pressure lowers, and muscles relax.

Such simple activities as resting at the beach, lying on a favorite hammock, or cuddling up with a good book can bring about this state. Also, just imagining resting at the beach or in your favorite hammock while taking a couple of minutes of quiet, deep-breathing time at work can have a similar stress-reducing relaxation effect. Deep relaxation can be accomplished through a variety of techniques, including yoga, tai chi, biofeedback, meditation, and self-hypnosis, all of which can be learned through apps, videos, and books. Such apps as Headspace, Calm, and Insight Timer have brought guided meditation and mindfulness to millions of people throughout the world. Just a few minutes each day doing some simple relaxation techniques can be effective in helping us to remain calm and perform at our optimal memory capacity (see Relaxation Exercises box).

Relaxation Exercises

• 2-Minute Break. Lie down or sit in a comfortable position. Begin by breathing slowly through your nose, regularly and deeply. Focus on your rib muscles, expanding them as much as possible, then slowly pushing out as much air as possible. Be sure to use your diaphragm, and keep your breathing deep, slow, and calm. Feel your abdomen rise as you breathe.

• 5-Minute Break. Close your eyes and imagine yourself in a calm, soothing setting—at the beach, in a field, in a sauna, or anywhere you find relaxing. Breathe deeply and do not allow the thoughts that may enter your mind to remain there. Keep focused on your breathing and the relaxed setting.

• 10-Minute Break. Sit in a comfortable chair or lie down. Close your eyes and take a deep breath; let it out slowly. Focus your attention on your head and scalp, and then imagine releasing all the tension there. Bring your focus down to your facial muscles and release that tension. Let that relaxed feeling extend through your cheeks and jaw. Slowly continue this process, focusing down your neck and shoulders, releasing the tension and continuing to move systematically down your body through your arms, hands, abdomen, back, hips, legs, and toes. Continue to breathe deeply and slowly throughout.

CUT BACK ON CAFFEINE

Many of us have the caffeine habit, and we tend to get the bulk of our daily caffeine from drinking coffee. We may start with a wake-me-up cup, possibly followed by a midmorning espresso and perhaps an iced blended mocha at our afternoon coffee break. If we count added caffeine from soft drinks and chocolate, we can be well on the road to a caffeine-induced stress response.

When caffeine levels go beyond what the body will tolerate—and this toleration level diminishes with increasing age—symptoms of stress and anxiety emerge. You may say that caffeine helps you focus and maintain attention, and in small amounts it can. However, at higher levels, caffeine can cause irritability and distraction.

I recommend cutting back on caffeine and doing it gradually to avoid headaches and other side effects of withdrawal. Many experts recommend decreasing by the equivalent of a half-cup of coffee each day or every other day (see Chapter 7 for equivalencies). Most people will begin feeling more relaxed and notice other benefits as well. Many find that they sleep better and paradoxically have more energy.

GET ENOUGH SLEEP

More than a third of Americans do not get a good night’s sleep on a regular basis. Throughout the world, an even larger number of people live in a chronic state of sleep deprivation. Sleep-deprived people rarely awaken refreshed each morning, and they lack energy during the day. The average person needs about seven to eight hours of sleep each night, though our need for sleep decreases with age. Getting enough sleep is essential for normal brain development. Studies of laboratory animals indicate that adequate sleep enhances the connections between brain cells.

Insomnia and fatigue are major sources of stress that can impair concentration and memory. When sleep patterns improve, so do mood and memory. People who suffer from chronic sleep deprivation often feel better if they try getting to bed thirty to sixty minutes earlier. You know you’ve beaten the cycle if you start waking refreshed, notice more energy during the day, and find yourself waking naturally before the alarm goes off in the morning.

Those weekend days when you can sleep in may help you recover from chronic sleep deprivation, but if you sleep too long your body rhythms may get thrown off the next day. Daytime naps can help if you keep them short—you could feel groggy waking from naps that last over thirty minutes. Instead, twenty-minute “power naps” can be rejuvenating. Avoid early evening naps since they make it more difficult to fall asleep at bedtime. If you suffer from chronic insomnia, avoid daytime naps altogether, and try a systematic sleep inducement program instead (see box). Sometimes chronic insomnia is a symptom of depression or some other medical condition, so consult your physician if a sleep inducement program is ineffective.

Beat Insomnia at Its Own Game: A Systematic Approach to Sleep Inducement

1. What to avoid:

• Daytime naps

• Evening liquids

• Exercise or excitement an hour before bedtime

2. Begin your sleep inducement program on a weekend, preferably a Friday night.

3. Get into bed the same time each evening. Once in bed, do not look at your phone, watch TV, eat, or even read a book—just turn out the light, get yourself in a comfortable position and relax (see earlier Relaxation Exercises box).

4. If you are not asleep after 20 minutes, get out of bed and do something else: listen to music or read a book. Avoid watching TV because the emitted blue light may keep you awake longer.

5. Once you begin feeling tired, go back to steps 3 and 4: go to bed, shut off the light, relax. If you’re not asleep after 20 minutes, get out of bed and do something else.

6. Do not worry if you spend a good part of the night out of bed. A key step to the program is avoiding naps the next day. If you can manage to stay awake the next day, you will likely conquer your chronic insomnia in just a few days. The next night, your fatigue will kick in at bedtime (make sure it is a consistent time). Go back to steps 3 and 4 and continue to avoid daytime naps.

BALANCE WORK AND LEISURE

Although new technologies and devices help us save time and energy, Americans on average are working as long and as hard as ever. For most people, the 8-hour workday is long gone. According to a recent Gallup poll, on average Americans are working 9.4 hours each day, and in competitive areas, such as tech and finance, more than 60-hour workweeks are the norm, thanks to our ever-present smartphones. With many couples pursuing two careers, their family and leisure time becomes even scarcer. The word leisure comes from the Latin word licere, meaning “permission”—we need to give ourselves permission to take our leisure time and enjoy life. People who never allow themselves the leisure time they need experience greater levels of stress.

To tally the balance of work and leisure in your life, take out your notebook and add up the number of hours you spend in each area throughout the week, not including sleep. If you spend more than 60 percent of your week at work or doing work-related activities, you probably need to think about shifting the balance more toward leisure. We all need time for exercise, relaxation, socializing, entertainment, and hobbies, and this leisure time will reduce stress. Some of us resist taking “personal time” because it makes us feel guilty or selfish, or too much leisure time makes some people bored and restless—even stressed! We need to find our own balance of leisure time versus work time, one that allows us to limit our stress level, and maintain our optimal memory ability.

LAUGH YOUR HEAD OFF

Humor, too, can reduce stress—it puts uncomfortable feelings into perspective, giving us greater distance from them and releasing emotional discomfort and pain through the pleasure of laughter. Norman Cousins advocated the use of humor not just to reduce stress but also to cure physical ailments, through the physiological effects of laughter. During the past decade, many people have started practicing laughter yoga, which combines yoga with voluntary laughter that induces diaphragmatic breathing. When practiced in a group, the voluntary laughter becomes genuine and contagious and appears to improve mood and relieve depression. Although laughter does relieve tension, it has not been proven to cure physical illnesses, yet. However, I have never met an ill person who has complained to me about laughing too much.

TALK ABOUT FEELINGS

Whether you call it venting or getting emotional support or letting it all hang out, there is no question that talking about feelings is one of the most effective ways to reduce stress. Systematic studies of talking psychotherapies often find that the characteristics of the listener—whether they are empathic, responsive, and the like—have more importance to the therapeutic benefit than what type of therapy they practice. Talking about feelings can be effective with a spouse, sibling, parent, bartender, mah-jongg partner, psychiatrist, priest, or any of a number of people who make you feel comfortable. The experience sometimes leads to tears, a sense of relief, and, when the person listening does not judge or criticize, a sense of understanding and acceptance. It puts the troubling feelings into perspective, making us feel strength and distance from whatever the source of stress.

Review of Steps to Minimize Stress and Anxiety

• Set realistic expectations.

• Exercise regularly.

• Prepare ahead.

• Take breaks throughout the day.

• Learn how to relax and do it at regular intervals.

• Cut back on caffeine.

• Get enough sleep.

• Balance work and leisure.

• Let yourself laugh.

• Talk about feelings.

When Stress Becomes Chronic: Depression and Anxiety

Sometimes, despite our best efforts to reduce stress, we are unable to eliminate the sources of tension or emotional pain in our lives. Sometimes we may go from directing our anger at the outside world and instead turn it within, becoming mad at ourselves. This mental process tends to change from anger to sadness and, eventually, to depression.

An estimated 15 percent of the population develops an episode of depression requiring medical intervention at some point in life, and stress is not the only cause. Some people are born with a biological predisposition to get depressed, tending toward a brain chemical imbalance that favors a depressed mental state. In some situations, the depression appears to come from nowhere, even in the best of circumstances. Perhaps more frequently, the depression stems from a combination of stressful life events and internal biological factors.

Depression and Memory Loss

I have seen many patients become worried and depressed about their objective or subjective declining memory abilities. This syndrome can develop into a vicious cycle in which the worry over memory loss deepens the depression, which, in turn, increases the forgetfulness or memory loss. The situation can become exacerbated when it triggers the concern and anxiety of family members. Sometimes, there are people around us to guide us toward help; other times, we must seek help for ourselves.

Holly M. awoke from another midafternoon nap. She took a nap almost every day now, ever since their youngest daughter left for college. It was half past five and Carl, her husband of thirty-six years, would be home in an hour. She had time to shower and dress and fix him a T-bone, charred outside but pink inside—just the way he liked it. But wait… didn’t she make steak yesterday? Oh, never mind. Carl always ended up working late anyway, so it didn’t matter.

At 8:00, showered, dressed, and made up perfectly, Holly sat at the dining room table as the steaks grew cold and she longed to escape back to sleep. At 10:00 Carl finally came in and was shocked to see her sitting there like a zombie. He yelled, “What the hell is going on?”

“You could have called if you were going to be late for dinner again,” she said with a sarcastic clip.

He laughed quietly and shook his head. “This memory lapse thing of yours is getting out of control, Holly. I specifically told you, this morning, that I had to have dinner in the city with clients. Maybe you should see somebody. A shrink or something.”

Holly’s eyes teared. She asked him what was happening to her. Why was she forgetting so much? Why couldn’t she concentrate on anything? Why did she feel so sad all the time? She stared at him, pleading for help.

Carl was cold. “I have some calls to make. Why don’t you just go to bed and get some rest.” After closing himself in the study, Carl made a call and a woman answered. He said he had a wonderful evening and he’d like to see her again—tomorrow? She inquired about his wife, but Carl just laughed and said she didn’t remember a thing from minute to minute and not to worry.

The next day Holly decided to take Carl’s advice and got a referral for a psychiatrist. At the first appointment, she learned that she was depressed, and this could account for some of her memory problems. The doctor prescribed an antidepressant medicine and suggested they meet a few more times to talk about her feelings. Holly left his office feeling relief and optimism.

Over the next couple of weeks, Holly’s mood improved along with her memory. Unfortunately, Carl was so seldom at home, he didn’t notice. Friday morning, Carl came down to the kitchen with a packed overnight case and headed for the door. Holly, already dressed and about to leave for the gym, blocked his path. Carl raised his eyebrows. “Good for you, Holly. Get some exercise. It might help you feel better. See you Sunday night!” Holly was taken aback. “What? Where are you going?”

Carl snapped, “You don’t remember this either? I told you on Tuesday! I’ve got a statewide sales meeting at the regional office all weekend! For God’s sake, Holly, get a grip! I’ll call you.”

At this point, Holly had a pretty good grip. Something was amiss, and it wasn’t her memory. Now that her depression had lifted and her memory had improved, Holly took the initiative to figure out what was going on in her marriage. She discovered her husband’s affair and realized he had been using her own symptoms against her, tricking her into believing his lies.

Holly ended up with the house, the money, and the cars, but she let Carl keep his movie collection, including Alfred Hitchcock’s classic Gaslight.

Antidepressant drugs can have a major impact on depression (Chapter 9), but talking therapies can be powerful interventions as well. Dr. Charles Reynolds and his associates at the University of Pittsburgh studied a group of depressed patients who had been successfully treated with antidepressant medications. The researchers followed these patients for an additional twelve-month period while one-third continued taking antidepressants, one-third took placebo medicine, and the last third received psychotherapy. Dr. Reynolds found that only 20 percent of the subjects who stayed on antidepressant drugs had a relapse of their depression, whereas 80 percent of those who took a placebo became depressed again. By contrast, only 50 percent of the patients who received psychotherapy experienced another depression during the follow-up period, a clear and striking benefit over that of the placebo. What is remarkable about the study is that the psychotherapy involved only one hour a month, a far cry from in-depth psychoanalysis. For some forms of depression, then, brief monthly meetings with a therapist may be enough to relieve symptoms. Psychotherapy is even more accessible today than ever before thanks to the use of telepsychiatry that spread rapidly during the Covid-19 pandemic.

Whereas many people have a predisposition to get depressed when under prolonged stress, many others tend toward anxious states. And still others experience mixed states of anxiety and depression. Anxiety disorders can be disabling and come in many forms. Panic disorder is a condition involving intense, sudden attacks of anxiety and can often evolve into agoraphobia, wherein a person may avoid the situations associated with the attacks. These avoidance patterns can progress to the point where a person becomes housebound. Obsessive-compulsive individuals experience unwanted obsessive thinking and impulses, which can lead to compulsive behavior, such as washing hands or checking door locks over and over. These disorders can become so severe that the afflicted are unable to function in their lives. Some people experience a pervasive, continual generalized anxiety or even more focused fears and phobias, which can pervade all aspects of their lives.

These conditions result from both external stress and internal biological factors. Regardless of the cause or form of anxiety, these conditions often respond to drug treatment as well as specific psychotherapies. And, many such psychiatric disorders will affect learning and memory abilities.

If you find that your anxiety levels are so high that your work or personal life is affected, perhaps it is time to seek professional help (Additional Resources). The stress reduction techniques mentioned earlier may help to some extent, but severe anxiety and panic states can be just as debilitating and dangerous as extreme depressions.

Chapter Five

Get Fit with Mental Aerobics

Man’s mind, once stretched by a new idea, never regains its original dimensions.

—OLIVER WENDELL HOLMES JR.

Jill S. had never been very good at remembering names. When she was in her early forties, this lifelong difficulty took a turn for the worse. Because of her busy career in marketing, Jill had put off having children into her late thirties and was now in the heat of the carpool years. With her kids’ soccer practice and ballet lessons, and her husband’s frequent business trips, Jill was at her wit’s end trying to juggle everybody’s schedules, let alone keep the names of new business contacts straight. When she came to my office, Jill was exhausted and frustrated. She was becoming forgetful, and for the first time in her life, she was afraid things were going to fall through the cracks and she was going to “blow it.”

Jill’s story is similar to that of millions of people who are creeping into middle age. She wanted to take action to improve her memory now and organize her life more efficiently. She is one of many proactive individuals eager to get fit and benefit from a mental aerobics program. Mental aerobics is any mental activity that exercises your brain. Just as sit-ups tighten your abs, mental aerobics are jumping jacks for your mind.

In the memory-training section, we learned mental tools for improving learning and recall with the goal of practical daily use. Initially these techniques serve as mental aerobics, in a sense increasing the stamina and strength of our brain cells. Once mastered, they become routine and helpful in our lives, but we still stand to benefit from a daily regimen of mental aerobics, which continue to challenge us mentally and keep our neurons firing in top form. Just as joggers gradually lengthen the distances they run over time to increase their aerobic workout, we need to increase the complexity of our mental aerobics program, whether it’s doing crossword puzzles, solving brain-teasers, playing charades, or watching Jeopardy!

The Mozart Effect

Educators have observed that young children, from toddlers to preteens, who are exposed to Mozart compositions and other classical music, appear to perform better academically than those who are not. In studies of college students, Dr. Francis Raucher, Dr. Gordon Shaw, and other neuroscientists at the University of Wisconsin showed that listening to a Mozart piano sonata improved the students’ cognitive abilities. Interestingly, it was not verbal or language skills that improved; rather, spatial-cognitive skills, such as paper-folding tasks and following patterns, got better. The researchers speculated that listening to music helps to temporarily organize thinking and that mental processes involved in listening to music activate a neural network that is shared with spatial-reasoning processes. Other investigations have found that some college students perform better on cognitive tests when they take the tests with background classical music instead of silence.

Although the concept of the Mozart Effect has met controversy since not all studies show it, we do know that different kinds of music have different mental effects. Some music will calm us, lowering heart rate and blood pressure, whereas other musical styles are likely to agitate us. There is evidence that listening to music can enhance immune function and diminish pain. Several experts believe that the logic, symmetry, and aesthetic organization of classical pieces by Mozart, Beethoven, and others truly provide a mental advantage to people of all ages.

Dr. Gottfried Schlang and Dr. Gaser Christian of Beth Israel Deaconess Medical Center in Boston used MRI scans to study whether intense environmental demands, such as musical training at an early age, influenced actual brain growth and development. They found that, compared with nonmusicians in their study, the fifteen professional musicians had significantly greater volumes of gray matter—the outer part of the brain that contains the nerve cell bodies. The gray-matter areas showing the largest relative size were those involved in sensation, motor function, and one of the areas involved in memory function that is affected early by Alzheimer’s disease. Although the evidence is circumstantial, it is consistent with the possibility that musical training in early life could offer protection against Alzheimer’s disease later in life.

We know music can elevate a person’s mood, and a better mood certainly can sharpen mental ability—a depressed person is often distracted and unable to focus on mental tasks. Even without definitive proof, the potential for a benefit and the minimal risk involved convinces me that listening to classical music may be a worthwhile habit for us all.

Use It or Lose It

Charles W., a 47-year-old newspaper journalist and father of two, was a volunteer for one of our memory studies. He was having minor trouble remembering facts and background details of his feature stories, eventually requiring him to make at least twice as many notes as usual to get his stories down. Interestingly, during college he had a passion for crossword puzzles, but had given it up for lack of time. While he was consulting with me on his memory improvement program, I suggested he take up crosswords again for the potential mental aerobic benefits. He became a voracious puzzle solver—after six months he was completing the Sunday New York Times puzzle in ink, using a stopwatch. His crossword accomplishments gave him confidence, and his memory on the job improved.

A PhD in engineering is no guarantee against developing Alzheimer’s disease—the disease strikes people from all walks of life, including ex-presidents, Nobel laureates, and nuclear physicists. The scientific evidence, however, indicates a definite link between mental activity and staving off symptoms of Alzheimer’s disease. And both laboratory and clinical studies point to the memory benefits of mental activity.

Researchers at Case Western Reserve University found that the risk for developing Alzheimer’s disease was three times lower in people who had been intellectually active during their forties and fifties compared with those who had not. Their diverse mental activities included reading, working jigsaw puzzles, woodworking, painting, knitting, and playing board games. Couch potatoes didn’t reap the benefit: passive pursuits, such as going to the movies, did not contribute to the lowered Alzheimer’s risk. Of course, watching an enjoyable movie may reduce stress, which has its benefits for memory (Chapter 4), but beware of oversalted popcorn (Chapter 7).

Rush University researchers found higher mental stimulation in one’s twenties predicted better cognitive function late in life. People who spent time reading and had mentally stimulating jobs or educational experiences maintained their memories better and longer as they aged. As mentioned previously, other research groups have shown that college graduates have a lower risk of eventually developing Alzheimer’s disease than did people with less educational achievement.

At UCLA we added another dimension to this line of research by exploring whether educational achievement protects against brain aging. We used PET scanning to determine whether prior educational achievement, such as a four-year college education, is associated with higher brain activity levels in people with normal memory abilities (Chapter 1). The results confirmed our prediction based on the earlier population studies: college graduates had higher activity in a critical part of the brain, the posterior cingulate, which is involved in memory performance.

These observations point to the “use it or lose it” theory: people who use their brain cells will keep them fit and protect the cells from “wear and tear.” These neuron users may be less likely to “lose it” as they age. Of course, the PET scan may be showing us a healthier brain that was healthier at birth, and our genetic predisposition for a healthier brain may have also gotten us on the college trajectory to begin with.

Neuroscientist Fred Gage and colleagues at the Salk Institute added weight to the “use it or lose it” theory in studies of newborn rats in enriched environments with treadmills, toys, and a variety of foods. The rodents in the enriched environments had significantly more neurons in their hippocampal memory centers compared with rats living in ordinary laboratory cages. Dr. William Greenough’s research team at the University of Illinois found that rats in more stimulating environments grow new brain cells, more synapses, or communicating connections between the cells, and new blood vessels for transporting oxygenated blood to feed their more active brains. And, when running through their mazes and completing other memory tests, the stimulated rats appeared more intelligent.

Additional research supports the idea that continual, lifelong mental stimulation is healthy for human brains as well. Mentally and physically active people over age 65 have been found to have higher IQ test scores and higher blood flow in the brain compared with those who remain inactive over a four-year period. Not surprisingly, people with advanced education and professional accomplishments tend to have greater density of neuronal connections in brain areas involved in complex reasoning.

Other research from Case Western Reserve University has provided an additional interesting observation: people with mentally demanding jobs—managers, professionals, and so forth—experience less memory decline as they age when compared with their counterparts who have less demanding jobs. It must be noted, however, that although this observation agrees with the “use it or lose it” theory, people destined to develop Alzheimer’s disease may be predisposed to choose less demanding occupations in the first place.

These discoveries point to the conclusion that mental stimulation, or exerting our brains in various ways intellectually, may tone up our memory performance, protect us from future decline in brain function, and may even lead to new brain cell growth in the future!

Cross-Train Your Brain

Fitness trainers often advise their clients to cross-train, or vary their workout and avoid repeating the same exercise routine day after day. Cross-training challenges athletes, minimizes boredom, and maximizes results. Also, varying one’s workout by focusing on a particular muscle group one day and a different muscle group or activity the next allows an athlete to rest muscle groups between workouts, which builds stamina.

Neuroscientists believe the same principle holds true for brain training. Dr. Arnold Scheibel at UCLA has described the way our brains thrive on novelty. Unfamiliar stimulation and new mental challenges actually stimulate growth in a section of the brain known as the reticular formation. This brain region may have developed its novelty-seeking specialization as a survival mechanism or adaptation to the need for our ancestors to spot predators.

Brain Training, Not Brain Straining

An old tennis partner once told me that he suffered from an “exercise disorder.” He was a typical type A personality who embraced every new exercise program he could find and bought any workout gadget late-night TV had to sell. His disorder was that he would overdo each program and quickly injure himself, which would force him to take an extended break from all exercise in order to recover. Afterward, he would promptly begin a whole new exercise regimen designed to heal the injury, but would eventually injure a new joint and repeat the cycle.

Just as in physical fitness training, in memory training we want to avoid too much of a good thing. Our research team has found that people with the APOE-4 genetic risk for Alzheimer’s disease have to work harder to memorize and recall the same information as do people without the genetic risk. When research volunteers play a computer game for the first time, their PET scans reveal high brain-activity levels. After becoming proficient at the game, however, the brain scans show minimal activity during play. They need to use less of their brain capacity to accomplish the same task, much as an athlete becomes more proficient in lifting weights or running a marathon after training. This research points to the possibility that if we allow our brains to train gradually, just as a weight trainer increases the weight they lift gradually, it may be possible to accomplish the same performance level with less effort and frustration.

The scientific evidence points to mental stimulation and brain training as a way to maintain healthy brains throughout life. Suggestive evidence indicates that anything we do to exercise our brains in a new way may help to develop nerve pathways that can help to forestall the effects of Alzheimer’s disease. Most of these approaches are inexpensive, not harmful, and certainly worth a try.

It is critical to begin mental aerobic exercises at a level that stimulates but does not overexert. If a task is too difficult, a person may get frustrated and give up. If it is too easy, one may lose interest and get distracted. In our research using cognitive stress tests, we found that patients with even mild Alzheimer’s disease were unable to perform the more challenging memory exercises—they became frustrated and lost track of the task. Rather than seeing brain activity in their memory centers, as we did with volunteers who had only mild memory complaints, we saw either no activity or else activity in brain emotion centers, probably reflecting their frustration from trying to complete an overly challenging mental exercise.

Now that smartphones, tablets, and other devices have become so much a part of our lives, they offer new opportunities to train and strengthen our brains and can even improve memory performance and other cognitive abilities. To better understand how our devices impact brain function, our research team used functional MRI scanning to track brain neural activity patterns in a group of middle-aged and older adults while they performed simulated online searches. We found that volunteers with prior internet search experience showed significantly greater neural activation compared to those who had never searched online before. Moreover, the internet-naive group of volunteers had significant increases in neural activity when we repeated the experiment just one week after they practiced searching online for an hour a day. The findings suggest that the common mental activity of searching online can be a form of brain exercise that activates neural circuitry.

Prior research has shown that specific mental exercises not only improve cognitive abilities but also strengthen the brain regions that control cognitive performance. Professor Eleanor Maguire of the Institute of Neurology, University College London in the UK, as well as other investigators, have studied the size of the hippocampal memory center in London taxi drivers who have shown remarkable abilities to remember the details of a large, complex city and navigate within it. The research indicates that the number of years of taxi driving correlates with the size of the right hippocampus, which is the side of the brain that usually controls visual and spatial skills necessary for reading maps.

If it’s possible to train the brain’s hippocampus and boost a mental skill, such as map-reading, with practice, what is happening in the brains of a new generation that rarely uses maps or directions, but relies heavily upon GPS programs to tell them how to get around town? To address this question, neuroscientists studied the function of the brain’s hippocampus in research volunteers after use of an experimental GPS device. They found that after three months, there were significant declines in the functional connections between the hippocampus and other brain regions. The findings suggest that the use of such devices appears to decrease the functional capacity of the brain’s visual and spatial memory abilities.

So, there is good reason to be watchful of becoming overly reliant on technology. Although they offer convenience and immediacy, some people become so preoccupied with their devices and the internet that they become addicted and can experience withdrawal symptoms when they don’t get enough screen time. Too much technology use can also lead to social isolation. A study of nearly 1,800 people showed that using social media two or more hours each day can double the risk of feeling socially isolated compared with people who used these platforms less than thirty minutes each day. Extensive screen time also is associated with greater symptoms of attention-deficit hyperactivity disorder. Too much use of smartphones has been linked to shorter sleep duration and poor sleep quality that can lead to impaired cognitive abilities.

We are constantly distracted by rings, pings, and buzzes that cause us to lose mental focus on what we are doing at that moment. Too much technology can clearly strain the brain and interfere with memory abilities. When we’re multitasking with our technology, we are only able to pay partial continuous attention to our tasks, making it harder to learn new information and retrieve it later. To avoid the memory-disrupting effects of too much technology, it’s important to take breaks or silence any devices that might interfere with what we are concentrating on or trying to achieve.

New Technologies That Train Your Brain

The flurry of research linking mental stimulation and cognitive training to better memory performance has spurred the development of new computer games and memory apps for boosting brain performance. Not all of these online brain training programs have been studied carefully, but systematic research does show that some of these programs can lead to real cognitive benefits.

My longtime collaborator Dr. Karen Miller and colleagues studied the effectiveness of a computerized brain training program called Dakim Brain Fitness in older adults without dementia who were on average in their early eighties at the time of the study. The volunteers used the computer program five days each week for about twenty minutes each day. The research team found that volunteers who played the computer games for at least forty sessions over a six-month period experienced significant improvements in their memory and language abilities. These findings are consistent with other studies showing that a variety of these computerized cognitive training programs boost various aspects of cognitive performance, including attention, working memory, and learning abilities.

Games can also help us cope with some of the problems posed by our devices. Thanks to our new technology, multitasking is on the rise. Although some neuroscientists will argue that the brain cannot truly multitask, it is possible when the mental tasks have become automatic. When we multitask, we rapidly switch between mental tasks, and scientific evidence confirms that such task switching increases error rates particularly in middle-aged and older individuals.

However, there are benefits to be gained by playing some video games. Neuroscientists at the University of California, San Francisco, studied a video game called NeuroRacer, wherein players attempt to control a race car on a winding road while random signs pop up to distract or guide them. The researchers found that when older people (aged 60 to 85 years) played the game for just four weeks, they showed significant improvements in assessments of their multitasking abilities. The video game also improved other cognitive abilities, including short-term memory and sustained attention.

Other computer games improve problem-solving skills and working memory, which is the ability to retain information over a brief period of time. Dr. Susanne Jaeggi and collaborators at Columbia University in New York found that when research subjects played a video game designed to improve working memory and attention, their problem-solving skills also improved. The particular brain game they assessed is based on principles used in the card-matching game Concentration, and playing just twenty minutes each day, five days each week, was enough to improve the participants’ thinking and reasoning abilities. If you search “IQ Boost” in the app store, you will find a free version of this kind of game.

University of Rochester neuroscientists have demonstrated that playing action video games for one hour each day, four days each week, improves the player’s capacity to recognize and process visual information, task-switching abilities, and visual attention skills. Such benefits likely explain the findings that surgeons who played video games more than three hours each week make fewer errors in the operating room. Those surgeons in the study with experience playing specific games, including Super Monkey Ball 2, Star Wars Racer Revenge, and Silent Scope, made nearly 50 percent fewer surgical errors. So, the next time you need surgery, make sure you ask your doctor about their video game habits!

The bottom line is that while there are clear upsides to these technologies, we still need to be careful. Despite the potential brain enhancing benefits of video-gaming, many people still worry about the side effects of excessive gaming, such as declines in attention and social withdrawal.

Brain Workouts Through Creative Thinking: Puzzles and Brain-Teasers

The information in our brains is passed through billions of dendrites, or extensions of brain cells, similar to branches of a tree, which grow smaller as they extend outward. Without use, our dendrites can shrink or atrophy; but when we exercise them in new and creative ways, their connections remain active as they pass new information along. And, remarkably, new dendrites can be created even after old ones die.

Evidence shows we can “work out” our dendrites and extend their branches in many ways. Even routine daily activities, such as lacing a shoe or rinsing dishes, can be a trip to the gym for those little guys. Try tying your shoelaces backward or brushing your teeth with your left hand (if you’re right-handed)—both could stimulate a neuron or two. Basically, any conscious effort to tease your brain can potentially create new brain cell connections.

The fun of solving puzzles and brain-teasers often comes from pushing ourselves to make a mental leap from existing assumptions to find a new solution to a seemingly unsolvable problem. To do so, we need to break loose and explore the problem, puzzle, or brain-teaser in a new way.

When we view certain visual images, we often fix on seeing them in one way, as in this vase image:

If you look again and think of the vase as background instead of foreground, you may see the profiles of two people.

In the next figure, you probably see the black arrows. Try to see the figure from a different perspective and push those black arrows into the background. Can you now see the white arrows emerge facing the opposite direction?

Sometimes our mental assumptions actually distort reality. Look at the following figure. Does the upper line appear longer than the lower one?

Take a ruler and measure the two lines and you’ll see that they are of identical length.

These exercises are basic examples of visual brain-teasers, the type that can and should become a part of your daily mental aerobics workout. The goal of aerobically working out our brains is to get ourselves to think creatively in order to stimulate, strengthen, and enhance our brain cells, to maintain healthy dendrites and extend their branches.

Mental Aerobics: Getting Started

No fancy workout clothes, no expensive gym bag needed here. Your old comfy slippers and your favorite recliner will do fine. Your regimen of stretching, toning, and strengthening your brain can include music, puzzles, and computer games. Such activities are most effective when they not only are fun, but they also “shake up” your usual mental assumptions and force you to think of novel solutions.

Take a moment to review the results of your memory assessments from Chapter 2. These will point you to your optimal level to begin your workout. Also, take note of how you feel when you perform brain-exercise activities. If you find yourself getting frustrated quickly, go back and start at a less advanced level. If you find the activities too easy, move on to more difficult ones. Mental stimulation exercises should be challenging and enjoyable to achieve their best effect. Be sure to pace yourself and set reasonable expectations.

Many experts support the potential benefit of mental stimulation to our brains. But what form of mental stimulation is most effective? Several years ago, an experienced 52-year-old attorney consulted with me because of his gradually increasing forgetfulness and his family history of Alzheimer’s disease. After reviewing his current level of mental activity, it was clear that the caseload he had been carrying had become stressful. The challenge for his brain fitness program was to bring down the level of mental stimulation in his life, rather than add mental aerobics. In fact, we focused our discussion on ways for him to reduce stress in his life (Chapter 4).

The science has not absolutely proven that doing crossword and Sudoku puzzles can truly prevent dementia, but taken together, the research is compelling that these activities are associated with better cognitive performance, and longitudinal studies do support the link. Researchers at the University of California in San Diego and colleagues performed cognitive assessments every twelve to eighteen months on nearly five hundred volunteers who did not initially have dementia, to determine the impact of solving crossword puzzles on the onset of memory decline. They found that regularly solving crossword puzzles delayed the onset of accelerated memory decline by more than two and a half years.

My approach to mental aerobics is for each of us to identify a way to stimulate our brains without stressing them. The following includes a variety of mental aerobics exercises presented at different levels of difficulty that you can try out for yourself. As you familiarize yourself with them, you will be able to determine which level and type of exercise gives you a sense of mental stimulation without frustration. Once you know the kind of mental aerobics that works best for you, you may want to expand your repertoire by seeking additional resources on the internet or at the library.

The following exercises are divided according to beginning, intermediate, and advanced levels, as well as which part of the brain each exercise trains. For most right-handed people, visual and spatial tasks work the brain’s right hemisphere, whereas verbal or analytic tasks work the left hemisphere. For left-handers, the left side of the brain generally operates visual tasks, whereas the right side handles verbal skills.

LEFT BRAIN FUNCTIONS | RIGHT BRAIN FUNCTIONS
• Logical analysis (reasoning, drawing conclusions) | • Spatial relationships (reading maps, doing jigsaw puzzles)

• Information sequencing (making lists, organizing thoughts)

• Artistic and musical abilities
• Face recognition

• Language and speech | • Depth perception
• Reading and writing | • Dreaming
• Counting and mathematics | • Emotional perception
• Symbol recognition | • Sense of humor

Ideally, you want to work both hemispheres, and you may want to alternate your mental aerobic stimulation program from left hemisphere to right hemisphere.

Most of us must put our minds to coping with real problems in our daily lives—career, family, health, and so on—yet many of us still find time to enjoy solving puzzles and playing mentally stimulating games. It is precisely this enjoyment factor that makes it possible to maintain a mental aerobics program over the long haul.

Beginning Exercises

1. Warm-up Exercise. Take a piece of paper and a pencil and try writing your first name using your nondominant hand (i.e., left hand if you are right-handed). Now, take a second pencil and try writing your first name using both hands at the same time. Now, try it with your last name.

2. Right-Brain Exercise. How many squares are there in the following figure?

3. Right-Brain Exercise. Complete the sequence by choosing object A, B, or C:

4. Right-Brain Exercise. Look at the object on the left and then choose the version that matches: A, B, or C.

5. Right-Brain Exercise. Arrange five toothpicks of your own into the shape of a number five as shown. Now, try to rearrange them into the number sixteen—without breaking them!

6. Left-Brain Exercise. The following proverb has had all of the vowels taken out, and the remaining letters broken up into groups of four or three letters each. Replace the vowels and find the proverb:

RLLN  GSTN  GTH  RSN  MSS

7. Left-Brain Exercise. Starting with SOFT, change one letter at a time until you have the word LENS. Each change must be a proper word.

SOFT

••••

••••

••••

LENS

8. Left-Brain Exercise. A water lily doubles its size every day in a round pond, and after twenty days, the lily will completely cover the pond. How many days will it take to cover half the pond?

9. Left-Brain Exercise. Which is the odd one out?

CAT  MONKEY  WHALE  MOUSE  SHARK

10. Left-Brain Exercise. What number ends this sequence?

36  25  16  9  —

11. Left-Brain Exercise. Which letter or number is the odd one in each rectangle?

12. Whole-Brain Exercise (both hemispheres). A woman marries ten men in the space of ten years. She divorces none of them, none of them die, and she has not committed any crime. How is this possible?

13. Whole-Brain Exercise. You need to get a pair of matching socks from your drawer but the room is pitch black. You know there are ten blue socks and ten brown socks in the drawer. How many socks do you need to remove to be sure you have a pair of matching socks?

14. Whole-Brain Exercise. Hans is standing behind Gerrie and at the same time Gerrie is standing behind Hans. How can this be?

Answers to Beginning Exercises

1. Warm-up Exercise. No right answer.

2. Right-Brain Exercise. The total number of squares is 30 (don’t forget all the combinations of squares within squares).

3. Right-Brain Exercise. C.

4. Right-Brain Exercise. B.

5. Right-Brain Exercise.

6. Left-Brain Exercise. A rolling stone gathers no moss.

7. Left-Brain Exercise. SOFT, LOFT, LEFT, LENT, LENS.

8. Left-Brain Exercise. It will take 20 days to cover the entire pond, so half the pond will be covered in 19 days.

9. Left-Brain Exercise. Shark; all of the others are mammals.

10. Left-Brain Exercise. The answer is 4 (the square of 2) since the numbers are squares of the sequence 6, 5, 4, 3, and 2.

11. Left-Brain Exercise. In the first box, the letter I is the only vowel. In the second box, the number 23 is the only one that cannot be divided by 2 or 3.

12. Whole-Brain Exercise. She is a minister.

13. Whole-Brain Exercise. Three socks. If your first sock is blue and your second sock is brown, the third will have to make a pair with one of the first two.

14. Whole-Brain Exercise. Hans and Gerrie are standing with their backs to each other.

If you are having fun without frustration at this exercise level, you might want to check out the latest websites and other resources for puzzles and brain-teasers with similar levels of difficulties.

Advancing to the next level gets a bit more challenging. Sample a few to see whether they are challenging yet fun.

Intermediate Exercises

1. Warm-up Exercise. You’ll need a piece of paper and two pencils again for a more advanced simultaneous writing exercise. Try writing your first name with your left hand and your last name with your right hand, but use both hands simultaneously. After you get the hang of it, reverse the task: write your last name with your left hand and your first name with your right hand, but do it simultaneously.

2. Right-Brain Exercise. The following ten circles are arranged in a triangle. See whether you can turn the triangle upside down by moving just three circles.

3. Right-Brain Exercise. Without lifting your pencil from the paper, draw four straight connected lines that go through all nine dots, but through each dot only once. After you have tried two different ways, ask yourself what restrictions you have set for yourself in solving this problem.

4. Right-Brain Exercise. These cubes build from the bottom layer up. Figure out the total number of cubes in the following figure, including the number of hidden cubes.

5. Right-Brain Exercise. Look at the object on the left and then choose the rotated version: A, B, or C.

6. Right-Brain Exercise. Of the following six circles, try to move just one circle to form two rows, each with four circles.

7. Left-Brain Exercise. Which four colors have been mixed up in the following letters?

BYLV  GUEE  RLLO  IWEO  ELEN  T

8. Left-Brain Exercise. The following combinations of letters are unusual, but each is part of a word, exactly as they appear in that word. Try to discover the three words:

XYG  XOP  WKW

9. Left-Brain Exercise. Using the letters EEEENNNNPPSS, complete the following grid with four words. The words in the grid read the same across as down.

10. Left-Brain Exercise. Can you think of a word that starts with BR, and when you add the letter E to that word, the new word sounds the same as the first?

11. Left-Brain Exercise. See whether you can find the hidden countries in the following sequence, without using any reference material. The letter denotes the country’s first letter and the number indicates the number of letters in the country. For example, B6 could be Brazil.

U7,  T6,  A9,  M10,  F4,  V7

12. Left-Brain Exercise. Which of the following words is the odd one out?

IIAWAH  OHADI  HATU  ADIROLF  AIGREOG  NOGERO TNOMREV

13. Whole-Brain Exercise. Shirley has idiosyncratic tastes. She loves weeds but despises flowers. She adores confetti but hates party decorations. She likes feet but dislikes hands. Based on her preference pattern, would she prefer sitting or standing?

14. Whole-Brain Exercise. Two policemen are patrolling a one-way street looking for drivers who are violating local traffic laws. They see a limo driver going the wrong way down the street, but the policemen do nothing. How would you explain this?

Answers to Intermediate Exercises

1. Warm-up Exercise. No right answer.

2. Right-Brain Exercise.

3. Right-Brain Exercise. Letting go of our spatial mental assumptions allows us to solve the dot-connecting puzzle.

4. Right-Brain Exercise. Your total should add up to 35 cubes: 15 cubes are showing and 20 are hidden.

5. Right-Brain Exercise. C.

6. Right-Brain Exercise. Place the left-hand circle under the middle one as shown here.

7. Left-Brain Exercise. Blue, yellow, green, and violet.

8. Left-Brain Exercise. Oxygen; saxophone; awkward.

9. Left-Brain Exercise. The words are open, pane, ends, nest.

10. Left-Brain Exercise. Braking becomes breaking when you add the letter E.

11. Left-Brain Exercise. Uruguay, Taiwan, Argentina, Mozambique, Fiji, Vietnam

12. Left-Brain Exercise. AIGREOG. All the others spell one of the United States backward. AIGREOG is not the reverse of GEORGIA.

13. Whole-Brain Exercise. Sitting. She likes only words that contain double letters.

14. Whole Brain Exercise. Because the limo driver was walking rather than driving, no traffic laws were broken.

If you are not yet mentally exhausted (I know I am), then you are at the top of your mental aerobics game and may wish to move on to the following advanced exercises.

Advanced Exercises

1. Warm-up Exercise. You’ll need a pencil and piece of paper for the warm-up. Take the piece of paper, hold it against your forehead, and write your first name. View the results. Try writing your last name with the paper against your forehead. Now, try this exercise again while standing in front of a mirror.

2. Right-Brain Exercise. Which of the following shapes is different from the rest?

3. Right-Brain Exercise. Identify the square that completes the sequence: A, B, C, D, E, or F.

4. Left-Brain Exercise. Can you unscramble the letters below to find four cheeses?

CCEDHBHEAEMRSDIHEDIARRE

5. Left-Brain Exercise. Can you circle exactly four of these numbers such that the total is twelve?

1 6 1

6 1 6

1 6 1

6 1 6

6. Left-Brain Exercise. In the following string of letters, cross out nine letters so that the letters remaining spell a well-known appliance.

RNEIFNRIEGLEETRATTOERSR

7. Whole-Brain Exercise. In some cultures, parents prefer having sons over daughters. Consider a hypothetical culture where the practice has arisen that every family continues to procreate until a son is produced, at which point they stop having children. Assuming that boys and girls are born with equal probability, what is the ratio of boys to girls after one hundred generations?

8. Whole-Brain Exercise. You return from work and discover that your television is on. Not remembering having left it on, you turn it off and think nothing of it. A few days later, the same thing occurs. Over the next few weeks, it happens several more times and then stops. Deciding this case did not warrant calling in Mulder and Scully, or your local CSI team, you forget it. Now, several months later, it has begun again. The baffling facts of the case are as follows:

• You have never observed it occurring when you are home.

• All the doors and windows in your house are locked when you leave.

• There is no sign of trespass when you return.

• No one is at home while you are gone except your pet goldfish, Emma, who really is more of a radio fish.

• Your remote control’s batteries have been dead for some time.

• When the TV is found on, it is a seemingly random channel: news, soaps, static, or Baywatch.

• The television room is on the top floor, and there are no houses, buildings, or other structures within line of sight of any window.

• No other appliance in the house displays this behavior.

• There seems to be nothing odd about your electrical system—no surges or spikes.

• The TV is still under warranty and passed its most recent inspection by a trained technician.

Is your TV possessed by an unearthly couch potato or can you think of a more mundane explanation?

9. Whole-Brain Exercise. What is the missing letter?

10. Whole-Brain Exercise. Three men, Alan, Brian, and Charles, and their respective wives, Alice, Betty, and Cathy, were hunting in Africa, when they came across a large river. Luckily there was one boat, but it could only carry two people at the same time. Due to bitter jealousy, no woman could be left with another man unless her husband was present. How did they manage to cross the river?

11. Whole-Brain Exercise. There is a closed room with a light in it. Outside, there are three light switches. You can flick any of the switches any number of times, but only one at a time. You can only open the door and go into the room once. You know that the light is initially off. How can you determine which light switch operates the light?

Answers to Advanced Exercises

1. Warm-up Exercise. No right answer.

2. Right-Brain Exercise. The only piece with more sides on the inner shape than the outer one.

3. Right-Brain Exercise. B. Moving from left to right and top to bottom, the black and white circles move clockwise each step and the brick circle moves counterclockwise.

4. Left-Brain Exercise. Edam, Cheddar, Brie, Cheshire.

5. Left-Brain Exercise. Turn the grid upside down.

6. Left-Brain Exercise. If you cross out the letters NINE LETTERS, you spell REFRIGERATOR.

7. Whole-Brain Exercise. The ratio is 50-50. Intuitively, it may feel that the families are adopting a strategy favoring producing a son, but this is incorrect. Each family’s expected number of sons is one, by the definition of the strategy. But the expected number of daughters doesn’t drop.

8. Whole-Brain Exercise. Just like in the X-Files, the answer is that your TV is possessed by an unearthly couch potato: the sun. Your TV room’s windows face west, and during certain times of the year, the sun’s refracted rays come streaming in and strike your television’s remote control sensor. Since the remote operates on infrared light, certain frequencies of light emitted by the sun are interpreted by the sensor as commands to turn on or off, or change the channel. When you are home, you pull the shades, to keep out the glare of the setting sun.

9. Whole-Brain Exercise. N. The pyramid spells out the name AL EINSTEIN.

10. Whole-Brain Exercise. Alan and Alice cross and Alan returns. Betty and Cathy cross and Alice returns. Brian and Charles cross and Brian and Betty return. Alan and Brian cross and Cathy returns. Alice and Betty cross and Charles returns. Charles and Cathy make the final crossing.

11. Whole-Brain Exercise. Leave switch 1 alone. Flick switch 2 on for an hour, then flick it back. Flick switch 3. Now look. If the light is on, then the switch is 3. If the light bulb is warm, then it is switch 2. If not, then it is switch 1.

Building Your Mental Aerobics Program

Just as physical activity can keep your body strong, mental activity can keep your mind sharp and agile. You can continue to challenge yourself by using a variety of approaches. You might consider exploring a new hobby, learning a foreign language, or perhaps taking up a musical instrument. Making a change in your leisure reading—perhaps switching from romance novels to biographies or mysteries—could potentially tweak your dendrites.

Whether you were able to complete all of the exercises or only a few, you should have a sense of the difficulty level for mental aerobics exercises that suits you. As you build your skills over time, you may want to advance to a higher level to challenge yourself and keep yourself stimulated. Chapter 10 will help you fit a program into your weekly schedule, and you can readily expand your repertoire with novel puzzles, games, and brain-teasers from other sources, including magazines, books, apps, and websites.

Chapter Six

Build Your Memory Skills Beyond the Basics

I am always ready to learn although I do not always like being taught.

—WINSTON CHURCHILL

Whether it’s riding a bicycle, using a typewriter, or ironing a shirt, we take for granted most of the skills we learn throughout our lives. Yet, for each of these routine activities we had to build slowly upon basic steps to master a more complex activity. The same holds true for memory skills. Just as we systematically learn how to master everyday basic tasks—driving a car, using a smartphone—we can systematically learn memory techniques and incorporate them into our daily routines.

Longitudinal studies have shown that basic and advanced cognitive training clearly work. In the ACTIVE (Advanced Cognitive Training in Vital Elderly) study, nearly three thousand older adults were randomized into four groups: one group focused on cognitive training and memory skills; a second group was taught better reasoning skills; a third group emphasized learning to process information quickly; and the fourth group had no specific cognitive training. Each of the groups was trained for five to six weeks. The investigators found that the cognitive benefits of each of the intervention groups were specific to the type of training received, and several cognitive gains were still apparent after five and ten years of follow-up.

In Chapter 3, we saw how LOOK, SNAP, CONNECT, the basic building blocks for my memory training program, could improve our memory performance quickly. If you have begun to utilize these skills with ease, you are ready to address the next level of memory skills training.

Organization

A professor of mine once commented on the superb skills of a very accomplished neuroscientist. She attributed much of his accomplishments to his being “extremely organized.” That statement made an impression on me—she didn’t describe him as brilliant, creative, insightful, or scholarly. She merely said he was organized.

Rhonda C. and her husband, Ken, had postponed having children well into their thirties because their advertising careers were in high gear. After Ben and Nikki were born, they really didn’t need two incomes, so Rhonda stopped working. Now, in her midforties, she was up to her ears in managing the house; driving carpools; attending school functions, soccer practices, ballet lessons, and her husband’s social events; and taking care of what seemed like a million other little things. Rhonda never saw her mother’s broken hip coming.

Her 78-year-old mother had always been fiercely self-sufficient. She was an avid tennis player, a member of a bridge club, and loved to travel. Rhonda had been seeing her mother once a month or so, even though they lived less than ten miles apart. Now there were doctor appointments, medications, groceries, and a list of other errands and personal requirements that mother needed done and only one person for the job: Rhonda. Mother refused to have “some stranger” come to straighten her house and do laundry, so Rhonda did it. Mother wouldn’t dare have “precooked junk” meals delivered, even from good restaurants, so Rhonda cooked for her mother before going home to cook for her own family.

Rhonda began waking two or three times a night feeling anxious—had she forgotten to do something? Left something unfinished or not done well enough? She constantly felt guilty about spending too little time with the kids, Ken, and even her mother. She hadn’t had time to go to the gym or take a run for weeks, and then her memory started to go. First, she forgot to pick Ben up from basketball clinic—twice. Then, little Nikki was inconsolable when Rhonda “mixed up the dates” and didn’t show up to do an art project with her second grade class. Ken realized Rhonda might be having a real problem when he came in with an important out-of-town client for a home-cooked dinner, but Rhonda had “spaced out” and ordered pizzas as a treat for the kids.

Rhonda was exhausted. She lost weight and grew restless. She was constantly bickering with everyone, especially her mother. She felt terrible but she couldn’t stop—there were always three or four more things she had to do first. Rhonda became depressed, and her memory got even worse.

Ken convinced her to see a therapist they’d heard of. Once there, she broke down and sobbed that she was losing it. She used to run a successful advertising agency and now she couldn’t even manage a household! She felt overwhelmed, stressed out, and disorganized. She could hardly remember all the errands and tasks she had to do each day.

The therapist said she appeared to be under severe stress and was definitely depressed, and often when people are depressed, it affects their memory ability. Under some circumstances, he might prescribe an antidepressant, but he was struck by how much of her problems began when her mother broke her hip and Rhonda suddenly had to add parent care to her many tasks. Rhonda balked: at work, she used to have hundreds of tasks and a dozen employees vying for her time. Every minute of every day was scheduled, and she never had memory problems then. The therapist said that might just be the answer: when Rhonda was working, she adhered to a well-organized, scheduled agenda. With her new “job,” she needed to create a similar, effective system to organize her schedule.

Rhonda knew he was right. Organizing her new life was something she had neglected, long before her mother’s accident. She went home and began listing her many daily tasks and chores, and then sorted them by priority and geography. She bought an appointment organizer like the one she had used in her agency days and began scheduling her upcoming week. Rhonda felt empowered, and although she was relying on her appointment book as a memory tool, the process of going back to her familiar organizational strategies made it easier for her to remember her engagements without actually having to refer to the book itself.

Rhonda was able to see her mother back to health and never did need those antidepressants.

Organization is essentially the process of systematically arranging information according to structures, patterns, and groupings. Learning to organize daily activities effectively can make the difference between success, mediocrity, or outright failure. For maximum recall performance, organizing information according to obvious patterns facilitates quick memory storage and retrieval.

One of the more effective organizational memory skills involves chunking—basically, dividing a large group of random items into separate chunks with a common characteristic. Attempting to remember six random items at the market is going to be more difficult than trying to remember three cereals and three dairy products.

Consider the following pile of common grocery items:

Many of us would find them easier to remember if instead of seeing a random assortment, we split them up into two groups, or chunks: in this case, three fruits and three meats.

Four Organization Exercises

1. Group the following twelve items into three categories:

Hammer
Nail
Cucumber
Base

Carrot
Hoop
Romaine
Stopwatch

Golf club
Scalpel
Cabbage
Bolt

Without looking at the list, try to remember the items in each of your categories.

2. Dividing information into smaller groups or clusters is another form of chunking. For example, it is easier to remember three chunks of two- or three-digit numbers than an entire seven-digit phone number: 82-51-291 instead of 8251291. Some boomers may remember when phone numbers included a word, such as “Webster,” representing the first three numbers. Look up the phone number for your public library. Read it once, cover it, and say it out loud. Difficult? For many of us, it will be. Now, look at it again and cluster it into three smaller number groups. Then, say it aloud. You may find it easier to remember.

3. Group the following twelve items into four categories:

Sunscreen
Diskette
Shutter
Calculator

Slide rule
Goblet
Bottle
Visor

Drive
Abacus
Carafe
Motherboard

Without referring back to the first list or the list in Exercise 1, see whether you can remember ALL seven categories.

4. Try to memorize your driver’s license ID by chunking the numbers.

Peg Method for Remembering Numerical Sequences

With the advent of smartphones and other mobile devices, we don’t need to remember phone numbers or birthdates that often these days. But what if you’ve misplaced your phone or your battery just went dead and you have to make an urgent call to a number you often use but haven’t bothered to memorize? With a simple Peg Method, you can learn and recall those frequently used numbers and never, ever forget them.

The Peg Method was developed as a system for remembering phone numbers, addresses, or numerical sequences by visualizing objects as opposed to rote memorization of the numbers themselves. Just as a peg is something that pins down or fastens things, this technique helps us to systematically pin down or fasten bits of information. Pegging builds on the linking skills we learned in LOOK, SNAP, CONNECT by providing a way to remember items in any order one chooses, as opposed to linking, where we are limited to remembering information in its original sequence.

Although it requires effort, the Peg Method will forever remove uncertainty about remembering numbers—any sequence of numbers—whether it’s phone numbers, combinations, passwords, or Social Security numbers. You will be able to punch in your credit card number and its expiration date and never remove it from your wallet. Of course, pegging can prove to be challenging, so those satisfied with the linking method they mastered in LOOK, SNAP, CONNECT may choose to jump to the next section.

To use the Peg Method, you will need to commit to memory ten specific, simple visual images—one for each of the ten numerical digits. Begin by assigning each of the numbers one consonant letter of the alphabet that reminds you of that number. For example, I use the letter T to represent the number 1 because it has one downstroke. I then use this letter to begin a word that invokes a visible image, in this example, a tie, and this word tie, then, serves as my peg for the number one.

In Table 6.1, I provide a sample peg word for each of the ten digits. If you like, you can learn these words, or make up your own peg words based on your first association to the consonant sounds, and write them in your notebook.

Table 6.1

Number | Word | Consonant | Memory Aid
1 | Tie | T | Letter with 1 downstroke
2 | Nun | N | Letter with 2 downstrokes
3 | Mummy | M | Letter with 3 downstrokes
4 | Raisin | R | Last sound of the word four
5 | Leg | L | Roman numeral for 50 is L
6 | Jet | J | Letter J turned around looks like a 6.
7 | Kite | K | K looks like two 7s rotated and glued together.
8 | Fork | F | Lowercase cursive f looks like the number 8.
9 | Pot | P | Letter P turned around looks like the number 9.
0 | Zebra | Z | First letter in the word zero

In addition to being readily visualized, each of these words leads to distinct images. A raisin is hard to confuse with a mummy, and a pot can be readily distinguished from a fork. Effective peg words also tend to bring to mind many varied details, which lead to more memorable visual images, or snaps.

Using pegs and the link method together can also be very effective. Here is how you might remember your wife’s social security number using the above peg words.

SSN: 557-16-8043

Peg word sequence:

Leg
Leg
Kite
Tie
Jet
Fork
Zebra
Raisin
Mummy

Storyline-linking peg words: Imagine your wife putting on her jeans and you compliment her beautiful legs (55). She puts on her jacket and goes out to fly a kite (7). Unfortunately, she’s using your favorite tie (1) as a kite tail. The kite goes up so high that its tail gets sucked into the engine of a passing jet (6). The pilot is eating his meal with a fork (8), and a flight attendant comes in wearing a zebra (0) costume. She hands him a raisin (4) and sees that the copilot has turned into a mummy (3).

Admittedly, this is a rather bizarre sequence of events and would not occur often on a major commercial airline. But keep in mind, the more bizarre, unusual, and vivid your peg images, the easier they are to commit to memory. Also, these associations were the first ones that came to my mind, and oftentimes first associations stick best.

Review and memorize the peg word list in Table 6.2. Then, using your notebook, practice the Peg Method with the exercises in the Peg Method Exercises box.

Table 6.2

SAMPLE PEGS
Digit | Word
1 | Tie
2 | Nun
3 | Mummy
4 | Raisin
5 | Leg
6 | Jet
7 | Kite
8 | Fork
9 | Pot
0 | Zebra

Peg Method Exercises

1. Birth dates. Write down a friend’s birth date; for example, 09/21/54. Find the corresponding peg words and then create a story—as zany and vivid as possible. Now use the same method to commit to memory two more birth dates, those of a relative and a work associate.

2. Phone numbers. Use the Peg Method to remember the phone numbers you don’t already know of the following businesses: a favorite local restaurant, a good plumber, and a drugstore. For extra credit (type A personalities), learn three other numbers as well.

3. Credit card numbers. Do your two most-used cards. Don’t forget the expiration dates.

Remembering Names and Faces

One of the most frustrating things about the memory changes associated with aging is the increasing difficulty we have remembering names. We may recognize a person’s face but be unable to recall the person’s name. Even as young adults, the major reason many of us forget names, sometimes only seconds after people have been introduced to us, is that oftentimes we are not fully listening. Fortunately, there are many easy-to-learn strategies for remembering names.

Most strategies for remembering the name that goes with a face use the three basic skills we learned in Chapter 3: LOOK, SNAP, CONNECT. First, make sure you consciously listen to and observe the name (LOOK). Then, SNAP a visual image of the name and the face. Finally, CONNECT the name-snap with the face-snap. This systematic approach of linking a name to a face has been highly successful.

Other effective techniques include repeating the person’s name during your initial conversation, as well as commenting on how the person reminds you of someone else you know of the same name. Other mnemonics work well, also. I mentioned my challenge every school year, learning the names of my kids’ new classmates and their parents. My son’s first grade class was particularly challenging (I’m not sure why). However, one little girl was named Ashley and her mother was Laura. Laura; Ashley. Since my wife has an expensive yet seldom-indulged penchant for bedding by a company of that name, I found the names of this child and her mother very easy to remember.

If a person has a complicated or unfamiliar name, you might ask them to spell it for you, or sometimes just visualizing an image of the name spelled out will facilitate memory storage. Using their name when saying good-bye will certainly help secure it into your memory banks.

All names can be placed into two groups: those that have a meaning and invoke a visual image, and those that don’t. Such names as “Carpenter,” “Katz,” “House,” “Bishop,” “Siegel,” “White,” or “Silver” all have a meaning and can readily bring to mind an image. Of course, I am thinking of a seagull when I meet Mrs. Siegel.

Often names may have no immediate meaning but can still bring an image to mind. For example, “Bill” could be represented by the image of a dollar bill. The name “Washington” might conjure up the famous monument.

Any name that has no immediate meaning, such as “Shapiro,” “O’Malley,” or “Amaducci,” may require additional mental effort to remember. However, the names or the syllables and sounds within them can be associated to a substitute name or sound that does have a meaning. By linking these substitute words together, you can create a visual image that works. Sometimes we can break a name into syllables that contain meanings, and then link them afterward. For example, the name “George Waters” could be remembered through an image of a gorge with a stream of water rushing into it. The word or syllable substitutes do not need to be exact. “Frank Kaufman” could be a frankfurter being eaten by a coughing man. “Gene Phillips” could be a Phillips screwdriver wearing a pair of tight jeans. Of course, some scientists among us might prefer visualizing a double-helix gene downing a double-vodka screwdriver.

Finally, we need to CONNECT the name to the face. The approach here is to look at the person’s face and search for a distinguishing feature, whether it is a small nose, large ears, unusual hairdo, or deep wrinkles. Just pick the first outstanding feature you notice and link it to the name. For example, if Mrs. Stockton has a round face, think of a balloon falling on a ton of stock certificates.

To create a snap for remembering Mr. Bender’s name, you may see him bending forward, as shown.

Naturally, others might choose to picture him disheveled from a “bender” the evening before, when he had one too many.

Often, the first thing that strikes us about people is not visual but instead relates to their personality. Mr. Porter has a great sense of humor and a silly laugh, so we might visualize him as a porter carrying our suitcases, dressed as a circus clown. Again, the images and substitute words need not be perfect. The process of thinking up the images and making the connections, or links, will fix them into memory. Of course, practice makes perfect, and it can be found in the Name and Face Exercises box.

Name and Face Exercises

1. For the following first names, think of a visual image:

NAME | VISUAL IMAGE

Stewart

Cheryl

2. Write down the last name of two people you know and create a mental snapshot that represents the name:

PERSON’S NAME | VISUAL IMAGE

3. For the above people, list the first distinguishing feature that comes to mind:

PERSON | FEATURE NAME/FACE IMAGE

Finding That Word on the Tip of Your Tongue

One of the most common age-related memory complaints is that frustrating experience when you absolutely know you know a word, name, or title, but it just won’t roll off the tip of your tongue. Dr. Timothy Salthouse and associates studied this tip of the tongue phenomenon in over seven hundred volunteers aged 18 to 99 and found that even though these types of experiences become more common as people age, they do not predict future cognitive decline.

An upside of brain aging is that as years pass, we acquire more knowledge and information, so we can often compensate for word finding issues by using an alternative word or phrase until we can retrieve the information we seek. Each time we learn new information or create a new memory, it gets stored away in our brains’ filing cabinet. But if our brains’ filing cabinets are disorganized and overstuffed with data, it can be difficult to locate a particular file or memory within a moment’s notice. This is why it’s important to have tools for dusting off our brains’ memory files that we may have not accessed for years or decades.

Of course, our current reliance on the internet to look up facts rather than searching our own memories may make our brains’ memory files even dustier. When volunteers are instructed to search online for specific information, they gather the information more efficiently than they would if they looked it up in a printed encyclopedia, but they are less able to recall the information later. Many people complain that they just don’t remember as much detailed information as they used to because they have been spending so much time online. (There is some good news: relying on the internet for facts and figures may offer a cognitive benefit by freeing up the brain to undertake other mental tasks.)

The Memory Bible’s basic memory methods will help you fight back against those annoying tip-of-the-tongue moments. The next time it happens, don’t rack your brain searching for the word—that will only increase your anxiety, which in turn worsens memory retrieval. Instead, jot down a note to yourself that describes the word, phrase, or title you want to recall. Later, when it’s convenient, ask a friend or search the internet using your descriptions of the word to correctly identify it. Then, use LOOK, SNAP, CONNECT to ensure that the next time you search for that word, you can quickly retrieve it.

The following is an example of how it works. Gigi and I love watching old movies. I mentioned that I wanted to rewatch that terrific satire with Faye Dunaway involving a TV programming executive who kept shouting, “I’m mad as hell and I’m not going to take it anymore.” At that moment, the name of the movie just wouldn’t come to either one of us. I picked up my phone and googled my description of the film (Faye Dunaway, the memorable character’s quote, etc.), and retrieved the film’s title, Network. I then used LOOK, SNAP, CONNECT to make the word Network memorable to me: I visualized Faye Dunaway wearing a hair net while working out at the gym. We enjoyed watching the film that night, and I’ve never forgotten that film’s title again.

The Roman Room Method

To apply the Roman Room Method, originally developed by ancient Roman orators to help them remember long speeches, first visualize a familiar room. Then, place each item to be remembered in a specific location there. You can then retrieve the information when taking a mental walk around the room.

The method can be useful for speeches, lectures, or lists. You might imagine your living room, bedroom, or office as your “Roman room.” I can imagine myself in my office where I see from left to right the computer, phone, bookshelf, and couch. I need to remember the following errands after work: hardware store, carwash, cleaners, and market. I then visualize a wrench on top of the desk, a wet car on the phone, folded shirts in the bookshelf, and a shopping bag on the couch.

A variation uses a familiar route rather than a familiar room. On your commute to the office, you pass the following landmarks each day: water tower, bridge, gas station, and post office. You need to thank several people in your Academy Award speech, so you think of Steven Spielberg sitting atop a water tower, Meryl Streep walking across the bridge, Sylvester Stallone pumping gas at the station, and Joaquin Phoenix working at the post office.

Building Memory Skills: A Quick Review

1. Organization. Look for systematic patterns and groupings to facilitate learning and recall.

2. Peg Method for Remembering Numerical Sequences. Commit to memory a specific visual “peg” for each of the ten digits; then use the link method to create a story for remembering numerical sequences.

3. Remembering Names and Faces. Make sure you consciously listen and observe the name (LOOK), then SNAP a visual image of the name and the face, and finally CONNECT the name-snap to the face-snap.

• Observe distinguishing features in the person’s face.

• Repeat the name in conversation and when saying good-bye.

• Look for personal meaning in the name.

• Ask them to spell their unusual name.

4. Roman Room Method. Pick a familiar room or route and, in your mind, place the items to remember at key points or landmarks.

Chapter Seven

Start Your Healthy Brain Diet Now

I drive way too fast to worry about cholesterol.

—STEVEN WRIGHT

Most of us realize by now that the quality and quantity of the foods we eat affect our bodies and our physical health. Less widely understood is the critical impact our nutritional habits have on our brain health—particularly our memory performance and risk for developing Alzheimer’s disease.

Just as unhealthy diets can lead to physical ailments, such as diabetes, heart disease, and obesity, those same T-bone steaks, curly fries, and ice-cream sundaes can negatively, and sometimes irreversibly, damage our brain fitness—although the effects may take decades to appear.

Convincing scientific evidence indicates that long-term, healthy dietary habits may prevent future brain aging and memory decline and help protect our brains from developing Alzheimer’s disease symptoms. For many people, even a few weeks of healthy, low-fat eating can produce immediate benefits such as increased alertness and greater energy.

The sooner you start your healthy brain diet, the sooner you begin to reap the benefits. Chapter 7 provides the components of a safe mental-fitness diet to keep your brain young and protect it from Alzheimer’s disease.

Calories Count to Healthier Brains

By the time we reach middle age, many of us tend to carry around extra body weight. Whether it’s simply an additional five or ten pounds or true obesity, excess body fat increases our risk for such illnesses as diabetes and high blood pressure. These illnesses increase our risk for small strokes in the brain, which can lead to memory decline and dementia and even Alzheimer’s disease.

Among the most effective and widely accepted ways to drop weight and avoid these problems is limiting daily caloric intake while increasing physical activity—a practice at the heart of almost all traditional weight-loss programs. Any reputable book or program on dieting or weight reduction, no matter how miraculous its “breakthrough” methods may be, comes down to these tenets at some point. Who of us struggling against love handles wouldn’t want to “Lose weight while sleeping!” or try a month on “The more you eat, the more you lose!” diet? Alas, the Food and Drug Administration (FDA) has not yet approved the “Magical Fat Melters” and their ilk. Following a few practical tips has helped me maintain a reasonable diet and watch my calories (see box).

Dr. Roy Walford was among the gerontologists conducting animal studies showing that lifelong calorie restriction dramatically prolongs life expectancy as well as maintains optimal brain fitness. Calorie-restricted rats were found to have 25 percent better functioning of brain receptors involved in memory compared with animals on unrestricted diets.

Practical Tips for Keeping Tabs on Your Calories

• Drink plenty of water, at least six glasses a day.

• Plan your meals in advance. Don’t wait until you’re so hungry that you’ll eat junk food or overeat.

• Keep portions low, avoid large meals, and eat healthy between-meal snacks to avoid a sense of deprivation.

• Use spices, herbs, garlic, hot sauce, and other healthy taste enhancers.

• When dining out, try splitting an entrée with a friend.

• Cook or order small portions to avoid overeating.

• Limit nighttime snacking. Brush your teeth an hour or two before bedtime as a reminder.

• Consider substituting the following lower-calorie food choices for their higher-calorie counterparts:

YES | NO
Fish or poultry breast | Red meat
Non-fat frozen yogurt | Ice cream
Fresh fruit | Sweetened canned fruit
Low-fat or skim milk | Whole milk
Unbuttered popcorn | Buttered popcorn

Years ago while at UCLA, Dr. Walford told me that he was so convinced by his animal studies that he restricted his own calories by fasting at least one day each week in the hopes of maximizing his longevity. Intermittent fasting has become a popular weight-loss strategy because of the assumption that it is a better and easier way to lose weight than calorie restriction, but a recent randomized clinical trial showed that alternate-day fasting (one method of intermittent fasting) was no better than daily calorie restriction in helping people to lose weight and keep that weight off. Research volunteers had difficulty staying on the alternate-day fasting diet and were more likely to drop out of the study than if they were randomized to daily calorie restriction.

Although I do not recommend caloric restriction to maximize memory ability to my patients, I do think that for people who are overweight or obese, watching their calories can decrease their risk of developing weight-related illnesses and help slow down brain aging.

Yo-Yo Syndrome

Another joy of aging is our bodies’ gradual loss of its automatic ability to regulate appetite and maintain a constant body weight. In one study, both younger and older men were asked to eat approximately 1,000 calories above their normal daily intake. After several weeks, this high-calorie addition to their diet ended. The younger group automatically ate less and dropped back to their normal body weight without trying to reduce. The older group kept the weight on. This older group of men was similarly unable to bounce back from undereating. After three weeks on a reduced diet—about 800 calories less than usual—all were asked to return to eating normally. The older group tended to stay at their lower weight level, while the younger group gained back what they lost by the six-week follow-up.

One of the greatest problems I see with most diets is that people get into a “yo-yo” syndrome of going up and down in their body weight. They begin a crash diet, feel starved and deprived, and then go off the diet with a giant binge. Experts agree that in the long run, such yo-yo diets tend to backfire and actually lead to increased body weight.

Researchers put healthy laboratory rats on a yo-yo diet and found they developed 3 to 4 percent more body fat than animals kept on a steady caloric intake. Weight cycling, or the pattern of gaining, losing, and regaining weight, often leads to greater fat accumulation over time. The evidence from animal studies and the harmful physical and mental effects of obesity have convinced many experts that by sensibly watching our caloric intake we may help protect our brains.

Georgette B., a 46-year-old teacher, first sought help for her memory problems two years ago. She was already being treated for high blood cholesterol, and she was concerned about her family’s history of Alzheimer’s disease. During the first five minutes of her visit, it was clear that memory complaints were not her only problem. In describing herself, she said she was always the first of her friends to try the latest fad diet. She would typically begin a new diet regimen, maybe lose a few pounds in the first week or two, and then quickly grow discouraged as her weight loss tapered off. Georgette would then abandon the diet and almost ritualistically plunge into a postdiet binge to make up for her weeks of hunger and deprivation. Experiencing a sense of failure and defeat, she invariably became depressed until finally finding and latching onto the next miracle weight-loss program. During her bouts of depression, Georgette’s memory difficulties became markedly worse. It was clear that if I were going to help Georgette with her memory problems, her eating disorder would need to be addressed as well.

Her approach to dieting had been like a physical and emotional roller coaster. She understood that what she ate had an effect on her waistline, but she never imagined that what she ate could have an impact on her current memory and future ability to think.

I referred Georgette to a nutritionist, who helped design a diet that kept her satisfied. By feeling less deprivation, she was less likely to quit the diet and start binging.

Another issue for Georgette was chronic depression. After treatment with an antidepressant, her memory complaints diminished and she found it easier to stick with her diet. For Georgette, learning that food choices could ultimately affect her brain aging and risk for developing Alzheimer’s disease helped change her attitude about food and eating. She became more realistic in her dietary goals and began to focus on the type and quality of food choices rather than just calorie counting.

A healthy brain diet is not only about counting calories or losing or gaining weight. It involves learning to make simple, consistent food choices that incorporate common sense and some easily learned tips on what to look for and what to avoid.

Good Fats, Bad Fats, and the Men and Women Who Love Them

Dr. Hugh Hendrie of Indiana University compared rates of Alzheimer’s disease in African Americans living in Indianapolis, Indiana, with those of Africans living in the Nigerian city of Ibadan. The Americans developed dementia at a rate nearly three times greater than the Nigerians. The Americans also had higher rates of hypertension, high cholesterol, and diabetes than did the Nigerians, and these illnesses all contribute to the risk for dementia, particularly the vascular form.

Although genetic risk likely plays a role, many people of Ibadan, Nigeria, are unable to afford much more than vegetables to eat. Their diet consists of yams, palm oil, a small amount of fish, and other foods. This diet contrasts dramatically with the typical American diet, which is usually high in animal fats. The researchers judged the Nigerian diet, normally low in protein, fat, and total calories, to be a major contributor to the lower rate of dementia in their population.

Dr. Jim Joseph of the US Department of Agriculture has described the importance of dietary fats among a Native American tribe in New Mexico with similar genetics to their Mexican counterparts. The New Mexico portion of the tribe lives on “government food,” which includes processed flour, cheese, and related high-fat foods. Many are overweight and have early-onset diabetes. By contrast, their relatives in Mexico eat a healthier diet of rice and beans, and despite their identical genetic makeup, obesity and diabetes are unknown in these people. Native Alaskans on the Kenai Peninsula and their genetically identical relatives in Siberia share a similar story. The Native Alaskans are overweight and eat the “white man’s diet,” whereas the healthier Siberians eat from the land.

Some popular weight-loss diets advocate eating generous portions of animal proteins and fats, while minimizing or eliminating carbohydrate intake altogether. Despite the effectiveness of these diets in reducing body weight, often due to loss of body fluids associated with carbohydrate restriction, their ability to slow down brain aging is questionable, and these diets may increase the risk for heart disease, diabetes, and cancer.

Doctors agree that a healthier diet option might involve limiting animal fats and increasing whole grains, vegetables, fruits, and dairy products, whose benefits stem partly from their potassium and calcium contents. Concerned about the harmful effects of fat, many Americans and Europeans have in fact been lowering their fat consumption for several years.

Epidemiologists consistently find that eliminating most fats from our diets lowers our risk for Alzheimer’s disease, and it is never too early to begin a low-fat diet to keep our brains young and stave off Alzheimer’s disease. Dr. Robert Friedland and his associates at Case Western Reserve University reported that lower-fat diets in young and middle-aged adults may substantially reduce their risk for Alzheimer’s disease decades later. In fact, limiting fat intake appears to have its greatest benefit for people with a genetic risk for age-related memory loss or Alzheimer’s disease. Dr. Friedland’s group found that people with the APOE-4 Alzheimer’s risk gene who ate a low-fat diet had a strikingly lower risk for developing Alzheimer’s disease when compared with their counterparts who ate fatty diets. A similar lowering of Alzheimer’s risk was not observed in people without the genetic risk.

Some experts believe that the APOE-4 Alzheimer’s risk gene accelerates age-related memory loss through its effect on fat metabolism. Among its many functions, APOE’s protein product acts as a transport mechanism, or chaperone, for cholesterol in the blood. High blood cholesterol levels not only increase our risk for heart disease and stroke, but also make us more susceptible to Alzheimer’s disease. Another study showed that patients using statin cholesterol-lowering drugs had a 70 percent lower risk for developing Alzheimer’s disease (Chapter 9).

High blood pressure, one of the most common chronic diseases associated with aging, also increases people’s risk for multiple strokes, which can cause severe memory loss. It is widely known that limiting dietary salt helps lower blood pressure. A study in the New England Journal of Medicine showed that people with high blood pressure also benefited from adding several servings of fruits and vegetables and low-fat dairy foods to their diet.

Not all fats are bad and accelerate brain aging. Some fats actually promote brain fitness. Dietary fats come in four forms: cholesterol, saturated, monounsaturated, and polyunsaturated. Omega-6 and omega-3 fats are polyunsaturated. Omega-3 fatty acids, often considered “good fats,” come from such foods as fruits, leafy vegetables, nuts, fish, fish oil, and olive oil. We can also get omega-3 fats as capsules or supplements. By contrast, omega-6 fatty acids, often considered “bad fats” when consumed in excess, usually come from meat and other animal products. Common foods containing these fats include red meat, whole milk, cheese, margarine, mayonnaise, most processed foods, fried foods, and vegetable oils. However, when consumed in moderation from safflower and sunflower oils, nuts, seeds, poultry, fish, and eggs, omega-6 fatty acids can be beneficial for your heart as well.

Diets high in omega-6, or bad, fats may contribute to chronic brain inflammation, a possible underlying mechanism in Alzheimer’s disease and other neurodegenerative disorders. Omega-3, or good, fats help keep brain cell membranes soft and flexible, whereas bad fats make them more rigid. Omega-3 fatty acids reduce risk for cardiovascular disease and stroke. The American Heart Association recommends at least two servings of fish each week so people can get enough of those good fats.

A Dutch study of approximately thirteen hundred men found that those eating margarine and other foods high in omega-6 fats experienced more cognitive decline than those who had healthier diets. By contrast, foods rich in omega-3 fatty acids, such as olive oil, decrease the risk for cognitive decline. In an investigation of older Italians, their use of approximately 3 tablespoons of olive oil each day was enough to provide protection against memory loss when compared to a control group not using olive oil.

Omega-6 saturated fats appear to impair memory through their effects on the hormone insulin. Laboratory animals that are fed omega-6 fats have increased difficulty learning and getting through mazes. In addition, their brain cells show fewer branches, or dendrites. Eating omega-6 fats also increases risk for insulin resistance—insulin becomes less effective in getting glucose into cells, putting people at greater risk for the memory impairments associated with diabetes. Fortunately, diet-related insulin resistance can be reversed, and controlling diabetes with diet, weight loss, or drugs can improve memory as well as learning ability.

Clearly, a diet rich in omega-3 fatty acids is likely to benefit our brain fitness and overall health, but our bodies are also able to adapt to a limited amount of omega-6 fats. An occasional donut or slice of apple pie won’t necessarily wipe your mother’s maiden name from your memory stores. Some nutrition experts even suggest maintaining a ratio of one omega-3 fat for every omega-6 fat, rather than attempting to completely eliminate the bad omega-6 fats from our diets.

Table 7.1 lists a number of common foods containing mostly omega-3 or omega-6 fats. A well-planned healthy brain diet will emphasize foods high in omega-3 fats.

Table 7.1

SOME COMMON FOODS CONTAINING OMEGA-3 AND OMEGA-6 FATS
High in Omega-3 | High in Omega-6
Anchovies | Bacon
Avocados | Butter
Bluefish | Cheese
Brazil nuts | Corn oil
Canola oil | Donuts
Flaxseed oil | French fries
Green leafy vegetables | Ice cream
Herring | Lamb chops
Lean meats | Margarine
Mackerel | Mayonnaise
Olive oil | Onion rings
Salmon | Potato chips
Sardines | Processed foods
Trout | Steak
Tuna | Sunflower oil
Walnuts | Whipped cream
Whitefish | Whole milk

Extra-Credit Mental Aerobic Exercise

1. A group of unexpected out-of-towners will be arriving at your home in 15 minutes, and they are absolutely starving. You have at your house everything from the left-hand column (the good fats). As quickly as you can, create a dinner menu including as many food items from this list as possible.

2. Now, just as quickly, create a new menu using only items from the right-hand column.

3. Afterward, imagine six assorted people in your life who you invite to a dinner party. Which of the two menus you just created would each of these people choose?

4. Do you notice the people who pick the omega-3 “good fat” menu are more likely to be concerned about their health, diet, and possibly even their brain aging?

Catch of the Day

Scientists have shown that one of the omega-3 fatty acids, docosahexaenoic acid (DHA), which comes from fish oil, actually increases acetylcholine, the brain messenger critical to normal memory function but lost in Alzheimer’s disease. People with deficient DHA in their diet or low levels in the blood will experience learning difficulties and cognitive decline. These can and do improve when dietary DHA is high. Research indicates that omega-3 fatty acid capsules may improve memory difficulties and other symptoms in patients with Alzheimer’s disease.

Previous research suggests that omega-3-rich fish oil may benefit a person’s mood as well as their memory, acting as an antidepressant and diminishing symptoms of hostility and aggression. Fish oil also has an antioxidant effect that fights against free radicals that can damage brain cells and decrease the brain’s immune response (see later discussion), thus modulating the cell-damaging effects of inflammation. Because low-fat diets protect us against Alzheimer’s disease, a healthy brain diet should include all kinds of fish, not just those high in omega-3 fats but fish that are considered low in their overall fat content, such as swordfish, snapper, sole, cod, catfish, flounder, perch, shellfish, haddock, and grouper.

Dr. David Heber and Susan Bowerman of the UCLA Center for Human Nutrition make a distinction between ocean-caught and farm-raised fish. This might sound like splitting hairs, but it’s not. Farmed fish are fattier because they don’t move around much, and their ratio of omega-3 to omega-6 is not as desirable because they don’t eat the algae and other fish the way their free-swimming counterparts do in the ocean. Ocean-caught fish have less overall fat but more of the omega-3 fats because they are consuming natural diets.

Although those omega-3s from fish can certainly boost brain health, it’s best to limit fish intake to avoid consuming excess mercury. Larger predatory fish have higher levels of mercury than smaller fish, so if you’re concerned about heavy metal accumulation, opt for trout or catfish rather than swordfish or shark.

Healthy Brain Diet Tip

Eat fish twice a week.

It’s Not the Sixties—Beware of Free Radicals

As we age, our brain cells undergo wear and tear from various oxidants known as free radicals. These free radicals are impossible to avoid—they are present in the air we breathe, the food we eat, and the water we drink. They perform useful functions in the body, but in surplus they can harm normal cells, wearing down their genetic material, or DNA. Brain cells, too, can suffer from this oxidative stress, a continual bombardment from chemical reactions in the environment and from within our own bodies. Through the DNA damage, this oxidative stress accelerates aging and promotes nearly all chronic age-related diseases from cancer to cataracts to Alzheimer’s.

To keep oxidation in check, our bodies use antioxidants, such as vitamins C and E, that combat the effect of free radicals. People with low blood levels of these antioxidant vitamins have poorer memory abilities. Epidemiologists who’ve followed people over time in their communities while testing their memory and other cognitive performances report that those taking supplemental vitamin C and E appear to have better memory abilities and less cognitive decline.

Dr. Martha Clare Morris and her colleagues at Rush University and other centers looked at volunteers over age 65 years for four years. Although the usual percentage of people in that age group developed Alzheimer’s disease as expected, not one of the subjects who regularly took the antioxidant vitamins C and E were among the group that developed the disease.

Unfortunately, these studies only recorded whether or not the participant was taking a supplement beyond just a daily multivitamin, which generally contains about 30 international units (IUs) of vitamin E and 60 milligrams of vitamin C. The investigators did not determine the optimal vitamin supplement dosage for preventing Alzheimer’s disease. Exactly how much your doctor might recommend for you is a matter of clinical judgment.

In a major study of Alzheimer’s disease, the investigators chose a dose of vitamin E—2,000 units daily—high enough to feel assured that its antioxidant effects got to the brain. They found that this dose slowed down the advance of Alzheimer’s disease by approximately seven months. Patients taking the vitamin were less likely to enter nursing homes or to develop severe symptoms for that period or longer.

For people with only mild memory complaints who would like to benefit from vitamin E’s antioxidant effects that might prevent future severe memory losses, deciding on an optimal daily dose is complicated by the vitamin’s effect on the immune system. At low doses of 200 units each day, vitamin E may help reduce infections in older people, but at higher doses, it may have the opposite effect. Studies have shown that very high doses of vitamin E, for example, the equivalent of over 2,000 units daily, may suppress a person’s immune response and limit the body’s ability to fight off infections. More recent research suggests that vitamin E doses above 400 units each day may cause heart problems.

For healthy people who wish to take antioxidant supplements as part of their healthy brain diet, I recommend a daily dose of 400 units to 800 units of vitamin E, and 500 to 1,000 mg of vitamin C. Antioxidant foods and supplements not only help protect our brains but also protect our bodies against some forms of cancer, diabetes, and Parkinson’s disease, as well as increase our immune defenses to colds and viruses.

Antioxidant Brain Food

Antioxidants occur naturally in many fruits and vegetables, and nutritionists have been touting their benefits for years. Dr. Jim Joseph of the US Department of Agriculture found that laboratory animals fed these natural antioxidant foods show better memory ability in finding their way through mazes and other tasks. Dr. Joseph encourages people to regularly eat antioxidant-rich foods, such as strawberries, blueberries, raspberries, cranberries, broccoli, and spinach.

Researchers at Tufts University have devised a laboratory technique that measures the ability of different foods to counteract oxidative stress. Those foods with high oxygen radical absorbency capacity (ORAC) scores may protect our brain cells from the damage of oxidants—that of the free radicals, as mentioned earlier. Table 7.2 indicates some foods with potent antioxidant protection.

Table 7.2

THE TOP ANTIOXIDANT FRUITS AND VEGETABLES
Food | Antioxidant Power
| ORAC Units per 3.5 Ounces
Prunes | 5,770
Raisins | 2,810
Blueberries | 2,400
Blackberries | 2,040
Cranberries | 1,750
Strawberries | 1,540
Spinach | 1,260
Raspberries | 1,230
Brussels sprouts | 980
Plums | 950
Broccoli florets | 890
Beets | 840
Avocados | 780
Oranges | 750
Red grapes | 740
Red bell peppers | 710
Cherries | 670
Kiwis | 600
Onions | 450
Corn | 400
Eggplant | 390

Source: US Department of Agriculture Agricultural Research Service.

The Tufts University experts recommend we all eat about 3,500 ORAC units each day—and just 1 cup of blueberries nearly accomplishes this goal. Most Americans and Europeans consume just over 1,000 ORAC units each day and generally don’t get enough antioxidant foods in their diet. By simply doubling our average fruit and vegetable intake, we could each raise our diet’s antioxidant power by 25 percent. Although, during the past few decades, Americans have successfully reduced their fat intake, their fruit and vegetable consumption remains relatively low.

The usual assumption that fresh is better than frozen does not necessarily hold true when it comes to the antioxidant capacity of foods. Studies of strawberries and blueberries show that the antioxidant properties of the frozen versions can actually be five times greater than the fresh varieties.

Tomatoes have been found to contain high concentrations of a particularly potent antioxidant called lycopene. Dr. David Snowdon of the University of Kentucky determined that women in their late seventies and eighties who had low blood lycopene levels showed decreased cognitive performance and a greater need for assistance in performing daily activities compared with women with higher lycopene levels. Eating foods rich in lycopene, such as tomatoes, pink grapefruit, or watermelon, can dramatically increase the blood’s antioxidant capacity. The UCLA human nutrition research group found that just 6 ounces of tomato juice increases lycopene blood levels by 40 percent. Mixed with some nice omega-3-rich olive oil, a little fresh basil, and some linguine, and we’ve got a brain-healthy lunch! Pass the salad, please.

Healthy Brain Diet Tip

Eat ten servings of fruits and vegetables each day.

Dried fruits, such as raisins and prunes, are excellent sources of antioxidants; however, people concerned about calories might consider other sources, because dried fruit tends to have a high caloric content. Tea, the second-most-consumed beverage worldwide, just behind water, is an excellent antioxidant source that does not contain calories. Tea is one of the few foods to contain significant amounts of the potent antioxidant known as catechin. Caffeinated green teas have very high catechin levels, as do caffeinated black teas brewed from bags.

A new approach that encourages people to eat foods with high antioxidant capacity emphasizes the color factor in fruits and vegetables. Dr. Jim Joseph in his book The Color Code and Dr. Dave Heber in What Color Is Your Diet? describe how phytochemicals—rich antioxidant dietary sources—are responsible for the colors in fruits and vegetables. Among these, anthocyanin makes a blueberry blue and has antioxidants that fight cancer; lycopene makes tomatoes red and protects our hearts and brains.

Spice It Up

For many years, I have preferred dark, flavorful Dijon mustard, while watching my kids squirt that bright yellow stuff on their hot dogs. Little did I know that the more vividly colored mustard version contained much higher concentrations of turmeric, a spice from the thick, rounded underground stems of a large-leaved herb cultivated in tropical countries. Turmeric is also one of the spices in curry powder and traditional Indian medicines used for thousands of years, and its active ingredient is curcumin.

Laboratory studies indicate that curcumin is a powerful antioxidant that inhibits those pesky free radicals and has anti-inflammatory actions besides. Scientists have found that curcumin relieves symptoms in arthritis sufferers and inhibits the growth of various cancer and tumor cells. Such encouraging curcumin effects led Dr. Greg Cole and Dr. Sally Frautschy at UCLA and its affiliated Veterans Affairs Medical Center to study this ubiquitous spice’s potential for preventing Alzheimer’s disease. Their initial investigations of laboratory animals confirmed that curcumin not only suppresses oxidative damage to cells but also prevents loss of synapses—the connecting communicating terminals between brain cells—and decreases the deposition of amyloid protein and plaque burden in the brain. Additional research indicates that curcumin has other brain-protective and memory-boosting effects, such as fighting oxidative stress and lowering excess inflammation.

The initial human studies of curcumin supplements failed to demonstrate memory benefits, but in 2018 my research team reported on the first cognitive study of a form of curcumin (Theracurmin) that is readily absorbed from the gut. We found that middle-aged and older volunteers with mild memory complaints who consumed this curcumin dietary supplement twice a day for eighteen months had significant improvements in memory and attention abilities compared with those who took a placebo. The degree of cognitive benefits was impressive, but the study sample was relatively small so we are planning a follow-up investigation with a much larger group of volunteers at multiple testing sites throughout North America.

Vitamins and Minerals for Keeping Brains Young

When a patient complains of a memory problem, one of the first things we do is to test their blood levels of vitamin B_12. Low levels of thiamine (vitamin B_1), vitamin B_12, or folic acid (vitamin B_9) have been found to cause memory disorders. Some studies have shown that when Alzheimer’s victims are treated with high doses of vitamin B_12 or folate, their memory abilities improve. Almost any vitamin deficiency will affect brain fitness and should be avoided.

Dr. Katherine Tucker, a nutritional epidemiologist from Tufts University, advises healthy older people to take a daily vitamin B_12 supplement in addition to a daily multivitamin. Research has shown that 20 percent of people aged 60 and older, and 40 percent of those over age 80, lose some of their ability to absorb vitamin B_12. Folate, or folic acid, is an antioxidant B vitamin that also offers a certain amount of protection against strokes, heart disease, and circulatory problems. In his long-term study of aging nuns, Dr. David Snowdon found that, at autopsy, the most extensive evidence of Alzheimer’s disease was observed in the brains of those nuns who had the lowest concentrations of folic acid in their bloodstream.

Interestingly, folic acid supplements are recommended for women during their childbearing years because a high enough blood level at the time of impregnation greatly diminishes the risk of having a baby born with spina bifida or other neural tube disorders. Folic acid, as well as all antioxidants, is important to neural integrity and brain health throughout life, even before birth.

When neuropsychologist Asenath La Rue was at the University of New Mexico, she examined the mental and nutritional status of well-educated people aged 66 to 90 who were free of any major memory problems. Her study showed that the volunteers taking thiamine, riboflavin, niacin, and folate supplements scored better in abstract thinking tests. Also, volunteers with heightened blood levels of vitamin C scored higher in visual and spatial ability tests. These findings point to the potential brain-boosting effects of various vitamin supplements.

Further research has shown that older persons with low levels of thiamine, riboflavin (vitamin B_2), vitamin B_12, and vitamin C are more likely to experience anxiety, irritability, and depression. People who eat well-balanced meals generally don’t develop deficiencies, and most doctors recommend daily multivitamins to ensure that such deficiencies do not develop.

It is also important for all of us to keep in mind the potential toxic effects of unnecessary vitamin megadoses. This may be a particular problem with fat-soluble vitamins, such as vitamins A, D, E, and K, which get stored in our body fat and can hang around in our bodies for weeks, months, or longer. When a little bit is good, a lot isn’t always better.

Table 7.3 indicates the recommended daily allowance (RDA) of the vitamins we should all be taking—that is, their minimum doses according to the FDA; the safe dose or uppermost limit we can safely take each day; and some common food sources where we can get these vitamins and minerals without taking supplements.

Table 7.3

Source: Hathcock (1997).

Another Supplement: Phosphatidylserine

Phosphatidylserine is a naturally occurring nutrient that exists in common foods, such as fish, green leafy vegetables, soy products, and rice. This nutrient can be found in our cell membranes; in fact, approximately 10 percent of the fatty component of our brain cell membranes consists of phosphatidylserine.

Scientists have found that phosphatidylserine can increase neurotransmitters that improve memory and concentration, and animal studies indicate that it slows age-related memory decline. These encouraging observations have led to studies testing the effectiveness of phosphatidylserine as a supplement to augment recall abilities in people with mild age-related memory complaints.

Dr. Tom Crook, a neuropsychologist formerly with the National Institute of Mental Health, along with other investigators, has shown that people with age-associated memory impairment score better on memory and learning tests after taking phosphatidylserine when compared with those taking a placebo.

This nutrient may indeed be effective, and perhaps sixty or more studies have demonstrated this modest but positive benefit. A limitation of these studies, however, is their relatively brief duration, ranging from six to twelve weeks, raising the possibility that the benefit may not be long term. It is certainly possible that phosphatidylserine has a long-term beneficial effect, but it has never been systematically studied beyond twelve weeks.

Doctors who recommend phosphatidylserine suggest that people begin with 100 to 150 mg twice a day, and after several months, they drop the dose to only 50 mg twice a day for maintenance. No side effects have been reported.

The Ups and Downs of Caffeine

Every morning, millions of us drag ourselves out of bed, bleary-eyed, empty mug in hand, and grope our way to the coffeepot before we can imagine beginning our day. Coffee consumption exceeds 140 billion cups per year in the United States alone, where an estimated 80 percent of the adult population drinks coffee daily—making caffeine our most commonly used drug. We also get caffeine in our diet from sources that some people are not aware of, including chocolate and some sodas.

Too much caffeine increases cholesterol levels, may increase the risk of heart attacks, and is associated with urinary bladder cancer and high blood pressure. Caffeine also increases risk for bone thinning from osteoporosis. Acute caffeine intoxication causes rapid heart rate and can pose health hazards for cardiac patients.

Caffeine has both positive and negative effects on brain fitness. On the positive side, it diminishes fatigue, increases alertness and attention, and improves mood. We all know of the pick-me-up we get from our morning java. Systematic studies show that in the short term, caffeine can improve learning and recall abilities. In the Honolulu Heart Program, a thirty-year study of eight thousand people, the risk of developing Parkinson’s disease was five times lower in coffee drinkers compared with those who did not drink coffee. A recent meta-analysis (which examines data from multiple independent studies) showed that three to four cups of coffee each day compared with no coffee consumption is associated with longer life expectancy. Higher rates of coffee consumption were also associated with a lower risk for cancer, as well as metabolic, neurological, and liver diseases.

On the negative side, extended caffeine use can cause irritability, insomnia, and anxiety. Because caffeine’s effects are short-acting, suddenly interrupting the caffeine habit can cause withdrawal symptoms. Caffeine withdrawal usually begins twelve to twenty-four hours after the last exposure, with symptoms peaking in the first forty-eight hours but sometimes lasting up to two weeks. Headache, fatigue, poor concentration, and depression are common complaints when we can’t get our daily caffeine fix. Just ask my wife—but not before she’s had her morning coffee. The single greatest cause of postoperative headache is caffeine withdrawal. To prevent postoperative headaches, some surgeons have been known to actually add caffeine to the intravenous fluids of patients who cannot drink liquids after surgery.

For those of us who do consume caffeine, we need to be aware of the side effects and avoid overuse and withdrawal symptoms. Table 7.4 lists the caffeine content of some common foods and drugs to help you to keep track of how much you’re taking each day.

Table 7.4

CAFFEINE CONTENT OF SOME COMMON DRINKS, FOODS, AND DRUGS
Brewed coffee (6 oz.) | 100 mg
Decaf coffee (6 oz.) | 4 mg
Instant coffee (6 oz.) | 70 mg
Tea (6 oz.) | 40 mg
Caffeinated soft drink | 45 mg
Chocolate candy bar (40 gm) | 10 mg
Anacin | 32 mg
Excedrin | 65 mg
No-Doz | 100 mg

Sources: National Coffee Association, National Soft Drink Association, Tea Council of the USA, and Barone and Roberts (1996).

Sugar on the Brain: How Sweet It Is

Sugar, or glucose, is the brain’s main energy source, and blood sugar levels affect both mood and memory. Unlike other cells in our bodies, brain cells cannot convert fats or proteins into glucose, so they depend on daily dietary sugar for optimal functioning and survival.

When our blood sugar levels drop too low, many of us tend to feel lethargic, irritable, and may have difficulty learning new information. But give us a meal, power bar, or glass of juice, and our moods perk right up, as do our memory and concentration abilities.

Our brains don’t function well when blood sugar is too high either. Studies of both animals and humans have consistently shown that abnormally low or high blood sugar levels will affect memory and learning abilities. The reason may involve the brain messenger, or neurotransmitter, acetylcholine, a neuron communication link important for normal memory performance.

The acute effects of sugar on the brain are well documented. After drinking carbohydrate-spiked lemonade, volunteers show better memory performance and mental flexibility than after drinking saccharine-sweetened lemonade. Similar results have been documented in patients with Alzheimer’s disease.

When I was growing up, my father always encouraged my sisters and me to eat breakfast, “the most important meal of the day!” He never backed up this statement with facts, but I later learned that his was indeed good advice. Breakfast—breaking the fast of our nighttime sleep—increases blood sugar levels and leads to greater mental clarity during the day. Studies of elementary school students show improved academic performance and behavior when they eat breakfast, and adults who eat breakfast maintain higher blood sugar levels, quicker recall, and better overall memory performance than those who skip it.

Diabetes: When Your Blood Gets Too Sweet

Although sufficient blood sugar keeps our brains working optimally and a quick glucose fix can give us an immediate memory and concentration boost, many of us suffer from chronically high blood sugar levels. If sustained over months and years, these high blood glucose levels can lead to a prediabetic state and possibly impair memory and other mental abilities.

After a meal, our blood sugar increases, which triggers the pancreas to produce insulin, the hormone that facilitates sugar, or glucose, getting into cells where it is needed for energy. If, however, we are constantly experiencing repeated, sharp spikes of blood sugar, the pancreas can become overworked and eventually produce less effective insulin. This can cause the body to become insulin-resistant or unable to use insulin effectively, which puts one at risk for non-insulin-dependent diabetes, a.k.a. type 2 diabetes, as well as high blood pressure and circulatory problems affecting the brain. Arteries can become stiffer, restricting blood flow to the brain.

About thirty-four million people in the US suffer from diabetes, and an estimated seven million of those individuals have never been diagnosed. Diabetes can quadruple the rate of heart disease and stroke. The chronic high blood sugar levels of diabetes have also been linked to lower intellectual performance. Diabetics have an increased risk for developing severe memory loss associated with aging, including Alzheimer’s disease and other types of dementia. Genetic predisposition can partly determine our susceptibility to high blood sugar and diabetes, but a person’s daily dietary habits play a major role.

The good news is, even minor changes in our diets and other lifestyle areas can have a strong impact on our risk for diabetes. Dr. Jaakko Tuomilehto and his colleagues at the National Public Health Institute in Finland found that losing as few as ten pounds, eating a healthy diet, and exercising regularly can reduce the risk for developing type 2 diabetes by more than 50 percent. Although engaging in regular physical exercise and consuming a healthy diet have been shown to help prevent diabetes, genetics do contribute to risk. If you have a first-degree relative (i.e., a parent or sibling) with type 2 diabetes, you have a 40 percent chance of developing the disease, whereas in the general population the risk is only 6 percent.

Because our brains need a steady flow of sugar to keep them optimally fit, maintaining an even glucose level in the brain and avoiding blood sugar fluctuations should be everyone’s goal. We can begin to protect our brains from the onslaught of chronic sugar overload and insulin surges by attempting to avoid foods that spike blood sugar and, in turn, cause the pancreas to pump out more insulin.

The sugars we eat are technically carbohydrates and they come in two forms: simple sugars, such as sucrose or table sugar, and complex sugars or starches, including fruits, vegetables, milk, and cereals. When asked why the rate of diabetes has risen sharply over the last few decades, experts point to the changes in our diet. In contrast to our ancestors’ natural sources of carbohydrates—fruits and vegetables—many people today eat foods containing refined sugars and processed flour. These newer, less nutritional forms of carbohydrates can cause rapid rises and subsequent falls in blood sugar levels, which our bodies were not designed for.

Scientists have studied the actual blood sugar responses to a variety of foods. They are then able to compare the food’s true physiological effect on blood sugar levels, the glycemic index. This index ranks foods from 0 to 100, indicating whether the food raises blood sugar levels dramatically, moderately, or minimally. This research debunks many old myths about carbohydrates. First, starchy foods, such as bread, potatoes, and some types of rice, are digested and absorbed quickly, rather than slowly. Second, foods with lots of sugar, such as candy and ice cream, do not dramatically increase blood sugar, but lead to low or moderate blood sugar responses, even lower than bread. Carbohydrates with a high glycemic index tend to decrease the good form of HDL cholesterol and to increase the risk for diabetes, insulin resistance, and heart disease. They also increase hunger and promote overeating and obesity.

While avoiding high-glycemic-index foods, we should also try to eat the low-glycemic-index foods that don’t cause peaks and valleys in blood sugar levels but instead lead to gradual rises and falls in blood sugar levels. Low-glycemic-index “carbs” increase the good form of HDL cholesterol, tend to curb appetite, and help us burn off fat. Exercise physiologists have found that eating low-glycemic-index carbs before sustained, strenuous exercise improves physical performance.

A study of nearly thirty-six thousand women initially free of diabetes found that those eating low-glycemic-index grains, particularly whole grains and cereal fiber, had a lower risk for developing diabetes. Nutritional experts recommend the consumption of three servings of whole grains each day. On average, most Americans consume less than one serving.

Keep in mind that the glycemic index is an average from several studies of the physiological effects of different foods on glucose levels. The glycemic index is independent of serving size, so you can eat more of a low-glycemic-index food and experience the same blood sugar levels you would from eating less of one with a high glycemic index. Table 7.5 lists some common foods ranked according to glycemic index.

Table 7.5

HOW MUCH DO SOME COMMON FOODS SPIKE BLOOD SUGAR?
Minimal (Glycemic Index <40)
Apple | Lima beans
Apricots, dried | Nonfat yogurt
Cherries | Peanut M&M’s
Fettuccine | Peanuts
Kidney beans | Skim milk
Lentils | Soybeans
Low (Glycemic Index 40–54)
Baked beans | Orange
Bran cereal | Orange juice
Canned chickpeas | Oatmeal
Cooked carrots | Potato chips
Chocolate bar | Spaghetti
Grapes | Unsweetened apple juice
Moderate (Glycemic Index 55–70)
Angel food cake | Natural muesli cereal
Bananas | Oat bran cereal
Brown rice | Pineapple
Canned corn or beets | Sourdough bread
Croissant | Potatoes
Honey | Whole wheat bread
Ice cream | White bread
High (Glycemic Index 71–84)
Bagels | Bran flakes
Jelly beans | Pretzels
Cocoa Puffs | Puffed wheat cereal
Cheerios | Cornflakes
Raisin bran cereal | Total brand cereal
French fries | Vanilla wafers
Maximal (Glycemic Index >85)
Dried dates | Instant mashed potatoes
French baguettes | Instant rice

The groupings in the table are meant as a guide to carbohydrate choices. We generally don’t know the specific effect on blood sugar when we sit down to eat a particular meal because we usually eat foods in combinations that tend to minimize blood sugar spikes from high-glycemic-index foods. Highly acidic foods, such as vinegar, also will minimize blood sugar spikes. Lemon juice and vinegar, particularly red wine vinegar, have this effect, which might be attributed to an acidic food’s tendency to slow the digestive process (see Tips box). Such acidity may also explain why sourdough bread has a lower glycemic index than some other breads. Also, the lactic acid found in yogurt may explain its tendency to minimize blood sugar spikes.

Recent research has further detailed some of the potential benefits of a low-glycemic diet. For example, a meta-analysis of twenty studies concluded that a low-glycemic diet may lower the risk for developing certain cancers, including colorectal, bladder, endometrial, and kidney cancers. However, not all studies have confirmed the benefits of a low-glycemic diet. Another recent meta-analysis suggested an equivocal relationship between glycemic index and glycemic response to disease outcomes. The authors of that study concluded that other dietary factors, such as consumption of fibers or whole grains, have a greater impact on the prediction of health outcomes.

Tips for Avoiding Blood Sugar Spikes

• Eat fresh fruits and vegetables.

• Avoid instant rice.

• When you eat foods that tend to spike glucose, combine them with foods that don’t.

• Avoid processed foods.

• Add vinegar or lemon juice when you can.

• Eat small meals and avoid infrequent large meals.

• Eat a healthy breakfast every day.

The Brain-Gut Connection

In recent years, people have become increasingly interested in how our digestive tracts influence our minds. Much of that interest has focused on what’s known as the microbiome, the trillions of microorganisms that live in our guts and have been found to impact both mood and cognitive ability. Healthy intestinal bacteria are able to break down carbohydrates in the gut, and that process releases vitamins, nutrients, and fatty acids that can support the body’s immune system and in turn affect the nervous system.

Analyses of the typical Western diet and how it affects the microbiome indicate that processed foods characteristic of that diet heighten gut inflammation, which can accelerate cognitive decline. However, many people consume prebiotic and probiotic foods to improve their microbiome. Prebiotics are soluble fibers that assist in feeding the healthy organisms in the gut, whereas probiotics are microorganisms that already live within the large intestine. Onions, leeks, asparagus, bananas, and garlic are examples of prebiotic foods. These prebiotics are consumed by probiotic bacteria within the gut, which helps them function more efficiently. Examples of probiotic foods that supply healthy gut bacteria include sauerkraut, yogurt, pickles, kefir, and kimchi.

These kinds of foods can have an impact on mood, and when a person’s mood improves, it benefits the ability to think and remember clearly. Recent studies indicate that some probiotics may lower levels of anxiety. Other studies show that excessive consumption of saturated fats, such as red meat, butter, or ice cream, as well as refined carbohydrates, such as white bread, pastries, white flour, white rice, and sweet desserts (typical of a Western diet) negatively affect cognitive abilities, because high levels of fat and sugar change intestinal bacteria in a way that makes the brain more vulnerable to toxins that can travel from the blood to the brain.

Beyond the Mediterranean Diet

Numerous studies have demonstrated a link between a Mediterranean-style diet and better heart health. More recently, we learned that this same kind of diet also may promote brain health. A Mediterranean-style diet emphasizes fruits, vegetables, nuts, legumes, whole grains, olive oil, fish, and lean proteins. Although many people in the US are becoming more familiar with this eating style, it is still quite different from the typical American diet that emphasizes red meat, dairy products, and fried foods.

Investigators at the University of Miami found that people who consume a Mediterranean-style diet have less brain-scan evidence of damage to the small blood vessels in the area of the brain known as the white matter, which is essential for transmitting signals from one brain cell to another. Other scientists at Columbia University in New York have shown that people who adhere to a Mediterranean-style diet have a lower risk of developing mild cognitive impairment or dementia.

Dr. Martha Clare Morris and associates at Rush University Medical Center in Chicago wanted to see whether there is a dietary regimen even better for the brain than the Mediterranean-style diet. They decided to study a new hybrid diet called the MIND diet, which combines elements of the Mediterranean-style diet with the DASH diet, which has been found to protect brain health and to lower the risk for hypertension, heart attack, and stroke. The acronym MIND is short for Mediterranean-DASH Intervention for Neurodegenerative Delay (DASH stands for Dietary Approaches to Stop Hypertension).

In a five-year study of more than nine hundred volunteers, the investigators found that those who adhered to the MIND diet had significantly slower cognitive decline. The difference between the volunteer groups with highest and lowest adherence to the diet was equivalent to 7.5 years younger in brain age. A comparison of the hybrid MIND diet to the Mediterranean showed that those who adhered to the MIND diet enjoyed the best cognitive outcomes.

Another advantage to the MIND diet is that it is relatively easy to follow. The Mediterranean diet requires daily consumption of fish, three servings of fruits, and other vegetables, whereas the MIND diet includes daily choices from ten healthy food groups (green leafy vegetables, other vegetables, nuts, berries, beans, whole grains, fish, poultry, olive oil, and wine) combined with minimal or no intake from five unhealthy food groups (red meats, butter and stick margarine, cheese, pastries and sweets, and fried or fast food). For more detailed information on the MIND diet, check out https://www.healthline.com/nutrition/mind-diet or Maggie Moon’s book The MIND Diet: A Scientific Approach to Enhancing Brain Function and Helping Prevent Alzheimer’s and Dementia.

Stress Eating

What we eat and how we eat it has tremendous emotional meaning in our lives. Eating is often a symbol of love—mothers express anxiety or feelings of rejection when their children turn away their food, and the tradition of “breaking bread” is an important social and business ritual. Anxiety and stress can have a profound impact on some people’s ability to eat sensibly and make it difficult to maintain a healthy brain diet.

Many people lose their appetite under extreme stress, whereas the opposite problem is a complaint for many of today’s weight-conscious people. Stress often triggers impulse eating or perhaps leads you toward old habits, like downing your first grader’s leftover potato chips while driving home from the office.

Have you ever picked up the phone, suffered through an unpleasant phone call, hung up, and noticed that eight Oreo cookies have disappeared? Do you find yourself guiltily hiding the evidence of eating your child’s candy bar or ice-cream sandwich when your day has overwhelmed you? Nearly everyone has experienced some form of stress eating at some time. The phenomenon generally has two components: (1) a stressful event to trigger binge eating, and (2) conveniently available foods, often processed foods or desserts.

Lisa E., a 45-year-old accountant, became adamant about starting a memory-training and mental stimulation program due to the recent changes in her recall abilities. Her symptoms had gotten markedly worse during the last tax season, and she didn’t like it when both her boss and her 16-year-old son started making jokes about her middle-aged memory lapses.

She came to our clinic having already picked up some memory-training skills on her own, but wanting to learn more and hone her techniques. The results of Lisa’s initial evaluation were normal, except for a borderline elevation in blood sugar, so we referred her to a nutritionist, who provided dietary guidelines to help her control her blood glucose levels. She agreed to start a low-fat diet, high in omega-3 fatty acids and antioxidant foods, and agreed to avoid high-glycemic-index foods. She also began a memory-training course and a mental aerobics program.

After eight weeks, Lisa noted some memory improvement, but her blood test still showed slightly elevated sugar levels. She swore she had been true to the diet, shopping at the health food market, buying only the foods on the list, and preparing them correctly.

What Lisa failed to mention were the donuts, sweet rolls, and frosted flakes she had at home for her son, as well as the constant bombardment of bagels, breakfast bars, and almost daily birthday cakes surrounding her at work.

When Lisa’s nutritionist finally convinced her to keep a daily food log, diligently recording everything she ate for a week, Lisa learned the tragic truth she had been hiding, even from herself—she was a closet sugar addict. In moments of elevated stress, her unconscious sugar cravings would emerge. Like a vampire at nightfall, Lisa would reach out and devour the closest sugary snack food available—usually without even realizing it.

Thanks to her food log, Lisa learned to grapple with her sugar problem and get her blood glucose levels under control. She was able to keep her memory-training work on track and her job performance improved. Her boss gave her a raise, which was no joking matter, and the only person to complain was Lisa’s son, who had to give up the donuts and frosted flakes for the healthier, natural alternatives Lisa now bought and enjoyed.

Carbohydrates with a high glycemic index are the usual culprits when it comes to stress eating. There’s something extremely satisfying in that fleeting, momentary, crunchy, munchy, sugary experience. However, the resulting insulin spikes followed by subsequent blood sugar crashes often leave one feeling famished and can lead to additional overeating as well as other serious problems.

Although we can’t completely eliminate stress from our lives, we can follow some practical tips to avoid unhealthy stress eating (see box).

Practical Tips to Avoid Stress Eating

• Eliminate your favorite unhealthy stress foods from your house, car, and office.

• Keep snack bags of fresh-cut vegetables in convenient places where stress eating most often occurs—near the kitchen telephone, at the office desk, in the car, etc.

• Avoid processed-food snacks. Instead, if you need a quick snack, substitute “brain snacks”: power bars, sourdough croutons, blueberries, and strawberries.

• Keep bottled water nearby at all times—when stress hits, take a swig.

• Set reminders—post a sign in each of your stress-eating spots (near the kitchen telephone, workplace computer station) reminding you to “Relax and Eat Healthy.”

• When you catch yourself in a stress-eating mode, put yourself on pause: take a deep breath, toss out that cookie or donut, take a break from the stressful situation, and stretch.

• Develop other skills to reduce stress by reading Chapter 4.

Start Dishing Up the Smart Food

Eating a healthy brain diet is no more complicated than any physically healthy diet. Getting enough antioxidants, the right fats and carbs, and limiting calories are all easier than it may seem at first read. Probably the hardest part is just getting started. Once you’ve passed that hurdle, the rest is cake (only an expression, of course).

Dr. David Heber of UCLA emphasizes eating not just healthy foods, but tasty foods as well. He recommends fruits and vegetables; high-fiber breads, cereals, and grains; and low-fat animal proteins (e.g., skinless chicken, fish, skim milk products). Dr. Heber encourages people to use herbs, spices, garlic, chile peppers, avocados, nuts, seeds, and olives as taste enhancers. Emphasis on flavor as well as health usually helps keep us on our healthy brain diet longer, hopefully for the rest of our lives.

When it comes to food and brain health, setting reasonable goals and being patient can be your greatest assets. By following some basic guidelines, your brain fitness will likely improve quickly, and for the long run.

The Basic Elements of a Healthy Brain Diet

• Eat a low-fat diet.

• Stay aware of overall caloric intake.

• Avoid stress eating and late-night snacks.

• Toss away your yo-yo diet plan.

• Avoid processed foods and high-glycemic-index carbs.

• Eat foods rich in omega-3 fats.

• Avoid omega-6 fats.

• Remember you have choices: sourdough bread rather than French rolls, olive oil rather than corn oil.

• For a daily antioxidant boost, eat fruits and vegetables, and drink tea. Try frozen or fresh blueberries for a snack food.

• Avoid too much caffeine.

• Drink water throughout the day; shoot for six or more glasses daily.

• Take multivitamins as well as vitamins E and C and folate supplements.

• Create meals that are healthy and tasty—try using herbs, garlic, and spices to enhance taste.

The following is a sample of several days from one person’s Weekly Healthy Brain Diet Worksheet for you to examine. This individual starts out strong during the workweek, but has more difficulty as the temptations of the weekend rear their ugly head. The process of keeping a log and viewing overall progress throughout the week can help us to focus on times and situations when we need to work harder to stay on a healthy diet. This chart may serve as a guide to help you create a similar chart for yourself.

Chapter Eight

Choose a Lifestyle That Protects Your Brain

If I’d known how old I was going to be, I’d have taken better care of myself.

—ADOLPH ZUKOR, FOUNDER OF PARAMOUNT PICTURES, BEFORE HIS 100TH BIRTHDAY

Our Western approach to medicine has traditionally emphasized curing illness rather than maintaining wellness. Nearly all long-term studies on aging and memory have focused on markers that predict decline and loss. This trend, however, has been slowly changing. Scientists have begun focusing their investigations on successful aging and late-life health.

Successful aging means not only living longer but living better—avoiding disease, remaining engaged in activities, and maintaining optimal physical and mental health. During the past decade, the MacArthur Foundation supported a study that took an innovative approach to aging and stressed positive rather than negative outcomes.

Dr. Robert Kahn and Dr. John Rowe summarized the MacArthur findings in their book Successful Aging and gave people of all ages a reason for optimism: the lifestyle choices we make early in life determine our health and vitality as we age, even more than heredity and genetics. Only about a third of what determines successful aging is already programmed through our individual genetic codes. The other two-thirds result from our environments, and in large part, the choices we make that become our lifestyles.

Many of the lifestyle changes we need to consider for keeping our brains young are the same habits that will help us to maintain physical health and fitness. When he was the US surgeon general, Dr. David Satcher advised Americans to follow his prescription for healthy living with recommendations that include moderate physical activity—at least thirty minutes a day, five days a week; eating at least five servings of fruits and vegetables each day; and avoiding tobacco, illicit drugs, and alcohol abuse. Those recommendations still hold true today, and if there were a comparable office known as Surgeon General for Brain Fitness, I suspect it would issue similar recommendations.

Dr. Karen Ritchie, an epidemiologist from Montpellier, France, studied the mental status of a woman aged 118. Her memory ability was comparable to that of a normal 80-year-old. Although she had a genetic predisposition to longevity, her lifestyle likely kept her brain young: she was educated, remained mentally and physically active, and ate the typical diet of Provence, France—olive oil, fresh vegetables, and fish.

I am often asked at what age it becomes too late to change bad habits, start taking care of one’s body, and thereby help to protect one’s brain. Allow me to say it clear and loud: it is never too late. As soon as you start to change your lifestyle for the better, you’ll begin to repair yesterday’s damage. A previously sedentary 40-year-old who begins a walking program of just thirty minutes a day, four days a week, can achieve the same risk of heart attack after six months of conditioning as a 40-year-old who has exercised conscientiously for decades.

Physical Exercise and Brain Fitness

Compelling scientific evidence indicates that physical activity and aerobic conditioning promote brain fitness. Armed with convincing evidence from large-scale, long-term human studies, as well as experiments in laboratory animals, scientists are now recognizing that physical activity apparently protects the memory centers of the brain.

Most of us who do aerobic exercise on a regular basis generally do so to maintain physical stamina, health, and fitness. Physical exercise can also enhance our mental state by increasing the circulation of endorphins—hormones released in our brains after exercise that have immediate benefits on mood and memory—the body’s own internal antidepressant. Regularly scheduled aerobic exercise, with its accompanying mildly euphoric endorphin “boost,” also helps maintain maximum long-term brain health.

A well-balanced exercise program usually includes some toning and stretching, which allows people to avoid injury while they build stamina. The actual aerobic part of our exercise routine gets our hearts pumping faster, our lungs breathing deeper, and if we continue these activities on a regular basis, they can help reduce our risks for age-related illnesses, such as heart attacks and strokes. Many experts recommend walking as one of the safest and most effective forms of aerobic exercise. The MacArthur Study of Successful Aging noted that older adults who walked forty-five minutes, three to four times a week, doubled their endurance level after a year.

A convincing case can be made for the mental benefits of aerobic exercise, although a Heisman Trophy is not a 100 percent guarantee against developing Alzheimer’s disease. The disease has been known to strike people who have achieved remarkable feats of physical fitness, including triathletes, long-distance runners, and championship tennis players.

Numerous studies, however, indicate a definite link between physical activity and staving off Alzheimer’s disease. Small laboratory animals exposed to exercise—running on wheels and treadmills—show formation of new blood vessels and nerve cell communication sites, or synapses, in the brain. Dr. Fred Gage and his coworkers at the Salk Institute in La Jolla, California, have found that adult mice exercising regularly on a running wheel developed twice as many new brain cells in the hippocampus compared with mice in standard cages. The scientists speculate that running might increase the flow of oxygen and nutrients to brain tissues or release special growth factors that promote nerve cell growth. These landmark studies also contradict the old myth that new cell growth does not occur in adult brains. Physical exercise appears not only to keep brain cells alive but also to grow new neurons.

Dr. Robert Friedland and his associates at Case Western Reserve University studied over five hundred people to determine their physical activity levels. The volunteers who had been physically active between the ages of 20 and 60 were three times less likely to suffer from Alzheimer’s disease later in life, and these activities ranged from gardening a few times a week to racquetball to daily jogging.

Researchers have found that physical exercise provides benefits in mental performance, regardless of age. In fact, provided people do not overexert themselves, these benefits can be observed immediately following exercise. Long-term cognitive benefits have also been noted with continued physical conditioning.

One of the greatest short-term cognitive benefits of aerobic fitness involves task solving, or what psychologists call executive control: making plans, scheduling and carrying out activities, coordinating events, and controlling emotional outbursts, or “keeping a poker face.” These processes generally involve the frontal or prefrontal region of the brain, often considered the more highly evolved brain region. The frontal cortex of such animals as cats, turtles, and squirrels is clearly less developed than that of humans, and humans have the greatest capacity in this area of the brain of any animal.

As we age, this frontal lobe gradually shrinks in size. In addition, brain activity levels in this frontal area gradually decrease at a faster rate than the rest of the brain. Middle brain regions, bridging the front and back of the brain, remain at a constant level of activity throughout a normal human life span. These areas involve basic functions, such as sensation and motor control, and remain normally active, even in patients with advanced Alzheimer’s. Many experts agree that this frontal cortex of the brain is the area most likely to benefit from physical aerobic training.

Tennis players, runners, and other athletes in their sixties and older have faster mental responses and reaction times than those of nonexercisers of the same age. They also outperform their inactive counterparts on tests of reasoning, memory, attention, and intelligence. Studies of aging athletes, however, may reflect some other advantages associated with being physically active, such as a healthy diet, good genetic predisposition, or use of anti-inflammatory drugs. Research data vary according to the age of the volunteer. In fact, the older the study subject, the more prominent the mental benefits of physical exercise. Also, if a person is physically fit at the outset of testing, it may be more difficult to measure the mental benefits of working out.

Dr. Arthur Kramer and his associates at the University of Illinois demonstrated the mental benefits of physical aerobic exercise in a six-month study of healthy adults between ages 60 and 75. Divided into two groups, one followed an aerobic walking program, while the comparison anaerobic group followed a toning and stretching program. The aerobic exercise group learned basic principles and guidelines for exercise programming, including an adequate warm-up and cooldown period, and increases in exercise duration and energy expenditure in gradual and progressive increments. Subjects also received instruction on how to avoid exercise-related injury. The investigators predicted that this program would improve brain function in the frontal lobe.

The aerobic group worked out three times a week, beginning with 10- to 15-minute sessions, increasing by a minute each session, and eventually building up to 40 minutes per session. The control group worked on a similar schedule, but instead of aerobics, they were instructed in techniques for stretching their range of motion. Stretches were held to the point of slight discomfort and involved all large muscle groups throughout the body.

As the scientists predicted, mental tasks involved in executive control—monitoring, scheduling, planning, inhibition, and memory—improved in the aerobic group but not in the control group. The benefits on mental attention were particularly striking.

It’s not only aerobic exercise that boosts brain health. Strength training with dumbbells, weight-lifting machines, or resistance bands also offers cognitive benefits. Scientists have attached tiny weights to the tails of laboratory mice and found that such resistance training improved their memory performance. Dr. Teresa Liu-Ambrose and associates at the University of British Columbia found in human studies that female volunteers enjoyed improved cognitive performance after six months of strength training compared to a control group that did not exercise.

Geriatricians who studied weight training in older adults found that after just three months of training, older men could double the strength of their quads—the front thigh muscles—and triple the strength of their hamstrings—the back thigh muscles. Weight training also enlarged their muscles. The older adults not only increased their strength, they dramatically improved their balance in just a few months.

Increased muscle tissue allows the body’s metabolism to function at a higher rate throughout the day, which in turn, uses up more calories. The resultant weight control can help prevent physical illnesses related to obesity, including hypertension, stroke, and diabetes, all of which can accelerate brain aging.

Despite the wide variety of sports and fitness programs available today, many people avoid them entirely, allegedly too busy working, carpooling, and caring for parents and children simultaneously. Although it is challenging to squeeze a physical activity routine into a crowded week, it can be done, and it should be a priority.

Once you develop the exercise habit, you may quickly get hooked on the endorphin blast, and then the other benefits literally show up—in the mirror and in how good you feel. For those who absolutely don’t have the time, start by popping a bit of exercise into your normal daily routine: take the stairs instead of the elevator, choose a five- or ten-minute brisk walk over another coffee break, and involve your mate or a friend in an outdoor weekend activity instead of lounging all Sunday in pajamas watching a Twilight Zone marathon.

Any physical exercise program should include a series of stretching and toning exercises, along with a good aerobic component. The key is to blend exercise into your lifestyle and make it a part of your daily routine. Even if you can only spare ten or fifteen minutes a day at first, make the best use of that time and do it every day if possible.

Simply following some general tips for beginning a physical exercise program can help keep your brain young (see box).

Tips for Starting an Exercise Program for Healthy Brains

• Be sure to include adequate warm-up and cooldown periods.

• Always include stretching and toning of all large muscle groups to increase flexibility and avoid injury.

• Walk with friends on a regular basis for both the social and physical benefits.

• Learn about exercise-related injuries and how to avoid them. Wear proper footwear and clothing to avoid injury and temperature extremes.

• Increase your exercise duration and energy expenditure gradually and progressively over time. You don’t have to become a triathlete to maintain brain fitness—moderate but regular conditioning is more than enough.

• Incorporate both an aerobic and a weight-training component to your program.

• Slip some type of physical activity into your daily routine: take the stairs instead of the elevator, a brisk walk instead of a donut break.

• Choose sports and activities that you enjoy because you are more likely to continue them in the long run. If walking around the neighborhood bores you, try a treadmill or stationary bike so you can read or watch TV while you work out.

• Check with your physician when getting started, especially if you have a physical illness that an exercise program could affect.

Watch Your Head

When choosing an aerobic fitness program, I advise my patients to avoid those that increase risk for head trauma. Each year, from fifty to sixty million people suffer some type of traumatic brain injury, and nearly 50 percent of people throughout the world will experience such an injury at some point during their life. The scientific evidence points to the obvious: avoid head trauma—both mild and severe—to protect your brain from cognitive decline. Wearing seat belts, choosing a designated driver who is not drinking, and wearing helmets when riding bikes or doing sports are critical to protecting our brains.

Dr. Richard Mayeux and research associates at Columbia University found that people who have blacked out for an hour or more following a head trauma have a twofold increased risk for developing Alzheimer’s disease down the road. If such a person also has the APOE-4 genetic risk for Alzheimer’s disease, their overall risk for the disease increases to tenfold.

Dr. Brenda Plassman and her coworkers at Duke University studied medical records of veterans who had suffered varying degrees of head trauma, dating back as far as fifty years. They found that veterans with only moderate head injury—loss of consciousness or post-traumatic amnesia for more than thirty minutes and less than twenty-four hours—had a twofold increased risk for Alzheimer’s disease over those without a history of head trauma. And, the Alzheimer’s disease risk increased in correspondence with the seriousness of the injury—those who had been hospitalized or suffered amnesia for more than twenty-four hours following a head trauma had a fourfold increased risk of developing Alzheimer’s disease sometime in the future.

Nearly all these studies looked at moderate to severe head trauma, but many experts are convinced that even milder forms of repeated head injury could accelerate brain aging. Several investigative groups have focused their research on the memory effects of mild but repetitive brain injuries caused by contact sports. Dr. Erik Matser and his team at St. Anna Hospital in the Netherlands compared amateur soccer players in their midtwenties to same-aged swimmers and runners who were less likely to suffer head injuries. Over 30 percent of the soccer players suffered from memory impairments, whereas less than 10 percent of the swimmers and runners had similar impairments. Although the memory impairments in these athletes were mild, it does raise concern over possible risk for future progressive decline.

At UCLA, Dr. David Hovda and Dr. Marvin Bergsneider performed PET scans on patients who had experienced relatively mild concussions. They found the brain activity of patients with only mild concussions was similar to that of comatose, severely brain-injured patients. Dr. Hovda noted that although a person may be able to walk, talk, and appear normal and alert after a concussion, their brain may not be functioning normally.

With this mounting evidence in mind, if you’re the quarterback on your weekend touch football team and get sacked two or three times every Sunday, don’t be surprised if you forget your first two meetings on Monday morning. You may want to consider tennis.

Dr. Paul Satz at UCLA described a brain reserve capacity that varies among individuals, giving each person a different threshold of brain injury required before memory loss and other problems emerge. A high degree of reserve capacity will protect the brain, so that a mild blow to the head might cause no symptoms in one person while causing severe injury and cell loss in another—depending on the individual’s brain reserve capacity threshold. A redundancy in the neuronal networks may explain such reserve. Satz’s theory is consistent with the idea that multiple small injuries have a cumulative effect in whittling away brain reserves until a certain level or threshold of cumulative damage is reached and symptoms become apparent.

Other evidence supports this notion of brain reserve. Dr. James Mortimer and associates at the University of South Florida looked at head circumference as a reflection of neuronal numbers and density of their interconnections. His group, as well as others, found that the size of a person’s head does indeed predict their future risk for getting Alzheimer’s disease—big heads have lower risks. Studies using brain scans to measure brain size further supported this concept. Dr. Peter Schofield and coworkers at Columbia University found that the onset of Alzheimer’s disease is delayed by four months for every one square centimeter increase in brain size.

After head trauma, the brain immediately responds by forming amyloid plaques—those same collections of cell decay that indicate a diagnosis of Alzheimer’s disease—yet another link between head injury and the disease. Remarkably, although the plaques that develop following an injury are usually more obvious in older than in younger patients, such plaques have been observed in patients as young as 10 years of age.

The APOE-4 genetic risk for Alzheimer’s disease contributes to the cognitive decline following head injury. Dr. Barry Jordan found that possession of this Alzheimer’s risk gene was associated with more severe neurological deficits in boxers. Also, head-injured patients with a high dose of the risk gene have greater amounts of amyloid plaque deposition in their brains. The science tells us that people with the APOE-4 gene have an even greater reason to avoid sports and occupations that involve a high risk for head injury, such as boxing, football, soccer, race car driving, movie stunt work, and crash-helmet testing.

Sorry, No Smoking

Everybody knows that smoking is bad for us—it can lead to lung and other cancers, heart disease, stroke, and numerous other disorders. But many people are unaware of the damage smoking does to the health of our brains. Studies show that smokers have a definite increased risk for Alzheimer’s disease. Dr. Richard Mayeux’s group at Columbia University studied a large number of older adults and found that smokers had a twofold greater risk of getting Alzheimer’s disease than those who never smoked. However, when people quit smoking, at whatever age, they were able to slightly reduce their risk.

For many years, public health campaigns have helped smokers to quit. Once a person quits smoking, the benefits emerge rapidly. The body’s carbon monoxide levels drop dramatically, and within a week, the risk of dying from a heart attack begins to decline. Five years later, that person’s heart attack risk is similar to that of someone who never smoked. Treatment programs that include counseling, as well as educational and emotional support, do succeed when participants make a reasonable effort. Some intensive treatment programs have success rates for long-term abstinence approaching 50 percent. Nicotine patches and gum have proven effective as well, particularly when used along with other treatment approaches. Such antidepressants as bupropion (Wellbutrin) can also help some people to quit smoking. Of course, nothing will work if the smoker does not truly desire to stop, for whatever reason. Knowing the connection between smoking and cognitive function is just one more good reason to quit.

Researchers have been testing nicotine patches because of the potential benefits of this neurotransmitter in diseases raging from schizophrenia to Tourette’s syndrome. Because nicotine receptors decline in the brains of Alzheimer’s victims, use of nicotine-enhancing drugs is one treatment strategy for age-related memory loss (Chapter 9). Dr. Paul Newhouse of the University of Vermont has tested a synthetic form of nicotine on a small number of Alzheimer’s patients and found an improvement in their learning and memory abilities. He followed up this initial finding with a study of transdermal nicotine therapy in nonsmokers with mild cognitive impairment over a six-month period. The research team found that the nicotine patches led to improved attention, memory, and mental processing.

Although these results were promising, a larger, multisite study is needed to provide more definitive evidence that nicotine patches are truly safe and effective as a memory treatment. The Memory Improvement Through Nicotine Dosing (MIND) Study was designed to address this research question. The investigators have enrolled three hundred participants for two years of treatment. Half of the participants have been randomized to transdermal nicotine and the other half randomized to a placebo skin patch. The results should be available in 2021.

Although nicotine may benefit some brain receptors involved in memory performance, the negative health consequences of smoking outweigh any remote potential benefit. The good news for smokers is that it’s never too late to quit, and the benefits of cessation are possible at any age. Some people report a slight weight gain when they stop smoking, but regular physical exercise can help offset weight gain and other physical and emotional responses to quitting. And imagine how nice it will be not to have to slip out of your nephew’s wedding every fifteen minutes to have a smoke, while Aunt Emma gives you the evil eye. Who needs that?

Alcohol: How Much Is Too Much?

For many people, drinking alcohol isn’t really a lifestyle choice but merely a routine part of their daily social interaction. Having a work meeting over drinks has become as universally accepted as meeting for lunch. And, in some circles, even that lunch may involve two martinis. Alcohol is one of the most common substances that people both use and abuse. The health hazards of excess alcohol consumption are well known, from drunk-driving fatalities to liver disease. In terms of brain health, prolonged alcohol indulgence damages brain cells and leads to serious memory loss. And yet, surprisingly, studies have shown that some intake of alcohol, in moderation, may actually be good for our brains.

Sarah H. had been concerned about healthy living for most of her adult life: she was only an occasional social drinker, walked at least twenty minutes every day even after her husband and walking partner died, and rarely missed her daily crossword puzzle. For a 72-year-old, Sarah’s memory was outstanding. But her identical twin sister, Lydia, took a different approach to life. Known as the “party girl” of the two sisters, she had been a heavy drinker and smoker for many years, and abhorred exercise. She laughed at the suggestion she might be an alcoholic, claiming she just “liked to have a good time.” But as she got older, it seemed her body had more trouble tolerating the excesses. Several times during the past year, Sarah had found Lydia blacked out after one of her “parties.”

Despite their identical genetic makeups, the twins had different cognitive abilities as well as memory capacities. Lydia was in the beginning stages of Alzheimer’s disease. Clearly, the twins’ differing lifestyle choices had contributed to the differences in their cognitive function as well as Lydia’s developing Alzheimer’s disease. For Lydia, drinking, smoking, and lack of exercise appeared to have played a major role.

Sarah and Lydia are not alone in their experience. Our own studies of twins confirm that genetic predisposition is only one determinant of risk for brain aging. Lifestyle choices to drink, smoke, and eat fatty diets can contribute to cognitive decline even in identical twins.

An eight-year study from Rotterdam, Holland, found that mild-to-moderate alcohol consumption—defined as one to four drinks each day—actually lowered a person’s risk for developing severe memory loss. A similar study from Bordeaux, France, found that moderate wine drinkers had a lower risk for Alzheimer’s disease. In fact, the risk for developing any kind of serious cognitive impairment was lower than for either heavy drinkers or nondrinkers. This type of moderate alcohol use has other health benefits, lowering the risk for heart attacks as much as 40 percent in one study.

According to the CDC Dietary Guidelines for Americans, moderate alcohol consumption is sometimes defined as up to two drinks for men and one drink for women, per day. Although this level of drinking could worsen one’s risk for heart disease and stroke, the antioxidant effects of alcohol may slow down brain aging by interfering with free radical formation and inflammation. Exactly how alcohol might protect the brain or heart is not fully known, but it may involve an antiplatelet effect that lowers the blood’s tendency to clot and cause tissue damage.

Because the research on the association of low to moderate drinking with cognitive abilities has led to some mixed results, Dr. Ruiyuan Zhang of the University of Georgia College of Public Health and colleagues recently performed a long-term study of a representative sample of nearly twenty thousand middle-aged and older adults in the US. They found that low to moderate drinking—defined as fewer than eight drinks each week for women and fewer than fifteen drinks per week for men—was significantly associated with a consistently lower rate of cognitive decline.

Many experts argue for red wine as the preferred brain fitness beverage because of its particularly potent antioxidant capacity. If someone does not drink alcohol, experts rarely recommend that they start drinking, because the potential hazards still outweigh any possible benefits. However, heavy drinkers should definitely cut back, and light to moderate drinkers need not quit to continue protecting their brains.

Memory Effects of Recreational Drugs

Many of today’s baby boomers and seniors experimented with recreational drugs during the sixties, seventies, and beyond, and some used them regularly—particularly marijuana. LSD, amphetamines, and other hallucinogens were also popular, and in the late seventies and early eighties, cocaine became the drug of choice for many young, upwardly mobile people, or yuppies. As many users eventually became aware of the potentially harmful effects of recreational drugs, they gave them up.

I often hear questions and concerns regarding drug use in the past, and even decades ago. Studies on psychoactive drugs have shown they do affect memory abilities, but there are currently no data indicating exactly how long those effects last after a person stops using the drug.

Nick J., age 51, still lives and works in his northeast college town, where he owns a successful restaurant. He put himself through college by dealing marijuana, although he smoked up half his profits. After graduating, he went to chef’s school and stopped dealing, but he kept up his pot habit. He had occasionally experimented with LSD, cocaine, and amphetamines, but marijuana was his drug of choice and had become part of his daily lifestyle. To Nick, grass was merely a social convention, like his parents having their cocktails before dinner. He didn’t consider it to be a harmful or addictive drug—nothing like heroin or even alcohol.

Nick started to notice subtle memory changes about five years ago when he first began having trouble remembering the names of his regular customers. Then he started making errors in reservations, and even staff scheduling became a nightmare. His ex-wife actually accused him of “purposefully forgetting” to pick up their sons on two of his designated weekends.

When Nick sought professional help, his doctor did note some mild memory impairment, but his overall memory test scores were in the low normal range for his age group. The doctor strongly advised him to stop using marijuana, and explained that although Nick might experience some physical and emotional hurdles in giving up a decades-old habit, the evidence was overwhelming that chronic marijuana use worsens memory.

Quitting pot was harder than Nick had imagined. But after a few failed attempts, and with the support of his girlfriend and his business partner, he managed to get through the first three months pot-free. Nick noticed his memory improving after only a few weeks, and by month three others began to comment on his sharpness. He also started experiencing more energy, less moodiness, and an improved libido. His girlfriend was absolutely thrilled—she had always hated his moodiness.

Nick did continue to have mild memory complaints, but he no longer had difficulties that interfered with his job, and his memory test results remained in the normal range for his age.

Marijuana has been the most widely used illicit drug in many developed societies. As numerous states legalize marijuana for medical or recreational use or both, the number of people using marijuana has increased dramatically, especially among older adults. It is widely known that chronic marijuana use can impair memory, attention, and the ability to process information. Someone intoxicated from marijuana has a hard time recalling recent events and learning new information. Studies of chronic and heavy marijuana users show that they have difficulty with verbal and visual memory and attention.

Some of the middle-aged and older people who complain about their memory have a history of extensive marijuana use during their youth. Our research group studied whether such early use of the drug affects brain health later in life. We performed cognitive assessments and MRI scans on volunteers (average age of 67 years) and found that those who had been heavy cannabis users during their adolescence or twenties had smaller hippocampal memory centers compared to those who had not used cannabis.

Despite the potentially harmful effects of marijuana, any memory effects do diminish after people stop or cut down on their use. Marijuana is derived from the cannabis plant, which contains numerous chemical substances: Tetrahydrocannabinol (THC) brings on the euphoric high and cannabidiol (CBD) reduces pain and inflammation. In a study of primates, researchers at the Scripps Research Institute in La Jolla, California, found that CBD can oppose the cognitive-impairing effects of THC when the components of cannabis are administered in a 1:1 ratio. However, a recent controlled study in humans showed that CBD does not prevent THC-induced impairment of driving and cognition.

Several psychoactive drugs have become popular over the years, including MDMA, which is the acronym for 3,4-methylenedioxy-methamphetamine (nicknamed ecstasy or molly). Animal studies have shown that MDMA causes damage to the brain cells that produce serotonin, the neurotransmitter that modulates mood and keeps us from becoming depressed. Extensive MDMA use has been shown to impair verbal and visual memory. One study showed that even after a year of abstinence, MDMA users still showed evidence of memory impairment compared with those who had never used the drug.

During the past decade, investigators have been studying the possibility that psychedelic drugs may actually have therapeutic benefits for various mental disorders. Initial research indicated that a single 25 mg dose of psilocybin given in a psychotherapeutic setting led to long-lasting mood improvements. In addition to reducing negative mood, psilocybin decreases the brain’s response to negative emotional stimuli in the amygdala, the brain’s emotional control center. Current research is focusing on the antidepressant effects of a single, 25 mg psilocybin dose in patients suffering from treatment-resistant depression or anxiety and depression due to a diagnosis of a life-threatening cancer. More than thirty psychedelic drug trials are under way to determine potential therapeutic effects of psychedelics in psychiatric disorders ranging from anorexia to obsessive-compulsive disorder. Although improving symptoms in these various mental disorders could potentially improve cognition, possible cognitive side effects are still a concern, particularly in people with preexisting cognitive challenges.

In an atmosphere where new and untested drugs are being produced in bathtubs and widely distributed, people who experiment with these recreational drugs are putting their brain health in greater jeopardy than they know. At the risk of sounding like a square, my recommendation is to just say no.

Get Out and Socialize

In addition to encouraging physical and mental activity, a major finding of the MacArthur Study of Successful Aging was that staying in close contact with the people in our lives, as well as remaining involved in sports, hobbies, charitable causes, or other meaningful activities, were key elements to success in aging. The more personally invested we are in a given activity, the more our ongoing health will benefit from it. Because a large component of the MacArthur study’s definition for successful aging was cognitive success, such activities will likely promote brain health as well.

Remaining engaged with people means giving as well as getting support, and this support can take many forms. By maintaining close friendships, stable marriages, and long-term relationships, as well as spending time with people we love, respect, and esteem, our brains will function better in the long run. Research has linked healthy social relationships to greater longevity.

The practical support we get from close relationships may lead us to seek better medical care, and just hanging out with people who live a healthy lifestyle—such as not smoking, or eating a low-fat diet—may rub off on us, too. Social support, or the emotional and practical advantages we gain from others, may even directly benefit us biologically. In a sense, we are “hard-wired,” or genetically programmed, to interact with others. Talking, touching, and relating to others are key to maintaining well-being in our lives. It is within social groups that we protect each other and share our joys and concerns.

One study of men indicated that strong social support significantly lowered their levels of epinephrine, norepinephrine, and cortisol—all physiological measures of stress. The evidence makes a strong argument for avoiding isolation and remaining engaged with others to keep mentally and physically healthy.

Juan R. was a jovial 72-year-old retired mechanic who had been active and relatively healthy all his life, except for his recently developed type 2 diabetes, which he controlled with diet and medication under the watchful eye of his wife, Carla. When Carla died suddenly from a stroke, Juan was distraught and nearly catatonic for a week. His daughter, Anna, was afraid to leave him alone in his apartment. Juan gradually got back on his feet, but he remained withdrawn and depressed, and Anna felt uncomfortable leaving him alone to cook and care for himself.

Anna knew from her mother’s constant complaining that left to his own devices, Juan would sit in front of the television all day eating junk food, while his blood sugar ran all over the map. Since Carla’s death, Juan hardly ate at all and had no interest in attending his weekly poker game with his buddies.

Anna already had her hands full with her own job and her kids. One afternoon, she arrived with Juan’s groceries to find him passed out on the floor. The emergency room doctor diagnosed a hypoglycemic attack and clinical depression and recommended better diet supervision and a daily antidepressant for Juan.

That evening, after discussing it with her family, Anna insisted that Juan move in with them. It was no use protesting, and she would not take no for an answer. Besides, she persisted, she needed the free babysitting. He finally gave in, saying that Anna, like her mother, would never stop yapping until she got her way.

With her dad under the same roof, it was easier for Anna to keep an eye on him, and she started dropping him off at a local senior center three days a week. Juan enjoyed watching the kids and helping out with their homework, so Anna and her husband could actually get out some evenings.

Thanks to Anna’s healthy cooking and her supervision of his medications, Juan’s diabetes got back under control, his spirits picked up, and he eventually got back to beating his pals at poker.

Sex and Memory

We’ve seen how remaining engaged in meaningful pursuits, maintaining healthy relationships and physical activities, and making other smart lifestyle choices can go a long way to ensure physical and mental health as we age. Evidence also points to maintaining a meaningful sex life as yet another way to keep our brains young. People with healthy, active sex lives also tend to be more engaged in life and physically and mentally active—traits associated with successful brain aging. The physiological and mental benefits of a healthy sex life may well promote brain function as we age.

Systematic studies have shown that our sexual attitudes and interests are relatively consistent throughout life. Surveys of older people indicate that nearly all of them would like to engage in sex if the time, place, and partner were right, although the lack of available partners is often a barrier to an active sex life for many older adults. Another issue is that in men, testosterone levels decrease with age, sometimes as much as 2 percent each year after age 30, and by the seventh decade of life, 35 percent of men have lower testosterone levels than younger men. By age 40, an estimated 40 percent of men experience difficulties with ejaculation. The available drugs for male impotence, however, have clearly had an impact on this problem. Viagra and Cialis are both safe and effective for many forms of erectile dysfunction for men even in their eighties or nineties, helping them to maintain a healthy sex life, which likely contributes to their brain health.

The physical illnesses some of us experience as we age, as well as the drugs we may take for these illnesses, can interfere with our sex lives; however, these challenges can be managed. For instance, patients with arthritis might schedule their analgesic medicine to kick in just prior to a romantic encounter, when increased flexibility might be desirable. Estrogen and testosterone replacement therapies can also help facilitate a healthy sex life when indicated, and current research is exploring these hormones’ direct benefits on memory (Chapter 9).

Sleep on It

Sleep deprivation—another way we stress our brains—is a common problem for people of all ages, thanks in part to our multitasking lifestyles. Chronic insomnia and sleep deprivation can be either a symptom or a cause of depression, psychological stress, or both (Chapter 4). It can have a devastating effect on relationships and work performance.

Acute or chronic sleep deprivation impairs mental abilities and can lead to high blood sugar levels due to insulin resistance, a precursor of type 2 diabetes, as well as elevated brain cortisol levels—both associated with memory loss. Fortunately, this insulin resistance and memory impairment can be reversed if you spend approximately twelve hours in bed to make up for sleep debt. In a recent study of more than two hundred middle-aged and older volunteers (aged 60 on average), our research team found that those reporting better sleep quality had fewer memory complaints and better sustained attention. If the practical sleeping tips in Chapter 4 are not effective, professional help should be sought.

Aluminum on the Brain: Don’t Toss Out Your Pots and Pans Just Yet

Nearly every time I give a lecture on Alzheimer’s disease and memory loss, someone asks about the possibility that aluminum exposure contributes to the disease. People are concerned about using aluminum cooking utensils, deodorants, and a variety of aluminum-containing products.

Scientists have looked at this potential relationship in numerous ways. In an eight-year study, French scientists found a twofold increase risk for Alzheimer’s disease in geographic areas with higher aluminum concentrations in the drinking water, although these findings have not been replicated. Autopsy studies have detected some collections of aluminum in damaged areas of the brains of Alzheimer’s patients, but the studies have not yet provided conclusive results. It is possible that aluminum collects in brain areas after the damage occurs, rather than actually causing the damage.

Other Lifestyle Pitfalls

Exposure to lead, pesticides, environmental mold, or any toxic chemical does have the potential to damage brain cells. Pesticide exposure in particular has been under scrutiny because of its possible influence on risk for Parkinson’s disease. Although many of the epidemiological studies have not proved a direct connection between exposure to environmental toxins and the subsequent development of Alzheimer’s disease, individual cases have been reported, and it seems logical to avoid chronic or acute exposure.

Making lifestyle choices is not just about our resolve to change but also becoming informed about the right kinds of changes to make. Dr. Vladamir Hachinski and his colleagues at the University of Western Ontario studied brain autopsies of people who died from various forms of dementia and found that those with lower educational achievement showed more evidence of small strokes in the brain than those who had attended college and further. An individual’s educational achievement not only indicates their intellectual ability but also points to their ability to make better lifestyle choices that protect their brain. The study subjects with fewer years of education were more likely to smoke, eat fatty foods, and avoid exercise, activities that increase the risk of strokes and the likelihood of dementia later in life.

Making Lifestyle Choices to Keep Our Brains Young

Most of us know it’s best to avoid head trauma, sleep deprivation, and smoking to maintain physical and mental health, and keep our memory ability at peak performance. The daily lifestyle choices we make have long-lasting effects. A professional boxer is bound to get hit in the head; a motorcyclist without a helmet is at risk to crack his skull. Many people choose more wisely, but that is not enough to actively keep our brains young. Avoiding nicotine and other toxins, keeping physically fit, moderating alcohol use, maintaining close and healthy personal relationships, and engaging in stimulating careers and pursuits are crucial to slowing brain aging and maintaining health. The Lifestyle Choices box summarizes how to maintain our health and protect our brains.

Lifestyle Choices That Keep Brains Fit

• Start an exercise program to maintain aerobic fitness, flexibility, and peak memory performance.

• Get both the aerobic and social benefits of walking with friends.

• Choose sports and physical activities with low risk for head trauma.

• Never drink and drive and always wear your seat belt.

• Wear helmets when riding bikes or doing sports.

• If you smoke, quit. Ask your doctor for help.

• If you drink alcohol, do it in moderation (up to 2 glasses of wine for men and one for women per day).

• Get involved in activities that have personal meaning. Spend time with friends and family.

• Get plenty of sleep.

• Avoid exposures to pesticides, organic solvents, molds, and other potential toxins.

Chapter Nine

Wise Up About Medicines

My doctor says too much sex can cause memory loss. Now, what was I about to say?

—MILTON BERLE

In the early 1900s, most people could expect to live into their fifties—what we now consider middle age. Today, the average American man lives to age 77, while women can anticipate 82 years. Some experts estimate that by the year 2060, the average man will live to 84 and the average woman to 87.

Of the many advances that have helped to bring about this lifespan revolution, drug development is the leader. Although antibiotics, antiseptics, steroids, and other medicines have undoubtedly helped us to live longer, they have not necessarily helped us to live better. Several medications have become available to treat memory loss and other cognitive conditions in patients with Alzheimer’s disease, but the US Food and Drug Administration (FDA) has not approved these or other medicines for the treatment of mild cognitive difficulties that precede dementia. These medicines, including donepezil (Aricept), rivastigmine (Exelon), galantamine (Razadyne), and memantine (Namenda), benefit symptoms temporarily but do not alter the course of the underlying disease.

Even armed with lifestyle strategies to keep our brains young, the most powerful tool for preventing mental decline as we age may come from new drug development. Wisely using currently available medicines now, if indicated, and adding new medicines as they are developed, is surely a key element in maintaining brain fitness and protecting against Alzheimer’s disease.

Our research group has tested cholinergic drugs—FDA-approved medicines known to boost memory and cognitive abilities in Alzheimer’s disease victims—as “smart drugs” for people with normal memory. Researchers are also discovering unexpected memory benefits from medications currently marketed for other conditions, such as anti-inflammatory drugs and estrogen replacement hormones. Although initial human testing on a vaccine designed to prevent the brain from accumulating Alzheimer’s plaques has not been successful, research aimed at eliminating plaques and tangles or reducing brain inflammation is continuing throughout the world.

How Doctors Understand Medical Conditions

The first step to using medicines wisely is to communicate effectively with your doctor, the person who will write the prescription and advise you on how to use the medication. With managed care and other pressures in the current health-care system, physicians don’t always have time to sit and chat with their patients, so a concise, focused approach is your best bet. One of the more useful lessons I learned in medical school was the way in which doctors gather and organize information about their patients. Once I learned this straightforward system, I found that visits to my own doctor became more efficient. He appreciated my organized description of symptoms, and the approach helped us both remember to cover important areas in my medical history.

When reviewing your health history, keep in mind some of the problems that can cause memory loss, such as depression, vision or hearing problems, infections, or poor nutrition. It’s helpful to write a list of your symptoms before your doctor appointment. Also, try to be specific—provide details about the timing of symptoms, their quality, and any events associated with their onset. Bring in all your medicines (including nonprescription and herbal supplements), or a detailed list, to avoid confusion about what pills and how many of them you are taking. Ask questions, request explanations, and try to answer the doctor’s inquiries as honestly and accurately as you can. Your physician should explain the diagnosis and the pros and cons of alternative treatments. Therapeutic options often include both medications and nonmedicinal approaches.

A physician’s evaluation of memory loss usually involves a thorough history; a physical, neurological, and mental status examination; and a laboratory assessment. In the mental status exam, the doctor will screen for depression, memory loss, and other cognitive difficulties. Usually a brief mental status exam can be completed within ten to fifteen minutes, but more detailed memory assessments, or neuropsychological tests, can provide a better understanding of subtle memory deficits. The laboratory component should include blood tests to rule out thyroid disease, vitamin B_12 deficiency, and other disorders that could possibly cause memory changes. The doctor also may order a brain scan to determine whether a tumor, stroke, or other brain lesion is contributing to the symptoms. And, as noted in Chapter 1, a PET scan may help in differentiating Alzheimer’s disease from frontotemporal dementia.

If you are planning to see your physician for a memory loss assessment, I suggest preparing yourself by considering the format doctors use in gathering and organizing information about their patients (see box). It covers many key points of relevance to brain aging and memory loss and could help you form a partnership with your doctor and become proactive in your medical care.

How Doctors Gather and Organize Information About Patients

Identifying data. Brief description of the patient (age, race, marital status, etc.).

Chief complaint. The reason the patient is seeing the doctor.

History of present illness. The nature, onset, and progression of memory symptoms. Description of other relevant problems, such as depression, anxiety, and stress; time course and events related to the symptoms.

Past medical history. Other potentially pertinent physical conditions, including hypertension, diabetes, prior head trauma, increased blood cholesterol, Parkinson’s disease, strokes.

Past mental history. Previous depression, memory losses, and other relevant details are recorded along with treatments received.

Family history. Parents, siblings or other relatives who had Alzheimer’s disease, other dementias, or any of the above-mentioned medical or mental illnesses.

Medications. Current and relevant past medicines used, including over-the-counter drugs and supplements, with an emphasis on medicines that affect memory.

Social/personal history. A record of education, work, marital, and other relevant social history, as well as lifestyle choices and potential risks and protections for memory loss. Dietary habits, drinking, and smoking patterns are recorded.

Mental status. Includes assessment of appearance, behavior, memory, orientation, mood, judgment, and insight.

Physical examination. Findings from the examination, ranging from blood pressure and pulse to observed physical signs and abnormalities.

Laboratory assessments. Results of screening blood tests, brain scans, and other laboratory findings.

Impression. A summary of the most likely diagnoses and problems.

Plan. A listing of specific interventions for each of the above problems.

Getting Treatment for Physical Illnesses

Like any middle-aged or older adult, I am at risk for developing a variety of physical illnesses, including hypertension, high cholesterol, and diabetes, that can impair memory ability and affect long-term brain health. Studies have demonstrated higher rates of Alzheimer’s disease and other dementias in people with these conditions. Effective medicines are readily available to treat these illnesses, and getting appropriate and timely treatment is vital to keeping our brains young.

I have friends who have gone to their doctors for a head cold or a sprained ankle, and during the exam the doctor discovered an elevated blood pressure or a high blood sugar level. Picking up these incidental findings can not only save a person’s brain cells but their life as well. This is just one of many reasons why regular physical checkups are so important.

Hypertension

High blood pressure, or hypertension, affects more than 60 percent of people over age 60. The illness packs the added punch of increasing a person’s risk for strokes and vascular dementia, as well as heart attacks. Hypertension has been described as a silent epidemic because most of us wouldn’t know we had it unless we had our blood pressure measured. High blood pressure can be easily and effectively treated with a variety of proven medicines, but the most effective intervention for hypertension usually includes both medicine and lifestyle changes. Smoking, overuse of alcohol, and being overweight all contribute to one’s hypertensive risk. Regular exercise, a low-salt diet, and avoiding smoking and other high-risk activities all lower blood pressure.

Chronic high blood pressure during midlife (forties and fifties) leads to cognitive decline later in life. Chronic hypertension most likely affects memory because it thickens and stiffens blood vessels. Under high pressure, these stiffened blood vessels can rupture, possibly causing cerebral vascular disease involving blood leakage into the brain tissue and stroke. A stroke is often defined as the death of brain cells, resulting in a loss of physical or mental function or both. But treatment makes a difference. Dr. Edwin Jacobson of UCLA reported that rigorous control of mild to moderate hypertension can improve cognitive function. He noted significant improvements in visual and spatial skills, executive skills, and the speed that patients could process information after just twenty-four weeks of treatment.

Many Alzheimer’s patients also show evidence of cerebral vascular disease, which can further compromise their cognitive status. An autopsy study of patients who had been diagnosed with Alzheimer’s disease found that roughly one-third had cerebral vascular disease as well. There are also some patients with vascular brain injuries caused by hypertension and other illnesses who also have Alzheimer’s plaques and tangles in their brains. The coexistence of Alzheimer’s and cerebral vascular disease is much worse than experiencing either alone.

The Ups and Downs of Cholesterol

High blood cholesterol increases the risk for strokes and other circulatory problems that can affect memory. Inherited genetic factors as well as lifestyle choices are known to contribute to the risk for high cholesterol. The class of cholesterol-lowering drugs known as statins have been found not only to lower fat levels in the blood but also to help prevent age-related memory decline. These cholesterol-lowering drugs are known to prevent heart disease and stroke, and new research indicates that people who take them also have a lower risk for developing Alzheimer’s disease.

Dr. Benjamin Wolozin and Dr. George Siegel and their colleagues at Loyola University studied more than sixty thousand hospital medical records. They found that the rate of Alzheimer’s disease in patients taking cholesterol-lowering statins, including lovastatin (Mevacor) and pravastatin (Pravachol), was nearly 75 percent lower when compared to the entire population, or to patients taking other medicines for different conditions, such as hypertension or cardiovascular disease.

Dr. David Drachman, University of Massachusetts, found that a wide variety of statins have the effect of lowering one’s risk for Alzheimer’s, including atorvastatin (Lipitor), cerivastatin (Baycol), fluvastatin (Lescol), pravastatin (Pravachol), and simvastatin (Zocor). Scientists speculate that when the statin drugs interfere with cholesterol metabolism, they may also decrease the production of amyloid-beta, which forms the Alzheimer’s plaques. The benefits to the brain from statins may also stem from their ability to reduce cerebral vascular disease, thereby improving blood circulation to brain cells. Until a double-blind test comparing statin drugs against a placebo control is completed, we cannot state definitively that these drugs truly help to prevent Alzheimer’s disease.

Coronary Bypass Surgery

High cholesterol, high blood pressure, and other conditions sometimes damage the heart to the extent that surgery is needed. A report published in the New England Journal of Medicine noted a startling decline in memory ability in people five years after they had undergone coronary-artery bypass surgery. They found that memory and other cognitive declines were present in 53 percent of the patients at the time of discharge from the hospital after their bypass surgery. This high rate went down by about half after six months. However, five years later, the proportion of cognitively impaired patients was back up to 42 percent. The main predictor of memory loss five years after bypass surgery appeared to be lower cognitive function at initial hospital discharge following the surgery.

To perform coronary bypass surgery, the doctor has to stop the patient’s heart and divert their blood through the artificial pump of a heart-lung machine. Some doctors believe that, during this stopped-heart period, the brain sustains subtle damage. Another theory is that the operation may shake loose tiny particles of fat from the surgical site into the blood system. If and when these droplets make their way to the brain, they can cause cellular damage. The heart-lung machine also produces air bubbles that could block blood flow through tiny vessels, thus killing brain cells. The New England Journal of Medicine report opened the door for increased study of prophylactic treatments to prevent postsurgical cognitive decline. Dr. Murali Doraiswamy and colleagues at Duke University Medical Center in Durham, North Carolina, studied patients following coronary bypass surgery and found that twelve weeks of treatment with the anti-Alzheimer’s medicine donepezil (Aricept) led to significant memory benefits compared with a placebo.

Anesthesia used during surgery has also been studied as a possible contributor to postsurgical memory decline. Although most people have no long-term cognitive losses after one or two surgeries, the cumulative effect of multiple exposures to anesthesia has the potential to accelerate brain aging, particularly in someone already at risk. One study of people over age 64 showed cognitive decline in 53 percent of them up to three months after surgery. Several studies have found a greater susceptibility to dementia in older people who undergo surgery for hip fracture. It is possible that the decrease in blood pressure from anesthesia lowers blood circulation in the brain, resulting in neuronal death in vulnerable brain areas.

Because of the general risks of surgery and the possible risks to brain health from cumulative exposures to anesthesia, you may want to consider whether elective or noncrucial surgery is the best lifestyle choice for you.

Other Physical Illnesses

Diabetes, a disease resulting from the body’s inability to adequately control sugar levels in the blood, is another illness that can impair memory and brain fitness, and becomes more frequent with age. An estimated thirty-four million people in the United States suffer from diabetes, yet about one-fourth of them don’t even know they have it. In addition to exercise and diet (Chapter 7), there are well-known medications, such as insulin, that effectively treat diabetes. Control of diabetes will protect brain fitness and can improve memory function.

Any acute illness that attacks our bodies can overwhelm our brains (see Table 9.1). I have seen both older and younger patients experience memory impairment and word-finding difficulties during a flu or pneumonia. Usually these problems disappear or are reversible when the disease lifts, but some infections can be serious. Covid-19, for example, can directly infect the brain and can not only cause loss of sense of smell but also impaired memory and strokes. The infection can lead to heightened brain inflammation that can increase the risk for cognitive decline and dementia.

For bacterial infections, a common mistake many people make is to discontinue taking their antibiotics once they begin to feel better. A full course of antibiotics is crucial to prevent an infection from recurring, as well as preventing their bodies from building a possible immunity to that medicine.

The bottom line is to take your physical illnesses seriously, seek medical advice when indicated, and use medicines wisely.

Table 9.1

PHYSICAL CONDITIONS THAT MAY CAUSE MEMORY LOSS
Cardiac Disorders
Arrhythmias | Heart attack
Congestive heart failure |
Infections
Encephalitis | Meningitis
Hepatitis | Pneumonia
Influenza | Tuberculosis
Malignancies
Brain | Lymphoma
Leukemia | Pancreas
Metabolic and Endocrine Disorders
Cushing’s disease | Electrolyte imbalance
Dehydration | Thyroid disorders
Neurological Disorders
Epilepsy | Parkinson’s disease
Multiple sclerosis | Strokes
Other Conditions
Anemia | Pain
Kidney disease | Temporal arteritis
Liver disease | Thiamine deficiency
Lupus | Vitamin B_12 deficiency

Drugs That Can Worsen Memory

As our bodies get older, they become more vulnerable to certain physical illnesses and we tend to take more medicines. The average older adult takes more than half a dozen prescription medicines at any one time. The more medicines we take, the greater the possibility for negative drug interactions.

Aging causes our brain receptors to become more sensitive to the effects of medication, and this sensitivity can lead to side effects at much lower doses. Also, our bodies become less efficient in metabolizing and excreting medicines, so over time we may accumulate higher blood levels of these drugs. This can lead to new or increased side effects, as well as to interactions with other drugs that we hadn’t experienced in the past. Due to these changes in our bodies, doctors caring for older people often prescribe drugs in low doses initially and slowly increase them as needed to minimize any potential adverse reactions.

Many drugs have anticholinergic side effects, making them oppose the actions of the drugs prescribed for memory loss, thereby worsening memory ability. Drugs of particular concern include those often prescribed for anxiety—such as Xanax, Valium, or Librium—which can cause sedation and can also impair memory ability (see Table 9.2). Drugs used to regulate heart rate or treat high blood pressure can make blood vessels less taut and decrease the heart’s ability to pump blood. Since our vascular tone diminishes anyway as we age, medications that aggravate this problem can lead to falls, head trauma, and other complications that threaten brain fitness, and they should be taken with care.

Whenever I evaluate a patient for the first time, I ask them to bring in all their medications. Many older patients have arrived with shopping bags filled with prescription bottles. Often the easiest and most effective interventions are merely to eliminate unnecessary medicines and reduce the dosage level of drugs that are most likely contributing to the patient’s memory loss, depression, or both. Giving a patient the lowest effective dose of a medication will lower their risk for developing side effects; however, too low a dose, or a subtherapeutic level, can also be a problem.

Doris L., widowed for seven years, lived in a beautiful Park Avenue penthouse near Central Park South. Her successful surgeon husband, Melvin, had always treated the family’s minor ailments, prescribing antibiotics, ointments, or eye drops whenever Doris, the kids, or the grandkids needed anything. After Melvin died, Doris urgently shopped for a physician to fill the void of not having Melvin there to soothe her every ache and pain. Though several physicians throughout Manhattan had treated her once or twice, she couldn’t bring herself to trust any one doctor to truly understand her “complicated medical conditions,” which included high cholesterol, arthritis, chronic insomnia, migraines, and periodic depression. Doris took a different medicine for each ailment.

Throughout her adult life, Doris had experienced bouts of depression that recurred every two to three years. Melvin had always prescribed an antidepressant, which seemed to help. After his death, she experienced an extreme episode of depression and asked one of her new physicians to continue the antidepressant prescription. Her depression improved, but she began to complain of increasing forgetfulness. At first she merely misplaced things, but her symptoms worsened. She would put on her coat, get her purse, and push the call button for the elevator. When the doors opened, half the time she would have already forgotten where she was going.

Doris consulted a new doctor, who suspected she was experiencing some early symptoms of Alzheimer’s disease and prescribed a cholinergic drug. After a month, she noticed improved memory ability. A week later, Doris read about a newer anti-Alzheimer’s drug that sounded fantastic. Concerned about insulting her current doctor, she sought yet another physician to prescribe this new drug. Doris was now taking a daily antidepressant, a sleeping pill, and two cholinergic drugs, not to mention meds for her high blood pressure, arthritis, high cholesterol, and headaches. The second, unnecessary, cholinergic, which neither prescribing physician was aware of—Doris made sure of that—led to nausea and vomiting, which forced her to consult a gastroenterologist. This specialist insisted on seeing all her medical records and all medicines before he could help her.

Desperate, Doris came clean. Apparently, she was being treated by seven different doctors and getting multiple prescriptions for many of her conditions including pain, anxiety, depression, and memory loss. Most of her symptoms were intensified by the overuse and interactions of her drugs. The antidepressant she was taking actually had an anticholinergic effect that worsened her age-related memory loss. Also, the doubling up on the cholinergic drugs only served to upset her stomach but failed to give her any extra memory improvement over the original single dose. Her insomnia was a symptom of depression, so rather than a sleeping pill—which also worsened her memory—her gastroenterologist prescribed a newer antidepressant that helped with her sleep and had fewer side effects. He also reduced the pain from her arthritis and headaches by using a nonnarcotic anti-inflammatory drug.

Although her depression and memory function improved, Doris still missed Melvin. She began seeing a psychotherapist, who helped her to realize that her “doctor shopping” had been an ineffective attempt to feel cared for—the way she felt before Melvin passed away. That would never be possible. Doris began to accept things she couldn’t change and move on with her life. She became involved in social and volunteer activities and actually started dating two years later—a nice dentist from midtown.

If you are concerned that medication may be affecting your memory, you should consult your doctor about whether you truly need a particular drug, and be sure she is aware of all the medicines you take. This is especially important if you are under the care of more than one physician.

Table 9.2

COMMON MEDICINES THAT CAN IMPAIR MEMORY IF NOT TAKEN WISELY
Drug Category | Brand Name | Generic Name
Antiulcer/dyspepsia | Tagamet | cimetidine
| Zantac | ranitidine
Analgesic | | codeine
| Demerol | meperidine
| Fiorinal |
| Percodan, Percocet | oxycodone
Antihistamine | Benadryl | diphenhydramine
Antianxiety/sedative | Ambien | zolpidem
| Ativan | lorazepam
| Dalmane | flurazepam
| Halcion | triazolam
| Librium | chlordiazepoxide
| Restoril | temazepam
| Serax | oxazepam
| Valium | diazepam
| Xanax | alprazolam
Antidepressant | Elavil | amitriptyline
| Tofranil | imipramine
Antihypertensive | Benazepril | lotensin
| Dyazide | hydrochlorothiazide
| Tenormin | atenolol
| Toprol | metoprolol
Anti-Parkinson’s | Symmetrel | amantadine
Antipsychotic | Haldol | haloperidol
| Mellaril | thioridazine
| Thorazine | chlorpromazine
Hormone | Synthroid, thyroxine | Thyroid supplements
Steroid | | Prednisone

The Business of Antiaging

Consumers spend billions of dollars a year on “cures” for the aging process. Over-the-counter treatments, including ginkgo biloba, ginseng, and melatonin, as well as various vitamins and herbs, are proclaimed to be the answer we’ve all been seeking—veritable fountains of youth. However, despite dramatic claims of their effectiveness, these treatments and herbal tonics are not always rigorously tested, nor are they monitored by the FDA. It is fairly easy to make grandiose claims about unproven supplements—often touted as memory loss preventions—in an unregulated, multibillion-dollar industry.

The power of the “placebo effect” may help explain the popularity of these treatments. I know one mother who used this tried-and-true placebo effect to treat her children’s ailments. When one of them had a mild ache or pain, she would go to her medicine cabinet and pull out a large bottle of cherry-flavored liquid labeled “PLACEBO.” She would then dole out a large tablespoon of the syrup while commenting on its remarkable potency. The placebo usually reduced and sometimes even cured their ailments.

Scientists have long speculated on what causes this scientifically proven placebo effect—whether it is the patient’s belief or expectation that the treatment will work, the doctor’s confidence in the treatment, or some other physiological mechanism. In memory studies, we have found that sugar pills often make us better, but this improvement is temporary, usually lasting no more than six weeks.

As a result of the diminishing placebo effect, the gold standard for proving the effectiveness of any new drug or treatment is to show that the active drug is indeed more beneficial than a placebo—over time.

A study analyzing 114 published reports involving 7,500 patients with a variety of different conditions raised controversy about the placebo effect. Dr. Asbjørn Hróbjartsson and Dr. Peter Gøtzsche of the University of Copenhagen found that what many believe to be an effect of placebo is merely the result of the natural uneven course of an illness. When treatments were compared with no treatments, study participants not receiving treatment improved at about the same rate as when participants were given a placebo. Despite these results, placebos are still needed in clinical research to prevent scientists from knowing who is getting the real treatment, and who is not.

Drugs used to treat Alzheimer’s disease or prevent memory loss must undergo intense placebo-controlled testing before gaining FDA approval for distribution. In Alzheimer’s disease treatment studies, we have often seen an initial but temporary placebo effect, as illustrated in Figure 9.1.

In the study graphed in the figure, hundreds of patients with Alzheimer’s disease were given either the active cholinergic drug donepezil (Aricept) or an identical-appearing placebo pill. Note the gray arrow pointing to the first six weeks of the study—the placebo was just as good as the Aricept in improving memory and other cognitive abilities. This effect, however, waned after that initial period and the placebo patients began to decline, while the patients taking Aricept maintained their cognitive improvement. In fact, other studies indicate that this drug continues its benefit for several years. People who take treatments that have not passed a controlled study are probably wasting their time and money (they could just as easily gain placebo effect from a breath mint) and may be causing themselves unnecessary side effects that can harm their health.

Figure 9.1

All That Is Natural Is Not Necessarily Safe

About half of adults in the US report having used at least one dietary supplement in the previous thirty days. They use these natural remedies to treat a variety of ailments. In the United States alone, over $30 billion is spent each year on these supplements, and more than four in five Americans use these nutraceuticals and botanical preparations to improve their health.

More than 25 percent of people in the US aged 50 years and older take a supplement, such as ginkgo biloba, acetyl-L-carnitine, or Bacopa monnieri, for memory or brain health. As an issue expert for AARP’s Global Council on Brain Health, I participated in a review of the safety and effectiveness of dietary supplements for brain health. Our group reported that Americans spend approximately $3 billion each year on brain health supplements, and supplement use nearly doubled from 2006 to 2015. Studies show that those who take supplements actually live healthier lifestyles: they are more likely to exercise, consume a healthy diet, and not smoke. It may be that health-minded individuals are more likely to invest in nutritional supplements than are people who are not as fastidious about their personal health.

Unfortunately, the level of scientific evidence needed to support a supplement claim is not nearly as stringent as it is for prescription medicines to receive FDA approval. In the US and most other countries, double-blind placebo-controlled studies in humans are not necessary to establish a health claim for a dietary supplement. As a result, a lot of consumers are wasting their money on brain health supplements that only provide temporary placebo effects.

Heightened inflammation is a target for several brain health supplements. Because the risk of age-related cognitive decline appears lower in people who consume anti-inflammatory omega-3 fatty acids, many of us get our omega-3s from fish oil, krill, or algae. As mentioned earlier, a bioavailable form of the anti-inflammatory spice curcumin shows promise for improving memory, and our research group’s study showing cognitive benefits from daily consumption of bioavailable curcumin are encouraging.

Initial studies of the antioxidant supplement vitamin E demonstrated some benefits, but more recent research has not shown that it can prevent Alzheimer’s disease or delay its onset in people with mild memory symptoms. Despite promising animal studies, antioxidants including acetyl-L-carnitine, coenzyme Q_10, vitamin C, and beta-carotene have not been shown to improve memory in humans.

Although some people take high doses of B vitamins, they are not likely to provide much of a memory benefit unless the person has a B vitamin deficiency. Findings on the use of vitamin D supplementation for memory are conflicting. One study of older women showed that those who took the recommended vitamin D dose had better cognitive abilities than those who did not, but other research has not replicated these results. Of course, vitamin D supplementation is recommended for anyone with a deficiency.

Other brain health supplements show benefits in randomized clinical trials, but for many the findings are mixed. Clinical trials of phosphatidylserine suggest that it provides cognitive benefits above and beyond placebo. Although huperzine-A has been shown to increase levels of the brain messenger acetylcholine, which is depleted in brains with Alzheimer’s disease, studies in people with normal age-related memory complaints have not confirmed its effectiveness. Despite testimonials to the memory benefits of the protein apoaequorin (Prevagen), data from placebo-controlled trials are not convincing that it is effective.

Regardless of what you take, you need to be careful. The majority of us are unaware of the potential dangers of mixing our prescription medicines with herbal remedies, and we mistakenly assume that these treatments are safe because they are natural and don’t require government oversight.

The FDA reports thousands of adverse events each year from such supplements as ephedra, ginkgo biloba, St. John’s wort, ginseng, and others. Some herbs are therapeutic at a low dose but toxic at another, and can lead to liver disease or even cancer. When various herbs interact with each other, let alone prescription drugs, they also can become toxic, interfere with the action of the drugs, or both.

Ginkgo biloba, an herbal treatment that has been used for thousands of years, is made from a leaf extract and thought to improve memory ability by inhibiting oxidative cell damage and improving cerebral circulation. Ginkgo has been tested on several forms of memory impairment, including mild age-related decline, vascular dementia, and Alzheimer’s disease. Some studies have shown significant results, but the clinical relevance of the effects has been unclear. Moreover, experts have questioned the methods of these studies. A randomized, double-blind, placebo-controlled clinical trial conducted in more than three thousand older adults with normal cognition or mild cognitive impairment showed that ginkgo was not effective in preventing Alzheimer’s disease or dementia.

Because the FDA does not approve such dietary supplements as ginkgo biloba for safety and effectiveness before they reach consumers, the quality and consistency of the many brands available differ considerably. Ginkgo has been known to cause nausea, heartburn, headaches, dizziness, excessive bruising or bleeding, low blood pressure, and other adverse effects. Ingesting ginkgo along with caffeine can lead to blood clots surrounding the brain (subdural hematomas), and ginkgo can affect insulin secretion, making it potentially dangerous for diabetics. Because ginkgo biloba has anticoagulant properties, taking it with aspirin and other blood-thinning drugs requires careful monitoring. The current limited evidence for ginkgo’s effectiveness, and its potential for adverse effects, leads me to recommend against ginkgo biloba as a treatment for preventing memory loss at this time.

Ephedra is often used as a stimulant or appetite suppressant, or as an ingredient in other medicines, usually over-the-counter preparations. If people combine ephedra with coffee or other mild stimulants, they may experience rapid heart rate and anxiety. Guarana is an herb used as a stimulant and natural source of caffeine, which has some anticoagulant effects. Serious heart problems can result if it is mixed with ephedra. Ginseng, a popular herb used to increase endurance, reduce stress, and improve sexual function, can be harmful for diabetics. Ginseng supplements are sometimes packaged as orange-flavored treats and appear on the candy shelf rather than the supplement counter. Taken like mints or chewing gum, it is alarmingly easy for harmful doses to get into a diabetic person’s body. If taken in conjunction with antidepressants, ginseng can make some people manic. It can also augment the effects of sedatives or stimulants.

Kava kava has been used to reduce anxiety and stress. It can enhance the effects of alcohol and lead to intoxication. In conjunction with sedatives, it can cause excessive sleepiness or even coma. Valerian, an herb used for restlessness and insomnia, can interact adversely with sedatives or alcohol. Another herb native to Europe, St. John’s wort, is taken by more than seven million Americans as a natural treatment for depression or insomnia. Although previous research has not shown it to be effective in treating clinical depression, it can augment the effects of antidepressants, stimulants, or anticonvulsants in some situations. Rarely, when exposed to sunlight, people using St. John’s wort have experienced sensations of tingling, needle pricks, or pain, even when taking it alone.

The majority of people who use these natural untested remedies experience no negative side effects, and many individuals swear to their beneficial effects. In fact, herbal remedies may be effective for some people in certain situations that experts are not even aware of.

The scientific community and the public at large continue to wait for results of conclusive double-blind studies showing whether brain health supplements for memory loss actually work. If you are thinking of taking a brain health supplement, I recommend that you first discuss it with a doctor or pharmacist so you can avoid side effects as well as ineffective brands. You can obtain other reliable information from the National Center for Complementary and Alternative Medicine (nccam.nih.gov) and AARP’s Global Council on Brain Health (https://www.aarp.org/health/brain-health/global-council-on-brain-health/supplements/).

Pharmacogenetics: The Future of Alzheimer’s Disease Prevention

Several available drug treatments have proven effective for the memory loss and other cognitive declines of Alzheimer’s disease. But as scientists continually search to find a cure for Alzheimer’s disease and possibly prevent its onset in the first place, a new approach is emerging: the science of pharmacogenetics—the strategy of treating patients not just according to their diagnosed disease but also according to their genetic makeup.

Particular genetic variants may lead to differences in an individual’s drug response, and these differences can take effect at many levels. It could affect how well the drug is absorbed from the stomach and intestines, how well it is broken down in the body, how quickly it gets through the blood system and out of the body, or how effectively it binds to neurotransmitter receptors in the brain. By identifying and understanding the functions of these genetic variations, we can predict their role when determining a patient’s response to a particular drug.

The goal of pharmacogenetics is to provide doctors with a patient’s drug response profile before beginning medication treatment. A meaningful pharmacogenetic profile may help to define a subpopulation of individuals who are likely to respond or not respond to a particular drug, based upon that population’s underlying biology. The point is to avoid unnecessarily treating patients whose genetics indicate they may receive little benefit from a given drug yet have a high risk for side effects.

Because the damage is done by the time a patient develops Alzheimer’s disease symptoms, I am convinced that our best chance of “curing” the disease is to target mild forgetfulness. My research team has conducted several double-blind, placebo-controlled studies to develop a pharmacogenetic treatment strategy for delaying the onset of Alzheimer’s disease. In many of these investigations, research subjects have been tested for any APOE-4 Alzheimer’s genetic risk. They also often receive a PET scan before starting treatment, as well as a follow-up scan one or two years later. In these studies, we hypothesize that the volunteers who take placebo pills will show more rapid decline in brain function (i.e., accelerated brain aging) than those taking an active drug. We expect the actual drug to be more effective in volunteers with the APOE-4 genetic risk than those without the genetic risk. Our aim is to delay brain aging by one or more decades, thus allowing people to live longer, and better, without memory decline. These kinds of studies may eventually lead to the widespread use of pharmacogenetic testing to determine who is or is not likely to benefit from Alzheimer’s prevention drugs.

Maintaining Memory with Anti-Alzheimer’s Drugs

New research on neurotransmitters suggests that early intervention with a cholinergic drug can slow brain aging as well as delay the onset of Alzheimer’s disease. These studies support the idea that treating early brain-aging symptoms with cholinergic drugs—medicines currently used to treat Alzheimer’s disease—may actually interfere with the deposition of amyloids, the insoluble proteins that have accumulated in the brains of people with Alzheimer’s disease.

Dr. Diana Woodruff-Pak and her associates at Temple University treated rabbits with galantamine (Razadyne), a cholinergic drug that increases acetylcholine neurotransmitters. The neurotransmitter acetylcholine communicates with the brain’s nicotinic receptors, which gradually decline as we age, and more rapidly if one has Alzheimer’s disease. The researchers found improved learning abilities in both the young and old rabbits, as well as increases in nicotinic receptor activity in their brains.

The fact that the young animals showed improved learning has led some experts to speculate that the drug has an effect beyond its usual inhibition of the enzyme that breaks down acetylcholine. Even though cholinesterase inhibitor drugs were designed to increase the acetylcholine neurotransmitter directly, they have other effects that may slow down brain aging. Despite these encouraging animal data, human studies have been disappointing. A recent analysis of fourteen randomized controlled trials of anti-Alzheimer’s medicines, including donepezil, galantamine, and rivastigmine, concluded that in people with mild cognitive impairment, these medicines have only slight effectiveness but many safety issues.

Antidepressant Medicines: Good for Mood and for Memory

People become depressed for a variety of reasons. Often, a personal loss or disappointment can trigger sadness. Unresolved conflicts or persistent stress are sometimes the culprits. Other times, a biochemical imbalance in the brain may be to blame. Many depressions involve more than one trigger or cause, with overlapping psychological and biological factors contributing. Regardless of the specific cause, psychotherapy, antidepressant drugs, or both, can improve the symptoms, even if they are severe.

One feature of depression—decreased ability to concentrate—seems to become more prominent as we age. Middle-aged and older people tend to emphasize these concentration difficulties, and their depressions are often colored by memory complaints. A form of depression often seen in older people has been labeled as “pseudodementia” because it so closely resembles a dementia or Alzheimer’s disease. A person who is overwhelmed by sadness and despair may have trouble trying to learn, and remembering new information is the last thing on their minds. Their sleep patterns are also disturbed, further aggravating memory abilities (see Recognizing Features of Major Depression box). It is known that episodes of repeated and severe depression can lead to abnormal secretion of stress hormones, and this can further worsen memory problems (Chapter 4).

Many people still consider depression to be a sign of character weakness. To them, seeking professional help or taking antidepressants is a stigma to be avoided at all costs. What those people don’t realize is that untreated depression can increase a person’s risk for serious physical illness or even death, as well as raise the risk for suicide. The mortality rate for patients whose depressions are properly treated is half that of those who receive inadequate care or no care.

Recognizing Features of Major Depression: “SIG E CAPS”

Many psychiatrists use a simple mnemonic to remember eight of the features of major depression. The memory tool stands for “when to prescribe the energy capsules”: “SIG” is an abbreviation doctors use to stand for prescribe (check your next prescription from your doctor), “E” stands for energy, and “CAPS” stands for capsules. Each letter is an abbreviation for one of the symptoms:

S—Sleep decreased or increased

I—Interest decreased

G—Guilt feelings

E—Energy decreased

C—Concentration abilities decreased

A—Appetite decreased or increased

P—Psychomotor disturbance (pacing, hand-wringing, or slowing of thought and movement)

S—Suicidal thinking

If you or someone you know has four of these symptoms for two or more weeks, you should consult a doctor, because an antidepressant medicine is likely to improve the symptoms.

Geriatric psychiatrists have studied the combined states of memory loss and depression in older adults. Both Dr. George Alexopoulos at Cornell University and Dr. D. P. Devanand at Columbia University have found that the combined states, though treatable with antidepressants, still tend to progress to permanent cognitive losses that are characteristic of Alzheimer’s disease.

Some experts wonder whether aggressive treatment of depressive symptoms might stave off the chronic memory loss and/or the dementia that eventually develops in many of these patients. The possibility that antidepressant drugs could slow down or prevent brain aging requires further study. However, we do know that both antidepressant medicines and psychotherapy are effective treatments in their own rights, but combining the two, when indicated, appears to be more effective than either form of treatment alone.

Although all types of antidepressant drugs have been effective in relieving some symptoms of depression, the improved side-effect profiles of the newer antidepressants, such as fluoxetine (Prozac), sertraline (Zoloft), mirtazepine (Remeron), or citalopram (Celexa), to mention a few (see box), have become preferred treatments over such older medicines as amitriptyline (Elavil) or imipramine (Tofranil). These older medicines can potentially worsen memory performance because of their anticholinergic side effects.

It is best to start low and go slow with antidepressant medicines, particularly when treating older people. Many primary care physicians can treat depression quite effectively using antidepressants, but for a complicated and more severe depression, the expertise of a psychiatrist may be needed. For some older depressed patients, a psychiatrist with additional geriatric training would certainly offer the most sophisticated care (Additional Resources).

Some Commonly Used Antidepressant Drugs
DRUG | DOSE RANGE (MG/DAY) | POSSIBLE SIDE EFFECTS
Buproprion (Wellbutrin) | 37.5–450 | Insomnia, nausea, headache
Citalopram (Celexa) | 10–60 | Insomnia, nausea, sexual dysfunction
Desipramine (Norpramin) | 10–300 | Heart arrhythmia, sedation, sexual dysfunction
Paroxetine (Paxil) | 10–60 | Nausea, sexual dysfunction, drowsiness, insomnia
Fluoxetine (Prozac) | 10–80 | Insomnia, nausea, sexual dysfunction, anxiety
Levomilnacipran (Fetzima) | 40–120 | Constipation, sexual dysfunction, rapid heart rate
Mirtazepine (Remeron) | 15–45 | Sedation, weight gain, drowsiness, constipation
Nefazadone (Serzone) | 100–600 | Sedation, headache, nausea
Nortriptyline (Pamelor) | 10–200 | Heart arrhythmia, sedation, sexual dysfunction
Sertraline (Zoloft) | 25–200 | Headache, nausea, sexual dysfunction
Venlafaxine (Effexor) | 37.5–375 | Insomnia, nausea, drowsiness, constipation
Vilazodone (Viibryd) | 20-40 | Anxiety, heart arrhythmia, chest pain
Vortioxetine (Trintellix) | 10-20 | Sexual dysfunction, nausea, dizziness
Trazodone (Desyrel) | 25–600 | Sedation, heart arrhythmia, nausea

Using Sex Hormones to Prevent Memory Loss

Scientists have studied the effects of estrogen and other hormones on mood and memory in older adults. Studies by epidemiologists have found that taking estrogen supplements after menopause lowers a woman’s risk for developing Alzheimer’s disease. It is important to note that women who take hormone replacements are, on average, better educated and live healthier lifestyles.

Estrogen appears to improve connections between the brain’s nerve cells and to augment cerebral blood flow. It also boosts memory transmitters, such as acetylcholine. In addition, estrogen serves as an antioxidant, helping to prevent damage to cells over time. Based on estrogen’s proven benefits for treating such menopausal symptoms as hot flashes and insomnia, hormone replacement therapy is already a $16 billion annual industry and continues to grow.

There is still much debate over estrogen’s true benefits as well as its drawbacks. In addition to alleviating menopausal symptoms, estrogen may improve skin tone, prevent osteoporosis, and reduce the risk for stroke. However, estrogen taken without progesterone increases the risk for developing endometrial cancer and may increase the susceptibility to breast cancer. Use of estrogen replacement with or without progesterone is associated with a twofold increase in risk of developing gallstones.

Although evidence suggests that estrogen protects against some forms of age-related memory loss and may even help prevent Alzheimer’s disease from developing in healthy brains, it has shown no apparent benefits in patients who already have Alzheimer’s disease.

Dr. Susan Resnick at the National Institute on Aging found that women taking estrogen perform better on certain memory tests and have better blood flow to the hippocampus, a brain area involved in memory function. Dr. Barbara Sherwin at McGill University in Montreal has shown that estrogen’s benefit for postmenopausal women is concentrated on verbal, rather than visual, memory.

In one large-scale US study, the Women’s Health Initiative, investigators sought to determine whether or not postmenopausal estrogen use can truly stave off Alzheimer’s disease. The researchers randomized nearly ten thousand women aged 65 or older to different estrogen preparations or placebo and followed their rates of osteoporosis, heart disease, cancer, and Alzheimer’s disease. Several thousands of these women also were enrolled in a study that assessed their cognitive function. Unfortunately, the hormone replacement therapy had an adverse effect on cognition. The women who took estrogen plus progestin therapy also had an increased risk for developing dementia during the five years of the study.

New drug development has led to synthetic estrogens designed to isolate specific beneficial effects while eliminating unwanted side effects. Although animal studies of these “designer” estrogens, or selective estrogen receptor modulators (SERMs), were encouraging, so far they have not demonstrated cognitive benefits in humans.

The male sex hormone testosterone also has some important effects on mood and memory. Men experience a drop in this sex hormone as they age, but instead of a rapid decline, the levels decrease very gradually over decades. Only about one out of five men aged 65 and older end up with an abnormally low testosterone level, and initial studies suggested that men with low levels experience improvements in mood and memory following testosterone administration. More systematic controlled clinical trials, however, have failed to support its widespread use for protecting memory.

Anti-Inflammatory Drugs—for Pain, Memory Loss, or Both?

In the late 1990s, epidemiologists found that using the anti-inflammatory drugs ibuprofen (Advil, Motrin, Nuprin), naproxen (Aleve), and indomethacin (Indocin) was associated with reducing the risk of Alzheimer’s disease by as much as 60 percent—if people took them for at least two years. Some scientists trying to explain the connection have theorized that the drugs’ brain effects came from their action on inflammation. Looking closely at the amyloid plaques that collect during the course of brain aging and the development of Alzheimer’s disease, we can see the central core area consists of insoluble amyloid protein. Around the outer rim are traces of inflammation. The theory is that our brains mount an inflammatory response attack against the amyloid protein, attempting to get rid of it, and this inflammation causes cell death and memory loss.

Scientists are focusing their efforts on developing specific drugs to target the brain’s inflammatory response. Dr. Michael Mullan and his colleagues at the University of South Florida described how microglia cells promote an immune response that causes inflammation of the brain by releasing proteins known as cytokines, which are toxic to brain cells. The researchers found that the receptors involved in this response were present in the microglia cells of the brain’s frontal lobe and the hippocampus—the areas affected by Alzheimer’s disease. Although these receptors can also be found in the brains of people who are simply aging normally, the discovery still adds weight to the inflammatory hypothesis.

Dr. Anthony Broe and colleagues at the University of Sydney, Australia, found that low doses of anti-inflammatory drugs worked just as well as higher doses for lowering the risk for Alzheimer’s disease. Of the nearly 140 aspirin users in their study, 80 percent took only a half tablet of aspirin each day. This low dose would be insufficient to mount an anti-inflammatory response in the brain, which raises the possibility that interrupting the inflammatory reaction might not be the critical mechanism in protecting the brain.

Our own research group found that middle-aged and older adults with normal aging or mild cognitive impairment who took the anti-inflammatory drug celecoxib (Celebrex) for eighteen months, experienced improved cognitive function, compared with those who took placebo. However, our study sample was relatively small (eighty-eight volunteers), and large-scale, longitudinal, placebo-controlled trials have not shown that anti-inflammatory medicines prevent such individuals from progressing to Alzheimer’s disease. Because these medicines have multiple side effects when taken for long periods of time, they have not been recommended as preventive treatments.

Blowing the Smoke out of Nicotine: Transdermal Patches

Most of us know about the main consequences of smoking, particularly lung cancer and heart disease. Due to the damage it does to the brain’s circulation, smoking can also increase the risk for age-related memory loss. Surprisingly though, nicotine delivered through the skin and not smoked may have some benefits.

Nicotine receptors in the brain are important for memory performance because they respond to neurotransmitters, such as acetylcholine (tiny brain messengers carrying information we wish to remember). In Alzheimer’s disease, these same nicotine receptors decline and die out, making learning and recall more difficult.

Prior research has shown that if nicotine can be delivered to the brain through the skin using transdermal patches or another method, thus avoiding lung, mouth, and throat exposure, short-term memory performance improves, especially in people with only mild memory losses. The diminished nicotine receptors in Alzheimer’s disease patients may limit the usefulness of nicotine patches because these patients may have too few receptors left to augment. Investigators at the University of Vermont followed up on these leads and found that volunteers with mild cognitive impairment improved on cognitive testing after wearing nicotine patches for six months. Side effects are usually mild but may include nausea, headache, dizziness, and insomnia.

Getting More Oxygen to the Brain

An adequate oxygen supply to the brain is essential for neurons to function normally. We know that when the brain’s blood circulation is compromised due to mini-strokes, it puts a person at greater risk for developing Alzheimer’s disease. Such information has spurred neuroscientists to hypothesize that low oxygen blood levels, or hypoxia, in the brain might be contributing to Alzheimer’s disease.

Recent research has followed up on this hypothesis by exploring whether hyperbaric oxygen treatment may have an impact on the disease. Neuroscientists at Dalian Medical University in China explored the cognitive effects of this therapy, which heightens the supply of oxygen to the body’s cells, in patients with Alzheimer’s disease and amnestic, mild cognitive impairment (MCI), a form of MCI that includes memory impairment. Patients with amnestic MCI (aMCI) have a 10 percent chance of developing Alzheimer’s dementia each year.

To perform this study, the investigators treated patients with Alzheimer’s dementia or aMCI with forty minutes of hyperbaric oxygen each day for twenty days. They included assessments of cognitive abilities before the treatment, as well as after one, three, and six months of follow-up. The study results were encouraging: the treatment led to significant improvements in cognitive abilities in the Alzheimer’s patients, as well as those with amnestic MCI.

Plaque Busters and Detanglers: Vaccines and Other Treatments That Target Amyloid

The growing knowledge of what constitutes the basic brain lesions of Alzheimer’s disease, particularly amyloid plaques and tangles, has thankfully propelled drug research and discovery toward prevention. The “plaque busters” that could one day reverse the deviant protein structures forming in our brains include synthetic proteins to break up the sheets of amassed amyloid, and vaccines consisting of synthetic amyloid-beta, the building blocks of the insoluble amyloid proteins that lie at the heart of amyloid plaques. Several pharmaceutical companies are currently developing molecules that inhibit production of the enzymes that lead to the buildup of the amyloid-beta protein building blocks, and human testing is just now beginning.

Initial studies of a vaccine developed to create a heightened immune response that sloughs off the plaque deposits leading to Alzheimer’s disease offered promise. The immune system, or the body’s mechanism for fighting off disease, recognizes antigens or foreign bodies and responds with antibodies designed to search and destroy the foreigner.

Dr. Dale Schenk and his associates at Elan Pharmaceuticals worked on a system designed to stop the plaques from forming in the first place by attempting to jog the brain’s immune system memory. The researchers vaccinated mice with a synthetic form of amyloid-beta that had been genetically engineered to form Alzheimer’s plaques. Conventional vaccinations are designed to give the body’s immune cells a taste of a particular infection that may come at it in the future. Afterward, should the real infection develop, these cells are already primed to produce antibodies to that infection more quickly than they would have otherwise.

In Dr. Schenk’s study, the scientists found that monthly injections of this protein raised the level of antibodies the brain produced and actually prevented Alzheimer’s disease–type brain degeneration in young Alzheimer’s transgenic mice—ones that were genetically programmed to produce the amyloid-beta that creates the sticky plaques of the disease. Remarkably, the injections also eliminated plaques in older mice by as much as 80 percent. The vaccine improved their cognitive ability to master a maze.

However, Alzheimer’s mice differ from humans with Alzheimer’s disease. These animals do not show many of the symptoms seen in humans suffering from the disease, including the death of nerve cells. The only sure-fire way to know if the vaccine effectively treats the disease is to test it in humans in a large-scale, double-blind placebo-controlled trial. Unfortunately, early human trials were discontinued because the vaccine caused dangerous brain lesions in some patients. We don’t yet know whether the memory loss associated with Alzheimer’s disease will significantly improve following depletion of the amyloid plaques. In some of the early antiamyloid treatment studies, the interventions cleared the plaques from the brain but had no effect on memory loss.

Some scientists continue to pursue vaccination as a treatment option. Thus far, their studies have not been effective in treating Alzheimer’s patients who already have dementia. However, amyloid antibodies are being tested in people at risk for dementia. In addition to vaccines and monoclonal antibody infusions, scientists have tested insulin nasal spray because people who develop diabetes have a higher risk for Alzheimer’s disease. Meanwhile, new medications have been developed, and other studies are focusing on using low-frequency ultrasound waves to jump-start neural circuits in the brain’s memory centers. As yet there have been no significant breakthroughs, but research groups throughout the world continue to actively search for more effective treatments.

Making Headway in Healing: Growing Brain Cells, Gene Therapy, and What Lies Ahead

The not-too-distant future may bring interventions for memory loss that today would seem like science fiction. Although neuroscientists have long believed that humans cannot generate new brain cells, available research contradicts this belief. Dr. Fred Gage of the Salk Institute in La Jolla, California, has done a series of studies showing that new nerve growth, or neurogenesis, is possible in adult human brains.

Gage’s team established methods by which to isolate dividing progenitor cells from the adult brain and examine them in laboratory dishes. These progenitor cells are primitive, undifferentiated cells that can develop into specialized ones. The scientists’ ability to extract and propagate these cells has led to wide acceptance of the possibility of neurogenesis in the adult brain. The next step is to grow these cells and use them as replacements in brains with diseased cells, such as in Alzheimer’s-affected brains.

Several scientific groups are developing stem cells, unspecialized cells that eventually turn into all specialized tissues in the body. Dr. Daniel Geschwind and Dr. Harley Kornblum of UCLA reported that neural stem cells can develop into any type of nervous system cell as well as into nonneural tissues. Their studies are building the technology that may one day make stem cells a viable approach to treating Alzheimer’s disease and other brain disorders.

Fetal cell implants have been developed for growing new nerve cells in the brain; however, this approach had a setback in studies of Parkinson’s disease. A carefully controlled study attempting to treat Parkinson’s disease by implanting cells from aborted fetuses into patients’ brains gave relief to some patients by partially improving their rigidity and slowed movements. Unfortunately, approximately 15 percent of the patients had too much cell growth, and a year or so after the surgery, they produced an excess of the chemical that controls the movement problems in the disease. These patients ended up experiencing uncontrollable writhing and jerking.

The control group in this study had “sham” or fake surgery to make sure that the general aspects of the surgical procedure did not mask any potential benefit from new brain cell growth. Although critics argue for halting further studies using this technology, advocates note that successfully demonstrating fetal cell growth in a patient’s brain is a major step forward. These investigators believe that with further technical refinement, neurogenesis may eventually prove to be an effective approach to treating Parkinson’s and Alzheimer’s.

With genetic decoding, cloning, mapping, and other discoveries in the last decade, investigators are working to apply these genetic insights to practical interventions in patients with Alzheimer’s disease or people at risk. Scientists at the University of California, San Diego, made some headway in this direction when they performed the first surgery using gene therapy treatment on an Alzheimer’s patient. The rationale for beginning gene therapy studies in humans is based on previous work in laboratory animals showing that nerve growth factor gene therapy prevents the death of cholinergic cells and reverses cell aging.

Although not intended as a cure, the therapy may protect or even restore some brain cells and relieve symptoms such as short-term memory loss. In the procedure, Dr. Mark Tuszynski and his coworkers took skin cells from the patient and genetically engineered them in the laboratory to produce and secrete human growth factor. The genetically modified cells were then surgically implanted in the brain’s frontal lobe, an area involved in cholinergic neural transmission, memory processing, and reasoning. The scientists intend to determine whether preventing degeneration of this cholinergic system can improve memory performance in Alzheimer’s patients and whether the nerve growth factor could prevent cell death.

The hope is that the implants will take hold and stabilize in humans; however, there are potential risks. For instance, the implants could begin dividing like tumor cells, thus raising safety issues about the procedure in general. One of the challenges in treating Alzheimer’s disease has been to find drugs that can cross the blood-brain barrier and reach the area of the brain that is affected by the disease. If this gene therapy procedure proves to be successful, it will open the possibility of delivering drugs directly into the brain.

Other new drugs in the pipeline aim to boost the brain’s ability to form memories despite the plaques. A group of drugs called ampakines increase the activity of brain chemicals important to memory formation. Ampakines have been tested in patients with Alzheimer’s disease as well as people with only mild cognitive impairment. Additional drugs stimulate the production and release of growth factors in the brain’s memory centers. Such growth factors coax nerve cells to create new connections with each other. Some pharmaceutical companies are developing experimental drugs that enhance the activity and possible growth of undamaged neurons in the brain’s memory centers. Even if a successful approach is developed to eliminate plaque buildup, patients will still need to have treatment for memory problems. Thus, one medicine or course of treatment may affect disease progression while another improves function.

As newer technologies emerge, I predict even more profound breakthroughs to halt the devastating march of brain aging. I am convinced that our current technological capabilities will lead to major breakthroughs within the next few decades. In the meantime, available drugs for memory, depression, and physical illness do have an important impact on brain health and offer the potential for staving off further memory decline.

Using Medicines Wisely for Keeping Your Brain Young

• Learn how doctors organize information so you can be proactive in your medical evaluation.

• Numerous physical illnesses can further age your brain. Take them seriously—see your doctor sooner rather than later.

• Avoid using more medicines than you need. Talk with your doctor about any drugs you are taking that could influence memory ability.

• Remain cautious about taking herbal supplements.

• Hold off on using new or innovative treatments until results from clinical trials are in.

• Remember that treating a depression with the right antidepressant drug often improves memory performance.

Chapter Ten

Don’t Forget the First Nine Chapters

Why put off until tomorrow what you can forget to do today?

—GIGI VORGAN

The previous chapters have presented a lot of information and techniques for keeping our memories sharp as we age, but how, you may ask, are we to remember it all? The following can serve as a practical guide for pulling together your entire memory program and help keep you on track as you progress.

Pick and Choose

No matter how well we learn mnemonic techniques, there will always be too much information to remember. Even people with savant skills for memorizing lists of trivia have limitations in their ability to store facts and figures. Many of the people who succeed in learning and recall skills, and life in general, have learned to choose which information is useful to learn and which information is less important and can be glossed over.

This selective process requires a conscious effort at first but can become second nature with practice, and its usefulness is immeasurable. It might be a good idea to remember your boss’s birth date, but the date of his hip replacement is not one you necessarily need to commit to your long-term memory stores.

Once you have selected information you know you want to remember, then you can choose the best memory tool, whether it’s LOOK, SNAP, CONNECT (Chapter 3), the Peg Method (Chapter 6), or other tools at your disposal. Sometimes you can choose not to necessarily remember a fact outright, but to write it down, enter it into your date book, put it on your to-do list, or pass the buck and ask someone else to remember it.

Be sure to set achievable goals when picking and choosing which information to remember outright, and which information requires use of an internal memory tool (e.g., mnemonic technique) or external memory tool (e.g., reminder note). I know from embarrassing experience that I need to consult my son’s school roster before attending his first grade open house because I do not know the names of his classmates’ parents by heart, even as the end of the semester approaches. My wife does, and I’m sure she’s gloating about it as she reads this.

Getting Organized to Expand Your Memory Power

Beginning a memory program that encompasses as many methods and tools as we have learned may seem overwhelming unless we organize them into an easily implemented system. The following are some organizational approaches to help keep your memory abilities at peak performance.

• Write effective notes. I first learned about summary notes in high school. My senior English teacher had us look over each page of notes and write a brief summary at the top. The process of summarizing the information forced us to think about what we had learned that day, condense it, and rewrite it in different words. This process helped fix the information into my memory. Well-written summary notes condense the amount of material we have to remember, and sometimes the simple act of writing things down helps facilitate recall. The more thought and effort we put into creating a note of something to remember, the more helpful it will be.

• Organize memory places. One of the most common memory complaints is forgetting where we put things. An effective option for avoiding the “disappearing keys act” is to put commonly misplaced items in the same “memory” place—a hook near the door in the kitchen for your car keys, the same briefcase pocket for your organizer, and that convenient desk drawer for the scissors and the pencils.

Your office, home, and car can be more efficient if the storage areas and living spaces are organized with designated memory places. When my family moved across town several years ago, I was struck by how many things I could still not find in the new house, even after months. A major problem was that I had lost all my old memory places for various items, from lightbulbs to tools, and I had not adapted an organized memory place system in the new house. This kind of strategy involves planning. For example, you might keep writing utensils in a convenient place in the study or den, but ski equipment and other seasonal items stored out of the way. Some of us do this instinctively, whereas others take the concept of the “junk drawer” to its furthest household-encompassing limit and might benefit by creating “memory drawers.”

• Use daily planning lists. I learned about this technique while I was a busy first-year resident in internal medicine. Each of us had to care for a dozen or more hospitalized patients who were acutely ill. The only way to keep track of all the patient-care tasks was to make lists. I have continued to use this memory tool ever since. If you don’t already use daily planning lists of things to do, I urge you to try them. Once you complete a task, cross it off. After a few days, transfer the active items to a new list. When the lists get long or complex, place asterisks next to items that need more immediate attention.

• Use weekly or monthly planning calendars. A wall or desk calendar is a helpful way to keep track of regular or occasional events or meetings. Our family has one displayed prominently in the kitchen, and we have gotten in the habit of making sure important appointments and weekly activities are posted.

• Get a date book or use your smartphone. Pocket date books have long helped busy people keep track of the details in their lives. Today, most people use their smartphone to keep track of their calendar appointments, contacts, and photos; search the internet; and do just about anything. You can save all your device data on your desktop computer or a server cloud so that, should you lose your handheld device, you won’t lose all the information you’ve entered into it. You can also print out your schedule, phone book, and lists for others.

• Use sticky notes for quickies. Many people prefer sticky reminder notes as external memory aids. If you haven’t tried them, you might consider using them to augment your other strategies. They are a good quick fix as a reminder, but try not to overuse them. An inherent risk in using sticky notes is that sometimes they “unstick.” Either follow up on the thought or task or transfer it to a more stable memory tool.

• Develop memory habits. From the time we are children, we learn memory habits. We brush our teeth morning and night. We take vitamins or other supplements at breakfast (I do, especially curcumin—see Chapter 7). When the dentist notes your chronic incapacity to floss, you might create a new memory habit by placing the floss next to the toothpaste. I’ve noticed that if I ask my wife to drop my shirts at the cleaners, she scowls, then routinely puts them in the front passenger seat of her car. This is her memory habit to remind herself to get to the cleaners. Daily pill box organizers, alarm clocks, watches, and other tools are available to augment memory habits.

• Plan a daily routine. We all do better with a certain amount of structure in our lives. Many of us have had the experience of waking up in a hotel room and momentarily experiencing confusion about where we are. It usually takes a few seconds to recall that we’re not at home but in a hotel. If a person has Alzheimer’s disease or another serious memory problem, changing their daily activities randomly can make them more confused. If we build a general routine into our daily schedule, we will have more time to focus on work, leisure, and others things we want to learn.

• Don’t overdo it with memory aids. Too many lists, sticky notes all over your dashboard, and a date book so jam-packed that you can’t make out who you are lunching with won’t necessarily be useful or effective. Taking random, copious notes that are never read tend to be a waste of energy. On the other hand, succinct lists, notes, and reminders can be extremely helpful memory tools, and I sometimes keep mine for years. Picking and choosing the memory tool can be as important as picking and choosing the information you wish to remember.

An Innovative Strategy for Keeping Your Brain Young: Review and Organize

Jot down the ten chapters of The Memory Bible and post them prominently (see box).

An Innovative Strategy for Keeping Your Brain Young

Chapter 1: You Have More Control Than You Think

Chapter 2: Rate Your Current Memory

Chapter 3: LOOK, SNAP, CONNECT: The Three Basic Memory Training Skills

Chapter 4: Minimize Stress

Chapter 5: Get Fit with Mental Aerobics

Chapter 6: Build Your Memory Skills Beyond the Basics

Chapter 7: Start Your Healthy Brain Diet Now

Chapter 8: Choose a Lifestyle That Protects Your Brain

Chapter 9: Wise Up About Medicines

Chapter 10: Don’t Forget the First Nine Chapters

Staving off brain aging requires consistency and long-term commitment, but no one single memory program meets everyone’s needs. Each of us has areas of strength and weakness from the outset. If you’re already an athlete or jog four days a week, but you can’t seem to break your penchant for cheeseburgers, French fries, and beer, then you should focus more attention on adopting a healthy brain diet rather than a brand-new physical fitness program. If you have a stressful job, family life, or both, then minimizing stress and anxiety may take precedence over designing your optimum mental aerobics program. You’re probably getting plenty of mental aerobics just keeping up with your job. Many people are able to work on several different strategies in their memory improvement program if they can organize the individual tasks in a way that fits into their daily routine.

Our research team has carried out several studies that show the benefits of pursuing more than one healthy lifestyle strategy to protect your brain health, and the evidence suggests that when it comes to healthy behaviors and habits, the more the merrier. We found that a short-term healthy lifestyle program that combined mental and physical exercise, stress reduction, and healthy diet led to significant cognitive benefits and more efficient brain function as measured by PET scans. A later study demonstrated the significant memory benefits of a similar six-week healthy lifestyle program on both objectively measured memory abilities and self-perception of memory.

In collaboration with Gallup, our research group obtained systematic data on survey respondents throughout the US. We looked at memory problems and healthy behaviors in a representative sample of 18,552 Americans ranging in age from 18 to 99 years. Reports of memory problems were related to self-reports of smoking, unhealthy eating, and lack of exercise, and the findings pointed to an additive effect of these various behaviors. For example, people who did not smoke had fewer memory problems than those who did, whereas those who didn’t smoke and consumed fruits and vegetables had even fewer memory complaints. Add some regular exercise to the mix, and memory reports were even better.

The scientific evidence clearly supports the idea that several potentially modifiable factors—diabetes, midlife hypertension, midlife obesity, smoking, depression, cognitive inactivity or low educational attainment, and physical inactivity—contribute to risk for Alzheimer’s disease. Drs. Deborah Barnes and Kristine Yaffe at the University of California, San Francisco, have projected the effect of reducing such risk factors on prevalence of Alzheimer’s disease. Their conclusion: up to half of Alzheimer’s cases are potentially attributable to modifiable risk factors—behaviors under our own control.

To help you tailor your memory improvement program to your particular needs, the following is a brief summary of the first nine chapters. As you review them, check off key points in the shaded boxes where you feel you may want to focus extra attention, be it mental aerobics, memory training, diet, or physical exercise.

Chapter 1: You Have More Control Than You Think

We have all come to expect and accept occasionally forgetting our keys or people’s names, but new and compelling evidence shows that early age-related forgetfulness is actually the brain’s first warning sign of its gradual decline. Scientific discoveries show not only that we can begin to detect subtle early evidence of brain aging but that we can do something about it. By combining brain scans with discovered genetic markers, we can pinpoint the earliest indications of impending brain aging. We also now know that our brains have the power to fight back with an easy yet comprehensive program of memory training and brain fitness. If we accept that brain aging is a lifelong process, then why not embrace a memory fitness program to keep our brains healthy as a lifelong commitment? It’s never too late or too early to protect our brain cells and delay memory decline.

Chapter 2: Rate Your Current Memory

To begin a memory-training program and set reasonable goals, we need to rate our current subjective and objective memory abilities. Remember that subjective memory is our own perception of how well we think we do in memory functions, whereas objective memory is how well we actually perform on a pencil-and-paper memory test.

Go back to the subjective memory assessment in Chapter 2 and complete the questionnaire, using a different-colored pencil. Compare your current score with your earlier one (fill in chart in Figure 2.1), and you may be pleasantly surprised at the progress you’ve made already.

Afterward, reassess your objective memory by studying and recalling the new list of words in Assessment No. 3. Check your watch or timer before starting.

ASSESSMENT NO. 3 STUDY THE FOLLOWING WORDS FOR UP TO ONE MINUTE:

Arrow

Pepper

Elephant

Stain

Toast

Instructor

Cigar

Grandmother

Hammer

Swamp

Now, put aside The Memory Bible and reset your timer for a twenty-minute break. Do something else—water the plants, check your email, whatever you like. After twenty minutes, write down as many of the words as you can recall. Compare your score with your earlier ones recorded in the chart in Figure 2.1.

As you continue with your memory program beyond the reading of this book, you can refer back to these ratings and follow your improvement. If you stick with your program over time, you should continue to see results. At the very least, you should be able to maintain your earlier achievements and keep one step ahead of brain aging.

Chapter 3: LOOK, SNAP, CONNECT: The Three Basic Memory Training Skills

My approach to memory training comes down to three basic skills—LOOK, SNAP, CONNECT. That’s it. LOOK, SNAP, CONNECT. If you learn these three basic skills, then I probably won’t be seeing you at my memory clinic any time soon.

LOOK—Actively Observe What You Want to Learn. Slow down, take notice, and focus on what you want to remember. Consciously absorb details and meaning from a new face, event, or conversation.

SNAP—Create Mental Snapshots of Memories. Create a mental snapshot of the visual information you wish to remember. Add details to give the snaps personal meaning and make them easier to learn and recall later.

CONNECT—Link Your Mental Snapshots Together. Associate the images to be remembered in a chain, starting with the first image, which is associated with the second, the second with the third, and so forth. Be sure the first image helps you recall the reason for remembering the chain.

Chapter 4: Minimize Stress

Managing and reducing the chronic stress so many of us experience in our busy, frenetic lives is likely to slow brain aging and improve our physical health. Relaxation exercises and avoiding unnecessary outside stressors can lead to diminished anxiety and better recall.

Mastering internally driven stress may involve altering the way we behave, the way we think, or the lifestyle choices we make (Chapter 8). Chapter 4 describes several ways to minimize daily stress and anxiety:

Cut back on caffeine.

Exercise regularly.

Prepare ahead to avoid stress.

Learn how to relax and do it at regular intervals.

Get enough sleep.

Pace your day.

Balance work and leisure.

Set realistic expectations.

Talk about feelings.

Let yourself laugh.

Get treatment for anxiety and depression if necessary.

Chapter 5: Get Fit with Mental Aerobics

Research points to mental stimulation and brain training as a way to keep our brains young and healthy. Practicing mental aerobics using a cross-training approach, which varies our brain-training routine day by day, minimizes boredom and maximizes results.

It’s important to start your mental aerobic exercises at the correct level of difficulty for you. Mental stimulation exercises should be challenging and enjoyable to achieve their best effect.

Some people are naturally more inclined toward right-brain skills (e.g., spatial relationships, artistic and musical abilities, face recognition, depth perception) and may need extra work on their left-brain skills (e.g., logical analysis, language, reading, mathematics, symbol recognition). By contrast, others have the opposite balance of abilities.

Use your score on the subjective and objective memory assessments (Figure 2.1) as a guide to determine where best to begin to focus your mental aerobics program:

Beginning exercises (low memory performance scores)

Intermediate exercises (middle memory performance scores)

Advanced exercises (high memory performance scores)

Left-brain exercises

Right-brain exercises

You can find additional mental aerobics exercises through the internet or in your local bookstore.

Chapter 6: Build Your Memory Skills Beyond the Basics

Although LOOK, SNAP, CONNECT provides quick memory-improvement results, many of us would like to take these skills further. Review some of the more advanced memory-training skills below that you would like to practice and use:

Organization. Look for systematic patterns and groupings to facilitate learning and recall.

Peg Method for Remembering Numerical Sequences. Commit to memory a specific visual “peg” for each of the ten digits and then use the link method to create a story to remember any numerical sequence.

Remembering Names and Faces. Make sure you consciously listen and observe the name (LOOK), then SNAP and CONNECT to fix the name to the face.

Roman Room Method. Pick a familiar room or route and in your mind place the items to remember at key points or landmarks.

Chapter 7: Start Your Healthy Brain Diet Now

The sooner we start our healthy brain diet, the sooner we will reap the benefits. Note each of the dietary adjustments below that you would like to make:

Drink at least six glasses of water a day.

Plan your meals in advance, try to keep your portions low, and eat healthy between-meal snacks.

Brush your teeth a few hours before bedtime as a reminder to avoid evening snacking.

Get unhealthy stress foods out of your house, car, and office. Try replacing with snack bags of fresh cut vegetables when you need to munch.

If you catch yourself in a stress-eating mode, hit your pause button. Take only one bite of that cookie, candy bar, or crème brûlée, and take a deep breath. Try stretching for a few minutes.

Eat a low-fat diet that includes plenty of fruits and vegetables.

Avoid processed foods and high-glycemic-index carbs.

Eat foods rich in omega-3 fats and avoid omega-6 fats.

Avoid too much caffeine.

Take a multivitamin, vitamin E, vitamin C, and folic acid supplements.

Chapter 8: Choose a Lifestyle That Protects Your Brain

Whether we age successfully stems largely from our daily lifestyle choices and the environment in which we live them. In fact, lifestyle and environmental factors outweigh genetic factors by a 2:1 ratio. Most of us know it’s best to avoid smoking, sleep deprivation, and head trauma to maintain physical and mental health, but many of us don’t realize how many other daily lifestyle choices have long-lasting effects. Note any of the following lifestyle choices that you would like to incorporate, and start your own list of positive lifestyle changes you can make to begin protecting yourself from Alzheimer’s disease.

Start an exercise program to maintain aerobic fitness and flexibility.

Get the aerobic and social benefits of walking with friends several times a week.

Choose sports and physical activities with low risk for head trauma and always wear a helmet when riding a bike.

Don’t drink and drive and always wear your seat belt.

If you smoke, quit. Ask your doctor if you need help.

If you drink alcohol, do it in moderation.

Get out and stay involved in activities that have personal meaning. Spend time with friends and family.

Get plenty of sleep.

Chapter 9: Wise Up About Medicines

As new scientific technologies and pharmaceutical discoveries continue to emerge in the next decade, we can expect even more profound breakthroughs in our fight against brain aging and Alzheimer’s disease. However, right now, we have drugs available for memory, depression, and physical illness that have an important impact on memory performance and brain aging. To use these medicines wisely, it is important to keep in mind the following:

Learn how your doctor organizes information about your health so you can become more proactive in your medical care.

Physical illnesses can threaten brain fitness. Take them seriously—see your doctor sooner rather than later.

Avoid using too many medicines if you can. Ask your doctor about any medicine you feel is influencing your memory ability.

Remain cautious about taking herbal supplements.

Hold off on trying new or innovative treatments until conclusive clinical trial results are in.

Treating a true depression with the right antidepressant drug often improves memory impairment.

Chapter 10: Don’t Forget the First Nine Chapters

Keeping our brains young and protected against Alzheimer’s disease involves attention to nearly all the areas of our lives. As a practicing psychiatrist, I know firsthand how difficult it is for people to change their habits. As a father, husband, and son, I also know of the challenges of helping others we care about make positive changes, as well as making changes for ourselves. By reading this book you have begun your commitment to protect your brain, but your personal motivation will be the driving force behind your memory program for keeping your brain young.

To give you an idea of how to put a memory program together, here is an example of one person’s initial schedule.

How It’s Done: Putting The Memory Bible to Work

A senior executive in a manufacturing company had the flexibility in his schedule to keep up with several aspects of a brain fitness program, including memory training, mental aerobics, and physical exercise. He also worked hard during his first week to cut back his coffee consumption, although he did need to take Tylenol for several days to help with his caffeine-withdrawal headaches.

Because he felt he got enough mental aerobics on the job and through his daily reading, he used his time to work on memory-training techniques rather than specific mental aerobics exercises. For him, minimizing stress and anxiety was a greater challenge. Here’s how his memory program shaped up the first few days.

Sample Memory Program

Day 1

CHAPTER | ACTIVITY
3-Memory training | Active observation memory-training exercises (10 minutes)
4-Minimize stress | 10-minute yoga session at bedtime 20-minute afternoon work break
5-Mental aerobics | Read New York Times, did crossword at breakfast
7-Diet | Multivitamin (containing 400 micrograms folic acid), curcumin (90 milligrams twice a day)
| 6 glasses of water
| Breakfast—multigrain toast, Cheddar cheese slice, egg white, 1 cup of coffee
| Lunch—salad with low-cal dressing, ham, 1 cup of coffee
| Dinner—salmon, steamed broccoli, nonfat yogurt dessert
| Snacks—string cheese and blueberries
8-Physical exercise | Stairs 3 times at work
| Walked dog briskly after dinner—6 blocks
9-Medicine | Antihypertensive, antidepressant

Day 2

CHAPTER | ACTIVITY
3-Memory training | Mental snapshot memory-training exercises (10 minutes)
4-Minimize stress | 10-minute meditation session during lunch break
| Early to bed (9:30 PM)
5-Mental aerobics | Read New York Times, did crossword puzzle
7-Diet | Multivitamin, curcumin (90 milligrams twice a day)
| 7 glasses of water
| Breakfast—multigrain toast, Cheddar cheese slice, egg white, 1 cup of coffee
| Lunch—Nonfat yogurt, banana, tuna, orange, 1 cup of coffee
| Dinner—skinless chicken, rice, steamed vegetables, 1 glass of red wine, apple pie
| Snacks—cut vegetables, cottage cheese, 1/2 cup of coffee
8-Physical exercise | Stairs 2 times at work
| Paddle tennis at the sports club
9-Medicine | Antihypertensive, antidepressant, Tylenol (2)

Day 3

CHAPTER | ACTIVITY
3-Memory training | Association and linking memory-training exercises (10 minutes)
4-Minimize stress | 10 minutes meditating after discussing complicated personnel issue with coworkers
5-Mental aerobics | Math puzzle book, played word game with daughter
7-Diet | Multivitamin, curcumin (90 milligrams twice a day)
| 7 glasses of water
| Breakfast—Bran cereal, nonfat milk, grapefruit, 1 cup of coffee
| Lunch—Tuna sandwich, tea, strawberries
| Dinner—skirt steak, potato, steamed vegetables, 1 glass of red wine, nonfat yogurt
| Snacks—blueberries, string cheese, 1/2 cup of coffee
8-Physical exercise | Stairs 4 times at work
9-Medicine | Antihypertensive, antidepressant, Tylenol (4)

Starting Your Memory Boosting Program

As in the previous example, you may wish to follow a few, several, or all of the strategies at the outset of your memory program. You may want to incorporate the items you checked off in the shaded areas above in designing it. Some people may simply want to begin with a to-do list of tasks, such as:

• Get junk food out of the house.

• Buy small water bottles and distribute throughout house, car, office.

• Purchase sticky notes.

• Start using a to-do list on smartphone’s Notes app.

• Focus on left-brain mental aerobic exercises, such as word jumbles and crosswords.

The key is to be organized in adjusting your memory program to complement your schedule. Some of the organizational strategies described at the beginning of this chapter, such as planning lists and weekly calendars, can be particularly helpful.

On the following pages, you’ll find examples of how different people organize their memory programs. The person who contributed the worksheet was detailing his progress in both mental aerobics and stress reduction. The other individual used his computer’s daily calendar to record both positive achievements as well as areas where he had slipped during the day. You can create your own worksheet or calendar records, possibly emphasizing areas where you feel you need extra focus. For example, you might keep track of your daily fat intake, hours of sleep, and enjoyable activities you engage in each week outside the house.

Keep Your Brain Young for Life

You have read The Memory Bible and now have many tools to help keep your brain young, and protect it against future memory decline; as well as to delay, or possibly even ward off Alzheimer’s disease for your lifetime. The Appendixes that follow include research on detecting and treating brain aging and Alzheimer’s disease, as well as useful information for family members and caregivers of those with dementia or Alzheimer’s, including new and available medications and nonmedical strategies.

Because there are so many new potential treatments, including drugs, hormones, herbs, and even surgical treatments, I have included, in Appendix 3, a description of the more popular ones to help readers sift through what has been shown to be effective and what has not. The Appendixes also provide a glossary of terms and additional resources to help you build and continue building your program for the rest of your life. Good luck!

Appendix 1

The Amyloid/Tau Probe—Keeping Watch on Plaques and Tangles

When The Memory Bible was first released, our UCLA research group discovered an innovative method to view the Alzheimer’s amyloid plaques and tangles directly as they accrue in the brains of living people—thus avoiding the unnecessary delay, trauma, and, of course, death that is required by the conventional method of viewing these brain lesions only at autopsy. This new discovery not only provided investigators a way to monitor new drugs for treating and preventing Alzheimer’s disease, but it could help us detect the disease earlier and get a jump on thwarting it altogether.

After combining APOE genetic and PET scan information to better detect and treat Alzheimer’s disease and those people at risk for developing it, I brought together a few UCLA colleagues from diverse scientific backgrounds, in an effort to find an even more specific approach to imaging the Alzheimer’s brain—a method of visualizing plaques and tangles.

Our small group made quick progress. Within a few meetings, Dr. Greg Cole, a neuroscientist with extensive experience in Alzheimer’s disease, made clear that the internal environments of plaques and tangles were hydrophobic, that is, more friendly to fat than to water. Dr. Jorge Barrio, a renowned chemist, had synthesized a group of novel compounds that thrived in these hydrophobic environments, and these molecules passed easily from the bloodstream to brain tissues.

We began our initial studies by using these new compounds on autopsied Alzheimer’s brain tissues. These experiments were successful in clearly displaying the well-defined amyloid plaques and tangles characteristic of the disease. We then moved on to injecting the compounds into living Alzheimer’s patients, followed by PET scans. This allowed us to see, or probe, for the first time, increased signals coming from living human brains in areas that contained dense collections of plaques and tangles. Seeing the lesions with this new amyloid/tau probe gave scientists the ability to monitor plaque and tangle concentrations while testing experimental treatments to eliminate them.

The amyloid/tau probe essentially seeks out and temporarily attaches itself to the plaques and tangles, thus providing a clear PET scan signal in the areas of the brain where Alzheimer’s strikes first, the hippocampus and temporal cortex. In healthy people without Alzheimer’s, these regions produce little or no signal. However, in people with the disease the signal is so strong and accurate that it actually correlates with each individual’s degree of memory impairment.

Figure A.1 shows two different scans of a patient who suffers from Alzheimer’s disease. The image on the left is an amyloid/tau PET scan, while the image on the right is a conventional PET scan. Note that the temporal areas (arrows) are darker in the amyloid/tau scan, indicating an increased signal—this is where the plaques and tangles accumulate. The conventional PET scan, which measures the functional ability of brain cells, indicates low activity in these same areas (lighter gray area).

Our group has continued working with other researchers to use this amyloid/tau probe technology to study medications being developed to wipe out plaques and tangles (Chapter 9). Since the first publication of The Memory Bible, we have continued to study this technology and have shown that it can detect the subtle presence of Alzheimer’s disease in people with only mild cognitive impairment, and predict those who will progress to dementia and those who will not after two years. We have also demonstrated that the technology shows different patterns of amyloid and tau binding in patients with various forms of neurodegeneration, including those who have suspected chronic traumatic encephalopathy due to head trauma from contact sports or military blast injuries.

Figure A.1

Other research groups have developed PET probes that are specific to either amyloid plaques or tau tangles, and these technologies are being used to study drugs that clear one or the other of these abnormal proteins that accumulate in the brains of patients with Alzheimer’s disease. International enthusiasm for this kind of technology has been high since it promises to streamline drug discovery, particularly for treatments designed to slow and possibly eliminate age-related cognitive disorders and Alzheimer’s disease.

Appendix 2

What to Do If Alzheimer’s Disease Strikes

The Memory Bible will hopefully provide you an edge in the brain-aging game by introducing you to a mental and physical aerobics program, stress reduction techniques, and many other tools for maintaining brain fitness. If you bring the motivation, you can proactively stave off the advance of Alzheimer’s as effectively and as long as possible.

However, in some cases the genetic risk is high or a person already has several existing risks, such as head injury, high cholesterol, or hypertension, and brain aging may have progressed to the point where it is interfering with daily life. Anyone in this situation should seek professional help.

Age is the single greatest-known risk factor for getting Alzheimer’s disease. Approximately 5 percent of people age 65 years or older have the disease, but by age 85 that figure soars to almost 50 percent. Advanced brain aging and Alzheimer’s disease afflict nearly six million people in the US and nearly twenty-five million people worldwide. Despite such a high prevalence, Alzheimer’s disease and other dementias remain underrecognized. Timely recognition is important because treatment is available. Both medication and nonmedicinal interventions can slow the progression of the disease and improve functioning in most patients.

ALZHEIMER’S DISEASE: IT’S A FAMILY AFFAIR

The devastation of Alzheimer’s disease doesn’t stop with the patients, it spreads to their families and friends. Watching a loved one decline before your eyes, seeing the personality of someone you cherish gradually disappear, is a traumatic and confusing experience, often leading to anger, sadness, guilt, and depression in the family member and caregiver, as well as the patient. The physical characteristics of a person with Alzheimer’s disease remain, but who they are eventually vanishes. I have had family members express relief when the patient finally dies, since they have been mourning the loss of that person little by little for years. Research has shown that more than 50 percent of caregivers develop depressions serious enough to require medical intervention. Caregivers miss days at work, have a high risk of becoming physically ill, and often lose sleep, especially when the patient’s disease becomes more advanced and is accompanied by agitation and restlessness at night.

A diagnosis of dementia is a staggering consequence for patients and their families, many of whom may have a major economic burden to consider as well as this emotional blow. As baby boomers and gen Xers age over the next few decades, the number of older persons will rise steeply, as too will the cases of Alzheimer’s disease. Sadly, by the year 2050 an estimated fourteen million Americans will suffer from full-blown Alzheimer’s disease. I predict those numbers could be much lower if more people followed at least some of the strategies in The Memory Bible.

Alzheimer’s disease is the third costliest disease in the US, after cardiovascular disease and cancer. Annual costs exceed $100 billion, and most of that is not covered by medical insurance, leaving the families of Alzheimer’s patients to bear the greatest economic burden. Earlier intervention in mild to moderate cases can enhance the daily functioning of patients and improve their quality of life. Clearly, keeping our brains young and avoiding symptoms of Alzheimer’s disease should be the ultimate goal for all of us.

THE GRADUAL MARCH OF SYMPTOMS

Dementia is the general term doctors use to describe loss of memory and other cognitive functions when they impair daily life. With Alzheimer’s disease, the course is gradually progressive, memory loss is usually the first symptom to appear, and motor and sensory functions are spared until late stages of the disease. Early on, patients have difficulty learning new information and retaining it for more than a few minutes. As the disease advances, the ability to learn is increasingly compromised, and patients have trouble accessing older, more distant memories. Patients develop problems finding words, using familiar tools and objects, and remaining oriented to time and place.

Eventually, all aspects of their lives become impaired: patients are unable to plan meals, manage finances or medications, use a telephone, and drive without getting lost, and these kinds of difficulties may be the patient’s or family’s first sign that something is amiss. Social skills usually remain until late in the disease, which contributes, of course, to the delay in recognition of the disease. As the dementia progresses, judgment becomes impaired, and patients have trouble carrying out even the most basic functions, such as dressing, grooming, and bathing.

Sometimes families have to cope with personality changes, irritability, anxiety, or depression early in the disease, and as the patient worsens, these changes in mood and behavior become more common. Patients lose touch with reality and may become psychotic. They can experience delusions, hallucinations, and aggression, and often wander and get lost. These kinds of behaviors are the most troubling to caregivers, usually distress family members, and lead to nursing home placement.

Alzheimer’s disease accounts for approximately 65 percent of dementia cases, whereas an estimated 15 percent have a condition of motor stiffness and rigidity similar to that found in Parkinson’s disease. This combined dementia/Parkinson’s syndrome has been termed “dementia associated with Lewy bodies,” named for the small round abnormal accumulations found in the patients’ brains. Patients with Lewy body dementia often have visual hallucinations and altered alertness. Still another form of dementia strikes primarily the front of the brain and the areas under the temples, so it is known as frontotemporal dementia. These patients often show marked changes in personality, have particular difficulty in executive skills and planning complex tasks, yet their visual and spatial memory tends to be preserved. The cumulative effect of multiple small strokes in the brain causes vascular dementia. Approximately 20 percent of patients with Alzheimer’s disease also have vascular disease in the brain.

Many physical illnesses can cause dementia, including infections, cancers that spread to the brain, thyroid disease, or hypoglycemia. Chronic alcohol or drug abuse, as well as a variety of medicines, ranging from antidepressants to antihypertensives, over-the-counter drugs, sleeping pills, and antihistamines, can also cause symptoms of dementia (Chapter 9).

MEDICAL SCREENING: HOW THE DOCTOR CHECKS YOU OUT

When those middle-aged pauses are no longer a joke and become a serious matter, that is when Alzheimer’s disease can be diagnosed and hopefully recognized early. Too often, physicians and family members accept memory loss, symptoms of depression, and other important diagnostic clues as normal consequences of aging. In the early stages of dementia, I have heard about patients getting into a variety of complications: deeding their house away, being influenced about their will, losing track of substantial sums of money, or marrying a gold-digger.

A physician’s evaluation of memory loss usually involves an interview, physical examination, and laboratory assessment. In evaluating the patient’s mental state, the doctor will screen for depression, memory loss, and other cognitive skills. Laboratory assessments should at least include some blood tests to screen out thyroid disease, vitamin B_12 deficiency, and other disorders, which could possibly cause memory change.

Doctors often obtain a standardized score of cognitive ability using rating scales, such as the Mini–Mental State Examination, which consists of thirty items that rate memory, orientation, attention, calculation, language, and visual skills. The test takes only about ten minutes, but is limited because it will not detect subtle memory losses, particularly in college graduates. A similar but more sensitive assessment tool that is frequently used is called the Montreal Cognitive Assessment (MoCA). This assessment has slightly more challenging questions, so it is more likely to detect cognitive problems in people with greater educational achievements. More detailed memory assessments, known as neuropsychological tests, will provide a better idea about subtle memory deficits.

What’s really important to families is how the patient is getting along at home. Dr. Ken Rockwood and his colleagues at Dalhousie University in Nova Scotia have developed a way to measure the patient’s response to treatment in terms of how family members and caregivers assess them, focusing on those daily activities they find most important. The doctors created an individualized scale for each patient based upon the family’s own descriptions. They ask what drives family members crazy about a patient, then create an outcome measure based on those reports. For example, if Susie T. complained that it drove her crazy when her father asked the same question twenty times a day, Dr. Rockwood might set the six-month treatment goal for Susie’s father to asking the same question only five times each day.

BRAIN SCANS FOR EVALUATION OF DEMENTIA

Some experts recommend computed tomography (CT) or magnetic resonance imaging (MRI), which provide information on the brain’s structure. These kinds of scans will detect strokes, brain tumors, or cerebral hemorrhages, which occasionally cause symptoms resembling dementia. Unfortunately, in most cases, MRI and CT provide only nonspecific information about brain shrinkage or atrophy or white-matter changes, which show up as spots in the deeper brain areas. These changes are often difficult to interpret and rarely provide a diagnosis that will alter treatment.

By contrast, the positron emission tomography (PET) scan (Chapter 1) can detect brain cell dysfunction and identify patients early in the course of the disease, even before they have obvious symptoms of dementia. Medicare will reimburse for the cost of the scan if it is used to differentiate Alzheimer’s disease from frontotemporal dementia. PET scans enable a physician to make a positive diagnosis of Alzheimer’s disease and of other types of dementia, facilitating the initiation of antidementia drugs, which can improve symptoms and slow the progression of disease while a patient still retains a high level of cognitive function. Early detection also gives patients and their families more time to plan for the future.

Positron emission tomography can identify the Alzheimer’s brain pattern months, even years before obvious symptoms of the disease appear in patients. Dr. Daniel Silverman and others in our UCLA research group conducted an international study of nearly three hundred patients, focusing on the use of PET in the evaluation of dementia. We found that PET scanning is extremely sensitive to early changes in the brain and extraordinarily accurate in predicting the future course of dementia. It demonstrated nearly 95 percent accuracy in predicting the patient’s clinical course over three years.

The images in Figure A.2 show two-dimensional brain slices with the front of the brain toward the top and the back of the brain toward the bottom. The arrows point to lighter gray areas of decreased brain function.

Figure A.2

The scans reveal a consistent pattern in Alzheimer’s disease. Those parietal (see arrows in early Alzheimer’s) and temporal areas—where Alzheimer’s first strikes—show reduced activity in the early stage of the disease. At the late stage—when patients have extreme trouble talking and interacting with others—the frontal areas show decreases. The dark areas midway between the front and back (of the advanced Alzheimer’s brain) control sensation and physical movement and are still at work late in Alzheimer’s disease, so these patients are able to experience sensation and control muscle movement. It is remarkable to note that the PET scan of a late-stage Alzheimer’s patient looks very similar to that of a newborn.

SLOWING DECLINE WITH EARLY TREATMENT

The available cholinergic drugs not only improve memory and other cognitive functions but also benefit overall patient function and help manage some of the behavioral disturbances associated with dementia. Studies show that cholinergic drugs appear to have their greatest therapeutic effect in patients with mild to moderate disease, so early diagnosis is critical in order to help patients maintain the highest level of functioning they have left.

Dr. Murray Raskind, University of Washington, and his collaborators from other US institutions studied what happens when drug treatment is delayed in Alzheimer’s patients. They treated half of their volunteers with the cholinesterase inhibitor galantamine (Reminyl), and the other half took a sugar pill placebo. Six months later, the researchers began giving all the patients the active drug. The group of patients who had been on placebo showed rapid improvement, but they never tested as well as the patients with a six-month jump-start on the medication. In fact, the added benefit for the early starters appeared to continue for the entire year of follow-up, as illustrated in Figure A.3.

Figure A.3

Cholinergic drugs enhance the body’s level of acetylcholine, the chemical neurotransmitter that facilitates passage of nerve impulses across synapses. The brains of Alzheimer’s patients have a deficiency of acetylcholine, which can result from either impaired production or excess breakdown by enzymes called cholinesterases, and our currently approved treatments inhibit these enzymes, so they are called cholinesterase inhibitors. Tacrine (Cognex) was the first of these medicines to be approved, but it is now rarely used due to the extent of its side effects. The newer compounds have fewer side effects and include donepezil (Aricept, approved by the FDA in November 1996), rivastigmine (Exelon, approved in April 2000), and galantamine (Razadyne, approved May 2001). These drugs not only improve memory and thinking, but they can also reduce agitation and depression. Investigators have studied their effects on different forms of dementia. Razadyne has been shown to be effective in patients with vascular dementia and Exelon in patients with Lewy body dementia.

Although the majority of patients tolerate these drugs perfectly well, some have reported mild side effects including loss of appetite, indigestion, nausea, slowed heart rate, and insomnia. Most doctors increase the medications gradually in order to minimize side effects, which can occur when the medication is initially begun or the dosage increased. Side effects usually subside with time.

When beginning cholinergic drug treatment, most patients show improvement, but after months or even a year, they eventually plateau and begin to gradually decline. The big mistake is to assume the drug is no longer working and discontinue treatment once the patient starts this gradual but inevitable decline. But not so fast—the patient does have Alzheimer’s disease, remember? The drug is meant to treat symptoms and slow further decline. It is not a cure. Imagine this patient’s decline over a twelve-month period without the drug. It would have been much more rapid. So, if the patient is tolerating the medicine, stick with it. I advise patients to stay on their medication as long as they are tolerating it, since the overwhelming evidence shows that cholinesterase inhibitors can slow the rate of cognitive and functional decline even if patients don’t experience obvious initial improvement on the drug.

Alzheimer’s patients who take cholinergic drugs need fewer medications for treating depression and behavior problems. They also remain at home and out of nursing homes longer than patients who do not take these medicines.

Another medication that is used to support cognitive function and memory in combination with a cholinesterase inhibitor is memantine (Namenda, approved in 2003). Namenda is indicated for the treatment of moderate to severe dementia related to Alzheimer’s disease. This medicine blocks the action of a chemical neurotransmitter called glutamate, which is linked to symptoms of the disease. Dr. Pierre Tariot, now of the University of Arizona, and his colleagues found that patients with moderate to severe Alzheimer’s disease who were already taking donepezil experienced even better cognition, daily functioning, and behavior when memantine was added to their donepezil. The additional benefit has also been observed when Namenda is added to any of the other cholinesterase inhibitors.

TO “E” OR NOT TO “E”—THAT IS THE QUESTION

Back in the 1990s and up until 2005, your doctor might have recommended that you take the antioxidant vitamin E to do your part to help your body fight those pesky free radicals that wear and tear down your body’s DNA. The conventional wisdom was that once Alzheimer’s attacks the brain, vitamin E was as important as ever.

Recognizing the potential antioxidant benefits of vitamin E, Dr. Mary Sano, Columbia University, and her associates found that Alzheimer’s patients showed less rapid functional decline if they took 1,000 international units (IUs) of vitamin E twice daily when compared to patients on placebo. Functional decline was defined as amount of time—days, weeks, months—before the patient needed nursing home care, as well as other practical indicators of daily function.

The scientists chose a very high dose of vitamin E to ensure that enough was present to have an effect. Because such high doses could occasionally suppress immune function and the patient’s ability to ward off some infections, not all physicians recommended such high doses, preferring 800 to 1,000 IUs per day for patients suffering from Alzheimer’s disease. But a large-scale 2005 study published in JAMA demonstrated that taking doses of vitamin E greater than 400 IUs each day was linked to a 13 percent higher risk of heart failure and a 21 percent increased risk of hospitalization for heart failure. As a result, enthusiasm for the use of high doses of the antioxidant has waned.

TREATING BEHAVIOR DISTURBANCES

Behavior changes in patients with advanced Alzheimer’s disease can literally drive family members and caregivers into depression and their own health problems. If you are caring for someone who constantly yells at you or strikes out or watches you suspiciously all day, it is hard not to react with anger, guilt, or sadness. Unfortunately, caregivers often take the patient’s behaviors personally and interpret them as willful rather than resulting from misfiring neurons. These kinds of behavioral changes are what usually lead to the placement of Alzheimer’s patients into nursing homes. Caregivers just can’t take it anymore.

Sometimes medications will improve symptoms, and nonmedicinal approaches can make a big difference. When counseling caregivers on dealing with some of these problems, I often remind them of how we deal with young children. Similar strategies are useful in both situations: simplify communications, distract them when they get frustrated, and maintain a calm but firm attitude.

Antipsychotic drugs have been used to treat psychotic symptoms and agitation in patients with dementia. For a while, newly developed antipsychotics were preferred, including risperidone (Risperdol), quetiapine (Seroquel), ziprasidone (Geodon), and olanzapine (Zyprexa). These newer drugs appeared to cause fewer side effects than such older antipsychotics as haloperidol (Haldol) or chlorpromazine (Thorazine).

The FDA, however, has not yet approved a medication for treating dementia-related psychosis, so such treatment is considered “off label.” In 2005, an FDA analysis concluded that using these medicines in older adults with dementia is associated with increased mortality. Other research demonstrated that the older antipsychotics can heighten mortality risk and cognitive impairment and cause other side effects, which makes it important to limit the use of these drugs in older patients with dementia. One antipsychotic medicine known as Nuplazid (pimavanserin) has been approved for treating psychotic symptoms in patients with Parkinson’s disease, and studies of Nuplazid in patients with dementia-related psychosis have been encouraging. The FDA is currently considering a proposal to approve the use of Nuplazid for the treatment of dementia-related psychosis.

For symptoms of anxiety and agitation, the antianxiety drugs are often used. Most physicians prefer the newer drugs, including alprazolam (Xanax), lorazepam (Ativan), and oxazepam (Serax) because such older drugs as diazepam (Valium) and chlordiazepoxide (Librium) tend to accumulate in the blood and cause side effects, such as daytime sedation, unsteady gait, and confusion. The newer drugs get in and out of the body more quickly and tend to cause fewer side effects.

Some medicines used to treat epilepsy, the anticonvulsants—particularly carbamazepine (Tegretol) and divalproex sodium (Depakote)—represent another group of drugs that show promise as effective treatments for behavioral problems in demented patients. Dr. Pierre Tariot performed several studies using these drugs in this patient population and reported that agitated and aggressive patients who have a manic appearance of rapid thinking and irritability are responsive to anticonvulsant medications. For demented patients who develop depression, antidepressants are often prescribed (Chapter 9).

MEETING THE CHALLENGES WHEN THINGS GET TOUGH

If you are a caregiver, you may want to consider joining a support group to help answer your questions, make you feel less alone, and diminish your level of stress. Feelings of anger, frustration, and guilt are a normal part of caring for a relative or friend or patient with dementia. Community resources can offer some respite care, giving relatives and friends a chance to care for themselves, go to the gym, join a support group, see friends, and other personal activities to recharge their batteries.

Dr. Mary Mittelman and her colleagues at New York University have studied how education and emotional support for caregivers of Alzheimer’s patients may delay the patient’s placement into nursing homes. They found that the caregivers’ education and support had a definite impact on their patients, delaying nursing home placement up to a year.

Establishing a daily routine for patients will improve their behavior and mood (see box, here). The predictability gives them a sense of security. Clocks and calendars help keep patients oriented. Consider setting up an exercise program that allows patients to move about freely for as long as possible. Newspapers, radios, and televisions are great ways for patients to try to stay up on current events and keep links to the outside world. Try to help them maintain social and intellectual activities and continue to attend family events whenever possible.

If behavior becomes troublesome, try to understand what provokes it. Some patients’ symptoms get worse toward the evening, when rooms tend to darken. Other times a particular family member, friend, caregiver, or situation brings on aggressive outbursts. When possible, modify a situation to avoid provocation. Unfortunately, many patients become agitated out of mere frustration, or conversations become too complex, or perhaps they forget the content of the discussion. Try to use simple sentence structure and give reassurance by gently reminding the patient of the content of the discussion. If caregivers can stay calm, patients often pick up on their composure, which can help them to calm down as well.

For patients who tend to wander, using night-lights and perhaps even raising doorknobs up high may help keep them safe. Regular supervised walks will promote exercise and may cut down on wandering. However, if a large yard is available so the patient has the space to walk about safely, medications or other forms of restraint can be reduced or avoided. Also contact the Alzheimer’s Association (www.alz.org) for information and to register with the Safe Return program, which provides patient name tags and medical-alert bracelets that can help to locate lost patients.

The cognitive impairments of Alzheimer’s disease diminish driving skills, and even mildly demented patients often should not be driving due to their difficulties with visual and spatial skills and their diminished capacity to plan ahead. Some states, such as California, require the physician to report patients with Alzheimer’s disease to better monitor their driving skills. A diagnosis of dementia should clearly raise concern about a person’s driving abilities, and patients with advanced dementia should not be driving at all.

The overall goal of caregiving is to maintain the kindest, least restrictive environment as possible, for as long as possible. For many families, this means keeping patients at home and out of long-term care facilities unless it becomes absolutely necessary.

What to Do If Alzheimer’s Disease Strikes

• Seek professional help in attaining an accurate diagnosis so appropriate treatment can begin sooner rather than later.

• Ask the doctor about medication treatments, including cholinergic drugs and vitamin E. Discuss other practical and legal issues with the doctor.

• Join a support group for family members and caregivers through the Alzheimer’s Association or local community groups where available.

• Expect that the patient’s behavior will change over time and may become difficult. Remember that these changes are not willful but are a result of a physical brain disease.

• Maintain the patient’s social and family activities as much as and as long as possible.

• Individualize sensory input to the patient’s needs.

• Try to understand the cause of a patient’s troublesome behavior and attempt to avoid it.

• Keep daily activities routine and surroundings familiar.

• Arrange a regular exercise schedule to promote fitness and minimize wandering. If necessary and possible, provide an environment where the patient can wander safely.

• Display clocks and calendars to help orient the patient.

• For the safety of the patient as well as everyone on the road, patients with moderate to severe dementia should not drive under any circumstances.

Appendix 3

Current and Potential Treatments for Memory Loss and Alzheimer’s Disease

A wide range of drugs, hormones, herbs, and even surgical treatments have been proposed and tested for Alzheimer’s disease and mild forms of age-related memory loss. For many of these treatments, the strongest evidence available for their effectiveness is based on testimonials, so they may not be any more effective than placebos. Thus, consumers need to proceed with caution when considering any new intervention. At best, they may be wasting their time and money. At worst, they may be exposing themselves to a risk of harmful side effects and drug interactions.

Although cholinesterase inhibitors and memantine (Namenda) are the only approved treatments for Alzheimer’s disease, some people take vitamins and supplements that have varying degrees of scientific evidence supporting their effectiveness. It is still important to keep an open mind about some of the alternative treatments—just because scientists have not yet proven them to be effective doesn’t mean that they don’t actually work.

Acetyl-L-carnitine. Acetyl-L-carnitine promotes the neurotransmitter acetylcholine and may protect brain neurons. Some human studies show a benefit over placebo for memory performance.

Ampakines. Drugs that increase the activity of brain chemicals important to memory formation. Ampakines have been tested in patients with Alzheimer’s disease and milder forms of cognitive impairment.

Antiamyloid vaccine. A synthetic form of amyloid-beta used to vaccinate mice that have been genetically engineered to form the Alzheimer’s plaques. Initial studies in humans caused toxicity that led to discontinuation of the clinical trials. Newer vaccines are in development to determine whether they can treat or prevent Alzheimer’s disease.

Cholinesterase inhibitors. Drugs approved by the FDA for the treatment of Alzheimer’s disease. These drugs inhibit the cholinesterase enzymes, which break down acetylcholine, resulting in an increase in acetylcholine and improved cognition in patients.

Cox II inhibitors. A group of anti-inflammatory drugs that inhibit only one of the enzymes (cyclooxygenase II) involved in inflammation. These drugs have fewer side effects than older cyclooxygenase inhibitors, which inhibit both cox I and cox II enzymes and are more likely to cause gastric bleeding. Our research group found that the anti-inflammatory celecoxib (Celebrex) showed cognitive benefits compared with placebo when middle-aged and older adults with normal aging or mild cognitive impairment took the drug for eighteen months. Because this was a relatively small study and the medicine has potentially dangerous side effects, we don’t recommend it as a memory enhancer.

Deep brain stimulation. A neurosurgical procedure that involves implanting electrodes to provide electrical stimulation to specific brain regions. It has been used to treat chronic pain, Parkinson’s disease, and other neuropsychiatric conditions. Preliminary studies suggest that it may benefit cognitive function.

DHEA (dehydroepiandrosterone). The body converts DHEA into estrogen and testosterone. DHEA supplements may strengthen the immune system and heighten sex drive and activity level. Side effects include an increased risk for prostate cancer, facial hair growth, scalp balding, and acne. Studies of its potential memory benefits are inconclusive.

Donepezil (Aricept). A cholinesterase inhibitor drug used to treat Alzheimer’s disease.

Estrogen. Although women who take estrogen for menopausal symptoms appear to have a lower risk for Alzheimer’s disease, a large-scale study showed that estrogen replacement therapy did not prevent cognitive decline in postmenopausal women aged 65 or older.

Fetal cell implants. A technology under development for growing new nerve cells in the brain. Results to date have not been successful.

Galantamine (Razadyne). A cholinesterase inhibitor drug used to treat Alzheimer’s disease.

Ginkgo biloba. A Chinese herb used to treat memory loss. Large-scale studies have failed to show that ginkgo is any better than placebo in delaying age-associated cognitive decline.

Ginseng. An herb that has been considered as a treatment for memory loss because of its potential to enhance mental arousal. No systematic study has substantiated memory benefits.

Hydergine. Derived from a rye fungus, hydergine acts on several neurotransmitters that influence memory. It has been used extensively as a cognitive enhancer throughout the world. Studies of patients with dementia or with age-associated cognitive symptoms have yielded mixed results.

Hyperbaric oxygen therapy. A procedure used to treat decompression sickness, a hazard of scuba diving. Recent research has demonstrated potential cognitive benefits in healthy older adults.

Insulin nasal spray. Scientists are testing insulin nasal spray because people who develop diabetes have a higher risk for Alzheimer’s disease and cognitive impairment.

Lecithin. A major component of all living cells, lecithin is broken down in the body to active cholinergic compounds that have minimal but inconsistent memory benefits. The average diet contains about a gram of lecithin, and tenfold greater amounts are used as supplements given in daily divided doses.

Low-intensity focused ultrasound. A device is placed directly on the scalp to stimulate the brain’s neural circuits controlling memory; functional MRI is used to localize the targeted brain regions. Animal studies have shown that the procedure improves memory; our research team and others have begun initial studies in humans.

Melatonin. The principal hormone secreted by the pineal gland, melatonin is a brain messenger with a structure similar to serotonin. The hormone regulates mood, sleep, sexual behavior, reproductive alterations, immunologic function, and the sleep-wake cycle. Its antioxidant activity has led investigators to consider it as a treatment against Alzheimer’s disease, but no systemic study has demonstrated its effectiveness.

Memantine (Namenda). A drug that acts on the NMDA (N-methyl-D-asparate) brain receptor and affects the neurotransmitter glutamate, which is involved in memory function. The number of these receptors decreases in Alzheimer’s disease, and studies have demonstrated memantine’s benefits in patients with moderate to severe dementia.

Monoclonal antibodies. A form of immunotherapy that involves intravenous infusion of antibodies directed against amyloid plaques. Studies in patients with Alzheimer’s dementia have failed, but current research is focusing on using this technology in volunteers at risk for dementia or with mild symptoms.

Nerve growth factor. A group of chemicals secreted by genetically engineered nerve cells, which stimulate neuron growth and boost the brain’s cholinergic neurotransmitter system. A limitation of human use is the difficulty of getting nerve growth factor into the brain.

Nicotine patches. Transdermal nicotine applied through skin patches has shown promise as a therapy for conditions ranging from age-associated memory impairment to Alzheimer’s disease. Preliminary studies indicate that nicotine may improve short-term memory and attention in patients with Alzheimer’s disease. No study has yet proven its long-term effectiveness.

Nimodipine. A drug that blocks cellular channels that transport the ion calcium, which can destroy brain cells. Nimodipine has been marketed as a cognition-enhancing agent in Europe and has been studied in the United States.

Nonsteroidal anti-inflammatory drugs (NSAIDs). Drugs that interfere with the body’s inflammatory process, generally used to treat minor injuries and arthritis. Examples include aspirin, ibuprofen (Motrin, Advil), naproxen (Aleve), and cox-II inhibitors (Celebrex). Some studies suggest that these medicines may benefit cognitive abilities in nondemented people, but they have multiple side effects when taken for long periods of time, so they are not recommended as preventive treatments

Nootropics. A class of drugs, including piracetam, oxiracetam, pramiracetam, and aniracetam, that enhances brain circulation. An antidementia effect has not been established, and controlled studies have yielded mixed results.

Omental transposition. A surgical procedure wherein a membrane that surrounds the stomach and other abdominal organs is dragged up to the head and attached to the brain’s surface. Its potential benefit is thought to result from stimulation of small blood vessel growth. Although anecdotal reports are encouraging, no systematic study has demonstrated its effectiveness in Alzheimer’s disease.

Phosphatidylserine. A nutrient present in fish, green leafy vegetables, soy products, and rice, which some experts recommend as a supplement for age-associated memory impairment. Results of placebo-controlled studies have been positive but long-term benefits are not known.

Physostigmine. A cholinesterase inhibitor drug with a very brief duration of action, such that the pills need to be taken every few hours for a memory effect. Although some studies demonstrate a mild benefit, it is not generally used, and long-term effects are not known.

Rivastigmine (Exelon). A cholinesterase inhibitor drug used to treat Alzheimer’s disease. The oral form of the drug causes nausea, diarrhea, and other gastrointestinal side effects, but a rivastigmine transdermal patch is well tolerated.

Secretase inhibitors. Drugs under development to counteract enzymes (secretases) that form the toxic amyloid-beta fragment.

Selective estrogen receptor modulators (SERMs). Synthetic estrogens designed to isolate beneficial hormone effects and eliminate side effects. Studies have not yet shown SERMs to benefit cognitive function.

Selegiline (Eldepryl). A drug that inhibits monoamine oxidase enzymes that destroy neurotransmitters and has an antioxidant effect. Although selegiline has been found to delay functional decline in patients with Alzheimer’s disease, it is not used because of its side-effect profile.

Tacrine (Cognex). The first cholinesterase inhibitor approved by the FDA. The drug is rarely used today because of liver side effects and frequent dosing schedule.

Testosterone. The hormone may improve memory performance in men, especially those with low testosterone blood levels.

Vitamin C. An antioxidant vitamin that may offer protection against age-related cognitive decline.

Vitamin D. Low blood levels of vitamin D are linked to a greater risk for cognitive decline, and many experts recommend supplementation as a preventive measure.

Vitamin E. An antioxidant vitamin that has been prescribed in high doses (1,000 to 2,000 units daily) for patients with Alzheimer’s disease. Earlier studies suggested that taking vitamin E supplements may slow age-related cognitive decline, but side effects associated with high doses led many experts to recommend only 400 units per day.

Glossary

Acetylcholine. A neurotransmitter involved in memory, learning, and concentration. The cholinergic neurons that produce brain acetylcholine decline in normal aging and in Alzheimer’s disease.

Active observation. The process of focusing attention so that new information is stored into memory.

Aerobic exercise. Exercise that gets hearts pumping faster and lungs breathing deeper so more oxygen is delivered to the body’s cells. Examples of aerobic exercise include calisthenics, rapid walking, jogging, and swimming. Research suggests that aerobic conditioning benefits brain function in the frontal lobe.

Age-associated memory impairment. The term for the common memory changes that accompany normal aging, defined as a memory decline demonstrated by at least one standard memory test, along with a subjective awareness of memory changes.

Age-related cognitive decline. A condition of noticeable decline in mental ability without the presence of disease.

Alzheimer’s disease. The most common form of dementia. Its onset is gradual and its course progressive. The physician can make a “probable” diagnosis, but a “definite” diagnosis is made only through autopsy or biopsy.

Amyloid-beta. A small molecule consisting of about forty amino acids strung together like a beaded necklace. Amyloid-beta is the building block of the insoluble protein that forms the core of Alzheimer’s plaques, thought to be toxic to the brain.

Amyloid plaques. Collections of decayed material resulting from brain cell death and degeneration, present in high concentrations in the areas involved in memory in the Alzheimer’s brain. The central area of a plaque contains insoluble collections of amyloid-beta protein.

Antioxidants. Drugs, vitamins, or foods that interfere with oxidative stress.

Apolipoprotein E (APOE). A gene on chromosome 19 that comes in three different forms (2, 3, and 4). One copy of the APOE-4 gene increases the risk for Alzheimer’s disease and lowers the average age when people first develop symptoms. Two copies have the same effect, but more so.

Catechin. A potent antioxidant found in green teas.

Cerebral cortex. A thick folded layer of nerve cells that covers the cerebrum. The cortex is divided into parietal, temporal, frontal, and occipital lobes, and its cells are involved in learning, recall, and language function.

Cerebrum. The main portion of the brain considered the seat of conscious mental processes.

Computerized tomography (CT) scan. A computer-enhanced X-ray that provides pictures of brain structure that can assist in the diagnosis of brain tumors, strokes, and blood clots.

Cognition (cognitive function). Mental function involving memory, language abilities, visual and spatial skills, intelligence, and reasoning.

Cognitive stress test. An experimental method to tease out subtle brain abnormalities. Volunteers perform memory tasks while a functional MRI scanner measures brain activity response to memory performance.

Coronary heart disease. Heart disease caused by buildup of plaque in the coronary blood vessels, which provide blood and nutrients to the heart muscles.

Cortisol. A stress hormone secreted by the adrenal glands. Chronically high levels of cortisol can impair memory performance.

Dementia. Impairment in memory and at least one other cognitive function (e.g., language, visual-spatial skill) to the extent that it interferes with daily life.

Dendrites. Short, branching extensions of neurons that receive impulses from other neurons when neurotransmitters stimulate them.

Endorphins. Hormones responsible for the mild euphoria we feel after aerobic exercise, often described as the body’s own internal circulating antidepressant.

Enzyme. A protein that controls chemical reactions in the body.

Ephedra. An herb used as a stimulant or appetite suppressant, which may cause rapid heart rate and anxiety when combined with other stimulants, such as coffee.

Epidemiological studies. Studies of large numbers of participants that count up rates of disease and factors that might influence disease risk.

Executive control. Cognitive abilities such as planning, scheduling, coordination, and actively inhibiting information, generally mediated in the frontal and prefrontal brain regions.

Free radicals. Ubiquitous molecules, also known as oxidants, present in the air we breathe, the food we eat, and the water we drink. Free radicals cause oxidative stress and wear down the genetic material, or DNA, of our cells. This process accelerates aging and contributes to chronic diseases, such as cancer and Alzheimer’s.

Frontal lobe. The front part of the brain that mediates executive control.

Genes. The blueprint for life contained in all the body’s cells, inherited from parents, and consisting of deoxyribonucleic acid (DNA). The molecular configuration of the double-helical strands of DNA is an alphabet key, a genotype, that programs our phenotype—who we are mentally and physically. A minute molecular change can have a dramatic effect on a person’s risk for a particular disease.

Glucose. A simple sugar that is the main source of energy in the body’s cells and results from the breakdown of foods we eat.

Glycemic index. A measure of how rapidly a food causes blood sugar levels to rise. This index ranks foods from 0 to 100, indicating whether the food raises blood sugar levels gradually (low scores) or rapidly (high scores).

Gram (gm). A measurement used for drugs and equivalent to one-twenty-eighth of an ounce.

Gray matter. The outer part of the brain that contains cell bodies.

Hippocampus. A seahorse-shaped brain structure involved in memory and learning, located in the temporal lobe of the brain (near the temples).

Hormones. Chemical messengers produced by glands and organs in the body and absorbed into the bloodstream.

Hypercholesterolemia. Elevated blood levels of cholesterol. A risk factor for diseases affecting blood vessels in the heart, brain, and other body organs.

Hypertension (high blood pressure). A chronic disease that increases risk for circulatory problems, heart disease, and vascular dementia.

Immediate memory. Fleeting memories for sights, sounds, and other stimuli that last for milliseconds before moving into short-term memory.

Immune response. The body’s mechanism for developing a memory for foreign or threatening materials or organisms. Specialized immune cells are primed initially so they will quickly produce antibodies to ward off infection. The immune system recognizes and destroys proteins like insoluble amyloid-beta that are not normally present.

Inflammation. The body’s natural response to infection or stress, consisting of a mobilization of specialized cells to eliminate the offending foreign body.

Insulin. A hormone produced by the pancreas that gets sugar into cells.

Insulin resistance. The inability of cells to respond to insulin, resulting in high blood sugar levels.

Ischemia. Lack of oxygen to body tissue. In the brain, it can have several effects: if brief, it leads to transient ischemic attacks (TIAs) when the patient has a temporary loss of cognitive or motor function. When prolonged, it leads to death of brain cells and permanent deficits, known as strokes, or cerebral vascular accidents (CVAs).

Kava kava. An herb used to reduce anxiety and stress. When combined with alcohol, it can augment intoxication.

Lesion. Any damage to body tissues or cells.

Linking. A memory technique that associates or connects two or more bits of information.

Long-term memory. Relatively permanent memories that have been organized and rehearsed.

LOOK, SNAP, CONNECT. A basic three-step memory technique that includes (1) actively observing what you want to learn (LOOK), (2) creating mental snapshots of memories (SNAP), and (3) linking mental snapshots together (CONNECT).

Lycopene. A potent antioxidant present in high concentrations in tomatoes.

MacArthur Study of Successful Aging. A long-term study of aging that addressed positive rather than negative outcomes. Successful aging involves avoiding diseases, remaining engaged in life, and maintaining high physical and mental functioning.

Magnetic resonance imaging (MRI) scan. A brain-scanning technique that provides more detailed information on brain structure than CT scanning and that can be useful in diagnosing brain tumors, strokes, and blood clots. When modified, it can produce information on brain function, a technique known as functional MRI.

Major depression. A serious form of depression that can interfere with memory ability.

Microglia cells. Cells that serve to clean up debris in the brain and mediate the immune response that causes brain inflammation.

Mild cognitive impairment. A memory impairment similar to that observed in mild Alzheimer’s disease, but not great enough to interfere with a person’s ability to live independently. People with this condition have about a 15 percent chance of developing Alzheimer’s disease each year.

Milligram (mg). A measurement used for drugs—one-one-thousandth of a gram.

Mozart Effect. The term used to describe the observation that passive listening to classical music benefits mental abilities.

Neurofibrillary tangles. Collections of decayed material resulting from brain cell death and degeneration, present in high concentrations in the areas involved in memory in the Alzheimer’s brain.

Neurogenesis. New nerve-cell growth.

Neuron. Nerve or brain cell.

Neuropsychological tests. Standardized tests that measure memory, attention, and other cognitive abilities.

Neurotransmitter. A small molecule that serves as a brain messenger, allowing one neuron to communicate with another.

Nicotinic receptors. A small receptacle in nerve cells where brain messengers like nicotine or acetylcholine attach and communicate their information through a series of chemical reactions.

Nutraceuticals. Natural substances not regulated by the FDA and used as supplements, often to counteract the aging process.

Objective memory ability. An individual’s memory ability as measured by standardized memory tests or neuropsychological tests.

Omega-3 fatty acids. So-called good fats that keep brain cell membranes soft and flexible and come from fruits, leafy vegetables, nuts, fish, and supplements.

Omega-6 fatty acids. So-called bad fats that tend to make brain cell membranes more rigid and come from animal meat, whole milk, cheese, margarine, mayonnaise, processed foods, fried foods, and vegetable oils.

ORAC (oxygen radical absorbency capacity). The unit for a laboratory measuring technique that determines the ability of different foods to counteract oxidative stress. Foods with high ORAC scores may protect brain cells from the damage of oxygen radicals, or free radicals.

Oxidative stress. The wear and tear that free radicals cause to the body’s cells through a chemical reaction in which oxygen reacts with another substance to cause a chemical transformation. Antioxidants counteract this process.

Parietal lobe. The area of the brain above and behind the temporal region (near the temples).

Pharmacogenetics. The emerging field of drug effectiveness and safety based upon an individual’s genetic makeup.

Positron emission tomography (PET). A body-scanning method that measures structure as well as function. PET scans of the brain show characteristic patterns of decreased metabolism in the areas affected by Alzheimer’s disease.

Protein. A molecule that is the building block of neurotransmitters and enzymes.

Serotonin. A neurotransmitter necessary for relaxation, concentration, and sleep that is decreased in depression and dementia.

Short-term memory. Memories lasting only minutes and too transient for long-term recall.

Smart drugs. Medications, herbs, hormones, or supplements taken with the intent of improving memory and other cognitive functions in a normal individual who does not have obvious memory loss.

Statins. Cholesterol-lowering drugs that may reduce the risk for developing Alzheimer’s disease.

St. John’s wort. An herbal treatment for anxiety, depression, and insomnia.

Stress response. The body’s physiological reaction to stress, involving release of cortisol and other stress hormones.

Stroke. Death of brain cells resulting in a loss of physical or mental function or both.

Subdural hematomas. Blood clots surrounding the brain; a potential side effect of ginkgo biloba.

Subjective memory ability. A person’s self-awareness of memory ability.

Synapse. The interface between two nerve cells where they communicate information.

Valerian. An herb used for restlessness and insomnia, which can interact adversely with alcohol and other sedatives.

Vascular dementia. A dementia resulting from many small strokes.

Verbal memory. Learning and recall of information relating to language and words.

Visual-spatial memory. Learning and recall of visual and spatial information.

White matter. Brain areas consisting of nerve fibers that transfer information from distant brain regions.

Additional Resources

Many organizations provide information on memory and general health issues important to maintaining brain health. Several of the following national organizations also have local or state chapters.

AARP

Nonprofit, nonpartisan organization dedicated to helping older Americans achieve lives of independence, dignity, and purpose.

www.aarp.org

AARP’s Global Council on Brain Health

An independent collaborative, created to provide trusted information on how you can maintain and improve your brain health.

www.aarp.org/health/brain-health/global-council-on-brain-health

Administration on Aging

Provides information for older Americans and their families on opportunities and services to enrich their lives and support their independence.

https://acl.gov/about-acl/administration-aging

Alzheimer Europe

Nonprofit nongovernmental organization that provides a voice to people with dementia and their caregivers, makes dementia a European priority, and supports dementia research.

www.alzheimer-europe.org

Alzheimer’s Association

The national organization that provides information on services, programs, publications, and local chapters.

www.alz.org

Alzheimer’s Disease Education and Referral Center

National Institute on Aging service that distributes information and free materials on topics relevant to health professionals, patients and their families, and the general public.

www.nia.nih.gov/health/about-adear-center

AlzForum

News website and information resource dedicated to helping researchers accelerate discovery and advance development of diagnostics and treatments for Alzheimer’s disease and related disorders.

www.alzforum.org

American Academy of Neurology

Professional organization that advances the art and science of neurology, thereby promoting the best possible care for patients with neurological disorders.

www.aan.com

American Association for Geriatric Psychiatry

Professional organization dedicated to enhancing the mental health and well-being of older adults through education and research.

www.aagponline.org

American Diabetes Association

America’s leading nonprofit health organization providing diabetes research, information, and advocacy.

www.diabetes.org

American Geriatrics Society

National, not-for-profit society of healthcare professionals dedicated to improving the health, independence, and quality of life of older people.

www.americangeriatrics.org

American Heart Association

Nonprofit organization in the United States that funds cardiovascular research, educates consumers on healthy living, and fosters appropriate cardiac care.

www.heart.org

American Society on Aging

The go-to source to cultivate leadership, advance knowledge, and strengthen the skills of members and others who work with and on behalf of older adults.

www.asaging.org

Family Caregiver Alliance

National, nonprofit, caregiver support organization that works to improve the quality of life for caregivers and the people who receive their care.

www.caregiver.org

Gerontological Society of America

Multidisciplinary organization devoted to research and education on all aspects of gerontology: medical, biological, psychological, and social.

www.geron.org

National Center for Complementary and Integrative Health

United States government agency that explores complementary and alternative medicine.

www.ncciih.nih.gov

National Institute of Mental Health

Part of the National Institutes of Health, the NIMH is the principal biomedical and behavioral research agency of the United States government.

www.nimh.nih.gov

National Institute of Neurological Disorders and Stroke

The National Institutes of Health agency that supports neuroscience research; focuses on rapidly translating scientific discoveries into prevention, treatment, and cures; and provides resource support and information.

www.ninds.nih.gov

National Institute on Aging

The division of the National Institutes of Health that leads a broad scientific effort to understand the nature of aging and to extend the healthy, active years of life.

www.nia.nih.gov

National Stroke Association

Nonprofit organization working to reduce the incidence and impact of stroke, the fourth leading cause of death in the United States.

www.stroke.org

SeniorNet

Nonprofit organization specializing in computer and internet education for adults aged 55 and over and those in need.

www.seniornet.com

UCLA Longevity Center

University center that works to enhance and extend productive and healthy life through research and education on aging.

www.longevity.ucla.edu

Bibliography

Agrawal K, Onami S, Mortimer JE, et al. Cognitive changes associated with endocrine therapy for breast cancer. Maturitas 2010;67:209–214.

Alexopoulos GS, Meyers BS, Young RC, et al. The course of geriatric depression with “reversible dementia”: A controlled study. Am J Psychiatry 1993;150:1693–1699.

Amaducci L, and the SMID group. Phosphatidylserine in the treatment of Alzheimer’s disease: Results of multicenter study. Psychopharm Bull 1988;24:922–931.

Amir H, Malka D-K, Gil S, et al. Cognitive enhancement of healthy older adults using hyperbaric oxygen: a randomized controlled trial. Aging (Albany NY) 2020;12:13740–13761.

Amorim L, Magalhães R, Coelho A, et al. Poor sleep quality associates with decreased functional and structural brain connectivity in normative aging: a MRI multimodal approach. Front Aging Neurosci 2018 Nov 20;10:375. doi: 10.3389/fnagi.2018.00375. eCollection 2018.

Ancelin M-L, De Roquefeuil G, Ledesert B, et al. Exposure to anaesthetic agents, cognitive functioning and depressive symptomatology in the elderly. Br J Psychiatry 2001;178:360–366.

Anderson M, Jiang J. Teens, social media & technology 2018. Pew Research Center. http://www.pewinternet.org/2018/05/31/teens-social-media-technology-2018/. Posted May 31, 2018. Accessed June 4, 2018.

Anguera JA, Boccanfuso J, Rintoul JL, et al. Video game training enhances cognitive control in older adults. Nature 2013;501(7465):91–101.

Argyriou A, Prast H, Philippu A. Melatonin facilitates short-term memory. Eur J Pharm 1998;349:159–162.

Arkell TR, Lintzeris N, Kevin RC, et al. Cannabidiol (CBD) content in vaporized cannabis does not prevent tetrahydrocannabinol (THC)-induced impairment of driving and cognition. Psychopharmacology (Berl) 2019;236:2713–2724.

Atherton D. Towards the safer use of traditional remedies. Br Med J 1994;308:673–674.

Ayd FJ. Evaluating interactions between herbal and psychoactive medications. Psychiatric Times 2000;December:45–47.

Barnes DE, Yaffe K. The projected effect of risk factor reduction on Alzheimer’s disease prevalence. Lancet Neurol 2011;10:819–828.

Barone JJ, Roberts HR. Caffeine consumption. Food Chemistry and Toxicology 1996;34:119–129.

Barrio JR, Small GW, Wong K-P, et al. In vivo characterization of chronic traumatic encephalopathy using [F-18]FDDNP PET brain imaging. Proc Natl Acad Sci USA 2015 Apr 21;112(16):E2039–E2047. doi: 10.1073/pnas.1409952112. Epub 2015 Apr 6.

Benowitz NL. Pharmacology of caffeine. Ann Rev Med 1990;41:277–288.

Benson H. The Relaxation Response. Avon, New York, 1975.

Beyer CE, Steketee JD, Saphier D. Antioxidant properties of melatonin—An emerging mystery. Biochem Pharm 1998;56:1265–1272.

Bookheimer SY, Strojwas MH, Cohen MS, et al. Brain activation in people at genetic risk for Alzheimer’s disease. N Engl J Med 2000;343:450–456.

Bowen JD, Larson EB. Drug-induced cognitive impairment: Defining the problem and finding solutions. Drugs and Aging 1993;3:349–357.

Braak H, Braak E. Neuropathological staging of Alzheimer-related changes. Acta Neuropathol 1991;82:239–259.

Brand-Miller J, Volwever TMS, Colaguiri S, Foster-Powell K. The New Glucose Revolution: The Authoritative Guide to the Glycemic Index—The Dietary Solution for Lifelong Health. Marlowe & Co., New York, 2006.

Broe GA, Grayson DA, Creasey HM, et al. Anti-inflammatory drugs protect against Alzheimer disease at low doses. Arch Neurol 2000;57:1586–1591.

Burggren AC, Siddarth P, Mahmood Z, et al. Subregional hippocampal thickness abnormalities in older adults with a history of heavy cannabis use. Cannabis Cannabinoid Res 2018;3:242–251.

Caffarra P, Santamaria V. The effects of phosphatidylserine in patients with mild cognitive decline. Clinical Trials Journal 1987;24:109–114.

Caffilhas RC, Lee KS, Fernandes J, et al. Spatial memory is improved by aerobic and resistance exercise through divergent molecular mechanisms. Neuroscience 2012;202:309–317.

Carper J. Your Miracle Brain. Harper Collins, New York, 2000.

Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for FDG PET for Dementia and Neurodegenerative Diseases (220.6.13). https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=288&ncdver=3&bc=BAABAAAAAAAA.

Chang L, Douet V, Bloss C, et al. Gray matter maturation and cognition in children with different APOE ε genotypes. Neurology 2016;87:585–594.

Chen GS, Volle D, Jalil J, Wu P, Small GW. Health-promoting strategies for the aging brain. Am J Geriatr Psychiatry 2019;27:213–236.

Chen J, Zhang F, Zhao L, et al. Hyperbaric oxygen ameliorates cognitive impairment in patients with Alzheimer’s disease and amnestic mild cognitive impairment. Alzheimers Dement (NY) 2020;6(1):e12030.

Chen ST, Siddarth P, Merrill DA, et al. FDDNP-PET tau brain protein binding patterns in military personnel with suspected chronic traumatic encephalopathy. J Alzheimers Dis 2018;65:79–88.

Christensen MA, Bettencourt L, Kaye L, et al. Direct measurements of smartphone screen-time: relationships with demographics and sleep. PLoS One 2016 Nov 9;11(11):e0165331. doi: 10.1371/journal.pone.0165331. eCollection 2016.

Clough JD, Martin SS, Navar AM, et al. Association of Primary Care Providers’ Beliefs of Statins for Primary Prevention and Statin Prescription. J Am Heart Assoc 2019 Feb 5;8(3):e010241. doi: 10.1161/JAHA.118.010241.

Collins MW, Grindel SH, Lovell MR, et al. Relationship between concussion and neuropsychological performance in college football players. JAMA 1999;282:964–970.

Corder EH, Saunders AM, Strittmatter WJ, et al. Gene dose of apolipoprotein E type 4 allele and the risk of Alzheimer’s disease in late onset families. Science 1993;261:921–923.

Crook TH, Adderly B. The Memory Cure. Pocket Books, New York, 1998.

Cummings J, Feldman HH, Scheltens P. The “rights” of precision drug development for Alzheimer’s disease. Alzheimers Res Ther 2019;11:76. Published online 2019 Aug 31. doi: 10.1186/s13195-019-0529-5.

DeKosky ST, Williamson JD, Fitzpatrick AL, et al. Ginkgo biloba for prevention of dementia: A randomized controlled trial. JAMA 2008;300:2253–2262.

Del Ser T, Hachinski V, Merskey H, Munoz DG. An autopsy-verified study of the effect of education on degenerative dementia. Brain 1999;122:2309–2319.

Devanand DP. The Memory Program. John Wiley & Sons, New York, 2001.

Dong G, Potenza MN. Behavioural and brain responses related to internet search and memory. Eur J Neurosci 2015;42:2546–2554.

Doraiswamy PM, Babyak MA, Hennig T, et al. Donepezil for cognitive decline following coronary artery bypass surgery: a pilot randomized controlled trial. Psychopharmacol Bull 2007;40:54–62.

Doss MK, Sepeda ND, Pekar JJ, Griffiths RR. Emotions and brain function are altered up to one month after a single high dose of psilocybin. Sci Rep 2020 Feb 10;10(1):2214. doi: 10.1038/s41598-020-59282-y.

Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States: Prevalence, costs, and patterns of use. N Engl J Med 1993;328:246–252.

Espeland MA, Rapp SR, Shumaker SA, et al. Conjugated equine estrogens and global cognitive function in postmenopausal women: Women’s Health Initiative Memory Study. JAMA 2004;291:2959-2968.

Etherton GM, Kochar MS. Coffee: Facts and controversies. Arch Family Med 1993;2:317–322.

Fajnerová I, Greguš D, Hlinka J, et al. Could prolonged usage of GPS navigation implemented in augmented reality smart glasses affect hippocampal functional connectivity? Biomed Res Int. 2018;2018:2716134. Published online 2018 Jun 13. doi: 10.1155/2018/2716134.

Feltrow CW, Avila JR. The Complete Guide to Herbal Medicines. Pocket Books, New York, 2000.

Firth J, Torous J, Stubbs B. The “online brain”: How the internet may be changing our cognition. World Psychiatry 2019;18:119–129.

Fitten LJ, Perryman KM, Wilkinson CJ, et al. Alzheimer and vascular dementias and driving: A prospective road and laboratory study. JAMA 1995; 273:1360–1365.

Foer J. Moonwalking with Einstein: The Art and Science of Remembering Everything. Penguin Books, New York, 2011.

Foster NL, Heidebrink JL, Clark CM, et al. FDG-PET improves accuracy in distinguishing frontotemporal dementia and Alzheimer’s disease. Brain 2007;2616–2635.

Garattini S (ed.): Caffeine, Coffee, and Health. Raven Press, New York, 1993.

Ghebremedhin E, Schultz C, Braak E, Braak H. High frequency of apolipoprotein E ε4 allele in young individuals with very mild Alzheimer’s disease-related neurofibrillary changes. Exp Neurol 1998;153:152–155.

Gilewski MJ, Zelinski EM, Schaie KW. The Memory Functioning Questionnaire for assessment of memory complaints in adulthood and old age. Psychology and Aging 1990;5:482–490.

Global Council on Brain Health. The real deal on brain health supplements: GCBH recommendations on vitamins, minerals, and other dietary supplements. 2019. www.GlobalCouncilOnBrainHealth.org. doi: https://doi.org/10.26419/pia.00094.001.

Green CS, Bavelier D. Action video game modifies visual selective attention. Nature 2003;423(6939):534–537.

Gwyther LP, Rabins PV. Practical approaches for treating behavioral symptoms of people with mild to moderate Alzheimer’s disease. Primary Psychiatry 1996;3:27–38.

Haier RJ, Siegel BV, MacLachlan A, et al. Regional glucose metabolic changes after learning a complex visuospatial/motor task: A positron emission tomographic study. Brain Research 1992;570:134–143.

Hall W, Solowij N, Lemon J. Health and psychological consequences of cannabis use. 1994 National Drug Strategy Monograph Series No. 25. Canberra, Australian Government Publication Service.

Hathcock JN. Vitamins and minerals: Efficacy and safety. Am J Clin Nutrition 1997;66:427–437.

Heber D. The Resolution Diet. Avery, New York, 1999.

Heber D, Bowerman S. What Color Is Your Diet? Regan Books, New York, 2001.

Hebert LE, Scherr PA, Beckett LA, et al. Age-specific incidence of Alzheimer’s disease in a community population. JAMA 1995;273:1354–1359.

High KP. Micronutrient supplementation and immune function in the elderly. CID 1999;28:717–722.

Hill NT, Mowszowski L, Naismith SL, Chadwick VL, Valenzuela M, Lampit A. Computerized cognitive training in older adults with mild cognitive impairment or dementia: a systematic review and meta-analysis. Am J Psychiatry 2017;174(4):329–340.

Ivgi M, Schnaider B, Rabinowitz J, Davidson M. A naturalistic study comparing the efficacy of a memory enhancement course to a general academic course. Int Psychogeriatr 1999;11:281–287.

Jaeggi SM, Buschkuehl M, Jonides J, et al. Improving fluid intelligence with training on working memory. Proc Natl Acad Sci USA 2008;105(19):6829–6833.

Janus C, Pearson J, McLaurin J, et al. A beta peptide immunization reduces behavioural impairment and plaques in a model of Alzheimer’s disease. Nature 2000;408:979–982.

Jarvik LF, Small GW. Parentcare. Crown, New York, 1988.

Jick H, Zornberg GL, Jick SS, et al. Statins and the risk of dementia. Lancet 2000;356:1627–1631.

Johansson C, Skoog I. A population-based study on the association between dementia and hip fractures in 85-year-olds. Aging 1996;8:189–196.

Joseph JA, Nadeau D, Underwood A. The Color Code: A Revolutionary Eating Plan for Optimum Health. Hyperion, New York, 2002.

Kahn RL, Rowe JW. Successful Aging. Pantheon, New York, 1998.

Kramer AF, Hahn S, McAuley E, et al. Exercise, aging and cognition: Healthy body, healthy mind? In Fisk AD, Rogers W (eds.), Human Factors Interventions for the Health Care of Older Adults. Erlbaum, Hillsdale, NJ, 2001.

Kwan P, Konno H, Chan KY, Baum L. Rationale for the development of an Alzheimer’s disease vaccine. Hum Vaccin Immunother 2020;16:645–653.

Lim GP, Chu T, Yang F, et al. The curry spice curcumin reduces oxidative damage and amyloid pathology in an Alzheimer transgenic mouse. J Neurosci 2001;21:8370–8377.

Lloyd SL, Striley CW. Marijuana use among adults 50 years or older in the 21st century. Gerontol Geriatr Med 2018 Jan–Dec;4:2333721418781668. Published online 2018 Jun 21. doi: 10.1177/2333721418781668.

Lonn E, Bosch J, Yusuf S, et al. Effects of long-term vitamin E supplementation on cardiovascular events and cancer: A randomized controlled trial. JAMA 2005;293:1338–1347.

Lorayne H. How to Develop a Super Power Memory. Lifetime Books, Hollywood, FL, 1998.

Maas AIR, Menon DK, Adelson PD, et al. Traumatic brain injury: Integrated approaches to improve prevention, clinical care, and research. Lancet Neurol 2017;16:987–1048.

Maguire EA, Woollett K, Spiers HJ. London taxi drivers and bus drivers: A structural MRI and neuropsychological analysis. Hippocampus 2006;16:1091–1101.

Marseille DM, Silverman DHS, Hussain SA, et al. Cerebral hypometabolism characteristic of Alzheimer’s disease occurs early enough to affect ultimate educational level. J Nucl Med 2001;42:146P (No. 546).

Matser JT, Kessels AG, Jordan BD, et al. Chronic traumatic brain injury in professional soccer players. Neurology 1998;51:791–796.

Matser JT, Kessels AG, Lezak MD, et al. Neuropsychological impairment in amateur soccer players. JAMA 1999;282:971–973.

Matsunaga S, Fujishiro H, Takechi H. Efficacy and safety of cholinesterase inhibitors for mild cognitive impairment: A systematic review and meta-analysis. J Alzheimers Dis 2019;71:513–523.

McBride JA, Carson CC, Coward RM. Testosterone deficiency in the aging male. Ther Adv Urol 2016;8:47–60.

McCutcheon LE. Another failure to generalize the Mozart effect. Psychological Reports 2000;878:325–330.

McDaniel LD, Lukovits T, McDaniel KD. Alzheimer’s disease: The problem of incorrect clinical diagnosis. J Geriatr Psychiatry Neurol 1993;6:230–234.

McGaugh JL. Memory—A century of consolidation. Science 2000; 287:248–251.

McGeer PL, Schulzer M, McGeer EG. Arthritis and anti-inflammatory agents as possible protective factors for Alzheimer’s disease: A review of 17 epidemiologic studies. Neurology 1996;47:425–432.

McKeith I, Del Ser T, Spano P, et al. Efficacy of rivastigmine in dementia with Lewy bodies: A randomised, double-blind, placebo-controlled international study. Lancet 2000;356:2024–2025.

Merchant C, Tang MX, Albert S, et al. The influence of smoking on the risk of Alzheimer’s disease. Neurology 1999;52:1408–1412.

Meyer P-F, Tremblay-Mercier J, Leoutsakos J, et al. INTREPAD: A randomized trial of naproxen to slow progress of presymptomatic Alzheimer disease. Neurology 2019 Apr 30;92(18):e2070–e2080.

Miller KJ, Dye RV, Kim J, et al. Effect of a computerized brain exercise program on cognitive performance in older adults. Am J Geriatr Psychiatry 2013;21(7):655–663.

Miller KJ, Siddarth P, Gaines JM, et al. The Memory Fitness Program: Cognitive effects of a healthy aging intervention. Am J Geriatr Psychiatry 2012;20:514–523.

Mittelman MS, Ferris SH, Shulman E, et al. A family intervention to delay nursing home placement of patients with Alzheimer’s disease: A randomized, controlled trial. JAMA 1996;276:1725–1731.

Mohs RC, Ashman TA, Jantzen K, et al. A study of the efficacy of a comprehensive memory enhancement program in healthy elderly persons. Psychiatry Research 1998;77:183–195.

Moon M. The MIND Diet: A Scientific Approach to Enhancing Brain Function and Helping Prevent Alzheimer’s and Dementia. Ulysses Press, Berkeley, CA, 2016.

Morris MC, Beckett LA, Scherr PA, et al. Vitamin E and vitamin C supplement use and risk of incident Alzheimer disease. Alzheim Dis Associated Disorders 1998;12:121–126.

Morris MC, Tangney CC, Wang Y, et al. MIND Diet Associated with Reduced Incidence of Alzheimer’s Disease. Alzheimers Dement 2015 Sep; 11(9):1007–1014.

Nagamatsu LS, Chan A, Davis JC, et al. Physical activity improves verbal and spatial memory in older adults with probable mild cognitive impairment: A 6-month randomized controlled trial. J Aging Res 2013;2013:861893. doi: 10.1155/2013/861893.

Nahin RL, Barnes PM, Stussman BJ. Expenditures on Complementary Health Approaches: United States, 2012. National Health Statistics Reports 2016. Number 95. https://www.cdc.gov/nchs/data/nhsr/nhsr095.pdf.

Natural Medicines Comprehensive Database. www.naturaldatabase.com.

The Natural Pharmacist. www.tnp.com.

Newhouse P, Kellar K, Aisen P, et al. Nicotine treatment of mild cognitive impairment: A 6-month double-blind pilot clinical trial. Neurology 2012;78:91–101.

Newman PE. Could diet be used to reduce the risk of Alzheimer’s disease? Medical Hypotheses 1998;50:335–337.

Nicodemus NE, Becerra S, Kuhn TP, et al. Focused transcranial ultrasound for treatment of neurodegenerative dementia. Alzheimers Dement (NY) 2019;5:374–381.

Nikkelen SW, Valkenburg PM, Huizinga M, Bushman BJ. Media use and ADHD-related behaviors in children and adolescents: A meta-analysis. Dev Psychol 2014;50:2228–2241.

Novotný M, Klimova B, Valis M. Microbiome and cognitive impairment: Can any diets influence learning processes in a positive way? Front Aging Neurosci 2019;11:170. Published online 2019 Jun 28. doi: 10.3389/fnagi.2019.00170.

Oveisgharan S, Wilson RS, Yu L, et al. Association of early-life cognitive enrichment with Alzheimer disease: Pathological changes and cognitive decline. JAMA Neurol 2020 Jun 29;e201941. doi: 10.1001/jamaneurol.2020.1941.

Paivio A, Yuille JC, Madigan SA. Concreteness, imagery, and meaningfulness values for 925 nouns. J Exp Psychol Monograph Suppl 1968;76(1, part 2):1–25.

Paykel ES, Brayne C, Huppert FA, et al. Incidence of dementia in a population older than 75 years in the United Kingdom. Arch Gen Psychiatry 1994;51:325–332.

Pillai JA, Hall CB, Dickson DW, et al. Association of crossword puzzle participation with memory decline in persons who develop dementia. J Int Neuropsychol Soc 2011 Nov; 17(6)1006–1013. doi:10.1017/S1355617711001111.

Poole R, Kennedy OJ, Roderick P, et al. Coffee consumption and health: Umbrella review of meta-analyses of multiple health outcomes. BMJ 2017;359:j5024. Published online 2017 Nov 21. doi: 10.1136/bmj.j5024.

Price JL, Morris JC. Tangles and plaques in nondemented aging and “preclinical” Alzheimer’s disease. Ann Neurol 1999;45:358–368.

Primack BA, Shensa A, Sidani JE, et al. Social media use and perceived social isolation among young adults in the U.S. Am J Prev Med 2017;53(1):1–8.

Quaglio G, Gallucci M, Brand H, Dawood A, Cobello F. Traumatic brain injury: A priority for public health policy. Lancet Neurol 2017;16:951–952.

Raskind MA, Peskind ER, Wessel T, and the Galantamine USA-1 Study Group. Galantamine in AD: A 6-month randomized, placebo-controlled trial with a 6-month extension. Neurology 2000;54:2269–2276.

Rauscher FH, Shaw GL. Key components of the Mozart effect. Perceptual and Motor Skills 1998;86:835–841.

Rebok GW, Ball K, Guey LT, et al. Ten-year effects of the advanced cognitive training for independent and vital elderly cognitive training trial on cognition and everyday functioning in older adults. J Am Geriatr Soc 2014;62(1):16–24.

Reiman EM, Caselli RJ, Chen K, et al. Declining brain activity in cognitively normal apolipoprotein E ε4 heterozygotes: A foundation for using positron emission tomography to efficiently test treatments to prevent Alzheimer’s disease. Proc Natl Acad Sciences USA 2001;98:3334–3339.

Reiman EM, Caselli RJ, Yun LS, et al. Preclinical evidence of Alzheimer’s disease in persons homozygous for the epsilon 4 allele for apolipoprotein E. N Engl J Med 1996;334:752–758.

Relkin NR, Tanzi R, Breitner J, et al. Apolipoprotein E genotyping in Alzheimer’s disease: Position statement of the National Institute on Aging/Alzheimer’s Association Working Group. Lancet 1996;347:1091–1095.

Reneman L, Lavalaye J, Schmand B, et al. Cortical serotonin transporter density and verbal memory in individuals who stopped using 3,4-methylenedioxymethamphetamine (MDMA or “ecstasy”). Arch Gen Psychiatry 2001;58:901–906.

Rideout BE, Dougherty S, Wernert L. Effect of music on spatial performance: A test of generality. Perceptual and Motor Skills 1998;86:512–524.

Ritchie K. Mental status examination of an exceptional case of longevity: J.C. aged 118 years. Br J Psychiatry 1995;116:229–235.

Ritchie K, Kildea D. Is senile dementia “age related” or “aging related”?: Evidence from a meta-analysis of dementia prevalence in the oldest old. Lancet 1995;346:931–934.

Rogers SL, Friedhof LT, Apter JT, et al. The efficacy and safety of donepezil in patients with Alzheimer’s disease: Results of a US multicentre, randomized, double-blind, placebo-controlled trial. Dementia 1996;7:293–303.

Rondeau V, Commenges D, Jacqmin-Gadda H, Dartigues JF. Relation between aluminum concentrations in drinking water and Alzheimer’s disease: An 8-year follow-up study. Am J Epidem 2000;152:59–66.

Ronis MJJ, Pedersen KB, Watt J. Adverse effects of nutraceuticals and dietary supplements. Annu Rev Pharmacol Toxicol 2018 Jan 6;58:583–601.

Roses AD, Saunders AM. ApoE, Alzheimer’s disease, and recovery from brain stress. Ann NY Acad Sci 1997;826:200–212.

Rosser JC, Lynch PJ, Cuddihy L, et al. The impact of video games on training surgeons in the 21st century. Arch Surg 2007;142(2):181–186.

Sano M, Ernesto C, Thomas RG, et al. A controlled trial of selegiline, alpha-tocopherol, or both as treatment for Alzheimer’s disease. N Engl J Med 1997;336:1216–1222.

Satoh T, Sakurai I, Mihagi K, Hohsaku Y. Walking exercise and improved neuropsychological functioning in elderly patients with cardiac disease. J Internal Med 1995;238:423–428.

Schenk D, Barbour R, Dunn W, et al. Immunization with amyloid-beta attenuates Alzheimer-disease-like pathology in the PDAPP mouse. Nature 1999;400;173–177.

Schnabel J. Vaccines: Chasing the dream. Nature 2011;475:S18-S19.

Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: Meta-analysis of randomized placebo-controlled trials. JAMA 2005;294:1934–1943.

Schneider LS, Tariot PN, Small GW. Update on treatment for Alzheimer’s disease and other dementias. In Dunner DL, Rosenbaum JF (eds.), Psychiatric Clinics of North America: Annual of Drug Therapy 1997;4:135–166.

Schoentgen B, Gagliardi G, Défontaines B. Environmental and cognitive enrichment in childhood as protective factors in the adult and aging brain. Front Psychol 2020;11:1814. Published online 2020 Jul 21. doi: 10.3389/fpsyg.2020.01814.

Schofield PW, Marder K, Dooneief G, et al. Association of subjective memory complaints with subsequent cognitive decline in community-dwelling elderly individuals with baseline cognitive impairment. Am J Psychiatry 1991;154:609–615.

Schor JB. The Overworked American. Basic Books, New York, 1991.

Selye H. Stress Without Distress. Signet, Scarborough, 1975.

Shoghi-Jadid K, Small GW, Agdeppa ED, et al. Localization of neurofibrillary tangles (NFTs) and beta-amyloid plaques (APs) in the brains of living patients with Alzheimer’s disease. Am J Geriatr Psychiatry 2002;10:24–35.

Shumaker SA, Legault C, Rapp SR, et al. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women: The Women’s Health Initiative Memory Study: A randomized controlled trial. JAMA 2003;289:2651–2662.

Siddarth P, Thana-Udom K, Rashi Ojha, et al. Sleep quality, neurocognitive performance, and memory self-appraisal in people with age-related cognitive complaints. Intl Psychogeriatr 2020 (in press).

Silverman DHS, Ercoli LM, Huang S-C, et al. Perceived loss of memory function correlates with subsequent decline in metabolism of hippocampus. J Nucl Med 2001;42(228):61P.

Silverman DHS, Small GW, Chang CY, et al. Evaluation of dementia with positron emission tomography: Regional brain metabolism and long-term outcome. JAMA 2001;286:2120–2127.

Skaugset LM, Farrell S, Carney M, et al. Can you multitask? Evidence and limitations of task switching and multitasking in emergency medicine. Ann Emerg Med 2016;68(2):189–195.

Small GW. Estrogen effects on the brain. J Gender-Specific Med 1998;1:23–27.

Small GW. Living better longer through technology. Int Psychogeriatr 1999;11:3–6.

Small GW. The pathogenesis of Alzheimer’s disease. J Clin Psychiatry 1998;59(suppl 9):7–15.

Small GW. Positron emission tomography scanning for the early diagnosis of dementia. West J Med 1999;171:293–294.

Small GW. Recognizing and treating anxiety in the elderly. J Clin Psychiatry 1997;58(suppl 3):41–47.

Small GW. Treatment of Alzheimer’s disease: Current approaches and future prospects. In Dunner DL, Rosenbaum JF (eds.), Psychiatric Clinics of North America: Annual of Drug Therapy 2000;7:201–218.

Small GW, Donohue JA, Brooks RL. An economic evaluation of donepezil in the treatment of Alzheimer’s disease. Clin Therapeutics 1998;20:838–850.

Small GW, Ercoli LM, Silverman DHS, et al. Cerebral metabolic and cognitive decline in persons at genetic risk for Alzheimer’s disease. Proc Natl Acad Sciences USA 2000;97:6037–6042.

Small GW, Lee J, Kaufman A, et al. Brain health consequences of digital technology use. Dialogues Clin Neurosci 2020;22:179–187.

Small GW, Leuchter AF, Mandelkern MA, et al. Clinical, neuroimaging, and environmental risk differences in monozygotic female twins appearing discordant for dementia of the Alzheimer type. Arch Neurol 1993;50:209–219.

Small GW, Mazziotta JC, Collins MT, et al. Apolipoprotein E type 4 allele and cerebral glucose metabolism in relatives at risk for familial Alzheimer disease. JAMA 1995;273:942–947.

Small GW, Moody TD, Siddarth P, Bookheimer SY. Your brain on Google: Patterns of cerebral activation during internet searching. Am J Geriatr Psychiatry 2009;17:116–126.

Small GW, Rabins PV, Barry PP, et al. Diagnosis and treatment of Alzheimer’s disease and related disorders: Consensus statement of the American Association for Geriatric Psychiatry, the Alzheimer’s Association, and the American Geriatrics Society. JAMA 1997;278:1363–1371.

Small GW, Siddarth P, Ercoli LM, Chen ST, Merrill DA, Torres-Gil F. Healthy behavior and memory self-reports in young, middle-aged and older adults. Intl Psychogeriatr 2013;25:981–989.

Small GW, Siddarth P, Li Z, et al. Memory and brain amyloid and tau effects of a bioavailable form of curcumin in non-demented adults: A double-blind, placebo-controlled 18-month trial. Am J Geriatr Psychiatry 2018; 26:266–277.

Small GW, Siddarth P, Silverman DHS, et al. Cognitive and cerebral metabolic effects of celecoxib versus placebo in people with age-related memory loss: Randomized controlled study. Am J Geriatr Psychiatry 2008;16:999-1009.

Small GW, Silverman DHS, Siddarth P, et al. Effects of a 14-day healthy longevity lifestyle program on cognition and brain function. Am J Geriatr Psychiatry 2006;14:538–545.

Snowdon DA, Kemper SJ, Mortimer JA, et al. Linguistic ability in early life and cognitive function and Alzheimer’s disease in late life: Findings from the Nun Study. JAMA 1996;275:528–532.

Specialty Coffee Association of America: Document #1040: Forecast for continued growth, in Lingle TR. Avenues for Growth: A 20 Year Review of the U.S. Specialty Coffee Market. SCAA, Long Beach, CA, 1993.

Spencer JW, Jacobs JJ (eds). Complementary and Alternative Medicine: An Evidence-Based Approach. Mosby-Year Book, St. Louis, 1999.

Steele KM, Brown JD, Stoecker JA. Failure to confirm the Rauscher and Shaw description of recovery of the Mozart effect. Perceptual and Motor Skills 1999;88:843–848.

Sun B-L, Li W-W, Zhu C, et al. Clinical research on Alzheimer’s disease: Progress and perspectives. Neurosci Bull 2018;34:1111–1118.

Swan GE, DeCarli C, Miller BL, et al. Association of midlife blood pressure to late-life cognitive decline and brain morphology. Neurology 1998;51:986–993.

Tariot PN, Farlow MR, Grossberg GT, et al. Memantine treatment in patients with moderate to severe Alzheimer disease already receiving donepezil: a randomized controlled trial. JAMA 2004;291:317–324.

Thompson GW. Coffee: Brew or bane? Am J Med Sci 1994;308:49–57.

Trepanowski JF, Kroeger CM, Barnosky A, et al. Effect of alternate-day fasting on weight loss, weight maintenance, and cardioprotection among metabolically healthy obese adults: A randomized clinical trial. JAMA Intern Med 2017 Jul 1;177(7):930–938.

Turati F, Galeone C, Augustin LSA, La Vecchia C. Glycemic index, glycemic load and cancer risk: An updated meta-analysis. Nutrients 2019 Oct 2;11(10):2342. doi: 10.3390/nu11102342.

United States Census Bureau. Living Longer: Historical and Projected Life Expectancy in the United States, 1960 to 2060 Population Estimates and Projections. https://www.census.gov/content/dam/Census/library/publications/ 2020/demo/p25-1145.pdf.

van der Wal CN, Kok RN. Laughter-inducing therapies: A systematic review and meta-analysis. Social Science and Medicine 2019;232:473–488.

Van Dyck CH. Anti-amyloid-β monoclonal antibodies for Alzheimer’s disease: Pitfalls and promise. Biol Psychiatry 2018;83:311–319.

Vega-López S, Venn BJ, Slavin JL. Relevance of the glycemic index and glycemic load for body weight, diabetes, and cardiovascular disease. Nutrients 2018 Sep 22;10(10):1361. doi: 10.3390/nu10101361.

Wahjoepramono EJ, Asih PR, Aniwiyanti V, et al. The effects of testosterone supplementation on cognitive functioning in older men. CNS Neurol Disord Drug Targets 2016;15:337–343.

Weinstein IA, Kerem E, Lejoyeux IS. Internet addiction or excessive internet use. Am J Drug Alcohol Abuse 2010;36:277–283.

Whalley LJ, Starr JM, Athawes R, et al. Childhood mental ability and dementia. Neurology 2000;55:1455–1459.

Winblad B, Poritis N. Memantine in severe dementia: Results of the 9M-Best study (Benefit and efficacy in severely demented patients during treatment with memantine). Int J Geriatr Psychiatry 1999;14:135–146.

World Health Organization International Agency for Research on Cancer, Coffee, Tea, Mate, Methylxanthines and Methylgloxal. IARC Monogr Eval Carcinog Risks Hum 1991;51:1–513.

Wright MR, Vandewater SA, Taffe MA. Cannabidiol attenuates deficits of visuospatial associative memory induced by Δ(9) tetrahydrocannabinol. Br J Pharmacol 2013;170:1365–1373.

Wu Y, Ding Y, Tanaka Y, Zhang W. Risk factors contributing to type 2 diabetes and recent advances in the treatment and prevention. Int J Med Sci 2014;11:1185–1200.

Xia C, Dickerson BC. Multimodal PET imaging of amyloid and tau pathology in Alzheimer disease and non–Alzheimer disease dementias. PET Clin 2017;12:351–359.

Yeap BB, Page ST, Grossmann M. Testosterone treatment in older men: Clinical implications and unresolved questions from the Testosterone Trials. Lancet Diabetes Endocrinol 2018;6:659–672.

Youn JC, Kim KW, Lee DY, et al. Development of the Subjective Memory Complaints Questionnaire. Dement Geriatr Cogn Disord 2009;27:310–317.

Zelinski EM, Gilewski MJ, Anthony-Bergstone CR. Memory Functioning Questionnaire: Concurrent validity with memory performance and self-reported memory failures. Psychology and Aging 1990;5:388–399.

Zhang R, Shen L, Miles T, et al. Association of low to moderate alcohol drinking with cognitive functions from middle to older age among US adults. JAMA Netw Open. 2020 Jun; 3(6):e207922.

Acknowledgments

We are grateful to the many people who helped make this book a reality, particularly our children, Rachel and Harry, who keep our hearts young. Several friends and colleagues provided input and encouragement, including Helen Berman, Susan Bowerman, Dr. Josh Chodosh, Dr. Linda Ercoli, Stuart Grant, Dr. David Heber, Diana Jacobs, Dr. Lissy Jarvik, Dr. Jim Joseph, Dr. Stephen Read, Don Seigel, and Nazelie Hagopian Navarro. We are particularly grateful to our original editor, Mary Ellen O’Neill, and our new editor, Sam Haim, at Hachette Books, as well as our long-time agent and friend, Sandra Dijkstra.

NOTE:

The stories contained in this book are composite accounts based on the experiences of many individuals and do not represent any one person or group of people. Similarities to any one person or persons are coincidental and unintentional. Readers should consider consulting with their physician before initiating any exercise or treatment program.

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Source Credits

Chapters 3 and 6

Drawings by Diana Jacobs.

Chapter 5

Mental aerobics exercises were included with permission from:

Marge Engelman and AgeNet.Inc (Aerobics of the Mind: http://agenet.agenet.com): All warm-up exercises, beginning exercise 2, and intermediate exercises 2, 3, and 4.

Kevin N. Stone (Brainbashers: www.brainbashers.com): Beginning exercise 7, intermediate exercise 9, and advanced exercises 4, 5, and 7.

The Ultimate Puzzle Site (www.dse.nl/puzzle/index_us.html): Beginning exercises 8 and 14.

The Grey Labyrinth (www.greylabyrinth.com): Advanced exercises 7 and 8.

Chapter 9

Figure 9.1 from Rogers SL, Friedhof LT, Apter JT, et al. The efficacy and safety of donepezil in patients with Alzheimer’s disease: Results of a US multicentre, randomized, double-blind, placebo-controlled trial. Dementia 1996;7:293–303.

Appendix

Amyloid/Tau-PET scans (Figure A.1) courtesy of Jorge Barrio, PhD, Henry Huang, PhD, UCLA Department of Molecular and Medical Pharmacology.

PET scans showing brain function patterns (Figure A.2) courtesy of Michael Phelps, PhD; Diane Martin, UCLA Department of Molecular and Medical Pharmacology.

Graph showing six-month delay in cholinergic treatment (Figure A.3) adapted from Raskind et al. 2000.

Also by Gary Small, MD, and Gigi Vorgan

The Memory Prescription

The Longevity Bible
iBrain

The Other Side of the Couch

The Alzheimer’s Prevention Program

2 Weeks to a Younger Brain

SNAP! Change Your Personality in 30 Days

The Small Guide to Anxiety

The Small Guide to Alzheimer’s Disease

The Small Guide to Depression