The Memory Bible

An Innovative Strategy for

Keeping Your Brain Young

Gary Small, M.D.

Director of the UCLA Center on Aging
Contents

Cover

Title Page

Preface

Chapter One
You Have More Control
Than You Think

Chapter Two
Rate Your Current Memory

Chapter Three
Look, Snap, Connect:
THE THREE BASIC MEMORY TRAINING SKILLS

Chapter Four
Minimize Stress

Chapter Five
Get Fit with Mental Aerobics

Chapter Six
Build Your Memory Skills
Beyond the Basics

Chapter Seven
Start Your Healthy
Brain Diet Now

Chapter Eight
Choose a Lifestyle That
Protects Your Brain

Chapter Nine
Wise Up About Medicines

Chapter Ten
Don’t Forget the First
Nine Chapters

Appendixes

APPENDIX 1 The Amyloid Probe—Keeping Watch on Plaques and Tangles

APPENDIX 2 What to Do If Alzheimer’s Disease Strikes

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

APPENDIX 4 GLOSSARY

APPENDIX 5 Additional Resources

Bibliography

Source Credits

INDEX

Acknowledgments

About the Author

Copyright

Notes
Preface

Nearly everyone struggles with some form of memory loss before reaching middle
age. Thanks to recently developed brain-imaging and genetic technologies, scientists
can now observe the earliest physical indicators of brain aging in people as young as
twenty- ve. 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 ght back, and The Memory Bible will give you the tools. We can
improve our memory performance immediately and stave o , 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.
Gary Small, M.D.
Los Angeles, California, May 2002
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, le, or phone
at home, only to remember it while caught in rush hour tra c? 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 o 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, recent convincing scienti c 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 rst 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 o 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 nds 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. had a reputation as a fabulous hostess—her parties had always been the
talk of the town. For several weeks her daughter had been reminding her to prepare
a guest list for her sixty- fth birthday party, but Sally just kept forgetting to do it.
Finally her husband Jerry mentioned that she was forgetting quite a few things lately
and suggested she discuss this with their family internist.
Sally sco ed at Jerry’s “accusation” and told him that her mind was perfectly fine. If
anyone was getting old and losing their marbles, it was he. It was just that the
thought of a sixty- fth birthday didn’t seem right for someone like her. She didn’t feel
65, and thanks to Dr. Mark, she sure didn’t look it. In fact, lots of people at the club
said that she and her daughter looked just like sisters.
In the last ten years, Sally had undergone two face-lifts, cheek and chin implants,
liposuction, breast lift and augmentation, innumerable Botox and collagen injections,
and a tummy tuck. She was a regular at Dr. Mark’s surgery center and had met
almost every anesthesiologist, nurse, and orderly that worked there.
Jerry, still going on about her birthday, insisted Sally allow them to throw her a
wonderful party for a change—she wouldn’t have to do a thing! Sally laughed. “Of
course I will. I’ll have to call Dr. Mark and have my eyes done right away.”
Jerry hit the roof. “No more calling Dr. Mark, Sally. You can’t have plastic surgery
 every six months. It’s not good for you.”
Sally looked hurt and responded indignantly, “I haven’t had anything done in two
years.”
Jerry said softly, “Honey, what about the tummy tuck ve months ago? Don’t you
remember? You couldn’t walk for two weeks.”
Sally thought about it. “Oh, yeah, right. Well, that had nothing to do with my face.
Besides, that Linda Bens … Dens … something, at the club, gets a face-lift every year
for Christmas, and she looks just fine.”
Jerry cut a deal with her. If she’d accompany him to their family doctor to discuss
her memory changes, he’d back off about the surgery. Sally agreed.
The internist performed a standard memory test on Sally in the o ce 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 su ering from some mild age-related cognitive
impairment. As di cult as that was for her to accept, thankfully there were plenty of
things she could do to ght 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- fth 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 ling cabinet, ready
to be pulled out at will. However, because our brains are comprised of 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 laments 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 speci c 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 hyper-speci c 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 eeting 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.
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 e ort to
develop these skills, while 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. While
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 di culty 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

Recently, scientists have learned how the brain converts short-term memories into
permanent ones at the molecular and cellular level. A speci c 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
like 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, while 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, while men generally have the edge in spatial
and mathematical abilities. However, when I mentioned this to my wife, she nearly
managed to talk me out of it.
Various other factors in uence our memory abilities. Emotional states have a major
impact on the e ciency and the quality of memories. Ask yourself where you were and
what you were doing when President Kennedy was shot. (Or John Lennon, for you
youngsters.) 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 rst crush in second grade
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 di er 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 di cult for older
adults to learn a foreign language or scienti c discourse. (I wouldn’t want to try to pass
advanced calculus again at 50.)
Older people have greater di culty multitasking and our reaction time can slow
down as we age, which can a ect our daily activities. Many older drivers compensate
by driving more slowly, which can be a hazard in itself. Memory training (Chapters 3
a n d 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 de ned 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. These experts estimated that 40 percent of all people are a ected by this
condition upon reaching their fties, 50 percent in their sixties, and over 70 percent by
age 70 and older.
Although there is debate over whether or not 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 10 million Americans over age 65 su er 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 di culties we experience are continuous, uid processes beginning remarkably
early in our lives. Several recent studies point to just how early.

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

Several years ago, 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 signi cant memory loss or Alzheimer’s disease decades later, in their
seventies.
The study’s conclusion, that language ability at age 20 may predict whether or not
someone will get Alzheimer’s disease fty 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.
More recently, Scottish psychiatrist Dr. L. J. Whalley and his colleagues studied
intelligence test records to determine if a person’s IQ early in life predicted Alzheimer’s
disease up to fty 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 o ered 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 re ect the
early signs of the disease itself deteriorating the brain subtly early in life. This could
then in uence school performance and further educational pursuit. 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
e ciently. Messages ring 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 neuro brillary 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. 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 de nitive diagnosis of Alzheimer’s disease could only be made at
autopsy. 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 de ned
threshold the patient under examination de nitely had Alzheimer’s disease. Scientists
have studied brain autopsies in people who had only mild cognitive impairment rather
than Alzheimer’s. 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 de ned
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 ve years between ages 65 and 90. Scientists suspect that if the current
trend toward increased lifespan 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 am convinced 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 di erences between women and men likely in uence 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, while 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.
Recent studies of brain structure and function have shown that although women have
smaller brains, their brains are more e cient, 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 them. 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 nd 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 “ x 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 some day repair any existing damage.
Of course, we must all rst 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 a ects 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.
Nearly a decade ago, neuroscientists studied brain scans of volunteers playing the
computer game Tetris for the rst time. They found high levels of brain activity. A
month later, when the volunteers had become pro cient at the game, their scans
displayed signi cantly lower levels of brain activity. This lower brain activity,
indicating greater mental e ciency, 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 e ciency. Bench-pressing the same barbell
will require much less e ort 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 e cient 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, bene ts 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.
Recent 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.
Scienti c cause and e ect 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 ndings 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 town house overlooking the fth hole of a beautiful golf course in a
desert retirement community, six hours away. For almost ve years they used it on
weekends and holidays, usually inviting friends or family along to golf and enjoy the
views. Joe was ecstatic when he and Alice nally quali ed for early retirement—at
last they could stop working, move to the town house, and start living the good life
while they were young enough to enjoy it.
Alice cried at her o ce farewell party—after twenty-six years, her co-workers had
become like family and she had enjoyed the daily challenge of coming to work and
“putting out res.” As they nished packing, Joe was more excited than a kid on his
rst 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 rst six months passed quickly as Joe relandscaped, installed an outdoor grill,
and perfected his golf swing. Alice got busy redecorating the town 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 visited less frequently now, as did their friends.
Alice understood that everybody had hectic work and school schedules and that
nobody could 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
country 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 o ce 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 gure 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 had less she needed to remember 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 e ciently 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
bene ts 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 o memory loss that
might emerge in the future.

Windows to Your Brain: New Technologies to Detect Brain Aging

Despite our best e orts at 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 nd a way to view brain structure and function, so as to pinpoint a problem
that might improve with treatment and determine the speci c treatment, when to
intervene, and whether the patient was benefiting from it.
Recently there have been research breakthroughs from diverse scienti c disciplines—
genetics, chemistry, physics, biomathematics, as well as others—that are nally opening
windows into the brain, using new technologies like positron emission tomography, or
PET, scanning. We can now view brain aging directly and thereby speci cally guide our
treatments to prevent future memory loss.
During medical school in the mid-1970s, I remember our excitement the rst time we
viewed computed tomography, or CT, scans of the brain. We nally had a way to look
at brain tissue beyond what conventional X-ray machines could provide. With the
development of magnetic resonance imaging, or MRI, 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 o ered no information about how well
the still-living brain cells were functioning. If only we could actually see how e ectively
the neurons were or were not communicating with each other, then we might be able to
pick up, and treat, more subtle brain de ciencies before the cells died. Thanks to my
UCLA colleague Dr. Michael Phelps and others, we now have the stunning breakthrough
discovery of PET scanning and can nally 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 rst 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 currently the most
sensitive technology for making an accurate, early diagnosis for guiding treatment. In
our UCLA Memory Clinic, we use it 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 su er from much milder memory symptoms, and my UCLA
research team wondered whether these new technologies could help us to 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 baby boomers. These tools may
also help us to gauge the success of our memory tness 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 fteen years. Most of us know that
genes are the blueprints of life, and everybody’s DNA di ers 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 a ects
people after age 65, was not thought to have a genetic in uence, 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, or APOE. This APOE gene makes a protein that transports
cholesterol and fats through the body and is known to in uence the risk for heart
disease and related conditions, so it was a big surprise when geneticists found a link to
Alzheimer’s disease and memory loss. APOE comes in three di erent 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 co-workers at Duke University
were the rst 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 direct at UCLA recently achieved a signi cant advancement in understanding the
brain-imaging window using PET by linking it to the latest research in genetics.
Combining these scienti c technologies for the rst 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 bene t from
preventative treatments.
In the mid-1990s, our research group at UCLA 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 Alz-heimer’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 con rmed our discovery.
More recently, we 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, we have created the UCLA Memory Clinic, an
innovative clinical and research program wherein we test new treatments to see if 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 e ective, 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 below, 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 are testing several drugs in middle-aged and older people, and we are
beginning similar studies to test the e ects 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 di erences in the
language abilities of young people might predict the development of Alzheimer’s disease
fty years later—my research team attempted to use PET scans to detect such brain
function de cits 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 or not they had nished 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 ndings, Dr. Silverman and I systematically reviewed the PET scan
results of a much larger group of young adults according to their educational
achievement. We now have 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
di erences in language ability predicting Alzheimer’s disease fty years later. Figure 1.5
illustrates how people with higher education have enhanced brain activity and how this
effect disappears with age.

Figure 1.5
 Our study not only demonstrated subtle patterns of brain functional 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 fty years. When we looked at the e ect of higher education added
to the e ect 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 in uence 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.
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 recent study of brain autopsies found that people with lower educational
attainment had more evidence of vascular disease in their brains compared to those who
had attended college. 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.

The Cognitive Stress Test

My research group at UCLA 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
signi cantly 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?

Many experts anticipate that Medicare and private insurers will soon make
reimbursement available for PET scanning in the diagnosis of Alzheimer’s disease and
other memory problems. This would be a great step forward for preventative care
because PET technology detects the signature pattern of Alzheimer’s disease in people
without severe memory impairment, thus guiding appropriate early treatment. Anyone
with a new concern about increased forgetfulness or a sudden change in memory ability
should consult a physician and, if indicated, get a PET scan. You can nd a local PET
center through the Academy of Molecular Imaging (Appendix 5).
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 re ne and
automate our biological brain-imaging technologies.
 At our UCLA Memory Clinic we have seen encouraging results in people using our
memory-training and mental aerobics exercises, which incorporate games, puzzles, and
other mentally stimulating activities. It is critical that each of us begins memory training
at our own level. The key is to nd yours and get started. Even with a tight schedule
and limited time, you will bene t from memory training—if only for a few minutes a
day. And as you build skills, the benefits will keep getting greater.
Chapter Two
Rate Your Current Memory

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

—MARK TWAIN

To e ectively begin a program to improve memory performance and keep our brains
young, we rst 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 rst 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 rst 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 rst 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
the most 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 su ce. It will also help individuals to nd 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 Appendix 5 to nd 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 rst day back at the o ce, 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 o ce
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 or not we will complain about them to others. A person’s mood and sense of
well-being in uence how much they notice and complain about forgetfulness.
Depression and anxiety also increase self-awareness of memory di culties. 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 di erent factors
can in uence awareness of memory loss, some question whether these so-called
subjective memory measures accurately re ect true memory changes or whether they
merely re ect 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 re ect an objective, biological change. In one of our studies,
we used a particular memory self-rating questionnaire developed by Dr. Michael
Gilewski and his associates at Cedars-Sinai Medical Center in Los Angeles. We asked a
group of middle-aged and older adults with only mild memory complaints to complete
this questionnaire. 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.
More recently, 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 signi cantly 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. Here we will use a modi ed version of the self-rating questionnaire we have
used in our research studies at UCLA.
Answer the questions in the following Subjective Memory Questionnaire by circling a
number between 1 and 7 that best re ects how you judge your own memory ability.
Afterward, we will tally your results to use in determining the best training level for you
to begin your memory program.

SUBJECTIVE MEMORY QUESTIONNAIRE

 Add up all the numbers you have circled. If your total score is 200 or more, then your
subjective memory di culties are minimal. You may nd 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 100 and 200,
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 100 re ects an even greater self-awareness
of memory di culties. 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 (Appendix 5).

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 nd this memory assessment method too di cult or
perhaps too easy. It is designed to assess memory in people with a wide range of
abilities. It is also intended to be di cult at rst 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 1-minute period and recalling them after a 20-minute break. When ready,
set your timer for 1 minute, then read and learn the words on the list in Assessment No.
1.

ASSESSMENT NO. 1 STUDY THE FOLLOWING WORDS FOR UP TO 1 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 20-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 20 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
20 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 di cult 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 (Appendix 5).
Many factors can in uence 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 di culties may worsen actual
objective memory performance. If you scored well on objective word recall after 20
minutes but your subjective memory score indicated frequent memory di culties, you
may be su ering from stress and anxiety. If you t into this group, then I suggest
turning to Chapter 4 (Minimize Stress) before beginning basic memory training skills
(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 SCORES
Subjective Objective Program
Move quickly from basic (Chapter 3) to advanced (Chapter 6)
High High
memory training.
Take time and focus on basic training, then reassess score. If no
Low Low
improvement, consult expert.
Focus on stress reduction (Chapter 4) be-fore basic memory skills
Low High
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 gure, 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 shu ed deck or e ortlessly 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 ling cabinet for the brain. A
person’s prior knowledge and interests will in uence 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 ling and storage systems work most e ectively 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 while 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 speci c 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 speci cally dedicated to your memory-training exercises. This way you will
be able to see your progress and keep track of your exercises.

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 di culty 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 e ective 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 e ort 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 di cult 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. 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 rst trip, you
are likely to get lost on your rst solo trip. The goal in active observation (see Active
Observation Exercises box) is to mentally stay in the driver’s seat.
LOOK is the rst basic skill because our vision is so often our rst 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 co-
workers. 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 speci c 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 e ort to x the
observed image into a mental snapshot. Imagined snaps are those that you create from
your own memories and fantasies, but they still become xed 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 e ectively 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 xed in
my memory—“it’s a thick blue book with two white lines and some circlelike ower
things on it.” In the bookshelf below, the search image of one particular book helps it to
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
e ective 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 two drawings of sandwiches
below. 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 e ectively 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 e ective 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 x 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 Bu alo Bills
might work for you—as long as it helps you nd 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 rst 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 together 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, 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 the example above, 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 ne-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 each other—the ideas or images become part of a chain, starting
with the rst item, which is associated with the second, the second with the third, and so
forth. When initiating the rst 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 ow
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 ow 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 roles 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 e ective links or associations are ones we create ourselves, particularly
those stemming from our rst association. Psychoanalysts have used the method of free
association to help people uncover emotionally charged experiences. Often our rst
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 rst letters of items to be remembered. To create an acronym, rst think of one
word to represent each item to be remembered, and then form a word using the rst
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 rst 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 light bulb 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 rst, 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, co ee mug. After you complete the next ve
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–rose bush
Lamp–potato–motorcycle
Keyboard–cowboy–blimp
Apple sauce–parachute–hitchhiker
3. List five things you need to do tomorrow.
4. Now use the link system to recall the list above.
5. Now use the story system for the same list.
6. Create a one-word acronym by using a rst 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 di erent list of words so you can retest your learning and recall skills. Get out
your stopwatch or kitchen timer and set it for 1 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 1 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 20-minute
break, and distract yourself by doing something else. After 20 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 rst image, which is associated with the
second, the second with the third, and so forth. Be sure the rst 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

Our modern world is lled with new technological tools designed to make our lives
more e cient and stress-free—computers, voice mail, e-mail, cell phones, hand-held
organizers, and tiny digital devices to record our output. For many of us, having all this
modern equipment has not only failed to limit the stress in our lives but instead appears
to have increased it. Because these technologies allow us to be more e cient, we can
now take on more activities and responsibilities, which in turn put even greater
demands on our personal and professional lives. Tick tock, tick tock. Time is money. Get
more for less.
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 tness and overall
memory performance. You’ve had a tough week at work; you’re 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 re 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 stimuli such as noise, bright
lights, heat, or con ned 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 o
the job, are common reasons for getting our adrenaline pumping, as are major life
events, whether a negative one—death of a relative, getting red—or even a positive
one—getting promoted or having a new baby. And, let’s not forget the daily hassles of
commuting, misplacing keys, or a mechanical breakdown of one of the pieces of
equipment so many of us have accumulated to help us eliminate stress.
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 rm, attached his
heart monitor and prepared to begin working out in his customized super gym,
tucked into the loft of his town house. 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 nancial network ashing across the wide at 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 ipped 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 post-workout endorphin high.
He nally 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 OK?”
Justin, distracted, replied, “Yeah, man. I’ve got to get to the o ce, 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 di erently, 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 baby boomers, sometimes described as Type A personalities,
perfectionists, or workaholics, often set unrealistic expectations on themselves and over-
analyze 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 di erently, 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 blood stream that are
intended to put us into a protective mode. Adrenaline, a well-known stress hormone,
tends to result in the “ ght-or- ight response,” providing strength and energy to either
ght 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 o . Otherwise, you’d probably have run
for it.
When the stress hormone adrenaline pumps into the blood stream, 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 di erence
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: dgeting, 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 in uences the brain
and cognitive processes, showing that prolonged exposure to stress hormones has an
adverse, shrinking e ect on the hippocampus memory center in laboratory animals. The
hippocampus is a seahorse-shaped brain structure involved in memory and learning,
located in the area of the brain beneath the temples.
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 nd 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 e ects 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 signi cant 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 ght 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 rst, 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 di erently once the angry
feelings have diminished. Sometimes it’s better not to zoom down to the post o ce 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 tness, 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 nding new approaches for
expressing them.
A recent study 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 e ects 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 insu cient blood ow 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 mid-forties.
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
sta , closest friends, and patients. When Patricia brought it up, Frank insisted he was
ne—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 su er. Frank was seeing up to ve 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 nally 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 o ce 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 a ect 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.
The most recent nding 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-in icted 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

Recent studies indicate 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 o much of our “stress energy.”
With the ght-or- ight 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, ght or ight—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 e ective in reducing stress than gulping down a couple of beers. Any
aerobic activity can have the same e ect, 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 15 million Americans include some form of yoga in their tness
program. Yoga not only o ers a way to build strength, balance, and stamina, but it can
also reduce stress. Dr. Dean Ornish and his co-workers 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 e ective 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 ubbed 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 nd 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 ags 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 2-hour segments: mid-morning break, lunch, mid-afternoon 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
e ort 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 e ort 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 e ect. 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 courses,
books, and tapes. Just a few minutes each day doing some simple relaxation techniques
can be e ective 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 eld, in a sauna, or anywhere you
nd relaxing. Breathe deeply and do not allow the thoughts that may
enter your mind to remain there. Keep focused on your breathing and
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 ca eine habit, and we tend to get the bulk of our daily ca eine
from drinking co ee. We may start with a wake-me-up cup, possibly followed by a mid-
morning espresso and perhaps an iced blended mocha at our afternoon co ee break. If
we count added ca eine from soft drinks and chocolate, we can be well on the road to a
caffeine-induced stress response.
When ca eine 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 ca eine 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 ca eine and doing it gradually to avoid headaches and
other side e ects of withdrawal. Many experts recommend decreasing by the equivalent
of a half-cup of co ee each day or every other day (see Chapter 7 for equivalencies).
Most people will begin feeling more relaxed and notice other bene ts as well. Many
find that they sleep better and paradoxically have more energy.

GET ENOUGH SLEEP

An estimated 100 million 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 su er
from chronic sleep deprivation often feel better if they try getting to bed 30 to 60
minutes earlier. You know you’ve beaten the cycle if you start waking refreshed, notice
more energy during the day, and nd 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 o the next
day. Daytime naps can help if you keep them short—you could feel groggy waking from
naps that last over 30 minutes. Instead, 20-minute “power naps” can be rejuvenating.
Avoid early evening naps since they make it more di cult to fall asleep at bedtime. If
you su er 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 watch TV or 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:
watch TV, listen to music, or read a book.
5. Once you begin feeling tired, go back to steps 3 and 4: go to bed, shut 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 work about three hours longer every week than they did twenty years ago,
adding up to an extra month of work each year. With many boomer 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 sel sh, or too much leisure time makes some people bored and
restless—even stressed! We need to nd 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 e ects of laughter.
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 e ective ways to
reduce stress. Systematic studies of talking psychotherapies often nd that the
characteristics of the listener—whether they are empathic, responsive, and the like—
have more importance to the therapeutic bene t than what type of therapy they
practice. Talking about feelings can be e ective 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 e orts 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 mid-afternoon nap. She took a nap almost every day
now, ever since their youngest daughter left for college. It was half past ve and
Carl, her husband of thirty-six years, would be home in an hour. She had time to
shower and dress and x 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
nally 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 speci cally 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 rst 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 o ce 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 gure out what was going on in her marriage. She discovered
her husband’s a air 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
videotape 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, while 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 bene t 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.
While 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 like washing hands or checking
door locks over and over. These disorders can become so severe that the a icted 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 speci c psychotherapies. And, many such psychiatric disorders will
affect learning and memory abilities.
If you nd that your anxiety levels are so high that your work or personal life is
a ected, perhaps it is time to seek professional help (Appendix 5). 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. In her early forties, this
lifelong di culty took a turn for the worse. Because of her busy career in marketing,
Jill had put o having children into her late thirties and was now in the heat of
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 o ce, Jill was exhausted and frustrated. She was becoming forgetful, and for
the rst 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 baby boomers who are creeping into middle
age. She wanted to take action to improve her memory now and organize her life more
e ciently. She is one of many proactive individuals eager to get t and bene t 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. Just picture a mini Jack
La Lanne in your brain. You don’t remember him? Drop and give me 20!
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 ring 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 but rather spatial
cognitive skills, such as paper-folding tasks and following patterns. 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 E ect has met controversy since not all studies
show it, we do know that di erent kinds of music have di erent mental e ects. Some
music will calm us, lowering heart rate and blood pressure, while 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 recently used MRI scans to study whether intense environmental demands
such as musical training at an early age in uenced actual brain growth and
development. They found that, compared with non-musicians in their study, the fteen
professional musicians had signi cantly 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 a ected early by Alzheimer’s disease. Though
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 de nitive proof, the potential for a bene t 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 UCLA 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 consulting with me on his memory improvement program, I suggested he take
up crosswords again for the potential mental aerobic bene ts. 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 con dence, 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. Recent studies, however, indicate a de nite link between mental
activity and staving o 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 fties 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 bene t: passive pursuits like
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 bene ts for memory
(Chapter 4), but beware of over-salted 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 people with less educational achievement.
At UCLA we have recently 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 con rmed 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 t 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 signi cantly
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 ow 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 recent 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 di erent 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 su ered from an “exercise disorder.” He was
a typical Type A personality who embraced every new exercise program he could nd
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 tness training, in memory training we want to avoid too much of
a good thing. At UCLA, we have 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
people without the genetic risk. When research volunteers play a computer game for the
rst time, their PET scans reveal high brain-activity levels. After becoming pro cient 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 like an athlete becomes
more pro cient 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 scienti c 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 e ects 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
over-exert. If a task is too di cult, 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 re ecting their frustration from trying to
complete an overly challenging mental exercise.

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 like 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 e ort 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 nd a new solution to a seemingly
unsolvable problem. To do so, we need to break loose and explore the problem, puzzle,
or brainteaser in a new way.
When we view certain visual images, we often x on seeing them in one way, as in
the vase below:

If you look again and think of the vase as background instead of foreground, you may
see the profiles of two people.
In the gure below, you probably see the black arrows. Try to see the gure from a
di erent 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 gure below.
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.
The above exercises are basic examples of visual brain-teasers, the type that can and
should become a part of your daily mental aerobics workout. You may want to go up to
the attic and nd your old Rubik’s Cube. What is a Rubik’s Cube, you ask? Drop and
give me 50!
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 ne. Your regimen of stretching, toning, and
strengthening your brain can include music, puzzles, and computer games. Such
activities are most e ective when they not only are fun but they “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 nd yourself getting
frustrated quickly, go back and start at a less advanced level. If you nd the activities
too easy, move on to more di cult ones. Mental stimulation exercises should be
challenging and enjoyable to achieve their best e ect. Be sure to pace yourself and set
reasonable expectations.
Many experts support the potential bene t of mental stimulation to our brains. But
what form of mental stimulation is most e ective? Recently, 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 tness 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).
 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 di erent levels of di culty 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, while verbal
or analytic tasks work the left hemisphere. For left-handers, the left side of the brain
generally operates visual tasks, while the right side handles verbal skills.
LEFT BRAIN FUNCTIONS RIGHT BRAIN FUNCTIONS

• Logical analysis (reasoning, drawing • Spatial relationships (reading maps,

conclusions) doing jigsaw puzzles)

• Information sequencing (making lists,

• Artistic and musical abilities
organizing thoughts)

• 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 nd 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 rst
name using your non-dominant hand (i.e., left hand if you are right-handed). Now take
a second pencil and try writing your rst 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 ve toothpicks of your own into the shape of a

number ve as below. 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.
 8. Left-Brain Exercise. A water lily doubles its size every day in a round pond, and
after 20 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 11 men in the space
of 10 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 10 blue socks and 10 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 rst 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 rst 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 if 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 rst 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 10 circles are arranged in a triangle. See if you
can turn the triangle upside down by moving just 3 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 di erent 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 figure below, 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. Below are 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 below?

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 if you can nd the hidden countries below without using
any reference material. The letter denotes the country’s rst 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 owers. 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 tra c 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
below.

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 only likes 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 rst 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 the 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?

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. China has been grappling with a population problem for
some time. For many social and cultural reasons, families strongly prefer male children
to female children. Consider a hypothetical city somewhere in China 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 100 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 o 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
even Robert Stack, 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 gold sh, 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 oor, 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 ick 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 de nition 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 o , 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
ick 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 di culty 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 you stimulated. Chapter 10 will help you t 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, 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 hand-held organizer—we can systematically
learn memory techniques and incorporate them into our daily routines.
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

scientist at UCLA. 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
mid-forties, 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 ercely self-su cient. She was an avid
tennis player, member of a bridge club, and she 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
“pre-cooked 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 un nished 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 rst. 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 de nitely
depressed, and often when people are depressed, it a ects 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
e ectively can make the di erence between success, mediocrity, or out-right failure. For
maximum recall performance, organizing information according to obvious patterns
facilitates quick memory storage and retrieval.
One of the more e ective 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 pile of common grocery items below:

Many of us would nd 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 Carrot Golf club

Nail Hoop Scalpel

Cucumber Romaine Cabbage

Base Stopwatch Bolt

Without looking at the above 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 like “Webster”
representing the rst three numbers. Look up the phone number for your public
library. Read it once, cover it, and say it out loud. Di cult? For many of us it
will be. Now look at it again and cluster it into three smaller number groups.
Now say it aloud. You may find it easier to remember.
3. Group the following twelve items into four categories:

Sunscreen Slide rule Drive

Diskette Goblet Abacus

 Shutter Bottle Carafe

Calculator Visor Mother board

Without referring back to the rst list or the list in exercise 1 above, see if 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 cell phones, fax machines, e-mail, and pagers, many baby boomers
nd themselves su ering from numerical technology overload, or too many darn
numbers to keep straight. One might wonder: “Who needs to remember numbers when
there’s so many electronic phone book gadgets available? Why, I have one right here in
my bag!” But what if your bag isn’t right here, and you must call your boss’s cell phone
immediately? With a simple Peg Method, you can know your boss’s cell phone number
and never, ever forget it.
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 e ort, 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 satis ed 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 speci c, 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 rst association to
the consonant sounds, and write them in your notebook.

Table 6.1

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. E ective 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 e ective. 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 sitting and crossing her legs (55). (You could never
 forget this is her social security number since she has such great legs!) She loves being outdoors so
she has decided to y a kite (7) while sitting with her legs crossed. Let your eye follow the kite string
upward to where it connects to the kite and you see a tie (1) waving in the wind as its tail. But the tie-
tail suddenly gets sucked into the engine of a passing jet (6). You notice that the pilot is actually a
humanoid fork (8), and a zebra, (0), dressed as a ight attendant, enters the cockpit to serve the fork a
large raisin (4). As the fork tries to gure out how to eat the raisin, a mummy (3) dressed as the co-
pilot enters the cockpit.

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 their fax
numbers too.
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 e ective 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 rst-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. Names like “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, like “Shapiro,” “O’Malley,” or “Amaducci,”
may require additional mental e ort 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 rst 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 below.

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

The Roman Room Method

To apply the Roman Room method, originally developed by ancient Roman orators to
help them remember long speeches, rst visualize a familiar room. Then place each item
to be remembered in a speci c 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 o ce as your “Roman room.” I can imagine myself in my
o ce 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
o ce, you pass the following landmarks each day: water tower, bridge, gas station, and
post o ce. 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 Jerry Lewis 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 speci c
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 nally
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 a ect 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 like diabetes, heart disease, and
obesity, those same T-bone steaks, curly fries, and ice cream sundaes can negatively,
and sometimes irreversibly, damage our brain tness—although the e ects may take
decades to appear.
Convincing scienti c 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 bene ts such as increased alertness and
greater energy.
The sooner we start our healthy brain diets, the sooner we begin to reap the bene ts.
Chapter 7 provides the components of a safe mental- tness 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 ve or ten pounds, or true obesity, excess body fat
increases our risk for illnesses like 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 e ective 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 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 at UCLA is among the gerontologists conducting animal studies
showing that lifelong calorie restriction dramatically prolongs life expectancy as well as
maintains optimal brain tness. Recently, calorie-restricted rats were found to have 25
percent better functioning of brain receptors involved in memory compared with
animals on unrestricted diets.
Dr. Walford told me that he was so convinced by his animal studies that he had begun
restricting his own calories by fasting at least one day each week in the hopes of
maximizing his longevity. 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.

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, salsa, 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

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 a recent 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 in 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 o the diet with a giant binge. Experts agree that in
the long run, such yo-yo diets tend to back re 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 e ects of obesity has convinced many experts that by sensibly watching our
caloric intake we may help protect our brains.

Georgette B., a 46-year-old teacher, rst 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 rst ve
minutes of her visit, it was clear that memory complaints were not her only problem.
In describing herself, she said she was always the rst of her friends to try the latest
fad diet. She would typically begin a new diet regimen, maybe lose a few pounds in
the rst week or two, and then quickly grow discouraged as her weight loss tapered
o . Georgette would then abandon the diet and almost ritualistically plunge into a
post-diet binge to make up for her weeks of hunger and deprivation. Experiencing a
sense of failure and defeat, she invariably became depressed until nally nding and
 latching onto the next miracle weight-loss program. During her bouts of depression,
Georgette’s memory di culties 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 e ect 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
satis ed. 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 a ect 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, the people of Ibadan, Nigeria, are mostly
poor and unable to afford much more than vegetables to eat. Their diet consists of yams,
palm oil, a small amount of sh, 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 U.S. 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 our, 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,” while the healthier Siberians eat from the land.
Some recent, popular weight-loss diets advocate eating generous portions of animal
proteins and fats, while minimizing or eliminating carbohydrate intake altogether.
Despite the e ectiveness of these diets in reducing body weight, often due to loss of
body uids 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 bene ts stem
partly from their potassium and calcium contents. Concerned about the harmful e ects
of fat, many Americans and Europeans have in fact been lowering their fat consumption
for several years.
Epidemiologists consistently nd 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 o Alzheimer’s disease. Dr. Robert Friedland and his associates
at Case Western Reserve University recently 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 bene t 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 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 e ect 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. A recent study found
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 recent study in
the New England Journal of Medicine found that people with high blood pressure also
bene ted from adding several servings of fruits and vegetables and low-fat dairy foods
to their diets.
Not all fats are bad and accelerate brain aging. Some fats actually promote brain
tness. Dietary fats come in four forms: cholesterol, saturated, monounsaturated, and
polyunsaturated. Omega-6 and omega-3 fats are polyunsaturates. Omega-3 fatty acids,
often considered “good fats,” come from foods such as fruits, leafy vegetables, nuts, sh,
sh 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,” 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.
Diets high in omega-6, or bad, fats may contribute to chronic brain in ammation, a
possible underlying mechanism in Alzheimer’s disease and other neurodegenerative
disorders. Omega-3, or good, fats help keep brain cell membranes soft and exible,
while 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 a recent investigation of older
Italians, their use of approximately three 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 e ects on the
hormone insulin. Laboratory animals that are fed omega-6 fats have increased di culty
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 e ective 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 bene t our brain tness 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 GOOD AND BAD FATS

GOOD FATS BAD FATS
(HIGH IN OMEGA-3) (HIGH IN OMEGA-6)
Anchovies Bacon
Avocados Butter
Bluefish Cheese
Brazil nuts Corn oil
Canola oil Donuts
Flax seed 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
Good Fats Bad Fats
(High in Omega-3) (High in Omega-6)
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 side column above (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 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, docosahexaenic acid, or DHA,
which comes from sh oil, actually increases acetylcholine, the brain messenger critical
to normal memory function but lost in Alzheimer’s disease. People with de cient DHA in
their diets or low levels in the blood will experience learning di culties and cognitive
decline. These can and do improve when dietary DHA is high. Research indicates that
omega-3 fatty acid capsules may improve memory di culties and other symptoms in
patients with Alzheimer’s disease.
Recent studies suggest that omega-3-rich sh oil may bene t 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 e ect that ghts against free radicals that
can damage brain cells and decrease the brain’s immune response (see later discussion),
thus modulating the cell-damaging e ects of in ammation. Because low-fat diets protect
us against Alzheimer’s disease, a healthy brain diet should include all kinds of sh, not
just those high in omega-3 fats but sh that are considered low in their overall fat
content, such as sword sh, snapper, sole, cod, cat sh, ounder, perch, shell sh,
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 sh. This might sound like splitting
hairs, but it’s not. Farmed sh 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 sh the way their free-swimming counterparts do in the ocean. Ocean-caught
sh have less overall fat but more of the omega-3 fats because they are eating natural
diets.
 Healthy Brain Diet Tip

Eat fish at least 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 su er 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 Alz-heimer’s.
To keep oxidation in check, our bodies use antioxidants like vitamins C and E that
combat the e ect of free radicals. Recent studies show that 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 tablets
appear to have better memory abilities and less cognitive decline.
Dr. Martha 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 tablet, which generally contains about
30 units 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 high enough dose of
vitamin E—2,000 units daily—enough to feel assured that its antioxidant e ects 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. Many experts,
therefore, recommend taking vitamin E at 1,000 units, twice daily, for severe memory
loss as seen in Alzheimer’s disease.
For people with only mild memory complaints who would like to bene t from vitamin
E’s antioxidant e ects that might prevent future severe memory losses, deciding on an
optimal daily dose is complicated by the vitamin’s e ect 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 e ect. 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 ght o infections. Thus, doses
above 1,500 units are rarely recommended except in cases of full-blown Alzheimer’s
disease.
In response to concerns about vitamin mega-doses, the National Academy of Science’s
Institute of Medicine recently recommended upper limits for antioxidant vitamins: 2,000
mg of vitamin C and 1,500 units of vitamin E in the natural d-α-tocopherol form (1,100
units in the synthetic dl-α-tocopherol form). The key is to nd an e ective and safe
dose, while avoiding a mega-dose.
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 bene ts for years. Dr. Jim Joseph of the U.S. Department of Agriculture
found that laboratory animals fed on these natural antioxidant foods show better
memory ability in nding 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 di erent foods to counteract oxidative stress. Those foods with high “oxygen
radical absorbency capacity,” or 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 1/2 Ounces
 Prunes 5,770
Raisins 2,830
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

The Tufts University experts recommend we all eat about 3,500 ORAC units each day
—and just one 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 diets. By simply doubling our average fruit and
vegetable intake, we could each raise our diet’s antioxidant power by 25 percent.
Although during the last 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 tomato or V-8 juice, can dramatically increase the blood’s
antioxidant capacity. The UCLA human nutrition research group found that just six
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 linguini, and we’ve got a brain-
healthy lunch! Pass the salad, please.

Healthy Brain Diet Tip

Eat at least five 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 signi cant amounts of the potent antioxidant known as
catechin. Ca einated green teas have very high catechin levels, as do ca einated 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 ght
cancer; lycopene makes tomatoes red and protects our hearts and brains. Even the
National Cancer Institute advises people to color their diets in its new Sample the
Spectrum campaign.

Spice It Up
For many years I have preferred the dark, avorful Dijon variety of mustard, while
watching my kids squirt that bright yellow stu on their hot dogs. Little did I know that
the more colorful 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 the spice 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-in ammatory actions besides. Scientists have found that
curcumin relieves symptoms in arthritis su erers and inhibits the growth of various
cancer and tumor cells. Such encouraging curcumin e ects led Dr. Greg Cole and Dr.
Sally Frautschy at UCLA and its a liated Veterans A airs Medical Center to study this
ubiquitous spice’s potential for preventing Alzheimer’s disease. Their initial
investigations of laboratory animals con rmed 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.

Vitamins and Minerals for Keeping Brains Young

When a patient complains of a memory problem, one of the rst things we do is to test
their blood levels of vitamin B12. Low levels of thiamine, vitamin B12, or folic acid have
been found to cause memory disorders. Some studies have shown that when Alzheimer’s
victims are treated with high doses of vitamin B12, 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 B12 supplement in addition to a daily
multivitamin. Research has shown that 20 percent of people age 60 and older, and 40
percent of those over age 80, lose some of their ability to absorb vitamin B12. Folate, or
folic acid, is an antioxidant B vitamin that also o ers 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 child-
bearing years because a high enough blood level at the time of impregnation greatly
diminishes the risk of having a baby born with spina bi da 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.
Recently, neuropsychologist Asenath La Rue of the University of New Mexico
examined the mental and nutritional status of well-educated people ages 66 to 90, who
were free of any major memory problems. Her study showed that the volunteers taking
thiamin, ribo avin, 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 ndings point to the potential brain-boosting e ects of
various vitamin supplements.
Further research has shown that older persons with low levels of thiamin, ribo avin,
vitamin B12, and vitamin C are more likely to experience anxiety, irritability, and
depression. People who eat well-balanced meals generally don’t develop de ciencies,
and most doctors recommend daily multiple vitamins to ensure that such de ciencies do
not develop.
It is also important for all of us to keep in mind the potential toxic e ects of
unnecessary vitamin mega-doses. 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 (Food and Drug
Administration); 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
 Another Supplement: Phosphatidylserine

Phosphatidylserine is a naturally occurring nutrient that exists in common foods such as

sh, 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
e ectiveness 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 e ective, and perhaps sixty or more studies have
demonstrated this modest but positive bene t. A limitation of these studies, however, is
their relatively brief duration, ranging from six to twelve weeks, raising the possibility
that the bene t may be not be long-term. It is certainly possible that phosphatidylserine
has a long-term bene cial e ect, 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, blurry-eyed, empty mug in
hand, and grope our way to the co eepot before we can imagine beginning our day.
Co ee consumption exceeds 100 billion cups per year in the United States alone, where
80 percent of the adult population drinks co ee or tea daily—making ca eine our most
commonly used drug. We also get ca eine in our diet from sources that some people are
not aware of, including chocolate and some sodas.
Too much ca eine increases cholesterol levels, may increase the risk of heart attacks,
and is associated with urinary bladder cancer and high blood pressure. Ca eine also
increases risk for bone thinning from osteoporosis. Acute ca eine intoxication causes
rapid heart rate and can pose health hazards for cardiac patients.
Ca eine has both positive and negative e ects on brain tness. 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, ca eine can improve learning and recall abilities. In the Honolulu Heart
Program, a thirty-year study of 8,000 people, the risk of developing Parkinson’s disease
was five times lower in coffee drinkers compared with those who did not drink coffee.
On the negative side, extended ca eine use can cause irritability, insomnia, and
anxiety. Because ca eine’s e ects are short-acting, suddenly interrupting the ca eine
habit can cause withdrawal symptoms. Ca eine withdrawal usually begins twelve to
twenty-four hours after the last exposure, with symptoms peaking in the rst 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 ca eine x. Just
ask my wife—but not before she’s had her morning co ee. The single greatest cause of
post-operative headache is ca eine withdrawal. In order to prevent post-operative
headaches, some surgeons have been known to actually add ca eine to the intravenous
fluids of patients who cannot drink liquids after surgery.
For those of us who do consume ca eine, we need to be aware of the side e ects and
avoid overuse and withdrawal symptoms. Table 7.4 lists the ca eine 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 a ect 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 di culty 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 a ect 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 e ects of sugar on the brain are well documented. After drinking
carbohydrate-spiked lemonade, volunteers show better memory performance and
mental exibility 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 su cient blood sugar keeps our brains working optimally and a quick glucose
x can give us an immediate memory and concentration boost, many of us su er from
chronically high blood sugar levels. If sustained over months and years, these high blood
glucose levels can lead to a pre-diabetic 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
e ective insulin. This can cause the body to become insulin-resistant or unable to use
insulin e ectively, which puts one at risk for non-insulin-dependent diabetes, or type 2
diabetes, as well as high blood pressure and circulatory problems a ecting the brain.
Arteries can become stiffer, restricting blood flow to the brain.
About 16 million people in the U.S. su er from diabetes, an increase of nearly 40
percent during the last decade. 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.
Because our brains need a steady ow of sugar to keep them optimally t,
maintaining an even glucose level in the brain and avoiding blood sugar uctuations
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 diets. In contrast to our
ancestors’ natural sources of carbohydrates—fruits and vegetables—many people today
eat foods containing re ned sugars and processed our. 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.
In recent years, scientists have begun studying the actual blood sugar responses to a
variety of foods. They are then able to compare the food’s true physiological e ect 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 like bread,
potatoes, and some types of rice are digested and absorbed quickly, rather than slowly.
Second, foods with lots of sugar, like 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 to burn off fat. Exercise
physiologists have found that eating low-glycemic-index carbs before sustained,
strenuous exercise improves physical performance.
A recent study of nearly 36,000 women initially free of diabetes found that those
eating low-glycemic-index grains, particularly whole grains and cereal ber, 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.
In her book The Glucose Revolution, Dr. Jennie Brand-Miller of the University of
Sydney and her colleagues provide a glycemic index table that ranks common foods
according to how much they spike blood sugar levels. This index is an average from
several studies of the foods’ physiological e ects. 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
Low (Glycemic Index 40–54)
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 Corn flakes

Raisin bran cereal Total 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 speci c e ect 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 like vinegar also will minimize
blood sugar spikes. Dr. Brand-Miller found that lemon juice and vinegar, particularly
red wine vinegar, have this e ect, which she attributes 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.

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.

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, while the opposite problem is a
complaint for many of today’s weight-conscious baby boomers. Stress often triggers
impulse eating or perhaps leads you toward old habits, like downing your rst grader’s
leftover potato chips while driving home from the office.
Have you ever picked up the phone, su ered through an unpleasant phone call, hung
up, and noticed that eight Oreo cookies have disappeared? Do you nd 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 nally 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 akes 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 eeting, 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 baggies of fresh-cut vegetables in convenient places where stress
eating most often occurs—near the kitchen telephone, at the o ce 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 rst 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- ber breads, cereals, and grains; and
low-fat animal proteins (e.g., skinless chicken, sh, skim milk products). Dr. Heber
encourages people to use herbs, spices, garlic, chili peppers, avocados, nuts, seeds, and
olives as taste enhancers. Emphasis on taste as well as health usually helps keep us on
our healthy brain diets 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 tness 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 di culty 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.

Healthy Brain Diet Worksheet

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 ndings in their book
Successful Aging and gave baby boomers 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 tness. The U.S.
Surgeon General, Dr. David Satcher, advises Americans to follow his prescription for
healthy living with recommendations that include moderate physical activity—at least
30 minutes a day, ve days a week; eating at least ve servings of fruits and vegetables
each day; and avoiding tobacco, illicit drugs, and alcohol abuse. If there were a
comparable o ce 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 at age 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 30 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

Recent discoveries show that physical activity and aerobic conditioning promote brain
tness. 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 tness. Physical exercise can also enhance our mental
state by increasing the circulation of endorphins—hormones released in our brains after
exercise that have immediate bene ts 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 like heart attacks and strokes. Many experts recommend walking as one
of the safest and most e ective forms of aerobic exercise. The MacArthur Study of
Successful Aging noted that older adults who walked 45 minutes, three to four times a
week, doubled their endurance level after a year.
A convincing case can be made for the mental bene ts 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 tness, including triathletes, long-distance runners, and championship tennis
players.
Recent studies, however, indicate a de nite link between physical activity and staving
o 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 co-workers 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 ow 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 500 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 su er
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 bene ts in mental
performance, regardless of age. In fact, provided people do not over-exert themselves,
these bene ts can be observed immediately following exercise. Long-term cognitive
benefits have also been noted with continued physical conditioning.
Recent investigations suggest that the greatest short-term cognitive bene ts of aerobic
tness involve 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 animals such 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 lifespan. 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 non-exercisers of the same age. They
also outperform their inactive counterparts on tests of reasoning, memory, attention,
and intelligence. Studies of aging athletes, however, may re ect some other advantages
associated with being physically active, such as a healthy diet, good genetic
predisposition, or use of anti-in ammatory drugs. Research data vary according to the
age of the volunteer. In fact, the older the study subject, the more prominent the mental
bene ts of physical exercise. Also, if a person is physically t 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 bene ts 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 cool-down 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.
Aerobics are not the only aspect of exercise that keeps our brains young, however.
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 tness programs available today, many baby
boomers 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 bene ts 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 5- or 10-
minute brisk walk over another co ee 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 10 or 15
minutes a day at rst, make the best use of those 10 or 15 minutes 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 cool-down 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 tness—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 tness program, I advise my patients to avoid those that
increase risk for head trauma. More than 5 million Americans have su ered from some
type of traumatic brain injury, and nearly all those injuries could have been prevented.
The scienti c 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 co-workers at Duke University studied medical records
of veterans who had su ered varying degrees of head trauma, dating back as far as fty
years. They found that veterans with only moderate head injury—loss of consciousness
or post-traumatic amnesia for more than 30 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 su ered amnesia for more
than twenty-four hours 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. Recent studies have focused on the memory e ects 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 mid-twenties to same-aged
swimmers and runners who were less likely to su er head injuries. Over 30 percent of
the soccer players su ered from memory impairments, while 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 recently 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 company’s
team and getting 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 describes a brain reserve capacity that varies among individuals,
giving each person a di erent 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 e ect 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 re ection
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 Scho eld and co-workers 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. UCLA investigator Dr. Barry Jordan found that possession of this
Alzheimer’s risk gene was associated with more severe neurological de cits 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.

Just Say No to 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
de nite 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.
The U.S. Surgeon General, Dr. David Satcher, advises all smokers to quit. Once a
person quits smoking, the bene ts 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 e ort. Some
intensive treatment programs have success rates for long-term abstinence approaching
50 percent. Nicotine patches and gum have proven e ective as well, particularly when
used along with other treatment approaches. Antidepressants like 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 bene ts of
this neurotransmitter in diseases ranging 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.
Although nicotine may bene t some brain receptors involved in memory
performance, the negative health consequences of smoking outweigh any remote
potential bene t. The good news for smokers is that it’s never too late to quit, and the
bene ts of cessation are possible at any age. Although some people report a slight
weight gain when they stop smoking, regular physical exercise can help o set 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 15 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 20 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 di erent 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 di erent cognitive abilities
as well as memory capacities. Lydia was in the beginning stages of Alzheimer’s
disease. Clearly, the twins’ di ering lifestyle choices had contributed to the
di erences 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 UCLA studies of twins
con rm 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—de ned 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 non-drinkers. This type of moderate alcohol use has other health bene ts,
lowering the risk for heart attacks as much as 40 percent in one recent study.
In North America, moderate alcohol consumption is sometimes de ned 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 e ects of alcohol may
slow down brain aging by interfering with free radical formation and in ammation.
Exactly how alcohol might protect the brain or heart is not fully known, but it may
involve an anti-platelet e ect that lowers the blood’s tendency to clot and cause tissue
damage.
Many experts argue for red wine as the preferred brain tness 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 bene ts. However, heavy drinkers should de nitely 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 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 a ect memory abilities, but
there are currently no data indicating exactly how long those e ects 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 pro ts. 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 ve years ago when he rst
began having trouble remembering the names of his regular customers. Then he
started making errors in reservations, and even sta 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
di culties 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.
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 di culty with verbal and visual memory and attention. Despite the
potentially harmful e ects of marijuana, memory e ects do diminish after people stop
or cut down on their use.
A rash of new psychoactive drugs has emerged in recent years, including the popular
drug known as Ecstasy. Animal studies have shown that Ecstasy causes damage to the
brain cells that produce serotonin, the neurotransmitter that modulates mood and keeps
us from becoming depressed. Extensive Ecstasy use has been shown to impair verbal and
visual memory. A recent study found that even after a year of abstinence, Ecstasy users
still showed evidence of memory impairment compared with those who had never used
the drug.
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.

Don’t Overeat, Don’t Overdrink, But Get Out and Make Merry

In addition to encouraging physical and mental activity, a major nding 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 bene t from it.
Because a large component of MacArthur’s de nition 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—like not
smoking, or eating a low-fat diet—may rub o on us, too. Social support, or the
emotional and practical advantages we gain from others, may even directly bene t 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.
A recent study of men found that good social support signi cantly 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 nd him passed out on the oor. 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 nally 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 o 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. The lack of
available partners, however, is often a barrier to an active sex life for many older
adults. Women live longer than men, and by age 85 there are twice as many women
alive as men. Approximately 20 percent of men who live to age 65 or older have low
testosterone levels and di culties with ejaculation. The new drugs for male impotence,
however, have clearly had an impact on this problem. Viagra is both safe and e ective
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 exibility 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 today’s
baby boomers, with their two-career families and 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 e ect 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. 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 a recently
published 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 ndings 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 recent
scrutiny because of its possible in uence 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 e ects. 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
t, 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 tness, exibility, 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 two 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 fties—what we now
consider middle age. Today, the average American man lives to age 73, while women
can anticipate 79 years. Some experts estimate that by the year 2010, the average man
will live to 85 and the average woman to 91.
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. Only recently have drugs become available to treat memory loss and
other cognitive conditions, or possibly prevent Alzheimer’s 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 tness and protecting
against Alzheimer’s disease.
At UCLA, we are testing 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
bene ts from medications currently marketed for other conditions, such as anti-
in ammatory drugs and estrogen replacement hormones. Scientists have begun human
testing on a vaccine that may not only prevent the brain from accumulating Alzheimer’s
plaques but may also eliminate already existing plaques.

How Doctors Understand Medical Conditions

The rst step to using medicines wisely is to communicate e ectively 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 about 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 speci c—provide details about the timing of symptoms, their quality, and
any events associated with their onset. Bring in all your medicines, 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 non-
medicinal 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 di culties. Usually a brief mental status exam can be completed within 10 to
15 minutes, but more detailed memory assessments, or neuropsychological tests, can
provide a better understanding of subtle memory de cits. The laboratory component
should include blood tests to rule out thyroid disease, vitamin B12 de ciency, and other
disorders that could possibly cause memory changes. And, as noted in Chapter 1, a PET
scan is the most sensitive method of detecting possible Alzheimer’s disease.
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 all the other aging boomers, I am at risk for developing a variety of physical
illnesses, including hypertension, high cholesterol, and diabetes, that can impair
memory ability and a ect long-term brain health. Studies have found higher rates of
Alzheimer’s disease and other dementias in people with these conditions. E ective
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 ndings 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, a ects more than 60 percent of people over age
65. 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 e ectively treated with a variety of
proven medicines, but the most e ective 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.
Recent research shows that chronic high blood pressure during midlife (forties and
fties) leads to cognitive decline later in life. Chronic hypertension most likely a ects
memory because it thickens and sti ens blood vessels. Under high pressure, these
sti ened blood vessels can rupture, possibly causing cerebral vascular disease involving
blood leakage into the brain tissue and stroke. A stroke is often de ned as the death of
brain cells, resulting in a loss of physical or mental function or both. But treatment
makes a di erence. Dr. Edwin Jacobson of UCLA recently reported that rigorous control
of mild to moderate hypertension can improve cognitive function. He noted signi cant
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. A recent 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 a ect memory. Inherited genetic factors as well as lifestyle choices are known to
contribute to the risk for high cholesterol. In recent years, 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 60,000 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 di erent conditions such
as hypertension or cardiovascular disease.
Dr. David Drachman, University of Massachusetts, found that a wide variety of statins
have the e ect of lowering one’s risk for Alzheimer’s, including atorvastatin (Lipitor),
cerivastatin (Baycol), uvastatin (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 bene ts 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 de nitively that these drugs truly help to prevent
Alzheimer’s disease. However, current data are encouraging. In addition, the mounting
scienti c evidence of the cardiac bene ts of cholesterol-lowering drugs recently spurred
the National Heart, Lung and Blood Institute to change their guidelines to recommend
that a greater number of Americans should be taking these drugs—about 36 million
compared to the 13 million of previous guidelines.

Coronary Bypass Surgery

High cholesterol, high blood pressure, and other conditions sometimes damage the heart
to the extent that surgery is needed. A recent report published in the New England
Journal of Medicine noted a startling decline in memory ability in people ve 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, ve years later, the proportion of cognitively impaired
patients was back up to 42 percent. The main predictor of memory loss ve 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 arti cial 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 ow through tiny vessels, thus killing brain cells. The New England Journal of
Medicine report will likely open the door for increased study of prophylactic treatments
to prevent post-surgical cognitive decline, including the use of anti-Alzheimer’s drugs.
Anesthesia used during surgery is also being studied as a possible contributor to post-
surgical memory decline. Although most people have no long-term cognitive losses after
one or two surgeries, the cumulative e ect of multiple exposures to anesthesia has the
potential to accelerate brain aging, particularly in someone already at risk. A recent
study of people over age 64 found 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 non-
crucial 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 tness, and becomes
more frequent with age. An estimated 16 million people in the United States su er from
diabetes, yet about half of them don’t even know they have it. In addition to exercise
and diet (Chapter 7), there are well-known medications, like insulin, that e ectively
treat diabetes. Control of diabetes will protect brain tness 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-
nding di culties during a u or pneumonia. Usually these problems disappear or are
reversible when the disease lifts. One 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 B12 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 e ects of
medication, and this sensitivity can lead to side e ects at much lower doses. Also, our
bodies become less e cient 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 e ects, 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 e ects, 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 tness, and they should be
taken with care.
When a patient visits the UCLA Memory Clinic for the rst time, we ask them to bring
in all their medications. Many older patients have arrived with shopping bags lled
with prescription bottles. Often the easiest and most e ective 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 e ective dose of a medication will lower their risk for developing side e ects;
however, too low a dose, or a sub-therapeutic 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 ll 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 di erent
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 rst
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 di erent
doctors and getting multiple prescriptions for many of her conditions including pain,
anxiety, depression, and memory loss. Most of her symptoms were intensi ed by the
overuse and interactions of her drugs. The antidepressant she was taking actually had
an anti-cholinergic e ect 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 e ects. He also reduced the pain from her arthritis
and headaches by using a non-narcotic 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 ine ective 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 a ecting 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 Common Name Generic Name
Tagamet Cimetidine
Anti-ulcer/
Zantac Ranitidine
Codeine
Demerol Meperidine
Analgesic
Fiorinal Oxycodone
Percodan, Percocet
Antihistamine Benadryl Diphenhydramine
Ambien Zolpidem
Ativan Lorazepam
Dalmane Flurazepam
Halcion Triazolam
Anti-anxiety/Sedative Librium Chlordiazepoxide
Restoril Temazepam
Serax Oxazepam
Valium Diazepam
Xanax Alprazolam
Elavil Amitriptyline
Antidepressant
Tofranil Imipramine
Benazepril Lotensin
 Anti-hypertensive Dyazide Hydrochlorothiazide
Tenormin Atenolol
Toprol Metoprolol
Anti-Parkinson’s Symmetrel Amantadine
Haldol Haloperidol
Anti-psychotic Mellaril Thioridazine
Thorazine Chlorpromazine
Hormone Synthroid, Thyroxine Thyroid supplements
Steroid Prednisone Prednisone

The Business of Anti-Aging

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 e ectiveness, 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 e ect” may help explain the popularity of these
treatments. I know one mother who used this tried-and-true placebo e ect 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- avored 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 scienti cally proven placebo e ect
—whether it is the patient’s belief or expectation that the treatment will work, the
doctor’s con dence 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 e ect, the gold standard for proving the
e ectiveness of any new drug or treatment is to show that the active drug is indeed
more beneficial than a placebo—over time.
A recent study analyzing 114 published reports involving 7,500 patients with a
variety of di erent conditions raised new controversy about the placebo e ect. Dr.
Asbjorn Hrobjartson and Dr. Peter Gotzsche of the University of Copenhagen found that
what many believe to be an e ect 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 e ect, as
illustrated in Figure 9.1.

Figure 9.1

In the study graphed in the gure, 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 rst six weeks of the study—the
placebo was just as good as the Aricept in improving memory and other cognitive
abilities. This e ect, 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 bene t 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 e ect
from a breath mint) and may be causing themselves unnecessary side e ects that can
harm their health.

All That Is Natural Is Not Necessarily Safe

An estimated 124 million Americans have tried herbs, vitamins, minerals, enzymes, and
other “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 80 percent of the
world population uses botanical preparations as medicines. 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 U.S. Food and Drug Administration reports nearly 3,000 adverse events each year
from supplements such 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.
Food manufacturers have been trying to build on their earlier successes with dietary
supplements by adding herbs to foods. Because of concern about the potential harmful
results, the FDA recently noti ed several companies that this practice violates federal
regulations governing what manufacturers can and cannot add to food.
Of all the various herbal remedies marketed to treat the maladies of aging, ginkgo
biloba has received the greatest attention in the last few years. An estimated 11 million
Americans have used this 4,000-year-old herbal medicine, which 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 in several forms of memory impairment, including mild age-
related decline, vascular dementia, and Alzheimer’s disease. Some studies have shown
signi cant results, but the clinical relevance of the e ects has been unclear. Moreover,
experts have questioned the methods of these studies. Improved and better-designed
studies are currently under way, including a large trial comparing ginkgo biloba to
placebo in approximately 3,000 people aged 75 or older, so we look forward to more
reliable information in the future.
Because the FDA does not regulate ginkgo biloba, the quality and consistency of the
many brands available di er considerably. Ginkgo has been known to cause nausea,
heartburn, headaches, dizziness, excessive bruising or bleeding, low blood pressure, and
other adverse e ects. Ingesting ginkgo has been associated with blood clots surrounding
the brain (subdural hematomas), and ginkgo can a ect insulin secretion, making it
potentially dangerous for diabetics. Because ginkgo biloba has anti-coagulant
properties, taking it with aspirin and other blood-thinning drugs requires careful
monitoring. The current limited evidence for ginkgo’s e ectiveness, and its potential for
adverse e ects, 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
co ee or other mild stimulants, they may experience rapid heart rate and anxiety.
Guarana is an herb used as a stimulant and natural source of ca eine, which has some
anti-coagulant e ects. 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- avored 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 e ects 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 7 million Americans as a natural treatment for depression
or insomnia. Although recent studies have not found it to be e ective in clinical
depression, it can augment the e ects 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 e ects, and many individuals swear to their bene cial e ects. In fact,
herbal remedies may be e ective for some people in certain situations that experts are
not even aware of.
The scienti c community and the public at large continue to wait for results of
conclusive double-blind studies showing whether or not ginkgo biloba and other herbal
memory loss treatments actually work. For now, considering their potentially harmful
side e ects, I usually recommend my patients avoid taking unnecessary risks with
unproven anti–brain-aging remedies.

Pharmacogenetics: The Future of Alzheimer’s Disease Prevention

In recent years, several available drug treatments have proven e ective for the memory
loss and other cognitive declines of Alzheimer’s disease. But as scientists continually
search to nd a cure for Alzheimer’s disease and possibly prevent its onset in the rst
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 di erences in an individual’s drug response,
and these di erences can take e ect at many levels. It could a ect 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 e ectively 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
pro le before beginning medication treatment. A meaningful pharmacogenetic pro le
may help to de ne a sub-population 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. At UCLA we are conducting a double-blind study to develop a
pharmacogenetic treatment strategy for delaying the onset of Alzheimer’s disease
(Chapter 1). All research subjects are tested for any APOE-4 Alzheimer’s genetic risk.
They also receive a PET scan before starting treatment, as well as a follow-up scan two
years later. We predict 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 e ective 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. Our hope is that these ongoing studies will lead to the widespread use of
pharmacogenetic testing to determine who is or is not likely to bene t 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 Woodru -Pak and her associates at Temple University treated rabbits with
galantamine (Reminyl), 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 e ect 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 e ects that may
slow down brain aging. Large-scale human studies are already under way in people
with mild memory complaints to see if using such drugs early in the course of brain
aging might modify the progression of cognitive decline.

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 con icts 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 speci c 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 di culties, and their depressions are often colored by memory
complaints. A form of depression often seen in older people has been labeled as
“pseudo-dementia” 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 o 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 e ective treatments in their own
rights, but combining the two, when indicated, appears to be more e ective than either
form of treatment alone.
Although all types of antidepressant drugs have been e ective in relieving some
symptoms of depression, the improved side-e ect pro les of the newer antidepressants,
like uoxetine (Prozac), sertraline (Zoloft), mirtazepine (Remeron), or citalopram
(Celexa), to mention a few (see box), have become preferred treatments over older
medicines like amitriptyline (Elavil) or imipramine (Tofranil). These older medicines
can potentially worsen memory performance because of their anti-cholinergic 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
e ectively 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 o er the most
sophisticated care (Appendix 5).

Some Commonly Used Antidepressant Drugs

Dose Range
Drug Possible Side Effects
(mg/day)
Buproprion
37.5–450 Insomnia, nausea
(Wellbutrin)
Citalopram (Celexa) 10–60 Insomnia, nausea, sexual dysfunction
Heart arrhythmia, sedation, sexual
Desipramine 10–300
dysfunction
Paroxetine (Paxil) 10–60 Nausea, sexual dysfunction
Fluoxetine (Prozac) 10–80 Insomnia, nausea, sexual dysfunction
Mirtazepine
15–45 Sedation, weight gain
(Remeron)
Nefazadone
100–600 Sedation
(Serzone)
Heart arrhythmia, sedation, sexual
Nortriptyline 10–200
dysfunction
Sertraline (Zoloft) 25–200 Headache, nausea, sexual dysfunction
Venlafaxine (Effexor) 37.5–375 Insomnia, nausea
Trazodone (Desyrel) 25–600 Sedation, heart arrhythmia

Using Sex Hormones to Prevent Memory Loss

In recent years, scientists have taken increasing interest in the e ects 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 ow. It also boosts memory transmitters like acetylcholine. In
addition, estrogen serves as an antioxidant, helping to prevent damage to cells over
time. Based on estrogen’s proven bene ts for treating menopausal symptoms like hot
ashes and insomnia, hormone replacement therapy is already a $5 billion annual
industry and continues to grow.
There is still much debate over estrogen’s true bene ts 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 bene ts 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 ow to the
hippocampus, a brain area involved in memory function. Dr. Barbara Sherwin at McGill
University in Montreal has shown that estrogen’s bene t for post-menopausal women is
concentrated on verbal, rather than visual, memory.
Hopefully, in the next few years the Women’s Health Initiative will give us a
de nitive answer on whether or not post-menopausal estrogen use can truly stave o
Alzheimer’s disease. In this large-scale study, U.S. investigators are randomizing nearly
10,000 women to di erent estrogen preparations or placebo and following their rates of
osteoporosis, heart disease, cancer, and Alzheimer’s disease. If estrogen does turn out to
protect women from developing Alzheimer’s disease, then that bene t also needs to
offset such potential risks as breast cancer and heart disease.
New drug development has led to synthetic estrogens designed to isolate speci c
bene cial e ects while eliminating unwanted side e ects. Although investigations thus
far have not shown these “designer” estrogens, or selective estrogen receptor modulators
(SERMs), to improve cognitive function, many experts remain optimistic of their
potential benefit.
The male sex hormone testosterone also has some important e ects 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 ve men
65 and older end up with an abnormally low testosterone level, and initial studies
indicate that men with low levels experience improvements in mood and memory
following testosterone administration. Our UCLA research group is among those
systematically studying testosterone’s potential benefits for memory.

Anti-Inflammatory Drugs—for Pain, Memory Loss, or Both?

In the late 1990s, epidemiologists found that using the anti-in ammatory drugs
ibuprofen (Advil, Motrin, Nuprin), naproxen sodium (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 e ects came from their action on
in ammation. 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
in ammation. The theory is that our brains mount an in ammatory response attack
against the amyloid protein, attempting to get rid of it, and this in ammation causes
cell death and memory loss.
Scientists are focusing their e orts on developing speci c drugs to target the brain’s
in ammatory response. Dr. Michael Mullan and his colleagues at the University of
South Florida recently described how microglia cells promote an immune response that
causes in ammation 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 a ected 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
in ammatory hypothesis. If the current studies prove successful, people could choose to
take precautionary anti-in ammatory drugs for decades before reaching an age when
Alzheimer’s is likely to strike.
Recently, Dr. Anthony Broe and colleagues at the University of Sydney, Australia,
found that low doses of anti-in ammatory 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
insu cient to mount an anti-in ammatory response in the brain, which raises the
possibility that interrupting the in ammatory reaction might not be the critical
mechanism in protecting the brain.

Blowing the Smoke Out of Nicotine: Transdermal Patches

Most of us know about the negative consequences of smoking, particularly lung cancer
and heart disease. However, due to the damage it does to the brain’s circulation,
smoking can also increase the risk for age-related memory loss.
 Ironically, 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.
Recent studies have 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. The long-term memory bene ts of this approach are
currently being studied.

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.
One promising breakthrough of late is a vaccine developed to create a heightened
immune response that sloughs o the plaque deposits leading to Alzheimer’s disease.
The immune system, or the body’s mechanism for ghting o 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 have been working on a
system that may stop the plaques from forming in the rst 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.
Although the vaccine already appears safe in its initial human studies, experts remain
uncertain as to whether the approach will stave o Alzheimer’s disease. The Alzheimer’s
mice di er from humans with Alzheimer’s disease. These animals do not show many of
the symptoms seen in humans su ering from the disease, including the death of nerve
cells. We don’t yet know if the memory loss associated with Alzheimer’s disease will
signi cantly improve following depletion of the amyloid plaques, and it is possible that
immunization with amyloid-beta may simply clear the plaques from the brain and have
only minimal effects on memory loss.
The only sure- re way to know if the vaccine e ectively treats the disease is to test it
in humans in a large-scale, double-blind placebo test. If the vaccine does work, it will be
revolutionary. Not only might it prevent the disease in healthy people at risk for
Alzheimer’s disease but it may also lessen the existing symptoms in patients already
su ering from the disease. Early candidates for determining if the vaccine prevents
Alzheimer’s disease would likely be people with a family history of Alzheimer’s disease,
the APOE-4 genetic risk, or both.
Studies of the vaccine in Alzheimer’s patients are currently under way. Patients are
receiving four injections over a six-month period to assess safety and measure buildup of
the antibodies that will hopefully rid the brain of plaques. The hospitals where the
initial studies took place were kept secret so the public would not besiege the
investigators with requests to sign up for the trials. Unfortunately, studies were recently
discontinued because a small number of the vaccinated patients developed side e ects
from an in ammatory response in the brain. Scientists are now studying how to move
forward on the vaccine approach without causing such side effects.
Another recent report on a possible plaque buster treatment for Alzheimer’s disease
involves an older, lesser-known antibiotic called clioquinoline, once used to treat
traveler’s diarrhea. Dr. Ashley Bush and colleagues at Harvard Medical School screened
dozens of antibiotics and anti-in ammatory drugs to nd one that attached to copper
and zinc, prominent components of the Alzheimer’s amyloid plaques, in order to
develop a treatment that would eliminate these metals from the plaques. When
Alzheimer’s transgenic mice received clioquinoline, the antibiotic attached itself to the
metals in the brain plaques and cleared them out, leading to more than a 50 percent
reduction in plaques. The mice also improved in their general behavior. Clioquinoline
testing in human Alzheimer’s disease patients is currently under way.

Making Headway in Healing: Growing Brain Cells, Gene Therapy, What Lies
Ahead
The not-too-distant future may bring interventions for memory loss that today would
seem like science ction. Although neuroscientists have long believed that humans
cannot generate new brain cells, recent ndings now contradict 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,
undi erentiated 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, like in Alzheimer’s-affected brains.
Several scienti c 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 recently reported that neural stem cells can develop into any type of
nervous system cell as well as into non-neural 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 recent 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 bene t 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 re nement neurogenesis may eventually prove to be an e ective 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 recent genetic insights to practical
interventions in patients with Alzheimer’s disease or people at risk. Scientists at the
University of California, San Diego, recently made some headway in this direction when
they performed the rst 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 co-workers took skin cells from the patient and genetically engineered
them in the laboratory to produce and secrete human growth factor. The genetically
modi ed 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 nd drugs that can cross the blood-brain barrier and
reach the area of the brain that is a ected 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 are being 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 of memory problems. Thus, one medicine or course of treatment may
affect disease progression while another improves function.
As newer technologies emerge in the next decade, 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 ve
to ten years. In the meantime, available drugs for memory, depression, and physical
illness do have an important impact on brain health and o er 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 o 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

Some cynics, my wife included, may ask: “If we’re already su ering from brain aging
and annoying daily forgetfulness, how are we ever going to remember the last chapter,
or any of the strategies for keeping our brains young?” Well, to you, dear, and others of
your ilk, I submit this chapter as a practical guide to pull together your entire memory
program and 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 gures. 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 e ort at rst 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 rst-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 e ective notes. I rst 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 di erent words. This process helped x 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 e ort 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 e ective 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 o ce, home, and car can be more e cient 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 nd in the new house, even after months. A major
problem was that I had lost all my old memory places for various items,
from light bulbs 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, while 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
rst-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 o .
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 try an electronic hand-held organizer. Pocket date
books have long helped busy people keep track of the details in their lives.
For many people, the newer electronic pocket gadgets have replaced date
books because of their many programs, including calendars, phone books,
and to-do lists, as well as Internet access. You can download the
information onto your desktop computer so that, should you lose your
hand-held organizer, 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 Post-its for quickies. Many people prefer Post-its or stick-on 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 x as a reminder but try not to overuse them. An inherent risk in
using stick-on notes is that sometimes they “un-stick.” 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 after
breakfast (I do, especially vitamin E, 400 IUs—see Chapter 7). When the
dentist notes your chronic incapacity to oss, you might create a new
memory habit by placing the oss 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, Post-its 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 e ective. 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 o 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 tness 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 di erent strategies
in their memory improvement program if they can organize the individual tasks in a
way that fits into their daily routine.
To help you tailor your memory improvement program to your particular needs, the
following is a brief summary of the rst nine chapters. As you review them, check o
key points in the shaded boxes that you feel you may want to focus extra attention
upon, 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 rst warning sign of its gradual decline. Recent scienti c 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 recently discovered
genetic markers, we can pinpoint the earliest indications of impending brain aging. We
also now know that our brains have the power to ght back with an easy yet
comprehensive program of memory training and brain tness. 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, while 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 di erent-colored pencil. Compare your current score with your
earlier one ( ll 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 1 MINUTE:

Arrow
Pepper
Elephant
Stain
Toast
Instructor
Cigar
Grandmother
Hammer
Swamp

Now put aside The Memory Bible and reset your timer for a 20-minute break. Do
something else—water the plants, check your e-mail, whatever you like. After 20
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 di culty
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 nd 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 diets, the sooner we will reap the bene ts. 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 substituting
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 or not 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-to-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 e ects. Note
any of the lifestyle choices below 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 scienti c technologies and pharmaceutical discoveries continue to emerge in the

next decade, we can expect even more profound breakthroughs in our ght 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 rsthand how
di cult 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 exibility in his schedule to

keep up with several aspects of a brain tness program, including memory training,
mental aerobics, and physical exercise. He also worked hard during his rst week to cut
back his co ee 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 speci c
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
Active observation memory-training exercises (10 minutes)
training
4-Minimize
10-minute yoga session at bedtime 20-minute afternoon work break
stress
5-Mental
Read New York Times, did crossword at breakfast
aerobics
Multivitamin (containing 400 micrograms folic acid), vitamin E (800
7-Diet IU), vitamin C (1,000 mg)
6 glasses of water
Breakfast—sourdough toast, non-fat cheese slice, egg white, 2 cups of
coffee
Lunch—salad with low-cal dressing, ham, 1 cup of coffee
Dinner—salmon, steamed broccoli, non-fat yogurt dessert
Snacks—string cheese and blueberries
8-Physical
Stairs 3 times at work
exercise
Walked dog briskly after dinner—6 blocks
9-Medicine Anti-hypertensive, antidepressant

Day 2

CHAPTER ACTIVITY
3-Memory
Mental snapshot memory-training exercises (10 minutes)
training
4-Minimize
10-minute meditation session during lunch break
stress
Early to bed (9:30 P.M.)
5-Mental
Read New York Times, did crossword puzzle
aerobics
7-Diet Multivitamin, vitamin E (800 IU), vitamin C (1,000 mg)
7 glasses of water
Breakfast—sourdough toast, non-fat cheese slice, egg white, 1 cup of
coffee
Lunch—Non-fat 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, ½ cup of coffee
8-Physical
Stairs 2 times at work
exercise
Paddle tennis at the sports club
9-Medicine Anti-hypertensive, antidepressant, Tylenol (2)

Day 3

CHAPTER ACTIVITY
3-Memory
Association and linking memory-training exercises (10 minutes)
training
4-Minimize 10 minutes meditating after discussing complicated personnel issue
stress with co-workers
5-Mental
Math puzzle book; played word game with daughter
aerobics
7-Diet Multivitamin, vitamin E (800 IU), vitamin C (1,000 mg)
7 glasses of water
Breakfast—Bran cereal, non-fat milk, grapefruit, 1 cup of coffee
Lunch—Tuna sandwich, tea, strawberries
Dinner—skirt steak, potato, steamed vegetables, 1 glass of red wine,
non-fat yogurt
Snacks—blueberries, string cheese, ½ cup of coffee
8-Physical
Stairs 4 times at work
exercise
9-Medicine Anti-hypertensive, antidepressant, Tylenol (4)

Starting Your Memory Improvement Program

As in the example above, 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 o 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 Post-its.
Talk to brother-in-law about getting a hand-held organizer.
Focus on left-brain mental aerobic exercises like 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 nd examples of how di erent 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.

Mental Aerobics and Stress Reduction Worksheet

 Keeping Your Brain Young for Life

You have read The Memory Bible and now have many tools to help keep your brain
young, protect against future memory decline, and delay, or possibly even ward o
Alzheimer’s disease. The Appendixes that follow include very recent discoveries 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 non-medical 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 e ective 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 Probe—Keeping Watch on Plaques and Tangles

As I was nishing up The Memory Bible, 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 provides 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 scienti c backgrounds, in an e ort to nd an even more
speci c 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 recently synthesized a
new group of compounds that thrived in these hydrophobic environments, and these
molecules passed easily from the blood stream 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-de ned
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 rst 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 probe gives scientists the ability to monitor plaque and
tangle concentrations while testing experimental treatments to eliminate them.
The amyloid 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 rst, 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 di erent scans of a patient who su ers from Alzheimer’s
disease. The image on the left is an amyloid PET scan, while the image on the right is a
conventional PET scan. Note that the temporal areas (arrows) are darker in the amyloid
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).

Figure A.1

Our group is currently working with other researchers to use this amyloid probe
technology to study medications being developed to wipe out plaques and tangles
(Chapter 9). International enthusiasm for this technology is 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 tness. 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 gure soars to between 35 and 47 percent. Advanced brain aging and Alzheimer’s
disease a ict 4 million people in the U.S. and nearly 25 million people worldwide.
Despite such a high prevalence, Alzheimer’s disease and other dementias remain under-
recognized. Timely recognition is important because treatment is available. Both
medication and non-medicinal 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 nally 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 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 14 million Americans will su er 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 most costly disease in the U.S., 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 rst symptom to appear, and motor and sensory
functions are spared until late stages of the disease. Early on, patients have di culty
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 nding 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 nances or medications, use a telephone, and drive without getting lost,
and these kinds of di culties may be the patient’s or family’s rst 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,
like 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, while
an estimated 15 percent have a condition of motor sti ness 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 di culty in executive skills and planning complex tasks, yet their visual
and spatial memory tends to be preserved. The cumulative e ect 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 in uenced 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 B12 deficiency, and other disorders, which could possibly cause memory change.
Doctors often obtain a standardized score of cognitive ability using rating scales like
the Mini–Mental State Examination, which consists of 30 items that rate memory,
orientation, attention, calculation, language, and visual skills. The test takes only about
10 minutes but is limited because it will not detect subtle memory losses, particularly in
college graduates. 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 nd 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
non-speci c information about brain shrinkage or atrophy or white-matter changes,
which show up as spots in the deeper brain areas. These changes are often di cult to
interpret and rarely provide a diagnosis that will alter treatment.
By contrast, the positron emission tomography (PET) scan (Chapter 1) is the most
e ective way to arrive at an early diagnosis. PET scans enable a physician to make a
positive diagnosis of Alzheimer’s disease and of other types of dementia, facilitating the
initiation of anti-dementia 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.
At a cost of approximately $1,200 per scan, PET can minimize the need for repetitive
diagnostic tests. Depending on the particular clinical setting, such tests can cost upward
of $2,000. In the long run, PET scans may save money because earlier diagnosis can
eliminate lengthy, costly, and inconclusive evaluations.
Positron emission tomography can identify the Alzheimer’s brain pattern months,
even years before obvious symptoms of the disease appear in patients. Dr. Dan
Silverman and others in our UCLA research group recently conducted an international
study of nearly 300 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 rst 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 bene t 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 e ect 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 U.S.
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 bene t 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 de ciency 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 rst of these medicines to be approved, but it is
now rarely used due to the extent of its side e ects. The newer compounds have fewer
side e ects and include donepezil (Aricept, approved by the FDA in November 1996),
rivastigmine (Exelon, approved in April 2000), and galantamine (Reminyl, approved
May 2001). These drugs not only improve memory and thinking but they can also
reduce agitation and depression. Very recently, investigators have been studying their
e ects on di erent forms of dementia. Reminyl has been shown to be e ective 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 e ects including loss of appetite, indigestion, nausea, slowed heart
rate, and insomnia. Most doctors increase the medications gradually in order to
minimize side e ects, which can occur when the medication is initially begun or the
dosage increased. Side effects usually subside with time.

DOSING OF COMMONLY USED CHOLINESTERASE INHIBITORS

DRUG START DOSE HIGHEST DOSE

Donepezil (Aricept) 5 mg, once a day 10 mg, once a day
Galantamine (Reminyl) 4 mg, twice a day 12 mg, twice a day
Rivastigmine (Exelon) 1.5 mg, twice a day 6 mg, twice a day
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.

VITAMIN E FOR EVERYBODY

If you have been a dutiful follower of the strategies in Chapter 7, you have been taking
your antioxidant vitamins, including vitamin E, and doing your part to help your body
ght those pesky free radicals that wear and tear down your body’s DNA. Once
Alzheimer’s attacks the brain, vitamin E is as important as ever.
Recognizing the potential antioxidant bene ts 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 de ned 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 e ect. Because such high doses could occasionally suppress immune function
and the patient’s ability to ward o some infections, not all physicians recommend such
high doses, preferring 800 to 1,000 IUs per day for patients su ering from Alzheimer’s
disease. As I mentioned in Chapter 7, I recommend 400 IUs once or twice daily for
everyone as a preventative measure.

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 mis ring 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 non-medicinal approaches can
make a big di erence. 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 are often used to treat psychotic symptoms and agitation in
patients with dementia. Newly developed antipsychotics are preferred, including
risperidone (Risperdol), quetiapine (Seroquel), ziprasidone (Geodon), and olanzapine
(Zyprexa). These newer drugs cause fewer side e ects than older antipsychotics like
haloperidol (Haldol) or chlorpromazine (Thorazine). For symptoms of anxiety and
agitation, the anti-anxiety drugs are often used. Most physicians prefer the newer drugs,
including alprazolam (Xanax), lorazepam (Ativan), and oxazepam (Serax) because older
drugs like diazepam (Valium) and chlordiazepoxide (Librium) tend to accumulate in the
blood and cause side e ects like 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 e ective treatments for behavioral problems in demented
patients. Dr. Pierre Tariot at the University of Rochester has led the eld in using these
drugs in this patient population and nds that agitated and aggressive patients who
have a manic appearance of rapid thinking and irritability are especially 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 o er 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 de nite 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, page 264). 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 to 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 (800-272-3900) 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 di culties 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 di cult. 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 tness 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 e ectiveness is
based on testimonials, so they may not be any more e ective 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 are the only approved treatments for Alzheimer’s
disease, most experts also recommend antioxidant vitamins, and several promising
approaches are currently in development. 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 are being tested in patients with Alzheimer’s
disease and mild cognitive impairment.
Anti-amyloid vaccine. A synthetic form of amyloid-beta used to vaccinate mice
that have been genetically engineered to form the Alzheimer’s plaques. The
vaccine is currently being tested in humans to determine if it 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. Current investigations are focusing on their
potential for treating milder forms of memory loss and delaying the onset of
Alzheimer’s disease.
Clioquinoline. This antibiotic was once used to treat traveler’s diarrhea and is
now under investigation as a possible anti-amyloid treatment for Alzheimer’s
disease. Tests in transgenic Alzheimer’s mice indicate clioquinoline attaches
to the metals in the brain plaques and clears them out, leading to more than
a 50 percent reduction in plaques, as well as improved general behavior.
Scientists have begun comparing the drug with placebo in patients with
Alzheimer’s disease.
Cox II inhibitors. A new group of anti-in ammatory drugs that inhibit only
one of the enzymes (cyclooxygenase II) involved in in ammation. These
drugs have fewer side e ects than older cyclooxygenase inhibitors, which
inhibit both cox I and cox II enzymes and are more likely to cause gastric
bleeding. These drugs are currently being studied as treatments to prevent
Alzheimer’s disease.
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 e ects 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. Donepezil should be increased from 5 to 10 mg daily after six weeks.
Dose increases should be slower if patients have di culties tolerating side
effects.
Estrogen. Current studies will determine if estrogen replacement therapy after
menopause lowers the risk for Alzheimer’s disease. Studies of estrogen as a
treatment for Alzheimer’s disease have been disappointing, and it is not
recommended for treating memory loss.
Fetal cell implants. A technology under development for growing new nerve
cells in the brain. Results to date have not been successful.
Ginkgo biloba. A Chinese herb used to treat memory loss. Previous studies
suggesting a benefit have not yet been confirmed.
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.
Galantamine (Reminyl). A cholinesterase inhibitor drug used to treat
Alzheimer’s disease. Galantamine treatment should begin at 4 mg twice daily
and increased every month for a maximum dose of 12 mg twice daily. Dose
increases should be slower if patients have difficulties tolerating side effects.
Hydergine. Derived from a rye fungus, hydergine acts on several
neurotransmitters that in uence 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.
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 bene ts. The average diet contains about a gram of lecithin, and
tenfold greater amounts are used as supplements given in daily divided
doses.
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.
Memantine. A drug that acts on the NMDA (N-methyl-D-asparate) brain
receptor involved in memory function. The number of these receptors
decreases in Alzheimer’s disease, and recent studies indicate memantine’s
benefits in severely demented patients.
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 di culty of getting
nerve growth factor into the brain.
Nicotine patches. Transdermal nicotine applied through skin patches shows
promise as a therapy for conditions ranging from age-associated memory
impairment to Alzheimer’s disease. Preliminary studies indicate that nicotine
can 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 is marketed as a
cognition-enhancing agent in Europe and is under investigation in the United
States.
Nonsteroidal anti-in ammatory drugs (NSAIDs). Drugs that interfere with the
body’s in ammatory process, generally used to treat minor injuries and
arthritis. Examples include aspirin, ibuprofen (Motrin, Advil, Feldene), and
cox-II inhibitors (Celebrex, Vioxx).
Nootropics. A class of drugs, including piracetam, oxiracetam, pramiracetam,
and aniracetam, that enhance brain circulation. An anti-dementia e ect 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 bene t is thought to result
from stimulation of small blood vessel growth. Although anecdotal reports
are encouraging, no systematic study has demonstrated its e ectiveness in
Alzheimer’s disease.
Phosphatidylserine. A nutrient present in sh, 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 bene ts are not known. The recommended
starting dose ranges from 200 to 300 mg daily followed by a maintenance
dose of 100 mg daily after several months.
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
e ect. Although some studies demonstrate a mild bene t, it is not generally
used and long-term effects are not known.
Rivastigmine (Exelon). A cholinesterase inhibitor drug used to treat Alzheimer’s
disease. Rivastigmine can be increased every two weeks beginning at 1.5 mg
twice daily up to 6 mg twice a day or the highest dose tolerated. Dose
increases should be slower if patients have difficulties tolerating side effects.
Secretase inhibitors. Drugs under development to counteract enzymes
(secretases) that form the toxic amyloid-beta fragment.
Selective estrogen receptor modulators (SERMs). New synthetic estrogens
designed to isolate bene cial hormone e ects and eliminate side e ects.
Studies have not yet shown SERMs to bene t cognitive function, but many
experts remain optimistic of their eventual utility.
Selegiline (Eldepryl). A drug that inhibits monoamine oxidase enzymes that
destroy neurotransmitters and has an antioxidant e ect. Selegiline has been
found to delay functional decline in patients with Alzheimer’s disease.
Because this e ect is similar to that of vitamin E—and selegiline is more
expensive and has more side e ects—vitamin E is the preferred antioxidant
treatment for Alzheimer’s disease.
Tacrine (Cognex). The rst cholinesterase inhibitor approved by the FDA. The
drug is rarely used today because of liver side e ects and frequent dosing
schedule.
Testosterone. In men with low testosterone levels, the hormone may improve
memory performance, and it is currently under investigation as a treatment
for cognitive impairment.
Vitamin C. An antioxidant vitamin that may o er protection against age-
related cognitive decline. Many experts recommend 500 to 1,000 mg daily to
slow age-related cognitive decline.
Vitamin E. An antioxidant vitamin prescribed in high doses (1,000 to 2,000
units daily) for patients with Alzheimer’s disease. Epidemiological studies
suggest that taking vitamin E supplements may slow age-related cognitive
decline, and many experts recommend from 400 to 800 units daily as a
preventative therapy.
APPENDIX 4
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, de ned 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 “de nite”
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 di erent

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 rst 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 like 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 pre-frontal 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 like 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 con guration 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 blood stream.
 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 o 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 e ects: 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 modi ed, 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.

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.

Microglia cells. Cells that serve to clean up debris in the brain and mediate the
immune response that causes brain inflammation.

Milligram (mg). A measurement used for drugs—one-one-thousandth of a gram.

Mozart E ect. The term used to describe the observation that passive listening to
classical music benefits mental abilities.

Neuro brillary 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.

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.

Neuropsychological tests. Standardized tests that measure memory, attention, and

other cognitive abilities.

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 di erent 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 eld of drug e ectiveness 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 e ect 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 bers that transfer information from
distant brain regions.
APPENDIX 5
Additional Resources

Many organizations provide information on memory and general health issues

important to maintaining brain health. Several national organizations also have local or
state chapters. Check your telephone directory or Internet search engine for related
organizations and websites.
Name & Address Description Telephone
AARP 6601 E Street NW Non-profit, non-partisan organization 202-434-
Washington, DC 20049 dedicated to helping older Americans achieve 2277 800-
www.aarp.org lives of independence, dignity, and purpose. 424-3410
Academy of Molecular Provides leadership in research and clinical
Imaging Box 951735 Los aspects of molecular imaging of the biological 310-267-
Angeles, CA 90095-1735 nature of disease. Their website includes a 2614
www.ami-imaging.org listing of local PET centers.
Administration on Aging Provides information for older Americans and
202-619-
330 Independence Avenue their families on opportunities and services to
7501 800-
NW Washington, DC 20201 enrich their lives and support their
677-1116
www.aoa.dhhs.gov/ independence.
Aging Network Services
Nationwide network of private-practice
4400 E. West Highway, 301-657-
geriatric social workers serving as care
Suite 907 Bethesda, MD 4329
managers for seniors living at a distance.
20814 www.agingnets.com
Alliance of Information and
Referral Systems P.O. Box Professional organization that provides 206-632-
31668 Seattle, WA 98103 human services information and referrals. 2477
www.airs.org
Alzheimer Europe 145 Organizes caregiver support and raises
Route de Thionville L-2611 awareness about dementia through 352-29-79-
Luxembourg www.alzheimer- cooperation among European Alzheimer 70
europe.org organizations.
Alzheimer’s Association 919
The national organization that provides
N. Michigan Ave., Suite 800-272-
information on services, programs,
1000 Chicago, IL 60611- 3900
publications, and local chapters.
1676 www.alz.org
Alzheimer’s Association
Public Policy Division 1319
Lobbying branch of the Alzheimer’s 202-393-
F St. NW, Suite 710
Association. 7737
Washington, D.C. 20004
www.alz.org
Alzheimer’s Disease National Institute on Aging service that
Education and Referral distributes information and free materials on 301-495-
Center P.O. Box 8250 Silver topics relevant to health professionals, 3311 800-
Spring, MD 20907 patients and their families, and the general 438-4380
www.alzheimers.org public.
Alzheimer Research Forum Provides information and promotes
Foundation 82 Devonshire collaboration among researchers in order to
Street, S3 Boston, MA 02109 foster a global effort to understand and treat
www.alzforum.org Alzheimer’s disease.
American Academy of Professional organization that advances the
Neurology 1080 Montreal art and science of neurology, thereby 651-695-
Avenue St. Paul, MN 55116 promoting the best possible care for patients 1940
www.aan.com with neurological disorders.
American Association for
Professional organization dedicated to
Geriatric Psychiatry 7910
enhancing the mental health and well-being 301-654-
Woodmont Ave. #1050
of older adults through education and 7850
Bethesda, MD 20814
research.
www.aagpgpa.org
American Diabetes
Association P.O. Box 25757 America’s leading nonprofit health 703-549-
1660 Duke Street organization providing diabetes research, 1500 800-
Alexandria, VA 22314 information, and advocacy. 232-3472
www.diabetes.org

American Dietetic
312-899-
Association 216 W. Jackson Consumer Nutrition Hotline that provides
0040 800-
Blvd. Chicago, IL 60606- information on finding a dietitian.
366-1655
6995 www.eartright.org
American Geriatrics Society
Professional association providing assistance 212-308-
770 Lexington Avenue #300
in identifying local geriatric physician 1414 800-
New York, NY 10021
referrals. 247-4779
www.americangeriatrics.org
American Heart Association
Non-profit health organization whose mission
7272 Greenville Avenue 214-373-
is to reduce disability and death from
Dallas, TX 75231 6300
cardiovascular diseases and stroke.
www.americanheart.org
American Society on Aging
National organization concerned with 415-974-
833 Market Street, Suite 511
physical, emotional, social, economic, and 9600 800-
San Francisco, CA 94103
spiritual aspects of aging. 537-9728
www.asaging.org
Children of Aging Parents
1609 Woodbourne Rd., 215-945-
National organization providing information
#302-A Levittown, PA 6900 800-
and referrals for caregivers of older adults.
19057 227-7294
www.caps4caregivers.org
Family Caregiver Alliance
Resource center for families of adults with 415-434-
425 Bush Street, Suite 500
brain damage or dementia, which provides 3388 800-
San Francisco, CA 94108
publications for caregivers and professionals. 445-8106
www.caregiver.org
Gerontological Society of
America 1030 15th Street National interdisciplinary organi zation on 202-842-
NW, Suite 250 Washington, research and education in aging. 1275
DC 20005 www.geron.org

National Institute of Mental Part of the National Institutes of Health, the

Health 5600 Fishers Lane, NIMH is the principal biomedical and 301-443-
Room 10-75 Rockville, MD behavioral research agency of the United 1185
20857 www.nimh.nih.gov States government.
National Institute of
The National Institutes of Health agency that
Neurological Disorders and
supports neuroscience research; focuses on 301-496-
Stroke Building 31, Room
rapidly translating scientific discoveries into 5751 800-
8A-06 31 Center Drive, MSC
prevention, treatment, and cures; and 352-9424
2540 Bethesda, MD 20892-
provides resource support and information.
2540 www.ninds.nih.gov
The National Institutes of Health agency that
National Institute on Aging
supports research on aging and provides 301-496-
Building 31, Room 5C27 31
information about national Alzheimer’s 1752 800-
Center Drive Bethesda, MD
centers, and a free directory of organiza tions 438-4380
20892-2292 www.nih.gov/nia
that serve older adults.
National Stroke Association
Their mission is to reduce the incidence and 303-649-
96 Inverness Drive East,
impact of stroke disease and improve quality 9299 800-
Suite 1 Englewood, CO
of patient care and outcomes. 787-6537
80112-5112 www.stroke.org
Older Women’s League 666
202-783-
11th St. NW, Suite 700 An advocacy organization addressing family
6686 800-
Washington, D.C. 20001 and caregiver issues.
825-3695
www.owl-national.org
Joint program of the Alzheimer’s Association
and the National Center for Missing Persons

Safe Return P.O. Box 9307 that provides patients with a dementia
bracelet showing the person’s name, the 888-572-
St. Louis, MO 63117-0307
www.alz.org registered caregiver’s name, and a toll-free 8566
number (800-572-1122) to aid in that person’s
return if lost.
SeniorNet 121 Second
A national non-profit organization that works
Street, 7th Floor San 415-495-
to build a community of computer-using
Francisco, CA 94105 4990
seniors.
www.seniornet.com
UCLA Center on Aging
10945 Le Conte Avenue, University center that works to enhance and
310-794-
#3119 Los Angeles, CA extend productive and healthy life through
0676
90095-6980 research and education on aging.
www.aging.ucla.edu
U.S. Department of
Veterans Affairs 1120 Provides information on VA programs,
800-827-
Vermont Avenue NW veterans benefits, VA facilities worldwide,
1000
Washington, DC 20421 and VA medical automation software.
www.va.gov
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Source Credits
Chapter 2:

Subjective Memory Questionnaire adapted with permission from the work of Dr.
Michael Gilewski (Gilewski et al. 1990).

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 e cacy 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-PET scans (Figure A.1) courtesy of Jorge Barrio, Ph.D., Henry Huang, Ph.D.,
UCLA Department of Molecular and Medical Pharmacology.
PET scans showing brain function patterns (Figure A.2) courtesy of Michael Phelps,
Ph.D.; 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.
INDEX

The pagination of this electronic edition does not match the edition from which it was created. To locate a speci c
passage, please use the search feature of your e-book reader.

acronyms, 54
active observation, see LOOK
aging, 3, 164–65
memory loss in, see memory loss
treatments for, 202–4
see also brain, aging of
alcohol, 175–77, 191
aluminum, 184
Alzheimer’s disease, 1, 2, 3, 10, 11, 15, 16, 251–64
alcohol and, 177
anti-inflammatory drugs and, 215–16
antioxidants and, 139–40, 260, 271
beginnings of, 2
brain scans for evalution of, 255; see also PET scanning
cerebral vascular disease and, 192, 193
cholesterol-lowering drugs and, 192–93
diagnosing of, 254–57; see also PET scanning
diet and, 127–28, 132, 133–34, 135, 137–38, 145; see also diet
drug treatments for, 203–4, 207, 208–9, 216–19, 221, 257–62, 265–71
education and, 86
estrogen and, 213–14, 267
exercise and, 166–67, 168
gene therapy for, 220–21
genetic risk for, 23, 24, 27–29, 34, 88, 134, 172, 174
head trauma and, 171–74
and intelligence earlier in life, 11–12, 25–26
long-term memory and, 7
memory training and, 17, 20
mental activity and, 85–87
musical training and, 84
PET scans for diagnosing, see PET scanning
 and plaques and tangles in brain, see amyloid plaques and tangles
prevention of, 24–25
rate of new cases of, 13–14
smoking and, 174
symptom progression in, 253–54
see also memory loss
ampakines, 221
amyloid plaques and tangles, 2, 12–13, 192, 247–49
ampakines and, 221
anti-inflammatory drugs and, 215
cholesterol-lowering drugs and, 193
curcumin and, 145
amyloid plaques and tangles (continued)
head trauma and, 173, 174
medications targeting, 216–19
anger, 64–66, 77
antioxidants, 138, 139–45, 177, 260, 271
anxiety, 8, 33, 39, 59, 65, 77, 80–81, 157
see also stress
APOE-4 genetic risk for Alzheimer’s disease, 23, 24, 27–29, 34, 88, 134, 172, 174, 208

blood sugar, 151–57, 159, 183, 195

brain, 5, 7–8
education and, 25–27, 86, 87
gender differences in, 14–15
injuries to, 171–74
lifestyle and, see lifestyle
music and, 83–84
neurogenesis in, 219–20
neurons in, 5–6, 12, 18, 167, 173, 219–20
oxidation and, 139
size of, 12, 14–15, 18, 167, 173
strokes in, 128, 134, 153, 185, 192
“use it or lose it” theory and, 85–87
see also memory
brain, aging of, 2, 12–14, 16, 18
denial of, 3
 diet and, 127–28, 130, 133, 141, 145; see also diet
education and, 86
genetics of, see genetics
plaques and tangles in, see amyloid plaques and tangles
stress and, 64
technologies for detecting, 21–22
brain-teasers and puzzles, 17, 89–91
brain training, see memory training; mental aerobics
breakfast, 152

caffeine, 59, 72–73, 149–51

calories, 128–30, 143–44
cholesterol, 192–93
chunking, 114–16
cognitive stress test, 27–28
CONNECT (associating mental snapshots), 43, 50–55, 57, 111, 117, 231–32
in remembering names, 121, 122–23, 125
coronary bypass surgery, 193–95
curcumin, 144–45

depression, 8, 33, 64, 65, 77, 78–81, 84, 209–11

antidepressants for, 80, 175, 201, 206, 209–12
exercise and, 166
fish oils and, 138
diabetes, 133, 152–57, 195, 206
diet, 127–63, 235
antioxidants in, 138, 139–45, 177, 260, 271
caffeine in, 59, 72–73, 149–51
calories in, 128–30, 143–44
fats in, 132–37
fish in, 134, 135, 137–38
phosphatidylserine in, 148–49, 269
stress eating and, 157–60
sugar in, 151–57
turmeric in, 144–45
vitamins and minerals in, 139–41, 145–48
worksheet for, 162–63
 yo-yo syndrome and, 130–32
diseases, see illnesses
drugs, prescription, see medicines
drugs, recreational, 177–80

education, 25–27, 33, 39, 86, 87, 185

emotions, 8, 64–68
talking about, 76
ephedra, 205
estrogen, 213–14, 267
exercise, 69, 165–71, 191
head injuries resulting from, 171–74
expectations, setting, 68–69

fat, body, 128

see also weight
fats, 132–37
cholesterol, 192–93
omega-3 and omega-6 fatty acids, 134–38
fish and fish oils, 134, 135, 137–38
food, see diet
free radicals, 138, 139–41, 144
genetics, 22–24, 86, 88, 164–65, 176–77, 192, 220
APOE-4 risk for Alzheimer’s disease, 23, 24, 27–29, 34, 134, 172, 174, 208
gene therapy and, 220–21
pharmacogenetics and, 207–8
ginkgo biloba, 205, 206, 267
ginseng, 206, 267
glossary, 273–80
guarana, 205–6

heart surgery, 193–95

herbal remedies, 204–6
high blood pressure (hypertension), 134, 150, 191–92
hormone replacement therapies, 213–14, 267
humor, 76
illnesses, 195, 196
diabetes, 133, 152–57, 195, 206
getting treatment for, 191
high blood pressure, 134, 150, 191–92
high cholesterol, 192–93
see also medicines
insulin, 135, 153, 159, 183, 195

kava kava, 206

laughter, 76
learning, 5, 7, 18
styles of, 8
lifestyle, 164–86, 236
alcohol in, 175–77, 191
aluminum exposure in, 184
education and, 185
exercise in, 69, 165–71, 191
head trauma risk and, 171–74
recreational drugs in, 177–80
sex in, 182–83
sleep in, 59, 73–75, 183–84
smoking in, 174–75, 191, 216
social relationships in, 180–82
see also diet
linking, 52–54
Peg Method and, 117, 118–19
in remembering names, 122
LOOK (active observation), 43–45, 46, 54, 57, 111, 117, 231
in remembering names, 121, 125

medicines, 187–222, 237

for Alzheimer’s, 203–4, 207, 208–9, 216–19, 221, 257–62, 265–71
ampakines, 221
antidepressants, 80, 175, 201, 206, 209–12
anti-inflammatory, 214–16, 269
doctors’ patient information and, 188–90
 herbal remedies and, 204–6
hormone replacements, 213–14, 267
memory impairment from, 197–201
nicotine patches, 216, 268–69
pharmacogenetics and, 207–8
placebo effect and, 202–4
plaque-busting, 216–19
memory, 5–8
cognitive stress test and, 27–28
diet and, see diet
emotions and, 8
gender differences in, 8, 14–15
immediate, 6
learning in, 5, 7, 8, 18
long-term, 6–8, 17, 63
meaning and, 42–43
“photographic,” 6, 42
recall in, 5, 7
short-term, 6, 7–8, 17
stress and, 58, 63–64; see also stress
see also brain
memory improvement program:
sample, 238–41
starting, 242–45
memory loss, 9–11
cognitive stress test and, 27–28
current and potential treatments for, 265–71
depression and, 78–81; see also depression
from medications, 197–201
physician’s evaluation of, 188–89, 254–55
prevention of, 2
see also Alzheimer’s disease
memory performance, rating, 30–41
objective memory tests, 37–41, 55–56, 230–31
subjective memory questionnaire, 34–37, 40–41
and subjective versus objective memory loss, 31–34, 230
memory training, 16–20, 37, 39, 40–41, 42–57, 83, 111–26, 224, 234
 CONNECT (associating mental snapshots) method, 43, 50–55, 57, 111, 117, 121, 122–23, 231–32
linking, see linking
LOOK (active observation) method, 43–45, 54, 57, 111, 117, 121, 231
for names and faces, 121–24, 125
notebook for, 43
organization and, 111–16, 125, 224–28
Peg Method, 116–21, 125
Roman Room method, 124–25, 126
SNAP (creating mental snapshot) method, 43, 45–50, 54, 57, 111, 117, 121, 231
mental aerobics, 82–110, 233
advanced exercises for, 104–10
beginning exercises for, 94–98
building a program of, 110
cross-training in, 87–88
getting started in, 92–93
gradual training in, 88–89
intermediate exercises for, 98–103
puzzles and brain-teasers, 17, 89–91
stress and, 92–93
minerals, 145–48
mnemonics, 121
Mozart Effect, 83–84
music, 83–84

names, remembering, 43, 44, 121–24, 125

neurons, 5–6, 12, 18, 167, 173
growth of, 219–20
neurotransmitters, 6, 152, 175
nicotine patches, 216, 268–69
numerical sequences, Peg Method for remembering, 116–21, 125
nun study, 11, 25, 26, 68
nutrition, see diet
observation, active, see LOOK
omega-3 fatty acids, 134, 135, 136–38
omega-6 fatty acids, 134–37, 138
organization, 111–16, 125, 224–28
pain relievers, anti-inflammatory, 214–16, 269
Peg Method, 116–21, 125
PET scanning, 21–22, 24–26, 28–29, 31, 34, 86, 88, 247–49, 256–57
pharmacogenetics, 207–8
phosphatidylserine, 148–49, 269
plaques, see amyloid plaques and tangles
preparation, 69–70
puzzles and brain-teasers, 17, 89–91
recall, 5, 7
relationships, 180–82
relaxation, 71–72
resources, 281–89
Roman Room method, 124–25, 126

sadness, 64, 77, 209

see also depression
St. John’s wort, 206
sex, 182–83
sex hormones, 213–14, 267
sleep, 59, 73–75, 183–84, 209
smoking, 174–75, 191, 216
SNAP (creating mental snapshots), 43, 45–50, 54, 57, 111, 117, 231
CONNECT process and, 50–55, 57
in remembering names, 121, 125
social relationships, 180–82
story system, 52
stress, 8, 58–81, 92, 181, 232
causes of, 59–61
chronic, 62–63
eating and, 157–60
emotional reactions and, 64–68
memory ability and, 58, 63–64
reduction of, 59, 68–77
responses to, 61–63
strokes, 128, 134, 153, 185, 192
sugar, 151–57, 159, 183, 195
synapses, 6, 12
testosterone, 214, 270
turmeric, 144–45
“use it or lose it” theory, 85–87

valerian, 206
vitamins, 145–48
antioxidant, 139–41, 260, 271

weight, 128, 129–30, 133, 191

yo-yo syndrome and, 130–32
work, 87
taking breaks from, 70–71, 75–76

yoga, 69
Acknowledgments

I am grateful to many people who helped make this book a reality: my wife, best
friend, and collaborator, Gigi Vorgan, who helped translate a scienti c treatise into this
book; my children, Rachel and Harry, who make me laugh every day and keep my heart
young; and my parents, Gertrude and Dr. Max Small, who always see me as young, no
matter how beyond middle-aged I become. Several friends and colleagues provided
input and encouragement, including Helen Berman, Susan Bowerman, Rachel
Champeau, Dr. Josh Chodosh, Dr. Linda Ercoli, Stuart Grant, Dr. David Heber, Diana
Jacobs, Dr. Lissy Jarvik, Dr. Jim Joseph, Richard Hissong, Andrea Kaplan, Dr. Michael
Phelps, Dr. Stephen Read, Dr. John Schwartz, Dottie Sefton, Don Seigel, and Pauline
Spaulding. I am particularly grateful to my editor, Mary Ellen O’Neill, who kept me
focused on what is important, and my 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.
About the Author

Gary Small, M.D., is the director of the UCLA Memory and Aging Research Center. He lectures extensively all
over the world, and often appears on national television shows including 20/20, Good Morning America, Today,
CNN, NBC Nightly News, and CBS News.
Copyright

Copyright © 2002 Gary Small, M.D.

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

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10 9
Notes

* Formerly known as American Association of Retired Persons.

* From U.S. Department of Agriculture Agricultural Research Service.