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-five. Tiny plaques and tangles that
develop and grow ever denser in our brains often begin accumulating decades before any middle-age
forgetfulness sets in. A minute spot of plaque on a 30-year-old brain could possibly indicate Alzheimer’s
disease forty years from now, just as a tiny little snag of the dentist’s probe can mean a cavity in the
making.
But we need not despair. Misplacing your keys a couple of times doesn’t mean you should start
labeling your cabinets. Memory loss is not an inevitable consequence of aging. Our brains can fight back,
and The Memory Bible will give you the tools. We can improve our memory performance immediately
and stave off, possibly even prevent, future memory decline. The sooner all of us begin our memory
program, the sooner we will be on the path to keeping our brains young and healthy for the rest of our
lives.
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, file, or phone at home, only to
remember it while caught in rush hour traffic? Maybe you’ve struggled to remember the name of a
movie you saw last night or that new neighbor you just met, not five minutes ago. Ring a bell?
Most of us laugh off these so-called middle-aged pauses, considering them just another normal
annoyance of aging, not a true memory problem, and certainly not a sign of Alzheimer’s disease—not at
“our age.” I hate to pop another “I could party all night and still get to work on time if I wanted to”
baby-boomer bubble, but it’s time for us all to wake up—we are all one day closer to Alzheimer’s disease.

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

Just as all of us inevitably get older, recent convincing scientific evidence shows that Alzheimer’s disease
is not simply an illness that some old people get. Alzheimer’s disease or a related dementia may well be
everybody’s end result of brain aging—and it begins forming in our brains much earlier than anyone
previously imagined, even in our twenties.
The subtle, gradual aging of the brain starts as tiny plaques and tangles that begin accumulating there,
decades before a doctor can recognize any symptoms of the disease. In fact, these plaques and tangles
begin forming so early in our adult lives that subtle memory and language changes go unnoticed and
ignored for many years. Nonetheless, these minuscule spots of plaque in our otherwise healthy brains are
the first signs of brain aging, and they will increase insidiously if we do nothing about them.
When I speak on this subject I am often asked: Will my brain already be irreversibly damaged by the
time I reach middle age? Is it too late for me to try to head off this inevitable process? Is it too soon for
me to start? Is my memory ability destined to decline no matter what I try to do about it?
My answer to these questions is no. It is never too late or too early to start beating the brain-aging
game. Even if one day research finds a way to restore already lost brain cells, scientists agree that
preventing the loss of memory will always be easier than restoring it. The sooner we rise to the challenge,
the sooner we can intervene in the battle, like little neuron-gladiators, and, with luck, do so while our
forgetfulness is minimal or even imperceptible.

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

One of the biggest obstacles to starting a program to improve memory performance and protect our
brains from Alzheimer’s disease is denial that one’s brain, as well as one’s body, is aging. Many people
struggle to accept the physical changes that come with passing years, yet coming to terms with mental
changes is often an even greater challenge.
 Sally B. 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-fifth
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 scoffed at Jerry’s “accusation” and told him that her mind was perfectly fine. If anyone was
getting old and losing their marbles, it was he. It was just that the thought of a sixty-fifth 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 five 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 office and was concerned enough to
send her to a geriatric psychiatrist to get a more detailed assessment. After several meetings, the
psychiatrist sat down with Sally and Jerry together. Sally was indeed suffering from some mild age-
related cognitive impairment. As difficult as that was for her to accept, thankfully there were plenty
of things she could do to fight it; however, getting another face-lift or eye job surely wasn’t going to
help.
The psychiatrist recommended she start taking a cholinergic medication, begin a memory-training
program, and try various other strategies to protect her brain. He explained to Sally that success with
this treatment required acceptance and a strong commitment. The psychiatrist also expressed concern
about unnecessary elective surgeries because repeated general anesthesia can potentially worsen
memory ability.
Sally began walking a half hour every day and taking medication to improve her memory. She
started a program for keeping her brain young that included antioxidant foods and stimulating mental
aerobics. In several weeks, Sally, as well as her family and friends, noticed improvement in her
memory and her mood.
 Sally had a wonderful time at her sixty-fifth birthday party, as did everybody else. And she and her
daughter looked just like sisters.

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

What Is Memory?

Normal memory performance involves both learning and recall (Figure 1.1) and requires intact
functioning of several regions of the brain and the brain cells, or neurons, within them. We generally
think of memory as an abstract concept—a thought, image, sensation, or feeling that is stored
somewhere in our brain’s filing cabinet, ready to be pulled out at will. However, because our brains 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 filaments extending out like
little antennae, receiving and sending information. But the new info is not home free yet.
To allow all of our brain’s neurons to communicate with the others, the axons and dendrites form
thousands of branches, and each branch ends in a synapse, a specialized contact point or receptor that
recognizes only extremely specific information being passed between neurons. Each neuron has
approximately 100,000 synapses.
Electrical nerve impulses containing the new information, retrieved memories, or relayed messages
shoot down the neuron’s axon and slip through one of its skinny dendrites into a hyper-specific synapse,
where a packet of chemicals, known as neurotransmitters, gets released. These neurotransmitters are the
“carrier pigeons” that travel the minuscule space from one synapse to the next. Upon arrival, the correct
chemical neurotransmitter binds with its corresponding receiver, and voilà! The message is received. In
this way, thoughts and ideas are conveyed, information is learned, and memories are retrieved, all of
which cause us to do, think, or act in different ways.
In any waking situation, our senses are bombarded by sights, sounds, and other stimuli that pass
through our immediate memory and move into a holding area known as short-term memory. We usually
lose most of these fleeting sensations in milliseconds, and of the few retained in our short-term memory,
only a small percentage ever make it into long-term memory storage.
An essential key to retaining information longer is to organize and rehearse it, thus actively working it
into our long-term memory. Some people require great effort to develop these skills, 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 difficulty remembering their morning meal, have been
known to recall long-ago events, such as their first date with a sweetheart, in vivid detail.

Figure 1.1
 Recently, scientists have learned how the brain converts short-term memories into permanent ones at
the molecular and cellular level. A specific protein must be present in the brain’s cerebral cortex, the
outer rim of the brain containing gray matter, for the process to succeed.
The brain’s hippocampus, a seahorse-shaped brain structure located in the temporal lobe of the brain
(near the temples), stores information on a temporary basis—much 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 influence our memory abilities. Emotional states have a major impact on the
efficiency and the quality of memories. Ask yourself where you were and what you were doing when
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 first 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 differ in our degree of memory
change, our concern about it, and the steps we take to cope. By the time we reach our thirties and
forties, so-called “normal” memory complaints become more common.
Middle-aged and older people most often notice difficulties with:

People’s names
 Important dates
Location of household objects
Recent and past events
Meetings and appointments
Recalling information

Age-related memory loss more often involves recent memories rather than distant, past ones. We
might forget what movie we saw last weekend yet still recall our ninth-grade homeroom teacher’s name.
Neuropsychological evidence shows that age tends to slow down our learning and recall skills, perhaps
making it more difficult for older adults to learn a foreign language or scientific discourse. (I wouldn’t
want to try to pass advanced calculus again at 50.)
Older people have greater difficulty multitasking and our reaction time can slow down as we age,
which can affect our daily activities. Many older drivers compensate by driving more slowly, which can
be a hazard in itself. Memory training (Chapters 3 and 6) and a program of mental aerobics (Chapter 5)
can help lessen the impact of many of these age-related changes.
In the early 1990s, memory experts defined diagnostic criteria for the memory changes that
accompany normal aging. When someone over 50 had a memory impairment demonstrated by at least
one standard memory test, along with a subjective awareness of memory changes, they called the
phenomenon age-associated memory impairment. These experts estimated that 40 percent of all people are
affected by this condition upon reaching their fifties, 50 percent in their sixties, and over 70 percent by
age 70 and older.
Although there is debate over whether 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 suffer from this more severe memory decline, and this condition has a 10 to 15 percent chance of
developing into Alzheimer’s disease with each year that passes.

Figure 1.2

These diagnostic categories—age-associated memory impairment, mild cognitive impairment, and

Alzheimer’s disease—are basically categories of convenience, allowing doctors and scientists to better
understand our aging brains and test treatments to alleviate memory decline (Figure 1.2). In reality, the
changes in our brains and the memory difficulties we experience are continuous, fluid processes
beginning remarkably early in our lives. Several 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
significant memory loss or Alzheimer’s disease decades later, in their seventies.
The study’s conclusion, that language ability at age 20 may predict whether or not someone will get
Alzheimer’s disease fifty years down the road, stirred debate over whether learning and educational
enrichment protected the brain from decline over time, the “use it or lose it” theory.
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 fifty years later.
This group found that people with lower intelligence test scores in childhood had a greater risk for the
late-onset form of Alzheimer’s disease that begins after age 65.
Dr. Whalley offered several explanations for the observation, including the possibility that people with
lower intelligence in childhood might engage in behaviors later in life that put them in greater danger of
getting Alzheimer’s disease. They may eat a less healthy diet, avoid exercise, or smoke. Alternatively, the
low IQ score may reflect the early signs of the disease itself deteriorating the brain subtly early in life.
This could then influence school performance and further educational pursuit. Having less education
may not be the cause but may actually be the result of the early stages of brain aging.

The Incredible Shrinking Brain: Beware of Plaques and Tangles

As our brains age, the synapses, or connections between neurons, begin to function less efficiently.
Messages firing from one region of the brain to another may get scrambled, and crucial communication
from one part of the brain to the other may break down. One area of your brain may tell you to walk
into the kitchen and open the refrigerator, but then you just stand there. Unfortunately, the part of the
brain that should have told you to reach in and get a soda because you’re thirsty didn’t receive the
message.
Data show that as our neurons age and die, the actual overall sizes of our brains shrink or atrophy.
Also, our aging brains accumulate lesions known as amyloid plaques and neurofibrillary tangles. These
collections of decayed material result from cell death and degeneration of brain tissue, particularly in
areas involved in memory: the temporal (under the temples), parietal (above and behind the temples),
and frontal (near the forehead) regions of the cerebral cortex, the outer layer of brain cells. A healthy,
plump brain containing only sparse plaques and tangles gradually shrinks to an atrophied Alzheimer’s
brain riddled with plaques and tangles.
Historically, a definitive diagnosis of Alzheimer’s disease could only be made at autopsy. The
pathologist would count up the number of plaques and tangles that had accumulated in these key brain
regions, and if their concentration surpassed the defined threshold the patient under examination
definitely had Alzheimer’s disease. Scientists have studied brain autopsies in people who had only mild
cognitive impairment rather than 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 defined as full-blown Alzheimer’s disease.
 Studies of the annual incidence of Alzheimer’s disease, or the percentage of the population that
develops it each year, show that the rate of new Alzheimer’s cases doubles every five years between ages
65 and 90. Scientists suspect that if the current trend toward increased 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 differences between women and men likely influence memory abilities and brain
health as they age. Women have smaller brains than men. (It’s just a fact, don’t shoot the messenger.)
The average brain weight for an adult man is just over three pounds, 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 efficient, thus leveling the overall intellectual abilities between women and men.
Dr. Ruben Gur and his colleagues at the University of Pennsylvania looked at the amount of gray
matter in the brain—the outer part containing cell bodies that allow us to think—and found that, on
average, 55 percent of a woman’s brain contains gray matter, compared with only 50 percent of a man’s
brain. This may explain why women score higher in language and verbal ability tests than men. By
contrast, men have a higher proportion of white matter, which transfers information from distant
regions, perhaps a key to their greater visual-spatial abilities.

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

When I was growing up, Billy J., the kid across the street, had his grandmother living with 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 find her for an entire day. When my father, a physician, asked Billy’s
dad if he could recommend a doctor to help her, Billy’s dad laughed and said, “Granny’s not sick, she’s
just old and senile.”
Early in my clinical and research training in geriatric psychiatry and Alzheimer’s disease, Dr. Lissy
Jarvik stressed that senility was not a normal part of aging but instead a disease. This was an important
message at the time because most experts were ignoring the problems of aging, even the most common
ones: memory loss and dementia. By emphasizing the disease factor, investigators began to approach the
problem as an abnormality that required accurate diagnosis and specific treatment.
In fact, this has long been the basic approach of western medicine, to diagnose a disease and look for
the best treatment and cure. It is still a challenge to initiate proactive, preventive approaches to diseases.
We all want a quick cure, a magic pill to alleviate our problems when they occur. Patients and physicians
are reluctant to “fix it if it ain’t broke.” But when it comes to an aging brain, what we don’t know will
hurt us.
Understanding senility to be a disease state, whether in its early or late forms of dementia or as full-
blown Alzheimer’s disease, was crucial to getting researchers to focus on how our brains change with age
and the problems that can and do arise. With today’s knowledge, as well as new tools that allow
scientists to see the brain changing at its very earliest stages, the future lies in research and treatment to
help slow or halt these changes and some day repair any existing damage.
Of course, we must all first face our own fears about what our memory problems may imply and any
stigma we attach to “mild forgetfulness.” With the understanding that brain aging is a human
phenomenon that affects us all, hopefully people will begin using The Memory Bible’s strategies to
become proactive about preventing memory loss and protecting their brains from Alzheimer’s disease.
Those with more pronounced memory loss conditions may become empowered to come forward and
begin using new brain-imaging technologies for early detection and treatment of dementias and
Alzheimer’s disease.

Memory Training—Brain Fitness

If you’re reading this, you are most likely seeking knowledge on how to maintain a young and healthy
mind, maximize your memory performance, and protect your brain from Alzheimer’s disease. The
memory program described in the chapters ahead will help you accomplish these goals. What’s more,
you will see your memory improve as soon as you get started.
Nearly a decade ago, neuroscientists studied brain scans of volunteers playing the computer game
Tetris for the first time. They found high levels of brain activity. A month later, when the volunteers had
become proficient at the game, their scans displayed significantly lower levels of brain activity. This
lower brain activity, indicating greater mental efficiency, tells us that with time, practice, and
familiarity, our brains essentially adapt themselves to achieve the same results with less work. The
process is similar to what occurs when people train their muscles by lifting weights—their bodies
eventually develop muscular efficiency. Bench-pressing the same barbell will require much less effort
after a month of training, and most athletes have to add more weight if they wish to continue
strengthening.
Knowing that our brains can become more efficient if we practice or become skilled at memory
techniques, we can begin to systematically train our brains. By using games, puzzles, and some new
approaches to daily activities, we can improve our short- and long-term memory abilities and possibly
prevent future memory loss and Alzheimer’s disease.
Studies have shown that memory training, an integral part of any program to slow brain aging,
benefits more than just mild forgetfulness and overall memory. The training also gives the user an
awareness of their improvement, allowing them to feel good about their enhanced learning and recall
skills, which in turn improves their memory performance even more.
 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.
Scientific cause and effect has been proven in the laboratory using mature animals, half of which were
allowed to live in a mentally stimulating and exciting environment with mazes, toys, and hidden
surprises and snacks. The other half was exposed to dull, standard-issue laboratory living environments.
Although brain size in these mature laboratory animals generally shrinks with age, the animals exposed
to mentally stimulating environments had higher numbers of neurons in the memory areas of the brain
as well as better learning abilities than the experimental animals in the less interesting settings. If these
findings hold true for humans, they point to continued mental activity throughout life as a strong
preventative for future cognitive decline.

Joe T., an insurance agent, and his wife, Alice, a school administrator, used their savings to buy a
town house overlooking the fifth hole of a beautiful golf course in a desert retirement community, six
hours away. For almost five 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 finally qualified 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 office 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 fires.” As they
finished packing, Joe was more excited than a kid on his first trip to Disneyland. He kissed Alice, the
love of his life, as he carefully folded an array of new Hawaiian shirts and swore he’d never wear a
suit and tie again.
The first six months 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 office at least once a week. She missed her old life and was just
plain bored.
She began having trouble sleeping through the night and needed to nap during the day. Alice
became withdrawn and depressed, and Joe couldn’t understand it. He tried to make her see the bright
side—they were healthy, they were in love, and they were living their dream. Alice wondered if she
had ever actually had this dream. Perhaps it was just that Joe had wanted it so badly that she started
wanting it too, because she loved him. Well, it hardly mattered now.
Alice’s memory lapses started slowly—forgetting a barbecue at the clubhouse, mixing up the arrival
dates of visitors—but they were soon noticeable to Joe and their daughters. Alice had never before
 missed a birthday call to the grandkids or forgotten to buy half the items she needed at the market.
She was worried and told Joe that either she was going senile or the desert heat was cooking her
brain.
They consulted a local doctor to help figure out why these memory problems had come on so
quickly. After all, she had gotten rid of the stress and responsibilities of her job and 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 efficiently
pack a big memory punch in a short amount of time. Even if memory training doesn’t ultimately prevent
Alzheimer’s disease, it will improve current memory ability. It is eminently achievable. One of the
greatest benefits of memory training is that it gives us tools to use throughout our lives. If we master the
techniques early on, we have a better chance of heading off memory loss that might emerge in the
future.

Windows to Your Brain: New Technologies to Detect Brain Aging

Despite our best efforts 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 find a way to view brain structure
and function, so as to pinpoint a problem that might improve with treatment and determine the specific
treatment, when to intervene, and whether the patient was benefiting from it.
Recently there have been research breakthroughs from diverse scientific disciplines—genetics,
chemistry, physics, biomathematics, as well as others—that are finally opening windows into the brain,
using new technologies like positron emission tomography, or PET, scanning. We can now view brain
aging directly and thereby specifically guide our treatments to prevent future memory loss.
During medical school in the mid-1970s, I remember our excitement the first time we viewed
computed tomography, or CT, scans of the brain. We finally had a way to look at brain tissue beyond
what conventional X-ray machines could provide. With the development of 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 offered no information about how well the
still-living brain cells were functioning. If only we could actually see how effectively the neurons were or
were not communicating with each other, then we might be able to pick up, and treat, more subtle brain
deficiencies 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 finally see this kind of subtle brain
dysfunction in living humans.
 Positron emission tomography reveals a consistent pattern in Alzheimer’s disease. The parietal and
temporal areas—where Alzheimer’s first strikes—show reduced activity in the early stage of the disease.
It looks as if those important brain memory centers are subtly and gradually fading away (Appendix 2).
The PET scan is 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 suffer 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 fitness program and other
interventions at slowing that brain-aging process down.

DNA before AARP*—Genetics of Brain Aging

The science of genetics has ballooned in the last fifteen years. Most of us know that genes are the
blueprints of life, and everybody’s DNA differs just enough to make us all individuals—more reliable,
even, than fingerprints.
When we think of genetic traits being passed from one generation to the next, we usually think of
physical features such as hair and eye color, facial features, height and build, and so on. It is only in
recent years that medical conditions such as heart disease, high cholesterol, and cancer have been
discovered to pass within families genetically.
Traditionally, the common, late-onset form of Alzheimer’s disease, which affects people after age 65,
was not thought to have a genetic influence, but to be a normal result of aging. We now believe the
cause involves a combination of environmental, lifestyle, and genetic influences.
Many genes have been discovered to be involved with age-related memory loss and Alzheimer’s
disease. A defect in some genes causes early-onset familial Alzheimer’s, a rare and devastating form of
the disease that hits people early in life, before age 65, and normally strikes half the relatives in those
families.
For the common late-onset Alzheimer’s, however, one major genetic risk has been discovered:
apolipoprotein E, or APOE. This APOE gene makes a protein that transports cholesterol and fats through
the body and is known to influence the risk for heart disease and related conditions, so it was a big
surprise when geneticists found a link to Alzheimer’s disease and memory loss. APOE comes in three
different forms, or alleles: APOE-2, APOE-3, and APOE-4. All of us inherit one APOE form or allele from
each parent for a combination of two alleles, known as a genotype.
Drs. Allen Roses, Margaret Pericak-Vance, and their co-workers at Duke University were the first to
show that the APOE-4 allele was much more frequent in Alzheimer’s patients than in normal people.
Approximately 65 percent of the population has the APOE 3/3 genotype; 20 percent has the 3/4
genotype—a high risk for developing late-onset Alzheimer’s disease; and 2 percent the 4/4 genotype—an
even higher risk for Alzheimer’s disease.
Although the APOE-4 gene increases a person’s risk for Alzheimer’s and makes it more likely that
they’ll get the disease at a younger age, an APOE blood test result alone is not enough to accurately
predict whether an individual will get the disease. The research team I direct at UCLA recently achieved
a significant advancement in understanding the brain-imaging window using PET by linking it to the
latest research in genetics. Combining these scientific technologies for the first time provided a key for
early detection of subtle brain changes related to aging, changes that may precede the onset of
Alzheimer’s disease by several decades.

Prevention Is the Best Medicine

By the time a patient develops Alzheimer’s disease, the damage is done and irreversible. In the absence
of a “cure,” our best shot at beating Alzheimer’s lies in prevention, and targeting mild forgetfulness is
where we at UCLA started. A large challenge has been to determine which of the millions of forgetful
people would be most likely to benefit from preventative treatments.
In the mid-1990s, our research group 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 confirmed 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 effective, it must slow down the rate that brain activity
declines over the years compared with a placebo or an inactive intervention. In Figure 1.4 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 effects of memory training and mental aerobics on stabilizing brain function
and slowing brain aging.

Figure 1.4

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

Following up on the conclusions from The Nun Study—that subtle differences in the language abilities of
young people might predict the development of Alzheimer’s disease fifty years later—my research team
attempted to use PET scans to detect such brain function deficits in young adults. Dr. Daniel Silverman
and I looked at the scans of people with normal memory abilities and compared their brain function in
the posterior cingulate memory center, according to whether or not they had finished college. We found
that those who had completed college displayed higher brain function during mental rest; however, this
increased brain activity diminished with age. The 50-year-old college grads in our study had much
higher activity levels than the 50-year-olds who did not complete college, whereas the 80-year-old
college grads had only a very slight, if any, increase above 80-year-olds who did not complete college.
Age had worn away their brain function reserve.
Based on these findings, Dr. Silverman and I systematically reviewed the PET scan results of a much
larger group of young adults according to their educational achievement. We 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 differences in language ability predicting Alzheimer’s disease fifty
years later. Figure 1.5 illustrates how people with higher education have enhanced brain activity and
how this effect disappears with age.

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 fifty years. When we looked
at the effect of higher education added to the effect of the Alzheimer’s APOE-4 genetic risk, we found, as
expected, that the young adults with the greatest brain activity had completed college and did not have the
APOE-4 gene. It is interesting to note, however, that the influence of a college education on a person’s
brain activity reserve was even more powerful than that of the APOE-4 risk gene. Ideally, someone
concerned about their APOE-4 genetic risk could compensate for possible brain activity deficits through
further education.
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 significantly greater amount of brain activity to accomplish the same memory
task. The areas of the brain that worked the hardest to complete the memory tasks were the very same
areas where Alzheimer’s disease initially strikes. In fact, within the hippocampus, one of the brain’s main
memory centers, brain activity for the at-risk volunteers was double that of people without the genetic
risk. Not surprisingly, our cognitive stress test was fairly accurate in predicting which participants
eventually developed further memory loss several years later.

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

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 find 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 refine 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 find yours
and get started. Even with a tight schedule and limited time, you will benefit 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 effectively begin a program to improve memory performance and keep our brains young, we first
need to rate our current memory ability level. Knowing where our memory abilities stand now directs us
as to where to begin our overall anti–brain-aging program, enabling us to set an initial, easily attainable
goal to ease us into the program.

Elliot S. was an accomplished 68-year-old statistician—a member of the National Academy of

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

The system by which we assess our current state of brain aging can vary, from simple self-assessment
questions to more detailed biological measures. Although a PET scan is 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 suffice. It will also help individuals to find the
correct level at which to begin their personal anti– brain-aging program. If upon completing this
assessment, you feel you need additional consultation, see Appendix 5 to find organizations that provide
local and national resources and referrals.

Subjective Versus Objective Memory Loss

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

Audrey M. watched her grandfather and aunt succumb to Alzheimer’s disease before their sixtieth
birthdays. Although both her own parents died young in a car accident, she was convinced that she
too would develop the disease at a young age and in her early forties began seeking a specialist.
Audrey insisted on consulting the busiest neurologist in town, and hounded him to complete an
 extensive test battery she had read about on the Internet. Even though the doctor saw no indication
for such an evaluation, he went along with her demands and ordered an EEG, MRI, APOE screening,
and other laboratory tests, and a neuropsychological workup.
The doctor left for Europe after explaining that he’d give Audrey feedback when he returned and
had the test results in hand. His first day back at the office, he checked his voice mail and found
several messages from Audrey:
Message 1: Hello, doctor, this is Audrey M. You told me you’d be back in the office Thursday at 3
p.m. It’s now Friday, 10 a.m., you are not there, and neither are your nurses, Ilene, Carol, or Wendy.
Please call me.
Message 2: It’s Audrey M., and I misplaced my keys again, doctor. I’m getting much worse, my
memory is going. You must have all my test results by now. The APOE test was supposed to take
longest, and that was due back last Wednesday by 4 p.m. Please, please call me.
Message 3: This is Audrey. I just lost my address book. One minute it was here; then it disappears
into thin air. I don’t remember touching it. Thank god I know your phone number by heart. Call me
the moment you get in.
The doctor checked Audrey’s test results, which showed no signs of Alzheimer’s disease. When he
informed her, she broke down in tears of relief.
Clearly, Audrey’s anxiety and worry had colored her subjective memory awareness. Because of her
family history, she was convinced that every minor memory lapse was a drastic onset of her worst
fears. The doctor pointed out to her that even without her neuropsychological test results, her voice
mail messages demonstrated a remarkable attention to detail and high level of objective memory
ability.

Each individual is more or less aware of memory changes over a lifetime. Memory experts have found
many factors that influence how seriously we take these changes and whether or not we will complain
about them to others. A person’s mood and sense of well-being influence how much they notice and
complain about forgetfulness. Depression and anxiety also increase self-awareness of memory difficulties.
College graduates and others with higher education tend to rate their memory abilities better than do
those who have never attended college. Of course, people are more likely to complain about
forgetfulness as they get older. At a certain age, conversations, jokes, and complaints about middle-aged
pauses and senior moments are a socially correct form of bonding, just like young parents’ complaints
about their toddlers or teenagers’ complaints about their parents.
Memory scientists have developed standardized questionnaires for determining the degree to which
each of us is aware of memory loss. Because so many different factors can influence awareness of
memory loss, some question whether these so-called subjective memory measures accurately reflect true
memory changes or whether they merely reflect each person’s distortions, prejudices, moods, and
concerns rather than their actual memory ability.
My research group has performed extensive studies of these self-awareness measures and found that
they indeed reflect an objective, biological change. In one of our studies, we 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 significantly decreased activity in the hippocampus memory center of
the brain on the later scan.
These findings emphasize the “go with your gut” approach to detection of brain aging. If you think
your memory loss is “all in your head,” it may well be true, and worth looking into.

Rate Your Memory Change Awareness

To discover how aware you are of your own memory changes, you need a measuring system. Here we
will use a modified 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 reflects 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 difficulties are minimal. You may find that you quickly master the Three Basic Memory Training
Skills (Chapter 3) and can move right on to more advanced memory skills training (Chapter 6). If your
score is between 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 reflects an even greater self-awareness of memory
difficulties. A score in this range would suggest that memory training will be a greater challenge, so it is
important to take your time with the exercises in the following chapters. You also might consider
contacting your physician about these concerns or one of the experts in your area (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 find this memory assessment method too difficult or perhaps too easy. It
is designed to assess memory in people with a wide range of abilities. It is also intended to be difficult at
first to enable you to see concrete results from your memory skills training program soon after you start
it. I guarantee that your score will improve immediately after reading Chapter 3.
 The Objective Memory Test

Because the assessment is timed, you will need a stopwatch or kitchen timer or timepiece with a second
hand before beginning. The test involves learning a list of ten words over a 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 difficult for many people. Move on to Chapter 3 and then see how you
do on your retest. If your objective memory recall score improves, then continue to build your memory
skills program. If not, you might consider contacting your physician or an expert in your area for a
professional evaluation (Appendix 5).
Many factors can influence your objective memory score, particularly your age and level of
educational achievement. In general, younger people score better than older people, and people who
have had more educational experience will have better scores. The results are an indicator, a guide, not
the last word on your current brain fitness.
Ironically, a common cause of memory complaints is worry and anxiety about memory performance.
People with a family history of Alzheimer’s disease may fret about every memory slip. In fact, worry
about memory difficulties may worsen actual objective memory performance. If you scored well on
objective word recall after 20 minutes but your subjective memory score indicated frequent memory
difficulties, you may be suffering from stress and anxiety. If you fit into this group, then I suggest turning
to Chapter 4 (Minimize Stress) before beginning basic memory 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
High High Move quickly from basic (Chapter 3) to advanced (Chapter 6) memory training.
Take time and focus on basic training, then reassess score. If no improvement,
Low Low
consult expert.
Focus on stress reduction (Chapter 4) be-fore basic memory skills training.
Low High
Reassess score and consult expert if no improvement.
When you have determined your initial, or baseline, subjective and objective memory performance
scores, plot them in the charts in Figure 2.1. After completing the basic memory training (Chapter 3),
you will be asked to take the objective test again. To assess your progress, return to this figure, enter
your score, and congratulate yourself on your improved score after learning only a few basic skills. Try
repeating both the subjective and objective tests again after completing Chapter 10. I believe you will see
a clear and steady rise in both your subjective and objective performance as you continue to learn and
practice the memory training skills and initiate your program of mental aerobics, stress reduction, and
more advanced memory training.

Figure 2.1
Chapter Three
Look, Snap, Connect:
THE THREE BASIC MEMORY TRAINING SKILLS

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

—ALBERT EINSTEIN

Most of us have seen people with so-called photographic memories—they can rapidly learn and recall
the order of cards from a shuffled deck or effortlessly memorize long lists of words or numbers.
However, there is no such thing as a truly photographic memory; what we have seen are people with
good memory techniques.
A memory technique is merely a coding system, a filing cabinet for the brain. A person’s prior
knowledge and interests will influence how well they learn and recall new information. Many teenagers
can readily recall scores of their favorite sports teams but cannot remember a single important date they
learned in history class last fall. (You know who you are.)
Our memory’s filing and storage systems work most effectively when the new information contains
meaning for us. Experiments with champion chess players show that they can readily memorize the chess
pieces on the board if they are placed as they would be during a match, but the players’ ability to recall
a pattern of pieces placed at random is almost impossible. One arrangement of chess pieces has meaning
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 specific areas
of the frontal and temporal lobes. The greater the activity, the greater the likelihood that they would
remember the words later. Great memories are not born, they are made.
By mastering my three basic skills—LOOK, SNAP, CONNECT—you will incorporate a foundation for a
solid memory-training program. If you read only this chapter and learn only these three skills, your
memory will improve. I suggest you keep a notebook or writing pad specifically 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 difficulty remembering people’s names and connecting the names to the faces when
he met them again. Eventually he realized that his problem was that he never really learned the names
in the first place—he wasn’t actively looking and listening.
One of the most common barriers to effective learning is that people do not pay attention to situations
in which new information is presented. Think about what your husband or wife wore to work this
morning. Can you remember what tie he had on? Which blouse she wore? What color your son’s T-shirt
was? By actively looking and making a conscious effort to take in this type of information, trivial as it
may seem, you can begin to train your brain to log in details. By engaging in this active observation
process, we can absorb details and meaning from a new face, event, or conversation, which helps us to
learn and remember it.
When we have little interest in something, it is often difficult to remember because we are not paying
full attention. Many of us forget names seconds after being introduced to someone new. It’s as if we’re on
automatic pilot, responding to various internal and external cues during the introduction, which distract
us from retaining any new information. It is essential to slow down—just enough—to notice what is
being said and whether it is important to remember. Samuel Johnson put it succinctly: “The true art of
memory is the art of attention.”
Memory for street directions is an excellent example. If you drive yourself to a new destination by
following directions, you’ll probably remember how to get there on your own, days or even weeks later.
If you were merely a passenger on your first trip, you are likely to get lost on your first solo trip. The
goal in active observation (see Active Observation Exercises box) is to mentally stay in the driver’s seat.
LOOK is the first basic skill because our vision is so often our first exposure to the things we want to
remember, although we rely heavily on our other senses as well. By repeating information for later
memory retrieval, we are listening. Many report that the sense of smell can bring back the most vivid
memories of all. Textures and temperatures are useful details for focusing our observational skills that
employ sense of touch for future recall. LOOK, as it is used in the Three Basic Skills, is actually shorthand
for all five senses: LOOK, LISTEN, FEEL, TASTE, and SMELL.

Active Observation Exercises

1. The next time someone drives you to an unfamiliar location, mentally put yourself in the driver’s
seat. Check the directions ahead of time, note the street signs, major intersections, and
landmarks. Mentally drive yourself back there later.
2. Before you see a new movie, make a conscious decision to remember certain details at the outset.
Try to commit to memory the hero’s hairstyle, the furniture in a memorable indoor scene, and the
full name of a supporting character. When you get home, jot down as many details about the
movie as you can recall. The next day, check your list and try to write down even more details
about the movie if you can.
3. At work, notice a detail about the clothing or general appearance of several 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 specific article of clothing each member of your family put on
this morning before leaving the house. Tomorrow do it again, but make a conscious effort to
observe details before leaving the house.

2. SNAP—Create Mental Snapshots of Memories

Go back to that image of what your mate wore to work this morning. Red blouse, black slacks and shoes,
leather jacket. As you visualize the image, you are already developing the second basic skill—SNAP. You
are creating a mental snapshot of the information you wish to remember. Afterward you just pull out the
snapshot and describe what you see. Creating vivid and memorable images fixes them into our long-term
memory storage.
Snaps can take two forms, real or imagined. A real snap involves active observation, concentrating on
what you actually see and making a conscious effort to fix the observed image into a mental snapshot.
Imagined snaps are those that you create from your own memories and fantasies, but they still become
fixed in your memory as a mental snapshot. Imagined snaps can be a fantasy distortion of an image you
observe.
We all have real snaps in our heads that we use instinctively to help us seek and retrieve lost or hidden
objects. Our ability to use search images effectively likely evolved as an adaptive advantage in our
hunting ancestors, who visually spotted their skirting prey with such images. Likewise we use them to
quickly retrieve that partially hidden green folder on the desk or the slightly soiled lucky basketball
jersey in the hamper. Despite the disorganization and ridiculous overcrowding of my home library
shelves, I may have little trouble spotting a particular tome if it has a strong search image fixed in my
memory—“it’s a thick blue book with two white lines and some circlelike flower things on it.” In the
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 effective learning and recall techniques, we need to rekindle these
natural creative instincts.
Bright, colorful, enhanced snapshots stick best in memory, as do those with movement, three
dimensions, and detail. The more detailed the image, the easier it will be to recall later. The very act of
focusing on detail helps us to pay better attention and learn the information contained in the image.
Compare the 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 effectively it will stick in our minds. Imagination can be as
outrageous, vivid, or sensual as we like, as long as it enhances our ability to store and recall information.
You need to buy a pumpkin after work for your daughter’s Halloween party, so try personalizing it in
your mind. Your daughter loves to wear her pearl necklace to parties, so you could picture one draped
on a pumpkin, like so:

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

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

Mental Snapshot Exercises

1. Sit in a comfortable chair, close your eyes and think of the first thing that comes to mind, be it an
object, situation, person, or animal. Now try to imagine greater detail about how it looks or feels.
2. For each of the following, create a colorful, vivid, and detailed visual image (e.g., rather than a
rose, visualize a bright yellow rose with dew drops, lady bugs, and thorny stems):
Animal
Kitchen appliance
Tool
3. Visualize each of the following but alter them slightly so they become unusual in some way (e.g.,
an automobile with a wig, a snake wearing suspenders):
Table
Stadium
Stethoscope
Airplane
4. List three details that you might see in a visual image of each of the following places:
 Shopping mall
Car wash
Soccer field
Church

3. CONNECT—Link Your Mental Snapshots Together

Developing techniques to connect mental snaps 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 fine-tune your own connecting abilities (see box).

Connecting Exercises

1. For each of the following word pairs, imagine a situation or activity that involves the two
 together. Try to create a situation that is reasonable or logical in some way.
Telephone—hamper
Paper clip—stuffed animal
Apple—policeman
Stethoscope—football
2. Now go back to the word pairs above and imagine a bizarre or illogical situation for each.

CONNECT is the basis of the link method, which orders items by associating the things-to-be-
remembered with each other—the ideas or images become part of a chain, starting with the first item,
which is associated with the second, the second with the third, and so forth. When initiating the first link
in the chain, be sure that item number one helps you recall your goal or reason for creating this
particular list.
Linking often helps when we need to remember a list of unrelated things to do, particularly if writing
out the list is inconvenient or impossible (you may be exercising at the gym, sitting in a conference, or in
the middle of a shower).
If we need to remember a long list of items, the link method becomes a more elaborate method of
connecting mental snapshots and becomes a story. The story’s flow and visual images provide the cues
for retrieving the information. A weakness of the link method is that if we forget one link, we can forget
all the information that follows. With the story system, the flow of the story will allow most of the
remainder of the list to be retrieved even if one link is broken.
Here is a typical list that can be linked into a story line:

Buy eggs
Call your cousin in New York City
Take out the garbage
Feed your neighbor’s dog
Get cash at the ATM

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

Egg
A Big Apple
Garbage can
Dog
Dollar bills

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

Driving home from work you see a giant egg in the middle of the road
The egg 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 effective links or associations are ones we create ourselves, particularly those stemming from
our first association. Psychoanalysts have used the method of free association to help people uncover
emotionally charged experiences. Often our first association to an idea is the most vivid and can have the
strongest emotional charge or personal meaning, making it easiest to remember.
Another application of CONNECT is the use of acronyms, or the creation of words from the first letters
of items to be remembered. To create an acronym, first think of one word to represent each item to be
remembered, and then form a word using the first letter of each word to be remembered. As an example,
for the list of unrelated words Envelope, Bulb, Aardvark, and Telephone, we might use the first letter of
each word—E, B, A, and T—to form the acronym. The next step is to write down the letters and play
with their order to try to come up with one word or several words. If you can’t come up with a word,
then try substituting one of the words to be remembered. For example, changing bulb to 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
first, check your progress since reading this chapter.

More Connecting Exercises

1. Think up a story that will connect the following items: helicopter, movie theater, library,
houseboat, grandmother, coffee mug. After you complete the next five linking exercises, see if
you can recall the items from your story, without looking back at this list.
2. Create a single visual image to link each of the following groups of words:
Wire–teddy bear–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 first letter from each of the following items:
 Elephant
Blanket
House
Apple
Tree

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

After reading and practicing LOOK, SNAP, CONNECT, your memory abilities have already improved. I
have revised the objective memory test from the end of Chapter 2 to include a different list of words so
you can retest your learning and recall skills. Get out your stopwatch or kitchen timer and set it for 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 first image, which is associated with the second, the second with the
third, and so forth. Be sure the first image helps you recall the reason for remembering the chain.
Chapter Four
Minimize Stress

Pressure and stress are the common cold of the psyche.

—ANDREW DENTON

Our modern world is filled with new technological tools designed to make our lives more efficient 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 efficient, 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 fitness 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 fire the contractor. Not yet, anyway. Stress and anxiety
can be reduced and even eliminated from our lives, and there are many approaches to help us achieve
this. We can choose from a variety of stress-reduction methods, including yoga, jogging, meditation,
prayer, or even anger-management classes.

What Causes Stress?

Both external and internal events can trigger a stress response. In our physical environments, we are
constantly being bombarded by stimuli such as noise, bright lights, heat, or confined spaces—all of
which can bring on stress, if the intensity and timing are right. People and various social situations can
create stress, whether it’s a rude waitress, critical boss, or a crowded rock concert or amusement park.
Anything from a physical examination to a hospital visit, a public verbal presentation or just getting into
a heated discussion, can activate our stress response. Deadlines, on and off the job, are common reasons
for getting our adrenaline pumping, as are major life events, whether a negative one—death of a relative,
getting fired—or even a positive one—getting promoted or having a new baby. 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 firm, 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 financial network flashing across the wide flat screen hung before him, he watched
 his heart rate monitor climb to the optimal level. While increasing his level to 7, the TV, treadmill,
lights, and music went dead. He screamed in frustration over his “frigging fuse box” but it was worse.
Power was out in the whole neighborhood.
Justin grabbed the phone but then slammed it back into the cradle, yelling, “Damn electric phone
system!” He used his cell phone to call the power company, but the circuits were busy. He stomped
and cursed and flipped the fuses again and again. His heart was racing and he was sweating, but he
was feeling frustrated and angry instead of exhilarated by his usual post-workout endorphin high.
He finally got the power company on the phone and ranted and raved about his limited time, his
exercise machines, etc. The woman on the phone said they were doing all they could and suggested
that he try to relax and not get stressed out about it. Incensed, he yelled that his stress level was none
of her business. She apologized and wished him well with it.
Glancing out the window, Justin noticed an electric company truck parking across the street a few
houses away. He leaped down the stairs and out the front door, practically mowing down his
neighbor Rob, who was stretching out before his morning jog.
Rob asked, “Hey, Justin, you OK?”
Justin, distracted, replied, “Yeah, man. I’ve got to get to the office, my power’s out, and I haven’t
worked out …”
“So, want to go for a run?” Rob began running in place.
Justin, already across the street and about to chew out the electric company guys, looked back at
Rob incredulously. “What? No. I need these jerks to turn my power back on.”
Rob smiled as he jogged away. “Have a nice day, Justin.”

Although much of the stress we experience on a daily basis is self-generated, most people think only of
external stressors when they become upset. If only my boss, kids, or spouse would do things differently,
then I wouldn’t be so stressed out. If the stock market would just bounce back, I could relax. Coming to
terms with our own personality and how we can begin to eliminate some stress for ourselves is an
important step in minimizing our anxiety.
High-achieving 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 differently, and these responses are not
always negative. A college student stressed out about exams may study harder and perform better,
whereas another student may become overwhelmed by anxiety and freeze up at the exam.
Our bodies respond to stress by releasing hormones into the blood stream that are intended to put us
into a protective mode. Adrenaline, a well-known stress hormone, tends to result in the “fight-or-flight
response,” providing strength and energy to either fight impending danger or escape it. This
physiological response has been genetically programmed through evolution, perhaps dating back to our
caveman ancestors. If another caveman came along to steal your food and you were a bigger guy,
perhaps even had a big club, you might have fought him off. Otherwise, you’d probably have run for it.
When the stress hormone adrenaline pumps into the 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 difference between survival and death.
Unfortunately, this same physiological response can occur in people who are not exposed to physical
threats but instead to constant or repeated mental triggers or stressors that have no rapid resolution.
They persist and linger and smolder, leading to a chronic stress syndrome characterized by a variety of
physical and mental symptoms, sometimes leading to health problems.

Common Symptoms of Chronic Stress

Physical: headache, fatigue, insomnia, muscle aches and pains, rapid heart rate, chest
pain, upset stomach, appetite loss, trembling, cold hands and feet, sweating.
Emotional: depression, tension, anxiety, anger, frustration, worry, fear, irritability,
impatience.
Mental: poor concentration, memory loss, indecisiveness, confusion, poor sense of
humor.
Behavioral: fidgeting, pacing, nail-biting, foot-tapping, overeating, smoking, drinking,
drug abuse.

The Effects of Stress on Memory Ability

Dr. Robert Sapolsky at Stanford University has studied how stress influences the brain and cognitive
processes, showing that prolonged exposure to stress hormones has an adverse, shrinking effect on the
hippocampus 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 find their way back to a
designated target. Their memory was impaired most while the hormone levels were at their highest, up
to an hour after the initial shock. Although the memory loss in this experiment was temporary, it raises
questions about the long-term effects of repeated stress on the brain.
Dr. John Newcomer of Washington University School of Medicine in St. Louis observed similar stress
effects on memory in humans. His group showed that several days of exposure to high levels of the stress
hormone cortisol can impair memory. The scientists observed memory impairment only in people treated
with high doses—comparable to what a person would experience after a major illness or surgery. A week
later, however, their memory performance returned to normal. Although these results suggest that only
people who experience severe medical, physical, or psychological trauma will experience stress-related
memory impairment, many researchers are convinced that long-term exposure to lower stress levels is
also likely to accelerate brain aging.

Getting Mad, Sad, or Even

When faced with a frustrating, seemingly unsolvable problem, our emotional reactions can vary
considerably. Anger, fear, sadness, and denial—sometimes expressed as humor—are common responses,
and each of these feelings has positive and negative consequences. How our emotions motivate us to act
has a significant impact on keeping our brains young.
Some people tend to become overwhelmed by angry feelings or are unable to express them. As a
result, they may not fight for their beliefs, try to get even, or even get satisfaction, but instead give up—a
response sometimes leading to sadness or even depression.

Sonia J., a 70-year-old widow, was becoming increasingly frustrated and anxious about her
constant forgetfulness. It wasn’t so bad at first, but now she was reminding herself of her exasperating
older brother, Marty, who was constantly forgetting things and driving everybody crazy. Sonia’s son
was concerned that perhaps she was depressed and that maybe she should see a therapist. Sonia
dismissed the idea completely—she didn’t buy into all that “talk it to death” stuff.
At Sunday dinner, Sonia snapped so angrily at Marty for again repeating something he’d just told
her that she started shaking and had to go lie down. She realized later that part of why she got so mad
at Marty was because she was afraid about her own forgetfulness. The next day she called her doctor
for help.
Following an evaluation, Sonia’s physician began her on an anti-Alzheimer’s drug, and after several
weeks her memory showed improvement. Sonia was happy and relaxed for the first time in months.
Her son was pleased and relieved.
Sonia tried to get Marty to take the same medicine, or at least talk to his doctor about it, but he
vehemently denied any memory problems and refused Sonia’s urgings to see any doctors or take any
medicines. Unfortunately, Marty’s memory declined rapidly during the next twelve months when he
was eventually diagnosed with Alzheimer’s disease.

Anger can sometimes motivate us to act in a positive, constructive manner. However, anger, expressed
or not, can also lead to high levels of anxiety, stress hormones, depression, and even memory loss.
It doesn’t necessarily serve us to express every feeling or emotion, especially if we alienate relatives or
colleagues, and because we may feel differently once the angry feelings have diminished. Sometimes it’s
better not to zoom down to the post office at midnight in your pajamas with that irate letter to your
ungrateful, demanding boss until you have read it over again in the morning. The stress of
unemployment may prove more detrimental to your brain fitness, not to mention your pocketbook, than
the momentary thrill of yelling “I quit” in the boss’s face. Anger management therapy techniques involve
learning to understand our feelings and finding new approaches for expressing them.
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 effects of
anger, as well as those of physical exercise, on heart disease. They found that the group of cardiac
patients who exercised and learned anger management techniques ended up with the lowest risk for
ischemic chest pain, resulting from insufficient blood flow and oxygen to the heart. The group of patients
who only exercised without anger management instruction lowered their risk for chest pain slightly, but
only half as much as the other group. The physiological process leading to this kind of circulatory
problem in the heart has the potential for producing similar circulatory problems in the brain.

Dr. Frank B. was a busy internist on the Upper West Side of Manhattan. Although 61 years old, he
was in good shape and looked younger. He prided himself on keeping up with all his journals and
latest medical advances while continuing to practice like an old-style family doctor who still made an
occasional house call.
During the last four years, he had noticed his memory gradually declining. He used to know all of
his regular patients’ main health problems and the names of their close relatives. Lately he had to
refer to their charts—sometimes even for basic facts and details. On several recent occasions, if Frank
bumped into a patient at a local restaurant or bookstore, he would recognize their face but couldn’t
recall their name until hours later. This began to secretly terrify him.
Frank was five years into his second marriage with Patricia, now in her 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 staff, closest friends, and patients. When
Patricia brought it up, Frank insisted he was fine—and he should know, he’s a doctor, a healer. He
doesn’t need to be healed by anybody else, thank you.
His practice began to suffer. Frank was seeing up to five patients an hour and was still expected to
dictate notes between appointments. He started having stomach pain and headaches and couldn’t
keep up.
Patricia finally dragged him to a neuropsychiatrist specializing in memory problems. When his
physical exam and lab tests turned out normal, Frank grinned at Patricia, vindicated at last. However,
the doctor went on to explain that Frank did have subtle memory losses and a strikingly high level of
anxiety and stress, which was most likely aggravating his head and stomach pain, as well as his
concentration and memory.
Over the next few months, Frank made some changes in his lifestyle. He brought a young partner
into his practice, which greatly reduced his patient load and stress at work. He began playing tennis
again with friends and accompanied Patricia to her yoga class twice a week.
People at the office began remarking on how alert and focused he seemed, and Frank himself
noticed that his memory for names and details had improved. Also, he had fewer aches and pains and
he felt a general sense of well-being. He and Patricia felt closer than ever. Frank wasn’t sure which
stress-reducing change had done the trick, and he didn’t care—he just stuck with the program.

Stressing Down, Not Stressing Out

We are often powerless to affect or reduce the external stressors in our lives. However, because much of
our daily stress is internal or self-generated, we have the ability to do something about it, if we choose.
 People who are able to maintain positive outlooks on life may actually live longer. The most recent
finding from The Nun Study indicated that the nuns who expressed feelings of joy, happiness, love, and
hope in their early diaries lived as much as ten years longer than those who were less positive.
If time allowed, I would love to write a book called The Relaxation Bible: An Innovative Strategy for
Stress Reduction, but I don’t think I could tackle the added stress right now. In the meantime, the
strategies contained in the following pages should prove useful in reducing your stress and thereby
improving your memory ability.

SET REALISTIC EXPECTATIONS

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

LET’S GET PHYSICAL

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 off much of our “stress energy.” With the fight-or-flight reaction that adrenaline and other
stress hormones bring about, many of us are inclined to either act somewhat impulsively or keep these
hormones and impulses bottled up inside. In today’s modern world, fight or flight—though it worked for
cavemen under attack—may not be an option. Our bodies thus remain in a state of heightened energy
with no release.
Exercise helps us dissipate such excess energy. Channeling the energy into a brisk walk will be more
effective in reducing stress than gulping down a couple of beers. Any aerobic activity can have the same
effect, whether it’s jogging, walking, bicycling, swimming, racquet sports, or aerobics classes. Be sure to
choose activities you like and vary your exercises to maintain your interest.
Approximately 15 million Americans include some form of yoga in their fitness program. Yoga not
only offers a way to build strength, balance, and stamina, but it can also reduce stress. Dr. Dean Ornish
and his 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 effective approach is to prepare in advance. When I studied piano as a teenager, my father
always advised me to practice “110 percent” so I had 10 percent “cushion” room left for anxiety, fear,
and forgetfulness. I still flubbed a few notes at recitals, but I understood his point and it served me well.
When preparing for an oral report, speech, or exam, you might visit the location in advance, if
possible, and familiarize yourself with it. Taking slow, deep breaths, as well as closing your eyes and
envisioning a calm place just before a performance, can help you to relax when feeling anticipatory
anxiety or stress. Another useful technique when speaking in public is to focus on one person in the
crowd. Some people find it helpful to take their feelings of anxiety and rename and transform them into
feelings of excitement and energy. Others like that old trick of imagining their audience in their
underwear. I guess it all depends on your audience.

RECESS ISN’T JUST FOR KIDS

Most of us lead fast-paced lives and pay little attention to warning signs that it is time to rest. For
some, a certain mild, optimum degree of stress can lead to a healthy tension that helps them function at
their best. However, excessive stress, or distress, can cause fatigue and eventually exhaustion—glaring
red flags telling us to slow down and rest. Pacing ourselves while we work and play involves monitoring
our levels of stress and energy, and taking breaks when we need them, much like small children need
their naps to behave nicely.
A helpful approach to avoiding the workaholic syndrome is to take periodic time-outs. For many of us,
breaks are built into our daily schedules, as we tend to divide our days into four 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 effort you make
to relax, both mentally and physically, will reduce stress. Dr. Herbert Benson of Harvard University has
described this process as the relaxation response. Just as our bodies evolved and developed an automatic
stress response, we can teach ourselves, through conscious effort and repetition, to switch on a relaxation
response—a state of deep mental and physical relaxation. Physiological activities slow down—heart and
breathing rates decrease, blood pressure lowers, and muscles relax.
Such simple activities as resting at the beach, lying on a favorite hammock, or cuddling up with a good
book can bring about this state. Also, just imagining resting at the beach or in your favorite hammock
while taking a couple of minutes of quiet, deep-breathing time at work can have a similar stress-reducing
relaxation effect. Deep relaxation can be accomplished through a variety of techniques, including yoga,
tai chi, biofeedback, meditation, and self-hypnosis, all of which can be learned through courses, books,
and tapes. Just a few minutes each day doing some simple relaxation techniques can be effective in
helping us to remain calm and perform at our optimal memory capacity (see Relaxation Exercises box).

Relaxation Exercises

2-Minute Break. Lie down or sit in a comfortable position. Begin by breathing slowly
through your nose, regularly and deeply. Focus on your rib muscles, expanding them as
much as possible, then slowly pushing out as much air as possible. Be sure to use your
diaphragm, and keep your breathing deep, slow, and calm. Feel your abdomen rise as
you breathe.
5-Minute Break. Close your eyes and imagine yourself in a calm, soothing setting—at
the beach, in a field, in a sauna, or anywhere you find relaxing. Breathe deeply and do
not allow the thoughts that may enter your mind to remain there. Keep focused on your
breathing and relaxed setting.
 10-Minute Break. Sit in a comfortable chair or lie down. Close your eyes and take a
deep breath; let it out slowly. Focus your attention on your head and scalp, and then
imagine releasing all the tension there. Bring your focus down to your facial muscles
and release that tension. Let that relaxed feeling extend through your cheeks and jaw.
Slowly continue this process, focusing down your neck and shoulders, releasing the
tension and continuing to move systematically down your body through your arms,
hands, abdomen, back, hips, legs, and toes. Continue to breathe deeply and slowly
throughout.

CUT BACK ON CAFFEINE

Many of us have the caffeine habit, and we tend to get the bulk of our daily caffeine from drinking
coffee. We may start with a wake-me-up cup, possibly followed by a mid-morning espresso and perhaps
an iced blended mocha at our afternoon coffee break. If we count added caffeine from soft drinks and
chocolate, we can be well on the road to a caffeine-induced stress response.
When caffeine levels go beyond what the body will tolerate—and this toleration level diminishes with
increasing age—symptoms of stress and anxiety emerge. You may say that caffeine helps you focus and
maintain attention, and in small amounts it can. However, at higher levels, caffeine can cause irritability
and distraction.
I recommend cutting back on caffeine and doing it gradually to avoid headaches and other side effects
of withdrawal. Many experts recommend decreasing by the equivalent of a half-cup of coffee each day or
every other day (see Chapter 7 for equivalencies). Most people will begin feeling more relaxed and
notice other benefits as well. Many find that they sleep better and paradoxically have more energy.

GET ENOUGH SLEEP

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 suffer 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 find yourself waking naturally before the
alarm goes off in the morning.
Those weekend days when you can sleep in may help you recover from chronic sleep deprivation, but
if you sleep too long your body rhythms may get thrown off the next day. Daytime naps can help if you
keep them short—you could feel groggy waking from naps that last over 30 minutes. Instead, 20-minute
“power naps” can be rejuvenating. Avoid early evening naps since they make it more difficult to fall
asleep at bedtime. If you suffer from chronic insomnia, avoid daytime naps altogether, and try a
systematic sleep inducement program instead (see box). Sometimes chronic insomnia is a symptom of
depression or some other medical condition, so consult your physician if a sleep inducement program is
ineffective.
 Beat Insomnia at Its Own Game: A Systematic Approach to Sleep Inducement

1. What to avoid:
Daytime naps
Evening liquids
Exercise or excitement an hour before bedtime
2. Begin your sleep inducement program on a weekend, preferably a Friday night.
3. Get into bed the same time each evening. Once in bed, do not 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 selfish, or too much leisure time makes some people bored and restless—even
stressed! We need to find our own balance of leisure time versus work time, one that allows us to limit
our stress level, and maintain our optimal memory ability.

LAUGH YOUR HEAD OFF

Humor, too, can reduce stress—it puts uncomfortable feelings into perspective, giving us greater
distance from them and releasing emotional discomfort and pain through the pleasure of laughter.
Norman Cousins advocated the use of humor not just to reduce stress but also to cure physical ailments,
through the physiological effects of laughter. Although laughter does relieve tension, it has not been
proven to cure physical illnesses, yet. However, I have never met an ill person who has complained to
me about laughing too much.

TALK ABOUT FEELINGS

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

Review of Steps to Minimize Stress and Anxiety

Set realistic expectations.

Exercise regularly.
Prepare ahead.
Take breaks throughout the day.
Learn how to relax and do it at regular intervals.
Cut back on caffeine.
Get enough sleep.
Balance work and leisure.
Let yourself laugh.
Talk about feelings.

When Stress Becomes Chronic: Depression and Anxiety

Sometimes, despite our best efforts to reduce stress, we are unable to eliminate the sources of tension or
emotional pain in our lives. Sometimes we may go from directing our anger at the outside world and
instead turn it within, becoming mad at ourselves. This mental process tends to change from anger to
sadness and, eventually, to depression.
An estimated 15 percent of the population develops an episode of depression requiring medical
intervention at some point in life, and stress is not the only cause. Some people are born with a
biological predisposition to get depressed, tending toward a brain chemical imbalance that favors a
depressed mental state. In some situations the depression appears to come from nowhere, even in the
best of circumstances. Perhaps more frequently, the depression stems from a combination of stressful life
events and internal biological factors.
 Depression and Memory Loss

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

Holly M. awoke from another mid-afternoon nap. She took a nap almost every day now, ever since
their youngest daughter left for college. It was half past five and Carl, her husband of thirty-six years,
would be home in an hour. She had time to shower and dress and fix him a T-bone, charred outside
but pink inside—just the way he liked it. But wait … didn’t she make steak yesterday? Oh, never
mind. Carl always ended up working late anyway, so it didn’t matter.
At 8:00, showered, dressed, and made up perfectly, Holly sat at the dining room table as the steaks
grew cold and she longed to escape back to sleep. At 10:00 Carl finally came in and was shocked to
see her sitting there like a zombie. He yelled, “What the hell is going on?”
“You could have called if you were going to be late for dinner again,” she said with a sarcastic clip.
He laughed quietly and shook his head. “This memory lapse thing of yours is getting out of control,
Holly. I specifically told you, this morning, that I had to have dinner in the city with clients. Maybe
you should see somebody. A shrink or something.”
Holly’s eyes teared. She asked him what was happening to her. Why was she forgetting so much?
Why couldn’t she concentrate on anything? Why did she feel so sad all the time? She stared at him,
pleading for help.
Carl was cold. “I have some calls to make. Why don’t you just go to bed and get some rest.” After
closing himself in the study, Carl made a call and a woman answered. He said he had a wonderful
evening and he’d like to see her again—tomorrow? She inquired about his wife, but Carl just laughed
and said she didn’t remember a thing from minute to minute and not to worry.
The next day Holly decided to take Carl’s advice and got a referral for a psychiatrist. At the first
appointment, she learned that she was depressed, and this could account for some of her memory
problems. The doctor prescribed an antidepressant medicine and suggested they meet a few more
times to talk about her feelings. Holly left his office feeling relief and optimism.
Over the next couple of weeks, Holly’s mood improved along with her memory. Unfortunately, Carl
was so seldom at home, he didn’t notice. Friday morning Carl came down to the kitchen with a
packed overnight case and headed for the door. Holly, already dressed and about to leave for the
gym, blocked his path. Carl raised his eyebrows. “Good for you, Holly. Get some exercise. It might
help you feel better. See you Sunday night!” Holly was taken aback. “What? Where are you going?”
Carl snapped, “You don’t remember this either? I told you on Tuesday! I’ve got a statewide sales
meeting at the regional office all weekend! For God’s sake, Holly, get a grip! I’ll call you.”
At this point, Holly had a pretty good grip. Something was amiss, and it wasn’t her memory. Now
that her depression had lifted and her memory had improved, Holly took the initiative to figure out
what was going on in her marriage. She discovered her husband’s affair and realized he had been
 using her own symptoms against her, tricking her into believing his lies.
Holly ended up with the house, the money, and the cars, but she let Carl keep his 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 benefit over that of the placebo. What is
remarkable about the study is that the psychotherapy involved only one hour a month, a far cry from in-
depth psychoanalysis. For some forms of depression, then, brief monthly meetings with a therapist may
be enough to relieve symptoms.
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 afflicted are unable to function in their lives. Some
people experience a pervasive, continual generalized anxiety or even more focused fears and phobias,
which can pervade all aspects of their lives.
These conditions result from both external stress and internal biological factors. Regardless of the
cause or form of anxiety, these conditions often respond to drug treatment as well as specific
psychotherapies. And, many such psychiatric disorders will affect learning and memory abilities.
If you find that your anxiety levels are so high that your work or personal life is affected, perhaps it is
time to seek professional help (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 difficulty
took a turn for the worse. Because of her busy career in marketing, Jill had put off having children
into her late thirties and was now in the heat of carpool years. With her kids’ soccer practice and
ballet lessons, and her husband’s frequent business trips, Jill was at her wit’s end trying to juggle
everybody’s schedules, let alone keep the names of new business contacts straight. When she came to
my office, Jill was exhausted and frustrated. She was becoming forgetful, and for the first time in her
life, she was afraid things were going to fall through the cracks and she was going to “blow it.”

Jill’s story is similar to that of millions of baby boomers who are creeping into middle age. She wanted
to take action to improve her memory now and organize her life more efficiently. She is one of many
proactive individuals eager to get fit and benefit from a mental aerobics program.
Mental aerobics is any mental activity that exercises your brain. Just as sit-ups tighten your “abs,”
mental aerobics are jumping jacks for your mind. 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 firing in top form. Just as joggers gradually lengthen the distances they
run over time to increase their aerobic workout, we need to increase the complexity of our mental
aerobics program, whether it’s doing crossword puzzles, solving brain-teasers, playing charades, or
watching Jeopardy!

The Mozart Effect

Educators have observed that young children, from toddlers to preteens, who are exposed to Mozart
compositions and other classical music, appear to perform better academically than those who are not. In
studies of college students, Dr. Francis Raucher, Dr. Gordon Shaw, and other neuroscientists at the
University of Wisconsin showed that listening to a Mozart piano sonata improved the students’ cognitive
abilities. Interestingly, it was not verbal or language skills that improved 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 Effect has met controversy since not all studies show it, we do
know that different kinds of music have different mental effects. Some music will calm us, lowering heart
rate and blood pressure, 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 influenced actual brain growth and development. They found that, compared with non-
musicians in their study, the fifteen professional musicians had significantly greater volumes of gray
matter—the outer part of the brain that contains the nerve cell bodies. The gray-matter areas showing
the largest relative size were those involved in sensation, motor function, and one of the areas involved
in memory function that is affected early by Alzheimer’s disease. 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 definitive proof,
the potential for a benefit and the minimal risk involved convinces me that listening to classical music
may be a worthwhile habit for us all.

Use It or Lose It

Charles W., a 47-year-old newspaper journalist and father of two, was a volunteer for one of our
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 benefits. He became a voracious puzzle solver—
after six months he was completing the Sunday New York Times puzzle in ink using a stopwatch. His
crossword accomplishments gave him confidence, and his memory on the job improved.

A PhD in engineering is no guarantee against developing Alzheimer’s disease—the disease strikes

people from all walks of life, including ex-presidents, Nobel laureates, and nuclear physicists. Recent
studies, however, indicate a definite link between mental activity and staving off symptoms of
Alzheimer’s disease. And both laboratory and clinical studies point to the memory benefits of mental
activity.
Researchers at Case Western Reserve University found that the risk for developing Alzheimer’s disease
was three times lower in people who had been intellectually active during their forties and fifties
compared with those who had not. Their diverse mental activities included reading, working jigsaw
puzzles, woodworking, painting, knitting, and playing board games. Couch potatoes didn’t reap the
benefit: passive pursuits 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 benefits 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 confirmed our prediction based on
the earlier population studies: college graduates had higher activity in a critical part of the brain, the
posterior cingulate, which is involved in memory performance.
These observations point to the “use it or lose it” theory: people who use their brain cells will keep
them fit and protect the cells from “wear and tear.” These neuron users may be less likely to “lose it” as
they age. Of course, the PET scan may be showing us a healthier brain that was healthier at birth, and
our genetic predisposition for a healthier brain may have also gotten us on the college trajectory to begin
with.
Neuroscientist Fred Gage and colleagues at the Salk Institute added weight to the “use it or lose it”
theory in studies of newborn rats in enriched environments with treadmills, toys, and a variety of foods.
The rodents in the enriched environments had significantly more neurons in their hippocampal memory
centers compared with rats living in ordinary laboratory cages. Dr. William Greenough’s research team at
the University of Illinois found that rats in more stimulating environments grow new brain cells, more
synapses, or communicating connections between the cells, and new blood vessels for transporting
oxygenated blood to feed their more active brains. And, when running through their mazes and
completing other memory tests, the stimulated rats appeared more intelligent.
Additional research supports the idea that continual, lifelong mental stimulation is healthy for human
brains as well. Mentally and physically active people over age 65 have been found to have higher IQ test
scores and higher blood flow in the brain compared with those who remain inactive over a four-year
period. Not surprisingly, people with advanced education and professional accomplishments tend to have
greater density of neuronal connections in brain areas involved in complex reasoning.
Other 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
different muscle group or activity the next allows an athlete to rest muscle groups between workouts,
which builds stamina.
Neuroscientists believe the same principle holds true for brain training. Dr. Arnold Scheibel at UCLA
has described the way our brains thrive on novelty. Unfamiliar stimulation and new mental challenges
actually stimulate growth in a section of the brain known as the reticular formation. This brain region
may have developed its novelty-seeking specialization as a survival mechanism or adaptation to the need
for our ancestors to spot predators.

Brain Training, Not Brain Straining

An old tennis partner once told me that he suffered from an “exercise disorder.” He was a typical Type A
personality who embraced every new exercise program he could find and bought any workout gadget
late-night TV had to sell. His disorder was that he would overdo each program and quickly injure
himself, which would force him to take an extended break from all exercise in order to recover.
Afterward, he would promptly begin a whole new exercise regimen designed to heal the injury, but
would eventually injure a new joint and repeat the cycle.
Just as in physical fitness training, in memory training we want to avoid too much of a good thing. 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 first time, their PET scans reveal high brain-activity levels. After
becoming proficient at the game, however, the brain scans show minimal activity during play. They need
to use less of their brain capacity to accomplish the same task, much like an athlete becomes more
proficient in lifting weights or running a marathon after training. This research points to the possibility
that if we allow our brains to train gradually, just as a weight trainer increases the weight they lift
gradually, it may be possible to accomplish the same performance level with less effort and frustration.
The scientific evidence points to mental stimulation and brain training as a way to maintain healthy
brains throughout life. Suggestive evidence indicates that anything we do to exercise our brains in a new
way may help to develop nerve pathways that can help to forestall the effects of Alzheimer’s disease.
Most of these approaches are inexpensive, not harmful, and certainly worth a try.
It is critical to begin mental aerobic exercises at a level that stimulates but does not over-exert. If a
task is too difficult, a person may get frustrated and give up. If it is too easy, one may lose interest and
get distracted. In our research using cognitive stress tests, we found that patients with even mild
Alzheimer’s disease were unable to perform the more challenging memory exercises—they became
frustrated and lost track of the task. Rather than seeing brain activity in their memory centers, as we did
with volunteers who had only mild memory complaints, we saw either no activity or else activity in
brain emotion centers, probably reflecting their frustration from trying to complete an overly challenging
mental exercise.

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 effort to tease your brain can potentially
create new brain cell connections.
The fun of solving puzzles and brain-teasers often comes from pushing ourselves to make a mental leap
from existing assumptions to find a new solution to a seemingly unsolvable problem. To do so, we need
to break loose and explore the problem, puzzle, or brainteaser in a new way.
When we view certain visual images, we often fix 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 figure below, you probably see the black arrows. Try to see the figure from a different
perspective and push those black arrows into the background. Can you now see the white arrows emerge
facing the opposite direction?

Sometimes our mental assumptions actually distort reality. Look at the figure 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 find 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 fine. Your regimen of stretching, toning, and strengthening your brain can include music,
puzzles, and computer games. Such activities are most effective when they not only are fun but they
“shake up” your usual mental assumptions and force you to think of novel solutions.
Take a moment to review the results of your memory assessments from Chapter 2. These will point
you to your optimal level to begin your workout. Also, take note of how you feel when you perform
brain-exercise activities. If you find yourself getting frustrated quickly, go back and start at a less
advanced level. If you find the activities too easy, move on to more difficult ones. Mental stimulation
exercises should be challenging and enjoyable to achieve their best effect. Be sure to pace yourself and
set reasonable expectations.
Many experts support the potential benefit of mental stimulation to our brains. But what form of
mental stimulation is most effective? 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 fitness program was to bring down the level of mental
stimulation in his life rather than add mental aerobics. In fact, we focused our discussion on ways for
him to reduce stress in his life (Chapter 4).
My approach to mental aerobics is for each of us to identify a way to stimulate our brains without
stressing them. The following includes a variety of mental aerobics exercises presented at different levels
of difficulty that you can try out for yourself. As you familiarize yourself with them, you will be able to
determine which level and type of exercise gives you a sense of mental stimulation without frustration.
Once you know the kind of mental aerobics that works best for you, you may want to expand your
repertoire by seeking additional resources on the Internet or at the library.
The following exercises are divided according to beginning, intermediate, and advanced levels, as well
as which part of the brain each exercise trains. For most right-handed people, visual and spatial tasks
work the brain’s right hemisphere, 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, doing

conclusions) 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 find time to enjoy solving puzzles and playing mentally stimulating
games. It is precisely this enjoyment factor that makes it possible to maintain a mental aerobics program
over the long haul.

Beginning Exercises

1. Warm-up Exercise. Take a piece of paper and a pencil and try writing your first name using your
non-dominant hand (i.e., left hand if you are right-handed). Now take a second pencil and try writing
your first name using both hands at the same time. Now try it with your last name.
2. Right-Brain Exercise. How many squares are there in the following figure?
 3. Right-Brain Exercise. Complete the sequence by choosing object A, B, or C:

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

5. Right-Brain Exercise. Arrange five toothpicks of your own into the shape of a number five as 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 first box, the letter I is the only vowel. In the second box, the number
23 is the only one that cannot be divided by 2 or 3.
12. Whole-Brain Exercise. She is a minister.
13. Whole-Brain Exercise. Three socks. If your first sock is blue and your second sock is brown, the
third will have to make a pair with one of the first two.
14. Whole-Brain Exercise. Hans and Gerrie are standing with their backs to each other.

If you are having fun without frustration at this exercise level, you might want to check out the latest
websites and other resources for puzzles and brain-teasers with similar levels of difficulties.
Advancing to the next level gets a bit more challenging. Sample a few to see 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 first name with your left hand and your last name with
your right hand, but use both hands simultaneously. After you get the hang of it, reverse the task: write
your last name with your left hand and your first name with your right hand, but do it simultaneously.
2. Right-Brain Exercise. The following 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 different ways,
ask yourself what restrictions you have set for yourself in solving this problem.

4. Right-Brain Exercise. These cubes build from the bottom layer up. Figure out the total number of
cubes in the 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 find the hidden countries below without using any reference
material. The letter denotes the country’s first letter and the number indicates the number of letters in
the country. For example, B6 could be Brazil.

U7, T6, A9, M10, F4, V7

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

IIAWAH OHADI HATU ADIROLF AIGREOG NOGERO TNOMREV

13. Whole-Brain Exercise. Shirley has idiosyncratic tastes. She loves weeds but despises flowers. She
adores confetti but hates party decorations. She likes feet but dislikes hands. Based on her preference
pattern, would she prefer sitting or standing?
14. Whole-Brain Exercise. Two policemen are patrolling a one-way street looking for drivers who are
violating local traffic laws. They see a limo driver going the wrong way down the street, but the
policemen do nothing. How would you explain this?

Answers to Intermediate Exercises

1. Warm-up Exercise. No right answer.

2. Right-Brain Exercise.

3. Right-Brain Exercise. Letting go of our spatial mental assumptions allows us to solve the dot-
connecting puzzle.
 4. Right-Brain Exercise. Your total should add up to 35 cubes: 15 cubes are showing and 20 are
hidden.
5. Right-Brain Exercise. C.
6. Right-Brain Exercise. Place the left-hand circle under the middle one as shown 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 first name. View the results. Try writing your last
name with the paper against your forehead. Now try this exercise again while standing in front of 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 off and think nothing of it. A few days later, the same thing
occurs. Over the next few weeks, it happens several more times and then stops. Deciding this case did
not warrant calling in Mulder and Scully, or 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 goldfish, Emma, who really is more
of a radio fish.
Your remote control’s batteries have been dead for some time.
When the TV is found on, it is a seemingly random channel: news, soaps, static, or
Baywatch.
The television room is on the top floor, and there are no houses, buildings, or other
structures within line of sight of any window.
No other appliance in the house displays this behavior.
There seems to be nothing odd about your electrical system—no surges or spikes.
The TV is still under warranty and passed its most recent inspection by a trained
technician.

Is your TV possessed by an unearthly couch potato or can you think of a more mundane explanation?
9. Whole-Brain Exercise. What is the missing letter?

10. Whole-Brain Exercise. Three men, Alan, Brian, and Charles, and their respective wives, Alice,
Betty, and Cathy, were hunting in Africa, when they came across a large river. Luckily there was one
boat, but it could only carry two people at the same time. Due to bitter jealousy, no woman could be left
with another man unless her husband was present. How did they manage to cross the river?
11. Whole-Brain Exercise. There is a closed room with a light in it. Outside, there are three light
switches. You can flick any of the switches any number of times, but only one at a time. You can only
open the door and go into the room once. You know that the light is initially off. How can you determine
which light switch operates the light?

Answers to Advanced Exercises

1. Warm-up Exercise. No right answer.

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

3. Right-Brain Exercise. B. Moving from left to right and top to bottom, the black and white circles
move clockwise each step and the brick circle moves counterclockwise.
4. Left-Brain Exercise. Edam, cheddar, brie, cheshire.
5. Left-Brain Exercise. Turn the grid upside down.
 6. Left-Brain Exercise. If you cross out the letters NINE LETTERS, you spell REFRIGERATOR.
7. Whole-Brain Exercise. The ratio is 50–50. Intuitively, it may feel that the families are adopting a
strategy favoring producing a son, but this is incorrect. Each family’s expected number of sons is one, by
the definition of the strategy. But the expected number of daughters doesn’t drop.
8. Whole-Brain Exercise. Just like in the X-Files, the answer is that your TV is possessed by an
unearthly couch potato: the sun. Your TV room’s windows face west, and during certain times of the
year, the sun’s refracted rays come streaming in and strike your television’s remote control sensor. Since
the remote operates on infrared light, certain frequencies of light emitted by the sun are interpreted by
the sensor as commands to turn on or off, or change the channel. When you are home, you pull the
shades, to keep out the glare of the setting sun.
9. Whole-Brain Exercise. N. The pyramid spells out the name AL EINSTEIN.
10. Whole-Brain Exercise. Alan and Alice cross and Alan returns. Betty and Cathy cross and Alice
returns. Brian and Charles cross and Brian and Betty return. Alan and Brian cross and Cathy returns.
Alice and Betty cross and Charles returns. Charles and Cathy make the final crossing.
11. Whole-Brain Exercise. Leave switch 1 alone. Flick switch 2 on for an hour, then flick it back. Flick
switch 3. Now look. If the light is on, then the switch is 3. If the light bulb is warm, then it is switch 2. If
not, then it is switch 1.

Building Your Mental Aerobics Program

Just as physical activity can keep your body strong, mental activity can keep your mind sharp and agile.
You can continue to challenge yourself by using a variety of approaches. You might consider exploring a
new hobby, learning a foreign language, or perhaps taking up a musical instrument. Making a change in
your leisure reading—perhaps switching from romance novels to biographies or mysteries—could
potentially tweak your dendrites.
Whether you were able to complete all of the exercises or only a few, you should have a sense of the
difficulty level for mental aerobics exercises that suits you. As you build your skills over time, you may
want to advance to a higher level to challenge yourself and keep you stimulated. Chapter 10 will help
you fit a program into your weekly schedule, and you can readily expand your repertoire with novel
puzzles, games, and brain-teasers from other sources, including magazines, books, 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 fiercely self-sufficient. 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 unfinished or not done well enough? She constantly felt guilty about
spending too little time with the kids, Ken, and even her mother. She hadn’t had time to go to the
gym or take a run for weeks, and then her memory started to go. First she forgot to pick Ben up from
basketball clinic—twice. Then little Nikki was inconsolable when Rhonda “mixed up the dates” and
 didn’t show up to do an art project with her second-grade class. Ken realized Rhonda might be having
a real problem when he came in with an important out-of-town client for a home-cooked dinner, but
Rhonda had “spaced out” and ordered pizzas as a treat for the kids.
Rhonda was exhausted. She lost weight and grew restless. She was constantly bickering with
everyone, especially her mother. She felt terrible but she couldn’t stop—there were always three or
four more things she had to do first. Rhonda became depressed and her memory got even worse.
Ken convinced her to see a therapist they’d heard of. Once there, she broke down and sobbed that
she was losing it. She used to run a successful advertising agency and now she couldn’t even manage a
household! She felt overwhelmed, stressed out, and disorganized. She could hardly remember all the
errands and tasks she had to do each day.
The therapist said she appeared to be under severe stress and was definitely depressed, and often
when people are depressed, it affects their memory ability. Under some circumstances, he might
prescribe an antidepressant, but he was struck by how much of her problems began when her mother
broke her hip and Rhonda suddenly had to add parent care to her many tasks. Rhonda balked: at
work she used to have hundreds of tasks and a dozen employees vying for her time. Every minute of
every day was scheduled, and she never had memory problems then. The therapist said that might
just be the answer: when Rhonda was working, she adhered to a well-organized, scheduled agenda.
With her new “job,” she needed to create a similar, effective system to organize her schedule.
Rhonda knew he was right. Organizing her new life was something she had neglected, long before
her mother’s accident. She went home and began listing her many daily tasks and chores, and then
sorted them by priority and geography. She bought an appointment organizer like the one she had
used in her agency days and began scheduling her upcoming week. Rhonda felt empowered, and
although she was relying on her appointment book as a memory tool, the process of going back to her
familiar organizational strategies made it easier for her to remember her engagements without
actually having to refer to the book itself.
Rhonda was able to see her mother back to health and never did need those antidepressants.

Organization is essentially the process of systematically arranging information according to structures,

patterns, and groupings. Learning to organize daily activities effectively can make the difference between
success, mediocrity, or out-right failure. For maximum recall performance, organizing information
according to obvious patterns facilitates quick memory storage and retrieval.
One of the more effective organizational memory skills involves chunking—basically, dividing a large
group of random items into separate chunks with a common characteristic. Attempting to remember six
random items at the market is going to be more difficult than trying to remember three cereals and three
dairy products.
Consider the pile of common grocery items below:
 Many of us would find them easier to remember if instead of seeing a random assortment, we split
them up into two groups, or chunks: in this case, three fruits and three meats.

Four Organization Exercises

1. Group the following twelve items into three categories:

Hammer 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 first three numbers. Look up the phone
number for your public library. Read it once, cover it, and say it out loud. Difficult? For many of
us it will be. Now look at it again and cluster it into three smaller number groups. 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 first 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 find themselves
suffering 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 effort, the Peg Method will forever remove uncertainty about remembering
numbers—any sequence of numbers—whether it’s phone numbers, combinations, passwords, or social
security numbers. You will be able to punch in your credit card number and its expiration date and never
remove it from your wallet. Of course, pegging can prove to be challenging, so those satisfied with the
linking method they mastered in LOOK, SNAP, CONNECT may choose to jump to the next section.
To use the Peg Method, you will need to commit to memory ten specific, simple visual images—one
for each of the ten numerical digits. Begin by assigning each of the numbers one consonant letter of the
alphabet that reminds you of that number. For example, I use the letter T to represent the number 1
because it has one downstroke. I then use this letter to begin a word that invokes a visible image, in this
example, a tie, and this word tie, then, serves as my peg for the number one.
In Table 6.1, I provide a sample peg word for each of the ten digits. If you like, you can learn these
words or make up your own peg words based on your first association to the consonant sounds, and
write them in your notebook.
Table 6.1

In addition to being readily visualized, each of these words leads to distinct images. A raisin is hard to
confuse with a mummy, and a pot can be readily distinguished from a fork. Effective peg words also tend
to bring to mind many varied details, which lead to more memorable visual images, or snaps.
Using pegs and the link method together can also be very effective. Here is how you might remember
your wife’s social security number using the above peg words.
SSN: 557-16-8043

Peg word sequence: Leg

Leg
Kite
Tie
Jet
Fork
Zebra
Raisin
Mummy

Storyline-linking peg words: Imagine your wife 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 fly 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 flight attendant, enters the cockpit to serve
the fork a large raisin (4). As the fork tries to figure 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 effective techniques include repeating the person’s name during your initial conversation, as
well as commenting on how the person reminds you of someone else you know of the same name. Other
mnemonics work well, also. I mentioned my challenge every school year, learning the names of my kids’
new classmates and their parents. My son’s first-grade class was particularly challenging (I’m not sure
why). However, one little girl was named Ashley and her mother was Laura. Laura; Ashley. Since my
wife has an expensive yet seldom-indulged penchant for bedding by a company of that name, I found the
names of this child and her mother very easy to remember.
If a person has a complicated or unfamiliar name, you might ask them to spell it for you, or sometimes
just visualizing an image of the name spelled out will facilitate memory storage. Using their name when
saying good-bye will certainly help secure it into your memory banks.
All names can be placed into two groups: those that have a meaning and invoke a visual image, and
those that don’t. 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 effort to remember. However, the names or the syllables and sounds within them can
be associated to a substitute name or sound that does have a meaning. By linking these substitute words
together, you can create a visual image that works. Sometimes we can break a name into syllables that
contain meanings, and then link them afterward. For example, the name “George Waters” could be
remembered through an image of a gorge with a stream of water rushing into it. The word or syllable
substitutes do not need to be exact. “Frank Kaufman” could be a frankfurter being eaten by a coughing
man. “Gene Phillips” could be a Phillips screwdriver wearing a pair of tight jeans. Of course, some
scientists among us might prefer visualizing a double-helix gene downing a double-vodka screwdriver.
Finally, we need to CONNECT the name to the face. The approach here is to look at the person’s face
and search for a distinguishing feature, whether it is a small nose, large ears, unusual hairdo, or deep
wrinkles. Just pick the first outstanding feature you notice and link it to the name. For example, if Mrs.
Stockton has a round face, think of a balloon falling on a ton of stock certificates.
To create a snap for remembering Mr. Bender’s name, you may see him bending forward, as below.

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

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

NAME VISUAL IMAGE

Stewart

Cheryl

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

PERSON’S NAME VISUAL IMAGE

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

PERSON FEATURE NAME/FACE IMAGE

The Roman Room Method

To apply the Roman Room method, originally developed by ancient Roman orators to help them
remember long speeches, first visualize a familiar room. Then place each item to be remembered in a
specific location there. You can then retrieve the information when taking a mental walk around the
room.
The method can be useful for speeches, lectures, or lists. You might imagine your living room,
bedroom, or office as your “Roman room.” I can imagine myself in my office where I see from left to
right the computer, phone, bookshelf, and couch. I need to remember the following errands after work:
hardware store, carwash, cleaners, and market. I then visualize a wrench on top of the desk, a wet car on
the phone, folded shirts in the bookshelf, and a shopping bag on the couch.
A variation uses a familiar route rather than a familiar room. On your commute to the office, you pass
the following landmarks each day: water tower, bridge, gas station, and post office. You need to thank
several people in your Academy Award speech so you think of Steven Spielberg sitting atop a water
tower, Meryl Streep walking across the bridge, Sylvester Stallone pumping gas at the station, and 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 specific visual “peg” for
each of the ten digits; then use the link method to create a story for remembering numerical
sequences.
3. Remembering Names and Faces. Make sure you consciously listen and observe the name (LOOK),
then SNAP a visual image of the name and the face, and finally CONNECT the name-snap to the
 face-snap.
Observe distinguishing features in the person’s face.
Repeat the name in conversation and when saying good-bye.
Look for personal meaning in the name.
Ask them to spell their unusual name.
4. Roman Room Method. Pick a familiar room or route and, in your mind, place the items to
remember at key points or landmarks.
Chapter Seven
Start Your Healthy Brain Diet Now

I drive way too fast to worry about cholesterol.

—STEVEN WRIGHT

Most of us realize by now that the quality and quantity of the foods we eat affect our bodies and our
physical health. Less widely understood is the critical impact our nutritional habits have on our brain
health—particularly our memory performance and risk for developing Alzheimer’s disease.
Just as unhealthy diets can lead to physical ailments 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 fitness—although the effects may take decades to appear.
Convincing scientific evidence indicates that long-term, healthy dietary habits may prevent future
brain aging and memory decline and help protect our brains from developing Alzheimer’s disease
symptoms. For many people, even a few weeks of healthy, low-fat eating can produce immediate benefits
such as increased alertness and greater energy.
The sooner we start our healthy brain diets, the sooner we begin to reap the benefits. Chapter 7
provides the components of a safe mental-fitness diet to keep your brain young and protect it from
Alzheimer’s disease.

Calories Count to Healthier Brains

By the time we reach middle age, many of us tend to carry around extra body weight. Whether it’s
simply an additional five or ten pounds, or true obesity, excess body fat increases our risk for 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 effective and widely accepted ways to drop weight and avoid these problems is
limiting daily caloric intake while increasing physical activity—a practice at the heart of almost all
traditional weight-loss programs. Any reputable book or program on dieting or weight reduction, no
matter how miraculous its “breakthrough” methods may be, comes down to these tenets at some point.
Who of us struggling against love handles wouldn’t want to “Lose weight while sleeping!” or try a month
on “The more you eat the more you lose!” diet? Alas, the 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 fitness.
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 off
the diet with a giant binge. Experts agree that in the long run, such yo-yo diets tend to backfire and
actually lead to increased body weight.
Researchers put healthy laboratory rats on a yo-yo diet and found they developed 3 to 4 percent more
body fat than animals kept on a steady caloric intake. Weight cycling, or the pattern of gaining, losing,
and regaining weight, often leads to greater fat accumulation over time. The evidence from animal
studies and the harmful physical and mental effects of obesity has convinced many experts that by
sensibly watching our caloric intake we may help protect our brains.
 Georgette B., a 46-year-old teacher, first sought help for her memory problems two years ago. She
was already being treated for high blood cholesterol, and she was concerned about her family’s
history of Alzheimer’s disease. During the first five minutes of her visit, it was clear that memory
complaints were not her only problem. In describing herself, she said she was always the first of her
friends to try the latest fad diet. She would typically begin a new diet regimen, maybe lose a few
pounds in the first week or two, and then quickly grow discouraged as her weight loss tapered off.
Georgette would then abandon the diet and almost ritualistically plunge into a 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 finally finding and latching onto the next miracle weight-loss
program. During her bouts of depression, Georgette’s memory difficulties became markedly worse. It
was clear that if I were going to help Georgette with her memory problems, her eating disorder would
need to be addressed as well.
Her approach to dieting had been like a physical and emotional roller coaster. She understood that
what she ate had an effect on her waistline, but she never imagined that what she ate could have an
impact on her current memory and future ability to think.
I referred Georgette to a nutritionist, who helped design a diet that kept her satisfied. By feeling less
deprivation, she was less likely to quit the diet and start binging.
Another issue for Georgette was chronic depression. After treatment with an antidepressant, her
memory complaints diminished and she found it easier to stick with her diet. For Georgette, learning
that food choices could ultimately affect her brain aging and risk for developing Alzheimer’s disease
helped change her attitude about food and eating. She became more realistic in her dietary goals and
began to focus on the type and quality of food choices rather than just calorie counting.

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

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

Dr. Hugh Hendrie of Indiana University compared rates of Alzheimer’s disease in African-Americans
living in Indianapolis, Indiana, with those of Africans living in the Nigerian city of Ibadan. The
Americans developed dementia at a rate nearly three times greater than the Nigerians. The Americans
also had higher rates of hypertension, high cholesterol, and diabetes than did the Nigerians, and these
illnesses all contribute to the risk for dementia, particularly the vascular form.
Although genetic risk likely plays a role, 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 fish,
and other foods. This diet contrasts dramatically with the typical American diet, which is usually high in
animal fats. The researchers judged the Nigerian diet, normally low in protein, fat, and total calories, to
be a major contributor to the lower rate of dementia in their population.
Dr. Jim Joseph of the 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 flour, cheese, and
related high-fat foods. Many are overweight and have early-onset diabetes. By contrast, their relatives in
Mexico eat a healthier diet of rice and beans, and despite their identical genetic makeup, obesity and
diabetes are unknown in these people. Native Alaskans on the Kenai Peninsula and their genetically
identical relatives in Siberia share a similar story. The Native Alaskans are overweight and eat the “white
man’s diet,” 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 effectiveness of these diets
in reducing body weight, often due to loss of body fluids associated with carbohydrate restriction, their
ability to slow down brain aging is questionable, and these diets may increase the risk for heart disease,
diabetes, and cancer.
Doctors agree that a healthier diet option might involve limiting animal fats and increasing whole
grains, vegetables, fruits, and dairy products, whose benefits stem partly from their potassium and
calcium contents. Concerned about the harmful effects of fat, many Americans and Europeans have in
fact been lowering their fat consumption for several years.
Epidemiologists consistently find that eliminating most fats from our diets lowers our risk for
Alzheimer’s disease, and it is never too early to begin a low-fat diet to keep our brains young and stave
off Alzheimer’s disease. Dr. Robert Friedland and his associates at Case Western Reserve University
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 benefit
for people with a genetic risk for age-related memory loss or Alzheimer’s disease. Dr. Friedland’s group
found that people with the APOE-4 Alzheimer’s risk gene who ate a low-fat diet had a strikingly lower
risk for developing Alzheimer’s disease compared with their counterparts who ate fatty diets. A similar
lowering of Alzheimer’s risk was not observed in people without the genetic risk.
Some experts believe that the APOE-4 Alzheimer’s risk gene accelerates age-related memory loss
through its effect on fat metabolism. Among its many functions, APOE’s protein product acts as a
transport mechanism, or chaperone, for cholesterol in the blood. High blood cholesterol levels not only
increase our risk for heart disease and stroke but also make us more susceptible to Alzheimer’s disease. 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 benefited 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 fitness. 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, fish, fish oil, and olive oil. We can also get omega-3 fats as capsules or
supplements. By contrast, omega-6 fatty acids, often considered “bad fats,” 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 inflammation, a possible
underlying mechanism in Alzheimer’s disease and other neurodegenerative disorders. Omega-3, or good,
fats help keep brain cell membranes soft and flexible, 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 effects on the hormone insulin.
Laboratory animals that are fed omega-6 fats have increased difficulty learning and getting through
mazes. In addition, their brain cells show fewer branches, or dendrites. Eating omega-6 fats also
increases risk for insulin resistance—insulin becomes less effective in getting glucose into cells, putting
people at greater risk for the memory impairments associated with diabetes. Fortunately, diet-related
insulin resistance can be reversed, and controlling diabetes with diet, weight loss, or drugs can improve
memory as well as learning ability.
Clearly, a diet rich in omega-3 fatty acids is likely to benefit our brain fitness and overall health, but
our bodies are also able to adapt to a limited amount of omega-6 fats. An occasional donut or slice of
apple pie won’t necessarily wipe your mother’s maiden name from your memory stores. Some nutrition
experts even suggest maintaining a ratio of one omega-3 fat for every omega-6 fat, rather than
attempting to completely eliminate the bad omega-6 fats from our diets.
Table 7.1 lists a number of common foods containing mostly omega-3 or omega-6 fats. A well-planned
healthy brain diet will emphasize foods high in omega-3 fats.
Table 7.1

SOME COMMON FOODS CONTAINING 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 fish oil, actually increases acetylcholine, the brain messenger critical to normal memory function but
lost in Alzheimer’s disease. People with deficient DHA in their diets or low levels in the blood will
experience learning difficulties and cognitive decline. These can and do improve when dietary DHA is
high. Research indicates that omega-3 fatty acid capsules may improve memory difficulties and other
symptoms in patients with Alzheimer’s disease.
Recent studies suggest that omega-3-rich fish oil may benefit a person’s mood as well as their memory,
acting as an antidepressant and diminishing symptoms of hostility and aggression. Fish oil also has an
antioxidant effect that fights against free radicals that can damage brain cells and decrease the brain’s
immune response (see later discussion), thus modulating the cell-damaging effects of inflammation.
Because low-fat diets protect us against Alzheimer’s disease, a healthy brain diet should include all kinds
of fish, not just those high in omega-3 fats but fish that are considered low in their overall fat content,
such as swordfish, snapper, sole, cod, catfish, flounder, perch, shellfish, haddock, and grouper.
Dr. David Heber and Susan Bowerman of the UCLA Center for Human Nutrition make a distinction
between ocean-caught and farm-raised fish. This might sound like splitting hairs, but it’s not. Farmed fish
are fattier because they don’t move around much, and their ratio of omega-3 to omega-6 is not as
desirable because they don’t eat the algae and other fish the way their free-swimming counterparts do in
the ocean. Ocean-caught fish have less overall fat but more of the omega-3 fats because they are 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 suffer from this oxidative stress, a continual
bombardment from chemical reactions in the environment and from within our own bodies. Through the
DNA damage, this oxidative stress accelerates aging and promotes nearly all chronic age-related diseases
from cancer to cataracts to Alz-heimer’s.
To keep oxidation in check, our bodies use antioxidants like vitamins C and E that combat the effect 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 effects got to the brain. They found that
this dose slowed down the advance of Alzheimer’s disease by approximately seven months. Patients
taking the vitamin were less likely to enter nursing homes or to develop severe symptoms for that period
or longer. 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 benefit from vitamin E’s antioxidant
effects that might prevent future severe memory losses, deciding on an optimal daily dose is complicated
by the vitamin’s effect on the immune system. At low doses of 200 units each day, vitamin E may help
reduce infections in older people, but at higher doses, it may have the opposite effect. Studies have
shown that very high doses of vitamin E, for example, the equivalent of over 2,000 units daily, may
suppress a person’s immune response and limit the body’s ability to fight off infections. 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 find an effective 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
benefits 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 finding their way through mazes
and other tasks. Dr. Joseph encourages people to regularly eat antioxidant-rich foods such as
strawberries, blueberries, raspberries, cranberries, broccoli, and spinach.
 Researchers at Tufts University have devised a laboratory technique that measures the ability of
different foods to counteract oxidative stress. Those foods with high “oxygen radical absorbency
capacity,” 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 significant
amounts of the potent antioxidant known as catechin. Caffeinated green teas have very high catechin
levels, as do caffeinated black teas brewed from bags.
A new approach that encourages people to eat foods with high antioxidant capacity emphasizes the
color factor in fruits and vegetables. Dr. Jim Joseph in his book The Color Code and Dr. Dave Heber in
What Color Is Your Diet? describe how phytochemicals—rich antioxidant dietary sources—are responsible
for the colors in fruits and vegetables. Among these, anthocyanin makes a blueberry blue and has
antioxidants that fight cancer; lycopene makes tomatoes red and protects our hearts and brains. 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, flavorful Dijon variety of mustard, while watching my kids
squirt that bright yellow stuff 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-inflammatory actions besides. Scientists have found that curcumin relieves
symptoms in arthritis sufferers and inhibits the growth of various cancer and tumor cells. Such
encouraging curcumin effects led Dr. Greg Cole and Dr. Sally Frautschy at UCLA and its affiliated
Veterans Affairs Medical Center to study this ubiquitous spice’s potential for preventing Alzheimer’s
disease. Their initial investigations of laboratory animals confirmed that curcumin not only suppresses
oxidative damage to cells but also prevents loss of synapses—the connecting communicating terminals
between brain cells—and decreases the deposition of amyloid protein and plaque burden in the brain.

Vitamins and Minerals for Keeping Brains Young

When a patient complains of a memory problem, one of the first things we do is to test their blood levels
of vitamin 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 offers a certain amount of
protection against strokes, heart disease, and circulatory problems. In his long-term study of aging nuns,
Dr. David Snowdon found that, at autopsy, the most extensive evidence of Alzheimer’s disease was
observed in the brains of those nuns who had the lowest concentrations of folic acid in their
bloodstream.
Interestingly, folic acid supplements are recommended for women during their 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 bifida or other neural tube disorders. Folic acid, as well as all antioxidants, is
important to neural integrity and brain health throughout life, even before birth.
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, riboflavin, niacin, and folate supplements scored
better in abstract thinking tests. Also, volunteers with heightened blood levels of vitamin C scored higher
in visual and spatial ability tests. These findings point to the potential brain-boosting effects of various
vitamin supplements.
Further research has shown that older persons with low levels of thiamin, riboflavin, vitamin B12, and
vitamin C are more likely to experience anxiety, irritability, and depression. People who eat well-
balanced meals generally don’t develop deficiencies, and most doctors recommend daily multiple
vitamins to ensure that such deficiencies do not develop.
It is also important for all of us to keep in mind the potential toxic effects of unnecessary vitamin
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 fish, green leafy
vegetables, soy products, and rice. This nutrient can be found in our cell membranes; in fact,
approximately 10 percent of the fatty component of our brain cell membranes consists of
phosphatidylserine.
Scientists have found that phosphatidylserine can increase neurotransmitters that improve memory
and concentration, and animal studies indicate that it slows age-related memory decline. These
encouraging observations have led to studies testing the effectiveness of phosphatidylserine as a
supplement to augment recall abilities in people with mild age-related memory complaints.
Dr. Tom Crook, a neuropsychologist formerly with the National Institute of Mental Health, along with
other investigators, has shown that people with age-associated memory impairment score better on
memory and learning tests after taking phosphatidylserine when compared with those taking a placebo.
This nutrient may indeed be effective, and perhaps sixty or more studies have demonstrated this
modest but positive benefit. A limitation of these studies, however, is their relatively brief duration,
ranging from six to twelve weeks, raising the possibility that the benefit may be not be long-term. It is
certainly possible that phosphatidylserine has a long-term beneficial effect, but it has never been
systematically studied beyond twelve weeks.
Doctors who recommend phosphatidylserine suggest that people begin with 100 to 150 mg twice a day
and after several months they drop the dose to only 50 mg twice a day for maintenance. No side effects
have been reported.

The Ups and Downs of Caffeine

Every morning, millions of us drag ourselves out of bed, blurry-eyed, empty mug in hand, and grope our
way to the coffeepot before we can imagine beginning our day. Coffee consumption exceeds 100 billion
cups per year in the United States alone, where 80 percent of the adult population drinks coffee or tea
daily—making caffeine our most commonly used drug. We also get caffeine in our diet from sources that
some people are not aware of, including chocolate and some sodas.
Too much caffeine increases cholesterol levels, may increase the risk of heart attacks, and is associated
with urinary bladder cancer and high blood pressure. Caffeine also increases risk for bone thinning from
osteoporosis. Acute caffeine intoxication causes rapid heart rate and can pose health hazards for cardiac
patients.
Caffeine has both positive and negative effects on brain fitness. On the positive side, it diminishes
fatigue, increases alertness and attention, and improves mood. We all know of the pick-me-up we get
from our morning java. Systematic studies show that in the short term, caffeine can improve learning
and recall abilities. In the Honolulu Heart Program, a thirty-year study of 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 caffeine use can cause irritability, insomnia, and anxiety. Because
caffeine’s effects are short-acting, suddenly interrupting the caffeine habit can cause withdrawal
symptoms. Caffeine withdrawal usually begins twelve to twenty-four hours after the last exposure, with
symptoms peaking in the first forty-eight hours but sometimes lasting up to two weeks. Headache,
fatigue, poor concentration, and depression are common complaints when we can’t get our daily caffeine
fix. Just ask my wife—but not before she’s had her morning coffee. The single greatest cause of post-
operative headache is caffeine withdrawal. In order to prevent post-operative headaches, some surgeons
have been known to actually add caffeine to the intravenous fluids of patients who cannot drink liquids
after surgery.
For those of us who do consume caffeine, we need to be aware of the side effects and avoid overuse
and withdrawal symptoms. Table 7.4 lists the caffeine content of some common foods and drugs to help
you to keep track of how much you’re taking each day.
 Table 7.4

CAFFEINE CONTENT OF SOME COMMON DRINKS, FOODS, AND DRUGS

Brewed coffee (6 oz) 100 mg
Decaf coffee (6 oz) 4 mg
Instant coffee (6 oz) 70 mg
Tea (6 oz) 40 mg
Caffeinated soft drink 45 mg
Chocolate candy bar (40 gm) 10 mg
Anacin 32 mg
Excedrin 65 mg
No-Doz 100 mg

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

Sugar on the Brain: How Sweet It Is

Sugar, or glucose, is the brain’s main energy source, and blood sugar levels affect both mood and
memory. Unlike other cells in our bodies, brain cells cannot convert fats or proteins into glucose, so they
depend on daily dietary sugar for optimal functioning and survival.
When our blood sugar levels drop too low, many of us tend to feel lethargic, irritable, and may have
difficulty learning new information. But give us a meal, power bar, or glass of juice, and our moods perk
right up, as do our memory and concentration abilities.
Our brains don’t function well when blood sugar is too high, either. Studies of both animals and
humans have consistently shown that abnormally low or high blood sugar levels will affect memory and
learning abilities. The reason may involve the brain messenger or neurotransmitter acetylcholine, a
neuron communication link important for normal memory performance.
The acute effects of sugar on the brain are well documented. After drinking carbohydrate-spiked
lemonade, volunteers show better memory performance and mental flexibility than after drinking
saccharine-sweetened lemonade. Similar results have been documented in patients with Alzheimer’s
disease.
When I was growing up, my father always encouraged my sisters and me to eat breakfast, “the most
important meal of the day!” He never backed up this statement with facts, but I later learned that his
was indeed good advice. Breakfast—breaking the fast of our nighttime sleep—increases blood sugar
levels and leads to greater mental clarity during the day. Studies of elementary school students show
improved academic performance and behavior when they eat breakfast, and adults who eat breakfast
maintain higher blood sugar levels, quicker recall, and better overall memory performance than those
who skip it.

Diabetes: When Your Blood Gets Too Sweet

Although sufficient blood sugar keeps our brains working optimally and a quick glucose fix can give us
an immediate memory and concentration boost, many of us suffer from chronically high blood sugar
levels. If sustained over months and years, these high blood glucose levels can lead to a 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 effective insulin. This can cause the body to become insulin-resistant or unable to
use insulin effectively, which puts one at risk for non-insulin-dependent diabetes, or type 2 diabetes, as
well as high blood pressure and circulatory problems affecting the brain. Arteries can become stiffer,
restricting blood flow to the brain.
About 16 million people in the U.S. suffer 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 flow of sugar to keep them optimally fit, maintaining an even
glucose level in the brain and avoiding blood sugar fluctuations should be everyone’s goal. We can begin
to protect our brains from the onslaught of chronic sugar overload and insulin surges by attempting to
avoid foods that spike blood sugar and, in turn, cause the pancreas to pump out more insulin.
The sugars we eat are technically carbohydrates and they come in two forms: simple sugars, such as
sucrose or table sugar, and complex sugars or starches, including fruits, vegetables, milk, and cereals.
When asked why the rate of diabetes has risen sharply over the last few decades, experts point to the
changes in our diets. In contrast to our ancestors’ natural sources of carbohydrates—fruits and vegetables
—many people today eat foods containing refined sugars and processed flour. These newer, less
nutritional forms of carbohydrates can cause rapid rises and subsequent falls in blood sugar levels, which
our bodies were not designed for.
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 effect on blood sugar levels, the glycemic
index. This index ranks foods from 0 to 100, indicating whether the food raises blood sugar levels
dramatically, moderately, or minimally. This research debunks many old myths about carbohydrates.
First, starchy foods 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 fiber, had a lower risk for developing diabetes.
Nutritional experts recommend the consumption of three servings of whole grains each day. On average,
most Americans consume less than one serving.
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 effects. 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
specific effect on blood sugar when we sit down to eat a particular meal because we usually eat foods in
combinations that tend to minimize blood sugar spikes from high-glycemic-index foods. Highly acidic
foods like vinegar also will minimize blood sugar spikes. Dr. Brand-Miller found that lemon juice and
vinegar, particularly red wine vinegar, have this effect, 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 first grader’s leftover potato chips while driving home from the
office.
Have you ever picked up the phone, suffered through an unpleasant phone call, hung up, and noticed
that eight Oreo cookies have disappeared? Do you find yourself guiltily hiding the evidence of eating
your child’s candy bar or ice cream sandwich when your day has overwhelmed you? Nearly everyone
has experienced some form of stress eating at some time. The phenomenon generally has two
components: (1) a stressful event to trigger binge eating, and (2) conveniently available foods, often
processed foods or desserts.
 Lisa E., a 45-year-old accountant, became adamant about starting a memory-training and mental
stimulation program due to the recent changes in her recall abilities. Her symptoms had gotten
markedly worse during the last tax season, and she didn’t like it when both her boss and her 16-year-
old son started making jokes about her middle-aged memory lapses.
She came to our clinic having already picked up some memory-training skills on her own, but
wanting to learn more and hone her techniques. The results of Lisa’s initial evaluation were normal,
except for a borderline elevation in blood sugar, so we referred her to a nutritionist, who provided
dietary guidelines to help her control her blood glucose levels. She agreed to start a low-fat diet, high
in omega-3 fatty acids and antioxidant foods, and agreed to avoid high-glycemic-index foods. She also
began a memory-training course and a mental aerobics program.
After eight weeks, Lisa noted some memory improvement, but her blood test still showed slightly
elevated sugar levels. She swore she had been true to the diet, shopping at the health food market,
buying only the foods on the list, and preparing them correctly.
What Lisa failed to mention were the donuts, sweet rolls, and frosted flakes she had at home for her
son, as well as the constant bombardment of bagels, breakfast bars, and almost daily birthday cakes
surrounding her at work.
When Lisa’s nutritionist finally convinced her to keep a daily food log, diligently recording
everything she ate for a week, Lisa learned the tragic truth she had been hiding, even from herself—
she was a closet sugar addict. In moments of elevated stress, her unconscious sugar cravings would
emerge. Like a vampire at nightfall, Lisa would reach out and devour the closest sugary snack food
available—usually without even realizing it.
Thanks to her food log, Lisa learned to grapple with her sugar problem and get her blood glucose
levels under control. She was able to keep her memory-training work on track and her job
performance improved. Her boss gave her a raise, which was no joking matter, and the only person to
complain was Lisa’s son, who had to give up the donuts and frosted flakes for the healthier, natural
alternatives Lisa now bought and enjoyed.

Carbohydrates with a high glycemic index are the usual culprits when it comes to stress eating. There’s
something extremely satisfying in that fleeting, momentary, crunchy, munchy sugary experience.
However, the resulting insulin spikes followed by subsequent blood sugar crashes often leave one feeling
famished and can lead to additional overeating as well as other serious problems.
Although we can’t completely eliminate stress from our lives, we can follow some practical tips to
avoid unhealthy stress eating (see box).

Practical Tips to Avoid Stress Eating

Eliminate your favorite unhealthy stress foods from your house, car, and office.
Keep baggies of fresh-cut vegetables in convenient places where stress eating most often
occurs—near the kitchen telephone, at the office desk, in the car, etc.
Avoid processed-food snacks. Instead, if you need a quick snack, substitute “brain
 snacks”: power bars, sourdough croutons, blueberries, and strawberries.
Keep bottled water nearby at all times—when stress hits, take a swig.
Set reminders—post a sign in each of your stress-eating spots (near the kitchen
telephone, workplace computer station) reminding you to “Relax and Eat Healthy.”
When you catch yourself in a stress-eating mode, put yourself on pause: take a deep
breath, toss out that cookie or donut, take a break from the stressful situation, and
stretch.
Develop other skills to reduce stress by reading Chapter 4.

Start Dishing Up the Smart Food

Eating a healthy brain diet is no more complicated than any physically healthy diet. Getting enough
antioxidants, the right fats and carbs, and limiting calories are all easier than it may seem at first read.
Probably the hardest part is just getting started. Once you’ve passed that hurdle, the rest is cake (only an
expression, of course).
Dr. David Heber of UCLA emphasizes eating not just healthy foods, but tasty foods as well. He
recommends fruits and vegetables; high-fiber breads, cereals, and grains; and low-fat animal proteins
(e.g., skinless chicken, fish, skim milk products). Dr. Heber encourages people to use herbs, spices, garlic,
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 fitness will likely improve quickly, and for
the long run.

The Basic Elements of a Healthy Brain Diet

Eat a low-fat diet.

Stay aware of overall caloric intake.
Avoid stress eating and late-night snacks.
Toss away your yo-yo diet plan.
Avoid processed foods and high-glycemic-index carbs.
Eat foods rich in omega-3 fats.
Avoid omega-6 fats.
Remember you have choices: sourdough bread rather than French rolls, olive oil rather
than corn oil.
For a daily antioxidant boost, eat fruits and vegetables, and drink tea. Try frozen or
fresh blueberries for a snack food.
Avoid too much caffeine.
Drink water throughout the day; shoot for six or more glasses daily.
 Take multivitamins as well as vitamins E and C and folate supplements.
Create meals that are healthy and tasty—try using herbs, garlic, and spices to enhance
taste.

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

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 findings 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 fitness. 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, five days a week; eating at least five servings of
fruits and vegetables each day; and avoiding tobacco, illicit drugs, and alcohol abuse. If there were a
comparable office known as Surgeon General for Brain Fitness, I suspect it would issue similar
recommendations.
Dr. Karen Ritchie, an epidemiologist from Montpellier, France, studied the mental status of a woman
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 fitness. Armed
with convincing evidence from large-scale, long-term human studies, as well as experiments in
laboratory animals, scientists are now recognizing that physical activity apparently protects the memory
centers of the brain.
Most of us who do aerobic exercise on a regular basis generally do so to maintain physical stamina,
health, and fitness. Physical exercise can also enhance our mental state by increasing the circulation of
endorphins—hormones released in our brains after exercise that have immediate benefits on mood and
memory—the body’s own internal antidepressant. Regularly scheduled aerobic exercise, with its
accompanying mildly euphoric endorphin “boost,” also helps maintain maximum long-term brain health.
A well-balanced exercise program usually includes some toning and stretching, which allows people to
avoid injury while they build stamina. The actual aerobic part of our exercise routine gets our hearts
pumping faster, our lungs breathing deeper, and if we continue these activities on a regular basis, they
can help reduce our risks for age-related illnesses like heart attacks and strokes. Many experts
recommend walking as one of the safest and most effective forms of aerobic exercise. The MacArthur
Study of Successful Aging noted that older adults who walked 45 minutes, three to four times a week,
doubled their endurance level after a year.
A convincing case can be made for the mental benefits of aerobic exercise, although a Heisman Trophy
is not a 100 percent guarantee against developing Alzheimer’s disease. The disease has been known to
strike people who have achieved remarkable feats of physical fitness, including triathletes, long-distance
runners, and championship tennis players.
Recent studies, however, indicate a definite link between physical activity and staving off Alzheimer’s
disease. Small laboratory animals exposed to exercise—running on wheels and treadmills—show
formation of new blood vessels and nerve cell communication sites, or synapses, in the brain. Dr. Fred
Gage and his 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 flow of
oxygen and nutrients to brain tissues or release special growth factors that promote nerve cell growth.
These landmark studies also contradict the old myth that new cell growth does not occur in adult brains.
Physical exercise appears not only to keep brain cells alive but also to grow new neurons.
Dr. Robert Friedland and his associates at Case Western Reserve University studied over 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 suffer from Alzheimer’s disease later in life, and these
activities ranged from gardening a few times a week to racquetball to daily jogging.
Researchers have found that physical exercise provides benefits in mental performance, regardless of
age. In fact, provided people do not over-exert themselves, these benefits 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 benefits of aerobic fitness 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 reflect some other advantages associated with being physically active, such as a healthy
diet, good genetic predisposition, or use of anti-inflammatory drugs. Research data vary according to the
age of the volunteer. In fact, the older the study subject, the more prominent the mental benefits of
physical exercise. Also, if a person is physically fit at the outset of testing, it may be more difficult to
measure the mental benefits of working out.
Dr. Arthur Kramer and his associates at the University of Illinois demonstrated the mental benefits of
physical aerobic exercise in a six-month study of healthy adults between ages 60 and 75. Divided into
two groups, one followed an aerobic walking program, while the comparison anaerobic group followed a
toning and stretching program. The aerobic exercise group learned basic principles and guidelines for
exercise programming, including an adequate warm-up and 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 fitness 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 benefits literally show up—in the mirror and in how good you feel. For those who absolutely don’t
have the time, start by popping a bit of exercise into your normal daily routine: take the stairs instead of
the elevator; choose a 5- or 10-minute brisk walk over another coffee break, and involve your mate or a
friend in an outdoor weekend activity instead of lounging all Sunday in pajamas watching a Twilight Zone
marathon.
Any physical exercise program should include a series of stretching and toning exercises, along with a
good aerobic component. The key is to blend exercise into your lifestyle and make it a part of your daily
routine. Even if you can only spare 10 or 15 minutes a day at first, 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 fitness—moderate but
regular conditioning is more than enough.
Incorporate both an aerobic and a weight-training component to your program.
Slip some type of physical activity into your daily routine: take the stairs instead of the
elevator, a brisk walk instead of a donut break.
Choose sports and activities that you enjoy because you are more likely to continue
them in the long run. If walking around the neighborhood bores you, try a treadmill or
stationary bike so you can read or watch TV while you work out.
Check with your physician when getting started, especially if you have a physical illness
that an exercise program could affect.

Watch Your Head

When choosing an aerobic fitness program, I advise my patients to avoid those that increase risk for head
trauma. More than 5 million Americans have suffered from some type of traumatic brain injury, and
nearly all those injuries could have been prevented. The scientific evidence points to the obvious: avoid
head trauma—both mild and severe—to protect your brain from cognitive decline. Wearing seat belts,
choosing a designated driver who is not drinking, and wearing helmets when riding bikes or doing sports
are critical to protecting our brains.
Dr. Richard Mayeux and research associates at Columbia University found that people who have
blacked out for an hour or more following a head trauma have a twofold increased risk for developing
Alzheimer’s disease down the road. If such a person also has the APOE-4 genetic risk for Alzheimer’s
disease, their overall risk for the disease increases to tenfold.
Dr. Brenda Plassman and her co-workers at Duke University studied medical records of veterans who
had suffered varying degrees of head trauma, dating back as far as fifty years. They found that veterans
with only moderate head injury—loss of consciousness or post-traumatic amnesia for more than 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 suffered 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 effects of mild but repetitive brain injuries caused by contact sports. Dr. Erik Matser and
his team at St. Anna Hospital in the Netherlands compared amateur soccer players in their mid-twenties
to same-aged swimmers and runners who were less likely to suffer head injuries. Over 30 percent of the
soccer players suffered from memory impairments, 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 different threshold of brain injury required before memory loss and other problems emerge. A
high degree of reserve capacity will protect the brain, so that a mild blow to the head might cause no
symptoms in one person while causing severe injury and cell loss in another—depending on the
individual’s brain reserve capacity threshold. A redundancy in the neuronal networks may explain such
reserve. Satz’s theory is consistent with the idea that multiple small injuries have a cumulative effect in
whittling away brain reserves until a certain level or threshold of cumulative damage is reached and
symptoms become apparent.
Other evidence supports this notion of brain reserve. Dr. James Mortimer and associates at the
University of South Florida looked at head circumference as a reflection of neuronal numbers and
density of their interconnections. His group, as well as others, found that the size of a person’s head does
indeed predict their future risk for getting Alzheimer’s disease—big heads have lower risks. Studies using
brain scans to measure brain size further supported this concept. Dr. Peter Schofield and 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 deficits in boxers. Also, head-injured patients with a high dose
of the risk gene have greater amounts of amyloid plaque deposition in their brains. The science tells us
that people with the APOE-4 gene have an even greater reason to avoid sports and occupations that
involve a high risk for head injury, such as boxing, football, soccer, race car driving, movie stunt work,
and crash-helmet testing.

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 definite increased risk for Alzheimer’s disease. Dr.
Richard Mayeux’s group at Columbia University studied a large number of older adults and found that
smokers had a twofold greater risk of getting Alzheimer’s disease than those who never smoked.
However, when people quit smoking, at whatever age, they were able to slightly reduce their risk.
The U.S. Surgeon General, Dr. David Satcher, advises all smokers to quit. Once a person quits smoking,
the benefits emerge rapidly. The body’s carbon monoxide levels drop dramatically, and within a week,
the risk of dying from a heart attack begins to decline. Five years later, that person’s heart attack risk is
similar to that of someone who never smoked. Treatment programs that include counseling, as well as
educational and emotional support, do succeed when participants make a reasonable effort. Some
intensive treatment programs have success rates for long-term abstinence approaching 50 percent.
Nicotine patches and gum have proven effective as well, particularly when used along with other
treatment approaches. 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 benefits 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 benefit some brain receptors involved in memory performance, the negative
health consequences of smoking outweigh any remote potential benefit. The good news for smokers is
that it’s never too late to quit, and the benefits of cessation are possible at any age. Although some
people report a slight weight gain when they stop smoking, regular physical exercise can help offset
weight gain and other physical and emotional responses to quitting. And imagine how nice it will be not
to have to slip out of your nephew’s wedding every 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 different approach to life. Known as the “party
girl” of the two sisters, she had been a heavy drinker and smoker for many years, and abhorred
exercise. She laughed at the suggestion she might be an alcoholic, claiming she just “liked to have a
good time.” But as she got older, it seemed her body had more trouble tolerating the excesses. Several
times during the past year, Sarah had found Lydia blacked out after one of her “parties.”
Despite their identical genetic makeups, the twins had different cognitive abilities as well as
memory capacities. Lydia was in the beginning stages of Alzheimer’s disease. Clearly, the twins’
differing lifestyle choices had contributed to the differences in their cognitive function as well as
Lydia’s developing Alzheimer’s disease. For Lydia, drinking, smoking, and lack of exercise appeared to
have played a major role.

Sarah and Lydia are not alone in their experience. Our own UCLA studies of twins confirm that genetic
predisposition is only one determinant of risk for brain aging. Lifestyle choices to drink, smoke, and eat
fatty diets can contribute to cognitive decline even in identical twins.
An eight-year study from Rotterdam, Holland, found that mild-to-moderate alcohol consumption—
defined as one to four drinks each day—actually lowered a person’s risk for developing severe memory
loss. A similar study from Bordeaux, France, found that moderate wine drinkers had a lower risk for
Alzheimer’s disease. In fact, the risk for developing any kind of serious cognitive impairment was lower
than for either heavy drinkers or non-drinkers. This type of moderate alcohol use has other health
benefits, lowering the risk for heart attacks as much as 40 percent in one recent study.
In North America, moderate alcohol consumption is sometimes defined as up to two drinks for men
and one drink for women, per day. Although this level of drinking could worsen one’s risk for heart
disease and stroke, the antioxidant effects of alcohol may slow down brain aging by interfering with free
radical formation and inflammation. Exactly how alcohol might protect the brain or heart is not fully
known, but it may involve an anti-platelet effect that lowers the blood’s tendency to clot and cause tissue
damage.
Many experts argue for red wine as the preferred brain fitness beverage because of its particularly
potent antioxidant capacity. If someone does not drink alcohol, experts rarely recommend that they start
drinking, because the potential hazards still outweigh any possible benefits. However, heavy drinkers
should definitely cut back, and light to moderate drinkers need not quit to continue protecting their
brains.

Memory Effects of Recreational Drugs

Many of today’s baby boomers experimented with recreational drugs during the sixties, seventies, and
beyond, and some used them regularly—particularly marijuana. LSD, amphetamines, and other
hallucinogens were also popular, and in the late seventies and early eighties, cocaine became the drug of
choice for many young, upwardly mobile people, or yuppies. As many users eventually became aware of
the potentially harmful effects of recreational drugs, they gave them up.
I often hear questions and concerns regarding drug use in the past, and even decades ago. Studies on
psychoactive drugs have shown they do affect memory abilities, but there are currently no data
indicating exactly how long those effects last after a person stops using the drug.

Nick J., age 51, still lives and works in his northeast college town, where he owns a successful
restaurant. He put himself through college by dealing marijuana, although he smoked up half his
profits. After graduating, he went to chef’s school and stopped dealing, but he kept up his pot habit.
He had occasionally experimented with LSD, cocaine, and amphetamines, but marijuana was his drug
of choice and had become part of his daily lifestyle. To Nick, grass was merely a social convention,
like his parents having their cocktails before dinner. He didn’t consider it to be a harmful or addictive
drug—nothing like heroin or even alcohol.
Nick started to notice subtle memory changes about five years ago when he first began having
trouble remembering the names of his regular customers. Then he started making errors in
reservations, and even staff scheduling became a nightmare. His ex-wife actually accused him of
“purposefully forgetting” to pick up their sons on two of his designated weekends.
When Nick sought professional help, his doctor did note some mild memory impairment, but his
overall memory test scores were in the low normal range for his age group. The doctor strongly
advised him to stop using marijuana, and explained that although Nick might experience some
physical and emotional hurdles in giving up a decades-old habit, the evidence was overwhelming that
chronic marijuana use worsens memory.
Quitting pot was harder than Nick had imagined. But after a few failed attempts, and with the
support of his girlfriend and his business partner, he managed to get through the first three months
 pot-free. Nick noticed his memory improving after only a few weeks, and by month three others
began to comment on his sharpness. He also started experiencing more energy, less moodiness, and an
improved libido. His girlfriend was absolutely thrilled—she had always hated his moodiness.
Nick did continue to have mild memory complaints, but he no longer had difficulties that interfered
with his job, and his memory test results remained in the normal range for his age.

Marijuana has been the most widely used illicit drug in many developed societies. Chronic marijuana
use can impair memory, attention, and the ability to process information. Someone intoxicated from
marijuana has a hard time recalling recent events and learning new information. Studies of chronic and
heavy marijuana users show that they have difficulty with verbal and visual memory and attention.
Despite the potentially harmful effects of marijuana, memory effects 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 finding of the MacArthur Study of
Successful Aging was that staying in close contact with the people in our lives, as well as remaining
involved in sports, hobbies, charitable causes, or other meaningful activities, were key elements to
success in aging. The more personally invested we are in a given activity, the more our ongoing health
will benefit from it. Because a large component of MacArthur’s definition for successful aging was
cognitive success, such activities will likely promote brain health as well.
Remaining engaged with people means giving as well as getting support, and this support can take
many forms. By maintaining close friendships, stable marriages, and long-term relationships, as well as
spending time with people we love, respect, and esteem, our brains will function better in the long run.
Research has linked healthy social relationships to greater longevity.
The practical support we get from close relationships may lead us to seek better medical care, and just
hanging out with people who live a healthy lifestyle—like not smoking, or eating a low-fat diet—may
rub off on us, too. Social support, or the emotional and practical advantages we gain from others, may
even directly benefit us biologically. In a sense, we are “hard-wired,” or genetically programmed, to
interact with others. Talking, touching, and relating to others are key to maintaining well-being in our
lives. It is within social groups that we protect each other and share our joys and concerns.
A recent study of men found that good social support significantly lowered their levels of epinephrine,
norepinephrine, and cortisol—all physiological measures of stress. The evidence makes a strong
argument for avoiding isolation and remaining engaged with others to keep mentally and physically
healthy.
 Juan R. was a jovial 72-year-old retired mechanic who had been active and relatively healthy all his
life, except for his recently developed type 2 diabetes, which he controlled with diet and medication
under the watchful eye of his wife, Carla. When Carla died suddenly from a stroke, Juan was
distraught and nearly catatonic for a week. His daughter, Anna, was afraid to leave him alone in his
apartment. Juan gradually got back on his feet, but he remained withdrawn and depressed, and Anna
felt uncomfortable leaving him alone to cook and care for himself.
Anna knew from her mother’s constant complaining that left to his own devices, Juan would sit in
front of the television all day eating junk food, while his blood sugar ran all over the map. Since
Carla’s death, Juan hardly ate at all and had no interest in attending his weekly poker game with his
buddies.
Anna already had her hands full with her own job and her kids. One afternoon, she arrived with
Juan’s groceries to find him passed out on the floor. The emergency room doctor diagnosed a
hypoglycemic attack and clinical depression and recommended better diet supervision and a daily
antidepressant for Juan.
That evening, after discussing it with her family, Anna insisted that Juan move in with them. It was
no use protesting, and she would not take no for an answer. Besides, she persisted, she needed the
free babysitting. He finally gave in, saying that Anna, like her mother, would never stop yapping until
she got her way.
With her dad under the same roof, it was easier for Anna to keep an eye on him, and she started
dropping him off at a local senior center three days a week. Juan enjoyed watching the kids and
helping out with their homework, so Anna and her husband could actually get out some evenings.
Thanks to Anna’s healthy cooking and her supervision of his medications, Juan’s diabetes got back
under control, his spirits picked up, and he eventually got back to beating his pals at poker.

Sex and Memory

We’ve seen how remaining engaged in meaningful pursuits, maintaining healthy relationships and
physical activities, and making other smart lifestyle choices can go a long way to ensure physical and
mental health as we age. Evidence also points to maintaining a meaningful sex life as yet another way to
keep our brains young. People with healthy, active sex lives also tend to be more engaged in life and
physically and mentally active—traits associated with successful brain aging. The physiological and
mental benefits of a healthy sex life may well promote brain function as we age.
Systematic studies have shown that our sexual attitudes and interests are relatively consistent
throughout life—surveys of older people indicate that nearly all of them would like to engage in sex if
the time, place, and partner were right. 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 difficulties with ejaculation. The new drugs for male impotence, however, have
clearly had an impact on this problem. Viagra is both safe and effective for many forms of erectile
dysfunction for men even in their eighties or nineties, helping them to maintain a healthy sex life, which
likely contributes to their brain health.
The physical illnesses some of us experience as we age, as well as the drugs we may take for these
illnesses, can interfere with our sex lives; however, these challenges can be managed. For instance,
patients with arthritis might schedule their analgesic medicine to kick in just prior to a romantic
encounter, when increased flexibility might be desirable. Estrogen and testosterone replacement
therapies can also help facilitate a healthy sex life when indicated, and current research is exploring
these hormones’ direct benefits on memory (Chapter 9).

Sleep On It

Sleep deprivation—another way we stress our brains—is a common problem for 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 effect on relationships and work performance.
Acute or chronic sleep deprivation impairs mental abilities and can lead to high blood sugar levels due
to insulin resistance, a precursor of type 2 diabetes, as well as elevated brain cortisol levels—both
associated with memory loss. Fortunately, this insulin resistance and memory impairment can be
reversed if you spend approximately twelve hours in bed to make up for sleep debt. 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 findings have not been
replicated. Autopsy studies have detected some collections of aluminum in damaged areas of the brains
of Alzheimer’s patients, but the studies have not yet provided conclusive results. It is possible that
aluminum collects in brain areas after the damage occurs, rather than actually causing the damage.

Other Lifestyle Pitfalls

Exposure to lead, pesticides, environmental mold, or any toxic chemical does have the potential to
damage brain cells. Pesticide exposure in particular has been under recent scrutiny because of its
possible influence on risk for Parkinson’s disease. Although many of the epidemiological studies have not
proved a direct connection between exposure to environmental toxins and the subsequent development
of Alzheimer’s disease, individual cases have been reported, and it seems logical to avoid chronic or
acute exposure.
Making lifestyle choices is not just about our resolve to change but also becoming informed about the
right kinds of changes to make. Dr. Vladamir Hachinski and his colleagues at the University of Western
Ontario studied brain autopsies of people who died from various forms of dementia and found that those
with lower educational achievement showed more evidence of small strokes in the brain than those who
had attended college and further. An individual’s educational achievement not only indicates their
intellectual ability but also points to their ability to make better lifestyle choices that protect their brain.
The study subjects with fewer years of education were more likely to smoke, eat fatty foods, and avoid
exercise, activities that increase the risk of strokes and the likelihood of dementia later in life.

Making Lifestyle Choices to Keep Our Brains Young

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

Lifestyle Choices That Keep Brains Fit

Start an exercise program to maintain aerobic fitness, flexibility, and peak memory
performance.
Get both the aerobic and social benefits of walking with friends.
Choose sports and physical activities with low risk for head trauma.
Never drink and drive and always wear your seat belt.
Wear helmets when riding bikes or doing sports.
If you smoke, quit. Ask your doctor for help.
If you drink alcohol, do it in moderation (up to 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 fifties—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 fitness 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 benefits from medications currently marketed for
other conditions, such as anti-inflammatory 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 first step to using medicines wisely is to communicate effectively with your doctor, the person who
will write the prescription and advise you on how to use the medication. With managed care and other
pressures in the current health care system, physicians don’t always have time to sit 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 specific—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 difficulties. 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 deficits. The laboratory
component should include blood tests to rule out thyroid disease, vitamin B12 deficiency, 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 affect long-term brain
health. Studies have found higher rates of Alzheimer’s disease and other dementias in people with these
conditions. Effective medicines are readily available to treat these illnesses, and getting appropriate and
timely treatment is vital to keeping our brains young.
I have friends who have gone to their doctors for a head cold or a sprained ankle, and during the exam
the doctor discovered an elevated blood pressure or a high blood sugar level. Picking up these incidental
findings can not only save a person’s brain cells but their life as well. This is just one of many reasons
why regular physical checkups are so important.

Hypertension

High blood pressure, or hypertension, affects more than 60 percent of people over age 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 effectively treated
with a variety of proven medicines, but the most effective intervention for hypertension usually includes
both medicine and lifestyle changes. Smoking, overuse of alcohol, and being overweight all contribute to
one’s hypertensive risk. Regular exercise, a low-salt diet, and avoiding smoking and other high-risk
activities all lower blood pressure.
Recent research shows that chronic high blood pressure during midlife (forties and fifties) leads to
cognitive decline later in life. Chronic hypertension most likely affects memory because it thickens and
stiffens blood vessels. Under high pressure, these stiffened blood vessels can rupture, possibly causing
cerebral vascular disease involving blood leakage into the brain tissue and stroke. A stroke is often
defined as the death of brain cells, resulting in a loss of physical or mental function or both. But
treatment makes a difference. Dr. Edwin Jacobson of UCLA recently reported that rigorous control of
mild to moderate hypertension can improve cognitive function. He noted significant improvements in
visual and spatial skills, executive skills, and the speed that patients could process information after just
twenty-four weeks of treatment.
Many Alzheimer’s patients also show evidence of cerebral vascular disease, which can further
compromise their cognitive status. 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 affect
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
different conditions such as hypertension or cardiovascular disease.
Dr. David Drachman, University of Massachusetts, found that a wide variety of statins have the effect
of lowering one’s risk for Alzheimer’s, including atorvastatin (Lipitor), cerivastatin (Baycol), fluvastatin
(Lescol), pravastatin (Pravachol), and simvastatin (Zocor). Scientists speculate that when the statin drugs
interfere with cholesterol metabolism, they may also decrease the production of amyloid-beta, which
forms the Alzheimer’s plaques. The benefits to the brain from statins may also stem from their ability to
reduce cerebral vascular disease, thereby improving blood circulation to brain cells. Until a double-blind
test comparing statin drugs against a placebo control is completed, we cannot state definitively that
these drugs truly help to prevent Alzheimer’s disease. However, current data are encouraging. In
addition, the mounting scientific evidence of the cardiac benefits 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 five years after they had undergone coronary-artery bypass surgery.
They found that memory and other cognitive declines were present in 53 percent of the patients at the
time of discharge from the hospital after their bypass surgery. This high rate went down by about half
after six months. However, five years later, the proportion of cognitively impaired patients was back up
to 42 percent. The main predictor of memory loss five years after bypass surgery appeared to be lower
cognitive function at initial hospital discharge following the surgery.
To perform coronary bypass surgery, the doctor has to stop the patient’s heart and divert their blood
through the artificial pump of a heart-lung machine. Some doctors believe that during this stopped-heart
period the brain sustains subtle damage. Another theory is that the operation may shake loose tiny
particles of fat from the surgical site into the blood system. If and when these droplets make their way to
the brain, they can cause cellular damage. The heart-lung machine also produces air bubbles that could
block blood flow through tiny vessels, thus killing brain cells. The New England Journal of Medicine report
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 effect 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 fitness, and becomes more frequent with age. An
estimated 16 million people in the United States suffer 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 effectively treat diabetes. Control of diabetes will protect brain fitness and can improve
memory function.
Any acute illness that attacks our bodies can overwhelm our brains (see Table 9.1). I have seen both
older and younger patients experience memory impairment and word-finding difficulties during a flu or
pneumonia. Usually these problems disappear or are reversible when the disease lifts. 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 effects of medication, and this
sensitivity can lead to side effects at much lower doses. Also, our bodies become less efficient in
metabolizing and excreting medicines, so over time we may accumulate higher blood levels of these
drugs. This can lead to new or increased side effects, as well as to interactions with other drugs that we
hadn’t experienced in the past. Due to these changes in our bodies, doctors caring for older people often
prescribe drugs in low doses initially and slowly increase them as needed to minimize any potential
adverse reactions.
Many drugs have anticholinergic side effects, making them oppose the actions of the drugs prescribed
for memory loss, thereby worsening memory ability. Drugs of particular concern include those often
prescribed for anxiety—such as Xanax, Valium, or Librium—which can cause sedation and can also
impair memory ability (see Table 9.2). Drugs used to regulate heart rate or treat high blood pressure can
make blood vessels less taut and decrease the heart’s ability to pump blood. Since our vascular tone
diminishes anyway as we age, medications that aggravate this problem can lead to falls, head trauma,
and other complications that threaten brain fitness, and they should be taken with care.
When a patient visits the UCLA Memory Clinic for the first time, we ask them to bring in all their
medications. Many older patients have arrived with shopping bags filled with prescription bottles. Often
the easiest and most effective interventions are merely to eliminate unnecessary medicines and reduce
the dosage level of drugs that are most likely contributing to the patient’s memory loss, depression, or
both. Giving a patient the lowest effective dose of a medication will lower their risk for developing side
effects; however, too low a dose, or a 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 fill the void of not having
Melvin there to soothe her every ache and pain. Though several physicians throughout Manhattan had
treated her once or twice, she couldn’t bring herself to trust any one doctor to truly understand her
“complicated medical conditions,” which included high cholesterol, arthritis, chronic insomnia,
migraines, and periodic depression. Doris took a different medicine for each ailment.
Throughout her adult life, Doris had experienced bouts of depression that recurred every two to
three years. Melvin had always prescribed an antidepressant, which seemed to help. After his death,
she experienced an extreme episode of depression and asked one of her new physicians to continue
the antidepressant prescription. Her depression improved, but she began to complain of increasing
forgetfulness. At first she merely misplaced things, but her symptoms worsened. She would put on her
coat, get her purse, and push the call button for the elevator. When the doors opened, half the time
she would have already forgotten where she was going.
Doris consulted a new doctor, who suspected she was experiencing some early symptoms of
 Alzheimer’s disease and prescribed a cholinergic drug. After a month, she noticed improved memory
ability. A week later, Doris read about a newer anti-Alzheimer’s drug that sounded fantastic.
Concerned about insulting her current doctor, she sought yet another physician to prescribe this new
drug. Doris was now taking a daily antidepressant, a sleeping pill, and two cholinergic drugs, not to
mention meds for her high blood pressure, arthritis, high cholesterol, and headaches. The second,
unnecessary, cholinergic, which neither prescribing physician was aware of—Doris made sure of that
—led to nausea and vomiting, which forced her to consult a gastroenterologist. This specialist insisted
on seeing all her medical records and all medicines before he could help her.
Desperate, Doris came clean. Apparently, she was being treated by seven different doctors and
getting multiple prescriptions for many of her conditions including pain, anxiety, depression, and
memory loss. Most of her symptoms were intensified by the overuse and interactions of her drugs. The
antidepressant she was taking actually had an anti-cholinergic effect that worsened her age-related
memory loss. Also, the doubling up on the cholinergic drugs only served to upset her stomach, but
failed to give her any extra memory improvement over the original single dose. Her insomnia was a
symptom of depression, so rather than a sleeping pill—which also worsened her memory—her
gastroenterologist prescribed a newer antidepressant that helped with her sleep and had fewer side
effects. He also reduced the pain from her arthritis and headaches by using a 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
ineffective attempt to feel cared for—the way she felt before Melvin passed away. That would never
be possible. Doris began to accept things she couldn’t change and move on with her life. She became
involved in social and volunteer activities and actually started dating two years later—a nice dentist
from midtown.

If you are concerned that medication may be affecting your memory, you should consult your doctor
about whether you truly need a particular drug, and be sure she is aware of all the medicines you take.
This is especially important if you are under the care of more than one physician.

Table 9.2

COMMON MEDICINES THAT CAN IMPAIR MEMORY IF NOT TAKEN WISELY

Drug Category 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
Anti-anxiety/Sedative Halcion Triazolam
Librium Chlordiazepoxide
Restoril Temazepam
Serax Oxazepam
Valium Diazepam
Xanax Alprazolam
Elavil Amitriptyline
Antidepressant
Tofranil Imipramine
Benazepril Lotensin
Dyazide Hydrochlorothiazide
Anti-hypertensive
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 effectiveness, these treatments and herbal tonics are not always rigorously tested, nor are they
monitored by the FDA. It is fairly easy to make grandiose claims about unproven supplements—often
touted as memory loss preventions in an unregulated, multibillion-dollar industry.
The power of the “placebo effect” may help explain the popularity of these treatments. I know one
mother who used this tried-and-true placebo effect to treat her children’s ailments. When one of them
had a mild ache or pain, she would go to her medicine cabinet and pull out a large bottle of cherry-
flavored liquid labeled “PLACEBO.” She would then dole out a large tablespoon of the syrup while
commenting on its remarkable potency. The placebo usually reduced and sometimes even cured their
ailments.
Scientists have long speculated on what causes this scientifically proven placebo effect—whether it is
the patient’s belief or expectation that the treatment will work, the doctor’s confidence in the treatment,
or some other physiological mechanism. In memory studies we have found that sugar pills often make us
better, but this improvement is temporary, usually lasting no more than six weeks.
As a result of the diminishing placebo effect, the gold standard for proving the effectiveness of any
new drug or treatment is to show that the active drug is indeed more beneficial than a placebo—over
time.
A recent study analyzing 114 published reports involving 7,500 patients with a variety of different
conditions raised new controversy about the placebo effect. Dr. Asbjorn Hrobjartson and Dr. Peter
Gotzsche of the University of Copenhagen found that what many believe to be an effect of placebo is
merely the result of the natural uneven course of an illness. When treatments were compared with no
treatments, study participants not receiving treatment improved at about the same rate as when
participants were given a placebo. Despite these results, placebos are still needed in clinical research to
prevent scientists from knowing who is getting the real treatment, and who is not.
Drugs used to treat Alzheimer’s disease or prevent memory loss must undergo intense placebo-
controlled testing before gaining FDA approval for distribution. In Alzheimer’s disease treatment studies,
we have often seen an initial but temporary placebo effect, as illustrated in Figure 9.1.

Figure 9.1

In the study graphed in the figure, hundreds of patients with Alzheimer’s disease were given either the
active cholinergic drug donepezil (Aricept) or an identical-appearing placebo pill. Note the gray arrow
pointing to the first six weeks of the study—the placebo was just as good as the Aricept in improving
memory and other cognitive abilities. This effect, however, waned after that initial period and the
placebo patients began to decline, while the patients taking Aricept maintained their cognitive
improvement. In fact, other studies indicate that this drug continues its benefit for several years. People
who take treatments that have not passed a controlled study are probably wasting their time and money
(they could just as easily gain placebo effect from a breath mint) and may be causing themselves
unnecessary side effects that can harm their health.

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 notified
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 significant results, but the clinical
relevance of the effects 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 differ considerably. Ginkgo has been known to cause nausea, heartburn, headaches, dizziness,
excessive bruising or bleeding, low blood pressure, and other adverse effects. Ingesting ginkgo has been
associated with blood clots surrounding the brain (subdural hematomas), and ginkgo can affect 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 effectiveness, and its potential for adverse effects, leads me to recommend
against ginkgo biloba as a treatment for preventing memory loss at this time.
Ephedra is often used as a stimulant or appetite suppressant, or as an ingredient in other medicines,
usually over-the-counter preparations. If people combine ephedra with coffee or other mild stimulants,
they may experience rapid heart rate and anxiety. Guarana is an herb used as a stimulant and natural
source of caffeine, which has some anti-coagulant effects. Serious heart problems can result if it is mixed
with ephedra. Ginseng, a popular herb used to increase endurance, reduce stress, and improve sexual
function, can be harmful for diabetics. Ginseng supplements are sometimes packaged as orange-flavored
treats and appear on the candy shelf rather than the supplement counter. Taken like mints or chewing
gum, it is alarmingly easy for harmful doses to get into a diabetic person’s body. If taken in conjunction
with antidepressants, ginseng can make some people manic. It can also augment the effects of sedatives
or stimulants.
Kava kava has been used to reduce anxiety and stress. It can enhance the effects of alcohol and lead to
intoxication. In conjunction with sedatives, it can cause excessive sleepiness or even coma. Valerian, an
herb used for restlessness and insomnia, can interact adversely with sedatives or alcohol. Another herb
native to Europe, St. John’s wort, is taken by more than 7 million Americans as a natural treatment for
depression or insomnia. Although recent studies have not found it to be effective in clinical depression, it
can augment the effects of antidepressants, stimulants, or anticonvulsants in some situations. Rarely,
when exposed to sunlight, people using St. John’s wort have experienced sensations of tingling, needle
pricks, or pain, even when taking it alone.
The majority of people who use these natural untested remedies experience no negative side effects,
and many individuals swear to their beneficial effects. In fact, herbal remedies may be effective for some
people in certain situations that experts are not even aware of.
The scientific community and the public at large continue to wait for results of conclusive double-
blind studies showing whether or not ginkgo biloba and other herbal memory loss treatments actually
work. For now, considering their potentially harmful side effects, 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 effective for the memory loss and other
cognitive declines of Alzheimer’s disease. But as scientists continually search to find a cure for
Alzheimer’s disease and possibly prevent its onset in the first place, a new approach is emerging: the
science of pharmacogenetics—the strategy of treating patients not just according to their diagnosed
disease but also according to their genetic makeup.
Particular genetic variants may lead to differences in an individual’s drug response, and these
differences can take effect at many levels. It could affect how well the drug is absorbed from the stomach
and intestines, how well it is broken down in the body, how quickly it gets through the blood system and
out of the body, or how effectively it binds to neurotransmitter receptors in the brain. By identifying and
understanding the functions of these genetic variations, we can predict their role when determining a
patient’s response to a particular drug.
The goal of pharmacogenetics is to provide doctors with a patient’s drug response profile before
beginning medication treatment. A meaningful pharmacogenetic profile may help to define a 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
effective in volunteers with the APOE-4 genetic risk than those without the genetic risk. Our aim is to
delay brain aging by one or more decades, thus allowing people to live longer, and better, without
memory decline. 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 benefit from Alzheimer’s prevention
drugs.

Maintaining Memory with Anti-Alzheimer’s Drugs

New research on neurotransmitters suggests that early intervention with a cholinergic drug can slow
brain aging as well as delay the onset of Alzheimer’s disease. These studies support the idea that treating
early brain-aging symptoms with cholinergic drugs—medicines currently used to treat Alzheimer’s
disease—may actually interfere with the deposition of amyloids, the insoluble proteins that have
accumulated in the brains of people with Alzheimer’s disease.
Dr. Diana Woodruff-Pak and her associates at Temple University treated rabbits with galantamine
(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 effect beyond its usual inhibition of the enzyme that breaks down acetylcholine. Even
though cholinesterase inhibitor drugs were designed to increase the acetylcholine neurotransmitter
directly, they have other effects that may slow down brain aging. 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 conflicts or persistent stress are sometimes the culprits. Other times a biochemical
imbalance in the brain may be to blame. Many depressions involve more than one trigger or cause, with
overlapping psychological and biological factors contributing. Regardless of the specific cause,
psychotherapy, antidepressant drugs, or both, can improve the symptoms, even if they are severe.
One feature of depression—decreased ability to concentrate—seems to become more prominent as we
age. Middle-aged and older people tend to emphasize these concentration difficulties, and their
depressions are often colored by memory complaints. A form of depression often seen in older people has
been labeled as “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 off the
chronic memory loss and/or the dementia that eventually develops in many of these patients. The
possibility that antidepressant drugs could slow down or prevent brain aging requires further study.
However, we do know that both antidepressant medicines and psychotherapy are effective treatments in
their own rights, but combining the two, when indicated, appears to be more effective than either form
of treatment alone.
 Although all types of antidepressant drugs have been effective in relieving some symptoms of
depression, the improved side-effect profiles of the newer antidepressants, like fluoxetine (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 effectively using antidepressants, but
for a complicated and more severe depression, the expertise of a psychiatrist may be needed. For some
older depressed patients, a psychiatrist with additional geriatric training would certainly offer the most
sophisticated care (Appendix 5).

Some Commonly Used Antidepressant Drugs

Drug Dose Range (mg/day) Possible Side Effects

Buproprion (Wellbutrin) 37.5–450 Insomnia, nausea
Citalopram (Celexa) 10–60 Insomnia, nausea, sexual dysfunction
Desipramine 10–300 Heart arrhythmia, sedation, sexual dysfunction
Paroxetine (Paxil) 10–60 Nausea, sexual dysfunction
Fluoxetine (Prozac) 10–80 Insomnia, nausea, sexual dysfunction
Mirtazepine (Remeron) 15–45 Sedation, weight gain
Nefazadone (Serzone) 100–600 Sedation
Nortriptyline 10–200 Heart arrhythmia, sedation, sexual 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 effects of estrogen and other hormones on
mood and memory in older adults. Studies by epidemiologists have found that taking estrogen
supplements after menopause lowers a woman’s risk for developing Alzheimer’s disease. It is important
to note that women who take hormone replacements are, on average, better educated and live healthier
lifestyles.
Estrogen appears to improve connections between the brain’s nerve cells and to augment cerebral
blood flow. It also boosts memory transmitters like acetylcholine. In addition, estrogen serves as an
antioxidant, helping to prevent damage to cells over time. Based on estrogen’s proven benefits for
treating menopausal symptoms like hot flashes 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 benefits as well as its drawbacks. In addition to
alleviating menopausal symptoms, estrogen may improve skin tone, prevent osteoporosis, and reduce the
risk for stroke. However, estrogen taken without progesterone increases the risk for developing
endometrial cancer and may increase the susceptibility to breast cancer. Use of estrogen replacement
with or without progesterone is associated with a twofold increase in risk of developing gallstones.
Although evidence suggests that estrogen protects against some forms of age-related memory loss and
may even help prevent Alzheimer’s disease from developing in healthy brains, it has shown no apparent
benefits in patients who already have Alzheimer’s disease.
Dr. Susan Resnick at the National Institute on Aging found that women taking estrogen perform better
on certain memory tests and have better blood flow to the hippocampus, a brain area involved in
memory function. Dr. Barbara Sherwin at McGill University in Montreal has shown that estrogen’s
benefit for 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 definitive answer on
whether or not post-menopausal estrogen use can truly stave off Alzheimer’s disease. In this large-scale
study, U.S. investigators are randomizing nearly 10,000 women to different 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 benefit also
needs to offset such potential risks as breast cancer and heart disease.
New drug development has led to synthetic estrogens designed to isolate specific beneficial effects
while eliminating unwanted side effects. 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 effects on mood and memory. Men
experience a drop in this sex hormone as they age, but instead of a rapid decline, the levels decrease very
gradually over decades. Only about one out of five men 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-inflammatory 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 effects came from their action on
inflammation. Looking closely at the amyloid plaques that collect during the course of brain aging and
the development of Alzheimer’s disease, we can see the central core area consists of insoluble amyloid
protein. Around the outer rim are traces of inflammation. The theory is that our brains mount an
inflammatory response attack against the amyloid protein, attempting to get rid of it, and this
inflammation causes cell death and memory loss.
Scientists are focusing their efforts on developing specific drugs to target the brain’s inflammatory
response. Dr. Michael Mullan and his colleagues at the University of South Florida recently described
how microglia cells promote an immune response that causes inflammation of the brain by releasing
proteins known as cytokines, which are toxic to brain cells. The researchers found that the receptors
involved in this response were present in the microglia cells of the brain’s frontal lobe and the
hippocampus—the areas affected by Alzheimer’s disease. Although these receptors can also be found in
the brains of people who are simply aging normally, the discovery still adds weight to the inflammatory
hypothesis. If the current studies prove successful, people could choose to take precautionary anti-
inflammatory 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-inflammatory drugs worked just as well as higher doses for lowering the risk for Alzheimer’s
disease. Of the nearly 140 aspirin users in their study, 80 percent took only a half tablet of aspirin each
day. This low dose would be insufficient to mount an anti-inflammatory response in the brain, which
raises the possibility that interrupting the inflammatory reaction might not be the critical mechanism in
protecting the brain.

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 benefits 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 off the plaque deposits leading to Alzheimer’s disease. The immune system, or the body’s
mechanism for fighting off disease, recognizes antigens or foreign bodies and responds with antibodies
designed to search and destroy the foreigner.
Dr. Dale Schenk and his associates at Elan Pharmaceuticals have been working on a system that may
stop the plaques from forming in the first place by attempting to jog the brain’s immune system memory.
The researchers vaccinated mice with a synthetic form of amyloid-beta that had been genetically
engineered to form Alzheimer’s plaques. Conventional vaccinations are designed to give the body’s
immune cells a taste of a particular infection that may come at it in the future. Afterward, should the
real infection develop, these cells are already primed to produce antibodies to that infection more
quickly than they would have otherwise.
In Dr. Schenk’s study, the scientists found that monthly injections of this protein raised the level of
antibodies the brain produced and actually prevented Alzheimer’s disease–type brain degeneration in
young Alzheimer’s transgenic mice—ones that were genetically programmed to produce the amyloid-
beta that creates the sticky plaques of the disease. Remarkably, the injections also eliminated plaques in
older mice by as much as 80 percent. The vaccine improved their cognitive ability to master a maze.
Although the vaccine already appears safe in its initial human studies, experts remain uncertain as to
whether the approach will stave off Alzheimer’s disease. The Alzheimer’s mice differ from humans with
Alzheimer’s disease. These animals do not show many of the symptoms seen in humans suffering from
the disease, including the death of nerve cells. We don’t yet know if the memory loss associated with
Alzheimer’s disease will significantly 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-fire way to know if the vaccine effectively 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 suffering 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
effects from an inflammatory 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-inflammatory drugs to find
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
fiction. Although neuroscientists have long believed that humans cannot generate new brain cells, recent
findings 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, undifferentiated cells that can
develop into specialized ones. The scientists’ ability to extract and propagate these cells has led to wide
acceptance of the possibility of neurogenesis in the adult brain. The next step is to grow these cells and
use them as replacements in brains with diseased cells, like in Alzheimer’s-affected brains.
Several scientific groups are developing stem cells, unspecialized cells that eventually turn into all
specialized tissues in the body. Dr. Daniel Geschwind and Dr. Harley Kornblum of UCLA 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 benefit from new brain cell growth. Although critics argue
for halting further studies using this technology, advocates note that successfully demonstrating fetal cell
growth in a patient’s brain is a major step forward. These investigators believe that with further
technical refinement neurogenesis may eventually prove to be an effective approach to treating
Parkinson’s and Alzheimer’s.
With genetic decoding, cloning, mapping and other discoveries in the last decade, investigators are
working to apply these 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 first surgery using gene therapy treatment on an
Alzheimer’s patient. The rationale for beginning gene therapy studies in humans is based on previous
work in laboratory animals showing that nerve growth factor gene therapy prevents the death of
cholinergic cells and reverses cell aging.
Although not intended as a cure, the therapy may protect or even restore some brain cells and relieve
symptoms such as short-term memory loss. In the procedure, Dr. Mark Tuszynski and his co-workers took
skin cells from the patient and genetically engineered them in the laboratory to produce and secrete
human growth factor. The genetically modified cells were then surgically implanted in the brain’s frontal
lobe, an area involved in cholinergic neural transmission, memory processing, and reasoning. The
scientists intend to determine whether preventing degeneration of this cholinergic system can improve
memory performance in Alzheimer’s patients and whether the nerve growth factor could prevent cell
death.
The hope is that the implants will take hold and stabilize in humans; however, there are potential
risks. For instance, the implants could begin dividing like tumor cells, thus raising safety issues about the
procedure in general. One of the challenges in treating Alzheimer’s disease has been to find drugs that
can cross the blood-brain barrier and reach the area of the brain that is affected by the disease. If this
gene therapy procedure proves to be successful, it will open the possibility of delivering drugs directly
into the brain.
Other new drugs in the pipeline aim to boost the brain’s ability to form memories despite the plaques.
A group of drugs called ampakines increase the activity of brain chemicals important to memory
formation. Ampakines 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 five to ten years. In the meantime, available drugs for memory,
depression, and physical illness do have an important impact on brain health and offer the potential for
staving off further memory decline.

Using Medicines Wisely for Keeping Your Brain Young

Learn how doctors organize information so you can be proactive in your medical
evaluation.
Numerous physical illnesses can further age your brain. Take them seriously—see your
doctor sooner rather than later.
Avoid using more medicines than you need. Talk with your doctor about any drugs you
are taking that could influence memory ability.
Remain cautious about taking herbal supplements.
Hold off on using new or innovative treatments until results from clinical trials are in.
Remember that treating a depression with the right antidepressant drug often improves
memory performance.
Chapter Ten
Don’t Forget the First Nine Chapters

Why put off until tomorrow what you can forget to do today?
—GIGI VORGAN

Some cynics, my wife included, may ask: “If we’re already suffering 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 figures. Many of the people who succeed in learning and recall skills, and life in general,
have learned to choose which information is useful to learn and which information is less important and
can be glossed over.
This selective process requires a conscious effort at first but can become second nature with practice,
and its usefulness is immeasurable. It might be a good idea to remember your boss’s birth date, but the
date of his hip replacement is not one you necessarily need to commit to your long-term memory stores.
Once you have selected information you know you want to remember, then you can choose the best
memory tool, whether it’s LOOK, SNAP, CONNECT (Chapter 3), the Peg Method (Chapter 6), or other
tools at your disposal. Sometimes you can choose not to necessarily remember a fact outright, but to
write it down, enter it into your date book, put it on your to-do list, or pass the buck and ask someone
else to remember it.
Be sure to set achievable goals when picking and choosing which information to remember outright,
and which information requires use of an internal memory tool (e.g., mnemonic technique) or external
memory tool (e.g., reminder note). I know from embarrassing experience that I need to consult my son’s
school roster before attending his first-grade open house because I do not know the names of his
classmates’ parents by heart, even as the end of the semester approaches. My wife does, and I’m sure
she’s gloating about it as she reads this.

Getting Organized to Expand Your Memory Power

Beginning a memory program that encompasses as many methods and tools as we have learned may
seem overwhelming unless we organize them into an easily implemented system. The following are some
organizational approaches to help keep your memory abilities at peak performance.

Write effective notes. I first learned about summary notes in high school. My senior English
teacher had us look over each page of notes and write a brief summary at the top. The
process of summarizing the information forced us to think about what we had learned that
day, condense it, and rewrite it in different words. This process helped fix the information
into my memory. Well-written summary notes condense the amount of material we have to
remember, and sometimes the simple act of writing things down helps facilitate recall. The
more thought and effort we put into creating a note of something to remember, the more
helpful it will be.
Organize memory places. One of the most common memory complaints is forgetting where
we put things. An effective option for avoiding the “disappearing keys act” is to put
commonly misplaced items in the same “memory” place—a hook near the door in the
kitchen for your car keys, the same briefcase pocket for your organizer, and that convenient
desk drawer for the scissors and the pencils.
Your office, home, and car can be more efficient if the storage areas and living spaces are
organized with designated memory places. When my family moved across town several
years ago, I was struck by how many things I could still not find in the new house, even
after months. A major problem was that I had lost all my old memory places for various
items, from 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 first-year
resident in internal medicine. Each of us had to care for a dozen or more hospitalized
patients who were acutely ill. The only way to keep track of all the patient-care tasks was
to make lists. I have continued to use this memory tool ever since. If you don’t already use
daily planning lists of things to do, I urge you to try them. Once you complete a task, cross
it off. After a few days, transfer the active items to a new list. When the lists get long or
complex, place asterisks next to items that need more immediate attention.
Use weekly or monthly planning calendars. A wall or desk calendar is a helpful way to
keep track of regular or occasional events or meetings. Our family has one displayed
prominently in the kitchen, and we have gotten in the habit of making sure important
appointments and weekly activities are posted.
Get a date book or 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 fix 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 floss, you
might create a new memory habit by placing the floss next to the toothpaste. I’ve noticed
that if I ask my wife to drop my shirts at the cleaners, she scowls, then routinely puts them
in the front passenger seat of her car. This is her memory habit to remind herself to get to
the cleaners. Daily pill box organizers, alarm clocks, watches, and other tools are available
to augment memory habits.
Plan a daily routine. We all do better with a certain amount of structure in our lives. Many
of us have had the experience of waking up in a hotel room and momentarily experiencing
confusion about where we are. It usually takes a few seconds to recall that we’re not at
home but in a hotel. If a person has Alzheimer’s disease or another serious memory
 problem, changing their daily activities randomly can make them more confused. If we
build a general routine into our daily schedule, we will have more time to focus on work,
leisure, and others things we want to learn.
Don’t overdo it with memory aids. Too many lists, 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 effective. Taking random, copious notes that are never read tend to
be a waste of energy. On the other hand, succinct lists, notes, and reminders can be
extremely helpful memory tools, and I sometimes keep mine for years. Picking and
choosing the memory tool can be as important as picking and choosing the information you
wish to remember.

An Innovative Strategy for Keeping Your Brain Young: Review and Organize

Jot down the ten chapters of The Memory Bible and post them prominently (see box).

An Innovative Strategy for Keeping Your Brain Young

Chapter 1: You Have More Control Than You Think

Chapter 2: Rate Your Current Memory

Chapter 3: LOOK, SNAP, CONNECT: The Three Basic Memory Training Skills

Chapter 4: Minimize Stress

Chapter 5: Get Fit with Mental Aerobics

Chapter 6: Build Your Memory Skills Beyond the Basics

Chapter 7: Start Your Healthy Brain Diet Now

Chapter 8: Choose a Lifestyle That Protects Your Brain

Chapter 9: Wise Up About Medicines

Chapter 10: Don’t Forget the First Nine Chapters

Staving off brain aging requires consistency and long-term commitment, but no one single memory
program meets everyone’s needs. Each of us has areas of strength and weakness from the outset. If you’re
already an athlete or jog four days a week, but you can’t seem to break your penchant for cheeseburgers,
French fries, and beer, then you should focus more attention on adopting a healthy brain diet rather than
a brand-new physical fitness program. If you have a stressful job, family life, or both, then minimizing
stress and anxiety may take precedence over designing your optimum mental aerobics program. You’re
probably getting plenty of mental aerobics just keeping up with your job. Many people are able to work
on several different strategies in their memory improvement program if they can organize the individual
tasks in a way that fits into their daily routine.
To help you tailor your memory improvement program to your particular needs, the following is a
brief summary of the first nine chapters. As you review them, check off key points in the shaded boxes
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 first warning sign of
its gradual decline. Recent scientific discoveries show not only that we can begin to detect subtle early
evidence of brain aging but that we can do something about it. By combining brain scans with 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 fight back with an easy yet comprehensive program of
memory training and brain fitness. If we accept that brain aging is a lifelong process, then why not
embrace a memory fitness program to keep our brains healthy as a lifelong commitment? It’s never too
late or too early to protect our brain cells and delay memory decline.
 Chapter 2: Rate Your Current Memory

To begin a memory-training program and set reasonable goals, we need to rate our current subjective
and objective memory abilities. Remember that subjective memory is our own perception of how well we
think we do in memory functions, 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
different-colored pencil. Compare your current score with your earlier one (fill in chart in Figure 2.1),
and you may be pleasantly surprised at the progress you’ve made already.
Afterward, reassess your objective memory by studying and recalling the new list of words in
Assessment No. 3. Check your watch or timer before starting.
ASSESSMENT NO. 3
STUDY THE FOLLOWING WORDS FOR UP TO 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 difficulty for you. Mental
stimulation exercises should be challenging and enjoyable to achieve their best effect.
Some people are naturally more inclined toward right-brain skills (e.g., spatial relationships, artistic
and musical abilities, face recognition, depth perception) and may need extra work on their left-brain
skills (e.g., logical analysis, language, reading, mathematics, symbol recognition). By contrast, others
have the opposite balance of abilities.
Use your score on the subjective and objective memory assessments (Figure 2.1) as a guide to
determine where best to begin to focus your mental aerobics program:

Beginning exercises (low memory performance scores)

Intermediate exercises (middle memory performance scores)

Advanced exercises (high memory performance scores)

Left-brain exercises

Right-brain exercises

You can find additional mental aerobics exercises through the Internet or in your local bookstore.
 Chapter 6: Build Your Memory Skills Beyond the Basics

Although LOOK, SNAP, CONNECT provides quick memory-improvement results, many of us would like
to take these skills further. Review some of the more advanced memory-training skills below that you
would like to practice and use:

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

Peg Method for Remembering Numerical Sequences. Commit to memory a specific visual “peg” for
each of the ten digits and then use the link method to create a story to remember any numerical
sequence.

Remembering Names and Faces. Make sure you consciously listen and observe the name (LOOK),
then SNAP and CONNECT to fix the name to the face.

Roman Room Method. Pick a familiar room or route and in your mind place the items to
remember at key points or landmarks.
 Chapter 7: Start Your Healthy Brain Diet Now

The sooner we start our healthy brain diets, the sooner we will reap the benefits. Note each of the
dietary adjustments below that you would like to make:

Drink at least six glasses of water a day.

Plan your meals in advance, try to keep your portions low, and eat healthy between-meal
snacks.

Brush your teeth a few hours before bedtime as a reminder to avoid evening snacking.

Get unhealthy stress foods out of your house, car, and office. Try 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 effects. 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 scientific technologies and pharmaceutical discoveries continue to emerge in the next decade, we
can expect even more profound breakthroughs in our fight against brain aging and Alzheimer’s disease.
However, right now, we have drugs available for memory, depression, and physical illness that have an
important impact on memory performance and brain aging. To use these medicines wisely, it is
important to keep in mind the following:

Learn how your doctor organizes information about your health so you can become more
proactive in your medical care.

Physical illnesses can threaten brain fitness. Take them seriously—see your doctor sooner rather
than later.

Avoid using too many medicines if you can. Ask your doctor about any medicine you feel is
influencing your memory ability.

Remain cautious about taking herbal supplements.

Hold off on trying new or innovative treatments until conclusive clinical trial results are in.

Treating a true depression with the right antidepressant drug often improves memory
impairment.
 Chapter 10: Don’t Forget the First Nine Chapters

Keeping our brains young and protected against Alzheimer’s disease involves attention to nearly all the
areas of our lives. As a practicing psychiatrist, I know firsthand how difficult it is for people to change
their habits. As a father, husband, and son, I also know of the challenges of helping others we care about
make positive changes, as well as making changes for ourselves. By reading this book you have begun
your commitment to protect your brain, but your personal motivation will be the driving force behind
your memory program for keeping your brain young.
To give you an idea of how to put a memory program together, here is an example of one person’s
initial schedule.

How It’s Done: Putting The Memory Bible to Work

A senior executive in a manufacturing company had the flexibility in his schedule to keep up with
several aspects of a brain fitness program, including memory training, mental aerobics, and physical
exercise. He also worked hard during his first week to cut back his coffee consumption, although he did
need to take Tylenol for several days to help with his caffeine-withdrawal headaches.
Because he felt he got enough mental aerobics on the job and through his daily reading, he used his
time to work on memory-training techniques rather than specific mental aerobics exercises. For him,
minimizing stress and anxiety was a greater challenge. Here’s how his memory program shaped up the
first few days.

Sample Memory Program

Day 1

CHAPTER ACTIVITY
3-Memory
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 IU), vitamin C
7-Diet
(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
exercise Stairs 3 times at work

Walked dog briskly after dinner—6 blocks

9-Medicine Anti-hypertensive, antidepressant

Day 2

CHAPTER ACTIVITY
3-Memory training Mental snapshot memory-training exercises (10 minutes)
4-Minimize stress 10-minute meditation session during lunch break
Early to bed (9:30 P.M.)
5-Mental aerobics Read New York Times, did crossword puzzle
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 exercise Stairs 2 times at work
Paddle tennis at the sports club
9-Medicine Anti-hypertensive, antidepressant, Tylenol (2)

Day 3

CHAPTER ACTIVITY
3-Memory training Association and linking memory-training exercises (10 minutes)
4-Minimize stress 10 minutes meditating after discussing complicated personnel issue with co-workers
5-Mental aerobics Math puzzle book; played word game with daughter
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 exercise Stairs 4 times at work
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 off in the shaded areas
above in designing it. Some people may simply want to begin with a to-do list of tasks, such as:

Get junk food out of the house.

Buy small water bottles and distribute throughout house, car, office.
Purchase 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 find examples of how different people organize their memory programs.
The person who contributed the worksheet was detailing his progress in both mental aerobics and stress
reduction. The other individual used his computer’s daily calendar to record both positive achievements
as well as areas where he had slipped during the day. You can create your own worksheet or calendar
records, possibly emphasizing areas where you feel you need extra focus. For example, you might keep
track of your daily fat intake, hours of sleep, and enjoyable activities you engage in each week outside
the house.

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 off 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 effective and what has not. The Appendixes also provide
a glossary of terms and additional resources to help you build and continue building your program for
the rest of your life. Good luck!
APPENDIX 1
The Amyloid Probe—Keeping Watch on Plaques and Tangles

As I was finishing 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
scientific backgrounds, in an effort to find an even more specific approach to imaging the Alzheimer’s
brain—a method of visualizing plaques and tangles.
Our small group made quick progress. Within a few meetings, Dr. Greg Cole, a neuroscientist with
extensive experience in Alzheimer’s disease, made clear that the internal environments of plaques and
tangles were hydrophobic, that is, more friendly to fat than to water. Dr. Jorge Barrio, a renowned
chemist, had 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-defined amyloid plaques and tangles
characteristic of the disease. We then moved on to injecting the compounds into living Alzheimer’s
patients, followed by PET scans. This allowed us to see, or probe, for the first time, increased signals
coming from living human brains in areas that contained dense collections of plaques and tangles. Seeing
the lesions with this new amyloid 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 first, the
hippocampus and temporal cortex. In healthy people without Alzheimer’s, these regions produce little or
no signal. However, in people with the disease the signal is so strong and accurate that it actually
correlates with each individual’s degree of memory impairment.
Figure A.1 shows two different scans of a patient who suffers from Alzheimer’s disease. The image on
the left is an amyloid 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 fitness. If you bring the motivation, you can proactively stave off the advance of Alzheimer’s as
effectively and as long as possible.
However, in some cases the genetic risk is high or a person already has several existing risks, such as
head injury, high cholesterol, or hypertension, and brain aging may have progressed to the point where
it is interfering with daily life. Anyone in this situation should seek professional help.
Age is the single greatest-known risk factor for getting Alzheimer’s disease. Approximately 5 percent of
people age 65 years or older have the disease, but by age 85 that figure soars to between 35 and 47
percent. Advanced brain aging and Alzheimer’s disease afflict 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 finally dies, since they have been mourning the loss of that
person little by little for years. Research has shown that more than 50 percent of caregivers develop
depressions serious enough to require medical intervention. Caregivers miss days at work, have a high
risk of becoming physically ill, and often lose sleep, especially when the patient’s disease becomes more
advanced and is accompanied by agitation and restlessness at night.
A diagnosis of dementia is a staggering consequence for patients and their families, many of whom
may have a major economic burden to consider as well as this emotional blow. As baby boomers 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 suffer from full-
blown Alzheimer’s disease. I predict those numbers could be much lower if more people followed at least
some of the strategies in The Memory Bible.
Alzheimer’s disease is the third 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 first symptom to appear, and motor and sensory functions are spared until late stages of the
disease. Early on, patients have difficulty learning new information and retaining it for more than a few
minutes. As the disease advances, the ability to learn is increasingly compromised, and patients have
trouble accessing older, more distant memories. Patients develop problems finding words, using familiar
tools and objects, and remaining oriented to time and place.
Eventually, all aspects of their lives become impaired: patients are unable to plan meals, manage
finances or medications, use a telephone, and drive without getting lost, and these kinds of difficulties
may be the patient’s or family’s first sign that something is amiss. Social skills usually remain until late
in the disease, which contributes, of course, to the delay in recognition of the disease. As the dementia
progresses, judgment becomes impaired, and patients have trouble carrying out even the most basic
functions, 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 stiffness and rigidity similar to that found in Parkinson’s disease. This
combined dementia/Parkinson’s syndrome has been termed “dementia associated with Lewy bodies,”
named for the small round abnormal accumulations found in the patients’ brains. Patients with Lewy
body dementia often have visual hallucinations and altered alertness. Still another form of dementia
strikes primarily the front of the brain and the areas under the temples, so it is known as frontotemporal
dementia. These patients often show marked changes in personality, have particular difficulty in
executive skills and planning complex tasks, yet their visual and spatial memory tends to be preserved.
The cumulative effect of multiple small strokes in the brain causes vascular dementia. Approximately 20
percent of patients with Alzheimer’s disease also have vascular disease in the brain.
Many physical illnesses can cause dementia, including infections, cancers that spread to the brain,
thyroid disease, or hypoglycemia. Chronic alcohol or drug abuse, as well as a variety of medicines,
ranging from antidepressants to antihypertensives, over-the-counter drugs, sleeping pills and
antihistamines, can also cause symptoms of dementia (Chapter 9).

MEDICAL SCREENING: HOW THE DOCTOR CHECKS YOU OUT

When those middle-aged pauses are no longer a joke and become a serious matter, that is when
Alzheimer’s disease can be diagnosed and hopefully recognized early. Too often, physicians and family
members accept memory loss, symptoms of depression, and other important diagnostic clues as normal
consequences of aging. In the early stages of dementia, I have heard about patients getting into a variety
of complications: deeding their house away, being influenced about their will, losing track of substantial
sums of money, or marrying a gold-digger.
A physician’s evaluation of memory loss usually involves an interview, physical examination, and
laboratory assessment. In evaluating the patient’s mental state, the doctor will screen for depression,
memory loss, and other cognitive skills. Laboratory assessments should at least include some blood tests
to screen out thyroid disease, vitamin 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 find most important. The doctors created an individualized scale for each patient
based upon the family’s own descriptions. They ask what drives family members crazy about a patient,
then create an outcome measure based on those reports. For example, if Susie T. complained that it
drove her crazy when her father asked the same question twenty times a day, Dr. Rockwood might set
the six-month treatment goal for Susie’s father to asking the same question only five times each day.

BRAIN SCANS FOR EVALUATION OF DEMENTIA

Some experts recommend computed tomography (CT) or magnetic resonance imaging (MRI), which
provide information on the brain’s structure. These kinds of scans will detect strokes, brain tumors, or
cerebral hemorrhages, which occasionally cause symptoms resembling dementia. Unfortunately, in most
cases, MRI and CT provide only non-specific information about brain shrinkage or atrophy or white-
matter changes, which show up as spots in the deeper brain areas. These changes are often difficult to
interpret and rarely provide a diagnosis that will alter treatment.
By contrast, the positron emission tomography (PET) scan (Chapter 1) is the most effective 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 first strikes—show reduced activity in the early
stage of the disease. At the late stage—when patients have extreme trouble talking and interacting with
others—the frontal areas show decreases. The dark areas midway between the front and back of the
advanced Alzheimer’s brain control sensation and physical movement and are still at work late in
Alzheimer’s disease, so these patients are able to experience sensation and control muscle movement. It
is remarkable to note that the PET scan of a late-stage Alzheimer’s patient looks very similar to that of a
newborn.

SLOWING DECLINE WITH EARLY TREATMENT

The available cholinergic drugs not only improve memory and other cognitive functions but also benefit
overall patient function and help manage some of the behavioral disturbances associated with dementia.
Studies show that cholinergic drugs appear to have their greatest therapeutic effect in patients with mild
to moderate disease, so early diagnosis is critical in order to help patients maintain the highest level of
functioning they have left.
Dr. Murray Raskind, University of Washington, and his collaborators from other 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 benefit for the early starters
appeared to continue for the entire year of follow-up, as illustrated in Figure A.3.

Figure A.3

Cholinergic drugs enhance the body’s level of acetylcholine, the chemical neurotransmitter that
facilitates passage of nerve impulses across synapses. The brains of Alzheimer’s patients have a
deficiency of acetylcholine, which can result from either impaired production or excess breakdown by
enzymes called cholinesterases, and our currently approved treatments inhibit these enzymes, so they are
called cholinesterase inhibitors. Tacrine (Cognex) was the first of these medicines to be approved, but it
is now rarely used due to the extent of its side effects. The newer compounds have fewer side effects and
include donepezil (Aricept, approved by the FDA in November 1996), rivastigmine (Exelon, approved in
April 2000), and galantamine (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 effects on different forms of dementia. Reminyl has been shown to be effective in patients
with vascular dementia, and Exelon in patients with Lewy body dementia.
Although the majority of patients tolerate these drugs perfectly well, some have reported mild side
effects including loss of appetite, indigestion, nausea, slowed heart rate, and insomnia. Most doctors
increase the medications gradually in order to minimize side effects, which can occur when the
medication is initially begun or the dosage increased. Side effects usually subside with time.

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 fight 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 benefits of vitamin E, Dr. Mary Sano, Columbia University, and
her associates found that Alzheimer’s patients showed less rapid functional decline if they took 1,000
international units (IUs) of vitamin E twice daily when compared to patients on placebo. Functional
decline was defined as amount of time—days, weeks, months—before the patient needed nursing home
care, as well as other practical indicators of daily function.
The scientists chose a very high dose of vitamin E to ensure that enough was present to have an effect.
Because such high doses could occasionally suppress immune function and the patient’s ability to ward
off some infections, not all physicians recommend such high doses, preferring 800 to 1,000 IUs per day
for patients suffering 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 misfiring neurons. These kinds of behavioral changes are what usually
lead to the placement of Alzheimer’s patients into nursing homes. Caregivers just can’t take it anymore.
Sometimes medications will improve symptoms, and non-medicinal approaches can make a big
difference. When counseling caregivers on dealing with some of these problems, I often remind them of
how we deal with young children. Similar strategies are useful in both situations: simplify
communications, distract them when they get frustrated, and maintain a calm but firm attitude.
Antipsychotic drugs 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 effects
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
effects 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 effective
treatments for behavioral problems in demented patients. Dr. Pierre Tariot at the University of Rochester
has led the field in using these drugs in this patient population and finds 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 offer
some respite care, giving relatives and friends a chance to care for themselves, go to the gym, join a
support group, see friends, and other personal activities to recharge their batteries.
Dr. Mary Mittelman and her colleagues at New York University have studied how education and
emotional support for caregivers of Alzheimer’s patients may delay the patient’s placement into nursing
homes. They found that the caregivers’ education and support had a definite impact on their patients,
delaying nursing home placement up to a year.
Establishing a daily routine for patients will improve their behavior and mood (see box, 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 difficulties with visual and spatial skills and their
diminished capacity to plan ahead. Some states, such as California, require the physician to report
patients with Alzheimer’s disease to better monitor their driving skills. A diagnosis of dementia should
clearly raise concern about a person’s driving abilities, and patients with advanced dementia should not
be driving at all.
The overall goal of caregiving is to maintain the kindest, least restrictive environment as possible, for
as long as possible. For many families, this means keeping patients at home and out of long-term care
facilities unless it becomes absolutely necessary.

What to Do If Alzheimer’s Disease Strikes

Seek professional help in attaining an accurate diagnosis so appropriate treatment can

begin sooner rather than later.
Ask the doctor about medication treatments, including cholinergic drugs and vitamin E.
Discuss other practical and legal issues with the doctor.
Join a support group for family members and caregivers through the Alzheimer’s
Association or local community groups where available.
Expect that the patient’s behavior will change over time and may become difficult.
Remember that these changes are not willful but are a result of a physical brain disease.
Maintain the patient’s social and family activities as much as and as long as possible.
Individualize sensory input to the patient’s needs.
Try to understand the cause of a patient’s troublesome behavior and attempt to avoid it.
Keep daily activities routine and surroundings familiar.
Arrange a regular exercise schedule to promote fitness and minimize wandering. If
necessary and possible, provide an environment where the patient can wander safely.
Display clocks and calendars to help orient the patient.
For the safety of the patient as well as everyone on the road, patients with moderate to
severe dementia should not drive under any circumstances.
APPENDIX 3
Current and Potential Treatments for Memory Loss and Alzheimer’s Disease

A wide range of drugs, hormones, herbs, and even surgical treatments have been proposed and tested
for Alzheimer’s disease and mild forms of age-related memory loss. For many of these treatments, the
strongest evidence available for their effectiveness is based on testimonials, so they may not be any more
effective than placebos. Thus, consumers need to proceed with caution when considering any new
intervention. At best, they may be wasting their time and money. At worst, they may be exposing
themselves to a risk of harmful side effects and drug interactions.
Although cholinesterase inhibitors 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-inflammatory drugs that inhibit only one of the enzymes
(cyclooxygenase II) involved in inflammation. These drugs have fewer side effects than older
cyclooxygenase inhibitors, which inhibit both cox I and cox II enzymes and are more likely to
cause gastric bleeding. 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 effects include an increased risk for prostate cancer, facial hair growth, scalp
balding, and acne. Studies of its potential memory benefits are inconclusive.
Donepezil (Aricept). A cholinesterase inhibitor drug used to treat Alzheimer’s disease.
Donepezil should be increased from 5 to 10 mg daily after six weeks. Dose increases should
be slower if patients have difficulties 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
influence memory. It has been used extensively as a cognitive enhancer throughout the world.
Studies of patients with dementia or with age-associated cognitive symptoms have yielded
mixed results.
Lecithin. A major component of all living cells, lecithin is broken down in the body to active
cholinergic compounds that have minimal but inconsistent memory benefits. The average diet
contains about a gram of lecithin, and tenfold greater amounts are used as supplements given
in daily divided doses.
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 difficulty 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-inflammatory drugs (NSAIDs). Drugs that interfere with the body’s
inflammatory process, generally used to treat minor injuries and arthritis. Examples include
aspirin, ibuprofen (Motrin, Advil, 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 effect has not been established, and
controlled studies have yielded mixed results.
Omental transposition. A surgical procedure wherein a membrane that surrounds the stomach
and other abdominal organs is dragged up to the head and attached to the brain’s surface. Its
potential benefit is thought to result from stimulation of small blood vessel growth. Although
anecdotal reports are encouraging, no systematic study has demonstrated its effectiveness in
Alzheimer’s disease.
Phosphatidylserine. A nutrient present in fish, green leafy vegetables, soy products, and rice,
which some experts recommend as a supplement for age-associated memory impairment.
Results of placebo-controlled studies have been positive but long-term benefits are not
known. 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 effect. Although some studies
demonstrate a mild benefit, it is not generally used and long-term effects are not known.
Rivastigmine (Exelon). A cholinesterase inhibitor drug used to treat Alzheimer’s disease.
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
beneficial hormone effects and eliminate side effects. Studies have not yet shown SERMs to
benefit 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 effect. Selegiline has been found to delay functional
decline in patients with Alzheimer’s disease. Because this effect is similar to that of vitamin E
—and selegiline is more expensive and has more side effects—vitamin E is the preferred
antioxidant treatment for Alzheimer’s disease.
Tacrine (Cognex). The first cholinesterase inhibitor approved by the FDA. The drug is rarely
used today because of liver side effects and frequent dosing schedule.
Testosterone. 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 offer 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, defined as a memory decline demonstrated by at least one standard memory test, along
with a subjective awareness of memory changes.

Age-related cognitive decline. A condition of noticeable decline in mental ability without the presence
of disease.

Alzheimer’s disease. The most common form of dementia. Its onset is gradual and its course
progressive. The physician can make a “probable” diagnosis, but a “definite” diagnosis is made only
through autopsy or biopsy.

Amyloid-beta. A small molecule consisting of about forty amino acids strung together like a beaded
necklace. Amyloid-beta is the building block of the insoluble protein that forms the core of Alzheimer’s
plaques, thought to be toxic to the brain.

Amyloid plaques. Collections of decayed material resulting from brain cell death and degeneration,
present in high concentrations in the areas involved in memory in the Alzheimer’s brain. The central
area of a plaque contains insoluble collections of amyloid-beta protein.

Antioxidants. Drugs, vitamins, or foods that interfere with oxidative stress.

Apolipoprotein E (APOE). A gene on chromosome 19 that comes in three different forms (2, 3, and 4).
One copy of the APOE-4 gene increases the risk for Alzheimer’s disease and lowers the average age when
people first develop symptoms. Two copies have the same effect, but more so.

Catechin. A potent antioxidant found in green teas.

Cerebral cortex. A thick folded layer of nerve cells that covers the cerebrum. The cortex is divided into
parietal, temporal, frontal, and occipital lobes, and its cells are involved in learning, recall, and language
function.

Cerebrum. The main portion of the brain considered the seat of conscious mental processes.

Computerized tomography (CT) scan. A computer-enhanced X ray that provides pictures of brain
structure that can assist in the diagnosis of brain tumors, strokes, and blood clots.

Cognition (cognitive function). Mental function involving memory, language abilities, visual and
spatial skills, intelligence, and reasoning.

Cognitive stress test. An experimental method to tease out subtle brain abnormalities. Volunteers
perform memory tasks while a functional MRI scanner measures brain activity response to memory
performance.

Coronary heart disease. Heart disease caused by buildup of plaque in the coronary blood vessels,
which provide blood and nutrients to the heart muscles.

Cortisol. A stress hormone secreted by the adrenal glands. Chronically high levels of cortisol can
impair memory performance.

Dementia. Impairment in memory and at least one other cognitive function (e.g., language, visual-
spatial skill) to the extent that it interferes with daily life.

Dendrites. Short, branching extensions of neurons that receive impulses from other neurons when
neurotransmitters stimulate them.

Endorphins. Hormones responsible for the mild euphoria we feel after aerobic exercise, often described
as the body’s own internal circulating antidepressant.

Enzyme. A protein that controls chemical reactions in the body.

Ephedra. An herb used as a stimulant or appetite suppressant, which may cause rapid heart rate and
anxiety when combined with other stimulants 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 configuration of the double-helical strands of DNA is an
alphabet key, a genotype, that programs our phenotype—who we are mentally and physically. A minute
molecular change can have a dramatic effect on a person’s risk for a particular disease.

Glucose. A simple sugar that is the main source of energy in the body’s cells and results from the
breakdown of foods we eat.
 Glycemic index. A measure of how rapidly a food causes blood sugar levels to rise. This index ranks
foods from 0 to 100, indicating whether the food raises blood sugar levels gradually (low scores) or
rapidly (high scores).

Gram (gm). A measurement used for drugs and equivalent to one-twenty-eighth of an ounce.

Gray matter. The outer part of the brain that contains cell bodies.

Hippocampus. A seahorse-shaped brain structure involved in memory and learning, located in the
temporal lobe of the brain (near the temples).

Hormones. Chemical messengers produced by glands and organs in the body and absorbed into the
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 off infection. The immune system recognizes and destroys proteins like insoluble
amyloid-beta that are not normally present.

Inflammation. The body’s natural response to infection or stress, consisting of a mobilization of

specialized cells to eliminate the offending foreign body.

Insulin. A hormone produced by the pancreas that gets sugar into cells.

Insulin resistance. The inability of cells to respond to insulin, resulting in high blood sugar levels.

Ischemia. Lack of oxygen to body tissue. In the brain, it can have several effects: if brief, it leads to
transient ischemic attacks (TIAs) when the patient has a temporary loss of cognitive or motor function.
When prolonged, it leads to death of brain cells and permanent deficits, known as strokes or cerebral
vascular accidents (CVAs).

Kava kava. An herb used to reduce anxiety and stress. When combined with alcohol, it can augment
intoxication.

Lesion. Any damage to body tissues or cells.

Linking. A memory technique that associates or connects two or more bits of information.

Long-term memory. Relatively permanent memories that have been organized and rehearsed.
 LOOK, SNAP, CONNECT. A basic three-step memory technique that includes: (1) actively observing
what you want to learn (LOOK), (2) creating mental snapshots of memories (SNAP), and (3) linking
mental snapshots together (CONNECT).

Lycopene. A potent antioxidant present in high concentrations in tomatoes.

MacArthur Study of Successful Aging. A long-term study of aging that addressed positive rather than
negative outcomes. Successful aging involves avoiding diseases, remaining engaged in life, and
maintaining high physical and mental functioning.

Magnetic resonance imaging (MRI) scan. A brain-scanning technique that provides more detailed
information on brain structure than CT scanning and that can be useful in diagnosing brain tumors,
strokes, and blood clots. When modified, it can produce information on brain function, a technique
known as functional MRI.

Major depression. A serious form of depression that can interfere with memory ability.

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

Neurofibrillary tangles. Collections of decayed material resulting from brain cell death and
degeneration, present in high concentrations in the areas involved in memory in the Alzheimer’s brain.

Neurogenesis. New nerve-cell growth.

Neuron. Nerve or brain cell.

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 different foods to counteract oxidative stress. Foods with high ORAC scores may
protect brain cells from the damage of oxygen radicals, or free radicals.

Oxidative stress. The wear and tear that free radicals cause to the body’s cells through a chemical
reaction in which oxygen reacts with another substance to cause a chemical transformation. Antioxidants
counteract this process.

Parietal lobe. The area of the brain above and behind the temporal region (near the temples).

Pharmacogenetics. The emerging field of drug effectiveness and safety based upon an individual’s
genetic makeup.

Positron emission tomography (PET). A body-scanning method that measures structure as well as
function. PET scans of the brain show characteristic patterns of decreased metabolism in the areas
affected by Alzheimer’s disease.

Protein. A molecule that is the building block of neurotransmitters and enzymes.

Serotonin. A neurotransmitter necessary for relaxation, concentration, and sleep that is decreased in
depression and dementia.

Short-term memory. Memories lasting only minutes and too transient for long-term recall.

Smart drugs. Medications, herbs, hormones, or supplements taken with the intent of improving
memory and other cognitive functions in a normal individual who does not have obvious memory loss.

Statins. Cholesterol-lowering drugs that may reduce the risk for developing Alzheimer’s disease.

St. John’s wort. An herbal treatment for anxiety, depression, and insomnia.

Stress response. The body’s physiological reaction to stress, involving release of cortisol and other
stress hormones.

Stroke. Death of brain cells resulting in a loss of physical or mental function or both.

Subdural hematomas. Blood clots surrounding the brain; a potential side effect of ginkgo biloba.

Subjective memory ability. A person’s self-awareness of memory ability.

 Synapse. The interface between two nerve cells where they communicate information.

Valerian. An herb used for restlessness and insomnia, which can interact adversely with alcohol and
other sedatives.

Vascular dementia. A dementia resulting from many small strokes.

Verbal memory. Learning and recall of information relating to language and words.

Visual-spatial memory. Learning and recall of visual and spatial information.

White matter. Brain areas consisting of nerve fibers that transfer information from distant brain
regions.
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 dedicated to 202-434-
Washington, DC 20049 helping older Americans achieve lives of independence, 2277 800-
www.aarp.org dignity, and purpose. 424-3410
Academy of Molecular Imaging Provides leadership in research and clinical aspects of
310-267-
Box 951735 Los Angeles, CA molecular imaging of the biological nature of disease.
2614
90095-1735 www.ami-imaging.org Their website includes a listing of local PET centers.
Administration on Aging 330
Provides information for older Americans and their 202-619-
Independence Avenue NW
families on opportunities and services to enrich their 7501 800-
Washington, DC 20201
lives and support their independence. 677-1116
www.aoa.dhhs.gov/
Aging Network Services 4400 E.
Nationwide network of private-practice geriatric social
West Highway, Suite 907 301-657-
workers serving as care managers for seniors living at a
Bethesda, MD 20814 4329
distance.
www.agingnets.com
Alliance of Information and
Professional organization that provides human services 206-632-
Referral Systems P.O. Box 31668
information and referrals. 2477
Seattle, WA 98103 www.airs.org
Alzheimer Europe 145 Route de Organizes caregiver support and raises awareness about
352-29-79-
Thionville L-2611 Luxembourg dementia through cooperation among European
70
www.alzheimer-europe.org Alzheimer organizations.
Alzheimer’s Association 919 N.
Michigan Ave., Suite 1000 The national organization that provides information on 800-272-
Chicago, IL 60611-1676 services, programs, publications, and local chapters. 3900
www.alz.org
Alzheimer’s Association Public
Policy Division 1319 F St. NW, 202-393-
Lobbying branch of the Alzheimer’s Association.
Suite 710 Washington, D.C. 7737
20004 www.alz.org
Alzheimer’s Disease Education National Institute on Aging service that distributes 301-495-
and Referral Center P.O. Box information and free materials on topics relevant to 3311 800-
8250 Silver Spring, MD 20907 health professionals, patients and their families, and the 438-4380
www.alzheimers.org general public.
Alzheimer Research Forum
Provides information and promotes collaboration among
Foundation 82 Devonshire Street,
researchers in order to foster a global effort to
S3 Boston, MA 02109
understand and treat Alzheimer’s disease.
www.alzforum.org
American Academy of Neurology Professional organization that advances the art and
651-695-
1080 Montreal Avenue St. Paul, science of neurology, thereby promoting the best possible
1940
MN 55116 www.aan.com care for patients with neurological disorders.
American Association for
Professional organization dedicated to enhancing the
Geriatric Psychiatry 7910 301-654-
mental health and well-being of older adults through
Woodmont Ave. #1050 Bethesda, 7850
education and research.
MD 20814 www.aagpgpa.org
American Diabetes Association
703-549-
P.O. Box 25757 1660 Duke Street America’s leading nonprofit health organization
1500 800-
Alexandria, VA 22314 providing diabetes research, information, and advocacy.
232-3472
www.diabetes.org
American Dietetic Association 312-899-
Consumer Nutrition Hotline that provides information on
216 W. Jackson Blvd. Chicago, IL 0040 800-
finding a dietitian.
60606-6995 www.eartright.org 366-1655
American Geriatrics Society 770
212-308-
Lexington Avenue #300 New Professional association providing assistance in
1414 800-
York, NY 10021 identifying local geriatric physician referrals.
247-4779
www.americangeriatrics.org
American Heart Association 7272 Non-profit health organization whose mission is to
214-373-
Greenville Avenue Dallas, TX reduce disability and death from cardiovascular diseases
6300
75231 www.americanheart.org and stroke.
American Society on Aging 833
National organization concerned with physical, 415-974-
Market Street, Suite 511 San
emotional, social, economic, and spiritual aspects of 9600 800-
Francisco, CA 94103
aging. 537-9728
www.asaging.org
Children of Aging Parents 1609
215-945-
Woodbourne Rd., #302-A National organization providing information and
6900 800-
Levittown, PA 19057 referrals for caregivers of older adults.
227-7294
www.caps4caregivers.org
Family Caregiver Alliance 425 Resource center for families of adults with brain damage 415-434-
Bush Street, Suite 500 San or dementia, which provides publications for caregivers 3388 800-
Francisco, CA 94108 and professionals. 445-8106
www.caregiver.org
Gerontological Society of
America 1030 15th Street NW, National interdisciplinary organi zation on research and 202-842-
Suite 250 Washington, DC 20005 education in aging. 1275
www.geron.org
National Institute of Mental
Part of the National Institutes of Health, the NIMH is the
Health 5600 Fishers Lane, Room 301-443-
principal biomedical and behavioral research agency of
10-75 Rockville, MD 20857 1185
the United States government.
www.nimh.nih.gov
National Institute of Neurological
The National Institutes of Health agency that supports
Disorders and Stroke Building 31, 301-496-
neuroscience research; focuses on rapidly translating
Room 8A-06 31 Center Drive, 5751 800-
scientific discoveries into prevention, treatment, and
MSC 2540 Bethesda, MD 20892- 352-9424
cures; and provides resource support and information.
2540 www.ninds.nih.gov
National Institute on Aging The National Institutes of Health agency that supports
301-496-
Building 31, Room 5C27 31 research on aging and provides information about
1752 800-
Center Drive Bethesda, MD national Alzheimer’s centers, and a free directory of
438-4380
20892-2292 www.nih.gov/nia organiza tions that serve older adults.
National Stroke Association 96
Their mission is to reduce the incidence and impact of 303-649-
Inverness Drive East, Suite 1
stroke disease and improve quality of patient care and 9299 800-
Englewood, CO 80112-5112
outcomes. 787-6537
www.stroke.org
Older Women’s League 666 11th 202-783-
An advocacy organization addressing family and
St. NW, Suite 700 Washington, 6686 800-
caregiver issues.
D.C. 20001 www.owl-national.org 825-3695
Joint program of the Alzheimer’s Association and the
National Center for Missing Persons that provides
Safe Return P.O. Box 9307 St.
patients with a dementia bracelet showing the person’s 888-572-
Louis, MO 63117-0307
name, the registered caregiver’s name, and a toll-free 8566
www.alz.org
number (800-572-1122) to aid in that person’s return if
lost.
SeniorNet 121 Second Street, 7th
Floor San Francisco, CA 94105 A national non-profit organization that works to build a 415-495-
www.seniornet.com community of computer-using seniors. 4990
UCLA Center on Aging 10945 Le
University center that works to enhance and extend
Conte Avenue, #3119 Los 310-794-
productive and healthy life through research and
Angeles, CA 90095-6980 0676
education on aging.
www.aging.ucla.edu
U.S. Department of Veterans
Provides information on VA programs, veterans benefits,
Affairs 1120 Vermont Avenue 800-827-
VA facilities worldwide, and VA medical automation
NW Washington, DC 20421 1000
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 efficacy and safety of donepezil in patients
with Alzheimer’s disease: results of a US multicentre, randomized, double-blind, placebo-controlled trial.
Dementia 1996;7:293–303.

Appendix:

Amyloid-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

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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 scientific 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.