Although these questions are relevant at virtually all lifespan stages, firm answers can sometimes appear inconceivable.  Unfortunately with advancing age, attention to mental performance is often either abandoned or framed in terms of perceived impairment and decline.  Now, I have previously shared my message on minding the aging brain with SharpBrains readers.  As a cognitive neuropsychiatrist primarily interested in later-life phenomena, I tend to stick to my area of expertise.  Nevertheless, whether you are elder or not, I implore you to take these ideas to heart…do you mind?

Just as brain fitness is for all, aging is similarly universal.  Every thoughtful individual recognizes the unavoidable answer to “are you aging?”  However, the answer to “how are you aging?” is less obvious to most, and is even more obscure when considering lifespan cognitive trajectories.  In fact, no consensus lexicon yet exists to describe the ways in which cognition can be modulated to achieve desired lifestyle or clinical goals.

In my latest publication on technology-enabled cognitive training for healthy elders, I outline a proposed lexicon for positive cognition interventions, as well as a framework for classifying putative benefits of cognitive training.  Here, I will present these concepts without regard to age, as they apply equally well to all sapient sapiens:

●      Cognitive stimulation refers to nontargeted engagement that generally enhances mental functioning.  Examples might include educational endeavors or life review.

●      Cognitive training refers to theory-driven intervention, supported by a conceptual framework and specified neurocognitve mechanisms. Examples might include mnemonic strategy adoption or software-based brain fitness programs.

●      Cognitive rehabilitation strategies address impairments resulting from neuropsychiatric disorders.  Examples might include post-stroke language therapy or targeted programs to remediate attention deficits or dyslexia.

●      Cognitive enrichment further includes a range of lifestyle behaviors which can benefit cognitive performance, including multimodal brain fitness interventions involving physical, nutritional, and social activity.

Although there are similarities to these concepts, the distinctions are instructive and reflect a synthesis of perspectives.  Positive cognition is intended to be a descriptive term which subsumes these as well as enhancement or cosmetic approaches, which may involve pharmaceutical or direct modulation of neural systems with magnetic, electrical, or optical energy. The essence of positive cognition is the intent to influence lifespan cognition toward the optimal, or even to extend the range of possibilities defined by biology.

Now, whatever your stage of life and whichever approach to positive cognition is most relevant to your goals, be sure to ask yourself some tough questions.  If you come up with good answers, please don’t hesitate to leave your comments below.  Of course, if you would like to share your critique of my ideas or of positive cognition with other SharpBrains readers, I certainly won’t mind.

—-   Educated and trained at Harvard, Yale, Columbia, and in the heart of Brooklyn, Dr. Steinerman’s ambition is to contribute to the prevention of Alzheimer’s disease, one of the great challenges of the 21^st century.  He is Assistant Professor of Neurology at the Albert Einstein College of Medicine and Montefiore Medical Center in New York City, where he founded the Center for Healthy Brain Aging.  He is also the founding scientist of ProGevity Neuroscience.

More than any other organ, your brain is up to you. You are what you think, not just what you eat. Here’s some food for thought:

Design your Mind

Setting cognitive and behavioral goals raises challenging and worthy questions: What do you want from your brain? Will you know it when you achieve it?

To attain the brain of our choosing, we must understand our selves and current abilities. Introspection and curiosity are helpful if they trigger and sustain the effort to enrich the mind. However, objective information which leads to informed assessment of brain function is often lacking.

Mind your Brain

Honesty. Openness. Self-awareness.

Irrefutable virtues, but in practice most people fall short. Few regularly appraise their brain skills; even so, the ability to accurately judge one’s own mental performance is not guaranteed. I believe the first step to minding the brain is shedding hang-ups while offering and soliciting frank feedback from family and close confidants. In the clinical setting, routine cognitive screening and “mental check ups” are not currently practiced, in part due to time constraints and limited utility of traditional paper-and-pencil tests. From a public health perspective, the U.S. Preventative Task Force reviewed available evidence and could not determine whether the benefits of screening outweighs the risks (link here).

There is great promise in using computer-based cognitive assessments and innovative memory tests which are based on contemporary concepts in cognitive psychology. Highly desirable research aims will be to demonstrate their ability to 1) reliably capture a person’s “baseline” cognitive abilities; 2) promptly detect intraindividual change; and 3) accurately predict risk of future decline.

Equally critical will be establishing public and professional buy-in to the notion that peeking at the brain is worthwhile. Complicating the situation, especially with aging, is a widespread ambivalence–even objection–to taking stock of our cerebrum. If cognitive decline or an Alzheimer’s diagnosis would be the outcome, there is a common and unfortunate preference “not to know” (See Early Alzheimer’s disease diagnostics: Wait! Wait! Don’t Tell Me) for a recent editorial addressing the research and public policy implications of such willful ignorance).

Mend your Mind

It is true that motivating people to seek ongoing assessment of their mental status will identify people who are experiencing signs of brain aging. The challenge will then fall to professional and research communities to demonstrate the benefits of early diagnosis and intervention. Delivering clinical excellence will require interdisciplinary innovation.

In establishing the Einstein-Montefiore Brain Aging Center in New York City, I prioritized two overlooked but essential modes of intervention: education and community outreach. The goals are to counteract a prevailing therapeutic nihilism which is no longer justifiable, and to mobilize communities to promote brain longevity. Such culture change will presage successful research and development of the therapies so desperately needed. Disease-modifying biotechnologies and astounding cognitive neurotechnologies may be on the horizon, but the time is now to pique your brain.

SharpBrains readers: I would like to pick your brains on this subject. Please post your comments and thoughts on the following provocative statements:

1) Even if my cognitive abilities were declining, knowledge of this would leave me worse off.

2) I am concerned that family, friends, physicians, employers, or insurers would treat me differently if they found out I had cognitive decline.

3) Understanding my cognitive strengths and weaknesses will motivate me to establish and adhere to a personalized brain fitness program.

Thank you!

For a related article, you can read Alvaro’s Computerized Cognitive Assessments: opportunities and concerns.

– Dr. Joshua Steinerman is Assistant Professor of Neurology at New York’s Albert Einstein College of Medicine, where he established the Einstein-Montefiore Brain Aging Center and directs the Neurodegenerative Disease Clinical Trials Program. He is also Founding Scientist at ProGevity Neuroscience.

What is dementia? I, like many others who dedicate their professional efforts to its study and treatment, have no good answer. I believe we are lost in our lexicon, trying to define a brain state so vexing and elusive it drives us out of our minds.

I hope we can do better, and I am not alone. In a sensitive and forward-looking editorial entitled Dementia: A Word to be Forgotten, Drs. Trachtenberg and Trojanowski of the University of Pennsylvania argue that alternate terms are more appropriate for research, clinical, and everyday settings. From scientific and biological perspectives, dementia is unspecific and subjective. Within the walls of the physician’s office, delivering the diagnosis of dementia can erect unintended walls around patients and families; vulnerable individuals, assuming that the “cruel connotations in the lay language” actually apply to them, are unnecessarily isolated. The authors recount a patient and caregiver experience upon first hearing the term applied:

An immediate epiphany occurred, and suddenly the potential danger and threatening sentence of the word became manifest. It was frightening that somebody might say it to her while she was still able to fully grasp and sense its toxic effect and that it would hasten and seal her fate in the manner of a self-fulfilling prophesy. (Archives of Neurology 2008;65(5):594)

Words to Live by

Idiot, midget, lunatic, and many other pejorative terms have thankfully been excised from clinical and polite discussion. The resulting advantage goes beyond conformity to standards of socially-acceptable discourse. It enables the productive consideration of limitations which should not be dismissed or ignored. In the case of cognitive and behavioral disorders of aging, many resist confronting their concerns, preferring self-conscious group chuckles surrounding “senior moments.” What’s more, practicing physicians have few incentives or resources to probe for late-life neuropsychiatric conditions. While nihilism prevailed for some time, attitudinal change has taken hold. Proactive people are arriving at specialty evaluation centers with mild cognitive symptoms, well before one would ever consider dropping the D-bomb. Consequently, we need to employ alternative concepts to signify the presence of potentially serious brain dysfunction.

Witness Brain Fitness

SharpBrains readers young and old already know that Brain Fitness is an achievable goal. Increasing public awareness and diverse tools and venues for pursuing successful brain aging now exist. Useful starting points for discussion are emerging, many reflecting the concept of positive cognition. But what do you call that ghastly gray elephant?

Brain Failure describes the loss of Brain Fitness, and fittingly refers to the state of mental degeneration and dependence experienced by millions. Of the many more aging individuals who are threatened to endure such a fate, the reasonable approach is to confront the possibility of Brain Failure by pursuing Brain Fitness. Nihilists and slackers are of course welcome to slip down the blissful slope toward Brain Disaster. Those who perceive signs of Brain Failure should seek help in identifying the biological and environmental determinants of their symptoms. Cognitive and behavioral disorders are common in aging, and are now routinely detected and treated at earlier stages than ever before. When medical and neurodegenerative diagnoses are communicated, there is no benefit in evoking stigma or sounding the death knoll. Regardless, if I had to choose an obsolete and hurtful label, I’d rather be senile than demented. Everyone familiar with Brain Failure understands it can be unremitting and cruel; we must also recognize that is remediable. Brain Fitness is still the goal, even in the throes of Brain Failure.

– Dr. Joshua Steinerman wrote this article for SharpBrains. Dr. Steinerman is Assistant Professor of Neurology at New York’s Albert Einstein College of Medicine, where he directs the Neurodegenerative Disease Clinical Trials Program.  He is the founding scientist of ProGevity Neuroscience.

- Alvaro
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Minding the Aging Brain

– By Joshua R. Steinerman, M.D.

Scientists, philosophers, artists, and experts from all fields of human endeavor lament: it ain’t easy getting older. It? Do they refer to frailty and disability? To bodily disease? To life at its essence?

It’s all in your head

The mind is not set in stone, but it is encased by bone. It’s really all about the brain, the hyphen in the mind-body conundrum. That squishy gray neuronal jungle is the interface between internal life and environmental sensations and stimulation. As expected, the brain shows signs of aging just as a wrinkled brow, a stooped posture, or an arthritic finger might. The most common brain changes observed in aging and in age-associated neuropsychiatric disease include:

* Brain atrophy (shrinking may be generalized or more pronounced in a particular lobe or brain structure, such as the hippocampus)

* White matter changes (degradation of the connections between brain regions, often attributed to diseased cerebral blood vessels)

* Plaques and tangles (accumulations of proteins and degenerated bits of nerve cells)

Going out of your mind?

There is no doubt that brain aging takes a toll on cognition and mental performance. Individuals vary in their ability to tolerate age-related brain changes before manifesting overt symptoms (see Alvaro’s interview with Yaakov Stern on the Cognitive Reserve). Nevertheless, there will always be a threshold beyond which signs of deterioration can be perceived. Often, the effects of brain aging are subtle and undetected. The cognitive declines commonly associated with aging are observed in the following domains:

* Processing speed and reaction times

* Cognitive control and Executive function

* Memory

Some brains manifest accelerated or disproportionate changes. These are signs of pathological brain aging, and may take on the form or pattern of particular neurodegenerative diseases, such as Alzheimer’s disease. Concurrent brain pathologies, such as stroke or Parkinson’s-related changes, may act additively or synergistically. In these settings, cognitive symptoms may include profound memory loss and executive dysfunction, as well as language and visuospatial dysfunction. Behavioral symptoms can include depression, anxiety, apathy, agitation, or psychosis. When the ability to function independently is compromised, the term dementia may be used to describe this frightening mental state.

Getting into your brain

How do you think about your mind? Get cerebral and consider the possibility of successful cognitive aging. How do people envision such a prospect? A recent poll on Brain Health by the American Society on Aging/ Metlife Foundation reported the most common responses offered by Americans when asked to define brain fitness:

* Being alert/sharp

* Keeping your brain active/exercising the brain

* Good mental health/not senile

* Good memory

* Ability to function normally

* Ability to think clearly

* Not suffering from Alzheimer’s Disease

While these are all worthy goals, some cannot be empirically assessed. For example, with expertise, memory can be formally quantified, and Alzheimer’s Disease can be diagnosed with reasonable confidence. On the other hand: being alert, sharp, active, and thinking clearly are not only difficult to measure, they are closely coupled with self-perception and well-being. Such mental phenomena are not only of outstanding everyday relevance, they are sorely under-researched. Consequently, the scientific community may not have the necessary tools to study brain fitness interventions designed to achieve successful cognitive aging.

Brain training isn’t easy, either

In our initial forays into studying science-based cognitive training interventions, I propose that we have yet to apply the outcome measures of greatest interest. I believe there is a need to define and implement novel research outcomes for brain fitness research. These should be functionally-relevant, in that they reflect useful, everyday skills. They should be biologically-relevant, in that they track and distinguish normal and pathological brain aging. Many could be grounded in the largely-unexplored concept of positive cognition, much the way positive psychology energized a vision and research agenda for emotion and character.

Whether or not science-based mental fitness will make promoting brain longevity possible, it surely will not be easy. Establishing efficacy of the emerging technologies and techniques will require tremendous effort and investment. Motivating individuals to engage in brain-healthy activities may prove even more challenging than encouraging adoption of heart-healthy lifestyles. Ignorance will not yield bliss, and mental passivity can destroy. The challenge of minding and mending the aging brain must now be addressed head-on.

– Joshua Steinerman wrote this article for SharpBrains. Dr. Steinerman is a Postdoctoral Clinical Fellow in the Department of Neurology at Columbia University Medical Center. He is a Co-investigator on this Cognitive Training Clinical Trial, and looking for participants who are healthy adults between the ages of 60 and 75 living in New York City.