neuropsychology Archives - BrainWise Media

Tag Archive for: neuropsychology

Lifestyle changes for better brain health

in Featured, Highlight/by Dr. Gary Small

Dr. Gary Small knows all about brain health. As professor and chair of psychiatry at Hackensack University Medical Center, he oversees all professional and administrative activities within the behavioral health care transformation service at Hackensack Meridian Health. Prior to this gig, Dr. Small was a professor of psychiatry and biobehavioral sciences and a Parlow-Solomon professor on aging at the David Geffen School of Medicine at UCLA, director of the Division of Geriatric Psychiatry at the Semel Institute for Neuroscience and Human Behavior, and director of the UCLA Longevity Center. Now 72, Dr. Small is known for his public work in promoting the practice of psychiatry and innovative research on brain health, aging, and Alzheimer’s disease. He is a co-inventor of the first positron emission tomography (PET) scanning method that provides images in living people with Alzheimer’s disease with abnormal brain proteins, amyloid plaques, and tau tangles. Dr. Small has authored more than 500 scientific works and received numerous honors, including the American Psychiatric Association Weinberg Award in Geriatric Psychiatry. What’s more, Scientific American magazine named him one of the world’s top 50 innovators in science and technology. He is the author of 14 popular books, including a bestseller titled, The Memory Bible. (Dr. Small also recently spoke at a NAN workshop; to access the archived event, click here.) Earlier this year, BrainWise Managing Editor Matt Villano sat down with Dr. Small to discuss the most important aspects of brain health, and how aging adults can take better care of themselves for the future. What follows is an edited transcript of their conversation.

BrainWise: If we had to categorize lifestyle activities, what are some of the top things people can do to improve their brain health?

Dr. Gary Small: I would say number one is physical exercise. Mental exercise and challenging the brain is very important, but the scientific evidence is even more compelling that regular aerobic or cardiovascular conditioning protects your brain too. You don’t have to become a triathlete to achieve that. Some studies show that just a half hour of brisk walking each day will lower a person’s risk for Alzheimer’s disease. And it’s not just cardiovascular conditioning, which improves circulation to the brain, it increases levels of endorphins which lift a person’s mood and improves issues with pain. Physical exercise also increases levels of brain-derived neurotrophic factor, which is a protein that helps our brain cells communicate more effectively. Strength training appears to provide additional benefits. It may be that when you’re lifting weights or using resistance bands, it provides an additional cognitive challenge to get your form correct, or it may be that other factors are involved. We know that as people age, they are at risk for developing a condition called sarcopenia, which is loss of lean muscle mass, which is a predictor of shorter life expectancy. So that’s another area that strength training helps us in. A third component of physical exercise would be balance training. Older people are at risk for falls, and if you fall, you can hit your head and head trauma is not good for your brain health. [Literature such as this article, this article, and this article suggest that] people who hit their heads and lose consciousness for an hour or more [may have] greater risk for developing dementia or cognitive decline that interferes with their ability to care for themselves.

Brainwise: How can PET scanning help patients become better acquainted with and better in control of their own health?

Dr. Small: It’s a complicated issue because any test or technology that you’re going to use, you have to ask the questions, ‘How is it going to be helpful? What is the potential harm? What is the potential benefit?’ I have worked in this area for a number of years. In 2004, [PET scans were] used to differentiate Alzheimer’s disease from Frontotemporal Dementia (FTD). Today, PET scans are used for all sorts of other things. A PET scanner is essentially like a Geiger counter, it measures radioactivity. When a patient gets one, we inject the patient with a radioactive chemical marker that is taken up by the brain. The marker enables us to see how the brain cells are using sugar, which gives you a measure of cellular function. Of course, there is the risk that if you get these scans, it’s going to cause anxiety in [some] patients. I’m not really a big fan of telling people to go out and get a scan or get genetic testing [unless it’s medically necessary], because it could have negative effects. I am a big fan of encouraging everyone to live a healthy lifestyle, to see their doctor if they have cognitive concerns and get tested and find out where they are and whether these scans are [necessary] or not.

BrainWise: You mentioned genetic risk. What role do genetics play in all of this?

Dr. Small: I always want to encourage people to not be discouraged by their family history. One thing to keep in mind is that the age at onset of a cognitive decline tends to be consistent within families. So if you have a grandparent who developed dementia at 95, the chances are that’s more age-related, and whatever forgetfulness you’re experiencing in your forties is likely unrelated. Another factor, and we’ve done these studies, others have done these studies, is you find that even if somebody has a genetic risk, even if you’re an identical twin to someone who has dementia, that doesn’t necessarily mean you’re going to develop it, that if you live a healthy lifestyle, you can do better. We’ve done studies of people with that genetic risk for Alzheimer’s disease, and we find that if they exercise more, if they don’t have too much overweight or obesity in midlife, that they have less Alzheimer’s disease in their brain when we do brain PET scans.

BrainWise: Can someone be too cautious about protecting their brain?

Dr. Small: It’s never too early and it’s never too late to start protecting your brain. We see very good results in older adults, and one of the advantages of starting early is that you don’t have to change habits so much. It’s one thing to educate people about what’s good for their brain health, it’s another to get them to change. And we’re not just talking about becoming a weekend warrior and playing basketball once a month on Sundays; we’re talking about daily habits that have an impact. And we know from other research [such as Dr. Wendy Wood’s work; see this and this] that to convert a behavior into a habit takes a bit of time and takes some motivation and some consistency. It’s also important to develop a program that is not overwhelming. Not long ago, my wife (Gigi Vorgan) and I wrote a book called, Two Weeks to a Younger Brain. If we called it, ‘Two Years to a Younger Brain,’ I doubt anyone would read it, but the point was, two weeks is enough time to take baby steps to begin to change your life habits, your lifestyle habits, so that it becomes easy to protect your brain every day.

BrainWise: So how can someone jump-start momentum to make a change?

Dr. Small: It’s incremental. It starts with what we’re doing right now, educating people. If you let people know that ordering broccoli as your side dish rather than French fries is going to be better for your brain, you’re more inclined to do that. And part of that education is not just about physical exercise and mental exercise and healthy diet, but it’s also about how to get enough sleep, how to manage stress better, how to avoid experiences like head trauma that will worsen your brain health. If you have high blood pressure or high cholesterol, just taking the medicines for those illnesses can extend your life expectancy and lower your risk for dementia. Many of the books I’ve written outline these programs in some detail. There are many ways to get there. Sometimes it’s reading a book, sometimes it’s checking out a website. Other times it’s meeting with a [trained] professional [such as a psychologist or a neuropsychologist, a dietician, or a nutritionist, as the case may be]. Also, there are apps. I remember reading an article several years ago, it’s much easier to break into training with an app than with a person who will kind of give you a hard time if you don’t show up.

BrainWise: How much exercise is too much?

Dr. Small: When I see patients, I not only go through the standard medical interview and assessment and find out about their history, medications, illnesses, etc., but I ask about their lifestyle. I specifically ask, ‘How much exercise are you getting? How are you doing it? What holds you back?’ And I work with them to try to design something that makes sense for them. Let’s say somebody’s a very busy executive and they don’t have time to go to the gym. Well, what about parking your car a little bit further from the building and walking briskly to the office? Maybe take a few flights of stairs. We always think of it in terms of starting low and going slow. You don’t want people to injure themselves, but you want them to be able to build up in a gradual way. And if you can get the program going so that they get these endorphin rushes, the so-called endorphin high that elevates your mood, that’s very helpful in solidifying those exercise habits because people look forward to it. They know they feel better after they exercise. They have less pain after they exercise. I had a trainer who would always say, ‘Motion is the lotion,’ because it lowers inflammation. Exercise is really something that’s individualized and tailored to the person’s lifestyle. If you make it too daunting, they’re not going to do it.

In the aerobic area, exercise could be almost anything that gets your heart to pump oxygen nutrients to your brain. It could be swimming, jogging, or walking. Part of what determines a specific type of exercise is what’s convenient for you, what you enjoy, what kind of injuries you’ve experienced. For example, if you have a bad ankle, jogging may not be good for you, but you could probably swim. If you have a bad shoulder, maybe a treadmill might be better for you. I think that those kinds of considerations will come into play as someone tries to evaluate what form of exercise is best.

BrainWise: What about social activity? How can that impact the brain, and how much of that should people be emphasizing?

Dr. Small: It really needs to be individualized. My wife and I wrote a book about that called, Snap! Change Your Personality in 30 Days, and it brings up a couple issues. First, despite the clinical lore, it is possible to change your personality traits in a positive way to improve your health and improve your life. Personality is also important when it comes to brain health. If somebody is an introvert, they are not so keen on being so social. They come home at the end of the day, and they like to wind down by curling up next to a fire and reading a good book. An extrovert wants to talk about their day and kind of deprogram all experiences in that way. And so, an introvert wouldn’t necessarily want to spend so much time or need to spend so much social time. But a certain amount of social interaction, I think, is important for everyone, whether they’re an extrovert or an introvert, and it has several aspects that will affect brain health. If you’re having conversations, that’s a form of mental exercise and mental challenge, and that’s going to be good for your neural circuits. If you have conversations with friends who are supportive, that will lower your stress levels and that’s going to help your brain health. Loners don’t do well as they age. We saw this really impact people during the pandemic, among people of all ages. Isolation can lead to depression, and depression is a risk factor for cognitive decline.

BrainWise: Finally, what about diet? Can that really affect brain health?

Dr. Small: Diet is significant. Watching your calories, particularly in midlife, is key. The fat around the abdomen is inflammatory. Many of us think that heightened inflammation drives brain disease as we age, so watching out for that is important. The average western diet includes too much Omega 6 fat compared to Omega 3, and we want the Omega 3. Consuming at least seven servings of fresh fruits and vegetables, which lower oxidative stress in the brain and the heart, is wise. Processed foods and refined sugars, which can increase the risk for diabetes, [also may increase] your risk for dementia [as outlined in this CNN article about a recent study on this point]. I was just reflecting about diet this morning when I woke up. I got a reasonable night’s sleep and I felt pretty good getting up. And I thought, ‘Well, what did I eat for dinner last night?’ I had Mediterranean food. We hear a lot about the Mediterranean diet, and I felt a lot better than I did the day before. On that day, I had just returned from a business trip to Chicago where a lot of the airplane food, all that salt and more of a Western diet didn’t help me sleep so well and didn’t make me feel so great. People can experience subjective differences depending on diet. And you can talk to a lot of people who have changed their diet and notice subjectively they feel better. I think that’s one of the things I’d like to emphasize about taking these baby steps to improve your lifestyle. If you do it, you’re going to notice it’s not just the long-term effects on your brain health, but you’re going to start feeling better right away, which reinforces the habits.

BrainWise: Five years from now, what do you think we’ll be talking about when we talk about everyday ways that we can improve brain health?

Dr. Small: Well, I’m hoping that we’ll have more incentives for people to live healthier, because I know how hard it is to get people to change. We don’t want to force them to change, but we need carrots, not sticks, to motivate them.

This essay has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.

7 tips for navigating holidays with a loved one who has dementia

in Blog/by Matt Villano

The holidays are upon us, and whether your loved one is experiencing cognitive impairment due to Alzheimer’s disease, Parkinson’s disease, stroke, or any other cause, special planning and considering key changes to family traditions can help make the season more enjoyable for everyone.

Amelia Anderson-Mooney, clinical neuropsychologist with private practice in Glasgow, Kentucky, and assistant professor of neurology and graduate medical education for the University of Kentucky College of Medicine, said a few small tweaks to annual rituals can go a long way toward making everyone more comfortable.

“Adjusting holiday plans appropriately often begins with a good understanding of what disease stage our loved one is experiencing now,” she said. “If symptoms are mild, small adjustments can make a world of difference. If symptoms are moderate to severe, it’s likely that we will need to make more substantial changes. In mild stages, many elders with cognitive decline may be able to have a more active role in planning and preparing for family activities. In more advanced stages, their role will very likely be smaller but no less valuable.”

Here are seven tips for making the holiday season more comfortable for your loved one with dementia and everyone else.

Tip 1: Ask and learn

Sometimes we haven’t been fully aware of what our loved ones have been doing behind the scenes of our traditional holiday gatherings. When a loved one receives a diagnosis of dementia, it’s up to us to educate ourselves about the full extent of the responsibilities they have taken on over the years, and then have an open, direct discussion about what that loved one feels comfortable doing for this year’s holiday celebrations.

Anderson-Mooney said it’s important to make sure your loved one with dementia is involved in holiday preparation in a way that is meaningful to them. She said sometimes this can be accomplished by asking, simply, “What can we do to make the holidays easier for you?” Anderson-Mooney added that it’s critical to have this conversation with the understanding that elders with cognitive change may need additional time to gather their thoughts and respond.

“It is also important to remember some elders with cognitive change may not fully understand their limitations, which means a more substantial change in approach for us,” said Anderson-Mooney, who is a National Academy of Neuropsychology (NAN) board member and chair of NAN’s publications committee.

Tip 2: Delegate, delegate, delegate

If the person in your family with dementia is the person who has hosted holiday traditions, it might be necessary to rethink the entire celebration. Perhaps your loved one no longer feels able to prepare their home in a way that makes them feel ready. Perhaps they feel they can do it, but they need help. Anderson-Mooney said it’s always a good idea to offer to help make a list and gather volunteers to pitch in.

She added: If your loved one with dementia no longer feels comfortable handling the family meal solo, delegating tasks could be a golden opportunity to learn family recipes and traditions straight from the source so they can be passed down to future generations.

Tip 3: Keep tabs on overload

Anderson-Mooney noted that it’s also important to consider how much holiday cheer loved ones can handle at one time.

People with cognitive change often talk about how overwhelming it is to be in large groups of people, even people they love, because they feel like they can’t follow the conversations well. Because of this, they tend to withdraw, and that withdrawal can be hard for other family members to understand. If you have noticed your loved one having difficulty interacting in family gatherings during the year, your family may want to plan to have smaller gatherings more often.

Her advice: Make sure you build the day around what your loved one’s body needs Plan activities at a time of day when your loved one feels the sharpest and most energetic. Do your shopping outings before lunch. If your loved one feels and operates best in the morning hours, maybe a Thanksgiving breakfast is in order, with smaller visiting groups later in the day.

“The holidays are about being together,” Anderson-Mooney said. “That’s what matters most.”

Tip 4: Make travel easier

Cognitive decline often adds a layer of complexity if your family has traditionally traveled for the holidays. People with cognitive impairment often lean heavily on their daily routine to help them get by from day to day. Travel, by its nature, can disrupt that routine completely.

Anderson-Mooney said this means that travel might be out of the question for some people with cognitive impairment. She added that if a loved one has had trouble adjusting to relatively small changes in their daily routine at home, you can anticipate that they may not adjust well to the larger demands of traveling.

In extreme cases, or cases where a loved one is experiencing significant cognitive decline, it may be wisest to eliminate travel of any kind.

Tip 5: Build in time to rest

Sleep disruption can be very problematic for people with dementia. Anderson-Mooney said in practice, she often sees an increase in confusion and emotional upset from disrupted sleep. Again, if you have seen your loved one struggle to adjust to an earlier wake up time for a doctor’s appointment, or struggle to adjust to time changes or new time zones, for example, unusual holiday schedules or on quick trips can be doubly hard.

Consider also that traveling itself—whether it’s a one-hour car trip or a six-hour plane flight—can be exhausting.

Most people are familiar with the fatigue we feel after reaching our destination when we travel, even though we’ve just been sitting in a car all day or waiting for a plane. This fatigue happens, at least in part, because our brains are very busy processing all the novel scenery, keeping us safe in traffic, making sure we make our flight connections, helping us remember where we put our carry on bags, and so on. Anderson-Mooney said this fatigue can multiply in a serious way in people with cognitive impairment.

“If travel is in the plans for your loved one with cognitive impairment, consider breaking up the trip into smaller legs or adding a day before and/or after to allow your loved one to recover energy-wise,” she said.

Tip 6: Line up support

If you’re planning to travel for the holidays by car, be very realistic about whether your loved one can handle any of the driving. If you’re flying, airlines help vulnerable elders just as they do for unaccompanied minors. Most of this assistance is available in part because of the federal Air Carrier Access Act and the Americans with Disabilities Act. Airlines are required to offer assistance for seniors such as help in boarding and making connecting flights, and many airlines go above and beyond the basic requirements to ensure that their elderly passengers are well cared for in their travels. (This, this, and this are great websites for more information on the subject.)

Anderson-Mooney suggested that family members may want to consider adding an extra layer of support for loved ones with dementia.

Specifically, she advised that someone in the family (or a hired caregiver) accompany your loved one as the person’s personal “travel coordinator.” This person becomes responsible for carrying your loved one’s medications, keeping track of their valuables, and tracking the itinerary. The person also can be responsible for making sure that your loved one takes their medications on time while traveling and while on the ground at the destination. (Setting alarm reminders on the coordinator’s phone is a helpful way to make sure your loved one never misses a dose.)

Anderson-Mooney said the coordinator should travel with a full, printed list of medications, dose amounts, and dosage times, as well as names and phone numbers of your loved one’s doctors. She added that it’s important to keep the list and the medication in a carry-on bag so it’s not lost and separated from your loved one.

“It’s so important to consciously and deliberately appoint someone to ensure these things are done,” Anderson-Mooney said. “With some medications, missing doses can be dangerous. Replacing medications in lost baggage can be done, but it’s better to avoid the hassle in the first place.”

Tip 7: Providing physical care

Finally, Anderson-Mooney said it’s important to be mindful to maintain our loved ones’ physical needs in the hustle and bustle of the holidays.

Make sure your loved one is eating good quality food on a regular schedule. Make sure they stay hydrated while out and about in town and during busy family gatherings. Be very careful and limited with alcohol consumption. Deliberately add in more time for rest and recovery in your schedule. Set medication alarms to make sure we remember to take medicines during our activities (taking water with us is often necessary for this).

Again, it can be very helpful to have a dedicated person or group of people to watch over these needs for your loved one. If this is too big of a job for one person, designate a different coordinator for each day of the holiday, and switch throughout the celebration.

Closing thoughts

Of course, all these suggestions assume that your loved one is going to be an active, agreeable participant in adjusting to their own needs. Unfortunately, sometimes this is just not the case.

“Cognitive change is cruel and unforgiving, and it can completely change our loved ones’ personalities and ways of doing things,” Anderson-Mooney said. “Our loved ones may no longer be capable of understanding their own changes and adapting to their own needs. Our loved ones may no longer recognize us when we visit. We might deal with more agitation and anger, more upset, lashing out behavior. In these cases, our traditional plans just don’t make sense anymore.”

In these worse-case scenarios, Anderson-Mooney said we must adapt to a much heavier degree.

Specifically, if visits usually leave your loved one agitated and upset, it may be best to delay the holiday all together.

If visits leave your loved one confused, it may still be worth making the effort to celebrate together. Anderson-Mooney added that even if your loved one no longer recognizes you, they are very likely to recognize and understand that you are someone who loves and cares about them. They will appreciate your gesture of time and company, small gifts and comforts, favorite foods, and chatting about family photos. Spend time listening to their favorite music. Talk about their favorite memories from the past. Take the time to write down the family stories they tell before they fade away.

“This time can be a gift, even while you mourn the changes your family is experiencing,” Anderson-Mooney said. “Give the best love and honor that you can, and know that it matters, whether or not your loved one can appreciate it.”

This essay has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.

When age is really just a number

in Featured, Highlight/by Dr. Emily Rogalski

We all age. Some of us age better than others. This is an area of expertise for Dr. Emily Rogalski, professor of neurology at the University of Chicago. Dr. Rogalski heads the school’s brand-new Healthy Aging & Alzheimer’s Research Care (HAARC) Center, which will focus on building deep multidisciplinary expertise and bridging the gap between scientific disciplines to accelerate breakthroughs in cognitive resilience. This focus is increasingly important as the world’s population continues to age—the World Health Organization estimates that one in six people will be aged 60 years or older by 2030. Early in her career, while at Northwestern University, Rogalski operationalized the term “SuperAger” to describe people over the age of 80 whose memory still functions as well as that of someone in their 50s or 60s. That project has received considerable attention, including this piece from CNN. The project also received a $20 million from the National Institute on Aging and the McKnight Brain Research Foundation to establish an international multi-center SuperAging Consortium. BrainWise Managing Editor Matt Villano caught up with Dr. Rogalski before a talk at the recent NAN Conference in Philadelphia to discuss her work, its implications, and where SuperAger research goes from here. What follows is an edited transcript of their chat.

BrainWise: How did you get into this area of neuropsychology?

Dr. Emily Rogalski: I grew up the daughter of a schoolteacher who taught kids with learning challenges. From a very early age I was surrounded by brilliant kids that learned a little bit differently. That’s really where my interest in the brain came from. As a young kid, I had a very naive question: ‘If these kids are so brilliant but they can’t learn in the traditional way that our schools are set up, I wonder if there’s something different about their brains.’ I think I’ve been always attracted by things that are on the outskirts rather than in the main lane, and how those elements can inform both the mainstream, but also help those on the outside. When I was in graduate school, I learned about a really rare dementia called Primary Progressive Aphasia (PPA), where instead of losing memory like we lose in Alzheimer’s dementia, individuals lose language. And not only that, but they lose it at a really young age. They can be in their 50s and 60s, even [in their] 40s sometimes. When this is happening, nobody is thinking it’s dementia. It can take years to get a diagnosis. I was really struck by the lack of research that was going on 20 years ago in this space and thought, ‘This is a real opportunity to explore and help.’ This dementia can be caused by Alzheimer’s disease about 40 percent of the time. And so I found myself in an aging and Alzheimer’s center for my dissertation work.

In the trajectory of aging, you’re constantly told there’s nowhere to go but down. Normally, the first thing that’ll come out of the mouth of anyone who’s giving an aging talk is something like, ‘As we get older, we lose our memory.’ [We’re taught to know] that when you get older, your eyesight changes, your hair gets gray, your skin gets wrinkled, and your memory declines. And while that makes sense in general, I think if we all stop to think about that, it’s not in practice all of the time. We all know the Betty Whites of the world. We know these people who really stick out as being something different. We know them as our neighbors, we know them as our aunts and uncles in our daily lives. And so this thing that we talk about with aging and it being nothing but bad news doesn’t really fit with people’s lived experience of they know at least somebody in this other sphere.

The challenge was that 15 years ago, there were people already studying successful aging. I think that was a great change in something that really [John] Rowe and [Robert Louis] Kahn did a great job of getting that concept out there, that there could be another trajectory called successful aging. But that definition and that concept was general. There was a great review done by [Colin] Depp and [Dilip] Jeste [in 2006] and they looked at definitions of successful aging. What they found was that in 28 studies, there were 29 different definitions. In and of itself, that’s not a problem. They also found that in those studies, the percentage of people who met the criteria for successful aging ranged from 0.9 percent to something like 97 percent. So virtually nobody to virtually everybody. That proved the definitions for successful aging were all over the place. One was you’re over the age of 65, dementia free, and you have good physical health. Another definition was that if you’ve lived to age 90, you’re a successful ager. There also were definitions in between—sometimes requiring good cognition, sometimes requiring good physical health. I started looking into aging and what makes for ‘successful’ aging. That’s when I [coined the phrase], SuperAgers.

BrainWise: What characterizes a SuperAger?

Dr. Rogalski: I operationalized this term SuperAger so it would be very specific. [The paper that established the definition is here.] While it fits under the larger umbrella of a type of successful aging, the goal was really to say we wanted to have both a specific neuropsychological definition and an age criteria. SuperAgers are individuals who are over age 80 who have memory performance at least as good as individuals in their 50s and 60s. Why age 80? Again, kind of back to this idea is everything gets worse when you’re older. And it turns out that merely getting older is the biggest risk factor for Alzheimer’s dementia. It wins. It wins over all other factors right now. By age 80, you’ve reached a point where you’re at great risk for typical or average cognitive decline. You’re at greater risk for Alzheimer’s dementia. If you’ve reached this age and then you have memory performance that’s youthful, that’s unique. If you’ve gone through all of those lived experiences, all that wear and tear, and you’re able to really look like a 50- to 60-year-old, that is, neuropsychologically speaking, quite different.

BrainWise: So, neuropsychologically speaking, what do all SuperAgers have in common?

Dr. Rogalski: We require them to have this memory performance that’s at least as good as 50- to 60-year-olds. Then we say other cognitive domains have to be at least average, but we’re going to explore it and then we’re going to look at those as variables to say, well, how much does attention and executive function contribute? When Dr. Amanda Cook Mayer was a graduate student at Northwestern working with me (now she’s faculty at the University of Michigan), we did a study on that to say, what are their other strengths in cognitive function? What we found is there’s not one path to get there, but [SuperAgers] tend to have strengths in attention and executive function, and that there’s some variability that helps to explain some of their memory performance. Some SuperAgers, no matter which cognitive tests you give them, knock it out of the park. They perform like 50- to 60-year-olds or better across all the cognitive domains. In other instances, there’s people where memory is really their strength and other cognitive domains are average. There’s a third trajectory where people of course have great memory, and the other cognitive domains oscillate a little bit. I think this is important because it’s not that the SuperAgers had to get there all the same way. There can be different paths or trajectories that got them here. As we move more toward personalized medicine and precision health, we have an opportunity to understand the contributors to each of those pathways.

BrainWise: How does this translate to your current study?

Dr. Rogalski: Our goal in this study is not to just look at one domain. So some studies are like, ‘I’m a study of sleep.’ That’s very important, but that’s not what we are going for. We really wanted to cover as many domains as possible, do them well, and then look for that integration across the things. So we’re going to look at structural function, but how does that relate to cognitive function? We’re going to look at genetic factors. What’s the interplay between cognition, genetics, neuropathology, and brain structure? What can we detect during life, knowing that in a living person, we can only see with a certain resolution? I liken this to when we first got digital cameras and we were all excited, we didn’t need film anymore, and we could take a bunch of pictures and that seemed great and they looked great on the back of our cameras. And then we printed them out in our home printers, and everybody’s faces looked like little squares. They were pixelated. Well, that’s about the resolution we can see during life. And so this is where someone donating their brain at the time of death gives us that better resolution where we’re at with our iPhones now or better so that we can really look at contributors of cellular and molecular factors.

BrainWise: Can you give us specifics about one of your SuperAgers?

Dr. Rogalski: Our oldest SuperAger is 109. And I was at her house a couple of weeks before her birthday to bring her a present, and we did a little video shoot with her. The day before, she made us strawberry rhubarb jam. She’d never made strawberry rhubarb jam before. She’s still trying new recipes at age 109, and it was delicious. She enrolled [in the SuperAger study] when she was in her early 100s. At that time, she was driving, and I would’ve ridden in the car with her. She only stopped driving because she got gout, and the medicine she was taking messed with her grip strength. She’s sharp as a tack. We ended up doing a three-hour interview [with her]. Her best quotes were at the end of the interview. I mean, everybody was in tears as she was sharing aspects of her life. She was the first Black woman to graduate from Grinnell College in Iowa. She talked about the first time there was a radio in her house, the first time there was a phone. Think about what she’s lived through: two pandemics, World War I, [World War II]. That’s pretty remarkable. She’s seen a lot.

BrainWise: How many people over 100 are participating in the study?

Dr. Rogalski: Fewer than 10, out of about 300 total.

BrainWise: How do I know if I’m a SuperAger, and what can I do to increase my chances to become one?

Dr. Rogalski: We know that diet and exercise are important from [epidemiologic] studies and from other cohort studies. When we look at SuperAgers specifically, we see they have variable diet and exercise. The good news [there] is [that] it’s a good idea to pay attention to your diet and exercise, but all may not be lost if you’ve not paid the closest attention.

We know that SuperAgers range in education from 12 to 20 years. So it’s not just doctors and lawyers that we’ve enrolled. And every time we make a comparison in our study, the IQ of the control group is always in the same range. So that means it’s not just general intelligence or a measure of intelligence that’s differentiating the groups. I’ve worked with cohorts in South America where they have focused on enrolling or identifying SuperAgers that have little to no education, and they’ve been able to find them. We [too] are starting to enroll more diverse samples. It is possible to find SuperAgers who have lower education. We’re not just picking up on extreme levels of education that allow you to maintain good cognition over age 80.

I think one practical thing that we’ve seen, and now we’re trying to quantify it more objectively, is that SuperAgers report having stronger social relationships with others. We don’t know much about those relationships. We don’t know whether they have one best friend that’s a trusted partner, or if they are the social butterflies of their community. I know anecdotally many of them are the social butterflies of their communities.

Until recently all the data we collected on SuperAgers was self-reported. Then in 2020 we had this opportunity to write a grant that expanded the program to make it multi-site and to change the depth and breadth of science that we do. And one of the ways that we changed the depth and breadth of science was to add in wearable sensors. Now we ask the SuperAgers to wear these in their daily lives for about 14 days so we can get measurements of activity and social engagement. Objectively we can get measures of sleep and autonomic function. For all the survey data and the anecdotes that we have collected over the first 15 years, we’re now collecting those data objectively and quantitatively moving forward across five cities in the U.S. and Canada.

BrainWise: To what extent could a SuperAger potentially have issues with eyesight or have some physical disability, and where does that come into play with your research?

Dr. Rogalski: I was very intentional in not requiring super agers to have good physical health. We know from the larger body of research that good physical health tends to be associated with good cognitive health. And this makes sense for a lot of reasons. However, if you make that an entry barrier, now you’re kind of penalizing people who were able to maintain great cognitive health, but they might need a wheelchair or a walker. Their physical aging or their physical brain age may outpace their cognitive brain age, and I didn’t want to have that penalty. Instead, I wanted to be able to look and say, ‘How many people do we find that are using wheelchairs or walkers?’ So our SuperAgers vary. Some of them are riding their bikes hundreds of miles a week or in the pool doing exercises and weightlifting in the pool. Others are leading a chair stretching class. There also are several who are like, ‘I don’t exercise and I don’t plan to start exercising.’

What we do see in our super agers is that their brain integrity and brain structure looks different. They tend to look more like 50- to 60-year-olds in brain structure than they look like 80-year-olds. In this instance, we’re talking about cortical thickness. That’s the outer layer of your brain where your brain cells live—we can measure that thickness and it gives us a proxy measure of the health of the brain. Generally speaking, thinner is worse and thicker is better. When we compare our average 50-year olds to our average 80-year olds, we see that same thing that others have shown: cortical thinning across the cortex of the brain. When we compare our super agers to the average 50-year olds, we don’t see any significant cortical thinning. In fact, we see a region in the anterior cingulate cortex that’s thicker in super agers than it is in the 50-year olds. This has spurred some of our investigations pathologically to make sure we’re paying close attention to this anterior cingulate region.

BrainWise: Where do biomarkers fit into this research? At what point do you hope we can begin to apply some of these lessons you’ve learned to say 40- and 50-year-olds to maybe help them get a sense of whether or not they will become a SuperAger?

Dr. Rogalski: The larger body of research tells us social isolation and loneliness are bad. There are studies that have shown those who are socially engaged and have Alzheimer’s dementia tend to have slower trajectories of decline and tend to fare better cognitively. Our data fit with that. The practical implication is that if you’re going to go home today and on your commute home, you’re thinking about calling your best friend, call them, talk to them, stay socially engaged. Why might that be important from a brain health standpoint? Conversation is hard. I don’t know exactly what you’re going to say next, but you’re going to ask me a question. And then I have to think really quickly on my feet to say, ‘Okay, how am I going to answer that?’ Our brain likes new and challenging things, and social engagement creates that newness all the time to keep you on your toes, so to speak.

Finding the thicker anterior cingulate, that was serendipitous and it led us to other research questions. Under the microscope, it turns out we see a greater density of a special type of neuron called Von Economo neurons. These are neurons that have only been described in two regions of the brain, the anterior cingulate [cortex] and the frontal insular cortex. They seem to have something to do with social behaviors and social function, and they tend to be abnormal in Alzheimer’s dementia, frontotemporal dementia, autism, schizophrenia, bipolar disorder. They also tend to only be present in higher order species like [humans and] whales and elephants. We can now look cellularly, molecularly, genetically at these neurons to say, what role are they playing? This [part of our research] isn’t going to have an actionable endpoint tomorrow, but we need to be looking at all of these different levels. And so that’s kind of the beauty of the design that we have, is that some things kind of glean more actionable things to think about today, where others might lead to whole new directions and protective factors that might take a little bit longer to get there.

[To speak to the issue of biomarkers], we are looking at blood-based biomarkers. Some of the SuperAgers have been getting amyloid PET and tau PET scans so that we can measure aspects of Alzheimer’s disease during life, and then also measure it at the time of death when they pass away. As I’ve mentioned, one thing about SuperAgers is that they tend to be healthier, so I always joke that I do better in my side of the study that’s on the living side than my colleagues who have to wait until they pass away because they keep living.

BrainWise: Which questions will you be asking in your research next?

Dr. Rogalski: I lead what’s called the SuperAging Research Initiative, which now has five sites across the U.S. and Canada. My particular expertise is in the cognitive aspects, the neuroimaging aspects, and in some of the social function and other survey data that we give. My partners in this are geneticists, neuropathologists, neuroanatomists, [and others]. I’m kind of fluent in many of these things, but they’re the primary leaders, and that’s the goal, to bring together these scientists with these different expertise so that we can really dig a little bit deeper. And so now we’ve got these partners across the U.S. and Canada, and we’ve got the SuperAgers.

Another goal is to diversify our sample, make sure we’re identifying SuperAgers in different communities, both regionally across the U.S. and Canada, but also racially and ethnically. We’re working hard to make sure we’ve got strong community partnerships and trusted relationships, and we’re not just coming in and saying, ‘Sign up for research!’ We want to make sure we’re intentionally there and building partnerships because these folks are with us for life. When they sign up, they’re coming back year after year after year. It’s a relationship we’re starting with them. It’s not a study where they come in for one blood draw, and we never see them again. This is longer term.

This essay has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.

What brain imaging can tell us about brain conditions

in Featured, Highlight/by Dr. Marek Marsel Mesulam

Attendees at the annual NAN Conference in Philadelphia last month were treated to a keynote speech from Marek Marsel Mesulam, MD, the Ruth Dunbar Davee Professor of Neuroscience and Founding Director Emeritus of the Mesulam Center for Cognitive Neurology and Alzheimer’s Disease at Northwestern University. Dr. Mesulam’s talk spotlighted what happens in the temporal pole, the very tip of the temporal lobe. Dr. Mesulam is a neurologist, and his textbook, Principles of Behavioral and Cognitive Neurology, has been part of training programs in neurology, psychiatry, neuropsychology and cognitive neuroscience. Dr. Mesulam’s current research focuses on the functional imaging of neurocognitive networks, the factors that promote memory preservation in advanced age, and treatment of dementia. After Dr. Mesulam’s talk at the NAN Conference, BrainWise Managing Editor Matt Villano caught up with him to ask him about the intersection between brain imaging and neuropsychology, and how 50 years of experience in the field has informed his perspectives today. Their chat was the latest in a series of interviews Dr. Mesulam has given on this subject (for another good one, click here). What follows is an edited transcript of the conversation.

BrainWise: You’ve been researching brains for more than 50 years. How has brain imaging evolved in that time?

Dr. Marek Marsel Mesulam: Until the 1970s, all we had were traditional X-Ray films of the skull. At that time, it was difficult to localize regions of the brain. If you had a patient and they showed certain deficits and you wanted to find out what part of the brain was causing that deficit, it was almost impossible. There were a few instances where arteriograms were done and that helped to find out which vessel was impacted. That might provide information about where a lesion might be, but that was it. It is important to realize that for the first 100 years of neuropsychology, the brain lesion correlation has been central to understanding brain function. Logic says that if you lose certain function and there’s a lesion in the brain, that was the part of the brain critical for that function.

There was revolution in imaging in the 1970s. We had the first CAT scan. Then we had the MRI, which was far more powerful. These are structural methods. They show you where a stroke is or where you have loss of substance. They helped establish an important distinction between stroke and the sudden death of a whole bunch of neurons in a specific part of brain, like where there is atrophy that could be the result of degenerative disease. Then we had another revolution in the structural/functional relationship. This first came in the form of PET scans where blood flow was scanned. Later we had single-photon emission computerized tomography (SPECT) scans. This allowed us to see where function was lost in the brain physiologically. For instance, when a part of the brain doesn’t work it doesn’t draw blood.

The last layer in the revolution has been to use PET scan and MRI to do something called functional imaging. In the initial paradigm, when you lose function, you look at part of brain that’s injured either by stroke or atrophy and you correlate the two. With functional imaging—with PET and MRI—we have the ability to ask the converse question or complimentary question: If you do a function, which part of the brain shows activation? That is a different paradigm.

By the time the 90s were over, we had all these tools in place. That means the past 20 years they have kept getting refined. Temporal resolution got better. Spatial resolution got better. Computational methods for analyzing data became better. Right now, we’re still reaping the benefits of these various technologies. The downside is that this is not something you just take off the shelf. You have to be pretty sophisticated in order to make sense of this. What I’m saying here is that images don’t come with labels. Interpretations can vary because the methods are so noisy. There is sometimes a lot of fantasy in interpreting results. By and large, compared to the 70s, where it was just a desert in terms of imaging, right now it’s really like being in a toy store. I think there will be continuous improvement.

BrainWise: From a research and clinical perspective, what do these new techniques offer?

Dr. Mesulam: They enable us to address impairment, for one. Where is the structural change in the brain? That gives you clues to identify the disease that is causing the problem. There are certain regenerative diseases that impair primarily the hippocampus. One other advantage, in addition to the scientific question of where in the brain is such-and-such a function, is to be able to understand what the underlying disease might be.

There are now dozens of different techniques. You can search for structural imaging of volume. Or structural imaging according to thickness. You can look at fibers. You can look at a resting state connectivity analysis. With PET scans alone, the options are multiplying. There are now metabolic PET scans, scans that show the number of synapses. We can also go in and look at amyloid distribution, tau distribution. Like I said earlier, there’s no such thing as ordering an image and getting an answer. The data provides information for a continuous hypothesis. As a doctor you start and try to make do with the least possible disruption and expense to the patient. If your initial imaging doesn’t give you an answer, then you keep getting deeper and deeper.

BrainWise: How does cognitive measurement assist imaging in getting a full picture of someone’s brain functioning?

Dr. Mesulam: People don’t come to you and say, ‘Doctor, I have atrophy in my frontal lobe.’ They come and say, ‘I have difficulty with x, y, and z.’ What people say and what really is there are two different things. People are not neuropsychologists. Many times, when we have patients coming in and saying, ‘My memory is not the way it should be,’ you have a have big differential. What do they mean by memory? Do they mean they can’t find words? Do they mean they can’t see faces from the past? Does it mean they can’t remember things from childhood? From yesterday? Does it mean they can’t hold someone’s phone number. Each one of these is a different kind of memory and each one of them has a different relationship to the brain. The job of neuropsychologist is to translate the lay language of patient into a language that can be correlated into what imaging shows. [For a systematic review of work on this subject, read this peer-reviewed article from the Archives of Clinical Neuropsychology.]

BrainWise: Looking forward, based on the decades of experience you have, how do you think artificial intelligence can help impact the way we read brain images?

Dr. Mesulam: Artificial intelligence (AI) is one of these totally ambiguous terms to me. Of course, we’re using artificial intelligence in interpreting images. We have powerful computers that are chewing out the data and comparing it to controls and giving us incredible and sophisticated information based on whatever thresholds we want. If one wants to call this artificial intelligence, they can suit themselves. To me the word is meaningless. We like to play with toys, and that’s what this is. If AI can find out the handedness of a patient, the developmental history, whether they had dyslexia in the past, that would be significant. If you assume that all the data in the world someday will be in some kind of computers, I suppose there eventually will be something slightly better, but right now it’s not as if we’re screaming out for some artificial thing doing something we can’t do.

BrainWise: So what does the future hold, Dr. Mesulam? How will better brain imaging make for better and more efficient neuropsychology?

Dr. Mesulam: We’ll get better inventions and statistics, better special resolution. We’ll invent new things that will show different chemicals in the brain. By 2028, I don’t think there will be much conceptual change. In 200 years, I don’t know. If we had a chance to introduce an electrode into each of the 40 billion neurons in the head, what questions would we ask? We don’t have a theory of brain function yet. Could we develop one? Data is a dime a dozen, and you need to interpret it to the best of your ability. We do our best and still even for the most seasoned clinicians there are surprises. Ultimately a clinician must believe the results of a clinical exam over imaging. That’s what the patient is experiencing. For people who take care of patients, at least as of now, that remains the primary source of data and therefore the primary part of the experience.

This essay has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.

The connection between nutrition and brain health

in Blog/by BrainWise

You’ve probably heard the saying, “You are what you eat.”

Some brain scientists like to riff on this trope with a more brain-specific version: “Your brain is what you eat.” It’s not so far-fetched; there are serious connections between nutrition and brain health.

We’ve compiled some of these connections in a quick tips video on the subject. The video can be found on the new Brain Health Hub section of the NAN website.

In a nutshell (see what we did there?), healthy nutrition habits can help us to stay fit, and certain diets are especially good for brain health. These include the Mediterranean, MIND, and DASH diets. All three diets include whole grains, olive oil, beans, nuts, vegetables, and fruits, and moderate amounts of fish and dairy products.

In contrast, diets that are high in unhealthy oils and fats, refined sugar, and processed foods could lead to excessive weight, inflammation, and declining brain health.

You might wonder how consistent you need to be about your eating habits, but you can get brain health benefits by following these diets even part of the time. Some research has shown that people who followed the Mediterranean and MIND diets at least moderately well could lower their risk of Alzheimer’s disease.

The best protection comes from continuing to follow these diets regularly over time.

New research into the intersection of nutrition and brain health has focused on gut microbes—tiny organisms in the digestive system which can possibly be helpful or harmful for brain health. While future studies may find medications or supplements that might be helpful here, we don’t know enough yet to make strong recommendations.

As you consider how you can embrace better nutrition to spark better brain health, remember to be careful; it’s always important to discuss any significant dietary changes with your healthcare team.

From neuropsychologist to young adult novelist

in Featured, Highlight/by Katie Keridan

Northern California resident Katie Keridan spent the first 12 years of her professional career as a neuropsychologist. Following her schooling, she served as a predoctoral intern at the Kennedy Krieger Institute at Johns Hopkins University School of Medicine in Baltimore, then moved on to become a postdoctoral research fellow and licensed clinical psychologist at Children’s National Health System in Washington, D.C. In 2017, she moved to California and started a private practice. She also was a member of the National Academy of Neuropsychology (NAN); the first annual conference she attended was in Vancouver, B.C., in 2010. During the Covid-19 pandemic, Keridan made a major life change, setting aside psychology and psychometric analysis for a new career as a young adult novelist. Since the switch, Keridan has published two full-length fantasy books for young adult readers, and she has already finished her third book in the series. The books and characters in them benefit from Keridan’s knowledge of psychology and neuropsychology. BrainWise Managing Editor Matt Villano recently caught up with her to talk about her journey and what’s next. What follows is an edited transcript of their interview.

BrainWise: Making the leap from neuropsychology to YA fiction is not a very traditional path. What prompted this transition?

Katie Keridan: Yeah. Who would go from being a doctor to a young adult fantasy author? Oh wait, that would be me. I have always loved to write, always. I mean, some of my earliest memories are of me taking paper and folding it and stapling it and making little books. And I’d go through and I’d write about these wild adventures I had as a child growing up on a ranch in Texas. And then I would illustrate my own little written books. However, I was the first person in my family to go to college and thinking about a career that is going to be sustainable, writing was not really up there at the top of what my parents hoped to see me do. Since my parents were paying for me to go to college, they had a real vested interest in what I was going to major in and what I was going to do. Probably because I love creating characters and I love figuring out how people think, psychology was a natural fit for me. I loved figuring out what’s going on for someone and how I can meet them where they’re at and help them. Neuropsychology is even a further branch off that, figuring out what’s going on in this child’s brain so that we can meet them where they’re at and help them and connect them with the resources that they need to be as successful as they possibly can. I loved the career that I developed, it was fantastic. The best part was obviously working with kids and their families. The worst part was insurance and billing and figuring out how you are going to help these people who are coming into your office today. I was very fortunate—once I moved to California and got into private practice, I had time to delve more into the writing that I wanted to do. And I thought, ‘40 is approaching swiftly on the horizon, why am I sitting around here waiting, thinking someday it would be fun to try to write a book? Let’s go for it. Let’s just try and put it out there.’ I connected with a great writing team. My first book, Reign Returned: The Felserpent Chronicles, Book 1, came out last year in 2022 and then the sequel, Blood Divided: The Felserpent Chronicles, Book 2, just came out October 3rd 2023. The final book in the trilogy has a publication date of October 2024. So, it’ll be three books in three years.

BrainWise: How did the first book come to life?

Keridan: That book started while I was still on the East Coast. I’d have these little moments where I knew these characters, I knew this was a story I wanted to tell and so in my spare time I would write little snippets. Sometimes the only writing I would do would be from 11 p.m. to midnight or midnight to 1 a.m. during the week because you’re working all day long and you have to find these bits of times to write when you can. The more I started doing it and letting that part of myself come out and breathe, the harder it was to keep putting it back into the box. Because the story started taking on a life of its own. So, it has been with me for a few years.

I really wasn’t sure what COVID would mean for the publishing industry at all. Thankfully with my first book coming out last year, I was fortunate that [Covid-related] shipping issues didn’t really affect it. Most of the worst had passed, bookstores were back to doing in-person events. [Once the book came out,] I had to figure out some changes. Was I going to pursue [writing]? Was I going to stick with what I had gone to college for, what I had decided was going to be my chosen career?

It was scary to make the transition, but it was incredibly exciting. Now that I’m at a point where I have two books out and I’m connecting with readers and starting to get feedback, it’s such a privilege to know that people enjoy the work and enjoy what I’m putting out there.

BrainWise: To what extent does neuropsychology play a role in your books?

Keridan: I try hard to include accurate mental health representations in my writing because that’s my background. And I would be remiss if I didn’t bring that into creating characters that I want readers to see. Anxiety doesn’t just have to look one way, depression doesn’t just have to look one way, trauma and processing, it doesn’t have to just look one way. And that’s been so incredibly rewarding.

We’re in a position in publishing right now where despite all of the really horrible things going on with book bans and libraries closing and school libraries closing, there’s never been a greater interest in accurate mental health representation. Ware getting a lot of own voices coming out and talking about their experiences—not just, ‘Here’s what happened to me,’ but instead, ‘Here’s what happened to me through the lens of this character that I created so that other people can better understand what it was like to go through this.’ Just as one example, my main character, Sebastian, was a victim of abuse as a child and I pulled directly from my own life experiences with that, having grown up in a very abusive, chaotic home. I wanted to show a character who thinks they’ve worked through this when they’re just ignoring it. Now that they’re in this new relationship with someone they love, they have to figure out what it means to be vulnerable? How do I open up about this trauma that I’ve experienced? What is my partner going to think if I have a nightmare and I wake up screaming? I’m just going to die of embarrassment. All these things that young adults go through, new relationships, big life changes—but experiencing that through characters who have a neurological or a neuropsychological diagnosis has been incredibly fun for me. And I love that I can reach so many more people than I could [as a neuropsychologist]. It is always a trade-off when you do cognitive testing with families, there’s a part of me that feels like I become part of that family, and they never leave me. The nice thing about writing a book is I can reach more people, the downside is it’s less personal than what I did before.

BrainWise: What was the most challenging aspect of leaving behind a career you had worked so hard to achieve?

Keridan: I have a Ph.D. That’s usually anywhere from five to seven years, then you do an internship. I did a two-year research fellowship. So, we’re talking into the double digits of [years of] schooling and commitment to [neuropsychology]. I think the biggest part was that I was more worried what other people were going to think of me for making this change. Thinking about looking around the room at my professional colleagues who have all these letters after their name and saying, ‘Hello, I’m going to be working on a YA fantasy novel.’ Just being able to believe in myself that I could do this and that I was not less-than for making a change—that was a challenge.

I’ve had some people ask, ‘Do you think you chose the wrong career? Do you think you went into the wrong field?’ Never. I love the education I got, I love the experiences I had, and the people that I connected with. Honestly, I don’t think I’d be writing the books that I am if I hadn’t had those experiences. We never know how things are going to play out ever. I’ve become so much better about trusting my instinct, listening to myself, and just going for it. I’m trying to be a little less of a Type-A Capricorn and a little more just go with the flow.

BrainWise: Can you please tell us a little about the series and what the enduring storylines are all about?

Keridan: In the first book, Reign Returned, we have an enemies-to-lovers story, because I’m a huge fan of [stories where] there’s all this conflict and we hate each other, [and then,] surprise, we’re actually going to fall in love. I’m a big fan of tropes in general. Some people will say they’re cheesy, I also say there’s a reason why they sell, and if it ain’t broke, don’t fix it. So, in the first book, we have a former king and queen who, before they die, bind their souls together and promise to return when it’s time to retake their kingdom and find one another. Centuries pass, they’re both reborn, but they come back with no knowledge of who they used to be, and they come back on warring sides. The first book is really about remembering the past in order to change the future. The second book comes around and my main characters have remembered their past, they know who they used to be, they know that they’re back and they’re ready to reunite the realms, but it’s not going to be that easy because…well, what would be the fun in that? So, they are back, and their arch enemy is back as well. This is really a story of found family, of figuring out who you are and who you want to be and gathering the support that you need in your life to make that happen.

BrainWise: Have you written the third book yet?

Keridan: Yes. The third book is currently undergoing proofreading. Without going into all the details here, with book three, I’m a huge fan of happily ever after, so I can tell you there is going to be a happily-ever-after. Our characters learn, they grow, family secrets are discovered, betrayals are survived. But in the end, as we always hope it does, good wins out and triumphs. [The book is scheduled to come out in October 2024.]

BrainWise: Now that your first series is behind you, what’s next?

Keridan: I’m working with an organization called The Novelry, because my next project is a middle grade book. This one is near and dear to my heart because my main character in this book is an 11-year-old girl with high-functioning autism. It’s a contemporary book, so it’s set in the present day, but there is a little bit of a dash of magic in there. I am incredibly excited. I’ve loved the young adult, YA, fantasy world, after three books, I needed a break because that’s a lot of plot lines and characters and layers to work through. I’m about three-fourths of the way done with this next book, and it will be for younger readers, which I’m really excited about.

[Another one] of the things I’m really excited about for 2024 and beyond is to have the opportunity to do more teaching. I am very fortunate that I have some fun events lined up for 2024, such as the San Diego Writers Festival. There’s a couple of different things that I can’t mention yet because they’re still potentially in the works. Writing is such a solitary activity. I mean, in the midst of it, it’s me with my laptop just sitting here with all these characters in my head. So, when I can get out in the real world and start connecting with readers and seeing people face-to-face, that’s so much fun. And I love that chance to interact and to hear something that they enjoyed about a book or a character.

BrainWise: To what extent are you keeping up with what’s happening in the world of neuropsychology?

Keridan: I could never fully disconnect from the brain community, no matter what. Even if I hit No. 1 on The New York Times Best Seller list, I will still be reading what’s happening with neuropsychology and especially pediatric neuropsychology. Any kind of breakthroughs involving kids, anything specifically related to oncology or autism or intellectually gifted kids who also have clusters of other things going on, I’m always paying attention to that and reading what I can because we need breakthroughs now more than ever. Especially since the pandemic, what kids have been facing from a mental health perspective, I don’t think we’ll fully even begin to understand it for years to come. But kids need services and support more than ever.

BrainWise: Do you ever see yourself going back into neuropsychology full-time?

Keridan: You just never know. I never thought I’d be sitting here doing this right now. But I will say I’m not actively seeing patients, I’m not actively taking on any cases or doing any neuropsychological testing at this point. Who knows? I would love to find a way to combine [writing and neuropsychology], whether it’s at a college-level class, to be able to talk about books and reading and brains and how this all goes together. Or it might just be a workshop that I put out. I’m going to think about that.

BrainWise: In conclusion, what advice can you offer others who are contemplating a career change, whatever their current careers might be?

Keridan: There comes a point where we have to decide, who are we living for? Are we living this life to make other people happy and do what we think they think we should do, or are we living this life for ourselves and figuring out how can we make the greatest contribution and connect with people? For me, growing up, books were an escape, they helped me stay sane. When I couldn’t leave the situation I was in, at least I could mentally check out and I had friends in books. That’s what I want to offer people today. Like saying, ‘Here’s a safe place where you can see someone, they might not be just like you, but there’ll be similarities and you can see yourself reflected on that page.’ We need more of that, it’s priceless.

This essay has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.

The science behind inattentional blindness

in Featured/by Sridhar Pappu

The video—the now-famous video—is riveting. The “gorilla” struts in with unbelievable coolness. It’s a walk that still radiates with purpose and virality, even now, a quarter century later. Of course, the beast has no problem moving through these two groups—six people in all—now moving around one another, passing basketballs in an otherwise empty hallway.

They mean nothing to this creature. It has nothing to fear. It is the great gorilla. Or rather, as the world later came to know, the woman in the gorilla suit.

Finally, the real show begins. As the players go about their business, the gorilla stops to stand at the center. Turning its attention to us, the beast beats its chest. With that, it walks away. There’s no need to stay longer. The gorilla has shown it is the true star. Or that it was the star, at least to 50 percent of the 12 people who were watching on this particular video display.

For the other 50 percent taking part in this 1999-year study, the proud, costumed beast never existed. Instead, study participants had focused solely on the task given to them—counting how many times those in white shirts passed the basketball between them.

But how? And why?

The inability to see an important, disruptive force in this type of situation is known as “Inattentional Blindness”—a term defined by Arien Mack and Irvin Rock in their 1998 book of the same name, a year before the gorilla came on and off the stage in a study titled “Gorillas in our midst: Sustained Inattentional Blindness for Dynamic Events,” conducted by Daniel Simons and Christopher Chabris at Harvard University.

Of course, there’s no “real” blindness here. Nothing’s medically wrong with those who failed to notice the peculiar primate. Those who ignored the gorilla simply could not see it—they were blind to anything they didn’t expect, or couldn’t account for in this setting.

Origins of studies in ‘blindness’

The famous gorilla study was a replication of a 1979 study led by Urlic Neisser (summarized in this book chapter). In his version, the teams were filmed separately and partially transparent and overlapping. Here, those watching were asked after if they had seen a ghostly woman carrying an umbrella.

Following the original study, scientists had assumed results were due to unusual displays and other possible outliers. Put differently, they assumed people missed the umbrella woman because the displays were ghostly and strange.

But a gorilla? Something fully visible? Filmed with a single camera shot? Research has shown that people are more likely to have their attention drawn to stimuli that are meaningful to them (like their own name) during a selective visual attention task.

Still, it seemed unlikely that people would miss a gorilla.

“That’s actually one of the things that probably made it go viral,” said Dr. Simons, a professor of psychology at the University of Illinois, Urbana-Champaign, where he runs its Visual Cognition Laboratory. “You can be in a room with a few people when only half of them see it.

Dr. Simons continued: “We knew that people can miss things. If you make something subtle enough, nobody will see it and nobody will care. But if people miss something that that’s visible enough that people would say, ‘Oh, yeah, of course, I would see that,’ then it becomes interesting. What’s interesting is not just that people miss things, but that people are convinced that they would see it. Mismatch between what people see and what they think they’ll see is why inattentional blindness can have practical consequences.”

(For a hilarious documentary-style video about the study, click here.)

When focusing matters most

It should be a good thing: Our ability to focus on the task at hand. As Dr. Simons said, our ability to focus our attention on the things that actually matter to us while ignoring everything else is what allows us to function.

“People sometimes ask how they can train themselves to always spot the gorilla,” Dr. Simons said. “You can’t, though—and even if you could, you wouldn’t want to. We need to be able to focus and avoid constant distraction.”

Sometimes this ability to focus has costs. The gorilla study showed that inattentional blindness can strike at any time. A later study, titled, “Did you see the unicycling clown? Inattentional blindness while walking and talking on a cell phone,” led to the same finding.

“If people are convinced that they’re going to notice when something unexpected happens, then they’re not going to take the precautions that they might need to,” said Dr. Simons. As an example, he said that when you’re driving and talking on the phone, if you’re convinced that you’d automatically notice if something important happened, you might take unnecessary risks like texting and talking on the phone.

“Even if your eyes are on the road, that doesn’t mean you’re necessarily going to see everything,” Dr. Simons said. “Most of the time, inattentional blindness doesn’t have huge consequences [but] every now and then it does—especially when we’re doing things that our visual system wasn’t really designed to do.”

Dr. Simons noted that traveling in a vehicle at 60 mph is one such activity. At this speed, he said, even a one- or two-second delay due to blindness can be huge. It can be the difference between having a fatal accident and avoiding one.

“I think that’s where intuition causes the biggest problems,” he says. “The most common kind of crash between a car and a motorcycle is the ‘look-but-fail-to see.’ That has all the hallmarks of inattentional blindness: Somebody’s turned left in front of an oncoming motorcycle and claims never to have seen them.”

That’s not to say that those experiencing inattentional blindness miss everything. Dr. Arien Mack, co-author of the “Inattentional Blindness” book and the Alfred and Monette Marrow Professor of Psychology at The New School for Social Research in New York City, said there is evidence (in this paper, for instance) of an unknown awareness from which we can build.

“While you are not conscious that you’ve seen anything, there is evidence that in fact the thing you did not see was processed below the level of consciousness in the brain,” Dr. Mack said. “If it’s a word [someone] didn’t see, for example, and you give them a word stem in which that word is a possible completion—and maybe an unlikely completion—they will more likely complete the word stem with the word that was there, even though they didn’t consciously see it.”

Evolution of blindness

The stakes for inattentional blindness have only grown since the gorilla came into our lives (or didn’t) in the late 1990s. The clunky cellphones handed out by consulting firms and dotcom 1.0 startups were just coming into widespread use. AOL—and a home-base landline—controlled our access to the internet. Our lives, however crazed, remained siloed.

Chabris and Simons chronicled these changes in their 2010 book, “The Invisible Gorilla.” Simons also speaks freely about this evolution. His perspective: Technological advancements changed everything.

“We have good intuitions about some things and not about others,” Dr. Simons said. “You know you can’t chew gum and whistle and talk at the same time. They use your mouth in conflicting ways. We don’t realize that the kind of visual attention and attention to a conversation also use the same sorts of resources in the same sorts of ways. So, we might think, ‘Oh, I can talk on the phone while I’m driving just fine. But we don’t realize we’re impaired because we don’t realize [these activities] are using the same cognitive resources.”

What Dr. Simons is really saying: Becoming aware that you can miss something as obvious as a person in a gorilla suit is impactful in that it makes you think about how much else you might be missing. Once you realize that you won’t automatically notice everything important, then you can take steps to think about how you’re using up the limited attention you have.”

The study of inattentional blindness has undergone real refinement over the decades. Researchers like Dr. Simons have moved studies away from videos to more computer-based analogs. This has allowed for the study of the timelines—when the disruptor showing up has an effect—and similarities to the objects already on the screen.

What’s next

Dr. Simons and his colleagues have also drilled down to this key question: Is there anything that might predict those who will notice that rough beast who walks onto the screen and those who continue to count the basketballs? Kind of like a biomarker, only for how we see the world.

So far, researchers have not found stable, individual differences that predict noticing.

“When we’ve looked, we haven’t found much evidence for differences between people who do and don’t notice unexpected objects,” Dr. Simons said. “At some level, that makes sense given that people aren’t actively looking for things that they don’t expect. At some level, who notices and who doesn’t might just be a matter of chance rather than a stable ability to notice unexpected things.”

Perhaps, said Dr. Simons, the lack of identifying characteristics for those who experience inattentional blindness is a good thing.

“We’re all subject to the same limitations,” he said. “Even if people vary a little bit in how well they can focus attention. That doesn’t really make a huge difference for the detection of unexpected things.”

Of course, this also raises the value and warrants mention of the fallibility of eyewitness testimony. Our minds are not tape or video recorders encoding every detail of our experience without fail; our brains and minds are interpreting our experience with “filters” for personal and emotional salience of that information. Thus, eyewitness testimony is generally considered to be subjective at best.

The reality is that our minds can miss critical details even when they might be glaringly obvious to others. If we are paying attention to something that matters to our brain, is that something supporting or refuting someone’s innocence or guilt erroneously or accurately? And how will our experience in that moment impact our connection to what we perceive to be the truth?

These are complicated questions with complicated answers. They’re worth consideration, with or without a gorilla in the room.

This essay has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.

Body photo provided by Dr. Daniel Simons; Simons, D. J., & Chabris, C. F. (1999). Gorillas in our midst: Sustained inattentional blindness for dynamic events. Perception, 28, 1059-1074.

My experience treating depression with magnetic waves

in Featured, Highlight/by Sandra Haney

Editor’s note: Sandra Haney lives in Waynesboro, Virginia, and recently turned to Transcranial Magnetic Stimulation (TMS) to treat chronic depression. BrainWise Managing Editor Matt Villano wrote this story in her voice after an extensive interview with her about the experience. For more on the science of TMS, click here.

Depression is like an old friend at this point; I’m 41 years old, and I’ve been dealing with depressive episodes since I was about 15.

It was episodic early on. Things came and went. I had more prevalent anxiety than I did depression. Pretty severe panic attacks. Really frequent intrusive thoughts of death—not so much suicidal ideation but more thoughts about my eventual demise. Throughout my teens and twenties, I did therapy. I tried tons of different medications. Some worked a little. Most didn’t. There were a lot of side effects. I was about 28 when I found a combo of meds that worked: Paxil and Wellbutrin. I still had lots of side effects.

By the time I was 32, I said, “This is ridiculous.” I was tired all the time. I had gained about 30 pounds. Finally, I did a GeneSight test. It turned out I have a very rare triple copy of an enzyme called CYP2D6. That makes me an ultra-rapid metabolizer, which means roughly 80 percent of medications won’t work on me like they should. I metabolize them too quickly.

It’s not a great thing to have if you’re battling depression like I am.

When I learned about being an ultra-metabolizer, when I realized that meds basically weren’t going to work for me, I started thinking about Transcranial Magnetic Stimulation (TMS). From what providers had told me, this is a type of treatment that can work for people who can’t do meds—people like me. I didn’t know anybody who’d done it TMS. I did some research. I got a packet of literature. That was basically it—at the time, I was deeply depressed and could barely make it to my appointments, much less seriously consider something like that. So, I didn’t pursue it.

Fast-forward to 2022. I started sleeping extremely poorly. I was getting more and more depressed. I had a severe bout of anxiety that lasted for four months. As the anxiety subsided, I started experiencing suicidal ideation. It was becoming more and more severe. It reached a point where things were going south quickly. I talked to my psychiatrist. Together, we decided it was time to give TMS a try.

I started the treatment in August. I finished in October. All told, I did 37 sessions. And it helped. But more on that later.

Understanding the basics

When you get the treatment, a machine sends magnetic waves through your skull into your brain. The idea is to stimulate neurons to change the way they’ve handled things in the past—kind of like rewiring the brain. For more about the science behind it, check out the sidebar that BrainWise published in conjunction with my story.

My TMS sessions started out at 21 minutes long. By the end they were at 31 minutes. It’s kind of boring to sit there while the treatment is happening. The doctors told me I needed to stay fully conscious. They let me talk. There was a TV in the room so I could watch TV. They were clear that they wanted me to keep my brain active.

Every time I went it felt like an electric zap. Like a static shock. There was no sense of pain. It was like tapping against my head. This may just be my own imagination, but I could swear I felt it going through my skull. I know the brain has no pain receptors, so maybe that’s impossible.

During the sessions I didn’t really experience any kind of change in thought processes or perception. I also didn’t experience any emotional effects. Initially there were headaches and a sense of really deep fatigue. That lasted the first two weeks. After that the immediate effects were a little brightening. My mood improved a little bit each time. It wasn’t a long-term thing; I felt better for a little while, and as the day wanes, my mood dropped back down. For me, it was all about the cumulative effect.

Side effects

After 4 treatments I had some interesting effects occur. One night, after cooking an elaborate dinner, I was sitting on the couch and, suddenly, it felt like I could smell everything. It felt like my sense of smell had been dampened that whole time and, suddenly, it had come into focus. It was like until the TMS treatment, I was smelling things at about 25 percent of what they were. The super smell lasted for about an hour each time, and then things went back to baseline. They say a lot of your senses get dampened with depression. I now know that’s real.

Another thing that happened during treatment: I started experiencing these perception switches. I would go from one state of mind to another. The switches occurred every 15 to 30 minutes. The only way I can describe what it felt like was to compare it to when I did acid a few times and ate mushrooms as a kid. The perception shift you get when you’re under the influence of those chemicals—that’s what it felt like for me.

Later in the treatment cycle I started to get very irritable and very angry. I’d have these mini bouts of rage that would last for 30 seconds or so each time. That was disturbing. Everybody in the house was jumpy and avoiding me. The cats were like, “We’re out of here!” I was told by the lead TMS tech that that was a good sign, that my brain was creating new neural connections and that’s what was causing the irritation. Most people experience a depressive episode in the first three weeks, but some people experience anger. That was difficult to deal with.

The suicidal ideation faded in the first week and a half. It faded out quickly. I don’t know if that was what was happening in my brain—something the machine was doing—or if it was the fact that I was getting help and I was actively doing something to improve things. I was looking at living and improving my health and having hope instead of thinking about ending things. That alone was worth everything.

Charting progress

Over the course of my treatment, there were several markers I used to evaluate how it was going.

The first were the markers from the doctor’s notes. Every Friday I did one of the DSM questionnaires about depression and anxiety. The doctor kept those scores. Over the duration of the treatment, the doctor said my scores decreased depression-wise by about half and anxiety-wise by about a little more than half. The reduction in anxiety was the biggest thing I noticed. The other thing is that I found myself to be more motivated, more hopeful and a little more energized. The reduction in anxiety has been fantastic. Suicidal ideation disappearing has been fantastic. Depression has decreased, for sure. They said I would start sleeping better, but I didn’t. I’m a lifelong insomniac.

I have mixed emotions about this progress. I was hoping for more. At the same time, I know my expectations were unrealistically high and the whole time I fought to bring my expectations back to reality. I had to come to terms with the fact that this is something that will improve things so that I can further improve on my own. It’s like the treatment gave me a toehold so I could get moving in the right direction.

My doctor said things would continue to improve for about two months after the last treatment finished. I’ve also read that each TMS treatment cycle lasts about a year, and that after the year it really varies wildly. About a month later I’m still seeing improvement.

I also recognize that I’m lucky to have insurance. This treatment runs anywhere from $12,000 to $16,000. With my copay it was $980. This is what my specific insurance company and specific insurance plan required before approving TMS. I’m sure requirements are different from company to company, and even plan to plan within the same company.

After dealing with depression for most of my life, this feels like having a future. A lot of possibilities are now open that weren’t open before. My husband and I have been planning trips. We’re talking about going to Iceland and Finland. We talked about doing a bunch of different things. I feel much more excited and motivated to do that. I feel more excited to live.

Spreading the word

I kept a journal about my experiences. Once a week, I shared these journal entries with my friend list on Facebook. The entries were straightforward. Here’s what’s going on with me. Here’s what’s happening. Here’s what it’s been like. People were really interested. After my journal entries, I have been contacted by phone and through Facebook by people who are either interested in TMS for themselves or for loved ones.

I would recommend TMS. Even if TMS doesn’t work for someone at all, I encourage people to try something. Depression is not a way to live well, and it can end in your demise. For me, TMS felt like going to the moon, doing something totally unknown and super frightening. At first, I felt like I was being a coward, but now I see the opposite is true. I can recognize it as being brave. The stigma around mental health is decreasing, which means more people are talking to each other about depression. Hopefully that means more and more people will start talking about TMS to help.

This essay has been factchecked by members of NAN’s Publications Committee. For more about that process, click here.

How social connections can improve brain health

in Blog/by BrainWise

Social connection is a fundamental human need, as essential to survival as food, water, and shelter. It’s also critical to brain health.

One of the missions of the National Academy of Neuropsychology (NAN) is to make facts about brain health available to as many people as possible. Our recent quick tips video spotlights the importance of social connection to brain health and healthy living.

The video can be found on the new Brain Health Hub section of the NAN website.

The video opens with some sobering facts. Loneliness and social isolation are considered epidemics by the US Surgeon General. Some surveys have found that one in two American adults—especially younger adults—report experiencing loneliness. A lack of social connection has been considered as dangerous as smoking up to 15 cigarettes a day.

The good news? We humans can change and increase our social activity over time. Three aspects of social connectedness seem to matter most: 1) the number and variety of relationships in our lives, 2) how often we interact with others, and 3) how satisfying our relationships and interactions with others are. In addition, science has shown us that developing meaningful friendships, nurturing them, and maintaining regular contact with friends and family members can stimulate our brain, reduce stress, and slow decline in our thinking skills.

Put differently, having meaningful connections, including having supportive listeners in our lives, matters.

Not only does it feel good to share a difficult day with a supportive friend, but it also helps preserve our thinking abilities. If you’re not very socially active, it’s a good idea to consider ways to become more active, such as reaching out to a friend for a coffee meet-up, joining a hiking or walking club, joining a book club, or volunteering in your community.

Having a socially active lifestyle has physical benefits too, such as a lower risk of heart disease and a better chance of living longer.

We all need positive social relationships for our brain health. Remember that a little kindness, a friendly chat, staying connected with those we already know, and embracing new connections can do wonders for our brains.

Former NAN President quoted in Reader’s Digest story about intelligence

in Blog/by Matt Villano

While most members of the National Academy of Neuropsychology (NAN) are at the annual conference in Philadelphia this week, former NAN President Dr. John DeLuca is proving that, figuratively speaking, the organization is everywhere.

DeLuca, a neuropsychologist and senior vice president for research at the Kessler Foundation, was quoted extensively in a recent Reader’s Digest article about intelligence. The story, titled, “What is IQ and how well does it predict success?” appeared in the print edition of the magazine, and also was published on the Reader’s Digest website earlier this month.

In the story, DeLuca said each IQ test measures a slightly different set of cognitive skills. Some of these skills include verbal reasoning, math, visual-spatial reasoning, processing speed and working memory. DeLuca noted that IQ also measures verbal and nonverbal aspects of intelligence.

Specifically, he noted that IQ tests measure an overall intellectual factor, which has been referred to as a “g.” DeLuca said, “A lot of things go into that factor, but ‘g’ is the idea of this overall intelligence.”

From here, the story provided a bit of history about Intelligence Quotient, or IQ, tests.

Author Laurie Budgar quoted an expert from MENSA International, which is an organization created by and for those individuals who score in the top 2 percent of all administered IQ tests. (Essentially, it’s a high-IQ society.)

The story also explained that when IQ tests were first developed in 1912, the IQ score was meant to reflect the ratio (or quotient) of a person’s “mental age” divided by their chronological age and then multiplied by 100. To provide an example of how this might work, a person whose chronological age was 10 and who also tested at a mental age of 10 would have an intelligence quotient of 100.

But IQ is about much more than intelligence. DeLuca, who is based in New Jersey, went so far as to say that, contrary to popular belief, IQ tests actually do not determine how smart you are.

“An IQ test will tell you if you have some level of overall intellectual ability,” DeLuca said. “Does it mean you have common sense? No. It means you have an ability to process information at a high level. It doesn’t mean you’re smart in everything you do. Einstein [may have] had a high IQ, but it doesn’t mean he was able to, for example, make good decisions about his financial life.”

The article also provided information about how traditional IQ tests are scored—on a bell curve, with that same score of 100 reflecting average intelligence.

DeLuca was the source who explained how IQ takes age into account. He said it’s normal for certain aspects of intelligence to change over time, and noted that cognitive processing speed at age 20 is likely to be a lot faster than it will be at age 50.

He also took the opportunity to discuss the intersection of intelligence and neuropsychology.

Specifically, in reference to the concept of cognitive reserve, DeLuca told the author: “People with a lifetime of highly intellectual stimulation will create a brain that’s more resistant to disease—not necessarily resistant to getting the disease or progressing in that disease, but resistant to the outcome of it. A person may be less likely to become demented even if they develop Alzheimer’s.”

To see if you can pass the world’s shortest IQ test, click here. For more on DeLuca’s work at the Kessler Foundation, click here.