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ner
The Memory Maximizer
Turning Memory Loss on its Head
Introduction 1

Types of Memory Impairment 4

Causes 16

Brain Injuries 17

Tumors 30

Stress 39

Medications 47

HIV and other Infections 59

Alcohol 66

Stroke 76

Hypertension 86

Hypothyroidism 91

Nutrition and Brain Health 97

Choline 98

Caffeine 107

Interview with a Dietician 115

Iron 116
 Antioxidants 121

Omega-3 Fatty Acids 131

Vitamin D 138

Saturated and Trans Fats 145

Sugar 149

Nutritional Recommendations 154

Dietary Supplements 166

Ginkgo Biloba 167

Curcumin 171

Huperzine 178

Sage 183

Conclusion 187

Summary 188

Don’t Forget about Exercise! 190

Glossary 192
 Over the last couple of years, my mom has become increasing-
Introduction ly more forgetful. Up until a week ago, I just assumed it was
typical age-related absent-mindedness. But when I received a
Memory is a way of holding onto the things you love, the things you
are, the things you never want to lose. frantic phone call from my mom while she was shopping at a
— Kevin Arnold.
market, I began to worry it was something more. She was call-
When The Way We Were came on the radio, the coincidence ing because she was lost…at a market that she had visited
struck a chord in me. The song reminded me of when I was a countless hundreds of times.
young boy. It was one of my mother
"I don't know how to get home!" she
Jenny's favorites. She was always
yelled. There was panic in my moth-
singing it. She had a beautiful voice
er's voice.
and she would fill our home with
harmony, especially while she was "Whoa, calm down, mom," I asked

cooking. The sound of her smoky her where she was.

voice and the savory aroma of the

Jenny whispered. "I don't know."
food she would prepare, are embed-
There was a long pause before she
ded forever in my memory. Ironical-
continued. "I'm looking at the name
ly, listening now to the hauntingly
of the store. It's called Darby's."
beautiful song composed by Marvin Hamlisch with lyrics by
Alan Bergman and Marilyn Bergman spoke to the heart of my I couldn't understand what my mom was talking about. The

fears regarding my mother. supermarket was just three blocks from her home and she had

1
been going there for years. “Please come and get me,” she
pleaded.
"Okay, okay. I'm on my way."
I left the office right away, canceling
all my afternoon appointments and
drove quickly to where Jenny was
waiting. As I hurried toward her, I
turned on the car radio. That's when
I heard the familiar melody and the
haunting lyrics:
Memories, light the corners of my mind. Misty, water-colored
memories of the way we were. Scattered pictures of the smiles
we left behind. Smiles we gave to one another for the way we
were. Can it be that it was all so simple then? Or has time re-
written every line? If we had the chance to do it all again, tell
me, would we? Could we? Memories may be beautiful and yet
what's too painful to remember, we simply chose to forget. So
it's the laughter we will remember whenever we remember the
way we were.
Perhaps no other song in the English language speaks so poig-
nantly about our ethereal connection to memory and every-
thing those recollections represent
to us. The music's fatalistic nuance
combined with mystical lyrics in-
stantly resonates in our hearts, filling
the listener with nostalgia and me-
lancholy about events in the past
that can never be changed. The
poignantly crafted song performed
by Barbara Streisand for the movie
The Way We Were was named by Billboard as the number one
pop hit of 1974.
Listening to the lyrics, now, as I drove towards Jenny, left me
feeling overwhelmed with emotion. How could she not realize
where she was? She wasn't a drinker, and she wasn't taking
any prescription medication, so why was she so confused. As
the song on the radio continued to play, I was flooded with
memories. In my mind's eye, I could see a younger version of
2
my mother: vital and confident, the sound of her voice filling
our family home with happiness and song.
Sitting behind the wheel of the car, I couldn't stop thinking
about how deceptively subjective our memories are. Often
shrouded in our personal perceptions, changing over the
course of time, they shift like desert sand, taking on new
shapes and forms with time.
When I arrived at Darby's, Jenny was sitting in front of the su-
permarket on a park bench. Pulling up beside her I could see
that she had been crying; fresh tears were still streaming from
her eyes. After stopping the car, I hurried to her side.
"I don't know what's wrong with me," she blubbered and
sobbed.
Opening my arms, I blanketed Jenny with a hug. "It's going to
be alright."
After she had calmed down, I gathered all the groceries she
had purchased and loaded them into my car and helped mom
into the passenger's seat. Once we drove about a block from
the supermarket, Jenny seemed to regain her orientation.
"I know where I am now." The look of apprehension on my
mother's face was replaced with relief. "Thank god, I was get-
ting a little nervous."
"Well, I still am nervous," I shook my head. "As soon as I get
you home, I'm going to call your doctor."
Jenny regarded me sheepishly, "I think that might be a very
wise idea."
3

Types of Memory Impairment
We don’t remember days, we remember moments.
— Cesare Pavese
It's best to be proactive. That's what I kept telling myself when
I began investigating the types of memory impairments that
exist. It filled me with fear and trepidation.
So many of the conditions alarmed me.
The last thing I wanted for my mother was
for her to be diagnosed with a debilitating
cognitive condition. So in spite of the an-
xiety my research was causing me, I plod-
ded on determined to learn everything I
could about cognition and memory. I owed
it to Jenny to learn everything I could
about memory loss.
Memory impairment is not always the same. On occasion,
memory loss may undermine our ability to remember things
that have happened a long time ago, while on other occasions,
we may be unable to recall the list of grocery items we just
composed. But not being able to remember a word or some-
one’s name occasionally is very different to those frightening
instances when entire segments of a person's past are forgot-
ten.
Memory is so much more than just remembering specific
events; its nuance is vastly more complicated. It's also about
recalling information that we have
learned, such as writing, speaking, and
driving. Such activities become second na-
ture to us and as a consequence, we can
do them without investing any hard
thought about the action. It's natural to
have the occasional memory loss, as it is
part of the natural aging process, but there
are also other more severe forms of mem-
ory loss resulting from such conditions as
Alzheimer’s disease that are not part of
normal aging. Being less physically active, uncontrolled di-
abetes, surging cholesterol levels, high blood pressure, not
engaging in stimulating brain activities, and a lack of social in-
4
teraction can all contribute to cognitive decline and contribute
to the advance of diseases such as Alzheimer’s (Fox 2011).
But, because all of these risk factors are things that can be
changed, it is possible to reduce your risk and decrease your
chances of developing cognitive problems (Fox 2011).
Hippocrates, the granddaddy of medical ethics, specifi-
cally the Hippocratic Oath, wrote many texts on the
brain. Born in 470 BC, Hippocrates was the first known
scientist to conclude that the two halves of the brain in-
dependently performed processing tasks, a behavior he
termed "mental duality".1
Normal Aging
As people start to age, transformations
occur that are not only external (on the
outside of a person), such as changes in
skin, hair, etc but many age-related
changes occur internally (on the inside) as
well. An important point to remain aware
of is that during normal aging, the decline
in cognitive abilities occurs slowly. Also, not all types of
memory are affected to the same extent.2,3 As people age,
they tend to be less attentive than they once were, and it can
take a longer time for them to process information.3 Although
these events occur naturally, it does not mean that everyone
will suffer from memory problems, or that each person will be
affected the same way.
Some brain functions, such as procedural functions, remain
relatively stable as we age. Examples of procedural functions,
include making a cup of tea, our ability to read and write, and
how to drive a car.2 Certain learned elements, such as vocabu-
lary, also tend to improve over the years.2 However, when it
comes to memory-related tasks, such as math calculations or
remembering a grocery list, age can defi-
nitely have a negative impact.2 Spatial
memory is also often impaired as we age.2
Another fact to remember about healthy
aging is how our brain cells die as we age.
Now don’t worry, not a huge amount of
5
brain cells die off, and new brain cells do continue to grow as
we age.2,4 Glial cells (neuroglia cells), which are involved in
helping or preventing recovery from injury in the brain, actual-
ly increase as people age.4,5 This means that as we age, there
are mechanisms that are naturally put in place that can help
us cope with injuries that may occur to the brain.
According to a 1998 text penned by NC Berchtold and
CW Cotman in The Neurobiology of Aging, little ad-
vancement in the understanding of dementia occurred
after the insights of the ancient Greeks and Romans. Ad-
vances in the understanding of the subject of dementia
were made in the 13th century when English philosopher
Francis Bacon authored Methods of Preventing the Ap-
pearance of Senility. Berchtold and Cotman concluded
that Bacon may have been one of the first few people in
that period to recognize dementia as a brain disease. The
authors note that it is also an increasingly accepted no-
tion that many victims of witch trials, who were drowned
or burned at the stake, may have been suffering from
6
dementia.
Mild Cognitive Impairment (MIC)
When people have difficulties with memory but their cognitive
functions remain relatively intact, the condition is known as
mild cognitive impairment (MCI).7 Individuals with MCI are not
severely impaired, so they are still able to lead normal lives.8
This transitional state of cognitive changes and memory prob-
lems happens when normal aging meets dementia or Alzhei-
mer’s disease.9 However, MCI is not always seen as a transi-
tional state.10 Often people who are experiencing it, as well as
their friends and family, are able to notice that something is
off.9 Despite the fact that individuals coping with mild cogni-
tive impairment do not meet the requirements to be diag-
nosed with dementia, generally within two to three years,
20%-50% of individuals with MCI may develop dementia.7
The hippocampus and the
amygdala, two parts of the
brain, are known to be in-
volved in memory-related
emotional content.11 Unfortunately, rapid degeneration
of the hippocampus has been observed in people with
6
 MCI and Alzheimer’s disease.12 Degeneration of the hip- decline in their cognitive abilities, which can eventually result
pocampus can be detected before cognitive impairment in a loss of their independence (Prince 2013).14 Some forms of
occurs. This degeneration can be detected about three dementia include 14,15:
years before an MCI diagnosis and six years before Alz-  Alzheimer’s disease
heimer’s disease is diagnosed.12  Vascular dementia
 Parkinson’s disease dementia
Mild cognitive impairment can be accompanied by several
 Frontotemporal dementia
symptoms; some of them include 13:
 Lewy body dementia
 Finding it difficult to navigate familiar places
 Multi-infarct dementia
 Forgetting things more frequently
 Mixed dementia
 Difficulty making decisions
 Wernicke-Korsakoff syndrome (explained in the alcohol
 Difficulty finishing a task
chapter)
 Loss of train of thought in the middle of a conversation
 Difficulty making proper judgment calls Alzhemier’s disease

Changes are not only noted by the individual, but also by fami-
ly, friends, and coworkers
Dementia
There are many types of dementia, a clinical syndrome that
comes about due to neurodegenerative changes in the brain
(Prince 2013).14 As dementia progresses, people experience a
With 5.5 million people in the United States affected by Alz-
heimer’s disease, it is the most prevalent type of dementia in
the entire world.12 When someone has Alzheimer’s disease,
their cognitive functions start to deteriorate leading to a state
where the person loses their independence.16 Various genes
are associated with the development of Alzheimer’s disease.16
A neurotransmitter called acetylcholine, which is important
7
for working memory, attention, and information processing,
among other cognitive functions, is also found to be decreased
in persons with Alzheimer’s disease.17 However, acetylcholine
has not been linked to long-term memory.17 In Alzheimer’s
disease, there is an accumulation of certain proteins in the
brain: the amyloid β protein and an abnormal form of the tau
protein.18 These proteins form plaques and neurofibrillary
18
tangles (tangled nerve fibers), respectively.
During the early stages of Alzheimer’s disease, individuals may
or may not notice any changes. Those who do notice a change
may realize, initially, that they are struggling to remember re-
cent events. The deterioration does not happen at the same
pace for everyone and may affect different cognitive domains,
such as memory, personality, behavior, planning, thinking,
reasoning, etc. Some of the symptoms may include 19:
 Misplacing their things
 Repeating questions that have already been asked
 Difficulty remembering how to play a favorite game
 Trouble remembering the correct word to identify things
 Getting lost in well-known places
 Experiencing depression, social withdrawal, irritability,
apathy, mood swings,
 Forgetting appointments
 Burning food while cooking
 Difficulty concentrating
 Sleeping habits might change
 Forgetting conversations
 Forgetting names of loved ones
 Forgetting names of objects used daily
 Difficulty handling finances
 Challenges related to bathing and dressing
8
 Loss of inhibitions Vascular dementia
It is important to note that as the Alzheimer's disease
This type of dementia is usually caused by conditions that
progresses, the individuals will begin to lose learned skills,
have caused problems in the blood flowing to the brain. As a
such as dancing, singing, reading, making crafts, and enjoying
consequence, the brain does not get sufficient oxygen and the
music (Mayo Clinic Alzheimer’s).19
required nutrients that it needs to function optimally.20 There
are a number of causes that can lead to this condition (they
will be discussed in the causes section of the book). Usually
people with vascular dementia experience 21:
 Restlessness
 Trouble making decisions regarding what to do
 Confusion
 Depression
 Issues with memory
 Problems with gait
 Have trouble organizing thoughts
In conditions where there is degeneration of the brain,
 Agitation
the ventricles (areas of the brain that contain cerebros-
 Have trouble analyzing a situation
pinal fluid), are seen to enlarge.12
 Problems with attention
 Problems concentrating
 Trouble executing a plan
9
Parkinson’s Disease Dementia member how to get to or from one place to another as well as
allowing us to differentiate shapes).25 One of the characteris-
Parkinson’s disease is a movement disorder. Symptoms gener-
tics in the brains of those with Parkinson’s dementia is depo-
ally include, but are not limited to, slowed movement, a shak-
sits of a protein called α-synuclein (a protein that is found
ing or tremor in the limbs, and muscle rigidity.22,23 Additional-
throughout the brain) as well as plaques and neurofibrillary
ly, cognitive changes and dementia have been detected in
22
tangles (tangled nerve fibers). 15,26
people with Parkinson’s disease as the disease advances. Pa-
tients with Parkinson’s disease have a six times greater chance Dementia with Lewy Bodies
of developing dementia than individuals who do not suffer
After Alzheimer’s disease, dementia with Lewy bodies is the
from the disease. Also, the person’s age, combined with the
second most frequent type of progressive dementia. A com-
intensity of the associated symptoms further increases the
mon symptom that accompanies dementia with Lewy bodies,
likelihood of acquiring dementia.22,24
is the experience of visual hallucinations. These hallucinations
Overall, 40% of people with Parkinson’s are affected by include the perception of animals, objects, and other people
dementia.25 who are not actually present.27 Problems with movement such
as those seen in Parkinson’s disease may also be evident.27,28
When patients with Parkinson’s suffer from dementia, there is
Other problems that accompany this type of dementia are
impairment in some of their cognitive abilities. Problems with
problems with attention, confusion, sleep problems, depres-
their long-term and working memory occur, and they are no
sion, and ultimately memory loss.27,28
longer able to learn and remember procedural tasks. They also
have difficulties with visuospatial memory (a type of memory Another interesting phenomenon with this disease is the ex-
that helps us do things, like navigate through a city and re- cessive daytime drowsiness sufferers may experience. Individ-

10
uals with the condition may also have orthostatic hypotension
(when blood pressure is lowered significantly as a person gets
up from a lying or sitting position).28 The reason why this type
of dementia is called dementia with Lewy bodies is that in
20%-35% of the people who have this form of dementia, Lewy
bodies are found in the brain during an autopsy.28 Despite the
similarities that Lewy body dementia shares with Alzheimer’s
disease, people who have Lewy body dementia have more
problems with attention and visual perception.28
Lewy bodies, pictured above, are abnormally formed
proteins that are found in the brain cells.29
Frontotemporal Dementia
Frontotemporal dementia is a condition that affects the front
and temporal lobes of the brain. About 20% of dementias are
thought to be the frontotemporal type.30,31 Individuals with
this condition typically present with behavioral changes, the
most pronounced characteristic present during the course of
the disease's advance.32 Examples of some behavioral changes
include being distracted, difficulty taking care of themselves
(low hygiene), inflexible and rigid thoughts, putting objects in
their mouth.32 Other difficulties that are seen, include lan-
guage impairment and difficulties with executive function,
changes in how they behave in social contexts, and personality
changes.32 In addition to problems in memory and behavior,
physical symptoms also manifest. These symptoms, include
incontinence, low blood pressure, rigidity, akinesia, and tre-
mors.32
11
Frontotemporal dementia tends to progress gradually. The
onset of the disease happens at such a slow pace that the per-
son is not aware of it at first.32 These individuals also lack in-
sight early into their disease and also suffer from emotional
blunting.32
Multi-infract Dementia
Multi-infarct dementia is a type of dementia that occurs as a
consequence of multiple strokes. People suffering from this
type of dementia might not even be aware that they have suf-
33
fered a stroke. When the brain doesn’t receive ample blood
flow as a consequence of strokes, damage occurs in the brain
tissue.33 There are many risk factors for stroke, which can
eventually lead to multi-infarct dementia (which we will get to
in later chapters). When someone gets multi-infarct dementia,
it happens abruptly, and if certain risk factors such as high
34
blood pressure are controlled, people may improve. In addi-
tion to problems with memory, symptoms of multi-infarct
33
dementia usually include :
 getting lost (even in well-known places)
 crying or laughing out of context
 inability to follow directions
 losing control of their bladder and bowels
 confusion
Ekbom syndrome is when people have delusions that
small living thing, such as insects are living under their
skin. Thinking that insects are crawling on them, these
people start to scratch, pick, and even use scissors to at-
tack their skin in an attempt to get rid of the imagined
pests. One of the associated organic conditions is de-
mentia; other conditions, such as brain tumors, depres-
sion, diabetes, have also been linked to Ekbom syn-
drome.35
Mixed Dementia
When a person has features of more than one type of demen-
tia, usually Alzheimer’s and vascular dementia, the term mixed
dementia is used to describe the condition.36 However, Alz-
heimer’s disease with Lewy body dementia or Parkinson’s dis-
ease would also be considered mixed dementia.36 More often
than not, clinical features that are seen in Alzheimer’s disease
12
and vascular dementia tend to occur simultaneously.37 When Conclusion
autopsies were performed on individuals who suffered Alz-
Of course, I am scared of the diagnosis that the neurologist is
heimer’s disease, many had features of vascular dementia in
going to return with once the proper tests and examinations
the brain.37 There seems to be evidence pointing to vascular
are run upon my mother. But I've always believed that in or-
disease as being the initial problem, which leads to a series of
der to be an effective problem solver you need to arm yourself
events that may ultimately cause Alzheimer’s disease. Similar-
with as much information you can gather on the dilemma so
ly, the clinical features of Alzheimer’s can increase the risk of
that the most comprehensive solution can be made. That's
vascular dementia.37 Also, it has been proposed that oxidative
why I have made a commitment to learning everything I can
stress causing damage to the DNA may also be a contributing
about memory loss. When it comes to my mother's health, I
factor to mixed dementia. So, it may help to incorporate anti-
will leave no stone unturned, no matter how disturbing are
oxidants to treat this condition.38
the facts that I dig up!
Free radicals are notorious culprits in a broad range of
diseases, but can be neutralized by antioxidants (e.g. Vi-
tamins A, C, E). Oxidative stress is the state in which
there is a shift in balance between the antioxidants and
free radicals.39

13
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14
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2010;4(8):118.

15
Causes

16

Brain Injuries
If any one faculty of our nature may be called more wonderful than
the rest, I do think it is memory….The memory is sometimes so re-
tentive, so serviceable, so obedient – at others, so bewildered and so
weak – and at others again, so tyrannical, so beyond control! –We
are to be sure a miracle every way – but our powers of recollecting
and of forgetting, do seem peculiarly past finding out.
— Jane Austen, Mansfield Park
Although golf is my favorite game to
play, football is by far my favorite sport
to watch. During autumn, once the NFL
is in full swing, I often find myself glued
to my television on Sundays, gravitating
towards the strategy, violence, grace,
and poetry that is football. Even in the
off-season, I am always surfing the net
searching for the latest NFL news.
So last March, just after the start of free agency and just a few
weeks before the 2016 draft, the NFL finally shifted its long-
held position that there was a lack of conclusive evidence link-
ing football players to chronic traumatic encephalopathy
(CTE). The fact that the league was now acknowledging how
repeated blows to the head resulting in concussions and brain
traumas can contribute to degenerative cognitive disorders,
was big news to me. The fact that many of the athletes I ad-
mire are putting their brains at risk playing the game I love to
watch, disturbed me. So, as I continued reading everything I
could on the subject, noting how players who suffer from CTE
often exhibit symptoms of rage, memo-
ry loss, and advanced dementia, I
couldn't help but think of Jenny and her
recent memory lapses.1
I racked my brain trying to recall
whether or not my mother had ever
suffered a head trauma. Back when I
was seventeen years old, I remember
Jenny was involved in a car accident,
but she had been protected by her car's
airbags and didn't suffer a scratch.
17
What is Traumatic Brain Injury?
A traumatic brain injury (TBI) results from an external injury to
the brain, commonly due to a fall (often seen in older individ-
uals), an accident (such as car accidents), a knife or gunshot
wound.2,3 As a consequence of the wars fought in Iraq and
Afghanistan, we have also become increasingly aware of blast-
induced traumatic brain injuries in military personnel. Athletes
who play contact sports (e.g. football, hockey or boxing) fre-
quently experience a mild form of TBI, known as chronic
trauma encephalopathy or CTE.3
Did you know that women are twice as likely to suffer
from concussion compared to men.4,5
I learned that traumatic brain injuries are a ‘silent epidemic’
because many people are unaware of the changes in their mo-
tor, somatosensory, and cognitive functions that have oc-
curred as a result of the injury.4 Domains of cognition that are
affected, include speed of information processing, memory,
executive function, and attention.6 At times even when the
injury is thought to be mild, some patients with a TBI demon-
strate impairment in all four of these domains.6
Traumatic brain injury is a public health issue in young adults
and teenagers because it directly affects their development
and performance in school and work.7,8 Approximately 1.7 mil-
lion Americans are affected with TBI annually, and nearly 5.3
million Americans suffer long-term consequences relating to
those injuries.3 Worldwide, approximately, 6.8 million cases of
TBI are reported annually.6
Research studies note that there is an increased risk of de-
mentia in individuals who sustain a TBI. Numerous studies
have observed that individuals suffering from just one mild TBI
(MTBI) may not have their cognitive functions affected or de-
velop dementia as a consequence.9
A “Hidden” TBI is a condition where a patient suffers
from cognitive issues but does not realize that these dif-
ficulties may be caused by a previous TBI. Because the
patient is not able to make the association, the physician
18
 needs to be vigilant to ensure that the correct treatment
is prescribed.10
People who suffer from TBI are more prone to psychological
conditions, such as panic attacks, depression, alcoholism, sub-
stance abuse, phobias, bipolar disorder, and schizophrenia,
amongst other things. Coincidently, it was also noticed that
individuals with a history of TBI were more often on welfare
and suffering from a combination of emotional and physical
problems.10

Fun Fact: It appears that King Henry VIII may have suffered from TBIs, the same kind experienced by ath-
letes who play contact sports. Evidence from Henry VIII’s letters indicates that he suffered from two major
head injuries when he was in his 30s. In 1525, he fell head first into a brook that he was trying to jump
across with a pole. He was knocked unconscious as a consequence! Eleven years later, in 1536, he was
knocked out for 2 hours during a jousting match when a horse fell on him. Henry VIII became known for his
violent temper, memory loss, headaches, and insomnia after 1536;11 and scientists at Yale believe that the
king's drastic behavior changes may have been the consequence of the potential brain injuries that he sus-
tained when he was knocked unconscious.11

Mild traumatic brain injuries account for 70% to 90% of
the TBI cases that are treated.7 A leading cause of injury-
related disability and death, in the United States, mod-
erate to severe TBI is seen in 500 out of every 100 000
persons.4
What are the different types of TBI?
TBIs are classified as focal or diffuse. In a focal TBI, the injury is
localized to a specific area leading to a subdural hematoma or
a contusion. In a diffuse TBI, the physical impact results in an
injury throughout the brain. The severity of a traumatic brain
injury is classified based on many factors, such as the Glasgow

19
coma scale, the level of consciousness, and whether or not with PCS, include anxiety, fatigue, depression, dizziness, atten-
there is an occurrence of amnesia following the trauma.3,4 tion, and memory issues.3,7

Individuals can suffer from different types of TBI. Those who Second impact syndrome
suffer from severe or moderate TBI tend to experience long-
As the name suggests, this concussion occurs following an ini-
term cognitive issues.3 On the other hand, people who suffer
tial TBI. A second impact, during the period when the symp-
from mild traumatic brain injury (MTBI)
toms of the initial TBI are not resolved,
return to their normal selves after ap-
may cause edema and elevated pres-
proximately 3 to 12 months following
sure in the brain. It often leads to coma
the injury, without complications. How-
and death in the individual. It is fre-
ever, there are some individuals (~15%)
quently seen in athletes, especially
with an MTBI, who suffer from persis-
those under the age of 20.4
3,7
tent complications.
Cerebral Edema occurs when the
Did you know that chronic traumatic
amount of water in the brain is increased due to condi-
encephalopathy (CTE) was initially known as dementia
tions, such as metastatic cancers, ischemic strokes, or
pugilistica or 'punch drunk' since the condition was origi-
TBIs, to name a few.12
5
nally identified in boxers?
Symptoms of TBI - The Signs
Post-concussion syndrome
There is usually no evidence of any injury to the brain struc-
The complications that arise due to MTBI are classified as
ture as a consequence of an uncomplicated concussion. The
post-concussion syndromes (PCS). The symptoms associated
20
severity of the concussion depends on how hard the head was
hit, when the injury occurred, and/or the level of force upon
impact. After a concussion if the person remains confused for
more than a day or loses consciousness for over half an hour,
it is no longer considered a concussion; instead it is called an
MTBI. Symptoms of a concussion, include amnesia, confusion,
dizziness, imbalance, headaches, nausea, vomiting, and inabili-
ty to coordinate movements.13
 blank stare
It is important to note that if the person has any preexisting
bleeding within the skull (known as an intracranial hemorr-
hage) or bruised brain tissue (a contusion), the concussion will
be more severe.13,15,16

Cognitive functions such as the speed at which we

process information, learning, and memory, and execu-
tive functions (e.g. planning, reasoning, attention) are
affected by a TBI.14
Diagnosing TBI – Digging up Clues
Impairment in memory and confusion may develop imme-
diately after the trauma, or they may gradually start appearing Computed tomography (CT), magnetic resonance imaging

over the next few minutes following the injury. Confusion (MRI), and positron-emission tomography (PET) can often

presents itself in several ways: detect TBI’s that are moderate to severe in intensity. Mild
TBIs, however, are harder to detect with these testing me-
 delays in speech and movement
thods.17,18
 disorientation
 trouble concentrating and paying attention

21
But diagnostic biomarkers and neuromonitoring are some of
the other ways of diagnosing TBIs. If required and when di-
rected by a clinician, neuropsychological assessments are rec-
ommended.19
Computed Tomography Scans and Magnetic Resonance Im-
aging
Computed tomography (CT) scans and magnetic resonance
imaging (MRI) are ideal for helping the physician visualize
moderate or severe TBI’s because they can detect structural
damage in the brain. CT scans are usually available for use and
cost less than an MRI scan.18 Hematomas, skull fractures, and
swelling of the brain can be detected with CT scans.18
Computed tomography scan (left) and magnetic reson-
ance imaging (right)
When it comes to identifying lesions from a TBI, magnetic re-
sonance imaging (MRI) is more sensitive than CT scans. MRI
does not use radiation. Rather, it uses a powerful magnetic
field to visualize images from various parts of the body.18,20 An
MRI is not able to identify new hemorrhages and bone dam-
age as well as CT scans, proving that both methods have their
pros and cons.18
Electroencephalograms (EEG)
An electroencephalogram measures the electrical activity in
your brain with the help of metal discs attached to the scalp
with a sticky paste, and the machine converts these signals
into waves that can be seen on the computer screen.21 Elec-
troencephalograms can be used to detect any underlying
problems that persist even after the symptoms of TBI are re-
solved.17,22
22
Fun Fact: German psychiatrist Hans Berger advanced the understanding of the brain when he developed the first
electroencephalograph in 1929, an instrument designed for recording electrical brain waves. An electroencephalograph (EEG) is also
known as the brainwave test. Berger’s invention was a breakthrough that provided a new and unique neurological, psychiatric
diagnostic tool. It continues to be routinely applied today as a diagnostic test in psychiatry, brain research, and neurology (Tudor
2004, mybrain.co.uk).23,24

Positron Emission Tomography

Positron Emission Tomography (PET) scans use radioactive

substances (tracers) to collect in areas of the body, which
show irregularities in their functions. In the case of the brain,
glucose is used as a tracer since the brain needs glucose to
function. The tracer lights up as bright spots once it accumu-
lates in the affected area.25,18 Brain activity (glucose uptake)
can be measured with PET scans, and health care profession-
als can detect regions of the brain that are not functioning
properly.18

23
 Explosive shock waves are
an unseen force that can
contribute to a TBI on the
battlefield. Though soldiers
are protected from shrap-
nel by wearing appropriate body armor, the shock waves
resulting from explosions can cause injury to the brain by
creating tiny bubbles (called microcavitations) in the
brain. The symptoms of these shock waves are head-
aches, memory loss, and even post-traumatic stress dis-
order.26,27
Biomarker diagnostic features of TBI
In the case of TBI, the biomarkers are proteins in the blood,
cerebrospinal fluid (CSF), urine, and saliva.18,22
Sometimes a person may not necessarily display the appropri-
ate symptoms, and the CT scan may not show any abnormali-
ties. So biomarkers provide information on the exact condition
being detected and the specific area where the injury oc-
curred.18
Neuropsychological Tests
The clinician will recommend neuropsychological tests, if ne-
cessary, for certain reasons, such as confirming the capability
of being a guardian, to be able to work, or to be able to live
independently. In adults with severe or moderate TBI, the as-
sessments need to be performed in the first six months follow-
ing injury while for those with mild TBIs, the tests are recom-
mended when symptoms of injury appear or 3 months after
the injury.28
Self-Awareness Tests
Many individuals are unaware of their cognitive deficits after a
brain injury. They are often in denial regarding the problems
or they become distressed when they are reminded of their
issues. When it comes to brain injury, an individual is said to
be self-aware if they are capable of recognizing that they do
have some deficits due to the injury, accept that the deficits
are interfering with their day-to-day activities, and when they
are setting goals regarding the future by taking those cognitive
limitations into account.29
24
Such individuals can compare their self-awareness with the  Diuretics are drugs, which increase the production of
ratings of a health professional, a relative, or a task output. urine and decrease the amount of fluid contained in tis-
sues.22 These drugs are used by people with TBIs in order
Pharmaceutical treatments – Fixing the Problem
to reduce the pressure on the brain and are given intra-
Brain injury due to the biochemical changes that occur as a venously. It’s important to note that diuretics often come
result of trauma to the brain is referred to as secondary with a host of side effects, such as potassium deficiency or
22
injury. To prevent secondary injuries, certain medications excess, low sodium as well as abnormal acid levels in the
can be used immediately following the brain body.22
injury.22  Medications that induce comas may be given
to people who have had a TBI; this is to give
 Anti-epileptic drugs (anti-seizure drugs or anti-
the brain a break and allow it rest, remain inac-
convulsants) are used to treat seizures in indi-
tive, and use less oxygen. The excess pressure
viduals with TBI of a moderate or severe inten-
in the brain may make it hard for the blood
sity. Since these individuals are at risk to de-
vessels to transport ample oxygen or nutrients
velop seizures in the first week, anti-epileptic
to the brain cells.22 So by giving these coma-
drugs may be administered after the trauma to
inducing medications, the brain does not re-
prevent potential brain damage, which can be
ceive the blood that it normally requires. However, it will
caused by a seizure.22 If seizures do occur, these drugs
be protected.22
may be prescribed again. Some of the medications, in-
clude levetiracetam (LEV), vigabatrin, zonisamide, and
phenytoin.22

25
Future therapies – What does research say?  Stem cell-based therapies that use stem cells for regene-
ration of brain tissue is another exciting form of
 Antioxidants, such as melatonin, resveratrol, and tempol
research.19
may be useful in treating TBI, according to research stu-
 Nanotechnology-derived drug therapies where chemical
dies.19
molecules are injected into the brain can induce tolerance
 Similarly, hypothermia, where the body temperature is
among the cells to future shocks.19
kept at a temperature between 89and 93F, appears to
 Cognitive remediation are behavioral techniques that are
reduce the swelling in brain cells while also decreasing the
taught to people to help them deal with difficult problems
metabolism in the brain. However, there have been con-
or tasks.30 The use of music in cog-
flicting reports on the effectiveness
nitive remediation is slowly gaining
of hypothermia, and more data is
popularity as a technique to help
required to confirm the potential
patients with TBI. When music was
therapeutic use of hypothermia.19
used in patients early on after the
 Hormones, such as progesterone
TBI, they were seen to be more
and erythropoietin, are also being
responsive, which led to better
touted as potential therapeutic
outcomes.30
candidates. These hormones appear to have a beneficial
neuroprotective effect in TBI patients. However, better
research methods need to be utilized to confirm their ef-
fectiveness in TBI.19

26
Conclusion When I mentioned all the reading I had been doing about
traumatic brain injuries, I wondered if my mom may have ever
After spending an entire weekend researching everything I
suffered a head injury. "I've been trying to remember if mom
could on traumatic brain injuries, I telephoned my older sister,
ever seriously hurt her head." I paused. "I remember the car
Sarah. She is seven years older than me and as a consequence,
accident she had when I was a teenager... but she miraculous-
her memories of the distant past that we shared are much
ly survived that without a scratch."
clearer than mine.
"Thank God for airbags," Sarah chimed.
Although Sarah lives two states over, she and Jenny are still
very close. Sarah visits five or six times a year, and they spend "Do you remember if mom ever injured her head?"
countless hours on the phone each week. As concerned as I
"Not that I can recall."
am regarding our mother's mental health, we talked for more
than an hour sharing opinions about what we believed was
the cause of Jenny's failing memory.

27
References
1. Belson K SA. N.F.L. shifts on concussion, and game may never be the same. 2015.
2. Newman D LA, MSKTC. Cognitive Problems After Traumatic Brain Injury.
3. Walker KR, Tesco G. Molecular mechanisms of cognitive dysfunction following traumatic brain injury. Front Aging Neurosci. 2013;5:29.
4. Laskowski RA, Creed JA, Raghupathi R. Pathophysiology of Mild TBI: Implications for Altered Signaling Pathways. In: Kobeissy FH, ed. Brain
Neurotrauma: Molecular, Neuropsychological, and Rehabilitation Aspects. Boca Raton (FL)2015.
5. Mez J, Stern RA, McKee AC. Chronic traumatic encephalopathy: where are we and where are we going? Curr Neurol Neurosci Rep. 2013;13(12):407.
6. Irimia A, Wang B, Aylward SR, et al. Neuroimaging of structural pathology and connectomics in traumatic brain injury: Toward personalized outcome
prediction. Neuroimage Clin. 2012;1(1):1-17.
7. Cancelliere C, Cassidy JD, Cote P, et al. Protocol for a systematic review of prognosis after mild traumatic brain injury: an update of the WHO
Collaborating Centre Task Force findings. Syst Rev. 2012;1:17.
8. Carroll LJ, Cassidy JD, Peloso PM, et al. Prognosis for mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild
Traumatic Brain Injury. J Rehabil Med. 2004(43 Suppl):84-105.
9. Smith DH, Johnson VE, Stewart W. Chronic neuropathologies of single and repetitive TBI: substrates of dementia? Nat Rev Neurol. 2013;9(4):211-221.
10. Silver JM, Kramer R, Greenwald S, Weissman M. The association between head injuries and psychiatric disorders: findings from the New Haven NIMH
Epidemiologic Catchment Area Study. Brain Inj. 2001;15(11):935-945.
11. M T. Traumatic Brain Injury Links Football Players to King Henry VIII. 2016.
12. Raslan A, Bhardwaj A. Medical management of cerebral edema. Neurosurg Focus. 2007;22(5):E12.
13. Kushner D. Mild traumatic brain injury: toward understanding manifestations and treatment. Arch Intern Med. 1998;158(15):1617-1624.
14. Kinnunen KM, Greenwood R, Powell JH, et al. White matter damage and cognitive impairment after traumatic brain injury. Brain. 2011;134(Pt 2):449-
463.
15. Clinic C. Intracranial hemorrhage, cerebral hemorrhage and hemorrhagic stroke. 2013.
16. Center CUM. Cerebral contusion and intracerebral hematoma.
17. Irimia A, Van Horn JD. Functional neuroimaging of traumatic brain injury: advances and clinical utility. Neuropsychiatr Dis Treat. 2015;11:2355-2365.
18. Zhang J, Puvenna V, Janigro D. Biomarkers of Traumatic Brain Injury and Their Relationship to Pathology. In: Laskowitz D, Grant G, eds. Translational
Research in Traumatic Brain Injury. Boca Raton (FL)2016.
19. Reis C, Wang Y, Akyol O, et al. What's New in Traumatic Brain Injury: Update on Tracking, Monitoring and Treatment. Int J Mol Sci. 2015;16(6):11903-
11965.
20. Radiological Society of North America IR. Head MRI (Magnetic Resonance Imaging). 2015.
21. Shelat AMMME. EEG. 2015.
22. Lu C, Xia J, Bin W, Wu Y, Liu X, Zhang Y. Advances in diagnosis, treatments, and molecular mechanistic studies of traumatic brain injury. Biosci Trends.
2015;9(3):138-148.
23. Tudor M, Tudor L, Tudor KI. [Hans Berger (1873-1941)--the history of electroencephalography]. Acta medica Croatica: c̆asopis Hravatske akademije
medicinskih znanosti. 2004;59(4):307-313.
24. MyBrain. A short history of brain research. 2016; http://goo.gl/ui7Yvb. Accessed June 06, 2016.
25. Staff MC. Positron emission tomography (PET) scan. 2014.
26. News-Medical. ONR researcher explores how explosive shock waves contribute to traumatic brain injury. 2016.
28
27. Sun S, Kanagaraj J, Cho L, Kang D, Xiao S, Cho M. Characterization of Subcellular Responses Induced by Exposure of Microbubbles to Astrocytes. J
Neurotrauma. 2015;32(19):1441-1448.
28. Authority MA. Neuropsychological assessment of children and adults with traumatic brain injury.
29. Fleming JM, Strong J, Ashton R. Self-awareness of deficits in adults with traumatic brain injury: how best to measure? Brain Inj. 1996;10(1):1-15.
30. Hegde S. Music-based cognitive remediation therapy for patients with traumatic brain injury. Front Neurol. 2014;5:34.

29
 lon, lungs, brain, thyroid, prostate, and breasts, etc. We all
Tumors know the effects of such tumors. While some tumors do not
tend to grow at a fast pace, there are others that grow at a
"The horror of that moment,” the King went on, “I shall never,
never forget"“You will, though,” the Queen said, “if you don’t phenomenal pace and consume the individual.1-3
make a memorandum of it.”
— Lewis Carroll, Through the Looking-Glass While we all are conscious that tumors exert harmful effects in
the areas where they appear, did you know that they can
All during this ordeal concerning my
cause memory loss? That is what Kairol
mother's memory, I have had my fin-
Rosenthal discovered after she was di-
gers crossed that her 'senior moments'
agnosed with thyroid cancer at the age
are not symptoms of something like
of 37. In her 2009 article in the New
dementia or cancer. But while we wait
York Times, Rosenthal noticed that her
on her neurologist all I can do is arm
memory was failing her in numerous
myself with as much knowledge I can
casual situations. However, she was
wrap my brain around. So once I began
aware that there is limited research that conclusively links
reading about the relationship between tumors and cognitive
cancer with memory loss, especially when it comes to non-
function, I discovered an enormous amount of hard science
brain tumors like thyroid cancer.4
that links the two together. In this chapter, you will learn what
I discovered. Since Kairol Rosenthal’s memory began failing in 2009, there
has been an increased interest in the potential effects of tu-
A tumor is an abnormal growth of cells in the body. Tumors
mors and their treatments on cognitive functions like memory
are found in different parts of the anatomy, including the co-
loss. Tumors exert effects not just on the physical well-being
30
of the body but also affect the mental health or cognitive
functions of the person.
Did you know that the state of an individual's cognitive
abilities affects the quality of life (social parameters) of
that individual?5 Cognitive health can also be an indica-
tor pointing to the outcome of a disease, such as cancer.6
Memory Loss
The way tumors affect memory depends on the type of tumor.
Sometimes, it is not the tumor but treatments, such as sur-
gery, chemotherapy, radiation, and medications, which affect
memory. However, it is not clear how these treatments affect
memory or if they have a significant, long-term effect on it.7
It has been observed that survivors of cancer who are
older than 55 years of age are more prone to deficits in
their cognition, especially memory loss.6
It is becoming increasingly clear that the cognitive functions of
people with brain tumors is an important indicator of the state
of the brain or the effect of the cancer treatment on the
brain.8
In a survey of multiple oncology centers funded by the Na-
tional Cancer Institute, a significant proportion of patients suf-
fering from gastrointestinal, breast, head and neck, prostate,
lung, and hematologic cancers complained of memory loss
and lack of concentration. Many of them suffered from these
problems before therapy acknowledging that their problems
became worse following either radiation or chemotherapy or
a combination of both.9
Did you know that cognitive functions can be an indica-
tor of tumor recurrence in certain brain tumors even be-
fore an MRI is performed?7 Similarly, cognitive functions
can provide an indication of the survival rate of patients.
Neurocognitive factors are used to assess the effective-
ness of treatments in patients with brain tumors.10
Brain tumors
Brain tumors or central nervous system (CNS) tumors are as-
sociated with reduced cognitive abilities, including attention
31
and memory. The quality of life (personal and professional) of toma multiforme show attention disorders, depression, and
these individuals is profoundly affected.5 verbal difficulties.14

Brain tumor patients tend to experience a change in their cog- Did you know that melanoma, breast, lung, and renal
nition that is not restricted to the region of the tumor alone. 11 cell carcinoma commonly spread to the brain?5
Brain tumors (e.g. gliomas, meningiomas, primary CNS lym-
Radiation
phomas) can affect memory by spreading within the healthy
tissue of the brain.12 The tumors also affect nerve connections Radiation treatments for brain tumors affect the white matter
located both away from and within the tumor. The changes in (nerve fibers and the external covering) in the brain. It is pre-
the structure and the function of the area surrounding the cisely in this nerve tissue that many of the brain networks op-
tumor may also influence the other parts of the brain.11 erate. So, damage to the nerve tissue causes problems with
attention, processing pace, learning issues, and motor move-
Cognitive deficits are mild in primary brain tumors (gliomas,
ments. Radiation effects are influenced by:
meningiomas). In brain tumors that have developed as a result
 The type of radiation treatment (whole brain radiotherapy
of other cancers, such as melanoma, lung cancer, and breast
or conventional radiotherapy)
cancer, the cognitive defects are proportional only to the size
 The characteristics of the individual receiving the radia-
of the tumor and not to the number of tumor sites within the
tion
brain.5
 The use of additional therapies, such as chemotherapy7
Different parts of our brain control various aspects of our
memory.13 For example, patients with tumors in the left he-
misphere of the brain and those with the tumor type glioblas-

32
Chemotherapy
The chance of developing cognitive difficulties following che-
motherapy is estimated to be 3.3 to 3.5 times higher than with
untreated patients.6 Chemotherapeutic drugs can affect areas
of the brain and cause impaired cognitive functions, including
memory problems. Cognitive functions affected by chemothe-
rapy have been observed in 17% to 75% of the patients.7
Medication
Drugs are used to treat brain tumors or brain diseases. While
they do treat the tumors, they also have a negative impact on
cognition. Hence, older medications that were prescribed to
treat seizures (antiepileptic drugs) have the potential to re-
duce cognitive function. One drug in particular, known as Be-
vacizumab and which may help stave off the progression of
brain tumors, seems to contribute to a continuous decline of
cognitive function.5 However, newer antiepileptic drugs have a
more positive effect on cognition.5
Treatment
Rehabilitation programs and medical treatment
Radiation in the range of 50 to 54 Gy (Gray – unit of mea-
surement for radiation) is considered a safe level to avoid
cognitive problems, including memory loss. Another way to
prevent or delay the development of cognitive problems is to
use this therapy following chemotherapy and not to combine
the two treatments together. This technique reduces the ad-
verse effects on cognitive function and appears to be effective
in maintaining cognitive behavior.12
Rehabilitation programs or combined drug and psychological
treatments are also useful in preventing the decline of cogni-
tive functions.5
Non-brain Cancers and Memory Loss
Research into the treatments of other cancers, such as breast,
colorectal, and prostate cancers has identified cognitive de-
cline in cancer patients. Some of them experience cognitive
33
decline before treatment, while others experience issues with
cognition after their treatment.
Breast Cancer
Chemotherapy
When breast cancer patients are treated with chemotherapy,
there is a noted reduction in their cognitive faculties. This ef-
fect is observed many years after the discontinuation of che-
motherapy. However, the exact process by which chemothe-
rapy affects cognitive abilities is not entirely clear. There are
no apparent risk factors. However, the dose appears to cause
the deterioration of cognitive functions.5
Did you know that approximately, 20% to 60% of breast
cancer patients note that their cognitive functions are af-
5
fected due to chemotherapy?
Researchers have also observed that it is helpful to assess the
cognitive state of patients before they go in for chemothera-
py, so that any significant changes in cognitive function that
result as a consequence of chemotherapy can be easily identi-
fied. The patient’s social and clinical features play a major role
in influencing cognitive function since the drugs work diffe-
rently from individual to individual.15
Did you know that “chemobrain” is a term coined by the
press to indicate the reduction in cognitive functions that
occur due to chemotherapy?16
Another way that chemotherapeutic drugs, such as 5-
fluorouracil or methotrexate, can affect memory is by causing
changes in the white matter of the brain in much the same
way as radiation does.7,17 A breast cancer study found that pa-
tients treated with cyclophosphamide, methotrexate, and 5-
fluorouracil (CMF) showed a decline in cognitive functions,
such as memory, attention, and information processing speed.
21% of 39 patients displayed problems with their memory. On
the other hand, hormonal treatment, depression, exhaustion,
no treatment, or anxiety, did not have any observed effect on
the cognitive functions of breast cancer patients.17
What needs to be kept in mind regarding chemotherapy is
that when it is used along with another treatment, such as
34
surgery, or hormone therapy, it may increase the likelihood of
cognitive impairment.16
Did you know that cognitive decline varies from individ-
ual to individual? While some may be affected long term,
others do not suffer to the same degree. Australian sing-
er Kylie Minogue complained of temporary short-term
memory loss while undergoing chemotherapy for her
breast cancer.18
Hormone treatment
Hormone therapy has also been found to affect the region of
the brain that controls memory and other motor functions.
Women treated with anti-estrogens have been diagnosed with
impaired memory function.7
Small-cell lung cancer
It has been observed that 70% to 80% of patients with small-
cell lung cancer demonstrated memory loss without any
treatment.7
Chemotherapy
Research has shown that patients with small-cell lung cancer
showed increased damage to the white matter (including the
nerve fibers and external covering) and enhanced cognitive
deficits following chemotherapy.19
Colorectal cancer
Although some studies have looked into the general quality of
life of colorectal cancer patients, there is no conclusive evi-
dence regarding the effect of chemotherapy on memory loss.
The overall consensus is, however, that colorectal cancer pa-
tients do suffer from some degree of memory loss.6
Australian researchers that conducted research on colo-
rectal cancer patients introduced the term “Cancer
brain” to replace the traditional term “Chemobrain”
since patients suffered from memory loss irrespective of
chemotherapy.20,21
35
Prostate cancer
Prostate cancer is treated with hormones or chemotherapy
based on the stage of the disease. Although in certain cases,
memory appears to be impaired, there are no concrete con-
clusions about the effects of hormones or chemotherapy on
memory in relation to prostate cancer.6
Hormone treatment
7
Testosterone appears to improve cognitive functions in men.
Perhaps that is why memory is impaired when men with pros-
tate cancer are treated with androgen-suppressing hormones
that stop the production of testosterone.22
Chemotherapy
Prostate cancer patients receiving chemotherapy also suffer
from memory loss. One study has highlighted nearly 16 che-
6
motherapeutic agents that affect memory.
Melanoma
Cytokine therapy
Cytokine treatment (e.g. interferon therapy) is used to treat
melanoma patients.7,23 Patients treated with cytokines tend to
develop cognitive issues in the areas of attention, memory
and diminished learning capacity, among others. More than
half the patients that receive cytokine therapy, experience a
decline in their cognitive functions.7
Interventions to Improve Memory
Although there are numerous tests to help individuals suffer-
ing from memory loss, such memory interventions are still in
the early stages of development. Research data on these tests
have found them to be helpful in improving many aspects of
cognition, such as memory, the speed of processing, and
mood changes. Some of these tests include the following:6
 Memory and Attention Adaptation Training (MAAT)
 Rivermead Behavioral Memory Test (RBMT)
 SeniorWISE
 Hopkins Verbal Learning Test (HVLT)
36
 Cognitive Behavioral Model of Everyday Memory But if my mother's moments of confusion are caused by can-
(CBMEM) cer, at least I can take comfort in the fact that research linking
 Brief Visual Memory Test (BVMT) tumors and cognitive functions have increased over the past
decade. It is now acknowledged that along with fatigue, de-
Conclusion
pression, and anxiety, cognitive functions are an important
After reading countless articles on the subject, I could safely side effect of tumors and their treatment.
assume that Jenny's bouts of memory loss and confusion were
So with improved tests and the greater involvement of physi-
not caused by any cancer therapies, but that did not mean
cians, the healthcare support system as well as family mem-
that cancer could be ruled out as a cause of her cognitive
bers, cancer patients will be able to deal and manage their
troubles. Unfortunately, it is a waiting game now. Once the
memory loss more efficiently than ever before.
neurologist has a chance to run some tests and study the re-
sults, we'll be in a better position to know what comes next.

37
References
1. Dutt SS, Gao AC. Molecular mechanisms of castration-resistant prostate cancer progression. Future Oncol. 2009;5(9):1403-1413.
2. Hanahan D, Weinberg RA. The hallmarks of cancer. Cell. 2000;100(1):57-70.
3. Stoler DL, Nowak NJ, Matsui S, et al. Comparative genomic instabilities of thyroid and colon cancers. Arch Otolaryngol Head Neck Surg.
2007;133(5):457-463.
4. Rosenthal K. When Cancer Muddles the Mind. Well. Vol 2016: New York Times; 2009.
5. Schagen SB, Klein M, Reijneveld JC, et al. Monitoring and optimising cognitive function in cancer patients: Present knowledge and future directions.
EJC Suppl. 2014;12(1):29-40.
6. McDougall GJ, Jr., Oliver JS, Scogin F. Memory and cancer: a review of the literature. Arch Psychiatr Nurs. 2014;28(3):180-186.
7. Wefel JS, Kayl AE, Meyers CA. Neuropsychological dysfunction associated with cancer and cancer therapies: a conceptual review of an emerging
target. Br J Cancer. 2004;90(9):1691-1696.
8. Taphoorn MJ, Klein M. Cognitive deficits in adult patients with brain tumours. Lancet Neurol. 2004;3(3):159-168.
9. Kohli S, Griggs JJ, Roscoe JA, et al. Self-reported cognitive impairment in patients with cancer. J Oncol Pract. 2007;3(2):54-59.
10. Meyers CA, Hess KR, Yung WK, Levin VA. Cognitive function as a predictor of survival in patients with recurrent malignant glioma. J Clin Oncol.
2000;18(3):646-650.
11. Bartolomei F, Bosma I, Klein M, et al. How do brain tumors alter functional connectivity? A magnetoencephalography study. Ann Neurol.
2006;59(1):128-138.
12. Behin A, Hoang-Xuan K, Carpentier AF, Delattre JY. Primary brain tumours in adults. Lancet. 2003;361(9354):323-331.
13. King TZ, Fennell EB, Williams L, et al. Verbal memory abilities of children with brain tumors. Child Neuropsychol. 2004;10(2):76-88.
14. Hahn CA, Dunn RH, Logue PE, King JH, Edwards CL, Halperin EC. Prospective study of neuropsychologic testing and quality-of-life assessment of adults
with primary malignant brain tumors. Int J Radiat Oncol Biol Phys. 2003;55(4):992-999.
15. Wefel JS, Lenzi R, Theriault RL, Davis RN, Meyers CA. The cognitive sequelae of standard-dose adjuvant chemotherapy in women with breast
carcinoma: results of a prospective, randomized, longitudinal trial. Cancer. 2004;100(11):2292-2299.
16. Wefel JS, Lenzi R, Theriault R, Buzdar AU, Cruickshank S, Meyers CA. 'Chemobrain' in breast carcinoma?: a prologue. Cancer. 2004;101(3):466-475.
17. Schagen SB, van Dam FS, Muller MJ, Boogerd W, Lindeboom J, Bruning PF. Cognitive deficits after postoperative adjuvant chemotherapy for breast
carcinoma. Cancer. 1999;85(3):640-650.
18. R E. Can cancer drugs harm your memory? Patients complain of mental problems after chemo. 2009.
19. Simo M, Root JC, Vaquero L, et al. Cognitive and brain structural changes in a lung cancer population. J Thorac Oncol. 2015;10(1):38-45.
20. Vardy JL, Dhillon HM, Pond GR, et al. Cognitive Function in Patients With Colorectal Cancer Who Do and Do Not Receive Chemotherapy: A Prospective,
Longitudinal, Controlled Study. J Clin Oncol. 2015;33(34):4085-4092.
21. J L. 'Cancer brain' not 'chemo brain': Researchers discover bowel cancer can cause memory loss. ABC News. http://goo.gl/ZwbwAZ. 2015. Accessed Jan
27, 2016.
22. Green HJ, Pakenham KI, Headley BC, et al. Altered cognitive function in men treated for prostate cancer with luteinizing hormone-releasing hormone
analogues and cyproterone acetate: a randomized controlled trial. BJU Int. 2002;90(4):427-432.
23. Trask PC, Esper P, Riba M, Redman B. Psychiatric side effects of interferon therapy: prevalence, proposed mechanisms, and future directions. J Clin
Oncol. 2000;18(11):2316-2326.

38

Stress
Memory is the mother of all wisdom.
—Aeschylus
Jenny is a worrier. My mother always has been inclined to-
wards such behavior. But her fretful ways have worsened ever
since she retired. I think it's because
she has too much time on her
hands, and her compulsion to worry
is often left unchecked.
Does stress affect Jenny's memory?
Well, I am not a doctor, but I know
from experience that stress can un-
dermine your train of thought. For
example, I remember once having to make a presentation in
front of a large audience. As I made my way towards the po-
dium, I noticed my palms had begun to sweat. I felt nervous
and light-headed, and my heart was racing a mile a minute. I
tried to calm myself, but the stage fright overwhelmed me,
and as soon as I opened my mouth to begin speaking, I sud-
denly blanked out, forgetting everything that I intended to
say. What happened?
Well, the truth about stress is that it has both a positive and
negative effect on memory. While the capacity to stabilize
memory is increased, the ability to retrieve information from
memory is reduced.1,2 This is the result of increased cortisol in
the bloodstream, also known as the stress
hormone, which your body releases during
episodes of stress.3 Cortisol has two prima-
ry functions: it promotes gluconeogenesis,
and it activates anti-stress and anti-
inflammatory processes.4 It also maintains
the level of glucose in the blood through
gluconeogenesis and blocks the absorption
of glucose from the blood in all the tissues
except the central nervous system.4 This provides you with an
advantage, in stressful situations, as cortisol makes fatty acids
readily available to be transformed into energy that can be
utilized by muscles5. Unfortunately, it also makes you lose
your train of thought.
39
Chronic Stress In a stress study using rats as a model, the animals were
exposed to a cat and placed in random groups each day.
In general, our bodies are in a state of homeostasis, but stress
The stress manifested itself as difficulty to coexist in the
interrupts this equilibrium.6 Chronic stress is, by definition,
7
new environment and heightened levels of anxiety.11
long-term stress. In cases of chronic stress, the body tends to
remain in a persistent state of arousal that interrupts homeos- In a 2009 study, 52 people between the ages of 65 and 97
tasis.8 years of age were followed for up to 3
years to assess their cognitive functions
Common chronic stressors include 7:
and their stress levels. Researchers con-
 Continuous pressures at work cluded from their findings that cognition
 Feeling isolated is affected in a different way by chronic
 Persistent financial concerns stress in people with normal cognitive
 Prolonged relationship difficulties function as compared with those with
mild cognitive impairment.13 According
The physiological effects of chronic
to this group of researchers, cortisol may
stress can have an adverse impact on
have a neurotoxic (damage to the nerve tissue) effect over
spatial memory,9 potentially making you forget locations and
time, but may enhance cognition in older adult subjects who
positions of objects.10 Additionally, it has a negative impact on
11
already have a cognitive deficit.13
learning, as studied in rats. This perhaps could be linked to
the neuronal damage found in rats exposed to chronic Chronic stress does not cause cognitive alterations to the
stress.12 same degree in all people. Gender, personality traits, and age
are three factors that have been identified as particularly im-
40
portant in the development of changes in cognition due to rats were subjected to social stress for several months.14 Addi-
chronic stress.14 tionally, it was found that interpersonal stressors (e.g. disa-
greements or arguments) in older adults, increased the like-
Gender. Studies of rats have shown that under stressful condi-
lihood of memory failures.15 So, once a person reaches midlife,
tions, males demonstrated impairment when testing their spa-
they are more likely to become sensitive to the effects of
tial memory tasks. But the memory functions in females were
chronic stress on memory.
either enhanced or not impaired.14
The effects of chronic stress on cognition
Personality traits. The anxiety trait has
are due to the structural effects it un-
been established as a risk factor for the
leashes in the brain.14 Chronic stress has
development of stress-related neuronal
adverse effects on the structure of the
and psychiatric disorders.14 So, if you’re an
hippocampus, amygdala, and prefrontal
anxious person, you are more prone to
cortex;14 these changes create a structural
developing cognitive deficits in stressful
imbalance, causing the brain to function
situations.14
abnormally.
Age. Aging has been identified as a risk factor in the develop-
Depression
ment of cognitive impairment due to stress.14 Mid-aged rats,
treated for months with hormones to simulate elevated hor- Chronic stress and depression are strongly linked. If a person
mone levels observed in mild stress, were found to have im- has difficulty coping with an ongoing stress, he or she can
paired learning; but the same observations were not detected have a higher risk of developing depression.16
in the younger rodents.14 A similar result was observed when

41
Depression affects memory, and it does so equally with both
old and young.17 Depression (without anxiety) is associated
with the inability to recall new facts and with a negative effect
on the total quantity of
acquired information,
least twice as high when compared with a person with no de-
pression.21
Acute Stress
Unlike chronic stress, acute stress is a momentary stressor

but leaves retention and perceived as a threat. Studies of acute stress and its effect on

recall unaffected.18 memory have shown something remarkably different from

However, stress coupled that of chronic stress.22 Past research has suggested that acute

with anxiety not only doses of stress hormones are beneficial for long-term memo-

affects the recall of new ry, enhancing its consolidation, but impair memory retrieval
data and the total quantity of information acquired but also and working memory.22 More recent research supports a bet-
affects the retrieval of new information18 ter memory formation of stress-related events under acute
stress.23
The brain itself is damaged with the onset of depression. The
Some common sources of acute stress include 7:
hippocampus was found to be smaller in people suffering from
 Danger
depression.19 The reduced hippocampal volume is also ob-
 Hunger
served in older individuals with both early and late onset de-
 Crowding
20
pression.
 Isolation
Evidence suggests that if an individual suffers from a mild cog-  Noise

nitive impairment and depression, he or she has an increased  Remembering a dangerous event

risk of Alzheimer’s disease, a more severe issue. This risk is at  Imagining a threat
42
 Infection
Stress treatment
Controlling stress is not an easy feat; it requires time, and it is
a lifelong process. But it is worth the effort because overcom-
ing stress will result in better health.
Exercise is a great way to deal with stress. In combination with
stress management techniques, it serves as a distraction from
stress and counteracts the effects of stress on the heart and
the blood pressure.7 Aerobics, a long walk, swimming, or yoga,
are some recommendations7.
Among the most efficient ways to treat and reduce stress, is
cognitive-behavioural therapy, or CBT. The approach of CBT
focuses on a series of steps that consist of 7:
1. Identifying the sources of stress. Once these sources are
identified, ask yourself if they fit in with your life goals, if
they can be reasonably accomplished, and if they are un-
der your control.
2. Restructuring priorities to introduce stress-reducing activ-
ities. Taking a vacation, listening to music, and making
time for recreation, are some examples of stress-reducing
activities.
3. Discuss feelings calmly as anger may cause the blood
pressure to rise.
4. Focus on positive outcomes.
The use of relaxation methods, alternative techniques, and
natural remedies are also prescribed to deal with stress. Medi-
tations, deep breathing exercises, muscle relaxation, biofeed-
back, and massage therapy, are recommended relaxation me-
thods. The use of acupuncture and aromatherapy are alterna-
tive and natural techniques that can also be employed to keep
you stress-free.7
43
Fun fact: Sigmund Freud published The Interpretation of Dreams in 1899. The grandfather of psychoanalysis presented a theory of
the unconscious mind and how unconscious impulses guide human behavior. Freud believed there was a tussle between primitive,
unconscious impulses and both morality and reason, causing psychological anxiety. Freud concluded that dreams were a way to re-
solve this tension.24,25

Last month one of Jenny's grandchildren, my sister Sarah's
child Don, purchased a motorcycle. Although she is well aware
that Don is a particularly cautious rider, it has not stopped
Jenny from worrying non-stop that Don might get into an ac-
cident.
I explained to her how chronic stress can negatively impact
her memory. But she just looked at me and said: "He is my
grandchild. If I could stop from worrying, I would, but I hate
that damn motorcycle."
"How about we go for a walk? It will take your mind off it."
My mother agreed, and we found ourselves walking through a
nearby park that faced the river. As we walked along the wa-
terfront, I steered the conversation away from motorcycles
towards subjects that wouldn't get Jenny worked up. Within a
half hour, she was noticeably more relaxed.
By the end of the walk, Jenny thanked me for helping her get
her mind off Don and his new Harley. "I feel so much better
now. Thanks for helping me to get back on track."
"Maybe we should go for walks like this more often," I sug-
gested. "I could stop by after work a few nights a week, and
we can take a stroll like this together."
I would like that, my mother smiled. "I could use the exercise
and fresh air. And walking like this has really helped me to
change my focus."

44
References
1. Kuhlmann S, Piel M, Wolf OT. Impaired memory retrieval after psychosocial stress in healthy young men. The Journal of Neuroscience.
2005;25(11):2977-2982.
2. Dominique J-F, Roozendaal B, McGaugh JL. Stress and glucocorticoids impair retrieval of long-term spatial memory. Nature. 1998;394(6695):787-790.
3. Mayo Clinic Staff. Stress management: chronic stress puts your health at risk. Mayo Clinic. http://goo.gl/R0Ln4V. 2013. Accessed 18 April, 2016.
4. Encyclopaedia Britannica. Cortisol. Encyclopaedia Britannica. http://goo.gl/16Qavs. 2016. Accessed 18 April, 2016.
5. Genetic Learning Science Center. How Cells Communicate During Fight or Flight. University of Utah. http://goo.gl/9byNAA. 2016. Accessed 22 April,
2016.
6. Encyclopaedia Britannica. Homeostasis. Encyclopedia Britannica. http://goo.gl/CjIvDx. 2016. Accessed 1 May, 2016.
7. Simon H, Zieve D. Stress. University of Maryland Medical Center. http://goo.gl/7pYcjE. 2016. Accessed 1 May, 2016.
8. Mathews A. Stress. The New Epidemic Grading Practices: A Systematic Review of Americas Grading Policy: Xlibris; 2016. https://goo.gl/CPIoQO
9. Conrad CD. A critical review of chronic stress effects on spatial learning and memory. Progress in Neuro-Psychopharmacology and Biological
Psychiatry. 2010;34(5):742-755.
10. Mehta MA. Spatial Memory in Humans. Encyclopedia of Psychopharmacology. http://goo.gl/IdmdJK. 2014. Accessed 5 May, 2016.
11. Park CR, Campbell AM, Diamond DM. Chronic psychosocial stress impairs learning and memory and increases sensitivity to yohimbine in adult rats.
Biological psychiatry. 2001;50(12):994-1004.
12. Leza JC, Salas E, Sawicki G, Russell JC, Radomski MW. The effects of stress on homeostasis in JCR-LA-cp rats: the role of nitric oxide. Journal of
Pharmacology and Experimental Therapeutics. 1998;286(3):1397-1403.
13. Peavy GM, Salmon DP, Jacobson MW, et al. Effects of chronic stress on memory decline in cognitively normal and mildly impaired older adults.
American Journal of Psychiatry. 2009.
14. Sandi C. Memory Impairments Associated with Stress and Aging. In: Bermúdez-Rattoni F, ed. Neural Plasticity and Memory: From Genes to Brain
Imaging. Boca Raton, Florida: CRC Press; 2007. http://goo.gl/UXVhX4
15. Neupert SD, Almeida DM, Mroczek DK, Spiro III A. Daily stressors and memory failures in a naturalistic setting: findings from the VA Normative Aging
Study. Psychology and aging. 2006;21(2):424.
16. Hall-Flavin DK. Can chronic stress cause depression? Mayo Clinic. http://goo.gl/5goRxj. 2014. Accessed 12 May, 2016.
17. Fossati P, Coyette F, Ergis A-M, Allilaire J-F. Influence of age and executive functioning on verbal memory of inpatients with depression. Journal of
affective disorders. 2002;68(2):261-271.
18. Kizilbash AH, Vanderploeg RD, Curtiss G. The effects of depression and anxiety on memory performance. Archives of clinical neuropsychology.
2002;17(1):57-67.
19. Videbech P, Ravnkilde B. Hippocampal volume and depression: a meta-analysis of MRI studies. American Journal of Psychiatry. 2015.
20. Hickie I, Naismith S, Ward PB, et al. Reduced hippocampal volumes and memory loss in patients with early-and late-onset depression. The British
Journal of Psychiatry. 2005;186(3):197-202.
21. Modrego PJ, Ferrández J. Depression in patients with mild cognitive impairment increases the risk of developing dementia of Alzheimer type: a
prospective cohort study. Archives of neurology. 2004;61(8):1290-1293.
22. Roozendaal B, Okuda S, De Quervain D-F, McGaugh J. Glucocorticoids interact with emotion-induced noradrenergic activation in influencing different
memory functions. Neuroscience. 2006;138(3):901-910.

45
23. Henckens MJ, Hermans EJ, Pu Z, Joëls M, Fernández G. Stressed memories: how acute stress affects memory formation in humans. The Journal of
Neuroscience. 2009;29(32):10111-10119.
24. HIstory of the Brain. Public Broadcasting Service. https://goo.gl/um90YK. 16 June, 2016.
25. Freud S. The Interpretation of Dreams. Vienna2011. http://goo.gl/j7VABe

46

Medications
So long as the memory of certain beloved friends lives in my heart, I
shall say life is good.
— Hellen Keller.
As I continued my research into memory and cog-
nitive decline, I spent a couple of days trying
to piece together everything I could about
medications and what effect they have
on the brain. Despite the fact that drugs
are designed to treat many illnesses
and ailments, they are often associated
with some unwanted side effects. My
mother, Jenny, has been taking medication
for both her high blood pressure and the aller-
gies she suffers from, and I wondered if those treat-
ments might be affecting her memory.
With that in mind I went to work researching everything I
could about prescription meds, focusing on various medica-
tions that are known to cause memory impairment, particu-
larly those drugs prescribed to an older population.
Anticholinergic Drugs
Anticholinergic medications inhibit the action of acetylcholine.
An example of such a drug is atropine.1 Anticho-
linergics are used to treat conditions such as
allergies, Parkinson’s disease, depression,
vertigo, incontinence, asthma and nu-
merous other conditions.2 When anti-
cholinergic drugs are prescribed to
older adults, it has been revealed that
patients appear to be more sensitive to
cognitive impairment as a side effect.2 The
reason why older people are more susceptible
to these side effects can be partly explained by the
aging process, since drugs are not metabolized as quickly in
the elderly, which results in the blood-brain barrier becoming
more exposed to the medications.2
47
It has been observed that the use of anticholinergic drugs re-
sults in acute cognitive impairment, where increased impair-
ment was seen with the use of a more potent medication.3
Such impairment has been detected when anticholinergic
drugs were administered to people with Alzheimer’s disease,
and their Alzheimer symptoms were
exasperated.3
Just because a medication is an anticho-
linergic it doesn’t necessarily mean that
every anticholinergic will trigger similar
effects. The reason: medications of the
same class may have more or less affin-
ity for certain receptors. Translated into
regular speak: if two anticholinergic
drugs have an affinity for different receptors, people will not
exhibit the same side effects for both. For example, the drugs
oxybutynin and darifenacin are anticholinergic medications
that are used to treat an overactive bladder.4 When subjects,
during a research study were given oxybutynin, individuals
showed significant memory impairment. But in the same
study, there was no evidence of memory impairment in peo-
ple who were given darifenacin.4 Therefore, despite the fact
that darifenacin can have the same side effects as any other
anticholinergic drug, such as confusion, headache, drowsiness;
it did not produce the same effect as oxybutynin when it
comes to memory impairment.4,5
Many of us have experienced motion
sickness while traveling, and scopola-
mine is a traditional medication taken
to help avoid the nausea and vomiting
that motion sickness causes.6 Scopola-
mine is an anticholinergic medication.7
Studies have shown that while taking
this drug, people may have difficulty
creating new memories. However, they did not experience any
problems when trying to remember previous memories.8 For
example, when people took scopolamine and were told to
learn a list of words, they demonstrated problems remember-
ing the majority of the words, but could still recall the list of
words learned before the administration of the drug.8 Sco-
48
polamine not only impairs memory functions it also causes
diminished reaction times and reduces finger tapping speeds
during a task.9
Some examples of anticholinergic drugs are 10:
 Atropine
 Scopolamine
 Oxybutynin
 Trihexyphenidyl HCL
 Benzotropine mesylate
 Belladonna alkaloids
 Dicyclomine
Fun fact: Although the ancient Greeks were renowned
for their sophisticated philosophies, mathematics, archi-
tecture, and astronomy, their understanding of the
brain, by today's standards, left much to be desired. Aris-
totle, Alexander the Great's trusted teacher, posited in
the fourth century BC, that the brain was a secondary
organ that both housed the spirit and served as a cooling
agent to ensure the primary “source of consciousness,”
the heart, did not overheat. 11,12
Benzodiazepines
Benzodiazepines are a class of medications termed as central
nervous system depressants (CNS depressants). They are used
to treat anxiety, induce sedation, for anesthesia, and to help
with alcohol withdrawal, seizures, muscle spasms, insomnia,
and panic attacks.13-18 However, these medications are associ-
ated with various side effects, including cognitive
impairment.14 Research has demonstrated that memory is af-
fected by the use of benzodiazepines.14 Lorazepam, a benzo-
diazepine of higher potency causes even more memory issues
than other benzodiazepines.9
While taking benzodiazepines, only long-term memory is af-
fected.19 Basically, benzodiazepines prevent new memories
from being consolidated into long-term memory.19 Upon fur-
ther examination, it was noted that the memories stored be-
fore consuming benzodiazepine remain intact.19 But there is
also evidence that shows that when the elderly take benzodi-
49
azepines for an extended period, there is an increased rate of
cognitive decline.19
Benzodiazepine use amongst the elderly has been asso-
ciated with an increased risk of falling and balance is-
sues, resulting in injuries. These symptoms are a conse-
quence of the sedative effects of the medication.19
Cholesterol-lowering Drugs
Statins are medications that help lower choles-
terol levels.20 The associations between statins
and memory are fascinating! Read on to discover
what that interesting association happens to be.
Did you know that the brain contains 25% of the
21
total cholesterol present in the body? Why
does the brain need so much cholesterol?—you
might ask. Well, the brain is composed of neurons that are
made up of a body and an axon.21 Signals from the neurons
can transmit with greater speed due to the myelin sheath that
covers the axons. About 70% of the cholesterol present in the
brain is believed to be associated with myelin.21 That's why
the brain requires cholesterol to function normally. Without
its needed supply of cholesterol, the brain may not work op-
timally. It’s important to note that cholesterol is made in the
brain (more than >95%) and recycled, however, as people age
less the brain inevitably produces less.21
Cholesterol is a key factor that contributes to learning as well
as in memory.22 For example, when cholesterol-deficient rats
were fed cholesterol it resulted in improved
learning and memory functions.23 Also, animals
that were fed a cholesterol-rich diet performed
better on certain tasks.23 These experiments
confirmed that cholesterol is essential for the
brain. But despite being a key component that
ensures proper brain function, too much choles-
50
terol can also cause health problems.22 rosuvastatin, the cognitive problems disappeared within a
couple of days.29
In some cases, statins have been positively associated with a
lowered risk of dementia when compared with people who do The FDA started sending out warnings regarding the negative
not take statins.24-26 A research experiment that conducted a cognitive side effects of statins in 2013, but another study was
5-year follow-up study noted that non-demented patients conducted to make sure the medication is safe. The results
who were taking statins were less likely to develop dementia showed that statins did not pose a greater threat to memory
or cognitive impairment.27 and other cognitive functions compared to other medications
which were prescribed for heart health.30,31 That said, more
However, statins are also known to have harmful effects,
research is required for us to get a comprehensive under-
though this is rare.28 A 65-year-old man who took atorvastatin
standing of the effects these drugs have on our brain.30
(a statin drug) for a year, complained of “brain fog” and “fuzzy
thinking”.28 When he stopped taking the medication, the Morphine and other Opioids
symptoms subsided.28 In another case study, a 53-year-old
Morphine and codeine are narcotic anal-
man began demonstrating symptoms of worsening memory
gesics (relieves pain), and originate from
and confusion only five days after starting treatment with ro-
the opium poppy.32 Patients in palliative
29
suvastatin (a statin drug). The symptoms made it difficult for
care that were asked to remember an im-
the patient to remember appointments and severely impacted
portant piece of information before re-
his ability to work and even drive.29 When his doctor exam-
ceiving morphine had trouble doing so,
ined him, it was evident that the patient was suffering from
proving that their ability to remember the information was
problems with attention, concentration, as well as short-term
impaired by the medication.33
29
memory impairment. Once the patient stopped taking the
51
Beta-blockers
Beta-blockers are one of the medications used to control,
treat, and prevent many conditions that include: heart failure,
high blood pressure, migraines, anxiety, glaucoma, etc.34 The
medication works by blocking the action of catecholamines on
the blood vessels, beta-blockers can cause the blood pressure
to simmer down.35
The release of epinephrine and norepinephrine is crucial in
areas of the brain involved in memory, such as the hippocam-
pus.36 These catecholamines are believed to be important in
improving and stabilizing memory.36 The importance of these
catecholamines on memory was elaborated in a study where
participants were given metoprolol (blocks the release of
norepinephrine and epinephrine) or yohimbine (a natural
supplement and stimulant of norepinephrine and epineph-
rine). The participants were presented with slides that de-
picted emotionally arousing material; those who took
37
metoprolol had a poor memory of the slides a week later.
Other Sedatives
Sedatives are often used to help with sleep in those who are
suffering from varying forms of insomnia. Some medications in
this category are zolpidem, zaleplon, and eszopiclone; and are
unlike the benzodiazepines that were mentioned earlier.38-40
These medications work by slowing the brain activity, hence
enabling the person to fall asleep.38-40 As people get older, it
has been observed that there is a prevalence of sleep disor-
ders.41 When older people are treated with sedative-hypnotics
for their sleep issues, despite the improvement in their quality
of sleep reported by participants, there is a risk of cognitive
impairment; in addition to other significant adverse effects
such as falls, headaches, vehicular accidents, and fatigue.41 A
research study looked at the effects on participants taking ei-
ther hypnotics (zolpidem), or melatonin, or melatonin with
zolpidem, or a placebo.41 Results showed that taking zolpidem
a hypnotic, resulted in decreased performance on various
tasks, including memory recall.41 However, the effects were
worse when zolpidem was taken with melatonin.41 A positive
aspect about zolpidem was that the following morning after
52
taking the drug, no residual effects of cognitive impairment
were seen although memory recall was affected.41
The pineal gland (a gland in the brain) produces mela-
tonin; the pineal gland is found in the central region of
the brain. Melatonin is a key player in regulating the
sleep-wake cycle. The pineal gland becomes active once
the sun sets, triggering the production of melatonin.
When this happens, melatonin levels rise in the body,
and people are more inclined to feel sleepy. Melatonin
levels peak in the body between 2 am and 4 am, and
later the levels gradually decrease after 4 am.42
Antihistamines
Histamine is a substance that is found throughout the body
including the brain.43,44 When we are allergic to something,
the substance is released in volume, and results in the annoy-
ing symptoms that we feel when we have an allergic reaction
(sneezing, runny nose, rash).44 Antihistamines are medications
that alleviate allergy symptoms.45 Although antihistamines re-
lieve many symptoms that accompany with allergies, these
medications can leach into the brain.45 Antihistamines work by
blocking histamine receptors so that histamine has nothing to
bind to.45 When this blockage happens in the brain, it may
cause unwanted problems related to attention and arousal
associated with histamine.45 Symptoms include diminished
alertness, blurry vision, and the feeling of sedation.45
Based on the degree of their effects, antihistamines are di-
vided into different generations, first generation, second gen-
eration, and third generation.45 The antihistamines of each
generation have different properties, and many of the un-
wanted side effects, such as blurry vision and not being alert
53
are not as pronounced as they are in the older generation First-generation (older) antihistamines include 50:
drugs, and sometimes the side effects are not seen at all.45  Brompheniramine
 Meclizine
There are different types of antihistamines, and they dif-
 Dexchlorpheniramine
fer by the type of receptor they block. Antihistamines
 Chlorpheniramine
that are used to treat allergies block a receptor known as
 Diphenhydramine
H1 and may indeed come with the unwanted side effects
 Pheniramine
of blurry vision and drowsiness.45 However, there are
other antihistamines that are used in the treatment of  Promethazine

gastrointestinal ulcers and other problems in the stom-  Pyrilamine

ach by blocking the H2 receptor.46 Unlike the ones that  Doxepin

are used for allergies, the side effects of H2 blockers are Second-generation antihistamines include 50:
less pronounced.47 Interestingly, H2 blockers have been
 Cetirizine
associated with later onset of Alzheimer’s in those peo-
 Loratidine
ple who are at high risk of developing the condition.43
 Desloratidine

Research studies indicate that the use of antihistamines re-  Emedastine

sults in diminished attention in those who take 1 st generation  Levocetirizine
antihistamines, while the effects are less pronounced or not
present in people who take 2nd generation antihistamines.48,49

54
Antidepressants Conclusion

Depression is observed in people of all ages; however, some I spoke to my mother about all the medications she is taking. I
medications used to treat depression come with the un- wrote down all the names of the prescription and non-
wanted side effects, including cognitive impairment.51 While prescription medicine she is taking and I made a mental note
the utilization of some antidepressants can improve cognitive to myself to speak to my mother's doctor about the high blood
function in the elderly, others cause the opposite effect.52,53 It pressure medication she has been prescribed and the over-
is important to understand that when a person is depressed, the-counter allergy medicine she takes. If something like
accompanying problems in cognitive functioning occur, such changing the medications my mother takes will result in her
as concentration problems.52 When patients were treated remaining sharp and vital... I will be profoundly grateful.
with certain antidepressants, cognitive problems were seen to
improve in the short-term.53 However, in other instances, it
has been observed that some antidepressants, such as
amitriptyline and imipramine have led to measurable long-
term and short-term cognitive impairment in healthy volun-
teers.52 This may be due to the anticholinergic properties of
these antidepressants, and anticholinergic effects in the eld-
erly appear to be linked to memory issues.52

55
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4. Kay G, Crook T, Rekeda L, et al. Differential effects of the antimuscarinic agents darifenacin and oxybutynin ER on memory in older subjects. European
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30. Richardson K, Schoen M, French B, et al. Statins and cognitive function: a systematic review. Annals of internal medicine. 2013;159(10):688-697.
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40. Eszopiclone. Medline Plus. https://goo.gl/5xpVSw. 2016. Accessed 26 June, 2016.
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58
 Unlike me and the others in the band, Bob entertained dreams
HIV and other Infections of becoming a successful musician. And for a good reason, he
played a mean, funky, bass. It was clear to all of us that Bob
Memory is the treasure and guardian of all things.
— Cicero had the talent and after we graduated from university, he
moved to New York where he began playing music with a
During my research on memory loss, I stumbled across some
number of local acts and quickly established himself as a ta-
information that left me shaking my
lented studio musician. But unfortu-
head. Although the facts that I unco-
nately for Bob, he had a bit of a weak
vered had no bearing on my mother's
spot for the Rock n' Roll lifestyle, espe-
condition, they still stabbed at my
cially drugs.
heart.
And by the late 80s, Bob was flirting
Back when I was in college, in the
with heroin. At first, he was just smok-
1980s, three friends and I started a
ing it, but within a year, track marks be-
band. We rented a practice space near
gan to emerge on his arms, and he had
the university, and on weekends we become a full-blown addict. Even
HIV virus infecting a human cell. Source: NIH.
would get together and cover the music worse, as a consequence of sharing a
of some of our favorite bands: The Talking Heads, The Rolling needle, he ended up HIV positive.
Stones, Iggy Pop, and Husker Du. I played drums and shared
Luckily for Bob, he quit smack and embraced a more cathartic
the rhythm section with a bass player named Bob Saint-James.
lifestyle including prescription drugs to control the virus. As a
consequence, his health has remained relatively stable. That
59
last time I ran into Bob was about three months ago at a HIV is generally transmitted by sexual contact (though
Greek Town Restaurant in Detroit. We shared a table and not always) and/or via blood. You can reduce, but not
caught up over lunch. Although the virus made him look older eliminate, the risk of HIV infection if you adhere to the
than his age, he still appeared virile, and his mind was sharp. following suggestions 3:
So during my research on memory loss, when I discovered  Choose less risky sexual behaviors. Anal sex and va-
how HIV can contribute to cognitive difficulties, my thoughts ginal sex have the highest probabilities of HIV transmis-
immediately focused on Bob Saint-James. sion. Oral sex and touching have the lowest chance of
transmitting HIV.
In 1983, scientists discovered the virus that causes AIDS. Orig-
 Use condoms. A simple barrier helps keep HIV and
inally named HTLV-III/LAV (human T-cell lymphotropic virus-
unplanned pregnancies away.
type III/lymphadenopathy-associated virus), it was later
 Have sex with fewer people. It's simple statistics: the
changed to the Human Immunodeficiency Virus (HIV). HIV is a
more partners you have, the higher the risk of having a
retrovirus that is responsible for the HIV infection, and over
partner with HIV.
time, can become Acquired Immunodeficiency Syndrome
 Don’t share needles if you do drugs. Shared needles
(AIDS).1 Memory and cognitive defects have been associated
contaminated with infected blood deliver both the drug
with HIV/AIDS since the initial discovery of the epidemic.2
and virus into the veins. Actually, don’t share needles re-
gardless of what you use them for.
The proper use of condoms is one
of the best ways to reduce the
risk of sexually transmitted dis-
eases.

60
HIV dementia The introduction of antiretroviral therapy
(therapy targeting HIV) significantly in-
Experiencing a decline in mental perfor-
creased patient survival and decreased the
mance is a common occurrence as we age.
occurrence of HIV dementia.4,7 However,
However, many HIV patients experience
HIV-infections can lead to mild to mod-
memory difficulties and cognitive issues as
erately severe versions of brain disease
a result of brain cells that become infected
(HIV-associated neurocognitive disorders or
with the virus. HIV-associated lesions in the
HAND).8 A study of AIDS patients taking an-
central nervous system occur as a conse-
tiretroviral therapy noted that the majority
quence of the apoptotic process, or the
had impaired neurological functions, includ-
programmed death of the brain cells.4
ing a poor working memory.8
When HIV reproduces in the non-neural
cells (microglia) that contain the brain’s immune system, it Did you know that HIV infection is the most common
results in swelling in the central nervous system, which then cause of dementia in adults under the age of 40?9
lead to behavioral and cognitive changes.5 In patients with
Hippocampal Function
AIDS, this mechanism contributes to HIV-induced dementia
(HIVD or HAD).4 However, brain cell loss does not occur until a You probably remember the important role that the hippo-

much later time following the HIV infection and, as a conse- campus plays regarding memory encoding from previous sec-
quence, does not appear to be the primary cause of HIV- tions of this book. Well, HIV-positive individuals have been ob-
induced dementia.4,6 served with both memory deficits and a hippocampus that has

61
altered integrity suggesting the virus affects this brain region
where memory is encoded and retrieved.10,11
Did you know that cats can also catch a virus that will
compromise their immune system? Such a virus is called
the Feline Immunodeficiency Virus (FIV), and like HIV,
symptoms may appear years after the initial infection.
This virus is transmitted between cats via bite wounds.
The FIV is not to be confused with the Feline Leukemia
Virus.12
Infections and Tumors
AIDS, the condition caused by an HIV infection, interferes with
the immune system. With a weaker immune system, opportu-
nistic infections are free to target the central nervous system
and cause neurological disorders.13 Furthermore, it has been
suggested that immune deficiency caused by HIV/AIDS in-
creases the risk of cancer, but has not yet been confirmed as a
direct cause of it.14 One good example is the development of
Karposi Sarcoma (KS). These tumors occur in HIV-infected in-
dividuals who have progressed to AIDS. With the decline of
the immune system, people infected with the Karposi sarcoma
associated herpesvirus (KSHV) are more likely to develop KS.15
However, the risk of cancer (in the presence of HIV) may be
affected by antiretroviral therapy administered since 1996.16
The following are the neurological complications that are a
result of HIV/AIDS.
 The Epstein-Barr virus is associated with central nervous
system lymphomas. These are cancerous tumors in the
brain. The symptoms include seizures, headaches, mental
decline, vision issues, dizziness, immobility, and problems
with speech. The prognosis of Epstein-Barr is worse in an
untreated long term case of AIDS, but if anti-retroviral
therapy is given to the patient, prognosis will be better.13
 The symptoms of Cytomegalovirus infections include loss
of strength in the limbs, disease of the retina, coma, hear-
ing problems, altered mental condition, peripheral neuro-
pathy, problems with balance, and dementia. A cytomega-
lovirus infection may occur alongside other infections, but
is less common in patients treated for HIV.13
62
 Infection by the fungus Cryptococcus neoformans is the
cause of cryptococcal meningitis. This fungus primarily in-
fects the lungs and then causes inflammation in the layers
covering the spinal cord and the brain (meninges). This
condition has been reported in approximately 10 percent
of AIDS patients who are not treated for AIDS. It may lead
to death if left untreated.13
 Herpes virus infections are frequent in people with AIDS.
The virus infects the spinal cord (myelitis)
and the brain (encephalitis), causing in-
flammation. Commonly, the herpes zoster
virus produces shingles; the signs, include
blisters, tingling, itching and pain due to in-
13
fected nerves.
 An improperly treated syphilis infection may
result in neurosyphilis, which appears more
frequently in people infected with HIV.
Nerve cells and fibers that transmit sensory-Candidiasis is an infection
caused by a fungus, and a sign
related information to the brain are damaged
of HIV in the mouth.
by syphilis infection. It may take many years for the symp-
toms that include reduced reflexes, deterioration of the
joints, defects in vision, problems with coordination, fra-
gile state, pain, personality differences, inability to hear,
decreased response to light, and dementia, to manifest.13
Increased use of recreational drugs, oral sex, and the use
of the internet to find partners for sex, are some of the
reasons for increased rate of syphilis among HIV-infected
patients.17
 When the John Cunningham (JC) virus in-
fects different sites in the brain, it destroys
the cells that produce the protective layer
that allows for the passage of nerve im-
pulses (myelin sheath) in the nerves and
brain cells. This results in progressive multi-
focal leukoencephalopathy, which affects 5
percent of the people with AIDS. Among the
various symptoms it produces, some people
may experience loss of memory and reduc-
63
 tion in cognition. Death occurs within six months follow-
ing the appearance of the initial symptoms.13
 Toxoplasma encephalitis is caused by the parasite Toxop-
lasma gondii. The parasite can be fought off by a healthy
body, but a person with AIDS has a suppressed immune
system, thus rendering them unable to fight it off. Ten
percent of AIDs patients who are not treated are at risk of
getting infected with Toxoplasma gondii. The disease is
caused when the parasite invades the body. Symptoms
include inflammation of the brain (encephalitis), dizziness,
sight issues, personality differences, vomiting, and issues
with speech and movement. The prompt use of antibiotics
can control the complication.13
 Vacuolar myelopathy causes the removal of the myelin
sheath (the envelope surrounding the nerves that facili-
tate nerve impulses) from the nerve cells. The removal of
the myelin sheath causes small holes in the nerve fibers.
In the long term, people suffering from this condition will
develop stiffness in the legs, making walking progressively
difficult up to the point of needing a wheelchair. This dis-
ease is prevalent in 30 percent of the AIDS adults who are
not treated for AIDS and is even more prevalent in child-
ren infected with HIV.13
After reading up on the HIV virus and how it affects brain func-
tion, I had an idea. Back in University when we were in the
band, we made a number of low-fi recordings of the songs we
were covering. Most of those recordings were lost, but about
six months ago, I discovered an old cassette filled with our
music. So I transferred the songs from the cassette to my lap-
top and then burned a CD.
Afterward, I wrote a letter to Bob that was filled with my ref-
lections of the old days and the fun we used to have. I empha-
sized about how well he was looking when I last ran into him
and reminded him to look me the next time he returned home
to Detroit. I included a copy of the CD I just burned and
promptly mailed it off to my old friend.
64
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227.
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Neurology. 2006;66(11):1688-1695.
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Neurology. 2009;72(19):1661-1668.
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13. National Institute of Neurological Disorders and Stroke. Neurological Complications of AIDS Fact Sheet. 2015; http://goo.gl/M9kgMK. Accessed 7 April,
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recipients: a meta-analysis. The Lancet. 2007;370(9581):59-67.
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Cancer. 2008;123(1):187-194.
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65

Alcohol
Me blacking out when I'm drunk is God's way of letting me know
that what I do when I'm under the influence is none of my business.
— Anonymous
Fifteen years ago, when Jenny was in her late fifties,
she read an article about the health benefits of
drinking a glass of wine with dinner. Since
then, my mother has religiously indulged in
the occasional glass of wine. Although I didn't
doubt that the wine was beneficial for my
mom's heart, I wondered if the consumption of
alcohol might be harming her cognitive faculties.
So I asked a doctor friend of mine about it the next time we
met up for a round of golf. David Cheung and I have been
friends since we were children, and the gifted surgeon and I
have been playing golf together since we were teenagers. I
have always trusted him to provide me with sound medical
advice. So, during our recent adventures out on the links, I de-
cided to pick his brain about Jenny's wine consumption.
We were approaching the third green when I brought up the
recent cognitive difficulties Jenny has been experiencing. We
spoke at length about the doctors and the dietitians she had
visited. After we sank our putts and walked towards the fourth
tee, I raised my concerns about my mother's drinking.
"Jenny isn’t an alcoholic, is she?"
"No, no, nothing like that." I paused before
continuing, “but she does drink one glass of
red wine every evening with her meal.”
David explained that excessive drinking can
very well affect long-term and short-term mem-
ory. He pushed me playfully, "Do you remember
when we were teenagers in our early twenties when we use to
drink ourselves silly?"
I shook my head. "That whole period is a bit of a blur."
“Exactly”, David laughed. "Heavy consumption affects the abil-
ity of the brain to form new long-term memories, but luckily it
leaves pre-existing long-term memories intact.1" “But as we're
66
both aware”, he placed a hand on my shoulder, “the more al-
cohol we consume, the more we impair our memory function,
including blackouts.”1 "Like that time you blacked out during
that frosh week party."
“Don't remind me,” I shook my head. "I don't think I've ever
been that drunk in my life."
During a psychological experiment that featured 18
drinkers and 17 non-drinkers, the subjects were shown
pictures and asked to write stories about them at three
separate points during a bout of social drinking. The next
day, the two groups were invited to recount the anec-
dotes they composed at each of the three time points.
Researchers found that there was a progressive decline
in memory based on the volume of alcohol consumed
while non-drinkers who did not consume alcohol remem-
bered all their stories with better recollections of the sto-
ries written at the later points of the drinking session.2
Effects of Alcohol on Memory and the brain
By the time we holed our putts on the fourth hole, David was
in full lecture mode: to understand how alcohol can under-
mine memory, first, we need to understand the model of how
memory forms. "The classic model proposed by Atkinson and
Shiffrin in 1968 is often cited and is widely accepted.3,1” This
model postulates that memory formation occurs in three
stages:
1) Sensory memory
2) Short-term memory
3) Long-term memory
Sensory memories last for only a few fleeting seconds, and
short-term memory lasts longer depending on the rehearsal or
repetition of information.1" “Although rehearsal plays a major
role in the coding of short-
term to long-term memory,”
David explained, “information,
motivation, and attention also
pay significant roles.1”
67
 Figure 1. Modal model of memory and the interference of alcohol. Modified from White, 2004. 1
“So, although Jenny may be experiencing some memory
lapses,” David elaborated, “alcohol affects the formation of
new long-term memories more significantly, but plays a less
significant role when it comes to recalling already established
memories or the formation of new short-term memories.”
Figure 1, (modified from the source1), shows the modal model
of memory and where alcohol impacts this process.
1.1 Blackouts
"For example, remember your blackout back in university?
Well, such episodes of amnesia occur when an intoxicated
person is unable to form new memories while drunk, but all
the memories that existed before the stupor typically remain
intact.1"
“In 1969,” David explained, “researchers described two types
of blackouts: en bloc and fragmentary blackouts.1” They noted
that people experiencing en bloc memory loss were unable to
recall any of the events that occurred while they were intox-
68
icated. Despite their ability to retain information in their short-
term memory, which allowed them to engage in conversation
or play a video game,1 they were unable to remember what
they said or did five minutes earlier.1 In contrast, fragmentary
blackouts occur when the intoxicated person can recall a few
of the details that took place while they were under the influ-
ence, but remain distinctly aware of the gaps between
events.1
DON’T DRINK AND DRIVE! In 2013,
10,076 people died in the USA in alco-
hol-impaired driving crashes. That’s
one-third of all traffic-related deaths in
the USA.4
"How much alcohol does one typically need to drink before
blacking out?"
"From the experimental evidence in which male subjects were
given alcoholic beverages and their ability to recall details
from various sources was measured, researchers determined
that blackouts occurred between 0.14 and 0.28 percent blood
alcohol level.1,5" “Imagine,” David giggled, “during the experi-
ment, one of the subjects completely forgot that he at-
tempted to hit another subject on the head with a chair!1,6“
But not everyone are susceptible to blackouts, David waxed. In
a study in 2003, subjects were divided into two groups: people
with a history of blackouts and those without such a history.
While sober, members of both groups per-
formed similarly on memory tests; once
they were mildly intoxicated—and even
after the effects of the alcohol began to
wear off—the group without a history of
blackouts outperformed its counterpart.7
"But keep this in mind. Indirect exposure
to alcohol also has an effect on memory. Back in the seventies,
Baer and colleagues started examining the drinking habits of
pregnant women and the effect on their offspring for the next
21 years. What they found led them to associate prenatal al-
cohol exposure to increased rates of blackouts, among a list of
of consequences that followed the children after birth.8"
69
 Blackouts begin to occur between 0.14 and 0.28 percent Wernicke’s Encephalopathy and Korsakoff’s Psychosis
blood alcohol level. 1
David began describing Wernicke-Korsakoff syndrome (WKS)
Cerebellar Degeneration that comprises two components: the severe short-
duration Wernicke’s encephalopathy (WE) and
In a more serious tone, David continued. "Now
the longer duration Korsakoff’s psychosis.
if Jenny is an alcoholic you might have some
The syndrome is found largely in alcohol-
concerns to consider. A common condi-
ics. Wernicke’s encephalopathy (WE) is a
tion among alcoholics is cerebellar dege-
neurologic disorder caused by vitamin B1
neration." He explained that this condi-
(thiamine) deficiency due to alcohol con-
tion develops slowly over many years (≥
sumption. Its symptoms include the ina-
10) of heavy drinking. As a consequence
bility to control joint movements, paralysis
of this condition, regions of the cerebellum,
of the nerves that control the movement of
which control the process of coordinating mus-
the eyes, and mental confusion. In nearly 80 to 90
cles, shrink. Thiamine deficiency is cited as one of the
percent of the cases, WE patients develop Korsakoff’s psycho-
reasons for cerebellar degeneration.9 "Research has shown
sis that is characterized by abnormalities in behavior and defi-
that patients with cerebellar degeneration are mainly im-
cits in memory.9
paired in executive functions while their memory works cor-
rectly.10,11"

70
Alcohol-induced Memory Loss required for storing those memories for at least a year follow-
ing the event.1"
In the Hippocampus
David teed up his ball on the par three, sixth hole. "It was not
David tapped his forehead, "the role that the hippocampus
until the 1980s that evidence demonstrated how alcohol al-
plays in forming memories was first discovered in the 1950s,”.
ters the communication within the brain.1" He made a nice,
The discovery occurred during the treatment of a patient
smooth swing, and the two of us watched his ball land softly
known as H.M., who suffered from severe seizures. As a con-
onto the green and roll with the slope to-
sequence, his hippocampus was removed.1 His
wards the hole. "Today, alcohol-
seizures decreased but it soon became
induced memory impairment is
apparent that he suffered from se-
linked to the selective disruption
vere memory loss.1" My golfing
of intercellular nerve communica-
partner noted that H.M. was still
tion in the hippocampus, particularly
capable of learning and retaining
the alteration of receptors in brain cells that
information with his short-term
bind the neurotransmitters necessary for long-
memory and was capable of remembering incidents in his
term memory encoding.1"
past, but he was unable to create or retain newly generated
long-term memories.1 "The case of H.M. made it clear that it In Other Regions of the Brain
takes time (several years) for the transfer of short-term mem-
When it was my turn to hit, I struck the ball solidly and fol-
ory to be stored as a long-term memory. And the hippocam-
lowed its trajectory, fading from left to right.
pus appears to play a vital role in this transfer process and is
"Nice shot."
71
“Memory formation can also take place outside the hippo-
campus,” David picked up his clubs, and we walked towards
the green. "Research has shown evidence that areas in the
frontal lobes are also involved in short-term and long-term
memory. One of the impairments resulting from damage to
the frontal lobe is the inability to form new memories.1" David
educated me on compelling evidence
that suggests the role of chronic alcohol
intake and the damage to these struc-
tures, which can lead to an inability to
perform memory tasks efficiently.1
Other Mechanisms
"Alcohol can trigger memory loss by
other means as well, specifically by in-
teracting with the absorption of and reducing the levels of vi-
12,13
tamins, e.g. vitamin B1, vitamin B12. Furthermore, mixing
alcohol with some medications may also lead to memory im-
14
pairment. "
"Is Jenny taking any medications?"
"Nothing that would interact negatively with alcohol."
B Vitamins
David elaborated on vitamin B12. It is an essential micronu-
trient and can be absorbed by the body from a wide number
of sources and nutritional supplements.15 Vitamin B12 defi-
ciency leads to among other things,
memory loss.16 Excessive alcohol con-
sumption can trigger vitamin B12 defi-
ciency due to its reduced absorption by
the intestine.17
"Thiamine or vitamin B1 is another mi-
cronutrient that is essential for the
body. Due to its inability to produce
thiamine, the human body needs to obtain it in a healthy
diet.9" Putter in hand, David approached his ball and rolled his
ball within two feet of the cup. "Thiamine is found in high con-
centrations in the heart, kidneys, liver, muscle, and brain.18 It
is a nutrient that is required for the proper assembly and func-
tioning of enzymes that are needed in the production of
72
chemicals (i.e. neurotransmitters), DNA, and other mole-
cules.9"
After I lined up my putt, I struck the ball firmly and watched
the ball roll down a slope and pick up speed. Had it not hit the
hole it might have rolled ten feet past! But instead it dropped
straight into the cup.
"Nice birdie," David raised his hand for a high five, before con-
tinuing his lecture on thiamine.
"Alcoholics have an inadequate nutritional intake of thiamine
since they consume, on average, 0.29 mg that is lower than
the required minimum (0.33 mg) amount of thiamine for every
1,000 kcal.9" In a study, he said that it was observed that 40 of
the 3,000 patients with alcohol-related illnesses presented
regular symptoms of thiamine deficiency during periods of
binge drinking.9 This means that when you drink alcohol, your
body is unable to properly absorb thiamine. "In contrast, in
high concentrations, thiamine transport occurs passively—that
is, without the need for energy.9 One final way alcohol can
cause thiamine deficiency is in its utilization—magnesium is
required to metabolize thiamine in the cell, but alcohol fre-
quently leads to magnesium deficiency.9"
A Harmful Mix
"Just remember that it is not recommended to mix alcohol
with medications." Mixing certain medications with alcohol
can cause fainting, drowsiness, vomiting, headaches, breath-
ing difficulty, heart problems, bleeding, and memory impair-
ment.14
"But," David concluded, "as long as Jenny’s consumption of
alcohol remains moderate, and she makes sure to never drink
booze with her prescription medication, an occasional glass of
wine shouldn’t be a problem.”
Table 1 lists the generic names of the medications that can
lead to memory impairment when mixed with alcohol
.
73
Table 1. Medications that cause memory impairment when
mixed with alcohol.
Symptoms/disorders Medication generic name
Anxiety and Epilepsy Alprazolam, buspirone, chloridiaze-
poxide, clonazepam, diazepam, lora-
zepam, paroxetine, herbal prepara-
tions (kava kava)
Muscle pain Carisoprodol, cyclobenzaprine
Severe pain from injury, Butalbital and codeine, hydroco-
surgery, or migraines done, merepidine, oxycodone, pro-
poxyphene
Sleep problems Diphenhydramine, doxylamine, es-
tazolam, eszopiclone, temazepam,
zolpidem, herbal preparations
(chamomile, lavender, valerian)
National Institute on Alcohol Abuse and Alcoholism14

74
References
1. White AM. What Happened? Alcohol, Memory Blackouts, and the Brain. 2004; http://goo.gl/Xa0PLq. Accessed 2 February, 2016.
2. Kalin R. Effects of alcohol on memory. The Journal of Abnormal and Social Psychology. 1964;69(6):635.
3. Atkinson RC, Shiffrin RM. Human memory: A proposed system and its control processes. The psychology of learning and motivation. 1968;2:89-195.
4. Centers for Disease Control and Prevention. Impaired Driving: Get the Facts. 2015; http://goo.gl/m7BSID. Accessed 1 March, 2016.
5. Goodwin DW, Othmer E, Halikas JA, Freemon F. Loss of short term memory as a predictor of the alcoholic “blackout”. 1970.
6. Ryback RS. Alcohol amnesia: Observations in seven drinking inpatient alcoholics. Quarterly Journal of Studies on Alcohol. 1970.
7. Hartzler B, Fromme K. Fragmentary blackouts: Their etiology and effect on alcohol expectancies. Alcoholism: Clinical and Experimental Research.
2003;27(4):628-637.
8. Baer JS, Sampson PD, Barr HM, Connor PD, Streissguth AP. A 21-year longitudinal analysis of the effects of prenatal alcohol exposure on young adult
drinking. Archives of general psychiatry. 2003;60(4):377-385.
9. Martin PR, Singleton CK, Hiller-Sturmhofel S. The role of thiamine deficiency in alcoholic brain disease. Alcohol Research and Health. 2003;27(2):134-
142.
10. Appollonio I, Grafman J, Schwartz V, Massaquoi S, Hallett M. Memory in patients with cerebellar degeneration. Neurology. 1993;43(8):1536-1536.
11. Brandt J, Leroi I, O’Hearn E, Rosenblatt A, Margolis RL. Cognitive impairments in cerebellar degeneration: a comparison with Huntington’s disease. The
Journal of neuropsychiatry and clinical neurosciences. 2004.
12. Mayo Clinic Staff. Memory loss: when to seek help. 2014; http://goo.gl/lmiHmw. Accessed 10 March, 2016.
13. Brody JE. It could be old age, or it could be low B12. The New York Times. 28 November, 2011.
14. National Institute on Alcohol Abuse and Alcoholism. Harmful interactions: mixing alcohol with medicines. National Institutes of Health; 2003.
15. National Institues of Health: Office of Dietary Supplements. Vitamin B12 fact sheet for health professionals. 2016; https://goo.gl/XiqOu9, 2016.
16. Web MD. Vitamins and Supplements Lifestyle Guide: Vitamin B-12 (Cobalamin). 2016; http://goo.gl/hmuAFE. Accessed 4 March, 2016.
17. Higdon J. Vitamin B12. 2000; http://goo.gl/Pd1FXZ. Accessed 3 March, 2016.
18. Martin P. Molecular mechanisms of thiamine utilization. Current molecular medicine. 2001;1(2):197-207.

75
 nearly 7 million people in the United States. Out of this num-
Stroke ber, 80% of the individuals are over the age of 65.2 The disabil-
ities that accompany stroke create a considerable financial
It kills me every time I think about how I will never remember
what I have already forgot. burden on the healthcare system, including public measures,
— Anonymous such as Medicare and caregivers.3

During my research on memory, I just assumed that the link Cognition involves mental processes, which include re-
between a stroke and memory loss had nothing to do with my membering, thinking, problem-solving, judging, and
mother. Although I was confident that Jenny never suffered knowing; these processes help us to comprehend and
from a stroke, after compiling together the facts, I wasn't so gain know-
sure. ledge.4

What is a stroke? A stroke occurs when there is bleeding or

‘hemorrhage’ inside the brain, or when a sudden interruption
in the blood flow to the brain occurs due to a clot.1

Twenty percent of strokes occur as a consequence of bleeding

in the brain (hemorrhagic stroke). The other 80% occur when
clots in the heart or the neck block an artery that supplies
blood to the brain resulting in an ischemic stroke.1

In the United States, 795,000 individuals suffer from stroke

(recurrent or first) annually. Chronic stroke is prevalent in
76
Effects of Stroke on Memory When the brain starts losing nerve cells it can result in memo-
ry loss.5 In the case of a stroke, when the blood supply to a
One of the major disabilities caused by a stroke is cognitive
particular area in the brain is cut off, it causes cells in that area
impairment.3 Among stroke patients, one-third will develop
of the brain to die. When the affected area of the brain hap-
problems with their memory.5
pens to control memory, individuals begin to suffer from
Here is a list of the additional changes that a stroke often con- memory loss.9
tributes to6:
Even before a stroke has occurred, older individuals often
 Behavioral changes
show a rapid decline in memory. Women, in particular,
 Paralysis
show a rapid decline in memory before the onset of
 Inability to control emotions
stroke. However, the race (black, Asian, white) of an
 Difficulty taking care of oneself
individual does not have any effect on the rate of
 Complications in reading, writing, speech, and analytical
memory decline.10
thinking
Risk Factors for Dementia Connected to Stroke
Did you know that approximately
one-quarter of the total number Individuals with dementia find it difficult to recollect words,

of human genes are manifested register names, learn new information, and can find them-

in the brain? The cerebrum of the selves feeling lost in familiar places.5 Dementia can develop

brain contains more than 20 bil- either before or following a stroke.11

lion nerve cells that transmit informa-

tion to and from both the brain and the spinal cord.7,8

77
 Dementia is a term used to describe the condition of  Delirium
memory loss that affects day-to-day activities. Older  Seizures
people display signs of dementia. If a stroke is the only  Reduced educational level
1
cause of dementia, then it is termed vascular dementia.  Recurrence of stroke
 Number of brain lesions
The risk factors predisposing an individual to develop demen-
 Damage to the white matter in the brain
tia before a stroke are:11
 Family history There appears to be a correlation between dementia and
 Deterioration of a region in the brain stroke. Dementia can cause stroke while stroke increases
 Old age the risk of developing dementia. Approximately 10% of
 Female gender patients with preexisting dementia suffer from a first
stroke while 10% of patients who suffer from stroke for
The risk factors predisposing an individual to develop demen-
the first time develop dementia within the first year.11
tia following a stroke are:5,11,12
 Stroke in the left side of the brain Individuals with higher education have a greater reserve of
 Old age cognitive function and a lifestyle that appears to protect them
 Numerous strokes from the effects of stroke. On the other hand, lower education
 Previous memory issues levels can increase an individual's risk of reduced memory, and
 High blood pressure decreased perception.12

 Smoking
 Problems in the heart

78
Silent Stroke
A silent stroke occurs when a section of the brain is damaged
and does not receive blood. The damaged brain area does not
control the essential functions of speech or memory. So, the
individual remains unaware that they have suffered a stroke.
This information made me take pause for thought. What if
Jenny had a silent stroke? She might not even be aware that
she suffered from one.
the brain even though the subjects had not demonstrated any
physical symptoms of stroke during their lives. Such individu-
als may have had mild cognitive impairment, such as slight
memory issues, but their daily life remained undisrupted.13
Although I was initially confident that my mother did not have
a stroke, the more I read, the less convinced I was of the fact.
So, I made a note to myself to ask Jenny's neurologist about
the possibility that my mother may have had a silent stroke.

What was even more troublesome was the revelation that

when an individual experiences a large number of these silent
strokes, the brain's cognitive functions and memory become
increasingly affected. For every individual that suffers from a
regular stroke, 14 people will suffer a silent stroke. The statis-
tics also indicate that one-third of the population above the
age of 70 suffer from silent strokes.9 And individuals who suf-
fer from diabetes or high blood pressure may be more likely to
experience silent strokes.1

During a study in which autopsies were performed on de-

ceased patients, researchers noted stroke-related changes in

79
Types of memory affected by stroke ers individuals struggling to remember faces, places, or things.
When a stroke occurs on the right side of the brain the verbal
Stroke can affect memory in different ways depending on the
memory is obscured, and individuals are unable to remember
area of the brain that has been affected. When the left side of
stories, words and/or names.5,14
the brain is affected, the resulting loss in visual memory rend-

Fun fact: During the 19th century, people with particular types of brain injuries made it possible for scientists to discover that lan-
guage skills were housed in the left hemisphere of the brain. Lesions growing in specific areas of the left hemisphere of the brain re-
sulted in people with those lesions to lose their speech. Experiments performed by Roger Sperry in the 1960s confirmed this fact.
Sperry, who was awarded a Nobel prize for his discoveries, explored the distinct and specific functions of each of the cerebral he-
mispheres. Sperry and his colleagues also examined people suffering from epilepsy where the connection (corpus callosum) between
both the hemispheres of their brain was surgically cut. The corpus callosum helps transfer signals between the right and left hemis-
pheres. Sperry and his surgical team got the opportunity to study the activity that occurred in each hemisphere of the brain inde-
pendently due to the surgery and proved that the two halves of the brain each performed distinct tasks.15

Did you know that deficits in cognitive functioning pre-
dict a risk of stroke? Memory decline is often rapid be-
fore a stroke occurs and it may be a sign of brain disease.
Silent strokes and an interruption in blood flow may
make an individual prone to stroke.16
Did you know that in 1978, the first research paper that
showed aspirin prevents stroke, was published?17
Diagnosis of Cognitive Impairment Following a Stroke
To determine the kind of rehabilitation program or treatment
that is necessary for patients with cognitive disorders caused
by stroke, cognitive deficits in the patient must first be as-
sessed. The features evaluated are:18
 The history of the patient (background and behavior)
 Patient complaints
80
 Motor functions (speech and voice) Rehabilitation programs
 Memory
Cognitive impairment can affect the quality of daily life of
 Language
people who have had a stroke. Cognitive impairment increases
 Attention
disability and reduces recovery following a stroke. Cognitive
 Visuospatial and visuoperception skills (understanding the
rehabilitation is effective when it is conducted in the initial
position and distribution of objects in our immediate envi-
weeks following a stroke.21
ronment with the help of our vision)
 Orientation Rehabilitation involves retraining methods that are beneficial
when implemented soon after a stroke. During the early phase
 Day-to-day activities
following a stroke, the connections in the undamaged section
Did you know that in 1970, research revealed that of the brain are trained with these retraining methods (e.g.
hypertension is an important risk factor that can poten- repetitive exercises). The rehabilitation is effective due to the
17
tially cause a stroke? natural recovery potential of the brain. Normally, retraining

Imaging the brain is a good way to diagnose strokes that may methods are only used following a mild stroke. In severe cas-

cause memory loss. Magnetic resonance imaging (MRI) and es, when the nerve circuits are considerably damaged, other

computerized axial tomography (CAT) are brain imaging tech- kinds of exercises are suggested to make up for the loss of

niques to detect tumors or strokes.19 Neurospsychological as- functions the individual is experiencing.21

sessments are used to assess the patient before initiating The following list includes the types of rehabilitation programs
20
treatment. for amnesia. They include strategies to deal with memory loss
as well as memory retraining programs:18

81
 Teaching specific skills Training with music has also been found to be effective. A
 Rhymes, mnemonics, visual images, and external aids rhythmic pattern of training actually improves memory and
 Recognize people based on the badges they wear and the helps individuals tackle information that is neither related to
unique clothing they wear the music nor to the rhythm.22

 Identify places with distinct landmarks, signs, and doors

The success of a rehabilitation program depends on the reha-
with color codes
bilitation team, the intensity of injury, the involvement of the
 Keep a track of time with pagers, timers, organizers, or
caregivers, and the time at which rehabilitation begins.5
reminders from loved ones

Secret Ingredients to Long Life? A review focused on potential ingredients that may be the secret
for a long, healthy life free of complications associated with old age, such as cardiovascular disease
and brain damage. It was found that Ashkenazi Jews, Japanese Hawaiian men, centenarians are
groups of people who live long lives with fewer complications, such as heart disease and cogni-
tive impairment. Some of the key features noted in these particular groups are the large particle
size of low density and high density lipoproteins (Ashkenazi Jews), low blood glucose (Japanese Hawaiian men), low blood pressure
(Japanese Hawaiian men), no cigarette smoking (Japanese Hawaiian men), and perhaps a specific region on chromosome 4 (centena-
rians), may be some of the contributing secret ingredients that control longevity.7

82
Pharmaceutical Therapies for Cognitive Deficits due to Stroke following preventive measures are key to reducing the risk of
stroke:1
There are no specific medications to treat memory loss due to
 Regular exercise
stroke.5 Inhibitors of acetylcholinesterase (a brain chemical)
 Quit smoking
are being evaluated for their effects in treating memory loss
 Practice good, healthy eating habits
and cognition deficits.18 Medications for Alzheimer’s disease
 Maintain normal cholesterol levels
are sometimes prescribed. Of course, some patients are able
 Keep blood pressure under control
to recover their cognitive
 Go for regular medical checkups
functions on their own
without rehabilitation or  Control diabetes19

medication. But when re- Conclusion

habilitation is used, it is
Stroke is a condition that appears to be largely associated with
dependent on the degree
old age. Research shows that memory decline could be a
of injury and the area of
warning sign of stroke. Many individuals actually suffer from
the brain that is injured.5
stroke (silent stroke) without being aware of it. I had my fin-
Ways to prevent memory loss due to stroke gers crossed that Jenny's condition wasn't the result of a

As mentioned previously, there are no medications that can stroke, hoping that her condition was the result of her diet.

restore memory following a stroke and so, the first thing to do But with that in mind, I kept an open mind about rehabilita-
is to avoid creating a condition that can cause a stroke. The tion programs designed to manage memory loss due to stroke.
The techniques involve repetitive training ideally combined
83
with music to strengthen the existing active nerve networks.
Preventive strategies of keeping the brain active with puzzles
and board games will also prevent our memory from taking a
walk! Play games, such as board games, dominoes, card
games, word games, computer games, and crossword puzzles
to improve your memory!14

84
References
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2. Veerbeek JM, van Wegen E, van Peppen R, et al. What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. PLoS
One. 2014;9(2):e87987.
3. Levine DA, Galecki AT, Langa KM, et al. Trajectory of Cognitive Decline After Incident Stroke. JAMA. 2015;314(1):41-51.
4. Moncayo R, Ortner K. Multifactorial determinants of cognition - Thyroid function is not the only one. BBA Clin. 2015;3:289-298.
5. Novitzke J. Privation of Memory: What can be done to help stroke patients remember? J Vasc Interv Neurol. 2008;1(4):122-123.
6. Staff MC. Stroke - Overview. 2016.
7. Gorelick PB. William M. Feinberg Lecture: Cognitive vitality and the role of stroke and cardiovascular disease risk factors. Stroke. 2005;36(4):875-879.
8. Merriam-Webster. Nerve.
9. Watch HWsH. Could a silent stroke erode your memory? 2012.
10. Wang Q, Mejia-Guevara I, Rist PM, Walter S, Capistrant BD, Glymour MM. Changes in memory before and after stroke differ by age and sex, but not by
race. Cerebrovasc Dis. 2014;37(4):235-243.
11. Pendlebury ST. Dementia in patients hospitalized with stroke: rates, time course, and clinico-pathologic factors. Int J Stroke. 2012;7(7):570-581.
12. Khedr EM, Hamed SA, El-Shereef HK, et al. Cognitive impairment after cerebrovascular stroke: Relationship to vascular risk factors. Neuropsychiatr Dis
Treat. 2009;5:103-116.
13. Gamaldo A, Moghekar A, Kilada S, Resnick SM, Zonderman AB, O'Brien R. Effect of a clinical stroke on the risk of dementia in a prospective cohort.
Neurology. 2006;67(8):1363-1369.
14. Sheet RF. Memory Problems. 2011.
15. Nobel Media A. The Split Brain Experiments. 2014.
16. Wang Q, Capistrant BD, Ehntholt A, Glymour MM. Long-term rate of change in memory functioning before and after stroke onset. Stroke.
2012;43(10):2561-2566.
17. Hachinski V, Donnan GA, Gorelick PB, et al. Stroke: working toward a prioritized world agenda. Int J Stroke. 2010;5(4):238-256.
18. Alladi S, Meena, A.K., Kaul, S. Cognitive rehabilitation in stroke: therapy and techniques. Neurology India. 2002;50(s1):S102-S108.
19. Administration USFaD. Coping with memory loss. 2010.
20. Duncan PW, Zorowitz R, Bates B, et al. Management of Adult Stroke Rehabilitation Care: a clinical practice guideline. Stroke. 2005;36(9):e100-143.
21. Zucchella C, Capone A, Codella V, et al. Assessing and restoring cognitive functions early after stroke. Funct Neurol. 2014;29(4):255-262.
22. Galinska E. Music therapy in neurological rehabilitation settings. Psychiatr Pol. 2015;49(4):835-846.

85

Hypertension
Grandpa's mind left us, gone wild and wary. When I walked with him
I could feel how strange it was. His thoughts swam between us, hid-
den under rocks, disappearing in weeds, and I was fishing for them,
dangling my own words like bait and lures.
— Louise Erdrich, Love Medicine
The sheer number of causes associated with
memory loss blew me away. I always knew
that the brain was a complex organ, but I
had no idea how vulnerable it was to dis-
ease and injury. I had already arranged
an appointment with the neurologist for
my mother; and since we had a couple of
weeks to wait, I started looking into the po-
tential sources of her memory lapses. Believe me
when I say that it was an overwhelming needle in the haystack
type scenario! But during my research, I did discover a handful
of articles that suggested short term memory loss may be at-
tributed to high blood pressure. It gave me pause for thought,
and I wondered if that might be the reason for my mother’s
difficulties with her memories.
My mother had been diagnosed with high blood pressure a
couple of years earlier, and she has been taking prescription
medication to combat the ailment ever since.
High blood pressure, I learned, is a health prob-
lem, which affects approximately 65 million
Americans, and that number continues to
rise.1 Ideally, blood pressure should be
less than 120/80 in adults above the age
of 20.2 Anyone with blood pressures
above 140/90 is considered to have
hypertension.2
While there are numerous causes of memory im-
pairment, hypertension stands out because it has been impli-
cated as a risk factor for developing both vascular and Alzhei-
mer’s dementia.3,4
When a person, like my mom, has hypertension, it results in
the thickening of the walls of the blood vessels leading to a
86
structural change of the vessel.5 When this happens, the resis-
tance in the blood vessels can no longer be reversed.5 This
damage causes blood vessels to become narrow and results in
less blood being able to flow through.1 When the brain
doesn’t get ample blood supply, it is no longer able to work at
its optimal level resulting in damaging effects, such as memo-
ry.1 The brain needs blood as the blood brings nutrients and
other substances required for it to work properly. Blood is also
responsible for removing toxic substances from the brain.6
A study found that being multilingual
(speaking more than two languages) is
associated with a delay in the develop-
ment of Alzheimer’s disease.7
In one study, differences in blood flow in the areas of the
brain involved with memory were looked at in people who
have hypertension and compared with those with normal
blood pressure. Spatial memory and verbal memory were
tested, and a brain scan (PET scan) was simultaneously per-
formed to measure the blood flow and detect which parts of
the brain were getting blood during the memory tests.1 To
measure verbal memory, the participants were asked to recol-
lect words; while for spatial memory, the participants were
asked to recall the positions of the items on the computer
screen.1
During the test, it was seen that people who had hypertension
had reduced blood flow to the areas that are usually involved
with memory, even though both groups performed similarly in
the memory tests.1 It was also seen that there was increased
blood flow to the other parts of the brain (not involved in
memory) in the group with hypertension than in the group
whose blood pressure was normal. The study concluded that
although people with high blood pressure were able to per-
form adequately by recruiting other regions of the brain, per-
sistent hypertension would eventually result in memory loss.1
87
Fun fact: Roman physician, Galen, after observing the effects of brain injuries on mental capacity concluded that the brain, not the
heart, was the site of the inner self. Although Galen had hit the mark, some of his other observations concerning the brain were wild-
ly inaccurate. The brain, he wrongly concluded, was a damp organ that was cold and consisted entirely of sperm.8

Another research study demonstrated similar observations
when they compared three groups of people: no hyperten-
sion, newly diagnosed hypertensive patients who were not
treated with any medications, and patients with previously
diagnosed hypertension who were treated with drugs.9 These
groups were tested with various neuropsychological tests that
measure eye-hand coordination, memory, and reasoning abili-
ties.9 Results showed that there was a similar decline in short-
term memory and eye-hand coordination between those with
previously diagnosed hypertension who were being treated
and the newly diagnosed patients with high blood pressure.9
However, the group with normal blood pressure outper-
formed the other two groups in the tests.9
Despite the fact that normal aging also comes with some cog-
nitive decline, some researchers delved deeper to see wheth-
er high blood pressure was a risk factor on its own, separate
from aging.10 Men and women over the age of 60 were admi-
nistered the Mini-Mental State Examination (to assess atten-
tion, recall, and orientation), their blood pressure was meas-
ured, and they were asked about their blood pressure history
and management.10 Results showed that people who had op-
timal blood pressure (less than 120/80) had the best measures
of cognitive function when compared with those who had high
blood pressure.10
Did you know that the brain con-
tains about 100 billion
neurons?!11 That’s roughly the
same amount of stars in the Milky
Way!12
Do medications used to control blood pressure have a positive
effect on memory and cognitive function? While some medi-
cations helped to prevent worsening of cognitive functions,
88
others demonstrated no effect.13,14 thiazide, did not exhibit the same findings.16 Therefore, it is
However, individuals over 60 difficult to say whether antihypertensive drugs are beneficial
years old who were given or not with regards to the prevention of cognitive impairment.
medications for high blood
What do the top and bottom number of a blood pressure
pressure, a calcium channel
reading mean?2
blocker, had a reduced
dence of dementia.15 It was noted Let’ use 145/95 as an example. The top number (Systolic)

that when blood pressure medications were used for long pe- is the measure of the blood pressure during a heartbeat.

riods of time, it led to fewer incidences of dementia (vascular The bottom number (Diastolic) is the measure of the

and mixed) as well as Alzheimer’s disease.15 blood pressure between heartbeats.

Other blood pressure medications, such as beta-blockers, ACE

inhibitors (angiotensin II-converting enzyme inhibitor), or thia-
zide diuretics, which were used to treat blood pressure did not
provide any protection against dementia or cognitive impair-
ment.15 The antihypertensive drug losartan (an ACE inhibitor)
was seen to have positive effects on cognitive functions, while
those who took another antihypertensive drug, hydrochloro-

89
References
1. Mercado JM, Hilsabeck R. Untreated hypertension can lead to memory loss by cutting down on blood flow to the brain. Neurology. 2005;64(8):E28-
E29.
2. American Heart Association. Understanding blood pressure readings. American Heart Association. http://goo.gl/oQMx9a. 2016. Accessed 15 June,
2016.
3. Peters R, Beckett N, Forette F, et al. Incident dementia and blood pressure lowering in the Hypertension in the Very Elderly Trial cognitive function
assessment (HYVET-COG): a double-blind, placebo controlled trial. The Lancet Neurology. 2008;7(8):683-689.
4. Sink KM, Leng X, Williamson J, et al. Angiotensin-converting enzyme inhibitors and cognitive decline in older adults with hypertension: results from the
Cardiovascular Health Study. Archives of internal medicine. 2009;169(13):1195-1202.
5. Beevers G, Lip GY, O'Brien E. ABC of hypertension: the pathophysiology of hypertension. British Medical Journal. 2001;322(7291):912.
6. Iadecola C, Park L, Capone C. Threats to the mind aging, amyloid, and hypertension. Stroke. 2009;40(3 suppl 1):S40-S44.
7. Chertkow H, Whitehead V, Phillips N, Wolfson C, Atherton J, Bergman H. Multilingualism (but not always bilingualism) delays the onset of Alzheimer
disease: evidence from a bilingual community. Alzheimer Disease & Associated Disorders. 2010;24(2):118-125.
8. A history of the brain. Stanford University. https://goo.gl/ZryOJs. 15 June, 2016.
9. Franceschi M, Tancredi O, Smirne S, Mercinelli A, Canal N. Cognitive processes in hypertension. Hypertension. 1982;4(2):226-229.
10. Obisesan TO, Obisesan OA, Martins S, et al. High blood pressure, hypertension, and high pulse pressure are associated with poorer cognitive function
in persons aged 60 and older: the Third National Health and Nutrition Examination Survey. Journal of the American Geriatrics Society. 2008;56(3):501-
509.
11. Azevedo FA, Carvalho LR, Grinberg LT, et al. Equal numbers of neuronal and nonneuronal cells make the human brain an isometrically scaled‐up
primate brain. Journal of Comparative Neurology. 2009;513(5):532-541.
12. Howell E. How many stars are in the Milky Way? Space.com. http://goo.gl/C9DKuu. 2014. Accessed 15 June, 2016.
13. Prince MJ, Bird AS, Blizard RA, Mann AH. Is the cognitive function of older patients affected by antihypertensive treatment? Results from 54 months of
the Medical Research Council's treatment trial of hypertension in older adults. Bmj. 1996;312(7034):801-805.
14. Peila R, White LR, Masaki K, Petrovitch H, Launer LJ. Reducing the risk of dementia efficacy of long-term treatment of hypertension. Stroke.
2006;37(5):1165-1170.
15. Forette F, Seux M-L, Staessen JA, et al. The prevention of dementia with antihypertensive treatment: new evidence from the Systolic Hypertension in
Europe (Syst-Eur) study. Archives of internal medicine. 2002;162(18):2046-2052.
16. Tedesco MA, Ratti G, Mennella S, et al. Comparison of losartan and hydrochlorothiazide on cognitive function and quality of life in hypertensive
patients. American journal of hypertension. 1999;12(11):1130-1134.

90

Hypothyroidism
Bad days my memory functions no better than an out-of-focus kalei-
doscope, but other days my recall is painfully perfect.
— Mordecai Richler
While researching the various conditions that cause memory
loss, I was surprised to discover a co-relation between the thy-
roid gland and cognitive difficulties. I had no clue that hypo-
thyroidism, a medical condition where the thyroid gland is not
producing the necessary amounts of thyroid hormones, can
affect memory and cognitive abilities.1
Cognition involves mental processes, which include re-
membering, thinking, problem-solving, judging, and ga-
thering and retaining information. The application of
these processes helps us to comprehend and gain know-
ledge.2
The human brain needs thyroid hormones. Even in the womb,
the human organism requires thyroid hormones that are pro-
vided by the mother during the first trimester after which the
fetus develops its own thyroid system.3Thyroid hormones are
essential for the maturation and the development of the
brain,4 and a deficiency in the hormone has a significantly
negative influence on cognitive functions and mood (neurop-
sychiatric functions).5The brain of people with hypothyroidism
is affected in varying degrees throughout their lives.4
Did you know that there are 2 types of thyroid hor-
mones: tri-iodothyronine (T3) and thyroxine (T4)? These
hormones regulate the genes that control memory?6
Types of hypothyroidism
Even though hypothyroidism is due to a deficiency in thyroid
hormones, there are differences in how the condition devel-
ops. That said, you have two different types of hypothyroid-
ism, classified by how the deficiency develops: primary and
secondary.
Primary hypothyroidism is believed to be a problem that oc-
curs in the thyroid gland itself. It results in lower production
levels of the hormone or no thyroid hormones produced at
all.7
91
Secondary hypothyroidism is due to a problem that exists in agnosed in the elderly. Executive functions (reasoning, plan-
the structures of the brain, hypothalamus, or pituitary gland. ning) and memory are the most common cognition problems
In such cases, the structures are unable to send signals from facing individuals with this condition.5
the brain to the thyroid gland to produce thyroid hormones.7
Patients, who are unaware that they have mild hypothyroid-
Primary hypothyroidism is further classified into overt hypo- ism, tend to be unaware of their cognitive issues. But on the
thyroidism and subclinical or mild hypothyroidism. In the flip side, if the individual is aware that they are affected with
former, cognitive deficits are evident, but such symptoms ap- mild hypothyroidism, then they tend to be more acutely
pear milder in the latter condition due to an imbalance in the aware of their cognitive issues.5
thyroid-stimulating hormone, which is high in both cases. Also,
the thyroxine hormone is low or average in overt and mild hy-
pothyroidism, respectively.5The effects of these two forms of
hypothyroidism regarding mood and cognitive functions of the
brain vary from individual to individual.5,7

Overt hypothyroidism affects cognitive functions, especially

memory. Verbal memory (e.g. recollecting names, places, or
numbers8) is also impacted in individuals suffering from the
condition.9

In subclinical or mild hypothyroidism, the deficits in cognition

are not as severe. This type of hypothyroidism is typically di-

92
Sometimes, to understand if memory loss or other forms Hypothyroidism in Adults
of cognitive decline are caused by hypothyroidism, the
Adults with hypothyroidism experience symptoms of confu-
recommended procedure is to measure the level of thy-
sion, learning deficits, hallucinations, memory deficits, and
roid-stimulating hormone (TSH) in the serum. This proce-
psychotic behavior. But replacing thyroid hormones appears
dure is the most reliable way to distinguish the difference
to reduce the deficits and subsequent difficulties.6
between cognitive deficits due to thyroid deficiency and
cognitive deficits caused by other conditions.5 1.7-5.7% of children are affected with mild hypothyroid-
ism.10

Lithium Drugs and Hypothyroidism

Lithium drugs can induce hypothyroidism in adults when used

over extended periods. Lithium drugs are often used to treat
bipolar depression. Middle-aged women are most vulnerable
to this form of hypothyroidism.11

Did you know that when the thyroid does not function
well, there is resulting memory and sleep problems, and
an inclination towards depression?12

93
Symptoms and Diagnosis of Hypothyroidism
It is difficult to diagnose the effects of hypothyroidism on cog-
nition as the effects themselves are difficult to detect.
Some of the physiological changes that occur because of hypo-
thyroidism are:11
 Voice change
 Reduced appetite
 Puffed-up and pale complexion
Treatment of Cognitive Deficits Associated with Hypothyroid-
ism
Levothyroxine (L-T4) (Synthroid, Levothroid) replacement
therapy appears to be the treatment of choice to improve
cognitive functions and memory in patients with hypothyroid-
ism.13-15Problems with mood and cognition have
been reversed with the use of Synthroid.16
However, in some patients, the symp-

 Dry and rough skin toms remain unresolved despite the L-T4

 Hair loss treatment.14,15 For example, cognitive

functions were unaffected in patients over
People should pay a visit to their doctor
the age of 65 years when they were subjected to
if they notice any of the following psycho-
thyroxine replacement therapy (TRT).17This may be explained
11
logical symptoms:
by genetic differences of the patients.5
 Reduction in their IQ
 Retardation of mental faculties Usually, treatment with levothyroxine is a lifelong commit-

 Confused thought processes ment.13So, if you do have hypothyroidism and are taking levo-

 Memory issues thyroxine, don’t forget to go to your scheduled appointments

with your physician as he/she needs to check your hormone
 Gradual disinterest in hobbies and passions
 Depression
94
levels annually to ensure that your treatment is going as
planned.13
In 2009, the effects of long-term treatment for hypothyroid-
ism with L-thyroxine were studied in a group of older adults.
Even after twenty years, it was concluded that the medication
did not result in adverse effects.18
When levothyroxine replacement (L-T4) therapy is provided, it
restores cognitive functions within 6 months.5
New treatment: Atomoxetine is a new drug prescribed
for the treatment of attention deficit hyperactivity dis-
order (ADHD). Atomoxetine is effective in reducing the
cognitive deficits in children with ADHD and congenital
hypothyroidism. Future studies need to confirm this posi-
tive effect.15
Magnesium: Recent research has shown that reduced magne-
sium levels often result from psychological or physical
(changes in the muscle and skeletal systems) stress. This type
of stress is observed in hypo- and hyperthyroidism. Magne-
sium citrate that is used to treat low magnesium levels can
help treat cognitive deficits and thyroid deficiency.2
Neuropsychological Tests
Additionally, neuropsychological tests help to provide a proper
assessment of cognitive function following therapy.10
Conclusion
It is crystal clear that our thyroid glands play a major role in
regulating our memory and personality. There are two main
types of thyroid deficiencies that influence memory by affect-
ing the hippocampus and the frontal cortex of the brain. Levo-
thyroxine (L-T4) replacement therapy is currently used to treat
cognitive deficits. In addition, neurological assessment tests
can detect and confirm the degree of cognitive deficits af-
fected by thyroid deficiency. The stage at which the deficiency
is treated can influence the degree of improvement of the
cognitive functions.
95
References
1. A G. Subclinical Thyroid Disease. Clinical Thyroidology for Patients. 2012;5(6):6-7.
2. Moncayo R, Ortner K. Multifactorial determinants of cognition - Thyroid function is not the only one. BBA Clin. 2015;3:289-298.
3. Willoughby KA, McAndrews MP, Rovet JF. Effects of maternal hypothyroidism on offspring hippocampus and memory. Thyroid. 2014;24(3):576-584.
4. Dugbartey AT. Neurocognitive aspects of hypothyroidism. Arch Intern Med. 1998;158(13):1413-1418.
5. Samuels MH. Psychiatric and cognitive manifestations of hypothyroidism. Curr Opin Endocrinol Diabetes Obes. 2014;21(5):377-383.
6. Rivas M, Naranjo JR. Thyroid hormones, learning and memory. Genes Brain Behav. 2007;6 Suppl 1:40-44.
7. Khandelwal D, Tandon N. Overt and subclinical hypothyroidism: who to treat and how. Drugs. 2012;72(1):17-33.
8. Sheet RF. Memory Problems. 2011; http://goo.gl/2nffm6. Accessed 16 June, 2016.
9. Oerbeck B, Sundet K, Kase BF, Heyerdahl S. Congenital hypothyroidism: no adverse effects of high dose thyroxine treatment on adult memory,
attention, and behaviour. Arch Dis Child. 2005;90(2):132-137.
10. Sangun O, Demirci S, Dundar N, et al. The Effects of Six-Month L-Thyroxine Treatment on Cognitive Functions and Event-Related Brain Potentials in
Children with Subclinical Hypothyroidism. J Clin Res Pediatr Endocrinol. 2015;7(2):102-108.
11. Awad A. The thyroid and the mind and emotions/Thyroid dysfunction and mental disorders. Thyrobulletin. 2000;7(3).
12. Pendick D. 7 common causes of forgetfuless. Harvard Health Blog 2013; http://goo.gl/l6cXLU. Accessed 16 June, 2016.
13. Mayo Clinic Staff. Hypothyroidism (underactive thyroid) - Treatment. 2015; http://goo.gl/D4LKol. Accessed 16 June, 2016.
14. Trachtenberg E, Passos IC, Kleina WW, Rocha NS, Fleck MP. Hypothyroidism and severe neuropsychiatric symptoms: a rapid response to
levothyroxine. Rev Bras Psiquiatr. 2012;34(4):501-504.
15. Yang R, Gao W, Li R, Zhao Z. Effect of Atomoxetine on the Cognitive Functions in Treatment of Attention Deficit Hyperactivity Disorder in Children with
Congenital Hypothyroidism: A Pilot Study. Int J Neuropsychopharmacol. 2015;18(8).
16. Miller KJ, Parsons TD, Whybrow PC, et al. Memory improvement with treatment of hypothyroidism. Int J Neurosci. 2006;116(8):895-906.
17. Parle J, Roberts L, Wilson S, et al. A randomized controlled trial of the effect of thyroxine replacement on cognitive function in community-living
elderly subjects with subclinical hypothyroidism: the Birmingham Elderly Thyroid study. J Clin Endocrinol Metab. 2010;95(8):3623-3632.
18. Kramer CK, von Muhlen D, Kritz-Silverstein D, Barrett-Connor E. Treated hypothyroidism, cognitive function, and depressed mood in old age: the
Rancho Bernardo Study. Eur J Endocrinol. 2009;161(6):917-921.

96
Nutrition and Brain Health

97

Choline
Memory is the diary that we all carry around with us.
— Oscar Wilde
Lily, a dietitian, is a childhood friend of mine. Her family lived
two doors down from us when we were growing
up. As children, we were best of friends.
Along with her two brothers and my sis-
ter, we spent countless hours hanging
out together.
Recently when my wife and I were at
the mall shopping, we ran into Lily and
her husband. As we were catching up, Lily
inquired about my mother Jenny. When I
mentioned her cognitive difficulties and memory
lapses, Lily expressed genuine concern. She spoke about a re-
cent client suffering from similar circumstances, and how the
client's poor diet contributed to her declining mental state.
I wondered aloud if my mom’s memory lapses might be nutri-
tional in nature.
"Why not bring her by my office?"
She said that by adopting a nutritious diet that feeds the brain,
my mother's cognitive difficulties could be lessened
significantly.1
My mother was reluctant to see a dieti-
tian because she kept insisting that her
memory had returned to normal ever
since the incident at the market. But
when I reminded her that it was Lily,
who she would be speaking with, she
warmed up to the idea.
Well, let me tell you the rendezvous with Lily was a
revelation. My mother was so happy to see Lily, she opened
up immediately and spoke honestly about her eating habits.
Lily kept notes trying to determine whether or not my moth-
er's diet was providing her with certain nutrients and essential
compounds necessary for optimum brain function.
98
She explained to us that a loss of mental agility may be due to
the failure of brain cells and billions of neurons to communi-
cate effectively. When your brain doesn't get enough vitamins,
minerals, and other nutrients (more than 40 nutrients are im-
plicated in brain function!) to keep it running properly, it
1
shorts out.
During the conversation, I mentioned to Lily that my mother
never eats eggs. "They’re disgusting!" Jenny shook her head,
"I've never been able to stomach them."
The dietitian smiled, and I continued. "I recently read that cho-
line is necessary for brain function. And because eggs are such
a rich source of the nutrient, I was wondering if my mom may
be choline deficient?"
Lily nodded, "Although choline is imperative for brain func-
tion, eggs are not the only source of the nutrient."
Choline, she explained, was previously considered as a non-
essential nutrient because our bodies are capable of manufac-
turing it in small amounts.2 But in 1998, there was a huge leap
in its status to essential nutrient after choline-deprived men
experienced organ dysfunction.2 So today, choline is now re-
garded as a vitamin-like nutrient and is often put in the same
family as the B-vitamins.3
Some nutrients possess the characteristics of vitamins,
but do not meet all the requirements to be termed such. 4
Instead, they are known as “quasi-vitamins”, and choline
is one of them.4 Since the body synthesizes choline in
small amounts, supplements may be required at certain
stages of development or as a consequence of a health
condition.4
Although the liver tucks away most of the choline in your
body, the kidneys and the brain also have a stash of their own,
the dietitian explained.5 Choline is found in every cell mem-
brane and is a vital nutrient for growth and development.5
"What does choline do?" My mother leaned forward.
“Well, one of its primary functions,” Lily responded, “is the
removal of the amino acid homocysteine from your body. Too
much of that amino acid can increase your risk of cognitive
decline.”6 "When the body contains too little choline, it can
99
lead to muscle damage and result in a “fatty liver”, as noted in
human studies where subjects were kept on low-choline diets
for several weeks or months." She continued to explain how
postmenopausal women are at a greater risk of being choline-
deficient.5,7 "Since estrogen is involved in the synthesis of cho-
line, premenopausal women who have higher levels of estro-
gen compared with postmenopausal women appear to with-
stand choline deficiency in a better manner.”7,8
Phosphatidylcholine is a part of the lipid-transporting
system in the blood. Choline deficiency impairs the pro-
duction of phosphatidylcholine and prevents fat or lipids
8
from being transported out of the liver. Lipids remain in
the liver causing the liver to become “fat”.
For obvious reasons, the demand for
choline is particularly high and criti-
cal during pregnancy and lacta-
tion.5 It was previously reported
that less than 15% of women con-
sume the recommended quantities of
choline.5" My mother and I were informed that there is a 4-
fold increased risk of babies with neural tube defects in wom-
en who consumed lesser amounts of choline, while the risk of
babies with cleft palate increased 2-fold.5 Furthermore, the
hippocampus (region of learning and memory) in the brain is
possibly the most sensitive to the effects of choline.8
Recommended Intake of Choline
Lily explained that the average intake range is quite large8
(200-600 mg per day).9 Above the age of 19, the recommend-
ed adequate intake (AI) for men is 550 mg per day, and it is
425 mg per day for women.10 However, these values may vary
depending on the stage of life, gender, lactation, pregnancy,
and intake of methionine (an amino acid used to synthesize
choline) and folate (a vitamin implicated in the conversion of
homocysteine) in the diet.10
Food Sources of Choline
Choline is present in foods either in free form or in other com-
plexes, such as lecithin.5 However, the percentage of absorp-
tion among the different forms has not been calculated.5
100
The best sources of choline, my mother and I were told, are
found mainly in foods that contain membranes;5 such as egg
yolks, pork, and glandular meats (brain, liver, kidney).11 Plant-
based foods, such as peanuts, soybean products, and wheat
germ also contain choline.11
Eating two eggs can double the amount of choline in the
blood.5
Adverse Effects
The dietitian warned that ingesting too
much choline (> 6 g) can cause vomiting,
gastrointestinal discomfort, sweating, and
salivation.5 The upper limit (UL) for cho-
line is set at 3.5 g per day from foods and
supplements.10

Table 2. Choline Content of Foods12 Choline Supplements

Foods Serving Choline content (mg/g) Although some people may be tempted to take choline sup-
Beef liver, cooked 2 ½ oz 314 plements in the hope of preventing cognitive impairment,

Chicken, cooked 2 ½ oz 53-64 they do not appear to promote im-

proved memory as it relates to age-
Salmon, cooked 2 ½ oz 85
related memory impairment or to
Egg 2 large 234-294
alleviate the symptoms of Alzhei-
Beans or peas, canned ¾ cup 55
mer’s disease.9 But keep in mind,
there is little evidence available to
evaluate its effect on overall cognitive performance.9

101
 The fishy body odor caused by
excess ingestion of choline is
caused by a product that comes
about as choline is metabolized. This compound is called
trimethylamine, and it is produced by bacteria.10
Citicoline Supplements
"So would you recommend choline as a supplement
for my mother?"
After pondering for a moment or two, Lily sug-
gested that if we were to give choline supple-
ments a try, citicoline would be the best bet in
the light of current evidence. Citicoline was initially
3
discovered in 1955 and is composed of four major compo-
nents, one of them being choline.13 It was first created by a
team of scientists in Japan for cerebrovascular disorders such
as stroke.13,14 While citicoline is prescribed as a drug in certain
European countries and Japan, in the United States, citicoline
is sold as a dietary supplement.15 It is being used by people to
treat Alzheimer’s disease and other types of dementia, Parkin-
son’s disease, head trauma, attention deficit hyperactive-
disorder (ADHD), glaucoma, and cerebrovascular diseases,
such as age-related memory loss.14
Although the jury is still out on citicoline and its ability to im-
prove cognitive function, results from taking the supplement
vary from person to person and depend on the person’s cur-
rent health status, Lily explained. “Thus, if dietary sup-
plements are taken, you should discuss it with her
physician and/or her pharmacist. While taking it,
special attention needs to be paid to changes
related to her health. If Jenny does not feel com-
fortable after taking the supplements, they
should be stopped. A check-up with the physician is
advised as a precaution.”
In the United States, the doses of citicoline as part of die-
tary supplements vary between 200 to 1000 mg per
day.16
"Citicoline is extensively absorbed by the intestinal tract with
less than 1% found in the feces.3 Once citicoline arrives in the
102
intestinal tract, it is “cut up” into two smaller pieces.3" These Does Citicoline Work?
smaller fragments, Lily elaborated, are important for the
"But will it work?" I interrupted. "Will my mother's cognition
structure of the neurons.3
improve?"
Citicoline, she continued, appears to exert the maximum ef-
There are limited findings on citicoline’s ability to protect the
fect on the frontal lobe, the area that harbors memory func-
brain, explained the dietician.15,18 According to the authors of
tion and may help to tone down the accumulation of harmful
the Natural Medicines Comprehensive Database, citicoline is
compounds in patients experiencing less blood flow to the
“possibly effective” in helping to alleviate age-related cogni-
brain.3
tive impairment and cerebrovascular diseases.14 Ingesting one
Adverse Effects of Citicoline dose of citicoline showed an increase of choline by 18% in the
brains of young adults.14 In contrast, this effect was less pro-
In general, citicoline appears to be
nounced in older adults.14 Nevertheless, adults with poor
well tolerated and has a solid safety
memory showed verbal memory improvement after taking a
profile, the dietitian explained.14,16-19
daily dose of 1 to 2 g of citicoline (pharmaceutical dose).14,16
Two common side effects are nau-
The dose most commonly taken is 1 g per day, although doses
sea and diarrhea.14 Other possible
reaching up to 4 g per day appear to be tolerated well by most
adverse events include hypotension,
patients.15 However, the European Food Safety Authority cau-
chest pain, insomnia, blurred vision,
tions to limit citicoline supplements intake to 500 mg per day
headache, constipation, skin rash,
13,14
for elderly and middle-age individuals.16 A Cochrane Review
and gastrointestinal discomfort.
concluded that citicoline could provide “modest but consistent

103
improvement of memory and behavior” in patients with
chronic brain disorders.17
In clinical settings, several countries allow the prescrip-
tion of this drug to treat acute ischemic stroke.20 Admi-
nistering citicoline within the first 24 hours of stroke re-
duces the size of the lesions in the brain.20
Phosphatidylcholine Supplements
Phosphatidylcholine supplements, the dietitian noted, are of-
ten used by patients with Alzheimer’s disease, memory loss,
and by those who wish to prevent aging,21 but further re-
search is needed to elucidate its efficacy and the mechanism
underlying its action.
Adverse Effects
Like choline, phosphatidylcholine can cause sweating, and
high amounts (> 30 g per day) could stir up trouble for your
digestive system.21
Lecithin Supplements
The terms lecithin and phosphatidylcholine are often
mistaken as one and the same, even though they are
not.21
Patients with Alzheimer’s disease fall short on the enzyme that
allows the conversion of choline into acetylcholine, a chemical
in the brain with various functions.22,23 Lecithin is the major
food source of choline, and it is believed that high lecithin
consumption can speed up the production of acetylcholine.22
According to the authors of the 2003 Cochrane Review on leci-
thin for dementia and cognitive impairment, the evidence is
insufficient to recommend lecithin as a treatment for demen-
tia, even though “a moderate effect cannot be ruled out”.22
"Indeed," concluded the dietitian, "memory performance eva-
luated in patients with Alzheimer’s disease is inconsistent with
both positive and negative outcomes from lecithin supple-
mentation.5"
104
 Cochrane is an independent global network of health ex-
perts working in the field of health sciences. Cochrane
Reviews’ main goal is to analyze current evidence on var-
ious topics and provide different treatment options.24

Adverse Effects

Side effects from taking lecithin include abdominal pain, diarr-

hea, fullness, and nausea.25 People with egg and soy allergies
may experience allergic reactions to lecithin supplements.25

105
References
1. Régime spécial mémoire. Oxygem. http://goo.gl/K9t0hV. March 31, 2016.
2. Leermakers ET, Moreira EM, Kiefte-de Jong JC, et al. Effects of choline on health across the life course: a systematic review. Nutr Rev. 2015;73(8):500-
522.
3. Pizzorno JE, Murray MT. Textbook of natural medicine. In: Qureshi I, Endres JR, Schauss AG, eds. Citicoline (CDP-Choline). 4th ed. St. Louis, MO:
Elsevier/Churchill Livingstone; 2013. http://goo.gl/v1JWCe
4. Mahan LK, Escott-Stump S. Krause's Food & Nutrition Therapy. In: Gallagher ML, ed. Intake: The Nutrients and Their Metabolism. St. Louis, MO:
Saunders/Elsevier; 2012.
5. Coates PM. Encyclopedia of dietary supplements. In: Zeisel SH, ed. Choline. New York: Informa Healthcare; 2010:136-143.
6. Choline in your pregnancy diet. BabyCenter. http://goo.gl/DQui8T. March 4, 2016.
7. Caballero B, Allen L, Prentice A. Encyclopedia of human nutrition. In: Niculescu M, ed. Choline and Phosphatidylcholine. Vol 1. 3rd ed. Amsterdam:
Elsevier Academic Press; 2013.
8. Sanders LM, Zeisel SH. Choline: Dietary Requirements and Role in Brain Development. Nutr Today. 2007;42(4):181-186.
9. Choline. Natural Medicines Comprehensive Database; October 28, 2014. http://goo.gl/0CKsYc. Accessed March 4, 2016.
10. Otten JJ, Hellwig JP, Meyers LD. DRI, dietary reference intakes : the essential guide to nutrient requirements. Choline. Washington, D.C.: National
Academies Press; 2006:218-223.
11. Combs GF. The vitamins. Quasi-Vitamins. Amsterdam; Boston: Elsevier/Academic Press; 2012:397-403.
12. Food Sources of Choline. Dietitians of Canada; 2009.
13. DerMarderosian A, McQueen CE. The Review of natural products. Citicoline. St. Louis, MO: Facts and Comparisons; 2014.
14. Citicoline. Natural Medicines Comprehensive Database. http://goo.gl/4CPttM. March 3, 2016.
15. Arenth PM, Russell KC, Ricker JH, Zafonte RD. CDP-choline as a biological supplement during neurorecovery: a focused review. PM R. 2011;3(6 Suppl
1):S123-131.
16. EFSA NDA Panel (EFSA Panel on Dietetic Products Nutrition and Allergies). Scientific Opinion on the safety of “citicoline” as a Novel Food ingredient.
EFSA Journal. 2013;11(10):3421.
17. Fioravanti M, Yanagi M. Cytidinediphosphocholine (CDP-choline) for cognitive and behavioural disturbances associated with chronic cerebral disorders
in the elderly. Cochrane Database Syst Rev. 2005(2):CD000269.
18. Grieb P. Neuroprotective properties of citicoline: facts, doubts and unresolved issues. CNS Drugs. 2014;28(3):185-193.
19. McGlade E, Agoston AM, DiMuzio J, et al. The Effect of Citicoline Supplementation on Motor Speed and Attention in Adolescent Males. J Atten Disord.
2015.
20. Alvarez-Sabin J, Roman GC. Citicoline in vascular cognitive impairment and vascular dementia after stroke. Stroke. 2011;42(1 Suppl):S40-43.
21. Phosphatidylcholine. Natural Medicines Comprehensive Database. http://goo.gl/YgYh9V. March 2, 2016, 2016.
22. Higgins JP, Flicker L. Lecithin for dementia and cognitive impairment. Cochrane Database Syst Rev. 2003(3):CD001015.
23. Hasselmo ME. The role of acetylcholine in learning and memory. Curr Opin Neurobiol. 2006;16(6):710-715.
24. About Us. The Cochrane Collaboration. http://goo.gl/KWE779. March 7, 2016, 2016.
25. Lecithin. Natural Medicines Comprehensive Database. http://goo.gl/pMBbtB. March 2, 2016.

106
 Did you know that the term “cognition” derives from
Caffeine Latin cognoscere, which means “to recognize” or “to
know”?1
Not only is my short-term memory absolutely shot... so too is my
short-term memory.
— Anonymous Branded as the “world’s most popular drug”2 and “the planet’s
most consumed psychostimulant”,3 caffeine has become the
It happens to all of us, Lily smiled, "Shortly after sun rises, the
wake-me-up that many Americans depend on to kick start
alarm clock begins to hum and whistle,
their day. As the top dietary source of caf-
and we wake up and face the morning.
feine,4 coffee is hands down America’s go-
Like zombies," she continued, "we drag
to beverage, and it is the second most
ourselves from bed and shuffle to the
popular drink in the world after water.5
kitchen in search of coffee and conscious-
ness. And once the coffee maker warms up You’ve undoubtedly heard about the myr-

and the brew begins to drip and the perco- iad of benefits associated with coffee, Lily

lated aroma fills our home, we start to waxed. "Not only can caffeine lift up your

shake sleep's dull hold from our brains." mood and boost your energy, but it can
also help silence nasty headaches and mi-
Lily was singing the praises of caffeine and
graines (although the effects of caffeine-
in my case preaching to the converted. But, Jenny, on the
containing pills vary among individuals).2,6 There is unmistaka-
other hand had long quit drinking the beverage. Ever since she
bly something going on between coffee/caffeine and our nog-
retired more than a decade ago, she said she no longer
gins."
needed the boost.

107
Caffeine and Your Brain
Lily explained that caffeine possesses an all-access pass to our
gastrointestinal tract, with ninety-nine percent of the brew
1
absorbed within just forty-five minutes of consumption. So, it
is no wonder why coffee is the wake-up bever-
age of choice when levels of stimulating caffeine
in the blood can reach its zenith just fifteen
minutes after polishing off a cup. With its influ-
ence continuing to energize us for up to two
hours,1 it's easy to understand why we have be-
come addicted to the beverage. Caffeine also
slips through the blood-brain barrier
effortlessly,1 which explains the accompanying
alertness that occurs after consuming just a single cup of java.5
In caffeine-containing capsules, it takes longer to absorb
caffeine, approximately 85 to 120 minutes.7
8
"Adenosine binds to adenosine receptors found in the brain.
This union slows down the brain activity, eventually allowing
8
sleep to occur. " Lily smiled. At the other end of the spectrum,
caffeine, a well-known adenosine antagonist, keeps the brain
awake and prevents it from falling asleep.7 Since these polar-
opposite substances bind to the same receptors, competition
arises for the companionship of adenosine receptors.8 That is
why even a minute amount of caffeine (= one
cup of coffee) is enough to ignite a war between
these opposing forces.5 "You have to wonder if
being a little extra alert wouldn't help Jenny."
I didn't know that caffeine also affects brain ac-
tivities through other pathways, one of which
causes the pituitary gland to unleash hormones
that encourage the production of adrenaline.8
This “fight or flight” hormone keeps your atten-
tion on point and refills your energy tank8 for better mental
performance.
Mental fatigue, the dietician explained can be measured
through protein biomarkers.9 It has been suggested that caf-
feine can affect the synthesis of branched-chain amino acids
used to build these biomarkers.9 A small Japanese study re-
ported better performance with lower plasma branched-chain
108
amino acids levels among participants who were given caf-
feine capsules, without the increased feeling of “ready to
drop”.9
Despite advocating coffee, Lily said that drinking the stimulat-
ing beverage does have one caveat. "While the thought of still
being “functional” without the need to sleep seems very ap-
pealing, good sleep is essential in order to
properly recharge your body's batteries. This
is why the sensation of fatigue is such a cru-
cial protection mechanism that the body uses
to tell us to take a break.7 When you hit the
wall, don’t test your luck: get some rest or
shut-eye as soon as you can. After all, it
would be a shame to become ill because you are overworked
and refuse to rest.9 So make sure that Jenny doesn't indulge in
a coffee to late in the day. We want her to get all the rest she
can."
What the Science Says
Caffeine can keep the “afternoon slump” that we often ex-
perience after lunch or long hours of work,1, at bay.5 A study
involving US Navy trainees who were sleep-deprived for 72
hours revealed that caffeine is a mild stimulant.1 Trainees who
received 200-300 mg of caffeine in the form of capsules
showed greater vigilance, memory, and learn-
ing capacity than those who weren't given
caffeine.1 The European Food Safety Opinion
Panel concluded that 75 mg of caffeine was
sufficient to increase attention and
alertness.10 This translates to shorter reaction
time and better concentration when execut-
ing a task.10 Even when caffeine did not result in better per-
formance, participants mentioned that they experienced more
energy and felt smarter.3
So, based on current evidence, Lily nodded, it appears that
caffeine from coffee and tea could have a modest effect in
countering neurodegenerative disorders, including cognitive
109
decline and dementia. "The effects appear to be more pro- Although we didn't have to
nounced in women!11-14" worry about caffeine with-
drawal when it came to Jenny,
While we may feel young at heart, keeping up with the young
Lily explained that cutting
people just gets harder as we get on in years, both physically
back on coffee can be difficult
and mentally. Cognitive decline starts to manifest itself after
since some people experience
the age of 60, resulting in slower reflexes and information
symptoms of “caffeine withdrawal” after they quit consuming
processing.14 So it comes as no surprise that elderly people
coffee. "Caffeine withdrawal symptoms generally occur 12 to
appear to be more sensitive than young people to the effects
2,14
24 hours after the last consumption of caffeine.5 Symptoms
of caffeine, especially when it comes to improving their de-
1
include drowsiness, headaches, and fatigue.5" Rest assured:
creased cognition over an extended period. Lily explained
they rarely last more than 48 hours. Caffeine does not cause
that women also appear to reap greater benefits from caffeine
dependence and has received the GRAS-stamp (GRAS: gener-
consumption, which could be explained by the estrogenic ef-
ally regarded as safe) of approval from the Food and Drug
fect of isoflavones.14 "Estrogens appear to exert neuroprotec-
Administration.5,16 But, if you’re looking to break up with caf-
tive effects on the brain, particularly those in the hippocam-
feine, the key is to gradually wean yourself off the beverage
pus.14,15 But to what extent caffeine exerts beneficial effects
instead of stopping it abruptly.5
on cognitive function, as a whole, remains to be seen."
If you are worried about caffeine messing with your ability to
Caffeine does not appear to have any role in long-term
“sleep like a log”, you’ll want to avoid coffee or any caffeine-
memory.1,14
rich beverages before bedtime. As you would have guessed,
sleep is highly sensitive to caffeine.14 A single cup of coffee

110
(taken up to 6 hours before bedtime)14 is capable of delaying regarding its role in reducing the risk of heart disease, type 2
your trip to dreamland and cutting back on your total sleep diabetes, as well as Parkinson’s disease,14,19,20 and
time.5 "So as a rule of thumb, Jenny should avoid drinking cof- Alzheimer’s.21
fee after four o’clock in the afternoon.17"
Myth or Reality? Caffeine can help you stay awake be-
Caffeine affects each person differently, and this can be ex- hind the wheel.
plained by a number of factors. For instance, here's a quirky Reality! Several studies have indicated that caffeine can
fact about the brew we love. Regular coffee consumption and contribute to reducing the risk of road accidents. 14
smoking increase caffeine clearance (removal of caffeine from
Did you know that caffeine is used in analgesic pills to
the body).5 Oddly, the more you drink, the quicker it leaves
provide improved pain relief?5
your system. Caffeine clearance tends to be slower in women,
especially if they are taking oral contraceptives.5 Dietary Sources of Caffeine

Coffee's Nutritional Make-up Americans, I learned, consume between 106 to 170 mg of caf-
feine daily.16 Dietary sources of caffeine consist mainly of bev-
Although the terms coffee and caffeine are often used inter-
erages such as tea, coffee, soft drinks, hot chocolate, mate,
changeably, the benefits of coffee are not limited to its caf-
and energy drinks.1 Ingesting
feine content. Aside from caffeine, coffee also offers a line-up
200 mg of caffeine (= 2 ½ cups
of other nutrients, such as antioxidant compounds (e.g.
of coffee) in a single sitting or
chlorogenic acid), magnesium, and niacin.18 Lily emphasized
400 mg (= 5 cups of coffee)
that there are more than 1000 compounds,5 and that coffee’s
daily is considered safe.5 "Even
nutritional profile has received the approval of health advisors

111
though low doses of caffeine have been shown to uplift mood,
heighten alertness, boost energy and well-being, and promote 22
Table 3. Caffeine content of food and beverage
good memory, ingesting more than 400 mg of caffeine in one
Coffee or coffee-based beverages
sitting can lead to adverse effects, including anxiety, jitteri- Coffee, brewed 1 cup 80-180
5
ness, rapid heart rate, insomnia, nervousness, and trembling. Coffee, instant 1 cup 76-106
5
Sensitivity and tolerance vary among individuals. So, remind Cappuccino or Latte 1 cup 45-75
Jenny, if she does decide to return to coffee, not to overdo it." Decaffeinated coffee 1 cup 3-15
Tea
Myth or Reality? Coffee is high in calories.
Iced tea, sweetened 1 can (355 ml) 15-67
Myth! One cup of coffee contains between 0 to 5 calo-
Tea (green, oolong, white) 1 cup 25-45
ries.23 Of course; it goes without saying that adding
Decaffeinated tea 1 cup 0-5
sugar and cream will increase the calories. For instance, Herbal tea, all varieties 1 cup 0
a cold and refreshing iced coffee can round up more than Soft Drinks and Energy Drinks
23
500 calories! Energy drink, various types 1 cup 80-125
Diet cola 1 can (355 ml) 25-43
Cola 1 can (355 ml) 30
Cocoa Products
Chocolate, dark 1 bar (40 g) 27
Hot chocolate 1 cup (250 ml) 5-12
Source: Dietitians of Canada

112
The Bottom Line
To sum up, caffeine/coffee (at moderate
doses) has a modest effect on attention,
mood/depression, sleep, reaction time,
information processing, but limited in
regards to short-term memory.5 Caffeine
is also likely to reduce the risk of Parkin-
son’s disease and possibly Alzheimer’s disease.5 So, consume
according to your comfort level and don't worry if you need a
java jolt first thing in the morning: coffee is good for you! 24

113
References
1. Nehlig A. Is caffeine a cognitive enhancer? J Alzheimers Dis. 2010;20 Suppl 1:S85-94.
2. Harvanko AM, Derbyshire KL, Schreiber LR, Grant JE. The effect of self-regulated caffeine use on cognition in young adults. Human
psychopharmacology. 2015;30(2):123-130.
3. Ullrich S, de Vries YC, Kuhn S, Repantis D, Dresler M, Ohla K. Feeling smart: Effects of caffeine and glucose on cognition, mood and self-judgment.
Physiol Behav. 2015;151:629-637.
4. Roberts A. Nutraceuticals : efficacy, safety and toxicity. In: Gupta RC, ed. Chapter 30 - Caffeine: An Evaluation of the Safety Database. San Diego:
Elsevier Inc.; 2016:417.
5. Nehlig A. Effects of coffee/caffeine on brain health and disease: What should I tell my patients? Pract Neurol. 2015.
6. La caféine peut-elle réduire les maux de tête? [TV serie]: Télé-Québec; 2015.
7. Snel J, Lorist MM. Effects of caffeine on sleep and cognition. Prog Brain Res. 2011;190:105-117.
8. How drugs affect neurotransmitters. The Brain from Top to Bottom. http://goo.gl/c0BFTH. February 19, 2016.
9. Ataka S, Tanaka M, Nozaki S, et al. Effects of oral administration of caffeine and D-ribose on mental fatigue. Nutrition. 2008;24(3):233-238.
10. EFSA Panel on Dietetic Products Nutrition and Allergies. Scientific Opinion on the substantiation of health claims related to caffeine and increased fat
oxidation leading to a reduction in body fat mass, increased energy expenditure leading to a reduction in body weight, increased alertness, and
increased attention. EFSA Journal. 2011;9(4):29 pp.
11. Santos C, Lunet N, Azevedo A, de Mendonca A, Ritchie K, Barros H. Caffeine intake is associated with a lower risk of cognitive decline: a cohort study
from Portugal. J Alzheimers Dis. 2010;20 Suppl 1:S175-185.
12. Martin C. Diet and nutrition in dementia and cognitive decline. Boston, MA: Elsevier; 2014
13. Arab L, Khan F, Lam H. Epidemiologic evidence of a relationship between tea, coffee, or caffeine consumption and cognitive decline. Adv Nutr.
2013;4(1):115-122.
14. Nehlig A. Café & Médecine en 20 questions. 3rd ed: Expressions Santé; 2014.http://goo.gl/NKufza
15. Fester L, Prange-Kiel J, Jarry H, Rune GM. Estrogen synthesis in the hippocampus. Cell Tissue Res. 2011;345(3):285-294.
16. Katz DL, Friedman RSC, Lucan SC. Nutrition in clinical practice : a comprehensive, evidence-based manual for the practitioner. 2015.
17. Doutres B. Un cerveau au top. Vergèze: Thierry Souccar; 2014
18. Kim YS, Kwak SM, Myung SK. Caffeine intake from coffee or tea and cognitive disorders: a meta-analysis of observational studies. Neuroepidemiology.
2015;44(1):51-63.
19. USDA. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. Washington DC2015.
20. Boire du café aide à prévenir la maladie de Parkinson. Extenso. http://goo.gl/d880p9. February 21, 2016.
21. Bordeaux B, R Lieberman H. Benefits and risks of caffeine and caffeinated beverages. UpToDate. http://www.uptodate.com/. February 22, 2016.
22. Food Sources of Caffeine. Dietitians of Canada. http://goo.gl/k3sqGe. July 4, 2014. Accessed October 23, 2015.
23. DesGroseilliers J. Manger des bananes attire les moustiques et plus de 150 autres mythes et réalités en matière d'alimentation. Montréal: Éditions La
Presse; 2009
24. Smith AP, Christopher G, Sutherland D. Acute effects of caffeine on attention: a comparison of non-consumers and withdrawn consumers. J
Psychopharmacol. 2013;27(1):77-83.

114
Interview with a Dietician
Let food be your medicine and medicine be your food
— Hippocrates

In a silken voice, the radio host queried. "Have you ever had
this incredible urge to chomp on ice? Or an unusual desire to
consume a plate of dirt?1 Okay, that may sound weird, but if
you do feel such compulsions, an iron deficiency might be the
culprit."

It was Saturday morning, and my son and I hit the road for a
football weekend. I was driving from Detroit to Chicago with
my son. We had tickets to watch our beloved and hard-luck
Lions take on our bitter rivals, the Bears. About an hour out-
side of Chicago, while scanning the dial on the car radio, I
stumbled upon a talk radio station that caught my attention.
The host had just introduced his guest, a dietician, who was
invited to discuss nutrition, the brain, and memory.

Normally I would change the station, but given my mother's

recent memory difficulties, my curiosity was piqued.

115
 Compulsively chomping on ice is a form of pica known as
Iron “pagophagia”. The desire to consume atypical nonfoods,
such as starch, dirt or paint could be a sign of iron defi-
God gave us memory so that we might have roses in December. ciency.5
— J.M. Barrie
I was under the impression that iron deficiency is more of a
How common is an iron deficiency?
liver issue than a brain issue.
Of all the nutritional disorders, iron deficiency is the most pre-
That's true to a degree. The liver is the organ with the highest
1
valent. This fact is not only true in the
iron content.1 But not to be outdone, the
Third World, but also in industrialized
brain is well stocked in iron as well.1 De-
countries where accessibility to food is not an
spite the high concentrations of iron in the
issue.1 According to the World Health Organization
brain, it wasn’t until after 1974 that the research
2
(WHO), there are two billion people who suffer from anemia.
community began to take a deeper interest in the role of iron
The main reasons for iron deficiency are problems with ab-
in the brain.1
3
sorption of iron and loss of iron in excess. Notably, women
are at risk of being deficient in iron compared with men, pri- How important is iron to the brain?

marily due to monthly visits from Aunt Flo and the greater
From the moment you are born, your body craves iron. The
4
demand for iron during pregnancy. Since a lack of iron is
dimensions of a newborn's brain, measure only a quarter of
more frequently present in children,1 older individuals,3 and
the size of an adult brain but iron levels in newborn brains are
1
pregnant women, it is important for these groups to pay
one- tenth of those found in adults.6 This is why adequate iron
close attention to their intake of this mineral.
intake is of utmost importance during the first two years of life
when brain growth is at its peak.6 During early life, the matu-
116
ration of the hippocampus is highly dependent
on iron; iron is a crucial mineral that is needed
to support the rapid development of the
brain.2 As a matter of fact, this mineral is ab-
undantly located in the hippocampus and cor-
tex (regions involved in learning and memory),
two regions of the brain that are easily affected by an iron de-
ficiency during this period.1 Because the brain has yet to be
fully developed at this stage of life, it is more susceptible to
damage caused by an iron deficiency.2 Even though much of
the brain's development occurs during early life, it continues
1,7
to undergo changes throughout the life of an individual.
However, in contrast to the adult brain,2 the infant’s brain is
more likely to suffer an irreversible blow from an iron defi-
ciency that can follow through to adulthood.1,8
Iron is essential in the production of energy within the
body and the synthesis of thyroid hormones that are im-
portant for brain development.2
Keep in mind that the timing of iron treatment could be a de-
termining factor in dodging the long-term consequences of
iron deficiency since early treatment is seen to
exhibit a greater beneficial effect.1,8 However,
the “point of no return” has yet to be deter-
mined. The reason why is that the brain does a
decent job at trying to keep its iron levels on
track. During an iron-deficient state, the body
protects the brain by limiting the reduction of the organ's iron
by 35%, and curtailing the iron in the liver by up to 90
percent!1
Symptoms of iron deficiency, include irritability, lack of
concentration, fatigue, and lower mental performance.1
Physical and cognitive problems related to iron deficien-
cy are easier to resolve in adulthood than in infancy.2,8
Can too much iron be a problem as well?
Although an iron deficiency is common,
keep in mind that too much iron is not
necessarily beneficial either. Ingesting
large doses of iron from supplements can
lead to adverse effects, such as constipa-
117
tion, diarrhea, vomiting, and nausea.9 Therefore, it is recom-
mended to stay below 45 mg of iron per day9 and to only take
iron pills under medical supervision.
How does iron affect cognitive function?
A study published in The Journal of Nutrition, Health and Ag-
ing reported lower mmse scores in geriatric patients with iron
deficiency, and this was not influenced by the presence or ab-
sence of anemia.10 The prevalence of dementia was also in-
creased in iron-deficient patients.10 The results from this study
also revealed that the brain can suffer from cognitive defects
due to lack of iron even before anemia sets in.10 It’s important
to act fast because the longer it takes to solve iron deficiency,
the harder it is to turn the tables on cognitive defects.10
Iron is important in the production of red blood cells in
the body; these cells transport oxygen throughout the
body. Iron deficiency anemia is a type of anemia when
there are not enough red blood cells in the body due to
11
low iron levels.
Even though the brain only weighs 1.4 kilograms (roughly 2%
of the total body weight), it devours twenty percent of the
resting total body oxygen.12 Hence, the effect of iron deficien-
cy on cognitive function could be explained by the disruption
of oxygen transported to the brain.10
What are the best sources of iron?
The main dietary sources of iron are meat and meat-related
products, notably offal, red meat, and dark meat poultry.3 Ve-
getarians get their fill of iron primarily from lentils, dark green
vegetables, fortified cereals, and soybeans.3 However, the iron
found in plant-derived foods is quite different from animal-
derived foods. Iron consists of two forms: heme and non-
heme.9 Heme iron is found only in animal flesh while non-
heme iron is found both in animal- and plant-derived foods.9
Heme iron is better absorbed compared with nonheme iron
(25% vs 17%).9 Meat-based products further enhance non-
heme iron absorption, and the credit goes to a peptide called
MFP factor.9 Nonheme iron can be increased by pairing it with
meat or sources of vitamin C (e.g. peppers, citrus fruits or
juices, tomatoes, broccoli).13 Just as little as 60 mg of vitamin
118
C (equivalent to ½ cup of orange juice or ½ a red pepper) is
Table 4. Iron content of foods13
14
enough to double the amount of iron that is absorbed. Tea
Foods Serving Size Iron content (mg)
and coffee are a no-no during meals for those who wish to in-
Spinach, cooked ½ cup 2.0-3.4
9
crease their iron absorption. Tea can prevent nonheme iron
Tomato puree ½ cup 2.4
from being absorbed by up to 70 percent.14 Impairment of Lima beans, cooked ½ cup 2.2
15
iron absorption by coffee may also reach this magnitude. Oatmeal, instant, ¾ cup 4.5-6.6
cooked
Cereals, all types 30 g 4.0-4.3
Beef, various cuts, 2 ½ oz 1.4-3.3
cooked
Chicken 2 ½ oz 0.4-2.0
Pork, various cuts, 2 ½ oz 0.5-1.5
cooked
Liver (chicken, turkey, 2 ½ oz 6.2-9.7
lamb), cooked
Oysters, cooked 2 ½ oz 3.3-9.0
Fish (mackerel, trout, 2 ½ oz 1.4-1.7
bass), cooked
Source: Dietitians of Canada

The daily iron requirement for women between the ages

of 19 to 50 is 18 mg per day and for men older than 19 is
8 mg per day.13

119
References
1. Yehuda S, Mostofsky DI. Iron deficiency and overload from basic biology to clinical medicine. New York, N.Y.: Humana Press; 2010.http://goo.gl/uZtC0K
2. Fretham SJ, Carlson ES, Georgieff MK. The role of iron in learning and memory. Adv Nutr. 2011;2(2):112-121.
3. Fairweather-Tait SJ, Wawer AA, Gillings R, Jennings A, Myint PK. Iron status in the elderly. Mech Ageing Dev. 2014;136-137:22-28.
4. Moncayo R, Ortner K. Multifactorial determinants of cognition - Thyroid function is not the only one. BBA Clin. 2015;3:289-298.
5. Sangun O, Demirci S, Dundar N, et al. The Effects of Six-Month L-Thyroxine Treatment on Cognitive Functions and Event-Related Brain Potentials in
Children with Subclinical Hypothyroidism. J Clin Res Pediatr Endocrinol. 2015;7(2):102-108.
6. Hulthén L. Iron deficiency and cognition. 2003. 2003:5.
7. Møller AR. Reprogramming of the brain. Amsterdam; Boston: Elsevier; 2006
8. Murray-Kolb LE. Iron and brain functions. Curr Opin Clin Nutr Metab Care. 2013;16(6):703-707.
9. Whitney EN, Rolfes SR. Understanding nutrition. 14th ed. Stamford, CT: Cengage Learning; 2016
10. Yavuz BB, Cankurtaran M, Haznedaroglu IC, et al. Iron deficiency can cause cognitive impairment in geriatric patients. J Nutr Health Aging.
2012;16(3):220-224.
11. Iron deficiency anemia. Mayo Foundation for Medical Education and Research. http://goo.gl/yC3A0f. 2014. Accessed May 24, 2016.
12. Clark DD, Sokoloff L. Basic neurochemistry molecular, cellular and medical aspects. In: Siegel GJ, Agranoff BW, Albers RW, Fisher SK, Uhler MD, eds.
Regulation of Cerebral Metabolic Rate. 6th ed. Philadelphia: Lippincott-Raven; 1999. http://goo.gl/KWpkyo
13. Food Sources of Iron. Dietitians of Canada. http://goo.gl/bynqvX. February 28, 2014. Accessed February 26, 2016.
14. Le thé et le fer ne font pas bon ménage. Extenso. http://goo.gl/viFmBL. February 29, 2016.
15. Wapnir RA. Protein nutrition and mineral absorption. Boca Raton: Boca Raton : CRC Press; 1990

120
 verse the brain-related ailments that plague so many lives?
Antioxidants Well, the dietician on the radio certainly inspired me to recon-
sider my own diet and encourage Jenny to adjust hers as well.
Sometimes you will never know the value of a moment until it be-
comes a memory.
What makes free radicals so harmful?
— Dr. Seuss

Throughout the day, cells from our bodies feed upon oxygen
I was impressed by the dietician that when I returned home, I
to fulfill various biological activities (e.g. converting food to
went online and searched the archives of the radio station
energy)2 that keep us functioning at our full potential.3 This
that broadcast the interview. I discovered three more pro-
process generates free radicals,2,3 which are
grams featuring her thoughts on memory and
highly reactive and unstable.1 From causing
diet. The second interview focused on the
bad cholesterol to accumulate in the arteries
subject of antioxidants. While listening to the
to altering strands of DNA,2 these notorious
interaction between the host and the inter-
marauders leave a trail of destruction in their
viewee, I realized how lacking my mother's
wake. Some of the damage they cause can be
diet was in these molecules.
patched up, but some destruction is beyond
As the hype surrounding antioxidants continues to gather legi- repair.3 The only way to neutralize these hell-raisers is to tame
timate support, more and more people are embracing a diet them with electrons.
that emphasizes on “superfoods” that are loaded with these
Free radicals can also be caused by other harmful beha-
multitarget healers of various health issues, such as aging,
viors, such as smoking, contact with pollution, sun expo-
heart disease, cancer, and diabetes.1 So the question that begs
sure, and alcohol consumption.3
to be asked is: are antioxidants the magic bullets that will re-
121
How do antioxidants combat free radicals?
Antioxidants can transform trouble-making free radicals into
harmless compounds by neutralizing them. The body is con-
stantly trying to get rid of free radicals and undo the subse-
quent damage they cause, and it requires antioxidants to do
so. The body is capable of creating
some antioxidants on its own and ab-
sorbs others2 from fruits and vegeta-
4
bles.
Generally, the body is equipped to hold
its ground against free radicals,5 but the
problem occurs when legions of free
radicals begin to outnumber the antioxidant forces. Also
known as “oxidative stress”,6 this phenomenon of uncon-
trolled free radical expansion contributes to a broad range of
diseases, such as cancer, Alzheimer’s disease, and even aging.1
While the media heavily showcases the ugly side of free radi-
cals, they are not always harmful.5 For instance, in the right
quantities, free radicals can help the body defend against bac-
teria.5,7,8 However, like everything in life, too much or too little
of anything can lead to detrimental outcomes.
What is the relationship between free radicals and the brain?
Even though the brain makes up only 2% of the body weight, it
devours a fifth of the oxygen consumption in the body, 9 which
makes it a highly active organ.10 The
brain is brimming with polyunsaturated
fats,11 but is poor in antioxidants,12
which makes it vulnerable to attacks by
free radicals.13 Evidence, to date, high-
lights the prominent role of oxidative
stress in cognitive dysfunction.14 In ro-
dent models, free radicals first target the cortex and hippo-
campus, which are regions of the brain involved in learning
and memory.15
Memory can start to deteriorate as early as your 30’s
and can deteriorate even further during mid-life.16
The idea that oxidative damage caused by free radicals is re-
sponsible for the aging process sprung up in the mid-1950s.17
122
Researchers discovered that when antioxidants are unable to nols, lipoic acid, and flavonoids.2 Perhaps the most well-
quench free radicals, neurons suffer, which in turn can contri- known antioxidants are vitamins A, C, and E.2
bute to brain aging and neurodegenerative diseases.18 Further
research is necessary to determine whether or not increasing
consumption of antioxidants (from foods and supplements)
could be the key to keeping the brain young and healthy.

Do antioxidants improve memory?

Since brain aging is unavoidable, prevention is the best tool

Foods with bright, vibrant colors tend to be rich in anti-
oxidants. Just think about the bright orange hue of car-
rots, indigo-colored blueberries, and bright red toma-
toes, the next time you want to up your dose of antioxi-
dants.19
Who is part of the antioxidant family?
Antioxidants are a cluster of hundreds (possibly even thou-
sands!) of molecules, including vitamins, minerals, polyphe-
for keeping accelerated aging at bay. There have been studies
connecting vitamins A, C, and E to improvements in memory.
Research suggests that high levels of vitamins A and C are as-
sociated with better memory performance while high levels of
vitamin E appear to slow the rate of memory decline.20,21 Al-
though a consistent amount of research supports the ability of
antioxidants to delay or slow down cognitive decline, 20,22
some studies yielded mixed results.14,17,20,23 While scientists
have a hard time determining the effects of antioxidant-
vitamin supplements on cognition, it’s safe to say that increas-
ing consumption of antioxidant-rich fruits and vegetables18 is a

123
 10,18,24,25
smart and safe approach that could potentially help
provide modest protection against cognitive decline.22
A study published in the Journal of Alzheimer’s disease
reported better cognitive function in participants who
consumed 5 servings of vegetables and fruits on a daily
basis compared with those consuming one serving or less
per day.25
Would you recommend supplements as a source of antioxi-
dants?
Taking supplements “just-in-case” is not recommended, since
they are not necessarily risk-free. For instance, too much vi-
tamin E can increase the risk of prostate can-
cer and even death; while overdoing it with
vitamin C supplements can make you more
vulnerable to cataracts.14 Just like with most
nutrients, getting your antioxidants from food
is always a superior choice to supplements.
Unless they are being taken for other purposes, antioxi-
dants and multivitamin supplements are not recom-
mended for preventing Alzheimer’s disease or other
types of dementia.26
What about vitamin E?
Besides its antioxidant power, vitamin E bears other proper-
18,27
ties that are essential to multiple brain functions. Despite
its numerous benefits, no positive outcome on cognition was
noted in studies where vitamin E supplements were taken
over the course of 10 years.14 Compounds classified as vitamin
E are known as tocopherol and tocotrienol, and there are 8
types of fat-soluble chemical variants. The
most abundant, easily absorbable and studied
compound28 is alpha-tocopherol.18 However,
some researchers believe that consuming vi-
tamin E in all of its forms may provide better
overall protection; as opposed to taking each
form individually. This could, in part, explain
the mixed results noted between supplementation and dietary
intake of vitamin E.10,18
124
 Vitamin E also has anti-inflammatory properties, pre-
vents formation of amyloid plaques, and protects neu-
rons or nerves.18
The majority of the US population (> 90%) does not consume
enough vitamin E in their diet.25 Supplements appear to
prompt improved cognitive functions in those who have lower
intake of vitamin E.10 The use of vitamin E in patients with Alz-
heimer’s disease is not universally accepted: some practition-
ers routinely recommend it while others are less inclined to
endorse such supplementation.16,28-31 Both the Canadian Con-
sensus Conference on dementia and the American Psychiatric
Association do not recommend vitamin E supplements or any
other antioxidant supplements, for that matter, to prevent,
treat, or slow down the progress of Alzheimer’s disease.29
Supplements could help preserve cognition if the person in
question is suffering from a vitamin deficiency; but if no defi-
ciency exists, the supplements may not provide any cognitive
improvment.10,22
A study published by the American Society for Nutritional
Sciences reported greater cognitive performance in el-
derly participants who were taking over half the recom-
mended dose of vitamin E.12
Vitamin E supplementation in rats, fed with a high fat-
high carbohydrate diet, is shown to shield their brain
against memory impairment.32
What are polyphenols and what is their role in cognitive per-
formance?
Polyphenols are compounds that wield several actions essen-
tial to the human body, including antioxidant, anti-
inflammatory, and antibiotic properties.19 Most of the antioxi-
dants from our diet consist of polyphenols, and they are found
abundantly in fruits and vegetables.33 Due to their ability to
protect neurons against toxins, polyphenols have piqued the
curiosity of cognitive researchers focused on studying aging.19
A type of polyphenol known as flavonoids,33 in particular, ap-
peared to slow down the rate of cognitive decline in a French
study.34 Similarly, studies on the intake of polyphenols called
125
lignans35 reveal that memory and global cognitive function comes to reversing cognitive decline. However, this verdict is
declines in persons with lowered lignan intake.36 not definitive.38

Lignans are found in plant foods, such as beans, whole Is there a method to measure the antioxidant potential of
grains, fruits, vegetables, and seeds.35 Flaxseed is the different foods?
food with the highest content of lignans.35
There are several laboratory tests that evaluate the antioxi-
What is the role of selenium when it comes to brain func- dant capacity of foods.39 Oxygen Radical Absorbance Capacity
tion? (ORAC), previously available on the USDA’s Nutrient Data La-
boratory (NDL) website, is perhaps the most frequently used
For the longest time, selenium was branded as toxic.37 It
method that you’ll see mentioned in advertisements and vari-
wasn’t until 1957 that a team of researchers discovered the
37
ous other marketing strategies.39 The higher the ORAC value,
essential role selenium in the maintenance of good health.
the greater the antioxidant capacity. However, the ORAC val-
Major food sources of selenium include seafood, cereal grains,
ues of foods were removed from the USDA’s Nutrient Data
eggs, soybean, meat, and dairy products.37 Selenium is found
Laboratory (NDL) in 2012 because the method of measuring
in the largest concentrations in the kidney, pancreas, liver,
the antioxidant capacity does not reflect the effects of indi-
spleen, and brain.37 When an individual is in a selenium-
vidual antioxidant compounds on our health.40 This test (and
deficient state, the brain, which is the organ that retains the
others as well) are based on the understanding of antioxidant
most selenium,37 is the last organ to be depleted.38 The few
mechanisms.40 Even though laboratory results thus far appear
research studies that have focused on selenium’s antioxidant
to be in favor of antioxidants, it is difficult to see exactly how
properties suggest that it is potentially beneficial when it
these findings relate to the body.40 The way these compounds
are broken down and absorbed in the body can modify their
126
“biological activities”, which may differ from what is measured
41
Table 5. Antioxidant capacity of fruits and vegetables42
in the lab.
Foods (raw) Serving Size ORAC units
While ORAC is great for research purposes, it may be less use- Blackberries ½ cup 4252

ful when it comes to choosing your everyday foods. For exam- Blueberries ½ cup 3502

ple, cranberries have a higher ORAC value than apples,42 but Red grapes ½ cup 1378

does not necessarily make them a “healthier” choice. All nu- Asparagus ½ cup 1508
Beets, sliced ½ cup 1208
trients should be taken into account when determining how
Corn ½ cup 531
healthy a particular food is, and the final verdict should not be
Cinnamon 1 tsp 3417
based on a single nutrient alone.
Oregano (dried) 1 tsp 3155
As a marketing strategy to promote sales, the ORAC val-
ues are sometimes misused to indicate beneficial anti-
Did you know? What we consume plays a significant role
oxidant effects for curing diseases.40
in our health. In fact, two-thirds of the leading causes of
death in America are intimately related to our diet.25

What’s the bottom line regarding antioxidants?

It is reasonable to believe that antioxidants can help to fend

off memory loss and other cognitive-related issues. However,
supplements should not be taken for the sole purpose of im-
proving or maintaining brain health due to possible side ef-

127
fects and a lack of conclusive evidence. As always, if you're
considering taking supplements, speak to your physician first.
More importantly, instead of going straight to the pharmacy in
search of supplements, start incorporating more fruits and
veggies into your diet to increase your body’s antioxidant ca-
pacity.
As soon as I finished listening to this interview, I hurried out to
the market and picked up a few baskets of blueberries, a doz-
en oranges, and a couple of heads of broccoli. I dropped it all
off at my mother's place. I explained to her how important
such foods are to the health of her brain and made her prom-
ise to make an effort to eat healthier choices. I told Jenny that
I was determined to change my own diet as a consequence of
everything I have learned about nutrition and the brain and
that it wasn't too late for her to do the same thing.
128
References
1. Hajhashemi V, Vaseghi G, Pourfarzam M, Abdollahi A. Are antioxidants helpful for disease prevention? Res Pharm Sci. 2010;5(1):1-8.
2. Antioxidants: Beyond the Hype. The President and Fellows of Harvard College. http://goo.gl/4FX8t4. February 5, 2016.
3. Antioxidants: What You Need to Know. American Academy of Family Physicians. http://goo.gl/0Xmy9K. February 5, 2016.
4. Antioxidants: In Depth. NIH National Center for Complementary and Integrative Health. https://goo.gl/LDzGuO. February 5, 2016.
5. Les radicaux libres. Tele-Québec (Une pilule, une petite granule). http://goo.gl/AuHQbm. March 13, 2014. Accessed February 6, 2016.
6. Whitney EN, Rolfes SR. Understanding nutrition. Fourteenth edition. ed. Belmont, CA: Cengage Learning; 2016
7. Pham-Huy LA, He H, Pham-Huy C. Free radicals, antioxidants in disease and health. Int J Biomed Sci. 2008;4(2):89-96.
8. Droge W. Free radicals in the physiological control of cell function. Physiol Rev. 2002;82(1):47-95.
9. Niedermeyer E, Lopes da Silva FH. Electroencephalography, basic principles, clinical applications, and related fields. Baltimore: Urban &
Schwarzenberg; 2005
10. Morris MC. Nutritional determinants of cognitive aging and dementia. Proc Nutr Soc. 2012;71(1):1-13.
11. Cherubini A, Martin A, Andres-Lacueva C, et al. Vitamin E levels, cognitive impairment and dementia in older persons: the InCHIANTI study. Neurobiol
Aging. 2005;26(7):987-994.
12. Ortega RM, Requejo AM, Lopez-Sobaler AM, et al. Cognitive function in elderly people is influenced by vitamin E status. The Journal of nutrition.
2002;132(7):2065-2068.
13. Morris M, Evans DA, Bienias JL, Tangney CC, Wilson RS. Vitamin E and cognitive decline in older persons. Archives of Neurology. 2002;59(7):1125-1132.
14. Naeini AM, Elmadfa I, Djazayery A, et al. The effect of antioxidant vitamins E and C on cognitive performance of the elderly with mild cognitive
impairment in Isfahan, Iran: a double-blind, randomized, placebo-controlled trial. Eur J Nutr. 2014;53(5):1255-1262.
15. Asha Devi S. Aging brain: prevention of oxidative stress by vitamin E and exercise. ScientificWorldJournal. 2009;9:366-372.
16. McDaniel MA, Maier SF, Einstein GO. "Brain-specific" nutrients: a memory cure? Nutrition. 2003;19(11-12):957-975.
17. La Fata G, Weber P, Mohajeri MH. Effects of vitamin E on cognitive performance during ageing and in Alzheimer's disease. Nutrients. 2014;6(12):5453-
5472.
18. Joshi YB, Pratico D. Vitamin E in aging, dementia, and Alzheimer's disease. Biofactors. 2012;38(2):90-97.
19. Bales CW, Locher JL, Saltzman E. Handbook of clinical nutrition and aging. Third edition / ed. New York: Humana Press; 2015
20. Rafnsson SB, Dilis V, Trichopoulou A. Antioxidant nutrients and age-related cognitive decline: a systematic review of population-based cohort studies.
Eur J Nutr. 2013;52(6):1553-1567.
21. Perrig WJ, Perrig P, Stahelin HB. The relation between antioxidants and memory performance in the old and very old. Journal of the American
Geriatrics Society. 1997;45(6):718-724.
22. Katz DL, Friedman RSC, Lucan SC. Nutrition in clinical practice : a comprehensive, evidence-based manual for the practitioner. 2015
23. Fitzpatrick-Lewis D, Warren R, Ali MU, Sherifali D, Raina P. Treatment for mild cognitive impairment: a systematic review and meta-analysis. CMAJ
Open. 2015;3(4):E419-427.
24. Peneau S, Galan P, Jeandel C, et al. Fruit and vegetable intake and cognitive function in the SU.VI.MAX 2 prospective study. The American journal of
clinical nutrition. 2011;94(5):1295-1303.
25. Polidori MC, Pratico D, Mangialasche F, et al. High fruit and vegetable intake is positively correlated with antioxidant status and cognitive performance
in healthy subjects. Journal of Alzheimer's disease : JAD. 2009;17(4):921-927.
26. Press D, Alexander M. Prevention of dementia. UpToDate. http://goo.gl/FjYpxe. 2016. Accessed February 8, 2016.
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27. Blazer DG, Yaffe K, Liverman CT. Cognitive Aging: Progress in Understanding and Opportunities for Action. Washington, DC: The National Academies
Press; 2015
28. Farina N, Isaac MG, Clark AR, Rusted J, Tabet N. Vitamin E for Alzheimer's dementia and mild cognitive impairment. Cochrane Database Syst Rev.
2012;11:CD002854.
29. Armour B, Freeze C, Mayerson D, Royall D. Mental Health Disorders. PEN. http://goo.gl/y4HCQ8. February 8, 2016.
30. Press D, Alexander M. Treatment of dementia. UpToDate. http://www.uptodate.com/. February 8, 2016.
31. La vitamine E ralentit la progression de la maladie d’Alzheimer. Extenso. http://goo.gl/FLjmdj. February 8, 2016.
32. Alzoubi KH, Khabour OF, Salah HA, Hasan Z. Vitamin E prevents high-fat high-carbohydrates diet-induced memory impairment: the role of oxidative
stress. Physiol Behav. 2013;119:72-78.
33. Watson RR. Handbook of nutrition in the aged. 2009.
34. Letenneur L, Proust-Lima C, Le Gouge A, Dartigues JF, Barberger-Gateau P. Flavonoid intake and cognitive decline over a 10-year period. Am J
Epidemiol. 2007;165(12):1364-1371.
35. Higdon J. Lignans. Linus Pauling Institute. http://goo.gl/bxwkPZ. February 10, 2016.
36. Nooyens AC, Milder IE, van Gelder BM, Bueno-de-Mesquita HB, van Boxtel MP, Verschuren WM. Diet and cognitive decline at middle age: the role of
antioxidants. Br J Nutr. 2015;113(9):1410-1417.
37. Wrobel JK, Power R, Toborek M. Biological activity of selenium: Revisited. IUBMB Life. 2016;68(2):97-105.
38. Berr C, Arnaud J, Akbaraly TN. Selenium and cognitive impairment: a brief-review based on results from the EVA study. Biofactors. 2012;38(2):139-
144.
39. Collins K. Taking On Information Overload: Helping Patients Find Evidence-Based Messages About Antioxidants, Weight Loss, Soy, and Cancer Risk.
Today's Dietitian. October 2015;17(10).
40. Oxygen Radical Absorbance Capacity (ORAC) of Selected Foods, Release 2 (2010). USDA. http://goo.gl/6JP91f. February 10, 2016.
41. Caballero B, Allen L, Prentice A. Encyclopedia of human nutrition. Third edition. ed. Amsterdam Netherlands: Elsevier/Academic Press; 2013
42. Duyff RL. American Dietetic Association complete food and nutrition guide. 4th ed. Hoboken, N.J.: John Wiley & Sons; 2012.Table of contents only
http://goo.gl/X8aSLQ. Contributor biographical information http://goo.gl/NePRaC. Publisher description http://goo.gl/hWOXkj

130

Omega-3 Fatty Acids
Science and technology revolutionize our lives, but memory, tradi-
tion, and myth frame our response.
— Arthur M. Schlesinger
The third of the four interviews on nutrition, brain, and mem-
ory, focused on omega-3 fatty acids. Here is what the dietitian
had to say.
Let's talk about omega-3 fatty acids.
Unless you’ve been living under a rock, it’s nearly impossible
to be oblivious to all the rage connected to omega-3s. And for
good reason, especially if you’re concerned with the health of
your mind. Omega-3s are an essential brain food.
Did you know that the brain is ranked second (after adi-
pose tissue) among the greasiest organs in
the human body?1 Omega-3 fatty acids are
the most abundant polyunsaturated fats that
1
make up one-third of the brain.
Could you elaborate on the types of omega-3s?
There are three main types of omega-3: eicosapentaenoic acid
(EPA), docosahexaenoic acid (DHA), and alpha-linolenic acid
(ALA). DHA and EPA tend to steal the spotlight from ALA be-
cause they are beneficial in treating or preventing many dis-
eases,2 whereas ALA is less potent. Even though the body can
convert ALA to DHA and EPA, this conversion is reported to be
less than ten percent.2
Did you know that considering the highest amount of
DHA is found in the retina, it’s no surprise that omega-3
fatty acids are crucial for eye health.3 Researchers be-
lieve that low concentrations of omega-3 fatty acids may
play a role in visual impairment, such as age-related ma-
cular degeneration and retinopathy.3
What is the relationship between omega-
3s and brain health?
Omega-3’s power in staving off heart dis-
ease is widely known, but the perks go way
131
beyond the heart. The brain relies tremendously on omega-3
fatty acids and, as nature would have it, the human body is
incapable of producing them.4 To reap the benefits of omega-
3, people have no choice but to fuel up on
foods and supplements. Consuming
omega-3s is especially important
for elderly people since the level
of omega-3 in the brain decreas-
es with age4, and patients with Alz-
heimer’s disease reveal even lower levels of
DHA in their brain.5 So, if a person is perpetually having
trouble recalling where they left their keys or repeatedly finds
him or herself forgetting to turn off the stove... increasing the
amount of fish and nuts consumed is a good idea.
The total lipids in the brain increase during the first
twenty years of our life but then gradually decrease, with
significant losses after the age of 80.6 Lower levels of
omega-3 in the brain could be explained by the lack of
active enzymes responsible for incorporating omega-3
into the membranes of the brain.4
As we grow older, our noggin tends to work at a slower
speed,7 due, in part, to oxidative stress and a decrease in the
release of neurotransmitters.6 To fend against age-related
cognitive decline, researchers believe that
omega-3 may be the iron shield our
think tank needs to preserve its
sharpness. It is an interesting
fact that omega-3 fatty acids
protect the brain from neuronal
damage, inflammation, and oxidative
stress.8 They also maintain the connections between neurons
or nerves, which are essential for memory performance.7 Low
omega-3 intake can also take a toll on other cognitive traits,
ranging from behavioral to neurodegenerative disorders.4
What does the latest science suggest about omega-3 fatty
acids?
Despite the fact that study results have been inconsistent
when it comes to determining whether or not omega-3s, from
fish or supplements, have a positive effect on cognitive func-
tion,5,9-11 most health practitioners agree that omega-3 fatty
132
acids are, without a doubt, essential to keeping our brains up
and running.
Did you know that It has been estimated that the risk of
being hit with dementia increases twofold every 5 years
12
after the age of 65?
We mustn’t forget that foods don’t just offer one nutrient but
are a source of a whole slew of nutrients. Fish, for example, is
not only a source of omega-3 fatty acids but is also packed
with proteins and vitamins D and B12,
which also contribute to brain
function.11,13
Cognitive decline related to age can be
caused by a number of factors,4 and it
seems only fair, like many other ail-
ments, to believe that a healthy diet
can impede that course of decline. As mentioned earlier, 60%
of the brain is fat. Consuming enough omega-3 is a definite
must to preserve the mind's integrity and performance.14
What about omega-3 supplements? Do you believe they are
as effective as food in maintaining healthy cognitive func-
tion?
Current evidence is not strong enough to recommend omega-
3 supplements in treating15 and preventing dementia or cogni-
tive impairment.16,17 Cognition and nutrition have a compli-
cated relationship,11 and further research is required to posi-
tively confirm their association. Therefore, it is necessary to
tackle the problem from different angles. Intervention should
not only be based on diet alone or by
singling out one particular nutrient. In-
stead, the focus should be on a healthy
lifestyle as a whole.11 Other lifestyle in-
terventions such as exercise can also
have an impact on cognition.11 The
ergistic effect of an overall healthy life-
style goes beyond what one single nutrient can do and may, in
part, explain the inconsistency found in studies.11
133
To provide better care for your brain, start by getting your fill Secondly, make sure you monitor your dosage. Studies show
of omega-3 from foods instead of supplements. Eating just as that the safest dosage for fighting dementia is between 180 to
little as two servings of fish per week is enough to meet your 2000 mg per day. Consuming over 3000 mg of DHA and EPA
omega-3 requirements.18 should only be done under medical supervision.

If you are unable to get enough of this healthy In light of current knowledge, here are some

fat from your diet, omega-3 supplements things to bear in mind 13:

are worth considering (for overall tip-top

 Omega-3 fatty acids are unlikely
health and possibly cognition). Here are
to be of any help to people who
a few things to keep in mind before
have already been diagnosed
13
doing so:
with dementia, but may help

First, discuss with your doctor or pharmac- those with mild cognitive impair-

ist whether omega-3 supplements are suita- ment.

ble to your current health condition. People who  Omega-3 fatty acids may help to pre-

are prone to gastrointestinal discomfort13 or bleeding may vent dementia.

need to avoid this product.  There isn’t enough evidence to fully support the no-
tion of omega-3’s effect on slowing down the aging
19
Don’t be shocked if your burps smell “fishy”. This common
process.
side effect is noted in nearly half the people who take omega-3
supplements.19 Pairing it with a meal or just before sleeping
may help to mask it.19
134
What foods would you recommend as the best source of Table 6. Omega-3 fatty acid content of foods

omega-3s?
Serving EPA+DHA ALA
Foods
Size (grams) 21
(grams)22
Fatty fish, such as salmon, trout, and mackerel are good
Mackerel, Atlantic,
sources of DHA and EPA,13 whereas plant-based food sources, 100 g 1.2 0.1
cooked
such as flaxseed, soybean oil, and walnuts contain omega-3
Sardine, canned in
100 g ~1.0 0.5
fatty acids in the form of ALA.20 Without a doubt, omega-3 fat- oil
ty acids are essential for brain health and only eating fish Trout, mixed spe-
100 g 0.9 0.2
cies, cooked
twice a week is enough to meet your needs.18 Even though
Salmon, Atlantic,
science has yet to grasp fully the action of omega-3s and their 100 g 1.84 0.1
cooked
impact on various cognitive traits (e.g. attention, memory, and
Herring, Atlantic,
4 100 g 2.0 0.1
emotions), inadequate intake of omega-3 will most likely do cooked

you more harm than good. While omega-3 fatty acids do not Canola oil 1 tbsp. 0 1.3

ward off all cognition-related impairment, they can indeed Flaxseed, whole 1 tbsp. 0 2.4

slow down cognitive decline.5 Chia seeds 1 tbsp. 0 1.9

Hemp seeds 1 tbsp. 0 0.9
Did you know that the source of omega-3 fatty acids is
not from fish itself but rather from the food fish con-
While it is true that omega-3 fatty acids are found in all
sume. Algae and the prey that feed on it are the reasons
fish,23 lean fish (e.g cod) provide less omega-3 fatty acids
why fish are such a good source of omega-3 fatty acids.13
than fatty fish.24

135
A study in the American Academy of Neurology journal
states that eating lean fried fish offers no protection
against dementia.25 This may be explained by the re-
duced amounts of omega-3 in lean fish,20 and by the
cooking process. Indeed, deep-frying can significantly de-
crease the amount of omega-3.26

136
References
1. La pêche aux oméga-3. Extenso. http://goo.gl/rE5lMl. January 22, 2016.
2. Swanson D, Block R, Mousa SA. Omega-3 fatty acids EPA and DHA: health benefits throughout life. Adv Nutr. 2012;3(1):1-7.
3. Essential Fatty Acids Omega-3: DHA and EPA. American Optometric Association. http://goo.gl/K8VhIr. January 23, 2016.
4. Denis I, Potier B, Vancassel S, Heberden C, Lavialle M. Omega-3 fatty acids and brain resistance to ageing and stress: body of evidence and possible
mechanisms. Ageing Res Rev. 2013;12(2):579-594.
5. Itua I, Naderali EK. Review: omega-3 and memory function: to eat or not to eat. Am J Alzheimers Dis Other Demen. 2010;25(6):479-482.
6. Ledesma MD, Martin MG, Dotti CG. Lipid changes in the aged brain: effect on synaptic function and neuronal survival. Prog Lipid Res. 2012;51(1):23-
35.
7. Joffre C, Nadjar A, Lebbadi M, Calon F, Laye S. n-3 LCPUFA improves cognition: the young, the old and the sick. Prostaglandins Leukot Essent Fatty
Acids. 2014;91(1-2):1-20.
8. Parletta N, Milte CM, Meyer BJ. Nutritional modulation of cognitive function and mental health. J Nutr Biochem. 2013;24(5):725-743.
9. Fotuhi M, Mohassel P, Yaffe K. Fish consumption, long-chain omega-3 fatty acids and risk of cognitive decline or Alzheimer disease: a complex
association. Nat Clin Pract Neurol. 2009;5(3):140-152.
10. Cederholm T, Salem N, Jr., Palmblad J. Omega-3 fatty acids in the prevention of cognitive decline in humans. Adv Nutr. 2013;4(6):672-676.
11. Coley N, Vaurs C, Andrieu S. Nutrition and Cognition in Aging Adults. Clin Geriatr Med. 2015;31(3):453-464.
12. Dementia numbers in Canada. Alzheimer Society of Canada. http://goo.gl/WFvChB. January 23, 2016, 2016.
13. Fish and long-chain omega-3 fatty acids, DHA & EPA. Alzheimer's Drug Discovery Foundation http://goo.gl/8LtFcN. January 23, 2016.
14. Chang CY, Ke DS, Chen JY. Essential fatty acids and human brain. Acta Neurol Taiwan. 2009;18(4):231-241.
15. Press D, Alexander M. Treatment of dementia. UpToDate. http://goo.gl/np640y. January 23, 2016, 2016.
16. Armour B, Royall D. Mental Health Disorders - Dementia. PEN; 2012.
17. Sydenham E, Dangour AD, Lim WS. Omega 3 fatty acid for the prevention of cognitive decline and dementia. Cochrane Database Syst Rev.
2012;6:CD005379.
18. Blais C. Les oméga-3 sont-ils tout-puissants ? Le Médecin du Québec. 2009;44(3):35-41.
19. Coates PM. Encyclopedia of dietary supplements. In: Harris WS, ed. Omega-3 Fatty Acids. 2nd ed. New York: Informa Healthcare; 2010:580-581.
20. Le point sur les acides gras oméga-3. Extenso. http://goo.gl/NrY5ht. January 2016.
21. USDA National Nutrient Database for Standard Reference Release 28. US Department of Agriculture; September 2015. http://goo.gl/OJv4pK. Accessed
January 22, 2016.
22. Canadian Nutrient File (CNF). Health Canada; April 2012. http://goo.gl/7fKTKo. Accessed January 22, 2016.
23. Healing Foods Pyramid™ - Fish and Seafood. Regents of the University of Michigan. http://goo.gl/N1E827. January 25, 2016.
24. Jacobsen C, Nielsen NS, Horn AF, Sørensen A-DM. Food enrichment with omega-3 fatty acids. Cambridge, UK: Woodhead Publishing;
2013.http://goo.gl/aBwxoV
25. Huang TL, Zandi PP, Tucker KL, et al. Benefits of fatty fish on dementia risk are stronger for those without APOE epsilon4. Neurology. 2005;65(9):1409-
1414.
26. Candela M, Astiasarán I, Bello J. Deep-Fat Frying Modifies High-Fat Fish Lipid Fraction. Journal of Agricultural and Food Chemistry. 1998;46(7):2793-
2796.

137
 time, I wished that I had encouraged Jenny to consider the
Vitamin D same regime.

Right now I’m having amnesia and déjà vu at the same time. I think Isn't vitamin D a supplement that ensures bone and muscle
I’ve forgotten this before.
― Steven Wright strength? How does the vitamin relate to cognitive function?

For years, I have been taking a daily vitamin D supplement. If you think that the actions of vitamin D are strictly bone-

Living in a northern state and having to deal with what feels related, it’s time to bury that thought in the ground. Re-

like the endless months of winter, I worried that I might be searchers are well aware of the extraskeletal role of vitamin D
1
vitamin D-deficient. Although it is common : from cumbersome health issues like

knowledge that the sunshine vitamin is muscle weakness to killer diseases such as

necessary for healthy bones and muscles, I cancer,1 the medical community is well

had no idea just how important the vita- aware of how crucial vitamin D is for

min is for the health of our brains. health, especially as we get on in years.
But did you know that roughly one billion
As I worked my way through the radio arc-
people worldwide, particularly those over
hives featuring interviews with a dietitian,
the age of 65, suffer from hypovitaminosis
I was intrigued when I came across the fi-
D, a condition that enhances the risk of
nal program on the benefits of vitamin D and memory. As I
dementia and other changes to the brain?2 Since close to half
listened to the interview, I felt proud of myself for taking a dai-
the older adults (≥ 65 years), and 70% to 90% of the adults
ly vitamin D supplement for almost a decade, but, at the same
with cognitive issues have low levels of vitamin D or hypovi-

138
taminosis D,2 recent research has focused on the link between
vitamin D and brain health.
Are there particular areas of the brain that require Vitamin
D?
Vitamin D receptors are present all over the brain,3 including
regions linked to cognition, such as the cortex and the hippo-
campus.2 So, it is reasonable to assume that reduced levels of
this bone-sustaining nutrient can also affect cognition and
4
mood.
Like kidneys, the human brain possesses the enzyme to
convert inactive vitamin D into its active form.1
How exactly can vitamin D improve cognitive function?
Vitamin D keeps our bones strong
and healthy by increasing calcium
absorption.5 However, findings show
that this sunshine vitamin also boosts
brain health as well.6 For instance,
vitamin D is involved in the produc-
tion of neurotransmitters present in the hippocampus of the
brain.2 Animal studies reveal the neuroprotective properties
of vitamin D during inflammation and oxidative stress.2 Clear-
ing off amyloid plaques is also a function that vitamin D pro-
vides.2
It has been suggested that the brain is more vulnerable
to stressors (e.g. diabetes) in the presence of vitamin D
deficiency.6
Is vitamin D consumption more important as we age?
The brain undergoes significant changes in different stages of
life. These changes are more important during childhood and
senior years, and less during adulthood.2. Elderly people are at
139
a high risk for vitamin D deficiency due to lower dietary intake
and low cutaneous synthesis of vitamin D.7 A comprehensive
analysis of 12 studies observed that in older individuals, vita-
min D supplementation not only ensures stronger bones but
may also contribute to better cognitive function.7
The skin’s ability to synthesize vitamin D can be reduced
by more than half beyond the age of 70 years. However
the ability of the intestines to absorb vitamin D does not
decline.7
Are there more specific links between vitamin D and memo-
ry?
Most cross-sectional studies reported the worst cognitive out-
come in people with low levels of vitamin D.8 Research on
non-demented individuals also showed that individuals deal-
ing with hypovitaminosis D tend to slide down the slope faster
than those with higher levels of vitamin D.2 However, the link
between vitamin D and memory is less clear,9,10 as few studies
evaluated the effect of insufficient levels of vitamin D on do-
main-specific cognitive traits such as memory.11 In a multieth-
nic cohort study of older individuals, episodic memory suf-
fered a greater decline in people with lower levels of vitamin
D.12 In contrast, no association was found between semantic
memory and low levels or absence of vitamin D.12
While there is undeniably a thread linking vitamin D to brain
function, current studies do not allow us to establish a clear
causality relationship between vitamin D and cognitive im-
pairment.6 In other words, does vitamin D deficiency cause
cognitive impairment, or does the impairment cause vitamin D
deficiency?2
What are the cognitive risks associated with vitamin D defi-
ciency?
Due to limited evidence, health advisors agree that it is too
early to confirm that a low level of vitamin D is a good bio-
marker for the prognosis or diagnosis of Alzheimer’s disease
and related disorders.2 Nonetheless, hypovitaminosis D can be
regarded as a risk factor for cognitive decline and dementia as
several studies reveal that low levels of vitamin D are corre-
lated with cognitive change in older adults.2 Experts recom-
140
mend screening for hypovitaminosis D in people with cogni-
tive impairment, especially in Alzheimer’s disease, and accor-
dingly, supplement with vitamin D.2 While the primary reason
for supplementation may not be for improving cognition, clini-
2
cal trials have shown positive outcome after it was given.
What are the mechanics of vitamin D?
higher in cholesterol.14 Americans obtain a large part of their
vitamin D from fortified foods, such as milk and cereals.13
Prolonged sun exposure and dietary food intake are un-
likely to cause vitamin D toxicity.13 However, high vita-
min D intake from supplements can result in vitamin D
toxicity.13

15
The synthesis of vitamin D from skin depends on multiple fac- Table 7. Vitamin D content of foods

tors, such as the time of the day, season, the length of expo- Food Serving Vitamin D
Size (UI)
sure, skin melatonin content, smog, and cloud cover.13 If you
Orange juice, fortified with vita- ½ cup 50
are not into fish and milk, satisfying your vitamin D needs may min D
prove challenging (unless you are getting lots of sunshine) Soy beverage, fortified with vita- 1 cup 88
since this fat-soluble vitamin is min D
Egg, yolk, cooked 2 large 57-88
found in a limited number of
Mackerel, Pacific, cooked 2 ½ oz 342
foods.13
Salmon, Atlantic, raw or cooked 2 ½ oz 181-246
Fatty fish are your best food Salmon, sockeye/red, canned, 2 ½ oz 530-699
sources of vitamin D.13 Even cooked or raw
Tuna, white, canned with water 2 ½ oz 60
though organ meats and liver
Cod liver oil 1 tsp 427
also provide vitamin D, they are
less often consumed and tend to be

141
 To fight against rickets, the U.S. initiated a milk fortifica-
tion program in the early 1930s.13
What advice can you offer regarding supplements?
The recommended daily intake for individuals between the
ages of one and 70 years is 600 IU (15 mcg), and the intake
increases to 800 IU (20 mcg) after the age of 70.13
The upper tolerated limit set for vitamin D is
4000 IU (100 mcg) for individuals above the
13
age of nine. Consuming more than 4000
IU (100 mcg) of vitamin D could lead to
adverse effects, such as arrhythmias, calci-
fication, and polyuria.13
Did you know…? A study published in the
Canadian Journal of Neurological Sciences sug-
gested a link between cognition, seasonal changes, and
vitamin D levels.11 Seasonal change (summer to winter)
coincides with a decrease in the levels of vitamin D and
working memory function.11
Vitamin D is found in two forms: D2 (ergocalciferol) and D3
(cholecalciferol). D2 is produced by irradiating yeast whereas
D3 is obtained by the chemical modification of cholesterol.13
They are both equally effective in treating rickets13 and in
maintaining serum levels of vitamin D.16 However, at higher
doses, D3 is believed to be more potent than D2.13
The recommended daily intake set forth for
vitamin D takes into account minimal sun
exposure.13 People who spend a lot of
time in the sun may have an easier time
reaching their vitamin D requirement.
Whether it is for bone or brain health, if you
are suffering from vitamin D deficiency, sup-
plementation is an option that is worth consider-
ing.
Memantine, a drug used to treat Alzheimer’s disease,
combined with vitamin D supplements was shown to im-
prove cognition when compared to individuals who were
not receiving supplements.17
142
What else would you like to say about vitamin D?

Even though current evidence is not unanimous about the ef-

fect of hypovitaminosis D on cognitive decline, it is clear that
the brain requires adequate amounts of vitamin D to function
properly. Since people tend to have a harder time meeting
their vitamin D requirements as they grow older, particular
attention needs to be given to ensure individuals are getting
adequate amounts of this neurosteroid.18

As soon as I finished listening to the program, I opened my

reminder app on my smartphone. I found the grocery list with
the catalog of items I needed to pick up. Adding to it, I typed
‘pick up two bottles of vitamin D’ in bold print. One for me and
one for Jenny.

143
References
1. Bouillon R. Vitamin D and extraskeletal health. UpToDate. http://goo.gl/gq0JzT. January 29, 2016.
2. Annweiler C, Dursun E, Feron F, et al. 'Vitamin D and cognition in older adults': updated international recommendations. J Intern Med. 2015;277(1):45-
57.
3. Soni M, Kos K, Lang IA, Jones K, Melzer D, Llewellyn DJ. Vitamin D and cognitive function. Scand J Clin Lab Invest Suppl. 2012;243:79-82.
4. Meehan M, Penckofer S. The Role of Vitamin D in the Aging Adult. J Aging Gerontol. 2014;2(2):60-71.
5. Pazirandeh S, Burns DL. Overview of vitamin D. UpToDate. http://goo.gl/MjDrOv. January 27, 2016.
6. Brouwer-Brolsma EM, de Groot LC. Vitamin D and cognition in older adults: an update of recent findings. Curr Opin Clin Nutr Metab Care.
2015;18(1):11-16.
7. Schlogl M, Holick MF. Vitamin D and neurocognitive function. Clin Interv Aging. 2014;9:559-568.
8. Van der Schaft J, Koek HL, Dijkstra E, Verhaar HJ, Van der Schouw YT, Emmelot-Vonk MH. The association between vitamin D and cognition: a
systematic review. Ageing Res Rev. 2013;12(4):1013-1023.
9. Krause D, Roupas P. Effect of Vitamin Intake on Cognitive Decline in Older Adults: Evaluation of the Evidence. J Nutr Health Aging. 2015;19(7):745-753.
10. Martin CR, Preedy VR, Abbatecola AM. Diet and nutrition in dementia and cognitive decline. 2015.
11. Pettersen JA, Fontes S, Duke CL. The effects of Vitamin D Insufficiency and Seasonal Decrease on cognition. Can J Neurol Sci. 2014;41(4):459-465.
12. Miller JW, Harvey DJ, Beckett LA, et al. Vitamin D Status and Rates of Cognitive Decline in a Multiethnic Cohort of Older Adults. JAMA Neurol.
2015;72(11):1295-1303.
13. Vitamin D - Fact Sheet for Health Professionals. National Institute of Health. https://goo.gl/Nrduxq. January 29, 2016.
14. Calvo MS, Whiting SJ, Barton CN. Vitamin D fortification in the United States and Canada: current status and data needs. Am J Clin Nutr. 2004;80(6
Suppl):1710S-1716S.
15. Food Sources of Vitamin D. Dietitians of Canada. http://goo.gl/t5vygH. February 25, 2014. Accessed January 28, 2016.
16. Postie C, Lavoie M-È. Du soleil en capsule? Le Médecin du Québec. 2012;47(6):89-91.
17. Annweiler C, Herrmann FR, Fantino B, Brugg B, Beauchet O. Effectiveness of the combination of memantine plus vitamin D on cognition in patients
with Alzheimer disease: a pre-post pilot study. Cogn Behav Neurol. 2012;25(3):121-127.
18. Yesil Y, Kuyumcu ME, Kara O, et al. Vitamin D status and its association with gradual decline in cognitive function. Turkish journal of medical sciences.
2015;45(5):1051-1057.

144
 “Listen”, David continued, “I just sent you a short email about
Saturated and Trans Fats fat consumption and the brain. It focuses on the hazards of
the Western diet and how it can undermine brain function.
It is strange how we hold on to the pieces of the past while we wait
for our futures. Food for thought, you might say."
— Ally Condie
I thanked David for the kindness and told him I'd see him on
A couple of nights ago, my friend, David Cheung, telephoned.
the first tee tomorrow morning. And as soon as I hung up the
The happy-go-lucky doctor had reserved a tee-time the follow-
phone, I sat in front of my laptop and searched for David's
ing morning and asked if I was up for a round. "Of
email.
course," I replied, eager to hit the links.
Fatty, sweet, and salty, David's missive be-
"So, how is your mother doing?"
gan... talk about a trio of flavorful sensa-
"She's sharp, but there are moments..." tions that tantalize our taste buds. Sad-
ly, despite its mouth-watering allure,
"It saddened me when you told me
this hazardous combo is the foundation
what Jenny is going through." David se-
of the Western diet, a.k.a. "The fatty di-
gued back in time, "I remember many a
et.” Such a diet is often top-heavy with
dinner with your family when we were kids."
“bad fats” and short on fresh fruits, vegeta-
David, who grew up in a traditional Asian family,
bles, and omega-3 fatty acids.1
noted how savory my mom's cooking was.

“If by savory, you mean rich and heavy?”, I interjected. We

both laughed.
145
A diet high in fat is thought to hinder the communication be-
tween the neurons in the hippocampus and affects an
individual's capacity to form and gather new
memories and information.2 Specifically, a
higher intake of saturated fats is linked to
diminished outcomes regarding memo-
ry, brain processing speed,3 and an in-
creased rate of cognitive decline.4,5
Omega-3 fatty acids and other unsatu-
rated fats form a robust defense against
brain degeneration.1 A study showed that the
odds of a person suffering extreme cognitive changes are
reduced when they substitute some of their saturated fat con-
sumption with monounsaturated fat.6 This shows that a diet
high in saturated fat and refined sugar can make the brain
even more vulnerable to impairment via oxidative stress, in-
flammation, and by undermining the integrity of the blood-
7
brain barrier.
Current U.S. guidelines recommend limiting saturated fat in-
take to less than 10% of your daily calorie intake (about 20 to
25 grams).8 Although saturated fat is required by the human
organism to perform various functions, your body is
fully capable of manufacturing the required
amount on its own.8 Furthermore, re-
searchers note that swapping saturated
fat with unsaturated fat has consistently
reduced the risk of heart disease that is
associated with cognitive impairment.8,9
Keep in mind that meat dishes and
cheese (e.g. pizza, pasta, burgers) are the
primary sources of saturated fat in the Ameri-
can diet.8
The Villain: Trans Fat
There is no evidence to suggest there are any health benefits
to be obtained from consuming trans fats.10 Even worse, this
fearful fat promotes oxidative stress which, in turn, can affect
cognition.11 In one research study, dietary trans fat was asso-
ciated with worst word recall performances in adults below
the age of 45.11 Interestingly, the Food and Drug Administra-
tion (FDA) retracted trans fat from the list of substances that
146
fall into the category of “generally recognized as safe”
(GRAS).11 Trans fat is primarily found in partially hydrogenated
oils (e.g. hard margarine) and in many processed foods (e.g.
croissants, donuts, instant noodles). In a natural setting, the
meat of goats, sheep, and cows, and similarly, milk contain
small amounts of trans fat that constitutes less than 6% of the
total fat. 8,12
After finishing David's email, I reflected on the type of foods
Jenny loves. Although my mother is an excellent cook, her
meals tend to be rich and meaty. Heavy cream-based sauces
and cheeses are staples in her kitchen. So, I decided to speak
to Jenny and try to convince her to consider leaner, less fatty
meals and to consume more fresh fruits and vegetables.
147
References
1. Elsayed El-Swefy S, Husseini Atteia H. Chapter 102 - Obesity and Neurodegeneration: A Focus on Dietary Influence. In: Martin CR, Preedy VR, eds. Diet
and Nutrition in Dementia and Cognitive Decline. San Diego: Academic Press; 2015:1097-1105. http://goo.gl/ZMmwob
2. Park HR, Park M, Choi J, Park KY, Chung HY, Lee J. A high-fat diet impairs neurogenesis: involvement of lipid peroxidation and brain-derived
neurotrophic factor. Neurosci Lett. 2010;482(3):235-239.
3. Francis HM, Stevenson RJ. The Effect of Western Diet on Cognition in Humans. In: Farooqui T, Farooqi AA, eds. Diet and Exercise in Cognitive Function
and Neurological Diseases: John Wiley & Sons, Inc; 2015:111-121. http://goo.gl/kBqSLo
4. Barnard ND, Bush AI, Ceccarelli A, et al. Dietary and lifestyle guidelines for the prevention of Alzheimer's disease. Neurobiol Aging. 2014;35 Suppl
2:S74-78.
5. Morris MC. Nutritional determinants of cognitive aging and dementia. Proc Nutr Soc. 2012;71(1):1-13.
6. Okereke OI, Rosner BA, Kim DH, et al. Dietary fat types and 4-year cognitive change in community-dwelling older women. Ann Neurol. 2012;72(1):124-
134.
7. Francis H, Stevenson R. The longer-term impacts of Western diet on human cognition and the brain. Appetite. 2013;63:119-128.
8. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans.
http://goo.gl/Mb6xMr. December 2015. Accessed March 30, 2016.
9. Leritz EC, McGlinchey RE, Kellison I, Rudolph JL, Milberg WP. Cardiovascular Disease Risk Factors and Cognition in the Elderly. Current cardiovascular
risk reports. 2011;5(5):407-412.
10. The truth about fats: the good, the bad, and the in-between. Harvard University. http://goo.gl/0ZgVtU. February 3, 2015. Accessed March 28, 2016.
11. Golomb BA, Bui AK. A Fat to Forget: Trans Fat Consumption and Memory. PloS one. 2015;10(6):e0128129.
12. Faut-il craindre les gras trans? Extenso. http://goo.gl/aXgN9p. March 30, 2016.

148

Sugar
Your memory is a monster; you forget — it doesn't. It simply files
things away. It keeps things from you — and summons them to your
recall with a will of its own. You think you have memory; but it has
you.
— John Irving
A couple of weeks after Lilly met with my
mother, she came back to see how my
mom was doing. Lily told me about the
house call, and I made sure that I was
there when Lily stopped by my mom's.
The last time we all met, Lily had asked
my mother to make some notes about
her eating habits. She had asked her to
write down every meal including the snacks
she consumed over a 3-day period.
Now as Lily looked over the list of the meals and snacks that
Jenny consumed, she immediately noted the amount of sugar
my mother was consuming. I mentioned that for as long as I
can remember Jenny has always started her morning with a
grocery store sticky bun and a cup of coffee with three tea-
spoons of sugar. And the sugar doesn't stop there. Sodas and
juices are her thirst-quenchers, and it has also been a lifelong
ritual of mom to conclude dinner with a generous slice of cake
or pie for dessert.
Lily expressed apprehension about sugars and how
they relate to brain function. So, she pro-
vided us with some background about the
relationship between carbohydrates and
the brain. Such food, she informed us,
provides our bodies with carbohy-
drates, which are then converted into
glucose, transported to the brain via the
bloodstream, and used as fuel.1 Glucose is
stored primarily in the liver in the form of gly-
cogen and is the body’s primary stockpile of readily
available energy we need during physical activity and labor.1
However, the glycogen supply needs to be regularly restocked
since liver glycogen is completely drained after 12 to 18 hours
following the last meal we consumed.1 During the state of
149
starvation, the body reluctantly turns towards the body's
stored fat and protein to take over glucose’s responsibility.2
Did you know that neurons never
cease to work, even during sleep?
Hence, a steady supply of glucose is
required to keep the brain running.1
Link between Sugar and Brain Health
The typically Western diet, the dietitian lamented, is often
criticized for being high in fat and refined sugars,3,4 namely
sucrose (table sugar) and high-fructose corn syrup (HFCS).5
"There is substantial evidence that suggests sugar-sweetened
beverages have an enormous impact on the obesity
5
epidemic. Obesity is a culprit responsible for a myriad diseas-
es, including diabetes, heart disease, and –hold your breath–
cognitive impairment.6"
Lily explained how a diet high in fat and refined sugar takes a
toll on the hippocampus more than the other regions of the
4
brain. "In fact, the hippocampus is fully sensitive to the
changes that affect the body. For instance, exercise and cogni-
tive training results in an increase in the size of the hippocam-
pus whereas hypertension and obesity are associated with a
smaller size.7" It's important to note, my childhood friend
tapped the side of her head, the hippocampus is one of two
regions of the brain that continues to form new neurons even
after the gestational period, in the womb, when most of the
brain growth occurs.7
If you are running low on sugar in your system or execut-
ing a demanding intellectual task,1 gobbling down simple
sugars like honey or just plain old table sugar might be
the solution to pull your brain quickly out of the fog.5,8
However, the effect of regular high consumption of sim-
ple sugars, in the long run, is an entirely different story.
High and low levels of blood sugar play
numerous tricks on the brain, con-
tinued Lily.8 "For example, glu-
cose is a required ingredient in
manufacturing neurotransmit-
ters,8 but excess consumption of
150
sugar may add superfluous calories to a diet, which can even- Diabetes and Alzheimer’s disease
tually result in weight gain. In particular, fat that settles
Diabetics have a higher risk of dementia
around the waistline increases insulin resistance, a gateway
and Alzheimer’s disease (AD).15
8
not only to diabetes but possibly to dementia as well. Insulin
Because the brain of AD pa-
bears a long list of functions in the brain, including memory
tients can become insensitive
formation.8 Lily looked at Jenny, "So, it would be wise to keep
to insulin, some researchers even call
your sugar intake in check."
it “type 3 diabetes”.16 Therefore, taking care of any diabetes
The glycemic index (GI) is a score that reflects the rate at risk factors you may be at risk for, and keeping an eye on your
which a food is capable of raising the blood sugar following its blood sugar levels can potentially lower your risk for AD.17
consumption compared to white bread or glucose.9 Low-GI
The Deal with High-Fructose Corn Syrup
meals are touted as a wise choice, since they allow for a
steady rise in blood sugar and a sufficient supply of sugar to While talking about sugar alterna-

the brain.10 While a few studies showed unfavorable effects of tives, Lily noted that the nutri-

high-GI meals on memory performance,4,11,12 overall evidence tional value differs only slightly

remain inconclusive, and further research is required.13 between honey, maple syrup,
brown sugar, and white sugar.18
Brain-derived neurotrophic factor (BDNF) is a protein that al-
"High-fructose corn syrup
lows fluid communication between the neurons11 and is found
(HFCS)," she warned, "which was
abundantly in the hippocampus.14 It has been seen that the
previously believed to be the 'future sugar for diabetics,'19 is
BDNF levels are lower after a high consumption of sugar and
now considered more harmful than sugar." HFCS is a swee-
saturated fats.11
151
tener created as a result of glucose conversion into fructose
by adding enzymes to cornstarch.20 Its chemical composition is
very similar to that of white sugar, consisting of roughly equal
parts glucose (45%) and fructose (55%).19
The name “high-fructose corn syrup” may seem to be confus-
ing since it seems to imply that the product is high in fructose
when it actually means that the syrup has a higher amount of
fructose compared to corn syrup.21 Some scientists believe
that HFCS is more harmful than white sugar.21,22 "Rather than
fussing about substituting various forms of sweeteners, I
would suggest that you limit your overall refined sugar in-
take, especially those sugars found in processed
foods."
The Grain Brain
I mentioned to the dietitian that I had picked up a
copy of the Grain Brain, a revolutionary book that
advocates a brain diet that has skyrocketed to the top of the
23 24
best-seller list. Much like the Paleo and Atkins diet,
Grain Brain diet follows the same trendy pattern of kicking
carbs to the curb. The author, neurologist David Perlmutter,23
proposes a four-week-program that gets our brain back in
shape by limiting 30 to 40 grams of carbohydrates per day and
then maintaining 60 grams of carbohydrates per day after
that.25
Combined with a set of brain-nourishing 30-minute workouts
five days a week, adequate sleep, a water-fasting period of 24
hours before the initiation of the protocol, and a line-up of
dietary supplements,25 this brain diet claims to reduce or
counter brain disease, remove symptoms of brain fog, and
hance memory and energy levels.23
Lily regarded me with skepticism. She explained
that she didn't believe cutting out carbohydrates
would be the wisest thing to do. Instead, she
encouraged a more balanced approach, saying
that “Jenny would be better served with a
lanced diet that emphasizes a reduction of added
gars. Placing the focus on heart-healthy fats,25 whole grains,
the
and balanced meals, food variety is a more efficient approach
to safeguarding the brain."
152
References
1. Glucose and mental performance. European Food International Council. http://goo.gl/NGRQe1. August 2013. Accessed March 22, 2016.
2. Whitney EN, Rolfes SR. Understanding nutrition. 14th ed. Stamford, CT: Cengage Learning; 2016
3. Francis H, Stevenson R. The longer-term impacts of Western diet on human cognition and the brain. Appetite. 2013;63:119-128.
4. Francis HM, Stevenson RJ. The Effect of Western Diet on Cognition in Humans. In: Farooqui T, Farooqui AA, eds. Diet and Exercise in Cognitive Function
and Neurological Diseases: John Wiley & Sons, Inc; 2015:111-121. http://goo.gl/FzTKC2
5. Elsayed El-Swefy S, Husseini Atteia H. Chapter 102 - Obesity and Neurodegeneration: A Focus on Dietary Influence A2 -. In: Martin CR, Preedy VR, eds.
Diet and Nutrition in Dementia and Cognitive Decline. San Diego: Academic Press; 2015:1097-1105. http://goo.gl/PeSi66
6. Sellbom KS, Gunstad J. Cognitive function and decline in obesity. J Alzheimers Dis. 2012;30 Suppl 2:S89-95.
7. Monti JM, Baym CL, Cohen NJ. Identifying and characterizing the effects of nutrition on hippocampal memory. Adv Nutr. 2014;5(3):337S-343S.
8. Ooi CP, Loke SC, Yassin Z, Hamid TA. Carbohydrates for improving the cognitive performance of independent-living older adults with normal cognition
or mild cognitive impairment. Cochrane Database Syst Rev. 2011(4):CD007220.
9. The Glycemic Index. Canadian Diabetes Association. http://goo.gl/naczqQ. March 23, 2016.
10. Dye L, Lamport D, Boyle N, Hoyland A. 6 - Macronutrients and cognitive performance. In: Benton D, ed. Lifetime Nutritional Influences on Cognition,
Behaviour and Psychiatric Illness. Oxford: Woodhead Publishing; 2011:131-159. http://goo.gl/GoU71U
11. Kanoski SE, Davidson TL. Western diet consumption and cognitive impairment: links to hippocampal dysfunction and obesity. Physiol Behav.
2011;103(1):59-68.
12. Wolever TMS. Glycaemic Index and Health. The glycaemic index a physiological classification of dietary carbohydrate. Wallingford, UK; Cambridge,
MA: CABI; 2006:130-131. http://goo.gl/4Rr75m
13. Philippou E, Constantinou M. The influence of glycemic index on cognitive functioning: a systematic review of the evidence. Adv Nutr. 2014;5(2):119-
130.
14. Hsu TM, Kanoski SE. Blood-brain barrier disruption: mechanistic links between Western diet consumption and dementia. Front Aging Neurosci.
2014;6:88.
15. Barbagallo M, Dominguez LJ. Type 2 diabetes mellitus and Alzheimer's disease. World J Diabetes. 2014;5(6):889-893.
16. Diabetes and dementia - is there a connection? Alzheimer Society of Canada. http://goo.gl/AFQz5H. March 22, 2016.
17. Katz DL, Friedman RSC, Lucan SC. Chapter 35 - Diet and Cognitive Function. 3rd ed. Philadelphia Wolters Kluwer Health; 2015
18. Le sucre à fruits, le miel, le sirop d'érable et la cassonade sont meilleurs pour la santé que le sucre de table. Extenso. http://goo.gl/ta6ZLz. March 22,
2016.
19. Le sucre, ce nouveau poison. Extenso. http://goo.gl/aKKaNo. March 22, 2016.
20. Webb FS, Piché LA, Whitney EN. Nutrition : concepts and controversies. 13th ed. Belmont, CA: Cengage Learning; 2014
21. Sanders LM, Lupton JR. Carbohydrates. In: Erdman JWJ, Macdonald IA, Zeisel SH, eds. Present Knowledge in Nutrition. 10th ed. Oxford: Wiley-
Blackwell; 2012:83-96. http://goo.gl/n2FaJy
22. Farooqui AA. Chapter 5 - Effect of Soft Drink Consumption on Human Health. High calorie diet and the human brain : metabolic consequences of long-
term consumption. Cham: Springer; 2015.
23. DrPerlmutter.com. David Perlmutter, MD. http://goo.gl/iD77k9. March 23, 2016.
24. Top diets review for 2016. NHS Choices. http://bit.ly/1mkQQaL. March 23, 2016.
25. Moore M. Grain Brain. eatright.org. http://goo.gl/jiZ0WY. March 22, 2016.
153
 the fog of sleep. Numerous studies have concluded that learn-
Nutritional Recommendations ing, concentration, and memory performance is sharper as a
Eat Your Way to a Better Memory consequence of consuming breakfast.2-5 Not only that," Lily
nodded her head as she spoke to us, "skipping breakfast can
All water has a perfect memory and is forever trying to get back to
affect your mood, making you feel grouchy and irritable.2"
where it was.
— Toni Morrison
But while we were roaming the aisles of the
During our last session with Lily, she gave my grocery store, Jenny tried to put two
mother a personalized shopping list cre- boxes of sticky buns into the cart.
ated for her. It featured ten eat-smart "Mom, remember what Lily said
tips for improved brain perform- about starting your day off with a
ance! So to make sure that Jenny healthy meal."
was adhering to Lily's plan, the next
Jenny nodded her head and reluc-
time she went grocery shopping, I
tantly returned the pastries she normally
tagged along.
eats first thing in the morning back onto the shelf.
Don’t Skip Breakfast
Lily told Jenny that because she was already in the habit of
Lily was adamant about the importance of this meal. Break- eating breakfast, that she received top grades for that. But she
fast, she insisted, not only helps you to maintain your weight also insisted that Jenny could reap rewards for her brain just
1
and control your appetite, it also jump-starts your brain after by consuming breakfast with a slower release of glucose. She
a long night of fasting. "Eating breakfast frees your mind from explained that a healthier breakfast will result in a steady rise

154
in blood sugar levels, instead of the blood sugar roller coaster Now if you can’t stomach eating
Jenny currently rides.3,6 So we picked up Jenny a fiber-rich first thing in the morning, Lily
breakfast (e.g. whole grains, fruits, vegetables, nuts, seeds, told us it’s ok! You can start
legumes),7 that consisted of sugar free yogurt, whole wheat by nibbling something light
toast and fresh fruits. I reminded Jenny to curb the amount of (e.g. crackers) or drink a
added sugars just like Lily said (e.g. honey, table sugar, maple glass of milk and continue
syrup, agave)8 to prevent her blood sugar from spiking and healthy snacking throughout
plunging.3 the morning. Or, simply postpone
your breakfast until your appetite kicks into high gear.2
So Jenny promised that she would try to stick to a well-
balanced breakfast by including a source of grain (preferably Reducing Calories at Lunch
whole grain), fruits/vegetables, and meat/milk/protein alter-
Like many of us, Jenny suffers from a post lunch dip. I notice
natives.9
that around mid day she tends to become more irritable. I just
 Grains: whole-wheat toast/bagel/cereal, oatmeal assumed overcoming this “post-lunch dip” in energy was next
 Milk and alternatives: cheese, yogurt, milk, enriched soy to impossible, but Lily insisted that is not the case. Lily noted
beverage that, while some unlucky individuals feel the fatigue more
 Meat and alternatives: nuts, tofu, eggs, peanut butter than the others, after-lunch drowsiness isn’t just the result of

 Fruits and vegetables: apples, oranges, berries, spinach, a biological process.10 "Certainly, chowing down on a 1000-

banana, cucumber calorie meals may send you straight to your coffee-maker for a

Source: Extenso2 well-needed Java jolt,10 but studies point out that protein-rich

155
and carb-rich lunches can make you feel more tired and con-
tribute to reduced alertness and performance.10"
Lunch is my mother's favorite meal and often the largest meal
she eats during the day. So the dietician addressed the issue.
"Jenny, if you need to unfasten a button on your pants after
lunch, it may be a good idea to reduce the size of your meal
portions."
Carbs: The Brain’s Fuel
Carbohydrates are the primary fuel for
the brain, the dietician reminded
us.11 "Unfortunately, the brain is
incapable of stashing an abun-
dance of that fuel away for fu-
ture use.12 Therefore, a steady
supply is needed to keep the brain ac-
tive and sharp.12,13 However, too many carbs can be equally
bad, since, in addition to the increased production of sero-
tonin (a neurotransmitter involved in sleep), the fatty compo-
nent of carbohydrate-rich foods can lead to obesity.3,14 "So try
to limit your consumption of starch and grains to 25% of your
meal.15"
With that in mind, I steered my mother away from many of
the purchases she might normally make at the supermarket
and I encouraged her to switch from her typical, refined car-
bohydrates, to more wholesome, fiber-rich whole-grain op-
tions that will supply her with a steady fuel of energy without
the dreaded crash.
Quench your Thirst
"I don't think you're drinking enough water." During our visit
with the dietician, Lily leaned close to my mother for emphasis
and reminded her not to underestimate the power of staying
well hydrated. "Keep in mind that 60% of our total body
weight is water.13" Dehydration lowers
the blood volume and puts a hold on
the shipment of nutrients through
various parts of the body, including
the brain.12,16
156
"Just a 2% water loss is enough to hinder your brain frunc-
tions.16 "Dehydration can trigger fatigue, dizziness, and a con-
centration deficit.17 And older folks should be especially mind-
ful of the fact since they are less susceptible to feel thirst,
which can explain the lower fluid intake.13 Moreover, their to-
tal body water is 10% to 15% less than that of younger
adults.16
Lily said not to wait for thirst –the first sign of dehydration– to
occur before you start gulping down fluids.17 Instead, keep a
bottle of water on standby and sip throughout the day. But
bare in mind that water, coffee, soup, tea, milk and healthy
drinks contribute to your fluid intake.
Myth or Reality? You need to drink eight glasses of wa-
ter per day.
Depends. The origin of this worn-out rule of thumb de-
rived from the fact that, generally speaking, the body
loses about 2 liters of fluids every day, primarily through
sweat, respiration, and urine.18 However, water con-
sumption depends on numerous factors, such as climate,
physical activity, and fiber intake.19 How do you know
when you’re well hydrated? Next time you take a leak,
peek at the color of your urine: if it’s light/clear-colored
(like in the image on the right), you’re on the right track.
If it’s dark yellow, drink more water.18
So when I put a case of bottled water into my mother's shop-
ping cart, at first she looked at me suspiciously. But when I
reminded her that she needs to drink more water, she quickly
consented.
Fish for Omega-3
When the dietician turned the subject towards omega-3s, she
told us that bad fats need to be exiled while good fats need to
be welcomed with open arms. "Specifically, marine omega-3
fatty acids have proven to be a sturdy shield against cognitive
defects.17,20 To meet your omega-3 requirements, consume at
least two servings of fatty fish per week.17 Fatty fish include
salmon, mackerel, trout, and sardines." Because Jenny is such
a huge fish lover, she grew in Maine after-all, I needn't worry
that was getting enough omega-3s.
157
 Shoping tip: Canned fish is a handy made sure that Jenny loaded up on some of her favorite fruits
tion. Opt for the ones that have less and vegetables.
than 360 mg of salt per serving of 55
Quick Tips 24:
grams (or better yet, no salt at all!),
 Make a smoothie, salad, soup
preserved in water instead of oil,21
 Add fruits to yogurt, cereals, and homemade drinks
and, preferably, eco-friendly. For a healthy
 Use lettuce as a “wrap”
dose of calcium, eat the bones!22 Some eco-friendly
 Garnish your sandwich with a lot of vegetables and/or
brands, include Wild Planet, American Tuna, and Ocean
save some on the side
Naturals.23
 Snack on fruits and vegetables (as crudités)
Color Burst
Bottoms Up (or Down?)
"It's important to remember that the loss of brain capacity is
During our visit with Lily, the dietician provided us with an in-
partially explained by oxidative stress, a state in which free
dulgent fact that she said would be sure to please us both. Lily
radicals raise havoc in the body.3" Lily insisted that Jenny
smiled, alcohol when consumed in moderation can help your
should load up on fruits and vege-
brain to age gracefully and stave off the advance of
tables. "The more vibrant their
dementia.25,26 "Researchers suggest that light to moderate
color, the higher their antioxi-
drinking has the potential to keep brain diseases at bay.27
dant content!12"
Jenny pointed a thumb at me and said, "I told him one glass of
So as we walked through the
wine a day was good for me."
produce section of the grocery store, I

158
We all laughed. "Red wine, in particular," the Lily continued,
"appears to strengthen your armor against memory, learning
and attention impairments.28" The benefits are believed to be
mainly due to alcohol's good cholesterol-raising effects,28 she
continued. "Red wine has the advantage of containing the an-
28
tioxidant compound resveratrol. "
So when we passed the wine and spirits
section in the grocery store, my mother
looked at me. "Any objections?"
None, I said. And I helped my mother pick
out a fine Merlot and Cabernet Sauvignon.
Light to moderate consumption of alcohol is defined as
one serving (=15 g alcohol) per day for women and two
for men,28 which translates to one bottle of beer, one
glass of wine, or one shot of 80-proof liquor.28 High-risk
drinking involves consuming ≥ 4 drinks a day or ≥8 drinks
weekly for women, and ≥ 5 drinks in a day, and ≥ 15
drinks weekly for men.29 Binge drinking refers to drinking
≥ 4 drinks for women and ≥ 5 drinks for men within a pe-
riod of two hours.29
That’s how much low-to-moderate con-
50% sumption of alcohol could lower your risk
for Alzheimer’s disease.28
I reminded Jenny that Lily told her not to overdo it. "Heavy
drinking can cause serious damage to the brain.30 Impairment
in learning, memory, personality change, brain shrinkage, and
shriveled nerve cells are just a few of the adverse effects that
high consumption of alcohol has on the brain.26 You remem-
ber that don't you?"
Jenny smiled mischievously. "Of course I do."
"Lily said that you should never feel obligated to drink alcohol,
that there are other safer ways to protect your brain."
My mother cleared her throat. "She also said that there is no
harm in enjoying a glass or two once in a while."
159
 Alcohol + Caffeine = A Dangerous Combination
Taken individually, these two substances may provide
benefits to the brain. However, taken together, caffeine
can “mask the effects of alcohol, giving you the impres-
sion of being more alert and awake” than you are.31
Did you know that men who consume approximately 2
or more drinks a day experience cognitive decline sooner
than those who consumed less?27
3 Top Alcohol FAQs — Answered!
 Can alcohol prevent dementia? Probably.
 Do people with mild cognitive impairment or dementia
reap benefits from consuming alcohol? Debatable.
 Can alcohol hold off the effects of aging? Probably.
(Based on low-to-moderate amounts of alcohol) Source: Alz-
heimer’s Drug Discovery Foundation28
Get your B(rain)-Vitamins
It is important to understand
that vitamin B1 (thiamine) is
implicated in the synthesis of
neurotransmitters,13 Lily re-
garded my mother and me.
"Sadly, the body is incapable
of storing significant amounts of vitamin B1.13 In as little as 14
days, this B-vitamin can be completely exhausted when there
is no supply to the body.13 Thiamine is also a part of the anti-
oxidant machinery that can help fend off free radicals.13” She
continued to explain how signs of vitamin B1 deficiency in-
clude concentration and memory impairment, depression, and
irritability.32 “Sweet potato, tuna, and pork are among the
foods with the highest content of thiamine.12"
Just 15 minutes or more of cooking wipes out 60% to
90% of the folate in food!33 So don't overcook your vege-
tables!
160
Vitamin B3 (niacin) can be synthesized from tryptophan, an DNA repair mechanism of neurons and by rendering neurons
amino acid found in meat, eggs, and dairy products32 (al- more vulnerable to oxidative stress.33
though this conversion can only be done with the help of B1,
In general, vitamin B supplements (B1, B9, B12, B6) do not pro-
B2, and B6 vitamins).13 Finding niacin deficiency in developed
vide cognitive benefits to healthy adults and those with mild
countries is rare.32 However, it is not the case in countries
or moderate dementia.36,37 However, vitamin B supplements
where poverty and malnutrition reign. "Memory impairment
are not recommended as a preventive or treatment measure
is a classic symptom of niacin deficiency that can be reversed
unless a deficiency is present.36
32
with adequate supplementation of the vitamin. "
While we were in the grocery store, I noticed that my
Lily described the associations of each type of B-vitamin.
mother's cart was short on green vegetables which are an ex-
Vitamin B6 is implicated in the chemical changes associated cellent source of B1. When I mentioned the fact, Jenny paused
with all amino acid neurotransmitters.32 for a moment before saying: "I really do love spinach. Why
don't we load up on some of that?"
Vitamin B12 (cobalamine) has a hand in the production of
nerve cells, red blood cells, and genes.32 Vegans may need to
take a supplement since this B-vitamin is found only in animal
and fortified products.34

Vitamin B9 (folate) is also a key player in brain function. It is

responsible for the production of neurotransmitters (e.g. do-
pamine, serotonin, noradrenaline).13 Folate deficiency paves
the way to neurological problems,35 possibly by disrupting the
161
 Iron Brain
3,32,38
Table 8. B-Vitamin Food Sources
Vitamin Source Iron lashes onto oxygen like a dog on a leash and carries it to
B1 (thiamin) Milk
the brain, explained Lily.3 "It is a critical component in the
Unrefined cereals
Green vegetables production of dopamine (attention, coordination of motor
Fresh meat
functions) and serotonin (sleep, mood, and appetite) neuro-
Fruit
B3 (niacin) Cereals transmitters.3,39 Major food sources of iron include legumes,
Liver fish, whole-grains, meats, egg, poultry, and cereals.40"
Chicken
Beef A life-long meat eater, I had no doubts that Jenny was getting
Legumes
Fish enough iron. Her shopping cart was a testament to the fact:
B6 (pyridoxine) Grains top-heavy with fish, meat and fresh eggs.
Meat
Vegetables Did you know that, like Popeye, who is strong to the fin-
B9 (folate) Green leafy vegetables
ish because he eats all his spinach, many health profes-
Whole or fortified grains
Legumes sionals (dietitian included!) have long believed that spin-
Offal
ach is an excellent source of iron? However, a typo listing
B12 (cobalamine) Eggs
Meat the iron content values in a German health database
Dairy products created a false impression; a misplaced comma created
Fish
the illusion that the iron content in spinach was ten-fold
Seafood
than it is!41

162
Get Your Fat Right

And don't forget, Lily coaxed, to consume heart-healthy fat for

a healthy brain.42 "For cooking, opt for unsaturated oils such
as olive and canola oils instead of palm oil, lard, and butter.
For dressings, you can stick with the traditional extra-virgin
olive oil or try out hazelnut, almond, or sesame oils.43"

When we reached the cooking oil section in the market, my

mother immediately reached for the Crisco. I reminded her
that extra virgin olive oil is a healthier choice. Although at first
she was reluctant to give up her beloved lard, with just a little
cajoling, she agreed to make the switch.

While we were waiting in the check-out line, my mother kept

singing Lily's praises. Jenny said that she was confident that
she could implement the necessary changes to her diet. "So
please invite Lily to stop by for lunch one day next week. I
really want to thank her for all her advice and demonstrate
that I am taking her suggestions seriously."

163
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Database Syst Rev. 2008(4):CD004514.
34. Vitamin B12. Extenso. http://goo.gl/LL5lG9. April 11, 2016.
35. Gomez-Pinilla F. Brain foods: the effects of nutrients on brain function. Nat Rev Neurosci. 2008;9(7):568-578.
36. Barbarich B, Corby L, Erick S, et al. Gerontology. Dietitians of Canada (PEN); December 10, 2014.
37. Agnew-Blais JC, Wassertheil-Smoller S, Kang JH, et al. Folate, vitamin B-6, and vitamin B-12 intake and mild cognitive impairment and probable
dementia in the Women's Health Initiative Memory Study. J Acad Nutr Diet. 2015;115(2):231-241.
38. Folate. Extenso. http://goo.gl/e6jOoA. April 8, 2016.
39. Anita JF, Sara ER, Michael KG. Micronutrient Needs of the Developing Brain. In: Packer L, Sies H, Eggersdorfer M, Cadenas E, eds. Micronutrients and
Brain Health: CRC Press; 2009. http://goo.gl/2WQe4G
40. Whitney EN, Rolfes SR. The Trace Minerals. Understanding nutrition. Stamford, CT: Cengage Learning; 2016:417.
41. Lavallée B. Erreur dans la base de données nutritionnelles de Santé Canada : un «super aliment» n’est plus si «super». Nutritionniste Urbain.
http://goo.gl/BFcTBP. June 3, 2014. Accessed April 11, 2016.
42. Harvard Women’s Health Watch. Boost your memory by eating right. Harvard University. http://goo.gl/8AMe22. August 1, 2012. Accessed April 11,
2016.
43. Gatewood J. Vegetable Oils – Comparison, Cost, and Nutrition. Iowa State University. http://goo.gl/Y1fgsP. August 19th, 2013. Accessed April 11,
2016.

165
Dietary Supplements
Sometimes you will never know the value of a moment until it becomes a
memory.
— Dr Seuss

During one of Lily's visits, I asked her if a regime of dietary supple-

ments might improve my mother's memory and keep her brain
sharp. Lily hemmed and hawed and shrugged her shoulders before
uttering: "Maybe. But before taking any kind of supplements, be
sure to consult with Jenny’s doctor and pharmacist. They will de-
termine whether the dietary supplements are suited for her current
medical condition and drugs treatment."

Lily provided me with a list of potential supplements that might be

beneficial to my mother, but insisted that we seek the approval of
her health care provider before starting dietary aids. The four sup-
plements included gingko biloba, turmeric, huperzine, and sage.

166

Ginkgo Biloba
A picture is worth a thousand words, but memories are priceless.
— Anonymous
Lily noted that Ginkgo is often prescribed in France and Ger-
many by physicians for memory loss and other
ailments;1 ginkgo’s popularity in the U.S. is
also growing rapidly. It quickly soared
to fame in the early 1990s to be-
come “one of the most popular
supplements for memory en-
hancement”,2 and wound up on
the list of “10 best-selling herbal
medications”.3
"But despite the plethora of studies
conducted on ginkgo,2 the results, I
fear, are inconclusive regarding its role in
preventing dementia and slowing the rate of cogni-
tive decline.4" The dietitian explained that the Ginkgo Evalua-
tion of Memory (GEM) was the first large clinical trial that
involved more than 3000 participants and was sponsored by
the National Institutes of Health (NIH).5 Much to the dismay of
Gingko believers, the results of this 8-year-long study found no
benefit associated with Gingko supplements and the reduction
of the incidence rate of dementia and Alzheimer’s disease in
elderly patients above the age of 75 years.5
While scientists have yet to reach a con-
sensus, Lily was encouraged to discover
plenty of studies that point to Gink-
go having a modest positive effect
on memory and the speed of cog-
nitive processes. The American
Family Physician, a semi-monthly,
peer-reviewed journal of the
American Academy of Family Physi-
cians, agrees that ginkgo provides
“modest positive effect” for dementia.3
Research studies spanning one year showed im-
provement in cognitive function among participants with de-
mentia.6 However, it remains unclear whether ginkgo is as ef-
167
fective as conventional drugs such as cholinesterase inhibitors happens, daily doses of ginkgo ranging between 120 to 240
used to treat Alzheimer’s disease.6 But, here is one handy fact mg are as or even more effective than doses reaching up to
that Lily passed on to me about the supplement: higher doses 600 mg.6
of ginkgo may not be more effective for brain health. As it

Fun fact: When Westerners think of Tibet, they focus on the mysticism associated with Himalayan people. But thousands of years be-
fore the emergence of the first Dalai Lama, evidence suggests that early brain surgery was being performed on the Tibetan Plateau.
In 1998, archaeologists unearthed human remains, including skulls with cracks that had healed before death. Scientists concluded
that some of these early craniotomies (some dating more than five millennia ago) were not conducted to correct physical ailments;
rather they were designed to heal the spirit. Was it a ritual to dispel evil and bring happiness? Your guess is as good as ours.7

erties,6 anti-Alzheimer’s fighting properties,3 anti-clotting ac-

tivity, and increased blood supply.8

Most ginkgo extracts used in research studies, Lily explained,

consist of 24% flavones and 6% terpene lactones, both active
constituents of ginkgo.9 It is advised to purchase brands that
are similar to the ones used in studies. These brands include
Ginkai, Ginkoba, Ginkgold,3 Target Up & Up Ginkgo Biloba,
and Finest Natural Ginkgo Biloba.10 The typical daily dose

Various mechanisms on how ginkgo protects the brain have ranges between 120 to 240 mg.11 Dietary supplements sold

been suggested. These mechanisms include antioxidant prop- contain 40, 60, or 120 mg of ginkgo in the form of capsules or

168
tablets.12 Cost-wise, I calculated that I would need to fork out noted, some people have reported heart palpitations, dizzi-
approximately $15 to $20 per month.3 ness, headaches, skin reactions, and gastrointestinal discom-
fort.9 People who are at risk of bleeding (i.e. surgery) may be
"If you’re worried about side effects associated with taking
advised to refrain from taking this supplement.9
ginkgo, most people can rest assured. Ginkgo is relatively
safe13 and severe reactions occur infrequently.9" However, Lily

Fun Fact: Part of the reason, humans remain perched on top of the planet's food chain, is due to the large brains we sport. From our
earliest origins as primates to present day, the human brain has nearly tripled in size. The size of the brains of our most distant ances-
tors, the Australopithecus afarensis, was contained within skulls that measured an internal volume of approximately 400 to 550 milli-
litres (ml). Our brains today are housed in a cranium that averages about 1,200 ml. It's quite the evolutionary development when you
consider that a gorilla's brain is contained within a skull of about 500 to 700 ml.14

169
References
1. Dwyer JT, Costello R, Merkel J, Coates PM. Chapter 23 - Dietary Supplements in Older Adults. In: Bales CW, Locher JL, Saltzman E, eds. Handbook of
clinical nutrition and aging. Third edition / ed. New York: Humana Press; 2015:403-404.
2. Scholey A, Stough C. Neurocognitive effects of herbal extracts. In: Benton D, ed. Lifetime nutritional influences on cognition, behaviour, and psychiatric
illness. Oxford: Woodhead Publishing Limited; 2011:277-280.
3. Sierpina VS, Wollschlaeger B, Blumenthal M. Ginkgo biloba. Am Fam Physician. 2003;68(5):923-926.
4. Armour B, Freeze C, Mayerson D, Royall D. Mental Health Disorders - Dementia. Dietitians of Canada; 2012.
5. DeKosky ST, Williamson JD, Fitzpatrick AL, et al. Ginkgo biloba for prevention of dementia: a randomized controlled trial. JAMA. 2008;300(19):2253-
2262.
6. Ginkgo. Natural Medicines Comprehensive Database. http://goo.gl/7kLxgJ. April 18, 2016.
7. Cohen J. Sacred Text Describes Successful Brain Surgery in Ancient Tibet. History. http://goo.gl/ZupDmY. 2011. Accessed 13 June, 2016.
8. Birks J, Grimley Evans J. Ginkgo biloba for cognitive impairment and dementia. Cochrane Database Syst Rev. 2009(1):CD003120.
9. Ginkgo Biloba. In: DerMarderosian A, McQueen CE, eds. The Review of natural products. St. Louis, MO: Facts and Comparisons [database online];
August 2011.
10. Saper RB. Clinical use of ginkgo biloba. UpToDate. http://goo.gl/4lVsuF. November 12, 2015.
11. Strømgaard K, Vogensen SB, Steet J, Nakanishi K. Ginkgo Biloba. In: Coates PM, ed. Encyclopedia of dietary supplements. 2nd ed. New York: Marcel
Dekker; 2010. http://goo.gl/ZqzwO7
12. McQueen CE, Orr KK. Natural Products. In: Berardi RR, Ferreri SP, Hume AL, et al., eds. Handbook of nonprescription drugs : an interactive approach to
self-care. 16th ed. Washington, DC: American Pharmacists Association; 2009:979.
13. Vellas B, Coley N, Ousset PJ, et al. Long-term use of standardised Ginkgo biloba extract for the prevention of Alzheimer's disease (GuidAge): a
randomised placebo-controlled trial. The Lancet. Neurology. 2012;11(10):851-859.
14. Schachner E. How Has the Human Brain Evolved? Scientific American. http://goo.gl/sZH5Z7. 2013. Accessed 25 May, 2016.

170
 Known as the 'golden spice of India,' turmeric, Lily informed
Curcumin me, is part of the ginger family2 and has been cultivated for
more than 4000 years.3 Turmeric, a featured ingredient in cur-
The best thing about memories is making them
— Anonymous ry and mustard,4 contains a pigment called xanthophyll that
provides its yellow shade.
I'm a huge fan of Indian cuisine. For years, I have heard about
the amazing benefits of turmeric, and although I was vaguely Turmeric (Curcuma longa)
aware about its powerful anti-inflammatory and antiseptic
Bitter, but warm to the taste,5 this frequently used
qualities and its supposed ability to destroy
spice not only adds a pop of vibrant color and an
cancer cells, I never took the health
earthy flavor to your dishes, but also serves
benefits of the spice that seriously.
as a medicine for a broad spectrum of
Sure, turmeric may enhance Indian
ailments.6 While little attention has
dishes with its healing properties,
been given to this yellow root re-
but the reason why I am drawn to Indian
garding its healing potential,6 recent
cooking is the taste. But when Lily mentioned that sup-
scientific discoveries have led to some noteworthy findings
plementing my mother's diet with turmeric may help to im-
that is taking the health-and-nutrition world by storm.
prove her cognitive well-being, I became intrigued.
Placed under a microscope, the widely studied compound cur-
Do not confuse cumin with curcumin! They originate
cumin, Lily explained, is regarded as the most potent element
from different plants.1
of turmeric.4 Curcumin is the color pigment that gives turmer-
ic its golden hue1 (keep in mind it stains as well!). "The idea

171
that curcumin might be the secret to winning the battle may potentially be helpful in the prevention of Alzheimer’s
against age-related brain disease stems from the unusually disease.11 Even people with dementia or mild cognitive im-
low incidence rate of Alzheimer’s disease (AD) in India7 as pairment could benefit from taking curcumin, although evi-
compared with the rest of the world.4" As a matter of fact, Lily dence is still limited.1
continued, the incidence of AD is 4.4 times lower in rural India
India’s reputation as a serious turmeric provider is no
than that in the United States.4 In previous studies, higher in-
joke. The country supplies 70% of the turmeric worldwide
take of curcumin (in the form of curry) was associated with a
amounting from approximately 10% of its farm crops.
lower likelihood of dementia,1 and turmeric also improved
This makes India the biggest grower, distributer, and us-
cognitive functions.8
er of turmeric in the world.6
Little importance is given to essential oils of the turmeric
plant even though the whole plant stem is employed in
traditional preparations, which could perhaps increase
the absorption of curcuminoids.6

Touted to be neuroprotective and a powerful antioxidant (on

par with vitamins E and C), and an anti-inflammatory agent,4
mounting evidence is available from animal and laboratory
experiments to support these claims.4,9 This fact sounded en-
couraging as it related to my mother, Jenny: researchers dis-
Figure 2.Turmeric Constituents6
covered that curcumin can increase the levels of dopamine
(attention and memory) and serotonin (mood).10 Curcumin
172
 In a previous WHO/FAO report (1974), the daily dietary Earlier clinical trials, Lily told me, failed to show benefits from
intake of turmeric in India is estimated to range between taking curcumin supplements, which could be explained by
2-2.5 g per person. Considering that turmeric contains the low bioavailability of curcumin.10,15,16 "However, recent
about 3%-5% of curcumin, this would be equivalent to breakthroughs in science have found ways of enhancing the
60-100 mg of curcumin.12 bioavailability of curcumin.1,17 Some manufacturers formulate
their products by adding ingredients, such as piperine (a con-
Can Turmeric Stave off Cancer?
stituent of black pepper),1 bromelain
Unlikely, based on limited (a compound found in
13,14
evidence. It is postulated that pineapples),18,19 by attaching fat
turmeric can pull the plug on cancer lecules to curcumin (Longvida®),1 by
cells. However, only a handful of reducing the size of the curcumin
studies have been conducted, and particles (Theracurmin™),4 by com-
most of them lacked robust metho- bining curcumin with a type of soy
dologies. While it's still early to ac- fat (Meriva®),4 or by adding back the

knowledge turmeric as an anti-cancer essential oils of the plant7

Figure 3. Squamous cell carcinoma
agent, to date, turmeric has proven to max™; most dietary supplements for
have a good safety profile (in food) even in large amounts. commercial use are formulated without essential oils).6 These
Hence, there is no harm in adding this earthy spice to your strategies help boost the bioavailability of curcumin."
dishes for an exotic taste!

173
Another phenomenon that scientists seek to understand is the
ability of curcumin to reach the brain. While animal models
clearly show that curcumin is capable of crossing the barrier of
the brain, it has yet to be confirmed in humans.6,17 Neverthe-
less, Lily said, this herb of the sun6 could provide some bene-
fits by acting indirectly on the side-
lines even if it does not easily reach
the brain.7 Of note, a clinical trial
administering a curcumin formula-
tion known as Longvida® provided Remember: Not to be confused! Cumin (left) is not the same as cur-
cumin (right)
promising results. The more Lily told
me about turmeric, the more my curiosity was piqued.
Healthy older adults who took the pill found their working
memory, mood, and attention improved considerably com-
pared with those who took the placebo.10 "In a recent article
published by the British Journal of Nutrition, the authors
stated that, to date, the formulations with the most reliable
evidence of increased bioavailability from human clinical trials
are Biocurcumax-95™ and Longvida®.16"
Healthwise is a nonprofit organization that seeks to pro-
vide readers with information to guide them in making
their health decisions. Their content is developed by
health experts.20
Despite the promising research
on curcumin and the brain, it is
difficult to translate what has
been observed in cells and an-
imals into concrete human
benefits,16 especially since only
a few well-designed clinical
human studies have been conducted to date.1,4-6,17 So, both
the authors from the Natural Comprehensive Medicine Data-
base and Healthwise agree that there is a lack of evidence to
rate the benefits of turmeric for Alzheimer’s disease.21,22
Although the body struggles to absorb and properly use
the curcumin found in turmeric, simply cooking it can
raise its bioavailability by 12-fold.1 To further increase its
bioavailability, consume it with fatty food sources, such
as milk, olive oil, seeds, or avocado.23
174
The safety range, Lily explained, set by the World Health Or-
ganization (WHO) is established at 0-3 mg of curcumin/kg/day
for humans, despite the fact that most turmeric supplements
largely exceed the safety range.6 "Nevertheless, clinical stu-
dies that administered doses of curcumin reaching up to 8
grams per day in healthy individuals appear to be safe.1 Even
though the clinical use of curcumin hasn't been formally ac-
knowledged, both dietary and supplemental curcumin are
generally recognized as safe (GRAS) for the majority24 of the
users when used as directed.1,25"
Nevertheless, adverse effects can occur; the most common
ones being stomach discomfort and nausea.1 High doses of
turmeric aggravated liver function in animal models, but this
has not been reported in humans.5 While the therapeutic dose
for prevention and treatment of various diseases has not been
precisely determined, it is unlikely that doses higher than 8
grams per day are required,1 especially if the body can effi-
ciently absorb novel formulations of curcumin. Commercial
products contain 3 types of curcuminoids, of which 50% is cur-
cumin, because it is difficult to obtain pure curcumin. 6 In gen-
eral, curcumin makes up half of the curcuminoid content. 6 The
cost of a bottle of about 60 to 120 curcumin supplements
ranges between $10 to $25.1
For all the vegans out there, here’s a savvy fact to keep
in mind. The results from a study conducted by the re-
searchers at the University of California at Los Angeles
suggest that turmeric can increase the conversion of
omega-3 found in plant-based food (ALA) to its more po-
tent form, DHA. Some neurological disorders develop
due to a deficiency in DHA. Hence, turmeric is a useful
supplement for vegans in their quest for the brain-
boosting omega-3.26
175
While I spoke with Lily, I wrote down some observations and
questions that I had about the spice that I planned to ask Jen-
ny's doctor during her next appointment. But in the mean-
time, I decided to purchase some of the spice myself and start
preparing a lot more curry... especially butter chicken.

176
References
1. Curcumin. Alzheimer's Drug Discovery Foundation. http://goo.gl/OzFh4R. April 25, 2016.
2. Ravindran PN, Nirmal Babu K, Sivaraman K. Turmeric : the genus Curcuma. Boca Raton, FL: CRC Press; 2007
3. S P, BB A. Turmeric, the Golden Spice: From Traditional Medicine to Modern Medicine. In: IFF B, S W-G, eds. Herbal Medicine: Biomolecular and
Clinical Aspects. 2nd ed. Boca Raton, FL: CRC Press/Taylor & Francis; 2011. http://goo.gl/lfowCV
4. Murray MT. Curcumin longa (Turmeric). In: Pizzorno JE, Murray MT, eds. Textbook of natural medicine. 4th ed. St-Louis, Missouri: Churchill
Livingstone; 2013. http://goo.gl/9AiEia
5. Turmeric. National Center for Complementary and Integrative Health (NCCIH). https://goo.gl/2EOWzh. April 25, 2016.
6. Funk JL. Turmeric. In: Coates PM, ed. Encyclopedia of dietary supplements. 2nd ed. New York: Marcel Dekker; 2010. http://goo.gl/HtBHYQ
7. Hu S, Maiti P, Ma Q, et al. Clinical development of curcumin in neurodegenerative disease. Expert Rev Neurother. 2015;15(6):629-637.
8. Ng TP, Chiam PC, Lee T, Chua HC, Lim L, Kua EH. Curry consumption and cognitive function in the elderly. Am J Epidemiol. 2006;164(9):898-906.
9. Edwards SE, Rocha I, Williamson EM, Heinrich M. Turmeric. Phytopharmacy : an evidence-based guide to herbal medical products. Chichester, West
Sussex, UK: Wiley Blackwell; 2015:379-382.
10. Cox KH, Pipingas A, Scholey AB. Investigation of the effects of solid lipid curcumin on cognition and mood in a healthy older population. J
Psychopharmacol. 2015;29(5):642-651.
11. Antioxidants, diet, polyphenolsand dementia. In: Benton D, ed. Lifetime nutritional influences on cognition, behaviour, and psychiatric illness. Oxford:
Woodhead Publishing Limited; 2011:405-407.
12. Shah BH, Nawaz Z, Pertani SA, et al. Inhibitory effect of curcumin, a food spice from turmeric, on platelet-activating factor- and arachidonic acid-
mediated platelet aggregation through inhibition of thromboxane formation and Ca2+ signaling. Biochem Pharmacol. 1999;58(7):1167-1172.
13. Le curcuma combat le cancer. Extenso. http://goo.gl/I2kso3. April 26, 2016.
14. Moynihan TJ. Can curcumin slow cancer growth? Mayo Foundation for Medical Education and Research. http://goo.gl/zbIuS5. December 23, 2014.
Accessed April 26, 2016.
15. Ringman JM, Frautschy SA, Teng E, et al. Oral curcumin for Alzheimer's disease: tolerability and efficacy in a 24-week randomized, double blind,
placebo-controlled study. Alzheimers Res Ther. 2012;4(5):43.
16. Goozee KG, Shah TM, Sohrabi HR, et al. Examining the potential clinical value of curcumin in the prevention and diagnosis of Alzheimer's disease. Br J
Nutr. 2016;115(3):449-465.
17. Higdon J, Delage B. Curcumin. Oregon State University. http://goo.gl/np7nUY. April 25, 2016.
18. Nagpal M, Sood S. Role of curcumin in systemic and oral health: An overview. J Nat Sci Biol Med. 2013;4(1):3-7.
19. Ehrlich SD. Bromelain. University of Maryland Medical Center. http://goo.gl/0t8LWr. April 25, 2016.
20. About Healthwise. Regents of the University of Michigan. http://goo.gl/WyFy0j. April 26, 2016.
21. Turmeric. Stockton, California: Natural Medicines Comprehensive Database; February 11, 2016.
22. Healthwise. Turmeric. Regents of the University of Michigan. http://goo.gl/DnSbas. April 25, 2016.
23. Frenkel M, Abrams DI, Ladas EJ, et al. Integrating dietary supplements into cancer care. Integr Cancer Ther. 2013;12(5):369-384.
24. Seo HJ, Wang SM, Han C, et al. Curcumin as a putative antidepressant. Expert Rev Neurother. 2015;15(3):269-280.
25. Ehrlich SD. Turmeric. University of Maryland Medical Center. http://goo.gl/l71rez. April 25, 2016.
26. Wu A, Noble EE, Tyagi E, Ying Z, Zhuang Y, Gomez-Pinilla F. Curcumin boosts DHA in the brain: Implications for the prevention of anxiety disorders.
Biochim Biophys Acta. 2015;1852(5):951-961.
177
 The words Alzheimer's disease made me uncomfortable. I
Huperzine knew it was a possibility, but I continued to hold out hope that
Jenny wouldn't be diagnosed with it. So at first, I didn't want
Life is short, so live it. Love is rare, so seize it. Anger is nega-
tive, so dump it. Fear is awful, so face it. Memories are sweet, to hear what Lily had to say about the supple-
so cherish them! ment, but I tempered that knee jerk
— Anonymous
reaction and listened to what the di-
Huperzine A etitian had to tell me, reminding my-
self that there is no room for denial
Lily started speaking about Huperzine A, a compound
when it comes to my mother's
found in a Chinese clubmoss that is advertised as a
health. I kept telling myself to hope
memory and learning enhancer.1 "This naturally occurring
for the best but prepare for the worst.
compound that is found in the Huperzia plant species is re-
puted to be an effective medicine for people with neurological
conditions like Alzheimer's Disease."

In 1901, Dr. Alois Alzheimer consulted with a 51-year-old patient named Mrs. Auguste Deter, who was staying at the Frankfurt Asy-
lum in Germany. Mrs. Deter's cognitive symptoms included a loss of short-term memory, sleep disorders, and agitation. Alzheimer
followed her case for the next five years. After Mrs. Deter’s death, Alzheimer performed an autopsy that revealed amyloid plaques
and neurofiber tangles as well as atrophy of her gray matter. He recognized this condition as presenile dementia especially for a
woman in her fifties. He dedicated his life to research in the brain.2,3

178
When I mentioned to Lily that I had never heard of the sup-
plement, she nodded her head. "Well, in the West, the herb
may not be that well known, but it has been used for centuries
in China to treat an extensive list of diseases, including blood
disorders, dementia, fever, cognitive dysfunction,4 weak mus-
cles,5 and swelling.6"
Despite not receiving approval as a pharmaceutical drug6 in
7
the U.S., it has been approved as a dietary supplement. In
contrast, China has approved huperzine as a treatment for
Alzheimer’s disease (AD) along with benign memory issues
since 1994.8 It has been reported that most general physicians
and psychiatrists in Shanghai prescribe huperzine.7 The typical
dose administered for AD ranges from 0.05 mg to 0.2 mg (tak-
en twice daily).1
Lily explained that the interest in huperzine stems from the
fact that it helps prevent the decline of a brain chemical called
acetylcholine, a chemical that is significantly reduced in pa-
tients with AD.9,10 Other beneficial effects of huperzine include
improved blood flow to the brain and lowering the production
of disruptive amyloid plaques known to accumulate in the
brain of Alzheimer’s patients. It also increases the brain-
protective factor known as nerve growth factor (NGF) as well
as the levels of glutathione, a natural antioxidant in the
brain.11
The nerve growth factor (NGF) is part of the neurotro-
phin family12. It is responsible for the growth and the
survival of neurons.13
179
There are only five Alzheimer’s drugs that are currently ap- results.18,19 The poor quality of the evaluation techniques in
proved by the U.S. Food and Drug Administration (FDA).14 In- the studies, Lily explained, and the small number of partici-
terestingly, huperzine just so happens to be a potent com- pants involved14 combined with the short duration of the stu-
pound that acts similarly to those approved drugs,15 but is dies have left some health care professionals pondering on
possibly less toxic16 while managing to effectively penetrate the results (although some U.S. physicians have begun pre-
the barrier of the brain compared with conventional AD medi- scribing it to their Alzheimer’s patients).11,20
cations.8
According to the Alzheimer’s Drug
"As a matter of fact," Lily contin- Discovery Foundation, huperzine
ued, "China approved this herb could “possibly” prevent demen-
for treating Alzheimer’s disease at tia and benefit people suffering
a dosage of 0.2 mg taken twice a from mild cognitive impairment
day,4 but a U.S. study found that a (MCI).11 Healthwise gives huper-
higher dose of 0.4 mg is more ef- zine 2 out of 3 stars for its use and
fecient.17" Furthermore, huper- efficacy in age-related cognitive
zine appears to be more bioavail- FIGURE 4. CHEMICAL STRUCTURE OF HUPERZINE A
decline and AD (2 stars: “Contra-
able and possesses a longer action dictory, insufficient, or prelimi-
time than some of the conven- nary studies suggesting a health
tional drugs.4 Despite the numerous favorable studies promot- benefit or minimal health benefit”).10 The authors of Cochrane
ing huperzine, most of the investigations are conducted in reviews put forth the potential use of huperzine treatment in
China4 and it is, therefore, difficult to extrapolate the

180
AD, MCI, and vascular dementia but concluded that the evi- end-product that is highly purified and potent.9" The most
dence is insufficient and/or poor to fair.6,8,18 common side effects include nausea, sweating, loss of appe-
tite, slow heart rate (bradycardia), vomiting, dizziness, and
MCI can be described as someone having “problems with
diarrhea.1 Serious adverse events have not been reported.15
memory, language, or another mental function severe enough
For age-related memory loss, the recommended dose is 0.05
to be noticeable to other people and to show up on tests, but
6
mg twice daily.9 For doses ranging from 0.05 mg to 0.2 mg, the
not severe enough to interfere with daily life.” Considering
average cost ranges from $10 to $25 for approximately 100
the multiple functions huperzine performs within the brain,
pills. Huperzine is also found as an ingredient in multi-
there is optimism that huperzine is useful for patients with
supplement products.11 Short-term use of huperzine up to 1 to
MCI although more rigorous testing must be carried out be-
6,21
3 months has proved to be safe.5 However, long-term safety
fore it can be routinely recommended.
use of huperzine remains unknown.10,11
But Lily added a caveat when describing this supplement.
"But before considering huperzine," Lily reminded me, "con-
"Don't mistake “natural” for safe. While huperzine is a com-
sult with Jenny's doctor first!"
pound derived from a plant, laboratory processing yields an

181
References:
1. McQueen CE, Orr KK. Natural Products. In: Berardi RR, Ferreri SP, Hume AL, et al., eds. Handbook of non-prescription drugs. Washington, D.C.:
American Pharmaceutical Association; 2009:978-979.
2. Hippius H, Neundorfer G. The discovery of Alzheimer's disease. Dialogues in clinical neuroscience. 2003;5:101-108.
3. History Module: Dr. Alois Alzheimer’s First Cases. The Brain From Top to Bottom. http://goo.gl/IROJWf. 14 June, 2016.
4. Hügel HM, Jackson N. Herbs and Dementia: A Focus on Chinese and Other Traditional Herbs. In: Martin CR, Preedy VR, Abbatecola AM, eds. Diet and
nutrition in dementia and cognitive decline. London, England: Academic Press; 2015:798-799.
5. Natural Medicines Comprehensive Database. Huperzine A. http://goo.gl/7kLxgJ. May 2, 2016.
6. Yue J, Dong BR, Lin X, Yang M, Wu HM, Wu T. Huperzine A for mild cognitive impairment. Cochrane Database Syst Rev. 2012;12:CD008827.
7. Ban CX, Xiao SF, Lin X, et al. Clinicians' prescription preferences for treating patients with Alzheimer's disease in Shanghai. Transl Neurodegener.
2016;5:8.
8. Hao Z, Liu M, Liu Z, Lv D. Huperzine A for vascular dementia. Cochrane Database Syst Rev. 2009(2):CD007365.
9. Turkington C, Mitchell DR. The encyclopedia of Alzheimer's disease. 2nd ed. New York: Facts On File; 2010
10. Healthwise. Huperzia. Regents of the University of Michigan. http://goo.gl/Tn51kU. May 3, 2016.
11. Alzheimer's Drug Discovery Foundation. Huperzine A. http://goo.gl/f3brvb. May 3, 2016.
12. Zhang H-y. New insights into huperzine A for the treatment of Alzheimer's disease. Acta Pharmacologica Sinica. 2012;33(9):1170-1175.
13. Neurotrophic factor. Merriam-Webster. http://goo.gl/ALusUa. May 3, 2016.
14. Yang G, Wang Y, Tian J, Liu JP. Huperzine A for Alzheimer's disease: a systematic review and meta-analysis of randomized clinical trials. PLoS One.
2013;8(9):e74916.
15. Murray MT. Alzheimer's disease. In: Pizzorno JE, Murray MT, eds. Textbook of natural medicine. 4th ed. St. Louis, Missouri: Churchill Livingstone;
2013:1196.
16. Xing SH, Zhu CX, Zhang R, An L. Huperzine A in the treatment of Alzheimer's disease and vascular dementia: a meta-analysis. Evid Based Complement
Alternat Med. 2014;2014:363985.
17. Rafii MS, Walsh S, Little JT, et al. A phase II trial of huperzine A in mild to moderate Alzheimer disease. Neurology. 2011;76(16):1389-1394.
18. Li J, Wu HM, Zhou RL, Liu GJ, Dong BR. Huperzine A for Alzheimer's disease. Cochrane Database Syst Rev. 2008(2):CD005592.
19. Ha GT, Wong RK, Zhang Y. Huperzine a as potential treatment of Alzheimer's disease: an assessment on chemistry, pharmacology, and clinical studies.
Chem Biodivers. 2011;8(7):1189-1204.
20. Ilkay J. Supplementing Memory Loss. Today's Dietitian. 2009;11(6):16.
21. DerMarderosian A, McQueen CE. Huperzine A. The Review of natural products. St. Louis, MO: Facts and Comparisons; 2010.

182

Sage
The saddest aspect of life right now is that science gathers know-
ledge faster than society gathers wisdom.
— Isaac Asimov
Another supplement that Lily suggested was sage.
She said that even after many millennia of
use, sage remains a common remedy in
numerous traditional healing practices,
including Greek, Ayurvedic, and Chinese
medicine.1 "From a common cold to
depression,2,3 this earthy-flavored herb4
has supposedly proven its medicinal
worth through on-the-spot doctor-patient
practice.2" The origin of the name Salvia stems
from the Latin word salvare, which means “to save”1
or “healing plant”.2 With approximately 700 to 900 species of
sage5, Salvia officinalis (Garden Sage) and Salvia lavandulaefo-
lia (Spanish Sage) are two of the Salvia species that show the
most encouraging evidence for the brain.1
Animal and laboratory studies with sage reveal anti-
inflammatory, antioxidant,6 and memory-enhancing proper-
ties,2 suggesting that it possesses a potential therapeutic ap-
proach for brain disorders. Lily told me that sage is capable of
preventing the breakdown of acetylcholine,2 a chemical mes-
senger that plays a role in learning, attention, and
memory.7 Taking into account all species (but
more so S. officinalis and S. lavandulaefo-
lia) and types of preparation (oil, extract,
raw),8 better cognitive performance,
including memory,5,7,9 was demonstrat-
ed in research studies where patients
were supplemented with sage.8,10,11 "Ac-
cording to the Natural Medicines Compre-
hensive Database, sage could be “possibly ef-
fective” at improving cognitive performance, symp-
toms of Alzheimer’s disease, and memory.3" But despite the
limited supportive6 evidence that suggests that sage is benefi-
cial, Lily said that a comparative study with currently utilized
pharmaceutical drugs is needed to determine just how effi-
183
cient the herb is for cognitive function.2 Furthermore, because
sage is processed into various forms (tincture, oil, herbal tea,
liquid extract,),12 she said that no study (to our knowledge)
has determined which type of sage is the most beneficial for
cognition. Lastly, higher research methodology is required to
better ascertain the benefits of sage for cognition.8
According to a study, sage appears to start to work its
magic for patients with Alzheimer’s disease within 4
6
months.
6
The typical dosage of various forms of sage is:
 Infusion: 1-4 g of dried leaves, taken 3 times a day
 Gargles and rinses: 2.5 g chopped leaves per 100 ml of
water
 Oil: 2-3 drops per 100 ml of water, several times a day.
 Liquid extract: 1-4 ml, 3 times a day (1:1 in 45% alcohol)2
Sage contains vitamins A, B-complex, and C.6 Since such
small amounts of sage are consumed (as a food herb), it
4
does not add a substantial nutritional value to the diet.
While it is unlikely to be toxic (as a food), Lily warned that in-
gesting extracts of sage in other forms at high doses and for
extended periods of time demands caution. "Sage contains a
toxic compound (when consumed in large amounts) called
thujone.8 The largest amount is found in S. officinalis,7 which
makes S. lavandulaefolia (the other reputed Salvia species that
has less thujone)1,5 a wiser choice.7" Reports of sage toxicity
are mostly due to the consumption of its oil in large doses,6
which is loaded with thujone.2 A study on the risk assessment
of thujone established an adequate daily intake (ADI) of 0.11
mg per kg of body weight/day.13 The European Medicines
Agency (EMA) recommends not exceeding 5 mg of thu-
jone/day for a maximum period of 2 weeks,14 although they
later released a public statement expressing that intake be-
tween 3 to 7 mg/day is safe.12 In other words, Lily continued,
consuming 6 cups or less of food sage tea (sold as food) or 3
cups or less of medicinal sage tea should keep you outside the
danger zone.12 In contrast, 12 or more drops of sage oil are
considered as toxic.4 Health Canada cautions not to consume
sage infusions beyond 4 weeks and other preparations for
184
more than 2 weeks unless otherwise specified by a healthcare
practitioner.15 Another variable regarding toxicity is geogra-
phy. Lily said that the amount of thujone can vary depending
on the location, the climate, the period of harvest, drying con-
dition, variations in seasons,12 and the herbal preparations.8
The content of thujone is estimated to fall between 0.7
mg to 5 mg per cup for 1 g of sage leaves prepared in
150 ml of hot water.12 Sage tea sold as food tends to
contain less thujone than the ones sold as a medicinal
product.12
The dietitian warned that possible adverse effects, included
dizziness, nausea, diarrhea, abdominal pain, vomiting, and agi-
tation.3 High doses of sage could even result in seizures and
restlessness.6 Interaction with anti-diabetic, anti-Alzheimer’s,
and anti-hypertensive drugs may also occur.3
Does putting a lid on the pot boost the amount of thu-
jone? It was previously believed that this procedure re-
duced the evaporation and supported better extraction
of thujone due to a lower temperature decline. However,
it was later confirmed in a study that, lid or no lid, the
content of thujone is not affected.12
Although the thujone did sound worrisome, the benefits of
sage certainly sounded intriguing. I made a mental note to
myself that the next time I brought Jenny to see the doctor, I
would enquire whether he thought sage might be both safe
and beneficial for my mother.
Is overstuffing your turkey with sage dangerous?
Considering that your turkey has been sitting in the oven
for a very long time, and that thujone is inactivated by
heat, you can enjoy your Thanksgiving dinner in peace.
However, simply soaking your sage tea bag in boiling
water for a few minutes is not enough to inactivate it.16
185
References
1. Kennedy DO, Scholey AB. The psychopharmacology of European herbs with cognition-enhancing properties. Curr Pharm Des. 2006;12(35):4613-4623.
2. Edwards SE, Heinrich M, Rocha I, Williamson EM. Sage (Salvia officinalis L.). Phytopharmacy : an evidence-based guide to herbal medical products.
Chichester, West Sussex, UK ; Hoboken, NJ: Wiley Blackwell; 2015:332-334.
3. Sage. Natural Medicines Comprehensive Database. http://goo.gl/7kLxgJ. February 1, 2015. Accessed May 11, 2016.
4. Kraft D, DerMarderosian A. Sage. The A-Z guide to food as medicine. Boca Raton: Taylor & Francis; 2016:273-274.
5. Scholey AB, Tildesley NT, Ballard CG, et al. An extract of Salvia (sage) with anticholinesterase properties improves memory and attention in healthy
older volunteers. Psychopharmacology (Berl). 2008;198(1):127-139.
6. Braun L. Sage. In: Braun L, Cohen M, Arthur R, et al., eds. Herbs & natural supplements : an evidence-based guide. Vol 2. 4th ed. Australia: Churchill
Livingstone; 2015:870-874.
7. Tildesley NT, Kennedy DO, Perry EK, et al. Salvia lavandulaefolia (Spanish sage) enhances memory in healthy young volunteers. Pharmacol Biochem
Behav. 2003;75(3):669-674.
8. Miroddi M, Navarra M, Quattropani MC, Calapai F, Gangemi S, Calapai G. Systematic review of clinical trials assessing pharmacological properties of
Salvia species on memory, cognitive impairment and Alzheimer's disease. CNS Neurosci Ther. 2014;20(6):485-495.
9. Tildesley NT, Kennedy DO, Perry EK, Ballard CG, Wesnes KA, Scholey AB. Positive modulation of mood and cognitive performance following
administration of acute doses of Salvia lavandulaefolia essential oil to healthy young volunteers. Physiol Behav. 2005;83(5):699-709.
10. Akhondzadeh S, Noroozian M, Mohammadi M, Ohadinia S, Jamshidi AH, Khani M. Salvia officinalis extract in the treatment of patients with mild to
moderate Alzheimer's disease: a double blind, randomized and placebo-controlled trial. J Clin Pharm Ther. 2003;28(1):53-59.
11. Scholey A, Pase M, Pipingas A, Stough C, Camfield DA. Herbal Extracts and Nutraceuticals for Cognitive Performance. In: Best T, Dye L, eds. Nutrition
for Brain Health and Cognitive Performance. Bosa Roca: CRC Press; 2015:231-234.
12. Walch SG, Kuballa T, Stuhlinger W, Lachenmeier DW. Determination of the biologically active flavour substances thujone and camphor in foods and
medicines containing sage (Salvia officinalis L.). Chem Cent J. 2011;5:44.
13. Lachenmeier DW, Uebelacker M. Risk assessment of thujone in foods and medicines containing sage and wormwood--evidence for a need of
regulatory changes? Regul Toxicol Pharmacol. 2010;58(3):437-443.
14. Community Herbal Monograph on Salvia offinalis L., folium. European Medicines Agency,. http://goo.gl/BXZi0d. 2009. Accessed May 11, 2016.
15. Health Canada. Sage - Salvia Officinalis - Oral. March 25, 2013:11.
16. Fugh-Berman A. Sage. In: Hiscock TY, Baze SL, Risko AL, eds. The 5-minute herb and dietary supplement consult. Philadelphia, Pennsylvania: Lippincott
Williams & Wilkins; 2003:274-275.

186
 lack of evidence regarding their effectiveness; it doesn’t mean
Conclusion we should dismiss them.

Consumers’ interest in dietary supplements, which include vi- As the web provides a jungle of information written by both
tamins, herbs, and protein powders continues to fuel the fast certified and so-called “health advisors”, readers should al-
and ever so burgeoning sales market. Dedicated stores like ways consult health professionals before attempting to self-
GNC are popping up one by one in practically every city cor- treat themselves with dietary supplements.1
ner. Marketed as “natural health products”, it’s easy how
people can mistake these so-called “natural” products as be-
ing “safe” (and even safer) to consume than prescribed drugs,
especially since they can easily be purchased over-the-
counter. However, don’t be fooled: some supplements can be
deadly; especially at doses that largely surpass the instructed
amount.1

Despite such supplements popularity, the evidence is often

lacking and prevents medical professionals from wholeheart-
edly recommending them. However, just because there is a

1
Group D. Herbs and Spices. Encyclopedia of mind enhancing
foods, drugs, and nutritional substances. 2nd ed. Jefferson,
NC: McFarland; 2001:45.

187
Summary
Dietary Supplements Common Uses* Drug Interactions Side Effects Notes

Headache2 Headaches: Begin ginkgo intake at

Spontaneous bleeding2 a lower dose and gradually in-
Memory loss1 Blood-thinning drugs Mild gastrointestinal crease it.2
Ginkgo
Dementia2 (e.g. warfarin, aspirin)3 discomfort1 Bleeding: People at risk of bleed-
Dizziness1 ing are advised caution and are
Constipation1 unsuitable to take the drug.2
Blood-thinning drugs
Alzheimer’s disease Indigestion
(e.g. aspirin, warfarin)5
Common cold Diarrhea
Beta-blockers (e.g. tali- Contraindication: gallbladder dis-
Curcumin Headache Nausea
nolol)6,7 eases5
Cancer Vomiting
Antidiabetic drugs4
Hyperlipidemia4 Acid reflux4
Antiacids drugs8

Blurred vision
9 Acetylcholinesterase Sweating Should not be consumed by those
Dementia
Inhibitors (e.g. donepe- Nausea with bradycardia, peptic ulcer
Huperzine Memory9
zil, galantamine, rivas- Vomiting disease,9 hypertension, liver or
Learning9
tigmine)10 Dizziness kidney disease.10
Muscle cramping11

Seizure
Inflammation
Anti-diabetic drugs Dizziness
Colds Sage contains a toxic compound
Sage Anti-hypertensive drugs Diarrhea
Indigestion called thujone, a convulsant.13
Anti-Alzheimer’s drugs13 Vomiting
Memory12
Nausea13
*Common uses indicated here may or may not have been scientifically verified.
This table is not exhaustive. Please refer to a pharmacist and/or a physician before attempting to take any supplements.

188
References
1. Ginkgo. Natural Medicines Comprehensive Database. http://goo.gl/HjesHO. April 18, 2016.
2. Table 3: Clinical Reports of Adverse Effects Associated with Commonly Used Natural Health Products. Dietitians of Canada. http://goo.gl/RDpwYX.
2005. Accessed April 18, 2016.
3. Table 4: Clinical Reports of Drug Interactions with Commonly Used Natural Health Products. Dietitians of Canada (PEN); 2005.
4. Turmeric. Natural Medicines Comprehensive Database. http://goo.gl/HjesHO. February 11, 2016. Accessed 25 April, 2016.
5. Higdon J, Delage B. Curcumin. Oregon State University. http://goo.gl/ODlI2d. April 25, 2016.
6. Edwards SE, Rocha I, Williamson EM, Heinrich M. Turmeric. Phytopharmacy : an evidence-based guide to herbal medical products. Chichester, West
Sussex, UK: Wiley Blackwell; 2015:379-382.
7. Murray MT. Curcumin longa (Turmeric). In: Pizzorno JE, Murray MT, eds. Textbook of natural medicine. 4th ed. St-Louis, Missouri: Churchill
Livingstone; 2013. http://goo.gl/0ICffz
8. Ehrlich SD. Turmeric. University of Maryland Medical Center. http://goo.gl/1n6QGE. April 25, 2016.
9. McQueen CE, Orr KK. Natural Products. In: Berardi RR, Ferreri SP, Hume AL, et al., eds. Handbook of non-prescription drugs. Washington, D.C.:
American Pharmaceutical Association; 2009:978-979.
10. Turkington C, Mitchell DR. The encyclopedia of Alzheimer's disease. 2nd ed. New York: Facts On File; 2010
11. Huperzine A. Medicines Comprehensive Database. http://goo.gl/HjesHO. 2014. Accessed 3 May, 2016.
12. Edwards SE, Heinrich M, Rocha I, Williamson EM. Sage (Salvia officinalis L.). Phytopharmacy : an evidence-based guide to herbal medical products.
Chichester, West Sussex, UK ; Hoboken, NJ: Wiley Blackwell; 2015:332-334.
13. Sage. Natural Medicines Comprehensive Database. http://goo.gl/HjesHO. February 1, 2015. Accessed May 11, 2016.

189
 ly) is featured in the guidelines established by the speakers at
Don’t Forget about Exercise! the International Conference on Nutrition and the Brain
garding Alzheimer’s disease prevention.2
My brain tends to take the scenic route. Things come to the fore-
front of my mind sooner or later, it just takes time.
— Richelle E. Goodrich I know for a fact that the walks that I take with my mother
have a beneficial effect. Worrisome by nature, she often
Jenny and I take long walks together two or three times a
works herself up into a state of stress and anxiety. But during
week. Fortunately, my mother only lives a few blocks away, so
our walks, the physical exertion distracts her from her fretting,
it's easy for the two of us to coordinate our excursions.
and consequently she feels calmer, and her thinking becomes
Physical activity is a great defense tool against many diseases, clearer.
and cognitive impairment is no exception. As we age, our
Mind blowing sex may be an enjoyable experience... but
brains have a tendency to “shrink”. For
when it wipes clean your memories, the mind-blowing
instance, the adult hippocampus (re-
aspect of intercourse may have been taken too seriously.
gion in the brain involved in
Take the case of a 54-year-old woman living in the
ing and memory) gets smaller in
Washington, D.C. area, who woke up with transient
size at an annual rate of 1 to 2
global amnesia. At Georgetown University Hospital,
percent after the age of 55. Several
she was admitted to the emergency room when she was
studies found that staying active is
unable to remember anything concerning the previous 24
associated with a sharper memory, an
hours. The only thing she recalled before the amnesia
easier time accomplishing cognitive tasks, and a larger brain.1
was having sex with her husband.3
Aerobic exercise (e.g. 40-min brisk walking, three times

190
References
1. Erickson KI, Gildengers AG, Butters MA. Physical activity and brain plasticity in late adulthood. Dialogues Clin Neurosci. 2013;15(1):99-108.
2. Barnard ND, Bush AI, Ceccarelli A, et al. Dietary and lifestyle guidelines for the prevention of Alzheimer's disease. Neurobiology of Aging. 2014;35:S74-
S78.
3. Pappas S. Live Science. http://goo.gl/bgp2tY. 'Mind-Blowing' Sex Can Wipe Memory Clean. Accessed June 10, 2016.

191
Glossary
Acetylcholine. A neurotransmitter, a chemical in the brain. It is found at neuromuscular junctions, where the nerve and muscle
come into contact, as well as in different areas of the brain. Once acetylcholine is released, it is degraded by enzyme called acetyl-
choline esterase.1 Acetylcholine is a very important neurotransmitter that appears to be involved in stimulating the process of mak-
ing new memories.2

Antihistamine. A drug or compound that inhibits the effects of histamines (compounds release by the body in response to allergic
and inflammatory reactions). It’s used specially in allergies.3

Bioavailability. The ability of the body to use a chemical following its absorption. 4

Blood-brain barrier (BBB). A structure that separates the brain from the blood circulation, and serves as a filtering system, deciding
what comes in and what goes out. For instance, it protects the brain from harmful substances by preventing them from entering. 5

Brain concussion. A term often used to refer to mild traumatic brain injury (MTBI). It indicates a temporary change in the function of
neurons following a mechanical force-induced injury.6

Catecholamines. Neurotransmitters, such as dopamine, epinephrine, and norepinephrine. They are produced either in the adrenal
glands or the brain, and they exert effects upon the blood vessels, the lungs, the gut, as well as the skeletal muscles. 7

Cerebrospinal fluid. A clear, colorless fluid that bathes the brain and spinal cord and serves as a cushion for the brain to absorb
shocks. It supplies nutrients, and it removes waste products from the brain.8

192
Cochrane. An independent global network of health experts working in the field of health sciences. Cochrane Reviews’ main goal is
to analyze current evidence on various topics and provide different treatment options.9

Cognition. Mental processes which include remembering, thinking, problem-solving, judging, and knowing; these processes help us
to comprehend and gain knowledge.10

Free radicals. Notorious compounds known to be implicated in a broad range of diseases, but can be neutralized by antioxidants.
Oxidative stress is the state in which the antioxidants are outnumbered by the free radicals. 11

Glasgow coma scale. The degree of loss of consciousness in brain injuries can be measured with the Glasgow coma scale. The sever-
ity of a traumatic brain injury (TBI) can be assessed as follows 12: 1) A score of 13-15 for mild cases; 2) A score of 9-12 for moderate
cases; 3) A score of 3-8 for severe cases. The GCS scale was developed by Graham Teasdale and Bryan J. Jennett in 1976.12
Gluconeogenesis. The breakdown of proteins and fat to be converted to glucose. 13

Hippocampus. A structure in the brain that is involved in the acquisition of memory.14

Homeostasis. A state of equilibrium of different aspects of an organism, group, or population.15

Intracerebral hemorrhage. When a blood vessel bursts inside the brain and leads to blood leakage. 16

Intracranial Hematoma. A collection of blood in the area between the brain and the skull due to the rupture of blood vessel in the
same area. This causes the hematoma (collection of blood) to press against the brain tissue. 17

Isoflavones. Plant chemicals that resemble human estrogen and act as an antioxidant. 18

193
Melatonin. A substance produced by the brain, it is a key player in regulating the sleep-wake cycle.19

Mild traumatic brain injury (MTBI). An acute brain injury resulting from mechanical energy to the head from external physical
forces.20

MMSE (Mini-Mental State Examination). A test is a questionnaire used to evaluate the mental status.21 A low score is an indication
of cognitive impairment.22

Nutrient bioavailability. The ability of the body to absorb the nutrient and to properly use it for various biological functions. 23

Pituitary gland. A pea-sized organ located below the base of the brain.24 Also known as the “master gland”, it produces a line-up of
crucial hormones in the body.24

Post-stroke dementia (PSD). A type of vascular dementia and appears three months following a stroke, whether it is the first stroke
or a recurrent stroke. Patients with PSD show a 23% to 55% decrease in memory. There are vastareas of dead tissues (infarcts),
damage to the white matter, and lesions in the brain hemispheres in PSD individuals.25

Spatial memory. Ability to remember the location or position of places and objects.26

Spatial memory. The ability to recall three-dimensional objects or places, e.g., the location of an object in space, the position of one
object in relation to another, or the correct path through a maze. 27

Working memory. The memory that is used when a person is completing a task that requires them to retain some memory of the
enterprise while completing a task such a doing a math problem without the utilization of a calculator or paper.28 It is a way of rep-
resenting something that just happened or something that was remembered from long ago actively for a temporary period. 29
194
α-synuclein. A part of a family of proteins, which include β-synuclein and γ-synuclein. These proteins are found in the neurons (brain
cells). The functions of these proteins are not entirely known. However, α-synuclein is believed to be involved in the management of
other proteins in the brain. It is also associated with the release of neurotransmitters (chemicals in the brain). The α-synuclein pro-
tein is also believed to play a part in age-related neurodegenerative diseases, such as Parkinson’s disease and Dementia, with Lewy
bodies, as well.30

195
References
1. Purves D, Augustine GJ, Fitzpatrick D, et al. Neuroscience. Second ed. Sunderland, MA: Sinauer Associates; 2001. http://goo.gl/c3ZZA1
2. Hasselmo ME. The role of acetylcholine in learning and memory. Current opinion in neurobiology. 2006;16(6):710-715.
3. Antihistamine. Oxfor Dictionary. http://goo.gl/gC5OiZ. 2016. Accessed 27 June, 2016.
4. Alzheimer's Drug Discovery Foundation. Glossary. http://goo.gl/SmFCTR. May 3, 2016.
5. Abbott NJ, Patabendige AA, Dolman DE, Yusof SR, Begley DJ. Structure and function of the blood-brain barrier. Neurobiol Dis. 2010;37(1):13-25.
6. Kushner D. Mild traumatic brain injury: toward understanding manifestations and treatment. Arch Intern Med. 1998;158(15):1617-1624.
7. The Free Dictionary. Catecholamines. Farlex. http://goo.gl/oLh1WH. 26 June, 2016.
8. Savic MM, Obradovic DI, Ugrešic ND, Bokonjic DR. Memory effects of benzodiazepines: memory stages and types versus binding-site subtypes. Neural
plasticity. 2005;12(4):289-298.
9. Kalso E, Tramèr MR, Carroll D, McQuay HJ, Moore RA. Pain relief from intra-articular morphine after knee surgery: a qualitative systematic review.
Pain. 1997;71(2):127-134.
10. Moncayo R, Ortner K. Multifactorial determinants of cognition—Thyroid function is not the only one. BBA clinical. 2015;3:289-298.
11. Whitney EN, Rolfes SR. Understanding nutrition. Fourteenth edition. ed. Belmont, CA: Cengage Learning; 2016
12. Reis C, Wang Y, Akyol O, et al. What's New in Traumatic Brain Injury: Update on Tracking, Monitoring and Treatment. Int J Mol Sci. 2015;16(6):11903-
11965.
13. Encyclopaedia Britannica. Cortisol. Encyclopaedia Britannica. http://goo.gl/16Qavs. 2016. Accessed 18 April, 2016.
14. Gerrig R, Zimbardo, PG. Psychology and Life - Glossary of Psychological Terms - Hippocampus. 2002.
15. Merriam-Webster Online Dictionary. Homeostasis. http://goo.gl/1d7YvF. 2016. Accessed April 29, 2016.
16. Center TIS. Intracerebral hemorrhage.
17. Staff MC. Intracranial Hematoma. 2014.
18. Whitney EN, Rolfes SR. Understanding nutrition. 14th ed. Stamford, CT: Cengage Learning; 2016
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Centre for Neurotrauma Task Force on Mild Traumatic Brain Injury. J Rehabil Med. 2005;37(3):137-141.
21. Richardson K, Schoen M, French B, et al. Statins and cognitive function: a systematic review. Annals of internal medicine. 2013;159(10):688-697.
22. Yavuz BB, Cankurtaran M, Haznedaroglu IC, et al. Iron deficiency can cause cognitive impairment in geriatric patients. J Nutr Health Aging.
2012;16(3):220-224.
23. Nutrient bioavailability - getting the most out of food. The European Food Information Council (EUFIC). http://goo.gl/xHWBLU. May 2010. Accessed
April 26, 2016.
24. What is the pituitary gland? The Pituitary Foundation. http://goo.gl/xaXQdW. February 23, 2016.
25. Khedr EM, Hamed SA, El-Shereef HK, et al. Cognitive impairment after cerebrovascular stroke: Relationship to vascular risk factors. Neuropsychiatr Dis
Treat. 2009;5:103-116.
26. Pam MS. What is spatial memory? Psychology Dictionary. http://goo.gl/ytzcRa. 15 june, 2016.
27. The Free Dictionary. Spatial Memory. Farlex. http://goo.gl/UKY7cA. 21 June, 2016.
28. Cowan N. What are the differences between long-term, short-term, and working memory? Prog Brain Res. 2008;169:323-338.
29. Curtis CE, D'Esposito M. Persistent activity in the prefrontal cortex during working memory. Trends Cogn Sci. 2003;7(9):415-423.
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