Welcome to all of you to our symposium here. This symposium is on brain health and well-being in older adults, the impact of lifestyle interventions, and it's sponsored by the Group for Advancement of Psychiatry, of which we are all members of the Committee on Aging. Our first talk is given by Dr. Seba Hussein Crowder, who's Assistant Professor of Psychiatry at the ICANN School of Medicine at Mount Sinai, and she's going to be talking about the role of physical and cognitive activity in delaying cognitive decline. So Seba, take it away. Good afternoon, everybody, and thank you for being here. I also want to thank the organizers for giving us this opportunity to present. So starting off with the symposium, I'll be mainly talking about the role of physical and mental activity on healthy aging, especially in the context of cognitive decline. I have nothing to disclose, except that I'm a member of the Committee for Aging, off the gap. So start with a little bit of background. Age brings many changes, physical as well as functional. The functional changes are immense. Change in muscle strength, balance, renal function, cardiac output, amongst other things. And there is change in cognitive function as well. Many others, including speed of processing, changes in working memory, and executive function. Physical activity has been reported to delay or prevent cognitive decline in several studies now. And cognitive interventions, such as leisure time pursuits or formal training, have also been reported to delay age-related cognitive decline and prevent or delay the onset of dementia. So this is what we know. What is the evidence of this being true? So the objective of this particular body of work was to review the evidence base for the proposed benefits of physical and cognitive activity on the aging brain, discuss the underlying mechanisms, and then identify opportunities for additional research on which to base recommended interventions. So we set about reviewing the literature. So there's a lot that's been published, especially in the last five years. So what we did is look at the meta-analyses that are there, and then we conducted a review of these meta-analyses, which were published in the last 20 years. We looked at PubMed, Google Scholar, and the Cochrane Systemic Library as the main databases. And the criteria, we had to limit the criteria because there were several meta-analyses there. So the criteria was the relationship between physical and mental activity and cognition. Since we were looking at older patients, we looked at persons age 55 and older, and only studies where the duration of the proposed intervention was for 12 weeks or more were included. And the outcomes that these studies were looking at were objective cognitive performance in one or more of the six cognitive domains. The main domains looked into were complex attention, executive function, learning and memory, and perceptual motor control. Some of the studies looked at language and social cognition as well, but mainly the other four domains were the chief outcomes measured. And what were the measures used? So global cognitive functioning measured, which was measured using validated tests, was the main outcome measure. And the tests that they used were a mini mental status exam, the Alzheimer's disease assessment scale, the R-bands, amongst others. And there were additional tools as well that they looked into, and these tools were to address episodic memory, speed of processing, executive functioning, verbal fluency, et cetera. So there were 35 meta-analyses that fulfilled the criteria that I mentioned before. And out of these, 23 studies included only individuals with cognitive impairment. Six studies included only cognitively healthy individuals, and six studies included both cognitively healthy and cognitively impaired individuals. We decided to divide these studies into the type of intervention that was used. So 26 studies employed only physical exercise-based intervention. Eight studies employed both physical and cognitive interventions, and one study employed only cognitive intervention. So now let's have a closer look at the studies that included physical activity alone as the intervention. So of the 26 studies in which physical exercise was the only intervention, the frequency of the exercise ranged from daily to about twice a week. The length of the sessions ranged from 30 to 60 minutes. And the main form of exercise was the multi-component exercise, which combined two or more types of exercises, such as, you know, aerobic training or strength or resistance training. There were three studies that used aerobic exercises alone, and there were two studies that used resistance exercise alone. So what was the outcome? So the studies of the 26 studies that had physical activity alone as the intervention, 25 showed significant improvement in at least one cognitive domain. There was one meta-analysis that was inconclusive. This study rather used some unconventional methods, and they examined the effect of exercise on the structure of cognitive-related areas. And of the nine RCTs that were included in this particular meta-analysis, at least three did not include cognitive outcome data. So it's hard to say. Now, looking at the eight studies that used combined physical and mental exercise on cognitive, as looking at the cognitive decline, the results of these studies show that eight, of these eight studies, seven studies showed significant improvement in at least one cognitive domain. One study showed a non-conjunctive effect One study showed a non-significant positive trend, and this particular study used virtual reality-based exergames as the intervention. And only one meta-analysis that employed cognitive exercise as intervention fulfilled that criteria. Not that there are not other meta-analyses that have done these kind of studies, but again, this was the only one that fulfilled that criteria. So I just wanted to talk a little more about this one particular study. So this study used computerized cognitive training for 12 or more weeks for maintaining cognitive function in cognitively healthy individuals. And in this, the participants were healthy individuals. At least 80% of the study population was aged 65 or older, and it included eight RCTs, and the number of the participants were about 1,200 in these RCTs. And the intervention was any form of interactive computerized cognitive intervention that involved repeated practice on standardized exercises or specified cognitive domains for the purpose of enhancing the function. And these employed either computer exercises or games, mobile devices, gaming consoles, and virtual reality-based games. And the duration was at least 12 weeks. And what they did was they compared the results against two control groups, one the active group and one inactive group. So the active group was all those control conditions that involved unguided computer or screen-based tasks that were not part of a planned intervention. These tasks involved watching educational videos or playing computer games with no particular training component. The inactive control group in which no intervention was applied was the group in which no intervention was applied. What the results show was that when compared to the test subjects, the active controls showed that after 12 weeks of training, but not after 12 months of training, there was slight improvement in global cognitive function. There was little or no effect on episodic memory or working memory. And as compared to inactive control, where the results showed that CCT slightly improved episodic memory with little or no effect on the executive function, working memory or verbal fluency. So the results were very mixed. There was another study that used cognitive exercises as the intervention. It did not fulfill the criteria, but it is worthy of mention, so I thought I'd just include it here. In this particular study, the effect of cognitive-based training for the healthy, so these were, again, healthy older individuals, they included 31 RCTs, but only 14 of these included overall cognitive function as the outcome measure. This review reported that cognitive-based training has a significant and moderate effect on overall cognitive functioning. They also reported that attending an intervention for three or more times a week, 24 or more training sessions, and or eight or more weeks in total yields a greater effect size. So the more you do, the better the results. Now going back to the possible mechanisms, first let's look into how physical activity actually improves cognition. So the proposed mechanisms are direct and indirect. So directly exercise-induced structural and functional changes in various areas of the brain, preservation of synaptic integrity, up-regulation of proteins including BDNF, vascular endothelial growth factor, insulin light growth factor, amongst others, and then reduction in inflammatory molecules such as IL-6 and TNF-alpha. And indirectly, through enhancement of metabolic health and vascular health, amongst other things. At this point, I just want to take a little segue and talk about a study that I have been a part of in a small way. So this study is called the Muscle for Memory Study at the Bristol Assisted Living Facility, and the PI for this project is Dr. Jeremy Koppell. And it's actually, it was done at the Feinstein Institute for Medical Research in New York. So this was a six-month non-randomized study at this particular assisted living facility, exploring the ability of strength training to combat frailty. And we called it the Muscle for Memory Study. And strength intervention involves exercises to build muscle in both upper and lower extremities. And the major outcome measures included changes in cognitive rating scales over time, IGF-1 and BDNF measurements, cytokine and inflammatory markers, and frailty ratings. 33 individuals participated, and the majority of the participants were women. So about 80% of the participants were women. And the mean age was 86. So this is one of the kind studies where strength-based exercise training was used on people in their 80s, with an age range of 67 to 97. We have some preliminary data from this particular study. We see that serum IL-6 levels, which is an inflammatory cytokine, are reduced post-intervention. As we are analyzing this data, we have come up with several other questions, some of the main ones being, what is the relationship between strength and inflammation? And, you know, what is the relationship between all these inflammatory markers and some of these other protein and molecules in the brain? And who is the perfect candidate for this intervention? When do we intervene? How often? And what's the dosing? So in terms of, now that we know that physical activity improves cognitive health, or at least prevents cognitive decline, so what are the recommendations? There's no clear protocol for type and intensity of systematized physical activity that is required to produce benefits in cognitive functioning. However, regular practice is required for adequate dosing. So since we don't know what the actual recommendation is, you know, so let perfect not be the enemy of good. Let's all practice regularly. But what we know is that we have to do it regularly and on an ongoing basis. The American Heart Association has guidelines for cardiovascular health. So at the least, we can employ the same guidelines for mental health as well. And these guidelines consist of 150 minutes per week of moderate-intensity aerobic activity, or 75 minutes per week of high-intensity aerobic activity and incorporating strength and training at least twice a week. There is also data showing that balanced training improves memory and spatial cognition in healthy adults. And this is an area that's catching on. You might have seen this in the popular media as well, you know, balancing on one foot and challenging yourself. Now, what are the mechanisms responsible for mental exercise and cognition? So this is still very unclear, and remains controversial, highly controversial. So there is a school of thought that it improves compensatory cognitive mechanisms. Cognitive reserve theory has also been hypothesized to play a role in individuals who perform better with mental exercises. However, in 2014, the Stanford Institute issued a consensus statement. They said that at this point, it is not appropriate to conclude that training-induced changes go significantly beyond the learned skills, that they affect broad abilities with real-world relevance, or that they promote brain health. To date, there's little evidence that playing brain games improves underlying broad cognitive abilities, or that it enables one to better navigate a complex realm of everyday life. Having said that, there is increasing data to show that when we learn a new language, when we stay socially connected, and we try and challenge ourselves every day, it does, to a certain degree, prevent cognitive decline. So I just want to end this talk by saying that preventive lifestyle interventions remain our best available defense against cognitive decline. Thank you. Thank you so much, Seba. All right, and our next speaker is Dr. John Baer from the Duke University School of Medicine, and he's a professor there, and he's going to talk about the evolving understanding of nutrition in brain and mental health. So, let's see. I'll close this one down. And... All right, thank you, Helen. I want to thank everyone for coming. I want to thank everyone for being here also as we kind of talk about it. As I get my slides ready, let me start with a little bit of a story about how I came to kind of talk a little bit about nutrition and mental health. I primarily do a lot of research with bipolar disorders, mood disorders, and its interaction in cognition, and we're running imaging studies in bipolar disorder, and I was asked to edit one of our journals, a series of articles on bipolar disorder, and so we had experts from all across the country kind of contribute talks, articles, about bipolar disorder and kind of what is the cutting edge. And I needed one more article, and I kind of thought, well, what can we do? And I had a nutritionist that was working with me in one of our studies, and we did a survey of our patients that had bipolar disorder, and one of those things was a survey on nutrition, and so I said, you know, we can grab some data. I don't think hardly anything's been written about mental disorders or mood disorders, especially, and nutrition. So this was about 10 years ago now. And we did. We pulled it together and put it in an article, and of all the articles that I've written, this one has received actually, I think, the most response. It seems to kind of trigger some needs that people have in thinking about nutrition and where it fits in. By the way, the bottom line to the article was that people with bipolar disorder have a significantly worse diet than people that do not have bipolar disorder. So I was not necessarily surprised at that, but it did raise the question about, is that contributory to the problem that person may have with mental illnesses? Now, that's not the talk that we have today. However, what the talk is, is what does diet have to do long-term with cognition and brain health in general, which was the other area of interest, and that's what got me to start thinking. I leave this potential conflict of interest. I do have ongoing studies and interactions with several different pharmaceutical companies and health concerns as well. What we're going to do in the next 15 minutes is just give you a framework to think about diets and nutrition for your patients, and what that means for cognitive health as we age. I'm going to give you a little historical reference for that. Am I? I'm too loud. Only my wife has said that. So what we're going to do is give a historical reference about how to think about diets, and then we're going to talk about why diets might actually cause changes in cognition as we age, changes in brain health as we age, and then come back and talk about, well, what does that mean for what we as providers need to do about that as well. So that's what we're going to do. Long way to go in 15 minutes. And we're going to start 70 years ago. Just post-war in the 1950s, there was a lot of discussion going on about the increasing problems Americans had with heart disease. Heart disease was becoming the number one killer of Americans, especially as people were living longer. It still is the number one killer of Americans in older age as well. And scientists wanted to understand why are we having so much problem with heart disease? Where does it come from? There were people saying it's because of blood pressure or it's because of medications taking or maybe because of this new thing called cholesterol that people were looking at. And Ancel Keys was a physiologist who lived in Minnesota that wanted to answer that question. He hypothesized that the rate of coronary artery disease in populations around individuals would vary based upon their relationship to their physical characteristics, their lifestyle, particularly their diet, and how much fat was in their diet, and especially serum cholesterol levels that derive from that. So he had this idea that he would compare different groups about their lifestyle and how that affected their hearts. So he did this seven-country study, seven countries, 16 different places in the countries, and started comparing over the subsequent 30, 40 years that this study went how different people responded with heart health. And what they did find was, yes, cholesterol and fats do make a difference as far as heart health goes. We all know that now. We understand that. But one of the things was, is there difference between different groups about how much heart disease they may have. And what they did find was that especially in countries like Italy, Greece, and Japan, there were significantly lower levels of heart disease in these countries, and he wanted to ask why. And so what he came up with was that it looks like it is the diet of these countries that made a significant difference on how much fat or how much cholesterol a person had and the subsequent how much heart disease they had. And when they looked at especially Italy and Greece, they said, this is what people are eating. This is the Mediterranean diet. It's a diet in which these groups actually had lots of vegetables and fruits. They emphasized beans, nuts, lentils, whole grains as well. If you're going to have fat sources, it would come from extra virgin olive oil. Only a small amount of meat, especially if the meat was going to be fish, was the derived derivation, and just a limited amount of red wine that they had. This is where we got the idea about a Mediterranean diet. So for those of you all interested in different diets, the Mediterranean diet has been the kind of catch phrase for what is considered to be a good diet. And this is what the diet is. Now I want to point out that this is the Mediterranean diet of the 1960s. What Ancel Keys found was that as the years progressed and different foods became available, such as McDonald's moved over into Europe and everything, the diet of the Mediterranean has changed. And with the change of diet, they could show there was also a significant increase in heart disease as well. This interesting was repeated here in the United States also. The same question were put down in the diet and health study that they had in certain regions of the United States following over 100,000, 567,000 older Americans. And again, what they found was diet did matter for things like cancer, heart disease, how a person might have hormone needs as they grew up. Whatever was happening, diet does play a difference in physical health. Now we like to make sure that these studies are actually real, that what we're capturing is real. And so Europe did another study looking at Mediterranean-style diets. Does it actually make a difference in health? This is the EPIC study. Again, across Europe, 520,000 people were involved in this. And what they ended up finding is that the more a person adheres to a Mediterranean-style diet, they have reduced mortality, reduced cardiovascular disease, reduced cancer, it was good for you. But in one of the sites in England, they actually decided to ask a second question, which is, if you were doing this diet, does it affect cognitive abilities over time? And so they started putting in questions about cognitive health, measuring cognition as they go. And what they didn't find was yes. If you had a high adherence to a Mediterranean-style diet over the four, ten years at least of the study that they looked at, people did better in cognitive performances across all cognitive domains. Now that was echoed also in this other study in Spain, in which they tried to randomize people to three different diets. A Mediterranean diet supplemented with extra virgin olive oil, a Mediterranean diet supplemented with just mixed nuts, and then a controlled diet for what people in Spain were eating at the time. This study was stopped after two years, because those people that were in the Mediterranean diet arm, either of those arms, had significantly less cardiovascular mortality as well. However, they also asked that same question about cognition. And they found that the people, again, that adhered to a Mediterranean-style diet, even after just the two years of the study before it was stopped, were found to do better cognitively over that time. Well, there might be other reasons that diet makes a difference. In the American cardiothoracic, American cardiology wanted to know if maybe it's hypertension that was the problem with cognitive or cardiovascular problem. So they came up with what they called a DASH diet. Now a DASH diet is very similar to a Mediterranean diet. Lots of leafy vegetables, fruits, emphasis in nuts, less red meat. The difference of a DASH diet is that they limited the amount of salt that was consumed to no more than two teaspoons in their diet. And again, what they ended up finding was that people that were on the DASH diet did better overall cardiovascular. But they also did better with their cognitive health over time. A higher adherence to a DASH diet showed less cognitive problems over the next 10 years compared with those that were not as adherent to the DASH diet. Meaning that whatever a person is eating makes a difference not just for their heart, but for their head as well. So this kind of brings up the question, what then is the best diet that should be on? Well, I will tell you that the U.S. News and World Report ranks not only colleges and med schools, but also diets. And what they have come up with is this saying that the best diet to have is number one the Mediterranean diet, number two the DASH diet, and then they have several other diets. Now they would also break it down saying there are certain diets that might be better for people that want to lose weight, or certain diets better for people with diabetes type 1 or type 2. But this is what they said was the best diets overall. They did not, or they do not yet have a category for what is the best diet for people that are interested in cognitive health, sustaining cognition as we get older. And that comes to some research that has been presented, developed at Rush University by a couple dietitians, what they call the MIND diet. By the way, you saw that as number four on the U.S. News and World Report list of good diets. The MIND diet, MIND stands for Mediterranean DASH Diet Intervention for Neurodegenerative Delay. Now, the MIND diet basically is a modified Mediterranean diet, or DASH diet. But what they want to emphasize were things that they thought were better for the brain. And that included things that had a lot of antioxidants, things like leafy green vegetables, and lots of berries. You may have seen in some of your news feeds, occasionally advertisements or studies come out saying you should eat blueberries for good brain health, or more recently, strawberries. Strawberries are the way to go for brain health. That's where some of this information has kind of come from. But what they ended up finding was that if you were adherent to this MIND diet, the risk for cognitive decline in late life was substantially reduced, and the risk for Alzheimer's disease was also substantially reduced over time. Now, I know many of you are probably thinking, okay, there's got to be a catch. You know, can you actually treat people by just telling them to change their diets? And it's true. These studies are not definitive. They are correlational studies. They're association studies. They evaluate associations, not cause. Could there be other reasons that people in these studies had improved cognition over time? And I could think of a few things. One, I could think that it might be an education level. People that had higher education may actually be more likely to stay on a good diet, a Mediterranean diet. So maybe it's the education level that actually is. Or maybe, maybe a difference is that it is how much a person has. If you have means, if you're not in poverty, you have means to purchase and buy better foods. And so maybe it is actually the monetary, the money that person has, not necessarily the diet itself. There might be other reasons that people have besides the diet themselves. But I want to point out there is a signal here. Something is going on that says what we eat matters with cognitive health overall. Now I'm going to, on a different talk, I will also suggest that that matters as far as mood disorders and problems like that too. But that's a different talk. Cognitive health, as we think as we get older, something is there that does matter, that does change it. Why is there such a signal? And it may be what we're, we're emphasizing in these diets. Number one is micronutrients. These are the vitamins and the minerals that we need in our diets. It's important that we make sure we have these in good amounts if we want to continue to have good cognitive health, keep our brain working. The second is polyphenols. These are things we usually don't talk that much about, but they're kind of plant-based chemicals that we ingest that we think significantly reduce inflammatory responses in the brain, decrease the oxidative load that's going on in our body. Not just in our hearts, not just in our liver, but also in our brain as well. And there are multiple types of these phenols so that if we do not get enough of these, we may be stressing the organs that are identified, like our brain, that we want to keep healthy. And the third are the omega-3 fatty acids. Now this is the one that many of us have been discussing, you know, and we even encourage some of our patients to take additional omega-3 fatty acids. Omega-3 fatty acids are those fatty acid chains that are not produced, manufactured within our body, but we need to get from an exogenous source. They form the cell walls, the cell membranes, the things that kind of keep our sacks of our cells and our neurons all together. They have to receive that because we can't make them within the body very well. And so that's why we think about things like EPA and DHA as potential good treatments for our patients that might be helpful for keeping healthy heart and healthy brain. But there are also other potential reasons that we can think of maybe that's why diets are helpful. First, they decrease cardiometabolic risk factors. If you have decreased amounts of cholesterol or fat, that's better, good for your heart, but it might also be good for your brain. It keeps the vasculature well. It might be that it prevents anemia. Anemia is still one of the major problems throughout the world that often leads to cognitive decline as well. But it may be that we are feeding into the mitochondria health that often cause stress onto our cells because of the energy that they produce or the free radical oxygens that might actually contribute to cancers that kind of go on or the regulation of intercellular calcium or just this thing that's becoming more and more popular to discuss, neuroinflammatory diseases, that good diets may actually decrease the inflammation. You know, one other option is it may be that it's less about what we're feeding ourselves, but what we're feeding our gut. We have more bacteria in our gut than we have cells in our body. And often it is that gut bacteria that interacts with our brain in ways that we are not often even aware that often does hormone regulations or preventive from infections or inflammatory responses with the brain. It may be keeping a good gut bacteria is what we're also looking at when we change our diet that's positive overall. So here we are. Can't we just take a pill for something instead of going through it for thinking about what we're eating all the time? And yes, we can. And there are people that have tried to do some of these things. And there are studies that have looked at specific vitamins or foods and put them in pill form to see, does that improve it? Now, you may have seen some of this research about does dark chocolate help improve cognition? We know dark chocolate helps improve mood, but does it help improve cognition? And actually, this is one of the studies that has been done. There have been studies that randomize people, and they have found that some dark chocolate, especially 85% and higher levels, do improve cognition over time, over a few weeks' time. In this study, it did not show improvement. So I don't want you to be totally disappointed. There is a signal that might be there. But there is evidence that just adding vitamins may actually improve cognition over time from this study as well. What I want to kind of show now is that there are a series of studies that are out there, usually somewhere between four weeks to 12 weeks to about six months, something like that, that show a variety of different foods. If you emphasize that to your patient, it may actually improve cognitive performances. These are studies that look at berries, studies that look at certain types of fruit juices, studies that look at nuts, the addition of nuts, studies that look at coffee and tea, kind of for attention and focus. And it begs the question, is food medicine? We do have some medicinal foods, and I think it's important to, I'm just going to point out that we are, have the FDA starting to approve some types of medicinal foods, but I'm not going to dwell on these, as much as to say we are starting to rethink how we approach diets in general. The last point, it may not be what we're eating. It may be what we shouldn't eat. What I have mentioned is the Mediterranean diet and the DASH diet and the MIND diet. What we have found is that the traditional Western diet is probably bad news for our cognitive health, heavy in processed foods, sweets and sugars. How do we make the changes? I'm going to say that in my clinics, I am starting to talk with patients about diets. We're having lessons about how to think about cooking as a lifestyle change to help people, not only with cognition, but also with moods over lifetime. And I think it's a new way to think about being supportive. Is it the answer for my patients? Not entirely. But is it there for my patients and for me? I think so. And something that I need to be more thoughtful about and deal with too. That's where we're going to stop right now. I have a little summary of slides, but I want to get on with our next speakers. We can take some questions in a moment. Thank you. Thank you so much, Dr. Baer. Thank you. All right. Our next speaker is Dr. Ebony Dix. She's assistant professor of psychiatry at Yale, and she will be talking about sleep and brain health. Thank you, Alan. I will be speaking now about sleep and brain health, and perhaps to segue off of the last speaker, it might be important to pay attention to what you eat, but also at the time of day and night. These are my disclosures. I'll be speaking a bit today about the importance of sleep for our brain health and general well-being, and I'll be discussing some medications, and the mention of those medications will be for educational purposes only. So to outline the talk, I'll be talking a little bit about brain health and well-being, and how do we really measure this, and how do changes that occur in the brain as well as to our circadian rhythms actually affect our sleep, and the sort of impact of poor and insufficient sleep on individuals and a society, and along with some of the lifestyle interventions and recommendations that there are. So first of all, Benjamin Franklin, very long, long, long time ago, was a wise man, said early to bed and early to rise makes a man healthy, wealthy, and wise. I would like to add a man, woman, or non-gendered person healthy, wealthy, and wise. So as we know, we've all been there, right? We've gotten poor sleep, and we felt crummy the next day, unable to really think straight. Well, in fact, poor sleep does lots of damage. It makes us mix up our words and stutter. I don't know if any of you have ever had sort of a transient aphasia when you haven't gotten any sleep, but I certainly have had that happen to me. And when you're tired, you tend to eat more, you know, lots of snacking. So even if it's good, healthy snacks, like almonds, too much could mean that you probably need to just get more sleep. It affects your concentration, reaction time, lack of sleep can damage brain tissue, right? We actually technically clear our amyloid deposits at night, every night when we get sleep. So chronic insomnia and chronic sleep deprivation unfortunately means that we're then accumulating amyloid plaques. And also our resistance sort of gets lowered, and our immune system makes us more susceptible to colds and different illnesses when we're not sleeping. So some common complaints in sleep that are common in aging and, well, really every adult, you know, are the prevalence of insomnia symptoms, which is about 50%, and people usually complain about difficulty staying asleep and difficulty initiating sleep, and a combination of the two. Another common complaint is just not getting restorative sleep, not feeling well rested the following day. How does this impact us as a society? Well, obviously we're probably more irritable and grouchy and not nice enough to one another, but this also impacts our productivity. You know, our ability to be efficient during our work day, and it affects absenteeism. It affects work-related accidents, and increased utilization of health care costs. So some recent published data shows that there are these hidden or intangible costs related to what individuals with insomnia would be willing to trade to avoid the negative consequences. Some of the negative consequences include the list below, especially in older adults. Chronic insomnia places older adults at increased risk of cardiovascular disease, but falls, chronic pain, and cognitive impairment, and my favorite one is car accidents, because that certainly can be affected big time by poor sleep, as we all know. So the National Sleep Foundation conducts a Sleep in America Poll every year, and in 2020, their poll looked at three main health impacts of feeling sleepy. Irritability, headaches, and just a general feeling unwell. And it looks like we have 52% of people feeling irritable within five to seven days of not getting good sleep. I think this is a very interesting poll with results, because it's not looking at anything very tangible, like stroke risk, or myocardial infarction, literally someone's self-reported feeling of their quality of life. In last year's Sleep in America Poll, they looked at a sleep health index by health and stress, and how individuals self-reported their overall health, and their personal levels of stress. And the sleep health index for people with high severe levels of severe personal stress is much lower, 67, versus individuals who rate that they have a high level of pretty much no personal stress. So that there's also a relationship overall between stress, overall health, and well-being. So what can we do to hopefully improve our sleep? Well, there are these four major areas that last year's Sleep in America Poll looked at. Physical activity is one of them. More than one-third of Americans do not meet the CDC's recommendations for moderate or vigorous activity. And I have to confess, I'm one of those people. Many of us do sit at desks and do lots of charting all day, and probably don't get enough exercise. Mealtime consistency is another. So in addition to the type and quality of the diet, it's the time that we're eating. It's probably not a good idea to have a really, really great large Mediterranean meal at 11 o'clock at night, followed by wine and dark chocolate. That's probably not going to help your sleep. Light exposure is another major contributing factor. In fact, there's some recent data that I think just came out this spring showing that people who are exposed to more natural light actually sleep better. And then screen time. As you all know about short-wave blue light from screens kind of tricking our bodies into thinking it's daytime. So even though there are lots of handy apps out there for relaxation and so on and so forth, it can be kind of counterproductive to have screens around us when we're trying to go to sleep at night. Other contributing factors, of course, which may be a little bit more difficult to modify for some of us, include some chronic medical conditions, such as sleep apnea. And especially if you need to wear a CPAP, if your CPAP doesn't really quite fit very well, or you're not getting a good seal, then that's going to disrupt your sleep. Obviously sleep disorders. There's some people who have parasomnias or things like REM sleep behavior disorder where they may just not get good, restful, restorative sleep. And then, of course, the environmental factors. If you live in San Francisco, in the city, you might not get the best night's sleep, depending on who your neighbors are or what might be going on in the mission district that night. And then, of course, medications. Medications, medications, medications. Here's just a small sample of medications that could potentially interrupt or interfere with one's sleep. And some of these medications even include drugs that are prescribed for sleep or to help those who have difficulty with sleep. So if you're getting up in the middle of the night four or five or six times because of your BPH, you're prescribed Tamsulosin to help with that, but then that also interferes with your sleep. It's this conundrum that a lot of us have difficulty with. So age-related changes. Let's talk a little bit about that and how that relates to sleep architecture. There's this myth that as you get older, you need less sleep. I used to think that, but wrong again. In fact, older adults actually need seven to eight hours of sleep per night, and this should be consistent. It's not like you can just catch up on weekends. It's really something that should be consistent. And the reason why there's this myth about older adults needing less sleep, I think it's just because of the changes that occur in the sleep architecture that are mismatched with our expectations. There's a shift in the sleep schedule. Older adults tend to wake up a little bit earlier in the morning, but that doesn't mean that they only need three hours of sleep. They still need seven to eight hours. There is also the notion of daytime napping. Once you're retired, you can nap during the day. It is nice to take naps here and there, but it can then interfere with your sleep at night. And then some of the other points listed, the changes in our restorative sleep, there's different stages of sleep, which we'll go over on this slide. So just for information purposes, as many of you may have remembered back in the day when we had to memorize this chart for one of our boards or MCATs, these are the stages of sleep and these are the norm. And this actually starts to shift a bit. There's a difference in babies to middle-aged adults than to older adults. And in general, even though the jury may still be out on this a little bit, in general, there's a decrease in the total REM and sleep efficiency in older adults. And that may very well be confounded by comorbid medical conditions, medications, so on and so forth, but also just the changes that are happening in the brain. So this is your beautiful brain when you're 20 years old, but as we age, it starts to shrink. And there's a dysregulation that occurs among the neurotransmitters and the neurons. And so our circadian rhythms start to shift and become less efficient. Some of the neuronal targets that are involved in sleep, luckily, include some of the orexin antagonists that have come out in the market and have been shown to be very efficacious and have limited side effect profiles. I believe doretorexin was the most recent last year to come out in the orexin antagonist category. And again, another informational slide. To bring you back to sort of how the neurotransmitters are involved and in relatively active states within areas of the brain. So how do we solve this problem? Well, obviously, non-pharmacological interventions are usually the first go-to, but there are medications because it's important to get a good night's sleep and we don't want to wait too long to make it happen. So I'm going to review some of the FDA-approved and off-label sleep aids. So over-the-counter products, there are many. Many of you have heard of probably dozens of these. I think the latest is magnesium, and I think there's even some literature out there about cannabis, but cannabis is out there for lots of different things. But teas, different herbal supplements. Obviously, there's sleep hygiene. Do yoga, take a hot bath, listen to Enya before bed. Make sure your environment's conducive to sleep, really. Is the temperature appropriate? Is there too much light or not enough darkness? Obviously, CBTI is really good if you have access to it. But really, it's the lifestyle and other interventions that are most accessible for people. CBTI, as many of you have probably heard, is the recommended modality of treatment. It's the evidence-based recommendation, not Ambien, even though most people will probably show up to their doctor's offices asking for Ambien because we all want a quick fix. But CBTI is supposed to be the standard. And it's not something that should be recommended as a sole modality of treatment. There are some other things that should continue to be offered to patients, such as, for instance, lifestyle. So, you are what you eat. You should be getting some exercise. And there's actually some data out there for foot reflexology. So, soaking your feet might actually help you get sleep. And, of course, spiritual religious interventions, which can also overlap a little bit with mindfulness, which was spoken about a little bit earlier. In summary, we know that poor sleep impacts our overall well-being, right? The Sleep in America poll showed people who didn't sleep well said they were more irritable and more grouchy and got more frequent headaches. There's a high prevalence of insomnia symptoms in aging adults. And that's not just in a country. It's a worldwide issue. And it really places older adults at an increased risk for several medical comorbidities if left untreated. Sleep complaints are related to many number of factors. And many of them are modifiable. We just have to sort of be creative when we are trying to make those adjustments. And then other factors are, of course, irreversible and related to the aging brain. The emerging evidence is lifestyle changes can improve our sleep. So, we should try the Mediterranean diet, plus some mindfulness, plus some CBTI, and soak your feet. Why not? And try to avoid too many medications, too many drugs over the counter, prescription, because as you saw from one of those other slides, some of the medications that are supposed to even maybe help us with some of our medical issues or sleep can actually paradoxically impact our sleep adversely. And lastly, I think that the recommendations for treatment should be interpreted with appropriate clinical context. There should be a shared decision-making approach for each individual patient, not one size fits all. And that's it. These are some of the references. Thank you all for your time. Thank you. Thank you so much, Ebony. All right. All right, so the last talk I'm gonna be giving, my name's Helen Kilman. I'm an assistant professor at Boston University. I also have faculty appointments at Tufts Medical School and Harvard Medical School. And if I can just find my talk here. Hold on just a second. All right, so I'm going to be talking about mindfulness and brain health for older adults. It's a little bit of a different topic from all the concepts and ideas that my colleagues have been sharing, but there's a lot in the media and a lot that people are talking about in terms of mindfulness. And one of the goals in this symposium was not to just talk about these very important things that we need to consider for brain health for older adults, but also to try to help figure out as clinicians when patients come to us and ask us about, I'd like to be on this diet, or I'd like to be on that diet, or I want to be on this sleep medicine, or not have any sleep medicine, or I want to do just brain puzzles for exercising for brain health. What do we actually recommend to the people who come to us for help? So this is the last talk on mindfulness, and I don't have any disclosures relevant to the content of this presentation. And the objectives of this session are to discuss the potential strengths and the shortcomings of mindfulness-based practices in older adults, looking at the peer-reviewed literature, and understanding how to incorporate this knowledge into current clinical care practices to promote brain health and well-being in older adults. So I thought I'd start out with defining mindfulness. So if you go to the dictionary, it's not a bad definition, really. Merriam-Webster says it's the practice of maintaining a nonjudgmental state of heightened or complete awareness of one's thoughts, emotions, or experiences on a moment-to-moment basis. Dr. Kabat-Zinn, who's really a pioneer in bringing these concepts to the clinical realm, he talks about it as the awareness that emerges through paying attention on purpose in the present moment and nonjudgmentally to the unfolding of experience moment by moment. And it's also been stated by other authors, including Dr. Kabat-Zinn, it's broadly defined as sustained attention in the framework of non-reactivity and acceptance. So the practice of mindfulness, it's rooted in Buddhist traditions. But in recent years, it's been popularized. So it's also in healthcare, in education, in workplace settings. It's for preschool children. It's for older adults. And it involves keeping grounded in the process of, quotes, letting go of the illusory future and past and focusing on the non-illusory present without focusing on feeling that one is progressing or even working towards a desired outcome. So it's very much focusing on what's going on right now without thinking of where you need to get to. So it's without attachment to outcome. It's a way of being, a way of seeing which is embodied, inhabited, grown into through the implementation of the methods and techniques that comprise the discipline. So in preparing this talk, I thought this is so interesting. We want to share about mindfulness and talk about it. And yet I'm looking at peer-reviewed literature to try to come up with what I want to share with you. And science is very outcome-oriented and mindfulness in practice really isn't. So I'm just going to read this because it's written so eloquently. From the outset of practice, we are reminded that mindfulness is not about getting anywhere or fixing anything. Rather, it's an invitation to allow oneself to be where one already is and to know the inner and outer landscape of the direct experience in each moment and as we engage in mindfulness practice, we rapidly discover that our experience in the present moment is severely edited and often distorted through the routinized, habitual and unexamined activity of our thoughts and emotions, often involving significant alienation from direct experience of the sensory world and the body. And I think one thing that's really important is even when your mind is wandering, it's still, you allow yourself to observe this wandering in a non-judgmental fashion, that's very important. So this emphasis on non-attachment to outcome is really a radical shift from the emphasis on outcomes in most clinical interventions or studies where researchers often judge the effectiveness of interventions by measuring outcomes. So I thought this was really quite a paradox, isn't it? We're talking about a practice that doesn't focus on outcomes, it's focusing on what's going on right now and trying to be observant about what's going on right now without being judgmental about that experience. And we're trying to do research on this, which is very outcomes-based. So for the purpose of navigating within the realm of scientific inquiry and to lead to a, quotes, evidence-based, the practice of mindfulness has been operationalized into mindfulness-based interventions. So there are two very widely accepted types of mindfulness-based interventions. One is mindfulness-based stress reduction, or MBSR, by Dr. John Kabat-Zinn. And the other one is mindfulness-based cognitive therapy, or MBCT, based on the MBSR by another group by Sigal, Teasdale, and Williams. So mindfulness-based stress reduction, or MBSR, is the most widely studied and disseminated mindfulness-based intervention. And this prototype, a prototype program with mindfulness-based stress reduction was launched by Dr. John Kabat-Zinn at the University of Massachusetts Medical Center in 1979. So looking at the traditional MBSR curriculum by Dr. Kabat-Zinn, it encompasses once a week, eight weeks long, and it's a group-based format. Classes meet once a week for about 2 1⁄2 hours with an additional 7 1⁄2 hours silent retreat. Participants complete formal meditation and informal practices throughout each week. And the primary techniques that participants learn are body scan, breathing meditation, mindful yoga, and loving-kindness meditation, which is internally sending well-being messages to oneself, a teacher or role model, a friend or family member, a neutral person, and a difficult person or enemy, and finally, to a living person. So this is a general overview of what the MBSR program started out as. And this was not designed necessarily for older adults. It was for people in general. So the purpose of mindfulness-based interventions is to increase present-focused awareness, to relieve suffering, and induce, encourage, or maintain positive physical and emotional effects in a variety of populations. If we look at mindfulness-based interventions in the general population, they've been found to be beneficial for mental and physical health, with depression and anxiety reduction, with moderate to strong effect sizes in general populations, stress reduction with moderately low effect sizes in healthy adults, and stress reduction with medium-sized effect sizes in risk groups, such as those living in stressful life situations. Chronic pain, managing chronic pain, there's a lot of evidence to suggest that mindfulness-based interventions help with managing chronic pain, and tolerating and accepting it. There's also some evidence suggesting that mindfulness-based interventions promote social health and pro-social behaviors, behaviors intended to benefit one another. Mindfulness-based interventions have not been as beneficial in the general population for the following conditions. It doesn't mean that it doesn't work or doesn't help, but there's just more research that needs to be done. Insomnia and sleep disturbances, there's some promising results. Eating disorders, there's some potentially beneficial findings. Addictions, there's some promising findings. There's some potential benefits, perhaps, with psychosis. With PTSD, there's inconclusive results. With attention deficit hyperactivity disorder, there's some encouraging effects. There's very limited findings with autism spectrum disorders, weak evidence for cognition. In terms of various physical conditions, like hypertension, diabetes, cancer, respiratory conditions, there are varying effects. And then going to mindfulness-based interventions for older adults. Some of the earlier studies have found that it's feasible and acceptable for older adults, so many older adults do tolerate this type of intervention. In 2017, there was a comprehensive literature review that provided evidence that supported the effectiveness of mindfulness-based interventions for the emotional well-being of older adults, and there were large effects on anxiety, depression, stress, and pain acceptance. In 2022, there was a systemic review with seven randomized controlled trials that reported that mindfulness-based interactions with a meditation component seemed to be promising in reducing anxiety symptoms in older adults. So most of the mindfulness-based research in older adults have been done in healthy older adults, or those living independently, not those who are living in long-term care facilities. For those living in long-term care facilities, there was a pilot study that suggested that an individual mindfulness-based intervention that is accessible to most long-term care facility residents still provided benefits to them. So most of the mindfulness-based interventions originally are done in a group setting. This group was saying that it might be better to do it one-on-one with people who live in long-term care facilities. So they shifted from a group format to an individual format. They used CDs or some sort of streaming audio platform to provide the course content for the weekly formal practices. And they took away the yoga and the full-day silent retreat that seemed to be less tolerated in people who were living in long-term care facilities. And they also shortened the duration of the formal meditation practices. So in spite of doing these things, it seemed like people were still able to have some benefits from mindfulness-based interventions. In terms of mindfulness-based interventions for older people who had cognitive issues, the current research does not support the use of mindfulness-based interventions for older adults with subjective cognitive concerns about cognitive impairment or dementia. So in terms of just take-home points, I just wanted to share, to emphasize, MBSR, Mindfulness-Based Stress Reduction, is the most widely studied and disseminated mindfulness-based intervention. Mindfulness-based interventions are feasible and acceptable to many older adults, and they can be helpful to improve the well-being of many older adults, reducing anxiety, depression, and stress. They can also be very helpful for older adults to help them cope with pain more constructively and accept pain, if necessary. And then for older adults in long-term care facilities, there may need to be modifications done so that they can make use of it in the long-term care facility. And current research does not support the use of MBIs for older adults with subjective cognitive concerns, MCI, or dementia. So what does this suggest to us? We really need to expand the evidence base. Even the studies that showed that it wasn't really helpful for people who had subjective cognitive concerns or had dementia, there are only a few studies. Their findings were robust, but there are only a few studies, and I think that for us to really come to a level of comfort, there need to be more studies showing the same thing and have some consensus within the scientific community. But a lot of times when people start out on the research, it takes a lot of time. There's a lot of expense that goes into doing a proper research project or research study, and it can take over 20 years sometimes to really bring something to fruition and to scientific publication. So we're all clinicians. Hopefully we all take care of patients in addition to all the other different folks and all the other different things we might do. So what do we do now when patients come to us and they hear about things in the media? We have some idea of what we can glean from the information and from the evidence base, but is there anything else we can do? And I just wanted to share this with you. This is sort of a little bit different from what most people might say. I think a lot of times when we're looking at randomized controlled trials or trying to shoot for something close to it, and we're looking for the bell curve, we wanna look at what the results are in the bell curve. We're trying to talk about the patients there, offer that to our patients. But a lot of patients that we see are in the tails, right? They're not really bell curve patients. And we don't always know whether an intervention that is said not to be helpful could be helpful, or maybe it's the other way around. But using the end of one study to help our patients is really, really valuable. And what I mean by end of one is, this is something we all see as clinicians, right? We have a patient, they have some sort of a condition, we treat it, they do better, they go away and live their life. And then something happens and they come back and they aren't on the intervention that was helping them. It might be that they thought that they didn't need it anymore, or maybe if it was a medication, they couldn't afford it anymore, or maybe they couldn't afford it as much as they could, so they rationed it, whatever it might be. We oftentimes see patients coming back to us because of not being on an intervention that was helpful to them. And we call it non-adherence or non-compliance for a variety of different reasons. But we see them and we restart them on something that we know helped them before and they tend to do better. So there's some level of confidence that hey, whatever we're doing right now is really helping the patient. So this is kind of the end of one study. Somebody else called it the on-off, on-off study. But I think that this is something that we all can do as clinicians to really help our patients, listen to them, help formulate what can be useful to them even if there's not enough data in the evidence base or if the patient doesn't seem to fit your model patient that was studied in a particular randomized clinical trial. So with any intervention, I just wanted to share, I think the most dangerous, with mindfulness, there's not a lot of harm that you can actually do. But I think the part where it can be difficult is if they are avoiding a certain type of intervention or treatment that they really need. That's something that you really need to assess to help the patient. But so you wanna consider the risk versus the benefit ratio. Whatever intervention that the patient may come to you and ask you for, if the benefits seem to outweigh the risk, then why not try it? Monitor them, though, follow them closely and make sure that the benefits continue to outweigh the risks. And then you wanna also discuss informed consent issues, the pros and cons of any intervention, the proposed treatment. Talk about what are the currently accepted treatments, what are alternative treatments, and then what are the consequences or the potential course if there's no treatment. So I think having this kind of conversation with the patient, having them as part of, you know, that you're really on the team to help them, that's really, really crucially important because there are so many things that are out there that might really be helpful to individuals that might not come to light because they haven't been studied fully. And I think the other thing is many times, you know, there are so many guidelines, and those are so valuable. I've sat on certain committees to try to come up with some of them. They're hard to come up with because they're generalizations. And you're trying to, like, really throw out a lot of data so you can say something very succinct and direct to people, to patients and clinicians. And those are okay, but they tend to sometimes focus and maybe even promote certain ideas that are useful and helpful and well-intentioned, but you're gonna get a patient who doesn't quite fit. And so using this end-of-one-study perspective might be helpful to them. Okay, these are my references. Okay, so that's our symposium, and so I'm going to just open it up for questions to everybody on the panel, if anybody wants to. And. Thank you. If you have any questions, please come to the microphone and state your question. It's being recorded, so it just helps to have the question be very clear. I may have missed the initial couple of speakers. Instead of making all this analysis of what is this, you know, what's the harm in using melatonin? I mean, I see a lot of people, it's non-prescription, they go and get it and take a little melatonin and, you know, sleep for the night, whether it's jet lag or whatever they go through. Can you speak to that issue of melatonin? Use, abuse, overuse? Sure, yes. Thank you for your question about melatonin. Melatonin actually, you know, the way that it works to help with the circadian rhythms, it actually take way too much melatonin. The melatonin dose that we probably need to take, if we needed to take it as a supplement, would be .5 milligrams, one milligram. So the over-the-counter melatonin, it's five milligrams, I believe, is the lowest dose that you can get. And in fact, really those higher doses of melatonin are not helpful. They can actually inadvertently, I guess, cause more problems with sleep. And it's important to figure out what type of sleep problem you're trying to impact. Is it sleep maintenance? Is it sleep onset? And then sort of going from there, because some of the medications out there really are targeting different areas of sleep. Can I ask you a question about melatonin? So one thing I learned, that I was taught about melatonin, is that we really shouldn't use it like a regular sleep medicine, that we need to give it around six o'clock or the early evening for it to really impact the circadian rhythms. Otherwise, if we take it at bedtime, they have trouble waking up in the morning. I don't know, does that still hold? Can you comment on that? Yes, and I think that the thing that's very confusing is that some people actually find that melatonin causes a sedating effect, when that is not actually the intended use of the medication. So it's not something you take as needed, and you don't just take it because it makes you drowsy so that you can sleep. It's something that you're supposed to take earlier in the evening, consistently, if you have a circadian rhythm disturbance, such as people who work night shift, right, and need to be able to sleep during the day. Yeah, I just wanted to comment on that and say, I was reading about sleep, and it said melatonin is actually like the referee at the start of a race. So it initiates your sleep, so it's not a sleep agent, but it is a sleep initiator. So you're right about taking it at the time that your body naturally makes melatonin, which is close to sunset. Hello, thank you all for the comprehensive presentation. I have a question about the relevance of the treatment of mild insomnia in elderly. I was pleased to hear the amount of sleep older patients need as well, because I wasn't aware, and usually my patients in the outpatient setting sleep a little bit less, so I guess about six hours, and they have mild depressive or mild anxiety symptoms. And I was wondering what your experience, Dr. Dix, is with treating the insomnia on these mild complaints, the mild depression, but usually these patients have, for example, also systemic problems. And I usually don't prioritize treating those mild cases of insomnia. I'm not sure of my question. Thank you, I think you asked about patients who are older and have comorbid, I think, anxiety, depression, and have also an insomnia. Yeah, and have mild insomnia, so I think sleep six hours a night or something. And I was wondering whether you think treating those relative mild insomnias would help in their overall brain health. Yes, I do, I do think it would help. The National Sleep Foundation has recommendations based on the data, and I think that that extra hour of sleep, if there's a way to figure out how to help your patient get that extra hour of sleep, it might actually also help their comorbid psychiatric conditions. So whatever it is, looking at just environmental factors, medications, are they taking their sertraline in the evenings, and maybe could it be moved to mornings, because it keeps them up at night, just the little things, and I think to just optimize their sleep. Thank you. When we talk about cognitive health and brain health and cognitive decline, we talked about the role of nutrition and sleep and physical conditions with the cholesterol and metabolic issues like diabetes, hypertension, cholesterol, whatever. But also, I think, like the gentleman asked about the comorbid condition, the psychosocial stressors can affect cognitive health. My question is about if there's a role that aging brains there is also decline of sensory systems, like vision, hearing, speech, the taste sensations and smell sensation, touch, and I think the most sensory sensations are going down. If they have some relevant impact on cognition health, if somebody could comment on that. Yeah, I mean, that's an interesting comment, because we are living longer than we did, and even though the brain is one of the last organs to be affected by age, we are living past what we did live in the past. So with that comes certain changes, and we have to, so people are not talking about the lifespan anymore, they're talking about healthspan, how many productive and healthy years you have. And taking care of, I mean, I can't really comment on all the five senses, but definitely certain areas, preventative measures, taking care of your overall health affects every organ of your body. So eating well, and then exercising and paying attention to sleep is the best tool we have, best defense we have against preventing some of these age-related cognitive decline, or at least slowing down the process to a certain extent. Not to belabor this topic, but is there any studies relating to this area that shows cognitive health, how that is impacted by the declining sensory systems? Especially so, because we are talking metabolic issues, cholesterol issues, hypertension, how they work toward inflammatory and oxidative, but is there anything about these declining senses? Yeah, there is evidence to show that if you don't hear well and if you don't see well, then correcting those areas using corrective measures definitely prevent certain declines. So the moment you realize that people who are hard of hearing, if you don't use hearing aids or if you don't take care of that problem, then you decline at a faster rate than people who do correct those measures. So we know that in terms of hearing and vision, but I can't really comment on the other three areas. If you have any reference to this. Yes. Thank you. My question is to Dr. John Beyer. Is fasting and also maintaining proper weight and maintaining BMI about 20 to 25, 20 may be too low, but about 25, is that really helpful for health? In general, yes it is, but can you give me some details about that, especially fasting? The question is about fasting and two ways of thinking about that. One is, is fasting in general good for health? In traditional fasting, the other has become more popular, which is intermittent fasting. As a diet, as a dietary way, is that actually good for you? One of the things that we did find is that the other part about good diet is knowing when to hold the diet. We actually, people that actually live longer and have good cognitive health, seem to eat about 80% less than what other people eat. And so there's something about not overeating or having too large of plate sizes of foods that actually is helpful for both cardiac and also cognitive health. Fasting itself can be helpful as part of that, as well as, especially if it's used for more of a spiritual or inner life kind of building, that also can be helpful for cognitive health as well. So yes, fasting does appear to be helpful for health. Certain types of fasting can be good for health. Too much fasting can be not good, and the other reasons we tend to treat patients too. But thank you for a good point about fasting. CBTI has been the recommended primary treatment for insomnia for several years now, but it's hard to find places to refer people to. Are there any specific apps or websites that you have recommended for patients? Just one point, especially all my residents swear by the CBTI app that's available for the VA, through the VA. It's an excellent resource and it's for, anyone can use that app. It says, though, it's not to be used alone. It's supposed to be used in conjunction with the treatment. Right, I think that I've recommended the CBTI app, but I've also recommended some other apps, like Calm. But of course, again, you don't want to use the apps at night while you're trying to go to bed. But there are several apps out there. And sometimes some therapists are willing to try to incorporate some CBTI aspects into treatment, and some clinicians can do that as well, because I think every little bit kind of helps, because it's hard to find that specific type of treatment. Thank you. I just wanted to, because I didn't hear you mention it, to make you aware of that, Dale Bredesen, Kathleen Tubes, and a number of other people completed a trial, I think three months ago, where they brought 84% of their Alzheimer's disease patients to remission using foundational health habits and functional medicine, precision medicine. So, and they are actually enrolling right now for their next trial, and this is Dale's fourth trial. So this stuff works, but it has to be applied rigorously. And in terms of CBTI, by the way, there are four or five online available treatments where they have PhD-prepared psychologists with sleep training available to help people nationwide. It is not hard to find. Are people saying every day that it's hard to find CBTI? That hasn't been my experience. I think the most challenging part of finding the CBTI apps, I would say for some of my older adults, are those who are not necessarily very tech-savvy. This isn't an app. This is a, it's therapy available online. Online, right, so they have to be able to, you know. To use a computer, that's a life skill. My mom's 82, she's fucking brilliant at it. So, you know, not everything is for everyone, but for those people who can use a computer, there's plenty out there. Thank you. Are there any other questions or comments? Okay, great.

brain health

older adults

lifestyle interventions

cognitive decline

physical activity

Mediterranean diet

DASH diet

sleep patterns

micronutrients

mindfulness

emotional well-being

personalized patient care