Watch the replay of this event held on May 17, 2023. (Transcript below.)

Everyone has a different idea of what it means to age well. Some people place the highest value on independent living, while others want to stay as close as possible to family and friends. One thing we all share is a desire to maintain our mental health and sharpness, but it can be difficult to know which actions — exercise, brain games, diet — to pursue with confidence as we get older.

What is clear is that attitudes toward aging matter, and the earlier we start thinking seriously about how we want to navigate our own aging process and taking steps to achieve our goals, the better. On Wednesday, May 17, join AARP’s Vijeth Iyengar and bioethicist Tia Powell to discuss how different areas of the brain and mental abilities change over time, the role of neuroplasticity and learning in healthy aging, and what we all need to know about neurodegenerative conditions like Alzheimer’s disease, including caring for people with dementia. This is a conversation for anyone keen to push back against ageism and take care of their brains for the long haul.

This event is the third in a series of events and articles exploring the brain across the lifespan. “Inside the brain: A lifetime of change,” is supported by a grant from the Dana Foundation.

Register here for “The baby brain: Learning in leaps and bounds” and “The teen brain: Mysteries and misconceptions.” If you can’t attend the live events, please register to receive an email when the replay videos are available.

Speakers

Vijeth Iyengar

Director of Global Aging, AARP

A cognitive neuroscientist by training, Vijeth Iyengar leads cutting-edge research and drives global aging policy at AARP. He previously served as a career civil servant, spanning three administrations in the US federal government — including as brain health lead and technical advisor to the deputy assistant secretary for aging and a policy advisor at the White House Office of Science and Technology Policy. Iyengar has contributed to the National Academy of Medicine (NAM) Perspectives and JAMA Health Forum, among other outlets.

Tia Powell

Bioethicist, Albert Einstein College of Medicine

Tia Powell holds the Shoshanah Trachtenberg Frackman Chair in Bioethics at Albert Einstein College of Medicine, where she is a professor of psychiatry and of epidemiology, division of bioethics. Her scholarship focuses on dementia, public health policy related to pandemic response, end-of-life care and bioethics education. She served four years as executive director of the New York State Task Force on Life and the Law, the state’s bioethics commission, and has worked with the National Academies of Medicine and Centers for Disease Control and Prevention. She is the author of Dementia Reimagined, a cultural and medical history of dementia and Alzheimer’s disease.

Moderator

Emily Underwood

Science Content Producer, Knowable Magazine

Emily Underwood has been covering science for over a decade, including as a neuroscience reporter for Science. She has a master’s degree in science writing from Johns Hopkins University, and her reporting has won national awards, including a 2018 National Academies Keck Futures Initiatives Communication Award for magazine writing.

About

This event is part of an ongoing series of live events and science journalism from Knowable Magazine and Annual Reviews, a nonprofit publisher dedicated to synthesizing and integrating knowledge for the progress of science and the benefit of society.

The Dana Foundation is a private philanthropic organization dedicated to advancing neuroscience and society.

Resources

More from Knowable Magazine

Related Annual Reviews articles

Other online resources

From the audience

Transcript

Emily Underwood: “Hi, everyone. I’m your host, Emily Underwood. On behalf of Knowable Magazine and Annual Reviews, welcome. Today we are going to talk about how our brains change as we get older, how to take care of our minds as they mature, and how to take care of each other on this path that we are all on together. So, thank you to all of you for joining us today. Thank you to the Dana Foundation for supporting this.

“So without further ado, let’s welcome our guests. Please bring Vijeth Iyengar, a cognitive neuroscientist by training who leads global aging policy at AARP, welcome him onto the stage.

“Hi, Vijeth. Welcome.”

Vijeth Iyengar: “Hi.”

Emily Underwood: “Next, I am delighted to welcome Tia Powell, a psychiatrist and bioethicist at the Montefiore Albert Einstein College of Medicine and the author of a 2019 book, Dementia Reimagined: Building a Life of Joy and Dignity From Beginning to End. Please welcome Tia. Hi, Tia.”

Tia Powell: “Hi, everybody.”

Emily Underwood: “Thanks for being here today. So I’m just going to dive right in. One reason I was excited to talk to the two of you about this topic is that even though you do really different jobs, you share a vision of a world where aging is less scary and less stigmatized and maybe even more joyful.

“So Tia, can we start with you? Can you tell us what this issue means to you on a personal level and what got you thinking about it?”

Tia Powell: “Yes, absolutely. This is really quite a personal issue for me, although of course aging in one way or another is personal for us all. But in my case, both my mother and grandmother had dementia. And that doesn’t affect everyone as we grow older, but it is a common illness, and everybody fears it. And I think that’s especially true for those of us who have a family history.

“So dementia is one notion that makes aging scary for many of us, and unfortunately, I’ve been watching for a long time the research into medications and interventions, and I’m not expecting a cure that will have a significant impact on someone like me, a baby boomer, and I’m not impressed with the currently available drugs. So we can right now take steps to make the experience of dementia better through our behavior — and we may discuss that more later — but I’d also say we can work by including families and communities, creating ones that are more inclusive and welcoming for people with dementia.

“Right now, a lot of people with dementia — and also their partners and families — are neglected or even rejected by old friends, and excluded from places and activities they once enjoyed. That happens partly because we’re all so scared about dementia. The illness can be bad. It’s an illness. There are symptoms. It can impose limitations on you. It’s really the isolation and the suffering created by this stigma that makes dementia so much worse than it need be, and that’s not fate or biology. That’s something we do.

“It’s something that I hope we can start to change without a miracle cure. And for me, knowing that the experience of dementia doesn’t need to be so terrible makes it easier for me to think about what else I can do to look forward to aging, whether or not dementia appears. How can I maintain or even improve connections with family, with friends and community? What makes me happy now that I can bring forward with me as I grow older? What new things can I explore? How can I have fun? How can I support those around me to help others and maintain my own sense of being a person who contributes? So, that’s my sort of initial comment, Emily.”

Emily Underwood: “Thank you so much. We have a little poll that you can see on the side, audience members, which is just to gauge all of our attitudes towards aging. So if you have a moment, fill that out and we’ll revisit it at the end of this conversation, just as a fun experiment to see if any of us have changed our minds at all based on what Tia and Vijeth have to say.

“So, with that, Vijeth, welcome, and how did you end up devoting your career to aging policy, starting in neuroscience?”

Vijeth Iyengar: “Yeah, thanks Emily. Big pressure on Tia and myself to change the attitudes and change the dial…”

Emily Underwood: “I mean…”

Vijeth Iyengar: “Well, it’s great to be here with you all today. First, I want to thank you, Emily, Knowable Magazine, Annual Reviews and the Dana Foundation for supporting this event and this series of events.

“As was mentioned, I’m a cognitive neuroscientist by training, and I currently serve as the director of global aging here at AARP. I understand that of the folks that are attending, there’s a good chunk of you that are not in the US, and so just a brief primer of what AARP is.

“We’re the world’s largest nonprofit, nonpartisan organization dedicated to the 100 million Americans that are aged 50-plus. We have offices in every state in the US. A lot of our work is at this very intersection of public interest, of research, policy and advocacy, and we have a vision that guides us every day, that guides me every day, of imagining a society in which people live with dignity where and when they choose, and to be able to fulfill their purpose, their goals and dreams.

“And so it was a bit of a whirlwind of a path from a pure neuroscience career in the lab working with fMRI, functional magnetic resonance imaging, to what I’m doing now. But what really drew me to this role was this idea of science in the service of society. How can we get all the insights from the lab and bring them to practice, and actually bring them into the hands of consumers, which a lot of you are that are attending this event. And so, I’m quite passionate about this intersection of science, policy and practice, and I’ve done so before coming to AARP and the US federal government, and looking forward to continuing AARP’s vision and goals in terms of ensuring that everybody can age with dignity and grace.”

Emily Underwood: “Wonderful, thank you. So we were talking a little bit about this before we started, but let’s define, figure out what we’re talking about, hone this in a bit.

“The aging brain — what is it? What timeframe are we talking about today? If we can answer that question. And then, we’ve received a lot of great questions already from the audience. I see one from Joyce Bender and Joseph Farley, who want to know what does normal aging look like in the brain?

“So let’s start with a healthy brain. What kinds of changes are typical or usual to see based on the data that exists at this point? And Vijeth, I’m going to ask you to take that one first since you’ve spent a lot of time in the lab thinking about this.”

Vijeth Iyengar: “Thanks for that reminder. Certainly there’s a robust wealth of evidence from animal studies, from studies in humans across different methodologies, across different modalities, revealing consistent hallmark of evidence around age-related changes to our brain, to our brain structure, and correspondingly its function. And so, I’m hoping two review papers that I will share, will enter the chat very shortly. There’s a great, really classic review paper from Nature Neuroscience from Gabrieli and Hedden and an Annual Reviews paper from Park and Reuter-Lorenz, who really chronicle these brain and behavior changes. And so stepping back, if we look at the two tissue types in the brain, we have gray matter and we have white matter, to be a bit reductionistic, but we see that there’s age-related volumetric declines in gray matter.”

Emily Underwood: “Which means shrinking, right?”

Vijeth Iyengar: “Which means shrinking, right, of these brain regions. You can consider these as hubs in the brain. And so we have canonical regions that decline over age. We have the lateral prefrontal cortex, we have the hippocampus, which is in the medial temporal lobe. We also have declines in white matter. And so if we think of gray matter as these cities or these hubs in the brain, the highways that connect these brain regions that allow transfer of information between brain regions is the white matter. You also see declines in this type of brain tissue, in the…”

Emily Underwood: “In the amount of tissue, so there’s less of it.”

Vijeth Iyengar: “Right, the integrity’s less. In terms of white matter, the integrity of these white matter fibers, so to speak, is less integrous over aging. So the question becomes, we have this consistent evidence about neural structural decline, what does that mean for behavior? And so, there are also some canonical regions and functions that get disturbed via aging. Some of the hallmark behavioral declines include losses for long-term memory, episodic memory, information processing, attention, working memory. These are all regions that are reliant on the prefrontal cortex or the medial temporal lobe, which tend to decline over age.

“However, it’s not all bad news bears. There’s some functions that stay stable across time and across age, and these include our ability or our knowledge of the real world. What some might say semantic memory or conceptual knowledge of the world is largely preserved, and so knowing that a chair is a chair and knowing that what it does is you sit on a chair. That type of knowledge is fairly preserved across time.”

Emily Underwood: “There’s so much to dig into there, and there’s a lot of gritty neuroscience stuff, and I know that we’re going to post those papers that people can dig into more. But just to back up a little, prefrontal cortex has to do with cognitive control, coordinating activity in the brain.”

Vijeth Iyengar: “Executive function.”

Emily Underwood: “Executive function. What does it mean that you are losing communication between regions that were established across a lifetime, and do you see compensation for that in brain activity? Is it all downhill? My understanding is that there are some changes that occur in the brain that appear to be taking over for places that are not communicating as well. I may have bungled that, but can you just follow up on that?”

Vijeth Iyengar: “No, no. Absolutely, I think it’s a fair question. As I mentioned, we do see declines in structure as a result of aging that corresponds to declines in behavioral function. But as you were getting at, there have been evidence looking at compensation, so older adults, do they recruit additional brain regions? Can they recruit other brain regions? Do they supercharge or turbocharge those regions to equate levels of behavioral performance that we see in younger adults?

“And, the answer is yes. When you look at equating behavioral performance across younger adults and older adults, we see that older adults tend to recruit in some cases, not all, and so there’s all sorts of caveats and nuances to this but if you had to take a 30,000-foot-level perspective on this, there are instances where older adults tend to over-recruit brain regions as indexed by neural activity that helps aid them — of course, all of this is correlative — helps aid them in terms of their behavioral performance.

“So, there are opportunities as one ages that the brain is exhibiting some opportunities to compensate. Some have called it de-differentiation. So it’s not always that a specific brain structure is tied to a specific brain function. There could be a bit of a co-opting or flexibility in which there are different types of regions recruited to complete a task.”

Emily Underwood: “OK. This sounds to me very complicated, but also overall it sounds like resilience, like the brain has some natural resilience that responds to maybe the damage or processes that can happen over time. So I’d like to talk about what a healthy, resilient brain looks like, and Tia, as a psychiatrist, I’m wondering what resilience in aging looks like to you.”

Tia Powell: “That’s such a great question, Emily. Thanks. So I’ll take a step back and talk about behavior, not thinking about the brain and what it looks like, but about the person and what they’re doing at a more holistic level. And, I’ll draw a picture of the behavior I’d expect to see in a healthy and resilient older person. And I’m actually thinking of people that I know and admire and what they’re up to.

“I see somebody who is full of things they’d like to do, either small or large. They have activities that bring joy. Maybe it’s paid work, maybe it’s volunteering. I’m an academic, and there are academics who love what they do so much, they have no plan ever to retire. There are lots of people who work and it’s OK, but they’re dying to retire. They’d love to retire today. But there are people who are finding things to do that they love and doing that.

“It could be anything. It could be gardening, it could be creating art, it could be going back to something you used to do before you worked for a living. You used to write poetry, but it was not very remunerative, so now if you’re retired, you may have a chance to go back to some things like that. When that person does all that stuff, whether it’s caring for the grandkids or creating art or whatever, they’re still learning. They’re still excited about what the day may bring, and they’re excited about tomorrow. They’re gaining mastery and the satisfaction of that, they have people that they want to see, maybe people they’ve known for years, but also new people — the family that moved in next door, somebody who joins their faith community, just different people.

“And, I bet this resilient person doesn’t limit their contact to only people of their same age. They’re connected with people who are older than they are, their mentor, their friends, their older relatives, and they know the young people in their community. Again, maybe they’re helping their adult kids, maybe they’re taking care of grandchildren, but maybe they’re also a mentor for people in their community. And I’ve heard lovely stories about ... because certainly in the US, but in many countries now, people are so mobile that you may have adult children and grandchildren, and they may live 5,000 miles from you, but there’s a lovely family next door that actually could use a grandparental influence. So there’s some lovely interactions of cross-generational friendships growing up.

“So that benefit of being a wise, older, caring person can be shared even if it’s not with your biological family. We can offer wisdom and kindness, and the younger people, whoever is ... there’s always somebody younger than you and there’s usually somebody older. So you can exchange wisdom and kindness for energy and excitement, and that’s to me what the really exhilarated, flourishing older person looks like.”

Emily Underwood: “Thank you so much. I think as I listened to both of you, I think it reflects where the science is at to some extent. We know a lot about behavioral signs of health that you can see from the outside and that may even be intuitive on some level. Looking inside the brain to see what changes inside the brain, the neuroimaging technologies, Vijeth, that you’ve been using, those are newer. And so overall, we know less and there are still some really big questions about how changes in the structure of the brain relate to behaviors. Is that fair?”

Vijeth Iyengar: “I think that’s fair. A lot of the neuroimaging technologies are 30, 40 years old. If you were to think about it, the 1990s, maybe late 80s, so we’re just scratching at the surface. And a lot of these others ... I mentioned functional magnetic resonance imaging. I just read an article maybe a week or two ago about that they’ve gotten the resolution even greater, even finer detail about what’s going on in the brain.

“And while that particular imaging modality has good temporal resolution, low spatial resolution, they’re trying to advance these technologies as fast as possible. But, there’s so many empirical questions out there.”

Emily Underwood: “We’re going to try to do something quite ambitious in this conversation, which is go from the micro-level to the macro-level. And right now, I’d like us to talk a little bit about something in the middle, which is at the individual level. How much control or agency do we have over how we age? So, I think a lot of people here are looking for suggestions and tips to boost their own resilience. Maybe they have had brain injuries and they want to recover, maybe they are looking forward to the future and they’re feeling apprehensive.

“So let’s focus on that area of control that is within our power. Vijeth, do you want to speak to that a little bit? Just where you think as individuals we have the most control?

Vijeth Iyengar: “Yeah, I think as individuals we hold immense potential and control in terms of being able to promote and maintain brain health. I’m at AARP. We are very much a consumer-facing organization. We rely on being a fierce advocate and also a trusted voice on health promotion, education and awareness. So, this is something we are actively thinking about.

“I just want to give a shout out to the Global Council on Brain Health, the GCBH, which is part of AARP. We’re putting in links to their work in the chat. But, the GCBH, the Global Council on Brain Health at AARP, targeted six pillars of brain health, where at the individual level you can make a difference.

“One is being social. There’s abundant evidence now looking at the levels of social engagement as it pertains to the size of brain regions. And so, being able to keep in touch with friends and family, volunteering and intergenerational engagement. Tia mentioned this idea of older adults being able to share wisdom, mentoring and engaging with younger adults and cohorts. That’s really important. So, one, being social.

“No. 2, engaging your brain. So, coming on events such as this, engaging in cognitively stimulating activities, selecting mental activities you enjoy. I think that’s incredibly important.

“Third is managing stress. Being able to develop a stable daily schedule to minimize uncertainty is important. And, establishing strong social ties and physical activity are important to being able to manage stress.

“No. 4 is ongoing exercise. And so, exercise supports memory, reasoning, problem-solving and attention capabilities, and so being able to be physically active is incredibly important.

“Five is restorative sleep — making sure sleep is a priority. Sleep is incredibly important for memories and the formation of memories, for memory consolidation, and also for brain health. And so ensuring that you’re getting quality sleep on a daily basis important.

“And lastly is eating right. I’m certainly not a spokesperson for eating right, but eating healthy is good for the brain. In sum total, the six pillars — social engagement; cognitive, stimulating activities; managing stress; ongoing exercise; eating healthy; and restorative sleep — these are efforts you could do by yourself, in your communities, individually, to help take that one extra step toward promoting or maintaining one’s brain health.”

Emily Underwood: “Tia, do you have any advice about this, or even questions for Vijeth about where the evidence is, or suggestions from your own practice and research?”

Tia Powell: “No, I would support everything that Vijeth said. That’s absolutely right on the nose, and I think people ask a lot of questions about exercise. It doesn’t have to be anything fancy. The exercise you actually do is the one that will help you the most, so it doesn’t have to be a fancy gym or involve equipment.

“I’m a big fan of walking. It is the first form of exercise that any of us ever tries, and for many throughout life, it is the best. It’s always available to you, assuming that you have accessibility, you haven’t lost the use of your legs. You can do it in almost any place, in almost any climate, if you’ve got the right shoes and something to keep you from getting cold if you’re in a cold place. But it’s so simple, and really satisfying. It’s great for thinking things through, and it’s even better if you do it with a friend. If you go for a walk with a friend and make that a regular habit, it’s such a calming, doable, feasible step to take to aid your health.

“So, I would say that there’s some things that I don’t recommend that people ask about. I’m not a big fan of supplements. Years ago, I was charged with writing a report for New York State on the regulation of dietary supplements, and I was really horrified. I think in our country, at least, the regulation is, I would say, somewhat limited, so when they tested all these supplements, there was all kinds of things in the bottle that weren’t on the label. There were many claims that were poorly supported by evidence. So, I think if you’re looking to manage your money with big impact to support your health, I wouldn’t buy a lot of expensive supplements. And the rarer and more special they are, the less I’m impressed with them. I’d take that money and buy yourself a nice pair of shoes and go for a walk. I think you’ll be better off. So, that’s all I’d add.”

Vijeth Iyengar: “I’m curious, Tia. You have the advantage of being in a hospital setting, in a clinic setting. Of folks that you either engage with, whether it be patients or family caregivers, are there tips or strategies to promote brain health that they’re particularly keen on learning about, or even staving off or minimizing the impact of dementia?”

Tia Powell: “Nothing more particularly, and I’m not involved in active patient care at this point anymore even though I do work for a hospital in a med school. I think people are always worried about what kind of exercise does it have to be? Do I have to run, do I have do this, that and the other? And there certainly are different regimens that are recommended by lots of different people.

“Do what you like. If you love to ice-skate and you can do it, you’re in a place that’s good, do that. But if you don’t know what to do, just start with something super simple and something where there’s very, what they say, a very low energy of activation. It’s easy to do. You don’t have to drive somewhere for a half an hour or buy fancy equipment and all that kind of stuff. So, that’s where I would stick with it.”

Emily Underwood: “Can I ask you both about brain games? Because you mentioned thinking about the consumer, Vijeth, and I think there’s this barrage of products, not just supplements but subscriptions and apps. You could make aging well a full-time job starting at age 14. How do you sift through what’s worth putting the time in, what’s worth putting the money in, and where you should just not bother?”

Vijeth Iyengar: “Yeah, no, I think that’s a great question. It’s a common question in terms of the value of brain training and Sudoku and crossword, and I think the jury’s still out, to be honest. I think in 2014-15, there was a lot of hype about a particular brain-training game, and the FTC came and slapped their wrist, because I think the evidence wasn’t there. And so just as similarly as you do with examining supplements or other medication, I think it’s important to find out what the evidence base is. Ask your PCP, your primary-care physician, ask trusted voices.

“You’re right, Emily. There are a bunch of brain training tools and aspects. I think the evidence is still out. I think there is evidence showing that if you train someone on a particular cognitive function, say information processing over and over and over again in a robust period of time, over weeks and maybe months, you can get some increments of improvement, but they don’t necessarily cross over to other cognitive domains such as memory or attention, or verbal recall. So, that’s my latest understanding of what is out there.

“I think sometimes you don’t need to even rely on those brain-training games. Even telling a story to a friend — if you think about it, if you break it down, it’s quite complicated. A story requires structure. There’s a temporal requirement to it. There’s a spatial component to it. It requires memory. It requires information processing, it requires attention. It’s tapping into all these sorts of cognitive domains, telling a story. There’s a schema, there’s an architecture, there’s a framework to it. And so, you don’t have to go buy an app or register, what have you. Being able to be active in your community, with your friends, with your social networks, I think there is growing evidence that even those very small, low-cost or even no-cost actions hold great abilities in terms of promoting brain health.”

Emily Underwood: “Thank you.”

Tia Powell: “I’d support that, and I’d add too, unless there’s strong evidence that an app or a computer game is really useful, we have a real problem with our sedentary lifestyle. A lot of us spend way too much time sitting and looking at screens already, so unless you know you’re really getting good value for that — as I hope you’re getting today in our presentation — I wouldn’t add something that’s going to be another two hours a day sitting in front of a computer screen unless you’re getting something that you know is valuable from it. So I’m a little bit worried about encouraging people to do a ton of brain-training games. I think you’d be better off gardening or walking or doing some other thing like that, woodworking, whatever you want to do.”

Emily Underwood: “OK, I’m going to zip through this next question because I really want to get to our wonderful audience questions. We’ve talked about the brain, the individual, but none of us are aging in a vacuum. We all live in communities, we all live in families, we live in broader societies. So I would like to hear from both of you about how do the way that our society is set up to support, or is not set up to support, people as they age doing us harm? Or, how could we do better? So I think, Vijeth, if you could take that first. What are some factors that affect how we age that aren’t within our individual control, that maybe we need to think about as a society?”

Vijeth Iyengar: “Yeah, I think it’s an really important question. We don’t live in a vacuum. There is an accumulating body of evidence that where we’re born, where we live, where we work, where we worship, for example, hold great influence on our personal health and well-being. And so, these factors that I mentioned are typically called social determinants of health or the social drivers of health, and they contribute to risk factors for chronic disease such as dementia. And so the social drivers could dictate, for example, if you reside in a community that doesn’t have adequate access to health-care resources or opportunities for social engagement, or the ability to engage in outdoor exercise. And so it limits our ability to address some of these modifiable risk factors for Alzheimer’s disease and related dementias, or age-related diseases.

“Just two quick points in interest of time. One, there is a growing body of research — it even appeared on the front cover of Nature Aging — looking at links between climate change and pollution and cognitive aging. And so, there are all sorts of great research looking at access to green space and cognitive aging, and access to pollutants and its harmful impacts on cognitive aging. And so what we see is that in also communities, there’s also disparities in health-care access and disparities in terms of health-care quality and utilization. And, I just want to underscore that in low- to middle-income communities and for members of racial ethnic minority population groups, these are individuals that are members of society that are at higher risk for developing chronic disease by virtue of lack of community access to some of these services. And so, these are some of the structural systemic factors that are beyond our control, but we can be cognizant of in terms of what actions we take personally.”

Emily Underwood: “Yeah, something that’s really struck me over the course of this series is how the conditions that a child is born in, that their mother is pregnant in, that a teenager grows up in, all of that adds up to have a real impact on our health, our mental health, and how we age. And so, I like that this is bringing it full circle where we talk about connecting generations. Why is it important to have less silo-ing of these different age groups? Tia, can you talk a little bit about the intergenerational connections as a way to help support everybody?”

Tia Powell: “Yes, absolutely. I really love that approach. There are a number of scholars who are really focusing on that. Marc Freedman is one through his work at CoGenerate, and Laura Carstensen has also done some great work on looking at the wonderful beneficial impacts, for everybody, of intergenerational collaboration.

“There was a great event I attended online a few weeks ago where they were looking at different projects around the country and in San Francisco, I believe it was, a group had brought together Korean older people and young people to do cooking together so that the young people could learn traditional recipes which they hadn’t been able to learn in their family. And it was an incredible positive, really wonderful experience linking the community together with great benefits on both sides, taking advantage of the traditional knowledge that was disappearing of food ways and recipes and culture, and helping the young people be able to bring that forward. So I think there can be great benefits.

“I’ll also say that there’s a theory that one reason women tend to live longer, which doesn’t really make any sense in evolution — once you’ve had babies, shouldn’t evolution not care so much about how you’re doing? — but there is a theory that women tend to live longer because the contribution of grandmothers has been enormous in sustaining the lives of children. And that is a role that’s been very widespread through places and time. There’s really interesting notions about, yeah, you’re not done contributing when you’re older. There are lots of ways where you can benefit, and you’re benefiting somebody, typically somebody younger. So I think there can be wonderful benefits across generations and I find this very exciting.

“I think it’s a pushback against the notion of each age group rightly should be often its own silo, like a ghetto, which is a word that comes from Venice, where Jews were forced to live in a particular section of Venice hundreds and hundreds of years ago. And that doesn’t usually work out better for the people who were in that silo, or for everyone else who loses the benefit of the contribution of the integration of everything that those people could bring.

“So, I’ll just give a strong plug for intergenerational efforts and I hope everybody here begins to think about, how can I be part of that? Wherever you are, is there something that you might be able to do to reach out and connect with people in a generation other than your own?”

Emily Underwood: “Thank you so much. OK, we have such a curious and hungry audience. People are looking for answers here. So I am going to go ahead and start looking at our questions.

“Just as a reminder for everybody here, this whole conversation is going to be posted on the Knowable website. You can replay it, you can share it, and we will post links to the articles we’ve referenced today. Thank you for supporting Knowable Magazine and thank you to the Dana Foundation for your support of these events.

“OK, so we were talking about how to structure society a little differently. We have a question from Moira Magneson about a community in the Netherlands that appears to be an ideal community in terms of taking care of its residents who all have advanced dementia. Do you know if there are similar communities in the making in the US? Can you mention a few standouts? Vijeth, does anything come to mind for you or do you want to pass it over to Tia?”

Vijeth Iyengar: “Can you repeat the question? Sorry.”

Emily Underwood: “Yes. So Moira Magneson points to the Netherlands as a place they’re really doing a good job of taking care of residents who have advanced dementia. How could we learn from other countries? Are there communities in the US that are following their lead?”

Vijeth Iyengar: “Tia, do you want to take it, given it’s dementia?”

Tia Powell: “I’d be happy to jump in. So this village in the Netherlands is very interesting. I’m not sure how you pronounce it correctly, but it’s Hogeweyk, or something like that. It is a small community. It’s essentially a gated community for older people with what they are labeling as severe dementia in the Netherlands, but it probably would not in the US meet criteria for that, the way we look at it. So these are people … it is largely funded by the state. It’s a lovely community, where people live and they can go out to the local little grocery store or the hairdresser, and all of that is within essentially this residential compound of the nursing home. And, they don’t have to use the real money. Everybody knows them. They go to the dining hall, they can have friends over, but everybody there is trained and understands. It’s not a regular community. It’s a closed community.

“So I think there’s some wonderful things. The people who live there have the experience of freedom. Certainly no one is telling them what they need to do, where they need to be, in a not-good example of a traditional nursing home: ‘Get up at this hour, have your breakfast. If you don’t get it then, you don’t get any.’ Almost treating the nursing home residents as if they’re prisoners, as if they’re felons. They’re in there because they’ve been naughty for being old.

“So, Hogeweyk is very appealing. It’s hard to do exactly that in the US because we don’t actually fund long-term care. Most long-term care in the US is paid for by Medicaid, for residential long-term care in nursing homes. And Medicaid doesn’t pay enough per person to actually sustain that, so a lot of nursing homes who just do long-term care are really having trouble surviving and they’re closing by the hundreds.

“So most skilled-nursing facilities, nursing homes, actually survive because they get Medicare patients who are there for 100 or fewer days doing rehab. Our policy-level funding issues make it very difficult to do something like this lovely experiment. We have some places that are trying. There’s something called the Green House setup, which are small nursing homes, 10, 12 people. It’s all usually typically on a first floor, or they’ve got some adapted to apartment building type thing, where there’s a different one on each floor. Everybody has their own bedroom. They’re all in a circle. The people who live there can help with preparing food and doing things, but it feels much less institutional and there’s a different way of staffing it so people have overlapping jobs, so anybody can help with anything. It feels more residential, much less institutional.

“A lot of people really like this. They’re relatively few. I think they don’t house more than ... I think they’re maybe 5 percent, less than 10 percent I think of nursing home residences. I hope I have that number right, but it’s certainly a small percent of what exists. I would love to see this kind of experiment. I think we might have to really rethink some of our regulations. I think we might have to have public-private payment. Some people don’t like them because only the old people are living there, and I agree that’s a problem. I’d love to see us set up things — and there’s some proposals about reusing shutdown shopping malls, or even office buildings in cities that aren’t used anymore — and making them so that it’s a safe space for people with dementia, but you also have multi-generational people living there. So, maybe the staff lives there with their family so there’s little kids, there’s a school. There’s a park.

“There’s a place that you can play, but it’s relatively contained and safe, so that all the different people, both little kids and older people with dementia can move safely within a limited community but it’s multi-generational. That’s my dream. I’d love to see something like that. It’s very hard to get that done because of the way we fund and regulate care here, but let’s see. It would be fun to try.”

Emily Underwood: “I’ll be looking that up and learning more about it. So, we’re going to go back to the more individual scale here with a question about sleep. Sleep is so important to forming memories, and deep sleep to the housekeeping of the brain, but sleep is challenging as we age. Any suggestions for promoting deep sleep and comments on changing sleep patterns? This is from one of our audience members, Lin Elder. Thank you, Lin. Vijeth, I’m going to send that to you.”

Vijeth Iyengar: “Yeah, sure. There’s some, what I would say, common-sense strategies in terms of minimizing distractions just before sleeping. I’m not sure of the particular social media usage of this questioner, but what I do is being able to shut down my phone maybe an hour before I sleep and trying to minimize any light exposure. At certain times, in terms of getting some physical exercise, maybe it’s a pleasant walk after your dinner, but enough distance before you sleep. Those are some things that we’ve found encouraging. I certainly don’t have the evidence on hand to be able to talk about, ‘Yes, you should do X, Y or Z,’ but I think being able to cultivate a place where you can sleep I think is exceptionally important. And there’s evidence to back why sleep is important for memories, but these are some of the things that I do before getting sleep, or getting a deep night’s sleep. But this idea of being able to get quality sleep consistently, I think there’s evidence showing that it’s exceptionally important for maintaining brain health.”

Emily Underwood: “Thank you. We have so many questions that are going back to this question of how do I know what’s normal and how do I monitor myself? I’d like to hear from you, Tia, about what this process is actually like. So for people who reach the point where they’re questioning whether their small memory lapses are really a problem, or if it’s an early sign of dementia. What is it like when you go the doctor? How does this actually play out in our current health system?”

Tia Powell: “Do you want me to crack at that one?”

Emily Underwood: “Yeah, I’m curious from your own experience with your family members.”

Tia Powell: “Yeah. So, two parts. One is it’s not always easy to know what’s normal aging and what might be the beginning of symptoms. I think a lot of people have some trouble with pulling up a name really quickly. But I think we can think of that as relatively normal in cognitive aging. Your reaction times might be a little bit slower. You know what? You probably run a little slower, too. Your brain is a physical thing. It’s working just like the rest of you, so I wouldn’t be too distressed about that. I think that’s pretty common, and unless that’s really having an impact on what you want to do, those wouldn’t be the signs I’m most worried about.

“I would be more concerned if you’re with your partner or friend, and you both saw the same movie yesterday or went to somebody’s house last month, and they’re talking all about it and it’s gone for you. Excuse me. I think that kind of thing, and things that really feel like I’m forgetting that I was cooking something, or you’re doing something that could really be dangerous. You’re a little bit worried about that. Maybe getting lost driving on familiar streets.

“So if you have that concern, I do think you should go the doctor, and that takes some courage because this is scary. You might not want to know the answer. But, I think that should be normalized. I think if you ask your primary-care physician about that, they should be able to do some tests for you and get you started. I have to say, and I’m sad to say this, at least in the US, not every doctor is willing to do that. There’s still some people who think, ‘Oh, I can’t do anything about it, so I don’t even want to talk to you about that.’ Of course, now I have a frog in my throat.

“So, if you have worries, and especially if they’re confirmed by the people who know you well, you don’t get a good answer from your first doctor, say,  ‘I’d like to have a referral. I’d like to have some tests done.’ Because there are some very specific tests that can help make sure that you’re where you should be.”

Emily Underwood: “Vijeth? Oh, sorry.”

Tia Powell: “There’s just a few things you can do, and there’s a lot of things that are treatable. Sometimes depression can look like dementia. Sometimes thyroid disease. There are a whole lot of other things that you want to have somebody take a look at. So now, let me hand it over to Vijeth, while I get some more water.”

Emily Underwood: “Thank you, Tia. I know, Vijeth, that AARP has a list of some warning signs to look for, which we can post in the chat. Can you highlight a couple of the ones that you pay most attention to?”

Vijeth Iyengar: “Yeah, I wouldn’t characterize it as paying most attention to because it’s idiosyncratic. Every individual is different in terms of the way they present for dementia. I just wanted to take a step back and say, look, aging is a normal process of life. It’s not a disease. Age is a risk factor for dementia, Alzheimer’s disease and related dementias, but it’s not like if you’re going to get old, if you reach some threshold, you’re going to get automatically dementia. There’s a whole constellation of factors. I just wanted to put that out there, because there seems to be some conflation of age and dementia. Age is certainly a risk factor, but there are all sorts of other risk factors for chronic disease. Diabetes is a risk factor. So, I wanted to just underscore, place in bold, underline that point.

“To get to your flag, Emily, about the resource, yes, I think there are five or six behavioral hallmarks or signs that we have shared with our consumers, and that hopefully will get in the chat, the link. But, in no particular order, one is getting lost or expressing visual or spatial difficulties. And why do we look for that? The region that gets impacted for Alzheimer’s disease is the hippocampus. Coincidentally, it’s the same region that’s important for our spatial navigation and orientation in our world.

“So, you have a double whammy there where if you think about a memory, there’s a spatial component to it. It’s the same region that’s important for facial navigation and for memory. So getting lost or expressing these difficulties, I think I would look for that.

“Again, confusion about time or place. If you think about memory, there’s a time component, there’s a spatial component.

“Personality or behavioral changes. That doesn’t get as much attention as it should. This idea of increased anxiousness and confusion and agitation and fearfulness. Troubling behavior, and what I mean by that is this idea of personal self-care, or lack of it. Lack of grooming, lack of cleanliness. And, I’m saying all this, this should be measured against — if you’re a loved one or a spouse or partner or caregiver — this should be measured against a baseline. What’s their typical regimen or what’s their typical behaviors?

“Difficulties with activities of daily living. What we mean by that is toileting, bathing, cooking. A lot of these operations we do on a daily basis. We rely on our executive function, rely on our prefrontal cortex that we talked about earlier in the panel.”

Emily Underwood: “I’d like to present a question from Sarah, who is an aging counselor and she says, ‘I am looking for ways of being at peace with my increasing age and managing myself emotionally and physically.’ So, Tia, would you mind taking that question? What are some ways of being at peace with increasing age? I liked what Vijeth mentioned about age not being a disease, and we often conflate aging with disease. So what are some ways of being at peace?”

Tia Powell: “That’s a beautiful question. I would like us all to be more at peace with aging. I think ageism, which is bias typically against older people, is just a huge problem globally. Thinking that to be old is to really ... If you just look at the metaphors we use: Her best years are behind her, she’s not in her prime. All these things about ... How do you know? We don’t know what’s going to happen next. So, I do think there’s some progress in that. If you just do a sample of the media, there are really interesting films and TV presentations of older people that are much more varied and much more robust than we’re used to seeing. There are television shows, and the ones I know are primarily in the US, but things like Frankie and Gracie, or Frankie and Grace, I guess it is — two older women who are funny, smart, totally active. They’re actually sexual beings. They have rich, full lives. They’re starting businesses. They’re doing all kinds of things.

“And similar, the current television show, Shrinking, also has portrayals of older people who are at the top of their game, incredibly admired professionals doing interesting things. So there is progress forward on this. I think there could be a lot more. There’s also a billion-dollar industry to try and make us, particularly women, not look old because that would be really terrible. So one of the few truly transgressive things that I do is that I don’t dye my hair. I don’t do any of that stuff because it really drives me crazy. My brothers have gray hair and they’re so distinguished-looking. They look great. And, I used to dye my hair because I started turning gray when I was 12, and I dyed it for years, and at a certain point I thought I can’t imagine how much money I’ve spent and time trying to not have gray hair when obviously that’s what my DNA wants to do.

“So I think, push back, present the image of this is what a healthy person of my age looks like. This is who I am, this is what I’m doing. There is no shame in that. And I do think there is some progress in that, and it’s fun to actually join in that battle and be part of ‘get used to it.’

“And by the way, Martha Stewart at the age of 81, is going to appear in the swimsuit edition of Sports Illustrated. That is not the battle I was most hoping that women would win, but you know what? Good for her. And I like that example because it shows that not just older people are thinking ... actually an attractive woman, we don’t know what age I’m referring to. It could be an 81-year-old. It could be an interesting attractive woman, so I’m all for it. That means that it’s not only older people who are thinking that way.

“So I think peace that if you were not this old, you would not have all the experiences you’ve had. You would not have loved all the people that you’ve loved. You would not have accomplished all that you’ve accomplished. So, there is great beauty in your age, even if it includes some wrinkles and gray hair, and I think that’s a message that really I would love to see us all embrace that more.”

Emily Underwood: “Thank you so much. I think along the lines of what you were just saying, Vijeth, ageism, we take it for granted in our society a lot of the time. I think it’s very casual. Can you talk about some of the supplemental papers that you shared, both of you, and pointed to the real impact that ageism can have. I think I saw something about how people perform worse on cognitive tests when they’re patronized. So, Vijeth, I’d just like to hear your thoughts on ageism and what are some ways we can combat it?”

Vijeth Iyengar: “Yeah, I think my theory of the case, or theory of change, is that we need to think upstream. And we’ve had wonderful questions, we’ve had a wonderful conversation, but we need to think a bit more upstream and there are actions we can take individually, but as individuals, we butt up against structural, systemic, societal barriers. And, a lot of those barriers are supported by the last accepted -ism, ageism. And so this idea of it’s acceptable to discriminate, to show bias against older people, is quite harmful. And, I think Becca Levy from Yale and others have done some great work looking at trying to unpack structural ageism in the health-care setting, in the workforce environment, and what does that mean for older adults that want to go back to the workplace but can’t because of either stereotype threat or ageist beliefs or biased against aging, or even age discriminatory practices?

“And so, at AARP, we try to marshal all our resources, whether it be advocacy, research, policy against that, because I think if we can change that narrative, we can change this idea that age and dementia are the same, or that older adults — whatever age we go with, whether it be 60, 62, 40, 50, whatever — are valued members of society.

“We have data showing that in the US in 2018, the 50-and-over population contributed to 40 percent of the US GDP — 40 percent. And that by 2030, 61 cents of every US dollar will be spent by that very population. So, that’s a population we cannot ignore. We have to embrace, we have to understand their unique values and needs, and we have to be respectful of them in every type of setting. So we’re full charge to the bore in terms of understanding how we can address this global threat of ageism, as the World Health Organization has said that we need to address this first, and then those beneficial effects will then filter downstream to a lot of the conversation we’ve had today.”

Emily Underwood: “I am so sad that we have to wrap up. We’re at our one-hour mark. Are there any last thoughts, Tia, that you wanted to share? Or, Vijeth?”

Tia Powell: “I think I would put out a challenge to the group to think about what small, or if you’re interested, large, thing could you do to make yourself and those around you happier as you age. Is there some activity you can take in your community garden, in your faith community and someplace else that would welcome older people or people with dementia that would bring people together? Is there something that you could do that would actually make the world you live in better for you and for people as they’re getting older? It doesn’t have to be big, but if we all did that, that would be awesome and we would really see the impact of that.”

Emily Underwood: “I love that. Thank you. I think that’s a perfect note to end on. I wish we had more time. Thank you to everybody who joined today. Thank you, Vijeth and Tia, so much for your time and thoughtfulness. Thank you, those of you who are with us today for supporting Knowable Magazine. If you can, please consider donating at KnowableMagazine.org/donate and thank you to the Dana Foundation for your support of these events. This conversation is going to be posted. As a reminder, please visit later and you’ll see the whole series all together from birth to old age — so much rich material, lots to go back and revisit, so please share that and go back there and enjoy it yourself. Thanks again for joining us today, and goodbye.”

Tia Powell: “Thank you, Emily. Bye-bye.”

Vijeth Iyengar: “Bye.”