Brain fitness, risk and safety

I have read a great deal about ways to promote “brain fitness.” Implicit in all these approaches–games, exercises or diet, is the implied benefit of reducing the risk of Alzheimer’s disease. None of these methods, to the best of my knowledge, has shown such a benefit through the use of a double-blind clinical trial—the gold standard approach. While these methods might have demonstrable benefits, preventing Alzheimer’s or any other dementia has not been shown. I wish they could testify to that, but we are not there yet.

There is another-cost effective path to brain fitness worth pursuing. It involves applies the “use it or lose it” tenet of good geriatric practice by encouraging elders to make choices from among meaningful alternatives. You may be familiar with this idea in the context of choice in dining or some of the other practices that are the foundation of person-centered care. I recommend this practice not just because it requires no special technology or product, but because it’s what we do countless times every day.

The brain is a choice maker by design. It seeks new information and stores it (learning) to be used when conditions call for it (retrieval). This process promotes new nerve cell growth and increases connections between nerve cells that fire together during an action. But, the brain—and the person whose head it resides in—would quickly become exhausted if it sought new information only.

To help save mental energy, people develop routines that can be handled—the everyday actions needed for existence but are not especially in need of modification. These are the habits and automatic behavioral sequences we use every day (brushing teeth, tying shoelace, and walking around our dwellings).

These and other routines become noticeable when we can’t perform them, well, routinely, some barrier to their automatic execution is encountered such as an injury to a dominant hand or noticing an obstacle that we could trip over necessitating an alternative path. Or someone else may feel that his or her routines are more important or “better” than yours (“We all get up at 6 am here.”), which negates your routines.

Over a lifetime everyone develops his or her own balance of novelty seeking vs. routinized behavioral tendencies. Much of how that balance shapes up is determined by how much risk a person likes to take in pursuit of novelty, and what the margins of safety are that they require. People are described as risk takers or risk-averse. Each person has his or her own profile of risk/reward scenarios. But whatever the pattern, each person will inevitably make a mistake—and that is a good thing. Why? If we don’t make mistakes, our brains don’t learn anything

But we in aging services have developed a culture where we are called upon to eliminate all risk for elders in the service of good care. So there is a tension between the need for our brains to develop and learn, which involves making mistakes and the responsibility we feel to avoid risk at all costs.

This model of risk and its management presumes that since no significant development takes place in the oldest old, there is nothing of significance to be gained from elders making mistakes. In this view, which is mostly unstated, risk carries no meaningful reward. This has led to a culture that Dr. Bill Thomas and I have characterized as creating a condition of “surplus safety”—safety that does harm by eliminating opportunities for growth and development in physical, psychosocial, vocational and spiritual domains.

This past September a symposium sponsored by the Hulda B. and Maurice L. Rothschild Foundation redefined risk as including both the probability that an action will lead to an outcome that is worse than expected, called downside risk, or an outcome that is better than expected, called “upside risk.”

The crucial question that the symposium began to address is: How can we identify ways to promote quality of life and, not coincidently, brain fitness through everyday actions that honor choice about novelty and wanting to develop and yet take into account both up- and downside risk with adequate safety?  I will have more to say on this next time.

In the meantime, think about your own balance of risk/rewards and how you learn.

I Advance Senior Care

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