July/August 2020

Brain Health in Memory Care
By Krystal L. Culler, DBH, MA; Cathee Stegall; Patrick Cleary; and Caroline Larimore
Today’s Geriatric Medicine
Vol. 13 No. 4 P. 22

It’s widely agreed upon that brain health is an important aspect of health, but what is brain health? It can be conceptualized simply in terms of “thinking, moving, and feeling.”1 A definition of brain health includes the notion of reducing the risks to individuals’ brains as they age to function well in late life and to avoid brain-related diseases or illnesses such as cognitive impairment.1,2 Brain health is linked to our lifestyles—the way in which we live our lives and the activities we engage in throughout our lives. In essence, everything we do or do not do matters to our brains.

What about brain health in memory care? Quality care for individuals with neurocognitive disorders supports brain health with appropriate modifications to meet individuals where they are in their disease progression. Brain health in memory care encompasses the notion that everyone has the ability to continue to engage in brain-healthy lifestyle behaviors such as physical exercise throughout life regardless of health diagnosis(es) or condition(s) with modifications. In a memory care setting, programming is therapeutically designed to provide optimal brain health benefits for individuals while participants are meaningfully engaged.

There are various models of brain health implemented in the United States and across the world. The pillars of brain health being endorsed vary based on an organization’s structure, geographical location, or service being provided. Many leading health care organizations, long term care providers, and for-profit/nonprofit organizations have adopted a model of brain health that their programs are able to support on a national or local level. This article summarizes the current research to support the adoption of a nonprofit organization’s model of brain health, provides examples of brain health in a memory care center, and offers suggestions for health care providers to consider the research-informed brain health interventions as part of their recommendations to patients within their own working environments.

Memory Matters, a 23-year-old nonprofit organization, is located in the South Carolina Lowcountry on Hilton Head Island. With the bold vision to optimize brain wellness, the organization balances brain health education and memory care services with demonstrated success, being a recipient of the 2019 Southern Gerontological Society’s “Best Practices” award. The organization proactively tackles memory care through early intervention and the promotion of a healthy lifestyle based on simple, research-informed interventions including physical exercise, Mediterranean lifestyle, lifelong learning, and restfulness. The social-model, adult day care center offers participants their best brain day through the incorporation of brain health in memory care.

Physical Exercise
Exercise has always been promoted as part of a healthy lifestyle. It keeps the heart healthy, adds to mental agility, and even improves sleep. Physical exercise gets blood flow to the brain, which provides multiple benefits including a boost in attention, memory, processing speed, decision-making, and mood enhancement.3 Physical exercise promotes the production of brain-derived neurotrophic factor, also referred to as “Miracle-Gro” for the brain, which is critical for the maintenance of healthy neurons and the creation of new neurons.4 Essentially, exercise can grow the brain and protect it against damage.

According to the Physical Activity Guidelines for Americans, at least 150 minutes of moderately intensive physical exercise per week is suggested; this includes anything that gets the heart beating faster, such as walking, dancing, and playing.5 Keep in mind the duration of engagement can be broken into smaller increments such as taking a short walk with a pet, parking farther away when accessing a building, taking the stairs, and even playing with grandchildren.

Although state regulations may guide the recommended offerings of physical exercise programs for some organizations such as adult day centers and senior living communities, there’s a general consensus that they are valuable programs. Within memory care settings, making movement a natural part of the day can be embraced as part of the Mediterranean lifestyle and built into the daily schedule. The environmental space can be optimally utilized for the programming, enabling participants the opportunity to navigate at a natural pace while shifting among the various components of their day, from their physical exercise class to a hydration break and lunch. Planning purposeful exercise programs such as chair yoga, tai chi, weight lifting, and even dancing offers individuals an opportunity to sustain their abilities and add quality to their lives.

For providers, discussing physical exercise with patients can influence their health. Knowing the physical activity guidelines for adults and making incremental suggestions for individuals who are below the standard can have a profound impact on their overall wellness. The suggestion to add more movement to their day and encouragement to stay active can assure individuals that they are on track to move their way toward adding more physical activity to their day and week.5

Hydration
The brain is composed of about 75% water, and when it becomes dehydrated, cognitive abilities such as focus, mental clarity, fatigue, low mood, headaches, and sleep issues, among other symptoms, may present in as little as two hours.6 Hydration is an important component of diet, and health care providers should consider it thoughtfully when planning programs for aging adults. Simply offering fruit-infused water canisters in an accessible area for patients or suggesting a small cup of water during a conversation can help patients keep hydrated during intakes or meetings.

Hydration and socialization are also important components of an exercise program and can be leveraged to support brain health for all attendees. It can be helpful to plan intentional water breaks throughout the day and to encourage opportunities to promote hydration. In memory care programming, participants can raise their fruit-infused water glasses to cheer a job well done following an exercise program or make toasts to share accomplishments or celebrate special occasions.

Lifelong Learning
Lifelong learning is crucial to brain health, and the desire for engagement in lifelong learning programs does not end with a neurocognitive disorder diagnosis. Research has found that despite the presence of a neurocognitive disorder, individuals are still able to generate new brain cells in the hippocampus, the area of the brain commonly associated with memory.7

High-quality lifelong learning programming is based on three core principles: It’s new, it’s novel, and it offers an appropriate level of challenge. Programming in memory care can be adapted to fulfill this demand.

The programmatic goal for a lifelong learning program in memory care offers therapeutic value, but the outcome is not learning based per se in a traditional sense. In a memory care setting, a lifelong learning program focuses on learning in the present moment, sparking a connection in the long-term memory among program attendees, and/or fostering a supportive environment that promotes a sense of belonging among other programming goals. Program directors may lead highly engaged lifelong learning programs based on a theme of the day centered on a current events topic or world calendar day such as national sleep day. Community partnerships can be explored to leverage regional resources such as zoos, art museums, and local experts or volunteers with memorabilia to show and tell.

It’s vital for health care providers to recognize that lifelong learning and education generate improvements for individuals with and without brain health concerns.7,8 Common recommendations for continuing lifelong learning program opportunities include online or in-person formats, computer-based brain games, puzzle books, adult coloring books, a new book/magazine, or trying something new. Despite patients’ ages or current health status, lifelong learning offers numerous brain health benefits.9,10

Mediterranean Lifestyle
U.S. News & World Report has ranked the Mediterranean diet as the world’s “Best Diet” for the past three years. Ranking at the top because it’s a structured eating pattern rather than a prescribed diet, it’s a lifestyle that encompasses daily exercise, socialization, and the consumption of water for hydration. It boasts a daily menu rich in fruits and vegetables, whole wheat grains, healthy fats (olive oil, nuts, seeds), and lean proteins (legumes, beans, fish, chicken) flavored with herbs and spices. Moderate amounts of dairy, seafood, and eggs are also included in this diet, with an occasional sweet and a glass of red wine.

Backed by a growing body of research, the Mediterranean diet lowers the risk of various age-related diseases and may delay or reduce cognitive decline.11-13 Researchers have called for further exploration of diet in the prevention or delay of cognitive decline.12,13 Growing evidence supports a strong link between diet and brain function such as memory and thinking abilities.11-14

A recent trend in health care is the endorsement or promotion of a diet that can be supported by an organization’s services. In 2018, Memory Matters adopted the Mediterranean diet for its programs and services, including its educational events and organizational fundraising activities. With the support of its brain health and memory care trained staff, a registered dietitian, and a volunteer chef in residence, a Mediterranean lifestyle–inspired food program was rolled out for the organization.

Because, as the adage goes, we eat with our eyes, the Mediterranean diet has been a good fit for the memory care program. Food entrées prepared adhering to the Mediterranean diet guidelines are served to the table with bright greens, vivid reds, and bold oranges. The proteins are lean and neither fried nor greasy, the vegetables are fresh and crisp, the whole grains are portioned to a healthful serving, and, most important, the meals are palatable, so clean plates return to the kitchen. Food brings people together, and meal times are intentionally designed to promote socialization among program attendees, staff, and volunteers. The goal of the healthy lunch program is multifaceted: to provide a nutritious meal, to spark lively conversations, and to promote laughter and camaraderie through the creation of a space that fosters social relationships via a shared meal experience—the essence of the Mediterranean lifestyle.15

Health care providers can continue to encourage their patients to engage in a variety of social programs to support their brain health. A referral to a social services professional with familiarity in local community-based resources can offer additional resources for the client. It’s important to keep in mind that access to healthful food is an important social determinant of brain health.14

The heartbreaking truth health care providers should keep in mind about many social care–based agencies is that the meal being served might be the best meal individuals receive for that given day or week. It makes sense to provide the highest-quality food and flavors possible, especially to individuals with neurocognitive disorders, which may take community collaborations, resource sharing, and creative problem-solving to address this important area of brain health in memory care.14,15 Utilizing the resources available to the interdisciplinary teams within providers’ organizations or health care settings can offer valuable programs to patients, caregivers, and families.

Restfulness
The term “restfulness” can be applied to exercises that include a relaxation component aimed to reduce bodily stress to promote a healthy, calm brain. Examples of restfulness-based activities include meditation, mindfulness, and sleep, which all contribute to relaxing the brain. Data have been mounting about the positive impact on the aging brain of interventions that address the mind-body connection.16-18

Until recent years, sleep has been an underrated aspect of health. The Centers for Disease Control and Prevention recommends that healthy adults aim to achieve seven to nine hours of sleep each night.19 Research has found that restorative sleep has been a proven part of a cleansing cycle that prompts cerebrospinal fluid to flow through the brain and spinal cord. The slow brain waves that occur during this phase of deep sleep wash out the toxic buildup of waste in the brain, a known precursor to neurodegenerative diseases.20 Essentially, obtaining restful sleep is a byproduct of a resting brain, and the promotion of restfulness-based exercises offers a variety of benefits to an individual’s brain health. Thus it is beneficial to foster healthy sleep habits at the end of the day.

Daily meditation practice and mindfulness encourage restfulness. Even in aging brains, meditation has been shown to increase the gray matter in the prefrontal cortex, the command center of the brain responsible for higher cognitive functions.20 Mindfulness, the practice of living in the moment, has shown decreased activity in the amygdala, the area of the brain initially affected by stress.21 Integrating restfulness-based exercises into memory care programming has been well received and documented in research. The Kirtan Kriya, a meditation from the Kundalini yoga tradition, is one of the most widely studied memory exercises for brain enhancement.17,18

Leading participants through the 12-minute guided meditation offered by the Alzheimer’s Research and Prevention Foundation or a shortened version to be adapted for one’s group or individual purposes via a guided CD, YouTube video, in-person yoga practitioner, or staff member is a straightforward way to introduce this research-informed memory exercise to patients. Additionally, short prompts to practice mindfulness such as breathing techniques, gratitude exercises, and minute mindfulness techniques, among other types of meditation, can be introduced to individuals to enhance their personal brain wellness journeys. It’s helpful for health care practitioners to keep in mind that various restfulness techniques will resonate differently with patients and exposure to a selection of stress-busting practices might be necessary to help them build their brain health toolboxes.

Ultimately, it is never too late to embrace a brain healthy habit. This is true even for individuals with neurocognitive disorders. Making shifts to support individuals to do as much as they can within their own health parameters can have an effect not only on their lives but also on their caregivers’ and families’. Health care providers play a vital role in brain health education in memory care.

— Krystal L. Culler, DBH, MA, is the founder of Your Brain Health Matters (www.YourBrainHealthMatters.com), where she provides educational training and corporate consultation to make brain health, wellness, and memory care services thrive. She is a Senior Atlantic Fellow for Equity in Brain Health with the Global Brain Health Institute, where she completed her year-long training in dementia prevention and residency at Trinity College Dublin, Ireland.

— Cathee Stegall, community services director at Memory Matters, has more than 14 years of experience working with innovative programming in brain health and memory care and is an active lifelong learner, having completed numerous courses in neuroscience, brain anatomy, biology, and brain health. She’s been an invited national speaker at the Brookdale Foundation National Group Respite Conference to share her innovative practices in memory care regarding the creative arts programming that she has created and curated for the organization’s cutting-edge early memory loss programs.

— Patrick Cleary is the acting associate executive director at Memory Matters (www.mymemorymatters.org) and holds a postgraduate certificate in gerontology from the University of North Carolina in Greensboro. He blends his extensive background from the food service industry, being a former restaurant business owner, and advanced training in aging services to ensure a quality dietary experience in the memory care center while overseeing the memory care operations for the organization.

— Caroline Larimore is a memory care program specialist II at Memory Matters, and holds a Bachelor of Arts degree in psychology and an undergraduate certificate in gerontology from the University of South Carolina. She’s been a leader among the program team members at Memory Matters in creating, curating, and teaching the brain health day program curriculum in the memory care center and community-based early memory loss classes.

References
1. Gorelick PB, Furie KL, Iadecola C, et al. Defining optimal brain health in adults: a presidential advisory from the American Heart Association/American Stroke Association. Stroke. 2017;48(10):e284-e303.

2. Olivari BS, French ME, MS, McGuire LC. The public health road map to respond to the growing dementia crisis. Innov Aging. 2020;(4)1:1-11.

3. Colcombe SJ, Kramer AF, Erickson KI, et al. Cardiovascular fitness, cortical plasticity, and aging. Proc Natl Acad Sci U S A. 2004;101(9):3316-3321.

4. Ratey JJ, Hagerman E. Spark: The Revolutionary New Science of Exercise and the Brain. New York: Little, Brown; 2008.

5. U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf. Published 2019. Accessed February 27, 2020.

6. Wittbrodt MT, Millard-Stafford M. Dehydration impairs cognitive performance: a meta-analysis. Med Sci Sports Exerc. 2018;50(11):2360-2368.

7. Tobin MK, Muscara K, Dicouky A, et al. Human hippocampal neurogenesis persists in aged adults and Alzheimer’s disease patients. Cell Stem Cell. 2019;6(24):974-982.

8. Vemuri P, Lesnick TG, Przybelski SA, et al. Association of lifetime intellectual enrichment with cognitive decline in the older population. JAMA Neurol. 2014;71(8):1017-1024.

9. Simone PM, Scuilli M. Cognitive benefits of participation in lifelong learning institutes. LLI Review. 2006;1:44-51.

10. Vickers J. Lifelong learning: Educational interventions for dementia and brain protection. Prof Educ. 2018;19(2):18.

11. Lourida I, Soni M, Thompson-Coon, et al. Mediterranean diet, cognitive function, and dementia: a systematic review. Epidemiology. 2013;4(4):479-489.

12. Luciano M, Corley J, Cox SR, et al. Mediterranean-type diet and brain structural change from 73 to 76 years in a Scottish cohort. Neurology. 2017;88(5):449-455.

13. Yian G, Brickman AM, Yaakov Stern Y, et al. Mediterranean diet and brain structure in a multiethnic elderly cohort. Neurology. 2015;85(20):1744-1751.

14. Global Council on Brain Health. Brain health and nutrition. https://doi.org/10.26419/res.00187.001. Published January 2018. Accessed March 10, 2020.

15. Global Council on Brain Health. The brain and social connectedness: GCBH recommendations on social engagement and brain health. https://www.aarp.org/content/dam/aarp/health/brain_health/2017/02/gcbh-social-engagement-report.pdf. Published February 2017. Accessed March 10, 2020.

16. Eyrea HA, Acevedoa B, Yanga H, et al. Changes in neural connectivity and memory following a yoga intervention for older adults: a pilot study. J Alzheimers Dis. 2016;(20):673-684.

17. Alzheimer’s Research and Prevention Foundation. Yoga and medical meditation: as Alzheimer’s prevention medicine. http://alzheimersprevention.org/downloadables/White_Paper.pdf. Published May 2015. Accessed March 5, 2020.

18. Alzheimer’s Research and Prevention Foundation. How kirtan kryia meditation benefits adults with early memory loss: findings from a randomized controlled trial. Published 2019. Accessed February 27, 2020.

19. Watson NF, Badr MS, Belenky G, et al. Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. Sleep. 2015;38(6):843-844.

20. Fultz NE, Bonmassar B, Setsompop K, et al. Coupled electrophysiological, meodynamic, and cerebrospinal fluid oscillations in human sleep. Science. 2019;366(6465):628‐631.

21. Taren AA, Creswell JD, Gianaros PJ. Dispositional mindfulness co-varies with smaller amygdala and caudate volumes in community adults. PLoS One. 2013;8(5):e64574.

A RECAP: TIPS TO PROMOTE BRAIN HEALTH

Physical Exercise
• The brain-boosting benefits are offered to all who engage, regardless of age, fitness level, or neurocognitive status.1
• Five minutes of movement can offer health benefits.2

Hydration
• Facilitate regular consumption of water, including fruit-infused varieties.

Lifelong Learning
• To keep one’s brain sharp, engage in learning exercises that are new, novel, and challenging to gain the most benefit.3

Mediterranean Lifestyle
• Eat to fuel the mind via a plant slant toward vibrantly colored vegetables and fruits.4
• Consider that this lifestyle incorporates day-to-day movement and socialization.2,4,5

Restfulness
• Practice meditation and mindfulness daily.6,7
• Prioritize seven to nine hours of sleep per night.8

References
1. The four pillars of Alzheimer’s prevention. The Dana Foundation website. https://www.dana.org/wp-content/uploads/2017/10/The-Four-Pillars-of-Alzheimers-Prevention.pdf. Published March 2017. Accessed March 13, 2020.

2. U.S. Department of Health and Human Services. Physical Activity Guidelines for Americans, 2nd edition. https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf. Published 2019. Accessed February 27, 2020.

3. Nussbaum P. Lifelong learning and wellness: one component to the enlightened gerosphere. http://www.paulnussbaum.com/Responses.pdf. Accessed March 15, 2020.

4. Global Council on Brain Health. Brain health and nutrition. https://doi.org/10.26419/res.00187.001. Published January 2018. Accessed March 10, 2020.

5. Global Council on Brain Health. The brain and social connectedness: GCBH recommendations on social engagement and brain health. https://www.aarp.org/content/dam/aarp/health/brain_health/2017/02/gcbh-social-engagement-report.pdf. Published February 2017. Accessed March 10, 2020.

6. Alzheimer’s Research and Prevention Foundation. Yoga and medical meditation: as Alzheimer’s prevention medicine. http://alzheimersprevention.org/downloadables/White_Paper.pdf. Published May 2015. Accessed March 5, 2020.

7. Wells RE, Kerr C, Dossett ML, et al. Can adults with mild cognitive impairment build cognitive reserve and learn mindfulness meditation? Qualitative theme analyses from a small pilot study. J Alzheimers Dis. 2019;70(3):825-842.

8. Watson NF, Badr MS, Belenky G, et al. Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. Sleep. 2015;38(6):843-844.