Carved in Sand: When Attention Fails and Memory Fades in Midlife
By Cathryn Jakobson Ramin
HarperCollins Publishers. 311 pp. ISBN: 0-060-59869-7
Just before I sat down to bang out this review, I met a friend for coffee at a neighborhood cafe. As we left, she pointed out that I'd forgotten to take my bag and hat, which were tucked on the ledge under the window. The day before, I'd forgotten the same bag at a brunch. My wife had to turn the car around for me to run into the house and fetch it.
That's the small stuff. Earlier in the summer, I returned from a bus trip from Buffalo to Toronto. In my living room, I opened my trusty glasses case and discovered that my reading glasses weren't there. I couldn't remember what I'd done with them. Where could I have dropped them? Small stuff still, you think. But the reading glasses were prescriptions, replete with costly no-glare and no-scratch coatings. Losing these glasses really bothered me. Damn, I thought, cursing myself and the fickle gods of memory!
Who hasn't got similar stories? How many things have you lost? Do you worry about fading memory—or whether these "senior moments" are the start of some horrible dementia or Alzheimer's? It's all a part of midlife decline, a time of life that could begin in your forties or later—or earlier!
This is the situation Cathryn Jakobson Ramin finds herself in, like many of us. She's an ambitious, busy freelance writer, who lives in northern California with her husband and two kids, whom she helps with homework and a thousand other tasks. She attends book club soirees and social gatherings as she juggles work assignments. On the face of it, she's your average supermom. Since she's cagey about her age, it takes nearly a hundred pages to find out she's 52.
But Ramin feels she has terrible cognitive deficits. In her forties, she started to notice she had problems. She felt "vague and foggy." She'd couldn't finish a page of a book before she'd forgotten what she'd read. "Words, my stock-in-trade as a writer, had started to play hide-and-seek," she writes. Thoughts raced into her mind, and then vanished before she'd had a chance to record them. Not only couldn't she remember names (a common enough problem): she couldn't remember faces, so she couldn't remember if she'd ever met somebody who was shaking her hand at a party. She felt "foreign" to herself and others.
She wasn't just worried about slowing down, which, as we learn, we all begin to do in our twenties. She was terrified about losing her edge. She was heavily invested in being a "quick and smart mistress of my good brain and sardonic tongue." Her wit and verve were not only central to her ability to earn money as a freelancer, but a big part of her identity.
Ramin is clever enough not simply to worry about her deficits: she uses them as the topic of her first book, Carved in Sand. Her cognitive rehab becomes her story. Luckily, she's plucky and works like hell, and has researchers and editors from a big publishing house to back her up, so her memory issues don't get in the way.
For two years, she talks to 200 people and applies herself, granted in a somewhat frenzied manner, to 10 "interventions" purported to help the retention of brain power. This is a "road book," in which the voyage of discovery is her own mind. She doesn't seek out amateurs or marginal alternative-health types, but visits big, respectable centers, like UCLA and other major universities. She wants to find out what's wrong with her, and we get to go along for the ride.
And quite a ride it is. Along the way, we learn an astonishing amount of information. She visits MIT, and finds out that her brain is filled with bothersome "background noise," caused by the fact that her prefrontal cortex—the lobes that guide, organize, and prioritize the information we take in—is overloaded. Dopamine keeps the frontal lobes hopping, but as we age, dopamine receptors diminish. So in living our intense, busy lives, our systems get more and more overloaded, and we no longer have the "cognitive reserves" of a younger person.
The problem is that many aging boomers want to remain at the top of their game for their entire working lives. So, throughout the book, Ramin believes she suffers from something more than just natural slowing down. She's worried and scared. And she has more than a touch of the first-year-medical-student-syndrome: feeling that you've got the disease you've just read about in your textbook. So she visits AD/HD doctors and begins to believe she suffers from adult attention deficit / hyperactivity disorder. This, not just normal aging, could be the cause of her frontal-lobe shutdown, she fears.
Ramin subjects herself to PET and MRI scans and other diagnostic tests, to rule out the dreaded Alzheimer's disease. She's great at packing information into the ongoing story, so we learn that by 65, the disease affects 1 in 10. By 80, it's 1 in 4, and by 85, nearly 5 in 10 people suffer from Alzheimer's. She finds out that this disease can begin early in midlife, decades before memory loss shows up. That's a new worry, but mercifully, after tests at UCLA, Ramin is given a "free and clear" Alzheimer's pass for three years.
Still, much else could be wrong with her. In a chapter called "Swallow This," she goes the nutrition route. Americans spend $23 billion a year on dietary supplements. They spend more than $1 billion on ginkgo biloba alone, which is even more popular in Germany, though little evidence for its effectiveness exists. Ramin's research convinces her she's "starving her brain." Because of our lousy diets, she writes, we're all "rusting from within" from oxidation (all those terrible free radicals). She begins to eat expensive, out-of-season blueberries imported from South America, and to take a lot of pills, including memory concoctions like "Brain Sustain." Magnesium, we're informed, is also crucial.
All told, Ramin spends $125 a month on supplements. She travels everywhere with Ziploc bags filled with capsules. It's a real pain, and after four months, she tosses them into the back of her fridge. A nutritionist might argue that four months isn't long enough (after all, supplements aren't quick-acting antibiotics), but she's impatient. Who can blame her? What evidence can you believe, with only the subtlest bodily sensations to go on? And look at the expense! I, too, have half-consumed bottles of vitamins in my pantry. And between rainbow-colored urine and constipation (or the runs), don't tell me supplements have no side effects!
Ramin tries "mental aerobics," which are becoming popular. This isn't crossword puzzles and sudoku (though these are useful because
they exercise the mind). Enterpris-
ing brain scientists, like Michael Merzenich, are developing computer programs for people with learning deficits, like dyslexia, and now for seniors and boomers who want to stay mentally nimble. He's discovered that hearing loss is often a factor in forgetfulness: elderly people forget because they can't hear or process sound adequately in the first place. His program Posit Science works on auditory processing by starting slowly, with simple sounds, which increase in volume and complexity. This software costs almost $500, so it isn't cheap. It's hard to say if it works, though some studies have been done and anecdotal testimony abounds. This sort of program probably is only the beginning of a new slew of consumer offerings.
In the past, rehab specialists have tried to compensate for lost skills by working around them, but with the new focus on neuroplasticity, scientists are discovering that the brain is malleable. New computer programs target weak areas in the brain in order to build them up, but they require real commitment on a student's part, and once again, Ramin is impatient.
Now she tries Provigil—part of the new pharmacology of "cosmetic neurology." These drugs are extraordinarily appealing because they increase alertness without agitation. Caffeine is great, but if you drink too much of it, you shake. Adderall and other stimulants (uppers) are addictive and lead to terrible crashes, but this new class of drugs is supposed to promote a "calm and attentive wakefulness." Forty versions of such drugs are in the pipeline, but the FDA is wary. Provigil is making its manufacturer nervous, too, because during one recent trial, someone developed a life-threatening skin rash—which, Ramin says, may or may not have been the result of the medication. It'll be a while before these medications are available, but in pill-popping America, their widespread use seems inevitable. Ramin gets a rare prescription to Provigil, and she likes it, but it isn't the magic potion she's seeking.
She tries meditation and mindfulness training (they put her to sleep) and neurofeedback (intriguing but uncertain about results), and consults sleep doctors because she has insomnia. Surprisingly, she has no time for an all-night sleep study (which could determine if she suffers from obstructive sleep apnea, which affects four percent of men and two percent of women). People with sleep apnea are continually exhausted, which Ramin is always complaining about. But deadlines and stress keep her from her appointment.
This brings us to the heart of Ramin's road trip. It's clear throughout the book that she's one unbelievably stressed-out person. You don't have to be a therapist to see the signs. Her "stress taps"—fight or flight responses—are on all the time, and stress is one of the great factors in memory loss and cognitive decline. She knows this; she devotes a chapter to it. Stress bathes your brain in "battery acid," she notes. This isn't exactly earth-shattering news. But like so many people, Ramin can't get off the stress treadmill. It's a national trait, which people almost seem proud of: going full steam with little sleep, engaging in orgies of multitasking, fueled with the tonic of ambition and workaholism. These people crash, and they get sick.
Ramin does think she might have an underlying medical condition. She sees a doctor who tells her she may have an underactive thyroid, a condition called "subclinical hypothyroidism." Her tests are normal, but this disorder often hides beneath the radar. So who knows? In the meantime, she believes that for years she's been misdiagnosed. She feels she's wasted a decade feeling ill—which causes more regret and, yes, more stress.
This determination leads to the two final points near the end of her book, which Ramin is wise enough to insist on, even in her frenzy. First, she says, doctors may not "connect the dots." Or you could say, they may add new dots for you to worry about. Yes, you have to be your own advocate, but how is an ordinary person supposed to sort through the conflicting scientific information? That's a tricky question. You can't always listen to your body because maybe your body is in permanent overdrive, like Ramin's, or just may not be talking to you.
During a bout of calmness in the final pages, Ramin makes her second point: like memory, worry diminishes with age. The psychologist Thomas Crook informs her, based on his studies, that the people most worried about memory and cognitive decline are in their forties. Then, in their fifties, they feel better. In their sixties, they feel as good about their memories as they did when they were in their early thirties. In other words, people adjust and accept the fact that they do slow down. It's natural.
Finally, she assures us that the conventional wisdom among cognitive researchers still works: exercise your body, stimulate your mind, and see friends and family. Social interaction is worth more than a drawerful of meds. Do these three things, and you can add to your "cognitive reserves." We can only hope Ramin takes this advice herself. As for me, I'll do all these things, gladly. But those new brain-enhancement pills do sound enticing.
Richard Handler is a radio producer with the Canadian Broadcasting Corporation in Toronto, Canada. Contact: firstname.lastname@example.org. Letters to the Editor about this article may be sent to email@example.com.