Dr. Snowdon received permission from about 800 nuns in 6 different locations to track their progress in aging. He had hand written autobiographies when the nuns entered in their twenties and detailed archives of their activities since then. They administered standard tests to determine the effects of aging on physical functioning with Activities of Daily Living as well as mental functioning. Then, they received permission to do a detailed autopsy on each brain at death.

The results and implications for Alzheimer’s and general aging with grace were very interesting.

=> Nearly one hundred years after Alois Alzheimer first described the disease, it still defies a simple diagnosis for clinicians and pathologists alike.

Dementia simply means “out of one’s mind” in Latin. The diagnosis is usually made if three types of symptoms are present: There must be impairment in short-term memory, in another area of cognition (such as language), and finally, in social or daily functioning (such as dressing).

Dementia has, to date, at least sixty known causes. It may result from infection by a bacterium, by a virus (as in AIDS), or by a newly discovered infectious agent called a prion (as in Creutzfeldt-Jakob disease).

Nutritional and metabolic disorders such as vitamin B12 deficiencies and hypothyroidism can cause dementia, as can drug side effects, toxins, tumors, strokes, and serious head trauma. Finally, it may result from degenerative diseases such as Huntington’s or Parkinson’s – or Alzheimer’s.

=> As we now know, diseases impact different people differently from cancer to diabetes, influenza to pneumonia, gout to asthma. A disease that quickly causes a severe illness in one person may take years or even decades to cause symptoms in another. Some people develop classic symptoms, while others hardly show any typical symptoms at all. What is common to most Alzheimer’s patients is their slow downward course of mental, physical and social deterioration.

In a textbook case of Alzheimer’s, the symptoms begin subtly. The person starts having trouble remembering the names of people and objects, whether it rained that morning, and other simple details of day-to-day life. Of course, these sorts of short-term memory lapses are experienced by everyone from time to time. However, in Alzheimer’s they increase in frequency and severity over time. A person with Alzheimer’s may repeatedly make the same request or tell the same story over and over, as if she can’t remember what happened just minutes before. Reasoning, planning and organizing become more difficult; some people may have difficulty preparing a meal or walking to a place they have visited many times. (87)

=> The point at which a family seeks help varies widely. Some may be alarmed when a retired accountant can no longer complete a tax return; for others, inability to balance a checkbook may be the turning point. Treatment is often delayed by ageism—the prejudice that failing capacities are normal for the elderly. Research has shown that the average person has symptoms for several years before a clinician diagnoses Alzheimer’s.

=> The diagnosis itself is a delicate blend of experienced clinical judgment, examinations such as the ones the Nun Study uses, and tests to rule out other causes of dementia. The American Psychiatric ASsoc. and other groups have developed detailed guidelines to distinguish non-Alzheimer’s dementia from possible or probably Alzheimer’s. But there is no definitive test—no blood workup or even brain scan—that can provide absolute certainty in a living person.

=> As the disease progresses, language skills continue to decline. People have more and more trouble finding the right words to describe an object or an experience. Reading and writing become increasingly frustrating processes. Some may have trouble recognizing the faces of friends and family members, or even distinguishing the family pet from a household object. Not only may the date escape them, they may not accurately recall the season or even the year. Some of the most difficult symptoms are emotional: The person may experience mood swings, depression and withdrawal, delusions, paranoia, or aggressive behavior.

=> In addition to these problems, most Alzheimer’s patients who live long enough gradually lose the ability to dress, bathe, toilet, and feed themselves, even though their muscles may still work perfectly. This is the breaking point for many families who have been caring for the patient at home. In the last stages, often eight to ten years after diagnosis, patients become bedridden and incontinent and cease communicating verbally. The official cause of death is often pneumonia, medical complications of a fall, or multiple organ failure.(88)

=> The tangles of an Alzheimer’s brain appear as dark flames or tadpolelike shapes. They are made up of a protein called tau. In a healthy nerve cell, normal tau helps form ropelike structures called microtubules, which act as a sturdy skeleton. The microtubules are essential to how the nerve cell communicates with other neurons. They guide cell nutrients and chemical messages from the main cell body down the long tail (axon) that sends the messages on to other cells. However, in Alzheimer’s disease, an abnormal form of tau accumulates, tangling the microtubules. The lines of communication are destroyed, and the cell is starved and immobilized. This crippled nerve cell then dies an early death. (91)

=> Kemper defined idea density as the number of propositions (individual ideas) expressed per ten words. He explained to me that idea density reflects language processing ability, which in turn is associated with a person’s level of education, general knowledge, vocabulary, and reading comprehension. Grammatical complexity, on the other hand, is associated with working memory capacity. In order to write a complex sentence, you have to keep many elements in play, juggling them until they are all properly coordinated. (109)

=> The level of idea density in the autobiographies was strongly associated with the scores from our cognitive tests. Grammatical complexity was also associated with the test scores, but the relationship was weaker. (112)

=> Nothing loves oxygen more than the brain, which accounts for only about 2 percent of the body’s weight but demands 15 to 25 percent of the available oxygen. The hippocampus, which is so critical to memory, is particularly sensitive to ischemic damage. So the brain literally chokes when a compromised heart or a clogged artery cannot deliver enough oxygen- loaded blood. Hypertension again comes into play here, as extra pressure on the walls of arteries stiffens them, making it easier for fatty plaques to form. Whatever culprit starves the brain of oxygen, the result if often the same: stroke.

First nerve cells die. Then, in a second wave of insult and injury, the brain tissue becomes inflamed. This initiates the so-called inflammatory cascade, in which the cells release toxic chemicals, killing more brain cells and further damaging the blood vessels. (148)

=> In my presentations around the country, I have now become a missionary for stroke prevention. High blood pressure causes more strokes than any other single cause. Anti- hypertension drugs, exercise, and a diet high in vegetables and fruits and low in fats all can help to lower the risk of stroke. If you are overweight, even a moderate weight loss can bring down your blood pressure. If your cholesterol is high, take steps to bring it within normal range.

=> Weight loss also lowers your risk of diabetes. This is important because diabetes increase your risk for heart attack and stroke two to four times above that for people who do not have the disease. If you already have diabetes, it’s important to work with your doctor and dietitian to maintain your blood sugar within the normal range. (156)

=> I also urge people to learn the symptoms of stroke, which include numbness or weakness on one side of the body, confusion or trouble speaking, sudden vision problems, dizziness or loss of balance, or severe unexplained headache. It is important to seek medical care immediately if one is suspected. Even a mini- stroke (TIA) warrants medical attention. (The symptoms of a TIA may last only a few minutes, but they signal that a major stroke may be on the way.) Every minute that elapses after a stroke is critical, since drugs are available that can help slow down the cascade of events that eventually leads to brain damage. But these drugs work best within the first three hours. A stroke is a brain attack. It demands the same emergency attention as a heart attack. And that quick action can help to preserve precious mental functioning—even if the plaques and tangles of Alzheimer’s have started to infiltrate the brain. (157)

=> Homocysteine is essential to the body’s functioning, but it can also participate in the process leading to atherosclerotic plague. High levels of homocysteine are now considered one of the primary risk factors for heart disease and stroke. One of the most crucial roles of folic acid in the body is to join with vitamin B12 in breaking down homocysteine into its useful form. If the body lacks enough of these vitamins, the homocysteine accumulates, with far-reaching consequences. (179)

=> Gross told me that his own nutritional program is quite simple: He eats a diet high in fruits and vegetables, takes a standard multivitamin every day, and takes an additional 200 IU of vitamin E on alternate days. Because he has a family history of heart disease, he also takes an aspirin about twice a week.

=> I take a standard balanced multivitamin each day, one that provides the full daily value for nutrients such as vitamin E (30 IU), vitamin C (60 mg), and folic acid (400 mcg). On alternate days I take two pills instead of one. This gives me a nice margin—about 50 percent higher intake of a broad range of nutrients than is usually recommended. (181)

=> Positive emotional content (in the nuns autobiographies written in their twenties) strongly predicted who would live the longest lives.(193)

=> In her studies of Alzheimer’s patients, Deborah Danner had found that memories connected with strong emotions were often retained even when the patient had appeared to have lost contact with the outside world.

=> I now made a conscious effort to regain my physiological balance quickly after an upset. Sometimes I have to express the negative feelings strongly in order to resolve them; I’ve learned that this can be a good thing….My goal is to return my body to its normal, healthier state as soon as possible. (196) [equanimity or Peace of God]

=> My sense is that profound faith, like a positive outlook, buffers the sorrows and tragedies that all of us experience. Evidence is now starting to accumulate from other studies that prayer and contemplation have a positive influence on long-term health and may even speed the healing process. The power of community. (202)

=> A study investigated the effects of different kinds of support on physical function in the elderly. The researcher’s data suggested that emotional support — including simply listening and talking in an affirmative way—could slow the development of disabilities. On the other hand, it appeared that offering unnecessary physical support—such as dressing an older person who can do it herself, or providing a wheel chair when she can manage with a walker—actually increased the incidence of disability. (203)

=> It appears that people who make it through their nineties without developing Alzheimer’s are actually at a lower risk than people in their eighties. As Perls puts it in Living to 100, “the older you get, the healthier you’ve been.” (206)

=> Alzheimer’s may dramatically slow its assault by about age 95. (216)